Comparing Wound Closure Techniques in Laparoscopic Surgery: Tissue Adhesive Versus Standard Sutures

MAY 25, 2007

The authors compared a tissue adhesive with Monocryl? suture closure in laparoscopic incisions. Several parameters were compared and the evaluations were made by the patient, a nurse, and a surgeon. A single horizontal mattress of 4-0 Monocryl gave the best aesthetic results. This is a good study evaluating one of the parameters of laparoscopic surgery, namely, a better cosmetic appearance, which is a good cosmetic outcome that is not solely based on the length of the incision. We are all convinced that smaller incisions produce better cosmetic results, however, this study shows that the method of closure is also important and that a simple horizontal Monocryl suture is better than a tissue adhesive. The study did not compare costs of each closure method, but the authors reference a study that showed that tissue adhesive was more costly when closing small incisions. Tissue adhesives could be less costly in wound closure for larger incisions when more time is required for suture closure. This study reinforces the concept that there is still a role for suture closure of small laparoscopic incisions and that the aesthetic results are very good.

Thomas Gadacz, MD,
Series Guest Editor, Professor and Chairman, Department of Surgery, Medical College of Georgia, Augusta, GA

Azul S. Jaffer, MD
PGY-4 Resident in General Surgery Berkshire Medical Center

Eric K. Osborne, DO

PGY-2 Resident in General Surgery Berkshire Medical Center

Robert D. Fanelli, MD

Director of Surgical Endoscopy Berkshire Medical Center Pittsfield, MA Director of Minimally Invasive Surgery and Surgical Endoscopy Surgical Specialists of Western New England, PC Pittsfield, MA

Currently, 2-octyl cyanoacrylate tis?sue adhesive (Dermabond?) is being used in various clinical settings, such as for closure of lacerations, cleft lip repairs, or for performing co?lonic anastomoses experimentally in rats.1-3 Few studies have evaluated its use in closing surgical incisions, such as 5-mm laparoscopic port sites.4-7 As the number of laparoscopic surgical procedures performed continues to increase, and as the number of small trocars used increases, surgeons must determine the most efficient wound closure technique that also offers patient satisfaction. We compared wound healing for three skin closure techniques applied to 5-mm laparoscopic port sites, including Der?mabond tissue adhesive, a single intracuticular horizontal mattress suture using 4-0 Monocryl?, or a running intracuticular suture closure using 4-0 Monocryl.

Methods
Informed consent for study participation was obtained from 40 consecutive patients scheduled for various laparoscopic operations between August 2003 and November 2003. There were a total of 177 incisions for 5-mm laparoscopic port sites, and patients were randomized to one of three skin closure techniques; tissue adhesive, a single intracuticular horizontal mattress suture, or a running intracuticular suture. Fifty-nine incisions were closed using tissue adhesive, 60 were closed using a single intracuticular horizontal mattress suture, and 58 were closed with running intracuticular sutures. Laparoscopic procedures included 17 Nissen fundoplications, 15 cholecystectomies, three enterolysis for small bowel obstruction, three right hemicolectomies, one low anterior resection, and one ventral hernia repair (Table). The surgical technologist randomly assigned the method of skin closure before creating the incisions at the start of each procedure. For procedures that required more than three incisions, all 5-mm incisions were randomized; thus, a patient undergoing a procedure requiring at least three incisions may have had each incision closed using a different technique. Local anesthetic was infiltrated before making any incisions. Each patient served as his or her own control. The surgeon was blinded to the closure method for each incision until the end of the operation. Once closed, all wounds were dressed using Tegaderm?, and these dressings were removed by patients 5 days later.

A standardized data collection form was initiated during surgery and data were en?tered during each postoperative visit by the patient, a registered nurse, and the attending surgeon. These data were analyzed for trending patterns and for statistical difference using confidence intervals. All patients were seen 14 days post??operatively. Wounds were evaluated for overall patient satisfaction, aesthetic re??sults, and postoperative discomfort. In?cisions for tro?cars larger than 5 mm and counter incisions used for specimen retrieval during laparoscopic bowel sur?gery were ex?cluded from consideration.


Results
? Overall patient satisfaction?The single intracuticular horizontal mattress suture closure was deemed the most satisfactory method of wound closure by 53.3% of patients, by the attending surgeon in 58.5% of incisions, and by registered nurses in 63.4% of incisions. The running intracuticular suture closure was considered most satisfactory by 36.7% of patients, by the attending surgeon in 31.7% of incisions, and by registered nurses in 26.8% of incisions. Closure with tissue adhesive was judged most satisfactory by 10.0% of patients, by the attending surgeon in 9.8% of incisions, and by registered nurses in 9.8% of incisions. The least satisfactory method of wound closure was tissue adhesive, as rated by 69.2% of patients, by the attending surgeon in 78.4% of incisions, and by registered nurses in 72.7% of incisions. There was agreement among the groups evaluating all three wound closure methods, with no statistically significant differences between any one closure method and the decisions made by patients, surgeons, or registered nurses. In overall sa?t?isfaction, the superiority of wound closure with a single intracuticular hori?zontal mattress suture was statistically significant (P < .05) as compared with the other methods. No significant difference was evident between the running intracuticular closures and the tissue adhesive closures.

Distribution of the 177 consecutive 5-mm trocar incisions studied
Laparoscopic procedure Procedures (n) Total incisions (n)
Nissen fundoplications 17 100
Cholecystectomy 15 45
Enterolysis 3 15
Right hemicolectomy 3 9
Low anterior resection 1 4
Ventral hernia repair 1 4
Table

? Aesthetic results?Closure using the single intracuticular horizontal mattress suture was reported to have yielded the best appearance by 60% of patients, by the attending surgeon in 58.5% of incisions, and by registered nurses in 63.4% of incisions. The running intracuticular suture closure was considered to have resulted in the best cosmetic result by 31.4% of patients, by the attending surgeon in 31.7% of incisions, and by registered nurses in 29.3% of incisions. Tissue adhesive was judged most satisfactory by only 8.6% of patients, by the attending surgeon in 9.8% of incisions, and by registered nurses in 7.3% of incisions. Thus, as with overall satisfaction, tissue adhesive received the poorest rating for appearance and was deemed to have resulted in the worst appearing wound closures by 69% of patients, by the at?tending surgeon in 79.5% of incisions, and by the registered nurses in 75.8% of incisions. There was statistical agreement among each closure type. The inferior cosmetic result of wound closures ac?complished with tissue adhesive was statistically significant (P < .05) compared with the suture closures studied.

? Postoperative discomfort?While 34.4% of patients reported no pain at their 5-mm trocar incision sites, 28.1% of patients reported that incisions closed with tissue adhesive were the most painful. The running intracuticular closure was cited as most painful by 21.9% of patients, with only 15.6% of patients reporting that the most pain resulted from the single horizontal mattress su?ture closure.

Discussion
Tissue adhesive is being used with increasing frequency to close surgical and traumatic wounds. Few studies have evaluated its effectiveness in closing small surgical incisions such as 5-mm laparoscopic port sites. As the number of laparoscopic surgical procedures performed continues to increase, and as surgeons increasingly use smaller trocars, the most efficient and acceptable wound closure technique must be identified.

In our study, patients served as their own controls to permit comparison of three wound closure methods applied to 5-mm laparoscopic trocar site incisions created during various procedures. The wound closure methods studied included tissue adhesive, a single intracuticular hori?zontal mattress suture, or a running intracuticular suture. Patients, registered nurses, and the operating surgeon all reported that wound closure using a single intracuticular horizontal mattress suture was associated with the highest overall satisfaction and yielded superior wound aesthetics. Tissue adhesive was associated with the lowest overall satisfaction and the poorest cosmetic outcomes. No statistically significant difference in operative site pain was identified between the three methods of wound closure studied. Incisional pain was poorly correlated with both the method of skin closure and the location of the incision in our study.

Few publications have compared both objective and subjective outcomes associated with different wound closure methods for laparoscopic incisions. Most existing works comparing tissue adhesive with monofilament suture closures have studied time and economic efficiency rather than patient satisfaction and wound aesthetics. Matin and colleagues identified no significant difference in overall patient satisfaction when comparing tissue adhesive and traditional suture methods of wound closure.5 Our data demonstrated a significantly higher level of overall satisfaction from wound closure using a single intracuticular horizontal mattress suture, but did not indicate a statistically significant difference in postoperative discomfort associated with the method of wound closure. Since patient satisfaction surveys routinely given to postoperative patients seek to assess levels of pain and the effectiveness of treatment, the study of pain associated with various wound closure methods is an area ripe for further investigation. We identified no other studies during our Medline search that comparatively studied wound closure methods for associated discomfort.

Several authors have studied the aesthetic outcome associated with various wound closure methods when applied to laparoscopic incisions.4,5,7 Szyllo and associates concluded that tissue adhesive yielded acceptable cosmetic results when compared with sutured wound closures.7 Switzer and colleagues concluded that suture closures were more aesthetically pleasing than tissue adhesive closures, although their study did not achieve statistical significance in reaching this conclusion.8 Our study identified with statistical significance that the single in?tracuticular horizontal mattress closure resulted in the best wound appearance, while tissue adhesive was consistently associated with the worst appearing wounds as determined by patients, registered nurses, and the operating surgeon.

Time efficiency of wound closure has been the central focus of many studies investigating the use of tissue adhesive.4-6,8 There is agreement among authors that tissue adhesive affords surgeons quick wound closure. While not evaluated directly in our study, our observations support the numerous published articles demonstrating the rapidity of tissue adhesive closures. Our preferred wound closure technique, however, is a single horizontal mattress suture, which is rapidly employed and ensures excellent skin edge approximation. The needle is introduced into the dermis and then exits the dermis one third of the way in from each corner of the incision before crossing over to the other side of the wound (Figure).

Several studies evaluated the cost of wound closure using various methods.4-6 Maartense and colleagues and Matin con??cluded that tissue adhesive closures are not cost-effective due to the materials acquisition cost compared with suture closures.4,5 Sebesta and Bishoff evaluated the amount of operating room time saved by using tissue adhesive and concluded that this method reduced costs by shortening operative times for closure of their incisions that averaged 44 mm in length.6 While our study did not address the issue of cost, we noted no difference in time required for closure of 5-mm laparoscopic trocar incisions in our patients regardless of the method used. We find it impossible to infer that any of the closure methods we used could be associated with substantial time savings and, therefore, cost savings. Since tissue adhesive is more costly to acquire than monofilament sutures, it is likely to be more costly than traditional suture closure methods, especially compared with the rapidly performed single horizontal mattress closure that patients, registered nurses, and the operating surgeon found to be superior overall; however, we agree that there may be cost savings with tissue adhesive when closing larger wounds.

While we realize that an evaluation of incisions 2 weeks after surgery may not be an indicator of the final appearance, it is an indicator of patient satisfaction. Patients undergoing laparoscopic procedures resume full activities early on and, therefore, are looking for more immediate results. While we tell all patients that incisional remodeling occurs for up to a year after surgery, most comment on the appearance of their incisions during the 2-week follow-up visit. Rarely do we have the opportunity to see patients after this examination, and while most patients are ultimately satisfied with their incisional healing, their early postoperative impression is the most important one.

Based on our results, we recommend closing 5-mm laparoscopic trocar incisions with a single intracuticular horizontal mattress suture rather than a tissue adhesive. This closure resulted in a superior aesthetic result and the highest level of overall satisfaction.

Conclusion
Tissue adhesive is presently being used in various clinical settings for closure of minor lacerations. In our study, 5-mm laparoscopic port site incisions were closed using a tissue adhesive, a single intracuticular horizontal mattress suture, or a running intracuticular suture. In?cisions were evaluated for overall satisfaction, aesthetic results, and postoperative discomfort. Patients, registered nurses, and the operating surgeon agreed with statistical significance that single intracuticular horizontal mattress suture closures yielded superior aesthetic results and the greatest overall satisfaction.

References
1. Bernard L, Doyle J, Friedlander SF, et al. A prospective comparison of octyl cyanoacrylate tissue adhesive (Dermabond?) and suture for the closure of excisional wounds in children and adolescents. Arch Dermatol. 2001;137(9):1177-1180.

2. Kanellos I, Mantzoros I, Demetriades H, et al. Sutureless colonic anastomosis in the rat: a randomized controlled study. Tech Coloproctol. 2002;6(3):143-146.


3. Magee WP Jr, Ajkay N, Githae B, et al. Use of octyl-2-cyanoacrylate in cleft lip repair. Ann Plast Surg. 2003;50(1): 1-5.

4. Maartense S, Bemelman WA, Dunker MS, et al. Ran?domized study of the effectiveness of closing laparoscopic trocar wounds with octylcyanoacrylate, adhesive papertape or poliglecaprone. Br J Surg. 2002;89(11):1370-1375.

5. Matin SF. Prospective randomized trial of skin adhesive versus sutures for closure of 217 laparoscopic port-site incisions.J Am Coll Surg. 2003;196(6):845-853.


6. Sebesta MJ, Bishoff JT. Octyl cyanoacrylate skin closure in laparoscopy. JSLS. 2004;8(1):9-14.

7. Szyllo K, Wlodarczyk B, Krekora M, et al. Application of skin glue in wound repair after laparoscopy [in Polish]. Ginekol Pol. 2002;73(6): 567-570.

8. Switzer EF, Dinsmore RC, North JH Jr. Subcuticular closure versus Dermabond?: a prospective randomized trial. Am Surg. 2003;69(5): 434-436.

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