Primary Skin Closure Research Articles

Leaving the Skin Incision Open May Not Be as Beneficial as We Have Been Taught.

Currently, various methods of skin closures are used in contaminated and dirty abdominal wounds without solid, evidence-based guidance. This study investigates whether closure methods affect surgical site infection (SSI) and other incisional complications. We hypothesize that open management of the skin would have the lowest complications, including SSI. Patients age ≥18 who underwent trauma laparotomy (TL) or damage control laparotomy (DCL) from 2008-2013 and had class III/IV wounds were included. Demographic, injury, treatment, and outcome variables were compared based on skin closure methods: Primary closure, intermittently stapled with wicks, or open management. Subgroup analyses for TL, DCL, and high-risk patients with stomach, colon, or rectal injuries were performed. Bivariable and multivariable logistic regression (MLR) analyses were performed to identify risk factors for superficial/deep SSI and surgical incision complications. A total of 348 patients were included. The median age was 47 years; 14% were female; 21% had blunt injuries. Overall SSI was highest for open incisions (p < 0.05), but there was no difference in superficial/deep SSI. Primary closures healed a median of 20 days, compared with 68 and 71 days for the intermittently stapled and open groups, respectively (p < 0.001). Primary closure in TL and high-risk patients also had the lowest SSI rates (all p < 0.05), but there were no differences in superficial/deep SSI in any subgroup. In TL patients, diabetes mellitus and colon injuries were independently associated with the development of superficial/deep SSI and surgical incision complications; however, skin closure method was not. In class III and IV wounds, primary closure was associated with the lowest SSI, shortest length of stay and healing time. Method of skin closure, however, did not have an independent effect on the development of superficial/deep SSI or surgical incision complications. These suggest that primary skin closure in contaminated and dirty abdominal wounds may be performed more safely than commonly perceived.

Reconstructive surgery of the amputated ring finger.

Loss of a fourth digit below the level of the proximal phalanx results in a weakened grip, loss of skilled movements, and the amputation stump is repeatedly traumatized. Transposition of an adjacent fifth digital ray can improve hand function and cosmetic appearance by closing the gap created by the missing digit. Digital ray amputation is not a commonly performed procedure. However, when performed correctly it can dramatically improve hand function and cosmesis. The aim of this study was to evaluate the functional and aesthetic results of the fifth ray radial translation and intercarpal arthrodesis in mutilating ring finger injuries. In this retrospective study, nine consecutive patients who sustained mutilating ring finger injury were managed by fourth ray amputation with fifth ray transposition between January 2008 and December 2014. There were six males and three females with a mean age of 30.2 ± 12.2years (age range, 16-56years) at the time of surgery who underwent delayed fourth ray amputation with fifth ray transposition (after 14days of injury). Eight cases had undergone previous surgical interventions: three ORIF using intramedullary K-wire fixation, one failed reimplantation, four debridement and application of split thickness skin graft. Primary skin closure of the amputated finger was not considered as previous surgery (one patient). All patients were followed up for a mean period of 17.1 ± 4.1months (range, 12-24months). Grip strength and RAS score improved after fourth ray resection. The postoperative grip strength and RAS (score) were not compromised by the associated hand dominance. The following conclusions can be made despite the fact that this was a limited study as well as a retrospective analysis: 1-In technical terms, resection of the fourth ray with transposition of the small finger with a wedge-shaped hamate-capitate arthrodesis secured by screw fixation is easier than metacarpal osteotomy/transposition and less liable to post-operative complications. 2-The results of this study suggest that fourth ray resection and transposition of the small finger with a hamate-capitate arthrodesis restores hand function and cosmetics.

Plate fixation in the treatment of complex forearm open fractures

Objectives: We aimed to evaluate the safety and outcomes of plate-screw fixation used for the immediate treatment of type-IIIC open fractures of forearm bones with complex soft tissue injuries. Methods: A total of 22 patients (mean age: 31.6, range: 24-60) treated between 2004-2010 were retrospectively analyzed. All injuries resulted from high-energy traumas and fractures were classified using AO classification. All patients had vascular and nerve injuries, and four had skin defects associated with double fractures of the forearm. All patients were operated on within the first eight hours following injury. Six patients with comminuted fractures or with bone defects underwent primary bone grafting, and one patient was treated with shortening. Primary skin closure was achieved in 17 patients and three patients underwent immediate repair using skin grafts, while two patients were repaired with immediate transposition flaps. Bony unions, complications, and functional results via a DASH questionnaire were investigated. Results: Mean follow-up was 28 months (range: 14-70). In all patients, radius bone union was achieved. Two patients underwent a Sauve-Kapandji procedure, utilizing the fractured segment of the ulnar diaphysis as a graft for radius. In one patient, osteosynthesis was repeated after 6 months because of nonunion. Mean period to bony union was 4.59 months (range: 3-6). Superficial infection developed in three patients after the operation, and was resolved with antibiotic therapy. The mean DASH score after surgery was 25.6. Conclusion: In high nergy traumas of the upper extremity associated with complex injuries and Type-IIIC forearm fractures, severity of soft tissue injuries determined the functional results in patients, demonstrating it is possible to achieve a safe and efficient fixation with immediate plate-screw osteosynthesis.

Comparative Study of Primary Skin Closure with Adhesive Skin Glue and Conventional Suture Material in Clean Elective Surgery

Comparative Study of Primary Skin Closure with Adhesive Skin Glue and Conventional Suture Material in Clean Elective Surgery

Temporary Relocation of the Testes in Anteromedial Thigh Pouches Facilitates Delayed Primary Scrotal Wound Closure in Fournier Gangrene With Extensive Loss of Scrotal Skin-Experience With 12 Cases.

To share our experience on the use of temporary testicular thigh pouches to facilitate scrotal wound closure in Fournier gangrene with extensive loss of scrotal skin. Patients seen over a 10-year period who had extensive (>50%) loss of scrotal skin precluding delayed primary closure of the residual scrotal skin over the testes were documented. Patients had serial debridement as required with scrotal wound dressing until healthy granulation tissue was achieved. The testes were placed temporarily in anteromedial thigh pouches to allow for scrotal wound closure. In the postoperative period, the testes were gradually massaged back into the residual scrotal pouch, thus acting as natural tissue expanders. Mean patient age was 38.1 ± 10.0 years. Mean duration of admission was 24.4 ± 4.7 days. Identified predisposing factors were ischiorectal fossa abscess in 2 patients and urethral stricture in 1 patient. The rest were idiopathic. Mean Fournier gangrene severity index was 6.0 ± 1.3. Mean number of debridements was 2.3 ± 0.5. There was no mortality. The residual scrotal pouches expanded sufficiently over time (3-8 months) to accommodate the testes. Normal testicular volume was maintained in all patients. Mean testicular volume was 19.0 ± 3.2 cm. Follow-up was for 14.8 ± 9.7 months. Temporarily relocating the testes in anteromedial thigh pouches facilitates scrotal wound closure in Fournier gangrene with extensive loss of scrotal skin and obviates the need for specialized reconstructive surgery.

A new technique to close open abdomen using negative pressure therapy and elastic gums

‘‘Open abdomen’’ is a routine surgical procedure in patients presenting with abdominal compartment syndrome, polytrauma requiring a second look and abdominal sepsis. In these cases, free access to the abdominal cavity may be necessary to drain fluid collections or to solve postoperative complications [1–3]. Several techniques for temporary abdominal closure have been described in the literature, but we observe a lack of experience as regards definitive closure techniques [4]. Here we present a kit which combines the use of a mesh, negative pressure therapy and elastic gums to attain definitive closure of the open abdomen in patients requiring a previous temporary closure and in whom it is impossible to accomplish primary closure of abdominal fascia, subcutaneous tissue and skin.

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.

Closure of Myelomeningocele Defects Using a Limberg Flap or Direct Repair.

BackgroundThe global prevalence of myelomeningocele has been reported to be 0.8–1 per 1,000 live births. Early closure of the defect is considered to be the standard of care. Various surgical methods have been reported, such as primary skin closure, local skin flaps, musculocutaneous flaps, and skin grafts. The aim of this study was to describe the clinical characteristics of myelomeningocele defects and present the surgical outcomes of recent cases of myelomeningocele at our institution.MethodsPatients who underwent surgical closure of myelomeningocele at our institution from January 2004 to December 2013 were included in this study. A retrospective chart review of their medical records was performed, and comorbidities, defect size, location, surgical procedures, complications, and the final results were analyzed.ResultsA total of 14 patients underwent surgical closure for myelomeningocele defects. Twelve cases were closed with direct skin repair, while two cases required local skin flaps to cover the skin defects. Three cases of infection occurred, requiring incision and either drainage or removal of allogenic materials. One case of partial flap necrosis occurred, requiring secondary revision using a rotational flap and a full-thickness skin graft. Despite these complications, all wounds eventually healed completely.ConclusionsMost myelomeningocele defects can be managed by direct skin repair alone. In cases of large defects, in which direct repair is not possible, local flaps may be used to cover the defect. Complications such as wound dehiscence and partial flap necrosis occurred in this study; however, all such complications were successfully managed with simple ancillary procedures.

Sessile fibrolipomas: A case report

To report a case of multiple sessile fibrolipomas of the lower dorsal trunk. A 27-year-old female patient presented with multiple, broad-based fibrolipomas of the lower dorsal trunk. The lesions were excised with primary skin closure. The histopathological diagnosis was fibrolipoma. Fibrolipomas are rare tumours. Excision with skin cover, either primary or secondary, is the treatment of choice.

A precancerous saree lesion: a rare occurrence

&lt;p class="abstract"&gt;&lt;span lang="EN-US"&gt;Skin cancers are relatively uncommon malignancies; their incidence in India being less than 1% of all cancers. The incidence of malignancy in scar tissues is 0.1-2.5%. Squamous cell carcinoma of skin is second most common amelanotic malignancy next to basal cell carcinoma. The occurrence of this disease is noticed in various parts of the body but waist line skin is not a common site. Saree is a type of female costume and dhoti is a male costume which is unique to the Indian subcontinent. The persistent and long term wearing of this costume results in depigmentation and glazing of the skin, acanthosis, dysplasia, scar and ulceration and subsequent, but very slow, malignant changes. The exact mechanism of the malignant transformation is unknown, but recurrent trauma over a long period with consequent interference with the healing process is a possible explanation. We are presenting a rare case of left flank ulcero-proliferative growth in a 75 year old woman. Wide excision with primary skin closure was done. Histopathology showed pseudoepitheliomatous hyperplasia with marked dysplasia without microinvasion. It is a premalignant lesion. The case needs its reporting due to its rarity. Awareness of saree cancer among Indians is important to prevent malignant lesions at waistline. Multimodality management with surgery, chemotherapy and radiotherapy is ideal for good outcome.&lt;/span&gt;&lt;/p&gt;

OC-100 Lorec registry–interim analysis of operative technique and perineal wound healing outcomes after abdomino-perineal excision

Introduction The LOREC perineal wound healing registry was developed to record data on abdomino-perineal excision (APE) for rectal cancer in colorectal units across the UK between 2012 and 2014 to understand current practice in operative techniques and patient outcomes. Initial interim results are reported. Method Surgeons wishing to participate received secure web-based access to the registry. Collected data included pre-operative staging, operative details, pathology, early outcome and follow-up at 12 months. Results Overall 43 units entered a total of 259 patients undergoing APE. These included 168 extralevator APE (ELAPE) procedures (65%) and 91 non-ELAPEs, comprising 73 ‘standard’ APE, 9 intersphincteric, 2 ischio-anal and 7 unspecified procedures. The ELAPE and non-ELAPE groups are compared. In the ELAPE group there were 120 males (71%) with a median age of 66 years (range 38–93). In the non-ELAPE group there were 64 males (70%) with a median age of 68 years (range 32–97). The perineal component was performed prone in 151 (90%) of the ELAPE group versus 13 (14%) of the non-ELAPE group. The coccyx was removed in 123 (73%) of the ELAPEs and 7 (8%) of the non-ELAPEs. In the ELAPE group primary skin closure for the perineal component was performed in 119 (71%) while in 34 (20%) a flap was used (13 VRAM, 9 local myocutaneous and 12 fascio-cutaneous flaps). In 15 cases (9%) the surgeons reported no closure. In 111 (66%) a mesh, generally biological, was used in perineal closure. Mesh was most commonly used where the closure was primary but 9 flap closures also used mesh. In the non-ELAPE group primary closure was more common, being used in 76 (84%) while in 5 (5%) a flap was used. In 10 cases (11%) the surgeons reported no closure. Mesh was used less frequently in non-ELAPEs, with only 30 (33%) using a mesh; the majority (57%) of these were non-biological. Primary healing was achieved in 29% of ELAPE patients, the majority of whom were closed primarily, compared to 9% in the non-ELAPE group. There was no difference in wound healing by 4 weeks and both groups had a small number of patients who took more than 3 months to heal completely. There was no significant difference in length of hospital stay for the two groups. There was one post-operative death in each group; a peritonitis of unknown cause in the ELAPE group and a GI bleed in the non-ELAPE group. Conclusion The LOREC registry has been a success in providing a summary of current practice and will be valuable in informing the design of future trials assessing APE techniques and reconstruction. In this series, ELAPE is performed in the majority of patients and primary closure with mesh appears to offer effective skin closure compared to flap. Disclosure of interest None Declared.

Prospective comparison of primary wound closure with tissue- adhesive versus suture materials

Background and Objectives: Nowadays the final outcome of wound closure using tissue adhesives and suture material is making a real competition for better results. Cosmetic outcome is regarded as the first demand for the patients. The aim of this study was to make a comparison between the two closure methods in terms of cosmetic outcome, complication and patients’ satisfaction. Method: A prospective comparative study was conducted at Rizgary Teaching Hospital and West Erbil Emergency Hospital in Erbil city from March 2012 to March 2013. A total of 105 patients were included in the study. The method of closure was selected alternatively between tissue adhesive (octylcyanoacrylate) and suture material. Analysis for cosmetic outcome, complications and patients’ satisfaction were done using the statistical package for the social sciences (version 19). Results: The complications were 25% (13 patients) in the tissue adhesive group and 18% (9 patients) in the sutured group. Of the 44 patients in the tissue adhesive group, 86.4% (38 patients) were satisfied; while of the 61 patients in the sutured group, 88% (54 patients) were satisfied with the end result. Excellent cosmetic outcome achieved in 77.3% in the tissue adhesive group and 80.3% in the sutured group. Conclusion: Tissue adhesive (octylcyanoacrylate) is effective and reliable in primary skin closure, yielding similar cosmetic results to standard suturing method. Tissue adhesive is faster and offers several practical advantages over suture repair.

Reconstruction of Large Perineal and Pelvic Wounds Using Gracilis Muscle Flaps.

The reconstruction of large defects after abdominoperineal resections and pelvic exenterations has traditionally been accomplished with vertical rectus myocutaneous flaps (VRAMs). For patients requiring two ostomies, robot-assisted abdominoperineal resections (APRs), and to avoid the morbidity of a VRAM harvest, the authors have used the gracilis muscle flap to reconstruct the large dead space in these patients. A retrospective analysis of 16 consecutive APRs (10 with concomitant pelvic exenterations) reconstructed with gracilis flaps during a 2-year period was performed. Gracilis muscle flaps were used to obliterate the dead space after primary skin closure was ensured with adduction of the legs. All 16 patients had locally advanced cancers and had received neoadjuvant chemotherapy and radiation. Of these 16 patients, 10 had pelvic exenterations. All the patients had reconstruction with gracilis flaps (6 bilateral flaps). One major wound complication in the perineum occurred as a result of an anastomotic leak in the pelvis, but this was managed with conservative dressing changes. Three patients had skin separation in the perineum greater than 5 mm with intact subcutaneous closure. No patients required operative debridement or revision of their perineal reconstruction. No perineal hernias or gross dehiscence of the skin closure occurred. Large pelvic and perineal reconstructions can be safely accomplished with gracilis muscle flaps and should be considered as an alternative to abdominal-based flaps.

Comparison between stainless steel staples and silk sutures for primary closure of skin in patients undergoing neck dissection: A comparative clinical study.

Introduction:Comparison between stainless steel staples and silk sutures for primary closure of skin in patients undergoing neck dissection, in context of rapid application, approximation of the skin edges, economy and aesthetics of the resultant scar.Aim:(1) To compare surgical stainless steel staples and silk sutures for primary wound closure, with respect to presence/absence of wound infection and dehiscence (2) To compare the resultant scar following the two different methods of the closure at 3rd month postoperatively with the help of visual analog scale and analyze the result statistically Design: This study was designed to compare skin closure using staples and silk sutures in patients undergoing neck dissection, using both methods in one-half of the same wound; thus each wound affording its own control.Materials and Methods:The study was conducted on patients requiring collar line incision (high submandibular incision) with or without a cephalad extension of midline lower lip split incision for surgical access, who presented to the Department of Oral and Maxillo-Facial Surgery. (1) Sample size: 10 (2) Study design: Prospective Comparative study (3) Study duration: One and half years (4) Surgical stainless steel staples: Proximate Plus MD 35 W, Ethicon Endo Surgery (5) Sutures: 3–0 Ethiprime NW 5003, Non-Absorbable Surgical Suture, Mersilk-90 cm, Ethicon, (16 mm 3/8 circle cutting needle).Conclusion:It was concluded that there is no significant difference between the scars observed in the regions of incision which underwent primary closure by two different methods, that is surgical stainless steel staples and 3–0 Mersilk Sutures.

Limited dissection and early primary closure of the tracheostomy stoma in head and neck oncology operations: a retrospective study of 158 cases

Tracheostomy is an efficient and widely used method to secure a patent airway in patients undergoing major oral and maxillofacial oncology operations. The inferiorly based Björk flap technique, through a limited incision, followed by early primary skin closure, has been the preferred method in our unit. Patients who underwent tracheostomy for major oral and maxillofacial oncology operations during the period June 2005 to December 2012 were reviewed. Age, gender, preoperative diagnosis, duration the tracheostomy tube was in situ, tracheostomy-associated complications, and long-term sequelae were evaluated. A total 158 tracheostomies were performed using the same surgical approach in patients aged 18–84 years (median 59, mean 58.2, standard deviation 14.24 years). The time the tracheostomy tube was in situ ranged from 3 to 40 days (median 7, mean 9.0, standard deviation 6.52 days). The complication rate was 5.06% (8/158 patients). A major concern highlighted in previous publications is the risk of surgical emphysema with early closure. In this study, no patients developed surgical emphysema, tracheal fistula, clinical tracheal stenosis, or cosmetically unacceptable scarring of the neck. No patient died of a tracheostomy-related cause. In summary, the Björk flap with early primary closure of the skin by simple sutures provides a safe and easily managed approach, causing minimal postoperative morbidity.

Primary skin closure after damage control laparotomy (Br J Surg 2015: 102: 67-75).

Primary skin closure after damage control laparotomy (Br J Surg 2015: 102: 67-75).

Risk factors for surgical site infection in emergency colorectal surgery: a retrospective analysis.

Since 2005, we have been conducting prospective surgical site infection (SSI) surveillance and infection control according to the U.S. Centers for Disease Control and Prevention guidelines for patients who undergo gastrointestinal surgery at our institution. Surgical site infection occurs with greater frequency in emergency than in elective surgery because of factors such as ill-conceived preoperative preparation and "dirty" operations. A large number of studies have been reported on risk factors for SSI in elective colorectal surgery; however, there are few papers on such factors in emergency colorectal surgery. The aim of this study was to identify risk factors for incisional SSI in emergency colorectal surgery. Using our SSI surveillance database, we analyzed retrospectively 78 patients who underwent emergency colorectal surgery between 2005 and 2010. Univariable and multivariable analyses were used to identify risk factors for incisional SSI. Moreover, we subclassified dirty-infected operations (class IV) by the extent of contamination according to our own definition to study the incidence of incisional SSI at each degree. The incidence of incisional SSI was 32.1% (25/78 patients). By univariable analysis, seven parameters correlated with a higher risk of incisional SSI: Surgical incision class III-IV, obesity (body mass index ≥25 kg/m(2)), American Society of Anesthesiologists score 3 or 4 points, chronic kidney disease (serum creatinine concentration >1.2 mg/dL), blood loss ≥200 mL, blood transfusion, and ventilator support. Multivariable analyses showed that surgical incision class III-IV (odds ratio [OR] 5.9; 95% confidence interval [CI] 1.7, 25.2) and obesity (OR 11.9; 95% CI 2.1, 87.8) were independent risk factors for incisional SSI. The incidence of incisional SSI in colon perforation with generalized contamination was statistically higher than that in prepared colon perforation and colon perforation with localized contamination (82.4% vs. 25.0%; p<0.001). The risk factors for incisional SSI in emergency colorectal surgery were incision contamination and obesity. Moreover, the incidence of incisional SSI among the incision class IV operations increased significantly with increasing extents of contamination. As a tactic for management of dirty abdominal wounds, we suggest that primary skin closure is suitable in cases of perforation of a prepared colon or colon perforation with localized contamination. On the other hand, in cases of colon perforation with generalized contamination, delayed primary skin closure or leaving an incision open to heal by secondary intention should be considered.

Delayed Wound Closure Increases Deep-Infection Rate Associated with Lower-Grade Open Fractures

Primary closure of skin wounds after debridement of open fractures is controversial. The purpose of the present study was to determine whether primary skin closure for grade-IIIA or lower-grade open extremity fractures is associated with a lower deep-infection rate. We identified 349 Gustilo-Anderson grade-I, II, or IIIA fractures treated at our level-I academic trauma center from 2003 to 2007. Eighty-seven injuries were treated with delayed primary closure, and 262 were treated with immediate closure after surgical debridement. After application of a propensity score-matching algorithm to balance prognostic factors, 146 open fractures (seventy-three matched pairs) were analyzed. After application of a propensity score-matching algorithm with adjustment for age, sex, time to debridement, American Society of Anesthesiologists (ASA) class, fracture grade, evidence of gross contamination, and a tibial fracture rather than a fracture at another anatomic site, the two treatment groups were compared with respect to the prevalence of infection. Deep infection developed at the sites of three of the seventy-three fractures treated with immediate closure (infection rate, 4.1%; 95% confidence interval [CI], 0.86 to 11.5) compared with thirteen in the matched group of seventy-three fractures treated with delayed primary closure (infection rate, 17.8%; 95% CI, 9.8 to 28.5) (McNemar test, p = 0.0001). Immediate closure of carefully selected wounds by experienced surgeons treating grade-I, II, and IIIA open fractures is safe and is associated with a lower infection rate compared with delayed primary closure.

Retrospective Study of Demographic, Etiological Factors, Clinical Outcome and Postoperative Complications Encountered In Tendon Achilles Injury

Injury to tendoachilles are common following sports, road traffic accidents, fall in Indian lavatory pan etc. Direct repair was done with prolene or stainless steel wires with primary closure of skin. Complications ranged from minor to deep tissue infection and persistent steel wire. This is a retrospective study of acute tendo Achilles injury, managed in SHIMOGA INSTITUTE OF MEDICAL SCIENCES during September 2012-13. It is a study of demographic, etiologic factors, clinical outcome and postoperative complications encountered.

Systemic review and meta-analysis of randomised controlled trials comparing primary versus delayed primary skin closure in contaminated and dirty abdominal incisions

Systemic review and meta-analysis of randomised controlled trials comparing primary versus delayed primary skin closure in contaminated and dirty abdominal incisions