Factors influencing wound complications: a clinical and experimental study.

Burst abdomen, incisional herniation, sinus formation and post-operative wound infection continue to bedevil the surgeon. A prospective study of 1129 laparotomy wounds defined the extent of the problem; 1.7% incidence of dehiscence, 7.4% herniation and 6.7% sinus formation, all significantly associated with wound infection. Mass closure reduced the dehiscence rate from 3.8% to 0.76%. Infection reduced wound strength in a rat laparotomy model due to a decrease in fibroblast concentration and activity. A monofilament non-absorbable suture was shown experimentally to be the most suitable suture for closing infected abdominal wounds. Electron microscopy demonstrated bacteria in the interstices of infected multifilament sutures. A randomised clinical trial comparing polyglycolic acid and monofilament nylon in the closure of abdominal wounds confirmed the experimental findings; polyglycolic acid resulted in a significantly higher wound failure rate with no decrease in sinus formation. A mass closure technique using monofilament nylon is recommended for laparatomy closure and efforts should continue to reduce wound sepsis.     

Comparative study of leg wound skin closure in coronary artery bypass graft operations.

A prospective randomised study of four different methods of leg wound skin closure after removal of the long saphenous vein was carried out in 113 patients undergoing coronary artery bypass grafting. These methods were: (1) continuous nylon vertical mattress suture (27 patients); (2) continuous subcuticular absorbable (Dexon) suture (29 patients); (3) metal skin staples (Autosuture) (27 patients); and (4) adhesive sutureless skin closure ("Op-site") (30 patients). All wounds were examined by two independent observers at five, 10, and 45 days after operation. At five days, inflammation, extent of oedema, discharge, and infection were assessed. At 10 days attention was paid to the state of wound healing and at 45 days to the final cosmetic appearance. The use of continuous subcuticular suture resulted in significantly less discharge than did the use of metal staples, nylon vertical mattress suture, or Op-site. The incidence of established wound infection was 4.5% overall, with no infection in the wounds closed with Dexon. Assessment of the healing process showed subcuticular Dexon to be more effective than metal staples or vertical mattress nylon suture. The final cosmetic result showed continuous subcuticular suture to be superior to nylon vertical mattress suture and skin staples but as effective as Op-site sutureless skin closure.     

Continuous absorbable vs interrupted nonabsorbable fascial closure. A prospective, randomized comparison

A prospective, randomized comparison of continuous, absorbable, No. 2, coated, polyglycolic acid suture (Dexon-Plus) vs interrupted, nonabsorbable, No. 28 monofilament stainless steel wire suture was performed in 105 patients for midline fascial closure following gastric surgery for morbid obesity. The preoperative weight, sex distribution, and type of operation were not significantly different between the two groups. No significant difference was found in the wound complication rate between the two closure methods (7/54 for wire and 8/51 for polyglycolic acid). There were one dehiscence and five incisional hernias in the wire group and five hernias in the polyglycolic acid group. Continuous closure was accomplished in significantly less time (21 +/- 8 minutes) than interrupted closure (43 +/- 19 minutes). An additional 121 patients underwent continuous No. 2 polyglycolic acid fascial closure after the end of the randomized trial, with 13 wound complications, including ten incisional hernias. In conclusion, continuous, absorbable suture closure for laparotomy wounds is recommended for its economy of time and the lack of significant difference from an interrupted, nonabsorbable wound closure.     

The choice of a suture to close abdominal incisions

Burst abdomen, incisional hernia and sinus formation continue to bedevil the surgeon. Significant associated factors include postoperative wound infection and the suture material used. A series of experiments was therefore designed to test suture materials for their use in infected abdominal would closure. The nearest to the ideal, is a monofilament nonabsorbable suture (monofilament nylon). It has a low infectivity, resulted in satisfactory would tissue strength when used in infected wounds, and retained its strength. Infected, braided sutures of silk, nylon and polyglycolic acid even after 70 days were seen to contain bacteria and polymorphonuclear cells when examined electron microscopically. Absorption of silk and polyglycolic acid and encapsulation of non-absorbable braided nylon was delayed by the presence of infection. Monofilament nylon, in contrast, was unaffected, a fibrous capsule having formed by 10 days even in the infected state.     

Antiseptic wick: does it reduce the incidence of wound infection following appendectomy?

The role of prophylactic antibiotics is well established for contaminated wounds, but the use of antiseptic wound wicks is controversial. The aim of this work was to study the potential use of wound wicks to reduce the rate of infection following appendectomy. This prospective randomized controlled clinical trial was conducted at a university hospital in the department of surgery. The subjects were patients undergoing appendectomy for definite acute appendicitis. They were randomized by computer to primary subcuticular wound closure or use of an antiseptic wound wick. For the latter, ribbon gauze soaked in povidone-iodine was placed between interrupted nylon skin sutures. Wicks were soaked daily and removed on the fourth postoperative day. All patients received antibiotic prophylaxis. They were reviewed while in hospital and 4 weeks following operation for evidence of wound infection. The main outcome measures were wound infection, wound discomfort, and cosmetic result. The overall wound infection rate was 8.6% (15/174). In patients with wound wicks it was 11.6% (10/86) compared to 5.6% (5/88) in those whose wounds were closed by subcuticular sutures (p = NS). We concluded that the use of wound wicks was not associated with decreased wound infection rates following appendectomy. Subcuticular closure is therefore appropriate in view of its greater convenience and safety.     

Abdominal wound closure--a comparison of monofilament nylon and polyglycolic acid

The incidence of burst abdomen, incisional herniation, and sinus formation after a vertical abdominal incision was studied in a prospective randomized trial that compared two suture materials--monofilament nylon and polyglycolic acid. Laparotomy wounds were closed with a continuous mass suture technique. Of the 210 patients studied, 15 died between 10 days and 6 months postoperatively with their wounds intact. The remaining patients were followed up for 6 months or longer. The two groups were well matched for known risk factors. The 104 patients in the polyglycolic acid group had a 12.5% wound failure rate (1 burst abdomen and 12 hernias), but the 106 patients in the nylon group had only a 4.7% wound failure rate (1 burst abdomen and 4 hernias) (P = 0.04). There was a significant association between the rate of infection and sinus formation, but there was no difference between the incidence of these complications between the two groups. Closure of abdominal wounds with absorbable sutures does not appear to be justified, and we suggest that nylon and the mass closure technique be used for all abdominal wound closures. Other etiologic factors significantly associated with wound failure include male sex and postoperative chest complications. However, infection remains the most significant postoperative complication because the incidence of incisional hernias and sinus formation would be reduced by the elimination of wound sepsis.     

Two methods of skin closure in abdominal operations: a controlled clinical trial

Operative bacterial contamination of surgical wounds is common. The ability of the host to eradicate these bacteria and prevent subsequent wound infection is affected by a number of factors; one of these has been shown experimentally to be the presence of suture material in the subcutaneous tissues. In a prospective randomized controlled clinical trial in 341 abdominal operations we compared the primary infection rates after two methods of skin closure: either vertical mattress monofilament nylon sutures (182 patients) or steel clips which penetrated only the dermis (159 patients). All patients received a single dose of a cephalosporin intravenously at induction of anaesthesia and neither sutures nor drains were placed in the subcutaneous plane. The overall wound infection rate in the sutured wounds was 17.0 per cent, compared with 6.3 per cent in those closed by clips (X2 = 9.26, P less than 0.01). We conclude that skin closure with clips reduces the incidence of wound infection in patients in whom operative parietal contamination has occurred.     

Suture reaction following skin closure with subcuticular polydioxanone in total knee arthroplasty

A retrospective study revealed a 20% incidence of suture reaction following closure of wounds with subcuticular polydioxanone after total knee arthroplasty. In a control group whose wounds were closed with subcuticular polyglycolic acid (Dexon, Davis & Geck, Wayne, NJ), no suture reactions occurred (P = .0012, Fisher's exact test). It is concluded that subcuticular polydioxanone should not be used for skin closure after total knee arthroplasty.     

Frequency of Use of Suturing and Repair Techniques Preferred by Dermatologic Surgeons

BACKGROUND: There are many closure techniques and suture types available to cutaneous surgeons. Evidence-based data are not available regarding the frequency of use of these techniques by experienced practitioners. OBJECTIVE: To quantify, by anatomic site, the frequency of use of common closure techniques and suture types by cutaneous surgeons. METHOD: A prospective survey of the members of the Association of Academic Dermatologic Surgeons that used length-calibrated visual-analog scales to elicit the frequency of use of specific suture techniques. RESULTS: A response rate of 60% (61/101) indicated reliability of the received data. Epidermal layers were closed most often, in descending order, by simple interrupted sutures (38-50%), simple running sutures (37-42%), and vertical mattress sutures (3-8%), with subcuticular sutures used more often on the trunk and extremities (28%). The most commonly used superficial sutures were nylon (51%) and polypropylene (44%), and the most common absorbable suture was polyglactin 910 (73%). Bilayered closures, undermining, and electrocoagulation were used, on average, in 90% or more sutured repairs. The median diameters (defined as longest extent along any axis) of most final wound defects were 1.1 to 2.0 cm (56%) or 2.1 to 3.0 cm (37%). Fifty-four percent of wounds were repaired by primary closure, 20% with local flaps, and 10% with skin grafting, with the remaining 15% left to heal by second intent (10%) or referred for repair (5%). Experience-related differences were detected in defect size and closure technique: defects less than 2 cm in diameter were seen by less experienced surgeons, and defects greater than 2 cm by more experienced surgeons (Wilcoxon's rank-sum test: p=.02). But more experienced surgeons were less likely to use bilayered closures (r=-0.28, p=.036) and undermining (r=-0.28, p=.035). CONCLUSIONS: There is widespread consensus among cutaneous surgeons regarding optimal suture selection and closure technique by anatomic location. More experienced surgeons tend to repair larger defects but, possibly because of their increased confidence and skill, rely on less complicated repairs.     

The stretched scar: the benefit of prolonged dermal support

A study of skin suture following elliptical excision of tattoos from the upper limb shows that when the dermis is supported by a subcuticular non-absorbable suture for 6 months there is (a) a highly significant and numerically considerable (37.5%) reduction of scar stretching over that following conventional interrupted skin suture and (b) a significant reduction of scar width (15.7%) when compared with the same material used as a subcuticular suture for 3 weeks. Subcuticular polyglycolic acid achieved no reduction in scar width at one year when compared with conventional interrupted sutures.     

Use of synthetic absorbable sutures for abdominal and chest wound closure. Experience with 650 consecutive cases.

The advent of synthetic collagen suture (polyglycolic acid and polyglacin 910) has provided a new dimension in surgical suturing. However, surgeons in general have not yet taken full advantage of the potential that this new material offers. Associated evisceration and wound dehiscence rates as well as the incidence rate of wound infection were assessed since these represent standards by which the suture material can be evaluated. In an entire series of 650 cases, there has been one case of wound dehiscence with evisceration. The incidence of infection has been less than 1%, which is comparable to previous experience with interrupted, nonabsorbable sutures. The time required for closure using the new material has been approximately one third of that associated with the use of conventional interrupted closure sutures. This implies a substantial cost reduction for the patient. As a result of this experience, the synthetic absorbable sutures seem to represent the material of choice for routine abdominal or chest wound closure.     

GS27PTECHNIQUES FOR CLOSURE OF MIDLINE ABDOMINAL INCISIONS

Background A recent meta‐analysis of randomised controlled trials of abdominal fascial closures concluded that in order to reduce incisional hernia rates without increasing wound pain, or the rate of dehiscence slowly absorbable continuous sutures appear to achieve the best results in abdominal fascial closures. We surveyed the techniques for abdominal fascial closure among general surgeons in Canberra, Australia. Methodology 49 out of 80 surgeons responded to the survey by form. The information collected included the seniority of the surgeon, the frequency of laparotomy closure, surgical technique and suture material utilised in abdominal fascial closure. Results 34 (69%) of the surgeons surveyed preferred a non‐absorbable monofilament suture material for abdominal fascial closure with nylon being the most popular. Most (38, 78%) also preferred a non‐absorbable monofilament suture in emergency surgery. 12 (24%) surgeons preferred to use slowly absorbable suture. The majority of surgeons (37, 76%) preferred continuous suture technique, whilst only 2 (4%) used continuous followed by interrupted suture closures. Only 5 (10%) complied with the dual recommendation of continuous suture technique and slowly absorbable suture. Conclusion The majority of surgeons preferred non‐absorbable monofilament suture rather than slowly absorbable suture. Only 1 in 10 surgeons complied with both components of evidence base, which supports the use of slowly absorbable suture material and a continuous technique in abdominal fascial closure. A definitive RCT would confirm this observation.     

SINGLE LAYER ABDOMINAL WOUND CLOSURE IN CHILDREN

A single layer closure of abdominal incisions was done, including the skin, musculo-aponeurotic layer and peritoneum, with a modified‘figure-of-eight’technique, using thick monofilament nylon interrupted sutures. This technique leaves no suture material in the wound after suture removal on the 14th postoperative day. One hundred and fifty-two transverse incisions of the abdomen in children of all ages were analysed. Easy closure in difficult cases, no wound dehiscence and a greatly reduced infection rate are the advantages. We recommend this technique as a routine, particularly in poor risk patients, contaminated wounds and closure of colostomy wounds.     

The use of sterile adhesive tape in the closure of arthroscopic puncture wounds: a comparison with a single layer nylon closure.

A prospective trial was undertaken comparing the wound healing and infection rates in arthroscopic arthrotomy wounds closed by sterile adhesive tapes on interrupted Nylon skin sutures. Two hundred and thirty consecutive arthroscopic procedures had arthrotomy wounds closed by a single layer skin closure of either interrupted Nylon (n = 62) or sterile adhesive tapes (n = 168). All wounds healed by primary intention. Only one wound developed a superficial infection around a Nylon suture and no patient developed a synovial herniation. It is concluded that closure of arthroscopic puncture wounds with sterile adhesive tape is effective and convenient for wound management.     

Controlled trial of polyglycolic acid versus catgut and nylon for appendicectomy wound closure.

Six hundred and fifty patients undergoing appendicectomy were included in a prospective randomized controlled trial. At operation patients were allocated to control (chromic catgut ligatures and muscle closure, nylon skin closure) or study (polyglycolic acid ligatures and muscle and skin closure) groups. Wounds were examined by an independent observer daily in hospital and 1 month after operation. Wound infection was defined as discharge of serous or purulent material, or a grossly inflamed wound without discharging pus, or any evidence of intra-abdominal sepsis. Of the 650 patients (335 men, 315 women, age 5-80 years, median 18 years), 615 have completed follow-up. Groups were well matched for age, sex, degree of sepsis at operation, histological diagnosis and surgeon. Infection was significantly reduced in the study (polyglycolic acid) group (12.0 per cent) compared with the control (chromic catgut/nylon) group (21.2 per cent) (chi 2 = 9.3, P = 0.002). Infection was significantly reduced in the polyglycolic acid group regardless of whether the appendix was inflamed or normal. These results indicate that suture material can influence the incidence of wound infection and that this is less frequent when polyglycolic acid sutures are used.     

Tensile strength of corneoscleral wounds repaired with absorbable sutures

The tensile strength of healing corneoscleral wounds repaired with 9-0 and 10-0 nylon, polyglycolic acid, and polyglycolic-lactic acid sutures was measured in rabbit eyes at the first, third, and sixth postoperative weeks. In all cases, the tensile strength of the wound increased to about 50 percent of that of intact control tissue by the sixth week. There were no differences between the tensile strengths of wounds and the severity of inflammation in the anterior chamber between eyes sutured with nylon and those sutured with absorbable materials. Conjunctival injection persisted longer around nylon sutures, however, than it did around either polyglycolic acid or polyglycolic-lactic acid sutures. The absorbable sutures maintain sufficient strength to support healing corneoscleral wounds.     

A comparative study on primary wound closure by subcuticular suture using different suture materials with emphasis on complications, cosmesis and cost-effectiveness

Background and Purpose

There are different methods and materials for closing a surgical wound by subcuticular stitch but controversy prevails as concerns the appropriate material for this stitch. This study aims to investigate the different suture materials and compare their technical accessibility, usefulness, complication rates, patient satisfaction and, above all, the general outcome.

Methodology

Over a period of 8 months (June 2011–January 2012), 160 patients underwent wound repair by subcuticular stitch in our unit. A prospective analysis of patients’ case notes was performed. Results: Each type of thread has its own and specific type of complications which is distinct from other types of threads. Among patients on whom polyglactin sutures were used, 15.79% and 14.29% (respectively) developed complications in the presence and absence of complicating comorbid factors. Specifically, 20% of <3 cm wounds, 10% of 3–6 cm wounds, and 20% of >6 cm wounds sutured with polyglactin developed complications. The corresponding complication rates for poliglecaprone sutures were less at 9%, 5.9%, and 8.3%, respectively. The number of patients who are very happy and satisfied with poliglecaprone sutures is much greater than that of those on whom polyglactin sutures were used; the difference is statistically significant. In terms of cost, nylon is the cheapest thread whereas polypropylene is the costliest.

Conclusion

Poliglecaprone seems to be the thread of choice with minimal complication rates both in the presence and absence of comorbid factors in < 3 cm and 3–6 cm wounds. However, nylon appears to be more useful for wounds > 6cm since minimal complication rates are reported.     

A comparison of upper abdominal wound closure with monofilament nylon and polyglycolic acid

In a trial of 104 consecutive patients undergoing upper abdominal surgery, 62 wounds were closed with continuous layered nylon and 42 with interrupted mass PGA sutures. All wounds were closed by one surgeon. There was a significantly greater incidence of wound infection (P less than 0.01) and incisional hernia (P less than 0.05) in the group closed with PGA. Wounds closed with PGA took longer to suture (1.00 min/cm) than wounds closed with nylon (0.76 min/cm), a highly significant difference (P less than 0.001). From this study it is recommended that upper abdominal surgical wounds should be closed with a continuous nylon suture.     

Reconstructive microsurgery of the vas deferens. Experimental study of suture materials

Microsurgery is the procedure of choice for vasectomy reversal. The aim of this study was two compare two different suture materials for vasovasectomy - a nonresorbable material (nylon 10/0 with a BV 6 needle), which is widely used, and a resorbable material (polyglycolic acid, also with a BV 6 needle), which has not yet been evaluated for this use. 28 Sprague-Dawley rats were operated on under microscope. Two groups were then compared, group A with nylon (n = 14) and group B with polyglycolic acid (n = 14). In each group, 8 animals had a vas deferens section and 6 had a previous vasectomy by ligature. Ten days postoperatively, the patency rate of the anastomosis was evaluated by the presence of sperm on both sides of the suture line. The contractility was assessed by mechanical stimulation. The existence of a sperm granuloma was considered as indicative of a non functional anastomosis. Three days later a fertility test was performed, lasting three months, and the number of litters was checked. The rats were sacrificed after three months, and each vas deferens was examined histologically or by electron microscope. The macroscopic results were: 57% patent anastomoses in group A and 77% in group B. 16% patent anastomoses after ligature in group A (n = 6) and 75% in group B (n = 6). The pregnancy rate was 54% in group A and 77% in group B. After previous ligation, the corresponding figures were 20% and 83% respectively.(ABSTRACT TRUNCATED AT 250 WORDS)     

Abdominal wound closure: a trial of nylon, polyglycolic acid and steel sutures.

Failures after abdominal wound closure (early dehiscences and late incisional hernias) are due to breakage of sutures, slippage of knots or tearing out of sutures from the tissues. The suture-holding capacity of the entire thickness of muscle and aponeurosis is nearly twice that of the anterior rectus sheath, and deep bites (1-0 cm from the cut edges) are nearly twice as secure as bites of 0-5 cm. In a random controlled clinical trial of 357 major laparotomies, closure with either layered monofilament nylon or mass polyglycolic acid or steel resulted in 2 burst abdomens (0-56%), 10 incisional hernias due to suture failure (3-4%) and 8 incisional hernias caused by deep sepsis (2-7%). There were no statistically significant differences among the treatment groups, but 1 patient in the nylon and 3 in the steel groups had persistent sinuses until their sutures were removed.