Primary Closure Technique Research Articles

Exposure of titanium implants after cranioplasty: A matter of long-term consequences

Abstract Although the use of titanium implants in cranioplasty has recently become common, long-term results of this strategy are sometimes difficult to manage. The aim of this study was to clarify the characteristics of patients developing exposure of titanium implants. Records of eight patients with exposure of titanium implants were reviewed. Patient ages ranged from 41 to 77 (mean, 56.8) years. Two patients were male, and six were female. The periods from implantation to exposure of titanium implants ranged from 5 to 87 (mean, 30.5) months. In seven cases, titanium mesh cranioplasty was performed after postcraniotomy infections. The titanium implants were removed in all cases. Scalp tissue was closed by applying a primary closure technique in five cases, though scalp reconstruction was performed with a rotation flap in the other three cases involving large scalp ulceration. Although the use of titanium implants is convenient, the indications should be carefully considered, especially in cases with postoperative surgical site infections and in patients with thin scalp skin. For these patients, long-term follow up is necessary.

Allgöwer-Donati Versus Vertical Mattress Suture Technique Impact on Perfusion in Ankle Fracture Surgery: A Randomized Clinical Trial Using Intraoperative Angiography.

The purpose of this study was to evaluate which primary wound closure technique for ankle fractures affords the most robust perfusion as measured by laser-assisted indocyanine green angiography: Allgöwer-Donati or vertical mattress. Prospective, randomized. Level 1 Academic Trauma Center. Thirty patients undergoing open reduction internal fixation for ankle fractures were prospectively randomized to Allgöwer-Donati (n = 15) or vertical mattress (n = 15) closure. Demographics were similar for both cohorts with respect to age, sex, body mass index, surgical timing, and OTA/AO fracture classification. Skin perfusion (mean incision perfusion and mean perfusion impairment) was quantified in fluorescence units with laser-assisted indocyanine green angiography along the lateral incision as well as anterior and posterior to the incision at 30 separate locations. Minimum follow-up was 3 months with a mean follow-up 4.7 months. Allgöwer-Donati enabled superior perfusion compared with the vertical mattress suture technique. Mean incision perfusion for Allgöwer-Donati was 51 (SD = 13) and for vertical mattress was 28 (SD = 10, P < 0.0001). Mean perfusion impairment was less in the Allgöwer-Donati cohort (12.8, SD = 9) compared with that in the vertical mattress cohort (23.4, SD = 14; P = 0.03). One patient in each cohort experienced a wound complication. The Allgöwer-Donati suture technique offers improved incision perfusion compared with vertical mattress closure after open reduction internal fixation of ankle fractures. Theoretically, this may enhance soft tissue healing and decrease the risk of wound complications. Surgeons may take this into consideration when deciding closure techniques for ankle fractures. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Do standard carotid artery endarterectomy and primary closure technique cause early restenosis in diabetic patients?

IntroductionWe aimed to investigate carotid restenosis in 2-year follow-up in diabetic and nondiabetic patients who underwent standard carotid endarterectomy with primary carotid closure and determine whether diabetes mellitus is a risk factor for early stenosis for this surgical procedure.Material and methodsWe retrospectively assessed the data of patients who underwent standard carotid endarterectomy with primary carotid closure from the hospital registry and outpatient clinic follow-up between January 2006 and January 2012. The study included 25 diabetics and 25 nondiabetics, in total 50 patients. The control carotid Doppler ultrasonographies and/or computed tomography angiographies of the patients at postoperative 1, 6, 12, and 24 months were examined and a stenosis rate between 70% and 99% was regarded as significant carotid restenosis.ResultsWhen the diabetic and nondiabetic group patients were compared for early carotid restenosis at 2 years, there were 3 (12%) patients in the diabetic group and 4 (16%) patients in the nondiabetic group with restenosis. A statistically significant difference in early carotid restenosis was not observed between the two groups (p > 0.05).ConclusionsStandard carotid endarterectomy and primary closure of the artery is a successfully performed surgical procedure in diabetic patients. We concluded that diabetes mellitus is not a risk factor for early restenosis in the diabetic patient population according to the results of our research.

Comparative analysis of the same technique-the same surgeon approach in the surgical treatment of pilonidal sinus disease: a retrospective cohort study.

PurposeAlthough there are several surgical methods for treatment of sacrococcygeal pilonidal sinus, there is no widespread consensus. In this study, we aimed to compare primary closure, Limberg, and modified Limberg flap techniques, with each performed by each of 3 surgeons.MethodsA total of 802 patients who were operated on for pilonidal sinus disease were included in this retrospective cohort study. Patients were evaluated in 3 groups: group 1 (limited excision + primary closure), group 2 (large excision + Limberg flap technique), and group 3 (large excision + modified Limberg technique). Development of early or late period complications was accepted as primary outcome.ResultsMean patient age was 28.1 ± 6.7 years. Operation time in group 1 was 44.0 ± 14.5 minutes, and was shorter in comparison to other 2 groups (P < 0.001). One or more complications developed in 171 patients (21.3%) within study group. Highest complication rate was in group 1, with a rate of 30.7% (P < 0.001). Rate of wound dehiscence and recurrence in group 1 were differed significantly from other groups (P < 0.001 and P = 0.001, respectively).ConclusionBased on the same technique-the same surgeon approach, comparison of surgical methods for treatment of pilonidal sinus showed that modified Limberg and Limberg techniques are superior to primary closure technique in terms of general complication, wound dehiscence, and recurrence rates.

Three-layer primary closure of the bipedicled TRAM flap donor site for unilateralbreast reconstruction: a 15-year experience with 124 consecutive patients.

The pedicled transverse rectus abdominis myocutaneous (TRAM) flap remains widely used as a breast reconstruction technique. The bipedicled TRAM flap is not as preferable as it was formerly, mainly because of its donor site complications. However, in a number of situations, a bipedicled TRAM flap may be the only alternative. Therefore, a three-layer primary closure technique used with bipedicled TRAM flap breast reconstructions that can avoid donor site complications without using a mesh is presented. A retrospective study was performed that included patients who underwent bipedicled TRAM flap breast reconstruction with the three-layer primary closure technique. Between 2000 and 2015, 124 breast reconstruction patients were reviewed for donor site morbidity. During the 15-year study period, 106 patients had conventional bipedicled TRAM flaps and 18 had bipedicled TRAM flaps with a surgical delay procedure. For all groups, none of the patients developed abdominal wall hernia, but three patients had bulging. Partial flap loss was the most common flap complication, present in 6 flaps (4.8%). The suturing technique studied provided abdominal wall closure without the use of a mesh even when utilizing a bilateral pedicle with very low complication rates.

A Comparison of the Results of the Karydakis Flap Procedure and Primary Closure in the Treatment of Pilonidal Sinus Disease Over the Short and Long Term: A Randomized Clinical Study

In the current prospective study, we compared the results of the Karydakis flap procedure (KFP) and primary closure (PC). This study compared the short and long-term results of the KFP and PC techniques. The sample of this study was a total of 352 patients (302 male: 85.7%; median age: 24 years) who underwent reconstruction after pilonidal sinus excision in our clinic. The reconstruction was performed using the KFP (group 1, n = 176, 50%) or PC (group 2, n = 176, 50%). The following data on the patients was obtained; sex, age, body mass index (BMI), duration of operation and hospital stay, length of time patient could walk without pain, length of time patients could sit on toilet without pain, complications (e.g., infection, recurrence). No significant difference was found between groups 1 and 2 with respect to sex, age, BMI, and duration of operation. Moreover, length of time patients could walk and sit on toilet without pain was similar in both groups. On the other hand, the rate of recurrence was significantly lower in group 1 (n = 4, 2%) compared with group 2 (n = 20, 11%, P &amp;lt; 0.001). KFP is preferable to PC since it is easier to learn and perform and has lower complication and recurrence rates.

A Novel Technique for Primary Closure of a Laryngotomy Incision and Follow‐up in 73 Cases

A Novel Technique for Primary Closure of a Laryngotomy Incision and Follow‐up in 73 Cases

Tracheocutaneous fistula closure in children

ObjectiveSystematic review of surgical techniques for tracheocutaneous fistula closure in children and successful closure or development of adverse events. Data sourcesPubMed, EMBASE, Web of Science, and Cochrane Library. Review methodsA medical librarian was utilized to perform a systematic review. ResultsFourteen studies were identified. Eight studies reported outcomes for primary closure alone; one discussed results for secondary closure alone; and five included a combination of children who underwent either primary and secondary closure alone. No difference between surgical techniques was identified for effectiveness of closure (RR = 1.03, 95% CI: 0.97 to 1.10) and major (RR = 1.68, 95% CI: 0.56 to 5.05) or minor complications (RR = 1.28, 95% CI: 0.50 to 3.27). No mortalities were identified. ConclusionsBoth primary and secondary closure techniques for persistent tracheocutaneous fistulas in children are effective and associated with acceptable rates of complications. Given the available evidence, neither approach appears to be superior. Considerations for decision making in surgical approach may include family and social considerations, facility resource utilization, and cost differential. Further investigation may be directed at improving patient selection.

Clarifying Scar Revision Techniques and Their Proper Use-Reply.

Clarifying Scar Revision Techniques and Their Proper Use-Reply.

Transverse primary closure technique of choledochotomy: simple, fast and safe

Transverse primary closure technique of choledochotomy: simple, fast and safe

Reconstructive Surgical Repair of a Forth Degree Iatrogenic Burn in a Dog

Background: Burns are uncommon in small animal surgery routine and represents a real therapeutic challenge. Skin can be affect in different degrees of deepness as superfcial, partial thickness, full thickness and full thickness affecting underlying tissues. Each degree has individual features. Progression through degrees can occur in the frst 24 h or if treatment is inadequate. This paper aims to describe therapeutic approach and surgical technique to treat a huge dorsal iatrogenic thermal burn injury. Case: A 4-year-old female German Shepard was referred to veterinary hospital after 11 days of elective ovariosalpingohisterectomy. The patient presented a severe skin injury with crusts, eschars, purulent discharge and myiasis on dorsal cervical, thoracic and lumbar region. Beside severity of the wound, animal present good general status and normal vital signs. Complete blood count and biochemical analysis were within normal ranges. Histopathologic analysis of a wound tissue sample revealed the presence of coagulation necrosis and inflammatory response. The absence of traumatic events, histopathologic result and wound features increased suspicious of an iatrogenic burn injury from a poorly regulated thermal mattress used during surgical intervention. “Rule of Nines” was estimated as 25% of total body surface area. Systemic antibiotics and topical treatment with 0.05% chlorhexidine digluconate and 2.5% silver sulfadiazine ointment followed by wet-wet bandage was performed after initial surgical debridement. Muscle and vertebral bone explosion were evident. Topical treatment with Silver Sulfadiazine and chlorhexidine persisted twice daily until granulation tissue formation. Pain killers and sedation were often necessary during bandage changes. At 65th day proceeded to en bloc excision of scar tissue and surgical reconstruction with skin advancement and recruitment technique. Tie-over dressing was applied to cover the fnal wound. After 14 days animal received hospital discharge, and was assessed bi-weekly for 60 days. Discussion: Besides great extension of the burn injury, patient’s age, absence of systemic involvement and fluid therapy or critical care the prognosis was good. Modifed “rule of nine” are used to estimate wound size in dogs. The wound was classifed as forth degree or full thickness injury due to exposed muscular layer and bone. Early debridement, standard topical and systemic treatment protocol applied granted good recovery of wound bed. Due to be uncommon in small animal routine, main diagnosis and therapeutic recommendations for veterinary patients are based on human data. Systemic antimicrobial drugs are usually not recommended due to low concentration in burned tissues, however, prophylactic use was necessary due to highly infected tissues and possible bacterial absorption from devitalized tissues. Delayed primary closure technique was necessary due to highly infection site and extension, which turns surgical approach hard to perform. After formation of a granulation tissue bed for wound reconstruction, surgical treatment was performed. Surgical reconstruction is indicated in large full thickness defects and for better cosmetic appearance. The correct use and regulation of thermal mattress can avoid burns that can be life threatening. This case report rises the important concept that even low contact temperatures when persistent for long time can cause burn injuries. Keywords: thermal, mattress, injury, dogs, plastic.

Wound Outcome Following Primary and Delayed Primary Skin Closure Techniques After Laparotomy for Non-Traumatic Ileal Perforation: a Randomized Clinical Trial.

To study the effect of primary and delayed primary closure of skin incision on wound outcome in patients with non-traumatic ileal perforation, 68 patients of ileal perforation were studied in a prospective randomized clinical trial. Patients fulfilling inclusion criteria were divided into ileostomy and non-ileostomy groups, both of which were then randomized into two subgroups each depending on whether skin was closed primarily or in a delayed primary manner. Wound infection and dehiscence were the main outcome parameters studied. The data collected was analyzed using appropriate statistical tools taking significant p value at 5%. Most patients were 21-30years of age. Male:female ratio was 3.2:1. The overall incidence of wound infection was 63%. Wound infection was strongly associated with the incidence of superficial wound dehiscence and total wound dehiscence that were 11.76 and 47%, respectively. Mortality was 10.3%. Methodology of wound closure has no significant impact on incidence of wound infection, wound dehiscence, and mortality, although the onset of wound complications is significantly delayed with delayed primary closure of the skin.

Presuturing: A simple technique for excision of large skin lesions

SOLUTION A simple and reliable way to reduce the number of staged excisions and risk of wound dehiscence is the so-called presuturing technique (Figs 1, A and 2, A). Under local anesthesia, multiple nonresorbable sutures (eg, with Ethilon) are placed across the lesion, pulling the edges and folding the adjacent skin over the area that is to be excised (Figs 1, B and 2, B). The sutures should be placed at least 24 hours up to 5 days before excision. The principle behind this technique is the stretching of adjacent skin beyond its inherent extensibility to reach sufficient skin laxity. Thus, reduction of the number of staged excisions or a complete 1-stage excision of the lesion with a standard primary closure technique can be achieved.

A Study of the Outcome of Primary Excision and Closure Technique in the Management of Lip Leukoderma in 30 Patients.

Context:Lips being one of the graceful cosmetic units of the face, any disfigurement, including depigmentation, can be embarrassing, psychologically distressing, and socially stigmatizing. Even with the evolution of various surgical modalities, none of the techniques ensure 100% pigmentation with a good cosmetic appearance. With this background, this study was undertaken to study the efficacy of the technique—primary excision and closure in treatment of lip leukoderma (LL).Aims:To study the efficacy, cosmetic outcome, and recurrence following primary excision and closure technique in the management of LL.Settings and Design:A prospective single-center open-label uncontrolled study.Materials and Methods:Thirty patients with LL involving inner margin of the lower lip and those who fulfilled inclusion and exclusion criteria were included in the study. After obtaining consent and physician fitness, patients were posted for primary excision and closure of the vitiliginous area of the lip. Patients were followed up at the immediate postoperative period and 6 months later. Patient satisfaction scale was done by asking the patient to grade the response between one and ten.Statistical Analysis Used:Mean and percentiles.Results:Out of 30 patients, 29 patients achieved complete clearance that was cosmetically acceptable. Only one patient showed recurrence at the end of 6 months. Average patient satisfaction scale showed an average of 9.66.Conclusions:Primary excision and closure technique is one of the safe, inexpensive modality in the management of LL involving the inner margin of the lip with immediate result.

Primary W-Plasty Closure for Surgical Repair of the Injured Lip.

To describe the results obtained using the primary W-plasty closure technique for the surgical repair of lip defects of traumatic etiology. This study followed both the Declaration of Helsinki on medical protocol and ethics and the Ethical Guidelines of Hospital San Francisco de Asis institutional review board. A retrospective case series study was designed and implemented. The medical status, demographic, etiology, complications, and outcomes associated to the primary W-plasty technique in patients with lip injuries seen at Hospital San Francisco de Asis Oral and Maxillofacial Surgery Department in Quibdó, Colombia between 2010 and 2013 were assessed. Data were collected and analyzed using a statistic package. Eighteen patients were treated, 8 women and 10 men, with ages ranging from 2 to 38 years. Patients presented lip avulsion injuries associated to different etiologies. They underwent surgery under general anesthesia after prophylactic antibiotic therapy and tetanus booster vaccination. Defect repair was performed using the primary W-plasty closure technique, obtaining satisfactory esthetic and functional results. Primary W-plasty closure is a surgical option that allows the safe and practical restoration of the injured lip, even in lesions exceeding 50% of the normal lip.

Randomized prospective comparison of midline and off-midline closure techniques in pilonidal sinus surgery

Pilonidal sinus is a chronic inflammatory disorder of the intergluteal sulcus. The disorder often negatively affects patients' quality of life, and there are numerous possible methods of operative treatment for pilonidal sinus. The aim of our study was to compare the results of 3 different operative procedures (tension-free primary closure, Limberg flap, and Karydakis technique) used in the treatment of pilonidal disease. The study was conducted via a prospective randomized design. The patients were randomized into 3 groups via a closed envelope method. Patients were included in the study after admission to our clinic with pilonidal sinus disease and operative treatment already were planned. The 2 main outcomes of the study were early complications from the methods used and later recurrences of the disease. A total of 150 patients were included in the study, and the groups were similar in terms of age, sex, and American Society of Anesthesiologists scores. The median follow-up time of the study was 24.2 months (range, 18.5-34.27) postsurgery. The recurrence rates were 6% for both the Limberg and Karydakis groups and 4% for the tension-free primary closure group. Therefore, there was no substantial difference in the recurrence rates. The search for an ideal treatment modality for pilonidal sinus disease is still ongoing. The main conclusion of our study is that a tension-free healing side is much more important than a midline suture line. Also, tension-free primary closure is as effective as a flap procedure, and it is also easier to perform.

A comparison of fasciotomy wound closure methods following extremity compartment syndrome at a regional trauma centre

Background Extremity fasciotomy wound closure following acute compartment syndrome is often prohibited by residual swelling, producing wounds that significantly contribute to patient morbidity. The aim of this study was to assess patient and fasciotomy wound outcomes associated with dynamic closure (DYN), delayed primary closure (DPS) and split skin grafting (SSG) techniques.

Multifilament Cable Wire versus Conventional Wire for Sternal Closure in Patients Undergoing Major Cardiac Surgery.

BackgroundStainless steel wiring remains the most popular technique for primary sternal closure. Recently, a multifilament cable wiring system (Pioneer Surgical Technology Inc., Marquette, MI, USA) was introduced for sternal closure and has gained wide acceptance due to its superior resistance to tension. We aimed to compare conventional steel wiring to multifilament cable fixation for sternal closure in patients undergoing major cardiac surgery.MethodsData were collected retrospectively on 1,354 patients who underwent sternal closure after major cardiac surgery, using either the multifilament cable wiring system or conventional steel wires between January 2009 and October 2010. The surgical outcomes of these two groups of patients were compared using propensity score matching based on 18 baseline patient characteristics.ResultsPropensity score matching yielded 392 pairs of patients in the two groups whose baseline profiles showed no significant differences. No significant differences between the two groups were observed in the rates of early mortality (2.0% vs. 1.3%, p=0.578), major wound complications requiring reconstruction (1.3% vs. 1.3%, p>0.99), minor wound complications (3.6% vs. 2.0%, p=0.279), or mediastinitis (0.8% vs. 1.0%, p=1.00). Patients in the multifilament cable group had fewer sternal bleeding events than those in the conventional wire group, but this tendency was not statistically significant (4.3% vs. 7.4%, p=0.068).ConclusionThe surgical outcomes of sternal closure using multifilament cable wires were comparable to those observed when conventional steel wires were used. Therefore, the multifilament cable wiring system may be considered a viable option for sternal closure in patients undergoing major cardiac surgery.

Modified Technique for Primary Dural Closure in the Lateral Suboccipital Approach:Dural Moisturizing with Fibrin Glue Coating

When employing the lateral suboccipital approach, the thin dura shrinks due to the drying effect of illumination and air exposure, and dural substitutes are often needed for closure. We developed a new technique involving dural moisturizing with fibrin glue coating that facilitates primary dural closure. We used this technique in 12 adults who underwent the lateral suboccipital approach for 5 hemifacial spasms, 3 trigeminal neuralgias, 2 cerebellopontine meningiomas, 1 vestibular schwannoma, and 1 vertebral artery aneurysm. Fibrin glue was sprayed on the outer surface before opening the dura, and additionally sprayed on the inner surface of the reflected dural flap after opening the dura. After the intradural procedures the dura was closed with the usual knotted sutures. Dural closure was performed 65-340 minutes (mean: 161.9 minutes) post-durotomy. This technique resulted in primary dural closure with a sufficient area of preserved dura in all but one patient. In this patient, the dura shrank due to coagulation of the dural attachment to the meningioma for which a small autologous substitute was required. There were no procedure-related complications such as cerebrospinal fluid leakage and meningitis. Dural moisturizing with fibrin glue coating is simple, protects the dura from drying and shrinkage, and facilitates primary dural closure in patients undergoing the lateral suboccipital approach.

Outcomes of the house advancement flap for pilonidal sinus.

Many surgical techniques have been described for the treatment of pilonidal sinus, yet rates of recurrence and prolonged wound healing remain high and consensus on the optimal technique is lacking. This retrospective study evaluates outcomes of the use of the house advancement flap in the treatment of pilonidal sinus including time to wound healing, sinus recurrence, wound infection and flap necrosis. Thirty-three consecutive patients who underwent excision and house advancement flap for pilonidal sinus, of whom seven patients (21%) had recurrent pilonidal sinus disease following previous surgical intervention, were reviewed retrospectively. Follow-up ranged from 4 to 59 months (mean 28 months). All 33 patients completed a follow-up survey. Age at time of operation ranged from 14 to 44 years with a mean of 25 years. No patients developed wound infection or flap necrosis. Four patients (12%) failed to achieve primary wound healing; mean time to wound healing for the remaining 29 patients was 62 days. Recurrence of pilonidal sinus occurred in eight patients (24%), at a mean time of 22 months post-operatively. The house advancement flap achieves primary wound closure in almost 90% of cases with few acute post-operative complications. However delayed wound healing and sinus recurrence remain issues with this technique and it appears to have little advantage over other primary closure techniques.