Clinical comparison of surgical wounds closed by suture and adhesive tapes

SCIENTIFIC

PAPERS

Clinical Comparison of Surgical Wounds Closed by Suture and Adhesive Tapes W. BRUCE CONOLLY, F.R.C.S., San Francisco, California THOMAS K. HUNT, M.D., San Francisco, BENGT ZEDERFELDT, M.D.,*

California

San Francisco,

California

H. TREAT CAFFER’ATA, ‘M.D., San Francisco,

California

J. ENGLEBERT DUNPHY, M.D., San Francisco,

Advances in anesthesia and surgery have not been paralleled by advances in the treatment of wound problems. Skin closure is one of many factors that are involved. Suture closures with suture canals, foreign material, areas of tension, and ischemia have been shown experimentally to have a higher complication rate than nonsurgical closure. Recently, Edlich et al. [I] showed that wound infection was much more likely to develop in moderately contaminated wounds closed by suture in experimental animals than in those closed by nonsuture technics. This paper analyzes complications of surgical wounds closed by adhesive tapesf and by sutures. The problems and difficulties associated with tape closure of wounds are also analyzed. Material and Methods From June 1967 through February 1968 the two general surgical services at th’e San Francisco General Hospital alternated every two months in closing wounds by suture and by adhesive tapes. Sixteen surgeons participated; and a total of 428 wounds were analyzed, of which 161 were closed by tapes and 267 by conventional suture. The wounds were mostly abdominal. Wounds around

From the Departments of Surgery, University of California School of Medicine, and San Francisco General Hospital, San Francisco, California. *Present Sahlgrenska

Address: Department of Sjukhuset. Gothenberg,

Surgery, Sweden.

Kir.

Klin.

Steri-Strip@, manufactured by the Minnesota Mining and Manufacturing Co., St. Paul, Minnesota. t

318

I,

California

the hairy regions and perianal region were excluded from the survey. Analysis cards listing 236 data points relevant to wound healing were completed for each patient. Wounds were classified as clean, clean-contaminated, or contaminated depending on the inevitability or avoidability of contamination by organisms or any tissues adjacent to the wound. Wounds with access to a hollow viscus, as in a cholecystectomy, were said to be clean-contaminated. A contaminated wound was one whose surfaces were contacted by pus or known infected fluid during the course of the operation or the making of the incision, as for example, in operations for peritonitis. Infected wounds in this survey were those which discharged purulent material. Twelve patients having adrenalectomy each had a bilateral, symmetrical, subcostal incision, one side of which was closed by suture and the other side by tape. These patients provided the best comparison of cosmetic results with the different methods of closure. Clinical and photographic examinations were carried out at intervals up to twelve months after operation. (Fig. 1.)

Results Four hundred twenty-eight wounds were analyzed. Of the 161 wounds closed by tapes, there were nine postoperative infections, three subcutaneous hematomas, two cases of partial skin dehiscence, and two cases of tape blisters. Premature separation of the tapes occurred in two cases. Of 267 sutured wounds, there were thirty-one infections, six subcutaneous hemotomas, and eight skin dehiscences. Of 267 wounds sutured, 131 were clean, 114 were clean-contaminated, and 22 were contamThe

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Surgical

Fig. 1.

Bilateral subcostal

incisions: A, left side closed

week. B. right side closed bv suture months.‘D, incision at eight mbnths.

inated. The infection rates in these groups were 4.6, 14, and 41 per cent, respectively. Of 161 wounds closed by tapes, seventy-four were clean, seventy-eight clean-contaminated, and nine contaminated. The infection rates were 5.4, 3.8, and 22 per cent, respectively. The difference in infection rates in the cleancontaminated wounds, sutured and nonsutured, is significant (P < 0.05). Table I compares the complications in the two groups of wound closure. There were no complications in the patients having adrenalectomy. These wounds were reevaluated every two months after the patients’ discharge from the hospital. The cosmetic appearance of each wound was about the same, except for the suture tracts and surrounding erythema which tended to disappear with time. Figure 1 compares a bilateral subcostal incision closed with tapes on the left and sutures on the right at one week, two months, and eight months.

at one

Infection.

wounds

Whether infection develops in denends on general and local resistance

Vol.117,March 1969

Closure

by tape at one C, incision at two

factors. Percutaneous suture closure provides an extra source of contamination via the suture cuff of canal, and results in a thin perisutural

TABLE

I

Comparison of Wounds Suture and Tape

Closed

by

Wound Complications Type of Closure

Tape

Suture

Total

Comments

week.

Wound

Number

Infection

74 78

4 3

2 1

1 1

contaminated Contaminated Total

9 161

2 9

0 3

0 2

Clean Clean-

131 114

6 16

4 2

2 4

contaminated Contaminated Total

22 267

9 31

0 6

3 8

Clean Clean-

205 192

10 19

6 3

3 5

contaminated Contaminated Total

31 428

11 40

0 9

2 10

Type of Wound

Clean Clean-

Skin Hematoma Separation

319

Conolly et al.

dead epidermis, dermis, and subcutaneous fat. Suture closure provides both a potential source of contamination via the suture canal and POtential source of foreign body reaction within the susceptible subcutaneous tissue [Z]. Clean wounds are usually able to withstand the insults of needles and sutures. In our survey, there WM little difference in clean wound infection rates between tape and suture closure. Clean-contaminated wounds, however, require minimal reduction of local defenses to cause infection. Edlich et al. [1] studied the determinants of infection in a primarily closed contaminated wound and concluded that percutaneous sutures increased the likelihood of infection in these wounds. That local defenses play an important role in wound infection was well illustrated by Dunphy and Jackson [8] and Elek and Conen [.4]. Our clinical survey supports the results of their experiments, namely, that, midline incisions for gastric and bowel operations and incisions by gastrostomy and cecostomy were all prone to the development of sepsis. The patients with clean-contaminated wounds in the two groups were statistically similar in terms of ages, obesity, pre-existing diseases, duration, and nature of operation. Fewer infections developed in the taped wounds than the sutured wounds. Hematoma. A good nidus for infection is provided by hematoma. In some wounds with oozing surfaces it is difficult to obtain hemostasis. Subcutaneous oozing in particular can often only be prevented or controlled by the tension of opposing wound surfaces. Skin sutures achieve this at the expense of tissue strangulation. Tape closure achieves surface apposition by distributing the skin tension only if the subcutaneous space is first closed by suture. In this regard, it is the subcutaneous fascia and occasionally dermis which should be sutured and not the fat. Other Complications. Complete wound dehiscence results from a heaIing failure at levels deeper than the subcutaneous tissue. Neither skin sutures nor tape closures can be incriminated in this process. Partial superficial dehiscence can be caused by subcutaneous serum collections due to postoperative oozing into a dead space or by subcutaneous infections which were more common in the sutured wounds. Blistering of the skin occurred in two patients, and in each case was avoidable. In these 320

Table

I.

II

Problem: Cause:

Solution:

II.

Problem: Cause: Solution:

III.

Problem: Cause:

Solution:

IV.

Problem:

Cause:

Solution:

V.

Problem: Cause: Solution:

Problems and Complications of Closure of Surgical Wounds by Tape Malalignment of wound edges. Nonperpendicular/irregular incision, especially on obese abdomens or around the umbilicus. Fine subcuticular and cutitular stitches to aid the tape and to oppose skin edges during ap. plication of strips. Nonadherence of tape. Skin edges not clean and dry; moist wound. Clean skin with alcohol and apply tincture benzoin compound; 100 per cent hemostasis essential (subepidermal bleeding). Seroma and hematoma. Faulty hemostasis plus lack of apposition in the subcutaneous tissues. 100 Per cent hemostasis. Occasional skin suture required; subcuticular stitches help. Separation of tape and superficial dehiscence of wound. Faulty application of tape. Seroma, hematoma, wound drainage. pHisoHex@’ applied postoperatively causes tape separation. Absorbent dressings. Separated tape(s) can be removed and replaced at any time. (Wounds can be secondarily closed in this way.) Use alcohol, not pHisoHex, for postoperative cleansing. Erythema, vesiculation at ends of tape. Postoperative distention on the wound. Add a vertical strip to anchor more securely the ends of the strips to the skin.

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Surgical Wound Closure

patients, the tape closures maintained wound apposition under great tension, especially when postoperative edema and postoperative distension became obvious. At this time the ends of the tape strips sheared off the epidermis. Both blisters healed within five days. This occurrence is avoided by fixing the ends of the strips by perpendicularly placed strips of tape. The patients reacted favorably to having their wounds closed by nonsuture technics. The patients having adrenalectomy in particular had less discomfort on the side in which tapes were used. Nonsuture closure demands attention to detail, as does any other surgical technic. Improper methods of applying these tape strips may result in wound complications. Table II summarizes the common problems and complications of nonsuture closure. It is interesting to note that of fourteen resident and two staff surgeons in the survey, ten residents were disenchanted with tape closure, finding it more time-consuming and more difficult to obtain hemostasis and accurate wound apposition than with suture closure. The others were impressed with the ease, accuracy, and reduced complications of nonsuture closure. Tape closure was found to be more rapid than suture closure by those experienced with the method. Skin closure of laparotomy wounds is only one of the many uses of tape. It is an accepted method of closure in the types of wound and circumstances outlined as follows : I. Indications A. Primary closure of wounds 1. tape alone 2. with retention sutures 3. with skin sutures, for example, umbilicus B. Secondary closure of wound 1. delayed closure of infected wound 2. closure of superficial separation C. After early removal of sutures-facial surgery D. Skin grafting E. Ischemic tissue, e.g., Raynaud’s disease F. Ke;oid diathesis G. Where suture removal is undesirable, e.g., infants, children II. Contraindications A. Scrotal area Vot.117,March 1969

III.

B. Perineum C. Areas where there is profuse drainage D. Scalp or beard E. Circumferentially around a digit Circumstances A. Operating room (operative wounds) B. Emergency stations C. General practitioner’s office (traumatic wounds) D. First aid

Ordman and Gillman [5] gathered clinical, histologic, and tensile strength data comparing the healing of surgical incisions in the pig in which the wounds were closed with sutures and adhesive tape. They concluded that, except in very special circumstances, no objectively valid or justifiable reasons can be elicited for continuing to use sutures for closing the cutaneous parts of surgical incisions. Our widespread experience at the San Francisco General Hospital lends support to these conclusions, although in the majority of clean wounds both methods of closure result in good healing. Tape closure seems indicated, however, in all clean-contaminated wounds in which technical factors are amenable to tape closure.

Summary Provided the surgeon has closed the subcutaneous dead spaces and secured hemostasis, tape closure of the skin yields advantages over suture closure. By avoiding percutaneous needle tracks, one avoids the risk of suture canal scarring, infection, actual wound infection, and separation. This difference in wound complications is most pronounced in clean-contaminated wounds. The problems in application of this method to wound closure are analyzed and solutions offered. Tape is indicated in the cutaneous closure of all clean-contaminated wounds except those which are mechanically inaccessible or those with profuse drainage. Acknowledgment: We wish to thank the resident surgical staff at the San Francisco General Hospital for participating in the survey, completing the analysis cards, and photographing wounds. We would also like to thank Mr. W. E. Walsh and the Minnesota Mining and Manufacturing Co. for supporting this clinical survey. 321

Conolly et al.

References 1.

2.

3.

922

EDLICH, R. F., TSUNG, M. S., ROGERS,W., ROGERS,P., and WANGENSTEEN,0. H. Studies in the management of the contaminated wound. In press. GOLDEN,T., LEVY, A. H., and O’CONNOR,W. T. Primary healing of skin wounds and incisions with a threadless suture. Am. J. Surg., 104 :603,1962. DUNPHY, J. E. and JACKSON,D. S. Practical applications of experimental studies in the

care of the primarily closed wound. Am. J. 104:2’73,1962. ELEK, S. D. and CONEN, P. E. The virulence of staphylococcus pyogenes for man: a study of the problems of wound infection. Brit. J. Exper. Path., 38:573, 1957. ORDMAN,L. J. and GILLMAN,T. Studies in the healing of cutaneous wounds. III. A critical comparison in the pig of the healing of surgical incisions closed with sutures or adhesive tape based on tensile strength and clinical and histological criteria. Arch. Surg., 93:911, 1966. Surg.,

4.

5.

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