Multiple Layer Closure Research Articles

The Frequency of Wound Infection with Single Layer versus Multiple Layer Closure of Wound in Patients undergoing Major Surgeries

Objective: To compare the frequency of post-operative wound infection with single layer versus multiple layer closure of wound in patients undergoing major surgeries. Study Design: Quasi-experimental Study. Place and Duration of Study: Department of Surgery, Combined Military Hospital, Rawalpindi Pakistan, from Aug 2018 toAug 2019. Methodology: After getting written consent and considering the inclusion criteria 150 patients were chosen for this study. They were indiscriminately separated in two groups by using chit method. In Group A, patients underwent surgery with single layer closure. In Group B, patients underwent surgery with multiple layer closure. Most of surgeries were done under general anesthesia. Then post-operative wound infection was noted in the patients of both groups by using proforma. SPSS version 20 was used for all the collected data analysis. Results: In this study mean age of the patients in Single Layer Group was 48.17±9.07years and in Double Layer Group was 51.55±18.72 years. Male to female ratio was 1:1.03. The most common cause of surgery was colostomy closure found in 34(22.67%) patients. Wound infection noted in 19(12.67%) patients. In Single Layer Group patients the wound infection was found in 4(5.3%) patients whereas in Double Layer Group the wound infection was noted in 15(20%) patients (p-value=0.007). Conclusion: Single layer closure is safe technique which showed significantly less post-op wound infection than to double layer closure of skin in patients undergoing major surgeries.

A review of the best method of leg wound closure following open harvesting of the long saphenous vein for coronary artery bypass grafting

Uncertainty exists around the optimal method of leg wound closure following open long saphenous vein harvesting in adults undergoing coronary artery bypass graft surgery (CABG). Such is evident from the variety observed in the closure approach utilised. Consequently, a best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was ‘following open long saphenous vein harvesting in adults undergoing CABG, is single-layer leg wound closure superior to multiple-layer closure in terms of post-operative complications encountered? ‘. Altogether 382 papers on Ovid Embase and Ovid Medline, 301 papers on PubMed and 11 papers on the Cochrane database were found using the reported search. From the screened articles, 6 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that the best method of leg closure following open saphenous vein harvesting for CABG is single-layer cutaneous closure. The use of a suction drain to eliminate the dead space should be considered on a case-to-case basis by the lead operating surgeon with the patient's characteristics and their own expertise in mind.

Single-layer versus Multiple-layer Closure after Postaural Tympanoplasty: A Comparative Study

Single-layer versus Multiple-layer Closure after Postaural Tympanoplasty: A Comparative Study

Single- vs multiple-layer wound closure for flank incisions: results of a prospective, randomised, double-blinded multicentre study.

To compare the incidence of postoperative flank bulges between patients with multiple-layer closure and single superficial-layer closure after retroperitoneal surgery via open flank incision in the SIngle versus MUltiple-LAyer wound Closure for flank incision (SIMULAC) trial. The study was a randomised controlled, patient- and assessor-blinded, multicentre trial. Between May 2015 and February 2017, 225 patients undergoing flank incisions were randomised 1:1 to a multiple-layer closure (SIMULAC-I) or a single superficial-layer closure (SIMULAC-II) group. The primary outcome was the occurrence of a flank bulge 6months after surgery. Overall, 177 patients (90 in SIMULAC-I, 87 in SIMULAC-II) were eligible for final assessment. The cumulative incidence of a flank bulge was significantly higher in the SIMULAC-II group (51.7%) compared to the SIMULAC-I group [34.4%; odds ratio (OR) 2.04, 95% confidence interval (CI) 1.11-3.73; P=0.02]. Rate of severe postoperative complications (4.4% SIMULAC-I vs 10.3% SIMULAC-II; P=0.21) or hernia (6.7% SIMULAC-I vs 10.3% SIMULAC-II; P=0.59) was similar between the groups. There was no difference in pain (visual analogue scale) and the requirement for pain medication at 6months postoperatively. Quality of life assessed with the European Quality of Life 5 Dimensions Questionnaire was higher in the SIMULAC-I group compared to the SIMULAC-II group at 6months postoperatively, with a (median range) score of 80 (30-100) vs 75 (5-100) (P=0.012). The overall risk of a flank bulge after flank incision is high. Multiple-layer closure after flank incision should be performed as a standard procedure.

Stapes footplate deformity leading to perilymphatic fistula and recurrent meningitis

We present a case of a 23-month old female with congenital malformation of her inner ear and perilymphatic fistula due to stapes footplate defect leading to recurrent episodes of bacterial meningitis and resulting bilateral profound hearing loss. Multiple-layer closure with obliteration of the malformation, middle ear and mastoid along with closure of the external auditory canal was performed to achieve definitive repair. Cochlear implantation in the contralateral ear resulted in age-appropriate language proficiency with excellent CI speech perception over a 12-year follow up. The importance of multiple-layer closure for adequate repair and early consideration of cochlear implantation are highlighted.

Postaural incision closure in single layer versus multiple layers: A comparison

Background: By tradition, the postaural incision is closed in single or multiple layers. In this study single layer closure is compared with multiple layer closure. Materials and Methods: Two hundred patients with Chronic suppurative otitis media undergoing ear surgery by post aural approach at our department were included in the study. Results: It was observed that time taken for single layer closure was far less compared with time taken for multiple layer closure, which was of statistical significance. Conclusion: single layer closure is as effective as multiple layer closure of postaural incision, with the distinct advantages of reduced closure time and lesser cost of suture material.

Multiple-layer Closure of Myoma Bed in Laparoscopic Myomectomy

ABSTRACT Objective To assess the feasibility and outcome of laparoscopic myomectomy and multiple-layer closure of myoma bed for management of myomas at a tertiary care hospital. Materials and methods Five hundred and ten patients from January 2011 to January 2017 with large and moderate size myomas were managed by laparoscopic myomectomy. Indications were subfertility, menorrhagia, and abdominal mass. Preoperative evaluation included history, clinical examination, and sonographic mapping. Myomas were enucleated and retrieved laparoscopically. Myoma beds were sutured in multiple layers by endoscopic intracorporeal suturing. Fluid as adhesion barrier was used. Results Three hundred and eighty two patients presented with subfertility, 69 with menorrhagia, and 59 with abdominal mass. The average maximum diameter of myoma was 9.1 cm. The mean duration of surgery was 90 minutes. The mean postoperative stay was 24 hours. No intraoperative complication occurred and the hospital course was uncomplicated. In seven cases, minilap incision was given for retrieval of myoma and suturing of the bed. Two patients had minor delayed wound healing of the morcellator port site. The patients did not report any complaints during follow-up except one patient who developed omental hernia at morcellator port site. There was no rupture of scar and very low adhesion scores in subsequent cesarean sections or second look scopies. Conclusion With proper multilayer closure of the myoma bed, laparoscopic myomectomy is feasible for moderate and even large myomas and has good outcomes in terms of fertility and alleviation of symptoms. How to cite this article Jain N, Singh S. Multiple-layer Closure of Myoma Bed in Laparoscopic Myomectomy. Int J Gynecol Endsc 2017;1(1):22-27.

Proximal hypospadias with small flat glans: the lateral-based onlay flap technique

PurposeThe lateral-based onlay (LABO) technique for patients with proximal hypospadias associated with flat glans and report of the follow-up. Materials and MethodsBetween January 2004 and December 2010, the LABO technique was performed in 107 patients. The principle is to use the lateral foreskin adjacent to the glans as the onlay flap. Patient age ranged between 8 months and 2 years (mean, 11 months). The records of 98 patients who maintained regular follow-up were reviewed. All the patients had proximal hypospadias with flat or incomplete cleft glans and did not have a deep chordee. Follow-up period ranged from 12 months to 8 years (mean, 32 months). A transurethral silastic catheter was used for 7 days. Results and ComplicationsSatisfactory results were obtained in 93 patients (95%). Two children developed fistula, 2 developed glans dehiscence, and 1 child had skin prolapsing from the meatus that required excision. ConclusionsThe LABO technique is a reliable technique for patients with proximal hypospadias in the absence of a deep chordee. It has particular value in patients with small or flat glans. With multiple layer closure and careful attention to technical details, a low complication rate (5%) was achieved in correcting this type of proximal hypospadias.

The slit-like adjusted Mathieu technique for distal hypospadias

PurposeThe aims of this study were to describe the slit-like adjusted Mathieu technique (SLAM) for distal and midpenile hypospadias and report the midterm follow-up. Materials and MethodsBetween January 2005 and December 2009, the SLAM technique was performed in 923 patients. The key modification is the design of a converging incision and the technique of suturing. Patient age ranged between 4 months to 30 years (mean, 1.5 years). The records of 872 patients who maintained regular follow-up were reviewed. The technique was performed in all forms of distal hypospadias, regardless of the size of the glans or the degree of glans clefting. Cutaneous chordee was corrected by skin mobilization. Follow-up period ranged from 22 months to 6 years (mean, 38 months). A transurethral catheter was used for 1 to 3 days. Results and ComplicationsSatisfactory results were obtained in 848 patients (97%). Fourteen patients developed fistulae. Four patients developed meatal stenosis. Six patients had wound dehiscence. ConclusionsThe SLAM technique is a reliable technique for correction of distal and midpenile hypospadias with persistent good results. It avoids the drawbacks of the classic Mathieu (a transverse rounded meatus that is not terminal). Multiple-layer closure and careful attention to technical details contributed to a 3% complication rate in primary distal hypospadias.

Multiple layer closure of myoma bed in laparoscopic myomectomy

Objective:To assess the feasibility and outcome of laparoscopic myomectomy and multiple layer closure of the myoma bed, for management of myomas, at a tertiary care hospital.Materials and Methods:From September 2005 to September 2010, 417 patients, with large and moderate size myomas, were managed by laparoscopic myomectomy. Indications were subfertility, menorrhagia, and abdominal mass. Preoperative evaluation included history, clinical examination, and sonographic mapping. The myomas were enucleated and retrieved laparoscopically. Myoma beds were sutured in multiple layers by endoscopic intracorporeal suturing.Results:Three hundred and fifteen patients presented with subfertility, 45 with menorrhagia, and 57 with abdominal mass. The average maximum diameter of a myoma was 9 cm. The mean duration of surgery was 120 minutes. The mean postoperative stay was 24 hours. No intraoperative complication occurred and the hospital course was uncomplicated. In one case, a minilap incision was performed for retrieval of the myoma with suturing of the bed. Two patients had minor delayed wound healing of the morcellator port site. The patients did not report any complaints during the follow-up, except one patient who developed omental hernia at the morcellator port site. There was no rupture of the scar and very low adhesion scores in the subsequent cesarean sections or second-look scopies.Conclusion:With proper multilayer closure of the myoma bed, laparoscopic myomectomy was feasible for moderate and even large myomas and had excellent outcomes.

Multiple Layer Closure of Myoma Bed in Laparoscopic Myomectomy.

Objective:To assess the feasibility and outcome of laparoscopic Myomectomy and multiple layer closure of myoma bed for management of myomas at a tertiary care hospital.Materials and Methods:Four hundred and seventeen patients from September 2005 to September 2010 with large and moderate size myomas were managed by laparoscopic Myomectomy. Indications were subfertility, menorrhagia and abdominal mass. Pre-operative evaluation included history, clinical examination and sonographic mapping. Myomas were enucleated and retrieved laparoscopically. Myoma beds were sutured in multiple layers by endoscopic intracorporeal suturing.Results:Three hundred and fifteen patients presented with subfertility, 45 with menorrhagia and 57 with abdominal mass. The average maximum diameter of myoma was 9 cm. The mean duration of surgery was 120 min. The mean post-operative stay was 24 h. No intra-operative complication occurred and hospital course was uncomplicated. In one case, minilap incision was given for retrieval of myoma and suturing of the bed. Two patients had minor delayed wound healing of the morcellator port site. The patients did not report any complaints during follow-up except one patient who developed omental hernia at morcellator port site. There was no rupture of scar and very low adhesion scores in subsequent caesarian sections or second look scopies.Conclusion:With proper multilayer closure of the myoma bed, laparoscopic Myomectomy is feasible for moderate and even large myomas and has excellent outcomes.

P154: Head and Neck Dog Bites in Children: A Retrospective Study

P154: Head and Neck Dog Bites in Children: A Retrospective Study

Single-Layer Versus Multiple-Layer Closure of Leg Wounds After Long Saphenous Vein Harvest: A Prospective Randomized Trial

The long saphenous vein harvested by traditional techniques is an important conduit for coronary artery bypass grafting (CABG). The purpose of this study was to determine if a single-layer closure over a drain improved wound healing compared with the traditional two-layer closure after harvest. Seventy-eight consecutive patients undergoing CABG were prospectively randomized to have their leg wound closed by either a single-layer technique with a suction drain or multiple layers. All wounds were assessed using the additional treatment, presence of serous discharge, erythema, purulent exudate, and separation of the deep tissues, isolation of bacteria, and the duration of inpatient stay (ASEPSIS) score postoperatively and 6 weeks later. Forty-four patients (5 females) had their wound closed by the single-layer technique and 34 (6 females) closed in multiple layers. The ASEPSIS scores were significantly lower (p = 0.001) in those patients closed with a single layer (mean, 4.4) than those with multiple layers (mean, 6.8). Patients whose legs were closed with the single-layer technique had less peripheral edema compared with the multiple-layer group (chi2, p < 0.001). Using univariate analysis there was no correlation between ASEPSIS scores and length of wound incision (p = 0.49), whereas increasing age was found to have a weak positive correlation (r =0.24; p = 0.04). Single-layer leg wound closure over a suction drain is superior to the traditional multiple-layer closure. A possible mechanism of better wound healing in the former technique might be through decreased tissue handling and a reduction in leg edema.

Management and long-term follow-up of patients with types III and IV laryngotracheoesophageal clefts

Background Laryngotracheoesophageal cleft (LTEC) is a rare congenital anomaly that occurs when the trachea and esophagus fail to separate during fetal development. The 2 most severe forms of LTEC are type III, with extension of the cleft from the larynx to the carina, and type IV, with extension of the cleft into one or both mainstem bronchi. Methods Over the past 25 years, we have accumulated an experience caring for 9 patients with severe LTEC, including 4 with type III and 5 with type IV. Results Morbidity and mortality from severe LTEC often result from aspiration and chronic lung disease. Patients with types III (1/4) and IV (5/5) LTEC have an extremely high incidence of microgastria with a shortened esophagus for which fundoplication is ineffective. Because gastric feeding often does not initially increase stomach volume and may cause severe aspiration, we suggest early gastric division with later reconstruction of intestinal continuity in patients with microgastria. Postoperative tracheoesophageal fistulas have occurred in 6 of 9 patients. Conclusions Generous interposition of vascularized tissue with a multiple-layer closure has helped to prevent further recurrences. Postoperative tracheomalacia may be managed with continuous positive airway pressure and may require customized endotracheal tubes. Evaluation of respiratory and digestive function, school performance, and quality of life for the surviving patients is described.

Metal lawn and garden edging: the hidden knife?

Lacerations account for many visits to the pediatric emergency department. We observed children presenting to local emergency departments in a large metropolitan area with lacerations incurred from metal lawn and garden edging, a landscaping tool. We sought to describe the severity of lacerations caused by metal edging, the characteristics of wound repair, and the need for subspecialty consultation. A retrospective chart review including all pediatric patients (< 18 years) presenting with lacerations caused by metal lawn and garden edging from January 1995 to October 1997 was performed. Patients were seen at one of three emergency departments in Colorado. One hundred twenty-six patients were enrolled (76% male, 24% female), with a median age of 9 years. The most frequent location of laceration was the foot (40%), followed by the knee (26%). The median length of laceration was 3 cm (range 1-22 cm). Sixteen patients (13%) received either intravenous or oral antibiotics, and six patients (5%) received orthopedic evaluation. Metal lawn and garden edging in landscaped neighborhoods presents a previously undescribed laceration danger to children. Some lacerations sustained from the metal lawn edging are extensive, receiving either multiple layer closure and/or the need for subspecialty consultation.

How I do it: closure of tracheoesophageal puncture site.

Tracheoesophageal voice prosthesis is highly effective in providing speech after total laryngectomy. Although it is a safe method, tracheoesophageal fistulas occasionally need to be closed, usually at the request of the patient, because of leakage through an enlarging fistula. We present our technique for closure of tracheoesophageal fistula. An incision is made at the mucocutaneous junction of the stoma from the 9 to the 3-o'clock position. Tracheoesophageal space is dissected down to and beyond the fistula. The tracheoesophageal tract is divided. The esophageal mucosa is closed with inverted sutures. After multiple layer closure of the esophageal fistula, the tracheal mucosa is closed with everted sutures. This technique has been used in nine patients. Eight were successful. The remaining patient had radiation therapy failure. This method of closure is simple and effective for those patients who require permanent closure of the tracheoesophageal fistula.

A Vesicovaginal Fistula: A Half-Century of Undiagnosed Urinary Incontinence

Urinary incontinence often goes undiagnosed because of a patient's reluctance to mention incontinence-related symptoms. We report a case of a symptomatic vesicovaginal fistula that went undiagnosed for 47 years. A 74-year-old, gravida 4, para 4, white woman complained to her gynecologist of vaginal bleeding of 3 months duration and pelvic pressure that had progressively worsened over the last 6 years. Further questioning revealed an astonishing 47-year history of urinary incontinence. She was diagnosed with uterine prolapse, endometrial cystic hyperplasia, and urinary incontinence and was referred for a presurgical urogynecologic evaluation. Inspection revealed a cystocele to the introitus. Speculum examination revealed obvious leakage during filling of the bladder from a defect in the anterior vaginal wall. Cystourethroscopy confirmed a vesicovaginal fistula, which was surgically repaired using a multiple-layer closure technique, resulting in postoperative continence. Fistula formation, regardless of etiology, should be an important consideration in the differential diagnosis of urinary incontinence. (J GYNECOL SURG 12:205, 1996)

Management of Facial Injuries

Because of the excellent blood supply to the head region, superficial lacerations to the soft tissue structures of the head generally heal rapidly without treatment. Lacerations of the equine tongue frequently go unnoticed because difficulty in eating usually is not apparent. The majority of lacerations heal if left untreated, with no loss in function. Surgical repair is indicated to promote healing and prevent deformity, to amputate a severely compromised apex, and to alter a scar or defect that is unacceptable to the owner. Surgical principles to be adhered to include thorough debridement and copious lavage, multiple layer closure, and placement of tension sutures away from the primary suture line and tied on the dorsum of the tongue. Full-thickness lip lacerations should be repaired using multiple-layer closure and tension sutures tied on the skin surface away from the primary suture line. Reconstructive techniques have been described for extensive lip lacerations when primary repair was inadequate or tissue loss was severe. Thorough evaluation of the equine lid, adnexa, and orbit is essential in determining severity of injury and appropriate treatment methods as well as for establishment of a prognosis. The injury may be minor or more severe, leading to blindness, disfigurement, or loss of the eye itself. Depression fractures involving the frontal, maxillary, or nasal bones are frequently open fractures. Skin abrasions, epistaxis, facial deformity, crepitus, and pain are clinical signs seen with this type of injury. Bone and soft tissue reconstruction should be performed to minimize potential complications. Facial fractures left untreated can result in facial deformity, sequestration, sinusitis, and osteomyelitis.

The repair of congenital and acquired skull defects in childhood

Methylmethacrylate (sulfix-6 and palakos) are very useful materials for the closure of skull defects. The age of the patient and the time of operation are of secondary importance. These substances have the lowest complication rate, can be easily handled and produce a cosmetically satisfactory result. Rib transplants have in our hand not been associated with any complications, but they are cosmetically not always satisfactory as palpable spaces between the ribs remain and the postoperative wearing of a protective helmet is advisable. The use of the patient's own piece of skull or the external lamina are less satisfactory because there is always a tendency of absorption. Nevertheless, it should be used as a primary measure. In all the operations, meticulous sterility is mandatory and a sufficiently large and viable flap of scalp and galea must be used. In children with encephaloceles, cerebral spinal fluid fistulae have to be closed completely watertight. This can only be achieved by a multiple layer closure of the soft tissues; fibrin seal has been found to be especially useful in this operation.

Perforated gastric and duodenal ulcers: An analysis of 200 consecutive cases

Two hundred patients with perforated ulcers of the stomach and duodenum were seen at University Hospital in a twelve-year period. The overall mortality rate was 26 per cent and 20 per cent for those who underwent operation. Sex, race and seasonal relationship did not show any prognostic trends in this series. The age of the patient was quite important in that the mortality rate rose with the age of the patient. The youngest patient was nineteen and the oldest seventy-six years of age. Sixty-two per cent of the patients were classified as laborers and the absence of the high-strung “ulcer type” patient was noted. Eighty-nine per cent of the patients had a history of previous gastric disturbances and 30 per cent a past history of moderate use of alcohol. Correct diagnosis was made in 95.5 per cent of cases by use of history and examination which revealed a board-like rigidity of the abdomen, muscle spasm, a quiet abdomen by auscultation, leukocytosis and x-ray evidence of free air in the peritoneal cavity. The most commonly used anesthetic was spinal and with it the patient mortality was lower (12 per cent) than that of general (21 per cent) and the combination of general and spinal (42 per cent). The abdomen was opened in many ways and the transverse incision was virtually abandoned after 1938. The right upper rectus incision became the popular choice followed closely by the right upper paramedian. Both of these incisions gave adequate exposure. The ulcer perforation was found to be gastric in 45.5 per cent, duodenal in 39.5 per cent and pyloric in 15 per cent of the patients. The lowest mortality rate was noted with the pyloric perforations and the highest with the duodenal perforations. (Table VI.) Three perforated malignant lesions were found and those patients died following closure of the perforation. During the series the more complicated procedures, such as multiple layer closure of the perforation and posterior gastro-enterostomy, were discarded for the simple, single layer closure and the omental graft because of a mounting mortality rate and more frequent complications. Suprapubic drainage has not been used for eight years and of the three deaths complicated by mechanical intestinal obstruction suprapubic drainage was present in each case. Post-operative therapy now consists of gastric siphonage for at least twelve to forty-eight hours, sips of water twelve hours postoperatively, adequate parenteral feedings with vitamins and amino acid preparations, chemotherapeutic and antibiotic agents prophylactically to combat and prevent peritonitis, wound infections and the pneumonities.