|Year : 2019 | Volume
| Issue : 1 | Page : 10-13
Comparative study of subcuticular suture, metal clips, and steri-strips for wound closure after thyroid surgery
Jnaneshwari Jayaram, CM Aruna Kumar, Rhea Pinto, Leo F Tauro
Department of General Surgery, Father Muller Medical College, Rajiv Gandhi University, Mangalore, Karnataka, India
|Date of Web Publication||14-Mar-2019|
Dr. Jnaneshwari Jayaram
Department of General Surgery, Father Muller Medical College, Rajiv Gandhi University, Mangalore - 575 002, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Pain and scar are the two important criteria bothering the patients after thyroid surgeries. Incisions on the neck when heal has to be scarless or minimum scar. Hence, we opted to study for the better methods of skin closure to obtain less pain and less scar.
Aim: The study compared subcuticular suture, metal clips, and steristrips for wound closure after thyroid surgery based on the postoperative pain assessment, neck mobility, and cosmetic appearance.
Materials and Methods: The prospective study which includes a consecutive series of 93 (n = 93). Patients undergoing thyroidectomy who were randomized to have their wound's closed by subcuticular sutures or steristrips or staples. The randomization code was generated using a table of random numbers, and the sealed envelope was opened at the end of each operation.
Results: In this study, wound closure by steristrips had less postoperative pain followed by subcuticular suture and metal clips. In our study, neck mobility after thyroid surgery, steristrips had acceptable neck mobility compared to subcuticular suture and metalclips. In our study, cosmetic appearance after thyroid surgery wound closure with steristrips had excellent scar appearance followed by subcuticular suture and metal clips.
Conclusion: In the final analysis, the choice of wound closure materials will depend on the surgeon's preference. However, this study showed that steristrips had less pain, acceptable neck mobility, excellent scar appearance followed by thyroidectomy surgery.
Keywords: Metal clips, neck mobility, pain, suture, thyroidectomy, wound
|How to cite this article:|
Jayaram J, Aruna Kumar C M, Pinto R, Tauro LF. Comparative study of subcuticular suture, metal clips, and steri-strips for wound closure after thyroid surgery. Saudi Surg J 2019;7:10-3
|How to cite this URL:|
Jayaram J, Aruna Kumar C M, Pinto R, Tauro LF. Comparative study of subcuticular suture, metal clips, and steri-strips for wound closure after thyroid surgery. Saudi Surg J [serial online] 2019 [cited 2020 May 30];7:10-3. Available from: http://www.saudisurgj.org/text.asp?2019/7/1/10/254110
| Introduction|| |
One of the most important outcomes of wound repair is long-term esthetic or cosmetic appearance of the scar. It has particular relevance in neck surgeries where the scar is placed a very easily seen area. The goal of surgery is to achieve such healing with minimal edema, no discharge or infection and minimal scarring In the selection of a suture, a patient's health status, age, weight, and comfort, and the presence or absence of infection are as important as the biomechanical properties of the suture, individual wound characteristics, anatomic location, and a surgeon's personal preference and experience in handling a suture material. There is often more than one appropriate method of closure. In the Indian set up, thyroid surgery is the most commonly performed surgery by general surgeons in the neck. Thyroid disorders are most commonly seen in females mostly women and young adults who are very cautious about their beauty and appearance. Skin closure is the last step of any surgery where much time should not be spent to avoid unnecessary exposure of anesthetic risks to the patient. The ultimate responsibility for the choice of the best material lies with the surgeon. Cosmetic acceptability of scar and neck mobility is important outcomes after collar line incision for neck surgery.
| Materials and Methods|| |
Ninety-three patients between May 2011 and September 2013 were selected for this prospective study. The procedure was performed only after obtaining consent from the patients. Patients were randomized to have their wound's closed by subcuticular sutures or steristrips or staples. The randomization code was generated using a table of random numbers, and the sealed envelope was opened at the end of each operation. All operations were performed by or under the direct supervision of the same consultant Standardized technique was used for thyroid operations. Assessment of pain: verbal response and visual analog scale (VAS) for three consecutive postoperative days (PODs).
Assessment of mobility: At 48 h and 1 week after surgery using verbal and VAS. Assessment of cosmetic appearance will be done by using VAS at the time of the 6th week.
Patients with poor compliance, secondary neck surgeries, combined neck dissection with thyroidectomy, who were not ready to give informed consent were excluded.
Collected data were analyzedby Fisher's exact test and Kruskal–Wallis test.
| Results|| |
The study population included (n = 93) 13 men (14%) and 80 (86%) women with a median age of 43.3 years. Of these 81 (87%) had multinodular goiter, 10 (10%) had neoplasm and 2 (2.1%) had inflammatory pathology. Of these patients, 8 underwent subtotal thyroidectomy, 75 near-total thyroidectomy, and 10 total thyroidectomy. Thirty-one each patients had steristrips closure, metal clip closure, and subcuticular closure. According to VAS and verbal analog scale (VEAS) patients in steristrips group experienced less pain compared to metal clips and subcuticular sutures on POD 1, 2, and 3.
Neck mobility assessment was done according to VAS and VEAS after 48 h and 7 days. According to this, patients with steristrips closure (P = 0.001) had easy neck mobility compared to subcuticular sutures and metal clips (P = 0.064). Cosmetic appearance after 6 weeks according to VAS found that wounds closed by steristrips were superior to subcuticular and metal clips closure.
| Discussion|| |
A suture is a strand of material used to tie or ligate blood vessels and approximate tissue together. The engineering of sutures in the synthetic material along with standardization of traditional materials such as catgut, silk has made good aesthetic results possible. The creation of natural glues, surgical staples, and tapes to substitute for sutures has supplemented the armamentarium of wound closure techniques. Wound care techniques have been documented since 1500 BC in ancient Egypt where lint was used as a fibrous base, animal grease as a protective barrier, and honey as a topical antibiotic.
The Greeks applied animal fat and wrapped the wounds, and the Roman applied ashes, oil, and herbs and wrapped the wounds to enhance wound healing.
Wound healing and repair
Wound healing, the body's response to tissue injury, is an essential and primitive process common to all multicellular organisms wherein a principal type of cell assumes embryonic features, undergoes migration, divides and then differentiates to produce an extracellular matrix in a seemingly less than optimal or hostile environment.
At maximal strength, the scar is only 70% as strong as normal skin.
Factors affecting wound healing
Many local factors influence surgical sound healing and determine the potential for an incidence of infection. The healing of closed surgical wounds depends on many factors, one of the most complexes of which is the influence of technique and expertise.
Surgical technique and principles
Keeping tissue trauma to a minimum promotes faster healing. The good surgical technique includes gentle handling of tissues, meticulous hemostasis, and prevention of dead space and avoidance of tissue necrosis resulting from excessive use of surgical diathermy or ligatures.
A good blood supply is a basic factor in the success of wound repair. It is essential for the supply of oxygen and other nutrients required in the cellular and biochemical process of repair, and it is necessary for the removal of wound metabolites.
The most common underlying event for all wounds is trauma. Trauma may be accidental or intentionally induced.
Surgeons have pursued the search for an ideal suture material suitable for all purposes since the time of Pare.
The search for new and improved suture materials started with the Egyptians, who as early as 2000 BC used linen to close wounds. Around AD 75, Galen experimented with catgut and in 1869; Listeria impregnated catgut with chromic acid. In the early part of the century, Halstead promulgated the advantages of silk over catgut and silk soon became the most common suture material in surgical practice.
The ability of the sutured tissue to resist infection varies depending on the kind of material implanted.,
Other techniques of skin approximation include steristrips, clips, tissue adhesives, and staples.
The use of stapling devices abolishes the risk of needlestick injury.
Procedures that take longer than two hours are associated with higher infection rates. Systemic factors include age, malnutrition, Vitamin C deficiency, trauma, hypovolemia, hypoxia, diabetes, uremia, malignancy, jaundice, steroids, irradiation, and cytotoxics. The tissue should be held in apposition until the tensile strength is sufficient to withstand stress. The level of bacterial burden is the most significant risk factor for wound healing.,, In our study, wound closure by steristrips had less postoperative pain followed by subcuticular suture and metal clips. In a study by Selvadurai et al., Thirty-eight patients were randomized to the Michel clip group and 42 to the subcuticular suture group. The two groups were well matched for age, sex, race, the ratio of the thyroid to parathyroid surgery, thyroid diagnosis, the degree of thyroid resection, and parathyroid diagnosis. Patients in the metal clip and subcuticular suture groups experienced similar degrees of pain on the first three PODs, and there were no statistically significant differences between the two groups using either visual analog or verbal response scales.
In our study, neck mobility after thyroid surgery steristrips had acceptable neck mobility compared to subcuticular suture and meatalclips. In a study Ridgway et al., Glued (n = 14) and stapled (n = 15) closures were performed for hemithyroidectomy (n = 8 vs. 6), subtotal thyroidectomy (n = 2 vs. 4), total thyroidectomy (n = 1 vs. 4), and parathyroidectomy (n = 3 vs. 1). Closure with tissue glue took significantly longer than with staples (mean, 95 vs. 28 s; P < 0.001). Neck mobility scores were comparable at 48 h and 1 week (mean, 4.8 vs. 4.4; P = 0.552: and 2.7 vs. 2.6; P = 0.886). The use of glued skin closure may increase the duration of surgery but acceptable neck mobility.
The multidimensional VAS is a photograph-based scale derived from evaluating
- Standardized digital photographs in four dimensions
- Observer comfort plus contour.
It sums the individual scores to get a single overall score ranging from “excellent” to “poor.” It has demonstrated high observer reliability and internal consistency when compared to expert panel evaluation, but it has shown only moderate reliability when used among lay panels.,,
In our study, cosmetic appearance after thyroid surgery wound closure with steristrips had excellent scar appearance followed by subcuticular suture and metal clips. In a study Yang et al., these patients were randomly divided into two groups (one experimental and one control group) of 70 patients each. In the process of the study, 8 patients were excluded because of intraoperative findings. Therefore there were 65 patients in the experimental group (tissue adhesive) and 67 patients in the control group (surgical staples). The objective of this study was to compare the effectiveness and cosmetic results of tissue adhesive or surgical staples in thyroidectomy through a supraclavicular incision. At the first month after surgery, the score was significantly lower in the experimental group (range: 5–7) compared to that of the control group (range: 8–10; P < 0.001). However, at the 3rd month after surgery, there was no significant difference between the two groups.
Comparison of studies
In a study by selvadurai et al, thirty eight patients were randomised to the Metal clip group and forty two to subcuticular group. The two groups were all matched for age, sex, race and ratio of thyroid to parathyroid surgery, thyroid surgery. Patients in the metal clip and subcuticular suture groups experienced similar degree of pain on the first three post operative days and there were no statistically significant differences between the two groups using either visual analogue or verbal response scales.
In a study by Yang et al., patients were randomly divided into two groups. One experimental and one control group of 70 patients each. The objective of this study was to compare the effectiveness and cosmetic results of tissue adhesive or surgical staples in thyroidectomy through a supraclavicular incision. At the first month after surgery, the score was significantly lower in experimental group compared to that of control group. However at the end of third month after surgery, there was no significant difference between the two groups.
Steristrips had less postoperative pain followed by subcuticular suture and metal clips. No difference in postoperative pain between metal clips and suture. Tissue adhesive less pain compare to staples.
Steristrips had acceptable neck mobility compared to subcuticular suture and metal clips.
Steristrips had excellent scar appearance followed by subcuticular suture and metal clips. At the time of discharge suture closed wound had good cosmetic appearance. And at 3rd and 6 months follow-up no difference in the outcome. At the end of 3rd month, no significant difference between tissue adhesive and staple.
| Conclusion|| |
To conclude, the choice of wound closure materials will depend on the surgeon's preference. However, this study does show that steristrips sutures can be removed more quickly and cause less discomfort than removal of metal clips. Steristrips had less pain, acceptable neck mobility, excellent scar appearance following thyroidectomy surgery. We strongly recommend steristrips for thyroidectomy wound skin closure.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hochberg J, Meyer KM, Marion MD. Suture choice and other methods of skin closure. Surg Clin North Am 2009;89:627-41.
Calabrese EJ. Historical foundations of wound healing and its potential for acceleration: Dose-response considerations. Wound Repair Regen 2013;21:180-93.
Moy RL, Waldman B, Hein DW. A review of sutures and suturing techniques. J Dermatol Surg Oncol 1992;18:785-95.
Madden JW. Text Book of Surger: The Biological Basis of Modern Surgical Sutures. 11th
ed. Philadelphia: WB. Saunders and Company; 1977. p. 271.
Goslen JB. Wound healing for the dermatologic surgeon. J Dermatol Surg Oncol 1988;14:959-72.
Boucek RJ. Factors affecting wound healing. Otolaryngol Clin North Am 1984;17:243-64.
Levenson SM, Geever EF, Crowley LV, Oates JF 3rd
, Berard CW, Rosen H, et al.
The healing of rat skin wounds. Ann Surg 1965;161:293-308.
Buggy D. Can anaesthetic management influence surgical-wound healing? Lancet 2000;356:355-7.
Leaper DJ, Gottrup F. Surgical wounds. In: Leaper DJ, Harding KG, editors. Wounds: Biology and Management. Oxford: Oxford University Press; 1998. p. 23-40.
Thomas H. Wound Healing and Wound Infection Theory and Surgical Practice, “Fundamentals of Wound Management”. South Plainfield NJ: Chirurgecom, Inc.; 1977. p. 192-8.
Giacometti A, Cirioni O, Schimizzi AM, Del Prete MS, Barchiesi F, D'Errico MM, et al.
Epidemiology and microbiology of surgical wound infections. J Clin Microbiol 2000;38:918-22.
Edlich RF, Panek PH, Rodeheaver GT, Turnbull VG, Kurtz LD, Edgerton MT, et al.
Physical and chemical configuration of sutures in the development of surgical infection. Ann Surg 1973;177:679-88.
Goldenberg IS. Catgut, silk, and silver – The story of surgical sutures. Surgery 1959;46:908-12.
Alexander JW, Kaplan JZ, Altemeier WA. Role of suture materials in the development of wound infection. Ann Surg 1967;165:192-9.
Katz S, Izhar M, Mirelman D. Bacterial adherence to surgical sutures. A possible factor in suture induced infection. Ann Surg 1981;194:35-41.
Bhatia R, Blackshaw G, Barr V, Savag R.J Hand surg Eur Vol 2002;27:53-4.
Haley RW, Culver DH, Morgan WM, White JW, Emori TG, Hooton TM, et al.
Identifying patients at high risk of surgical wound infection. A simple multivariate index of patient susceptibility and wound contamination. Am J Epidemiol 1985;121:206-15.
Edlich RF, Becker DG, Thacker JG, Rodeheaver GT. Scientific basis for selecting staple and tape skin closures. Clin Plast Surg 1990;17:571-8.
Berzard F, Gandon J. Postoperative wound infections: The influence of ultraviolet irradiation of the operating room and of various other factors. Ann Surg 1964;160:1-92.
Cruse PJ, Foord R. The epidemiology of wound infection. A 10-year prospective study of 62,939 wounds. Surg Clin North Am 1980;60:27-40.
Cruse PJ. Classification of operations and audit of infection. In: Taylor EW, editor. Infection in Surgical Practice. Oxford: Oxford University Press; 1992. p. 1-7.
Selvadurai D, Wildin C, Treharne G, Choksy SA, Heywood MM, Nicholson ML, et al.
Randomised trial of subcuticular suture versus metal clips for wound closure after thyroid and parathyroid surgery. Ann R Coll Surg Engl 1997;79:303-6.
Ridgway DM, Mahmood F, Moore L, Bramley D, Moore PJ. A blinded, randomised, controlled trial of stapled versus tissue glue closure of neck surgery incisions. Ann R Coll Surg Engl 2007;89:242-6.
Duncan JA, Bond JS, Mason T, Ludlow A, Cridland P, O'Kane S, et al.
Visual analogue scale scoring and ranking: A suitable and sensitive method for assessing scar quality? Plast Reconstr Surg 2006;118:909-18.
Durani P, McGrouther DA, Ferguson MW. Current scales for assessing human scarring: A review. J Plast Reconstr Aesthet Surg 2009;62:713-20.
Micomonaco DC, Fung K, Mount G, Franklin J, Yoo J, Brandt M, et al.
Development of a new visual analogue scale for the assessment of area scars. J Otolaryngol Head Neck Surg 2009;38:77-89.
Yang YL, Xiang YY, Jin LP, Pan YF, Zhou SM, Zhang XH, et al.
Closure of skin incision after thyroidectomy through a supraclavicular approach: A comparison between tissue adhesive and staples. Scand J Surg 2013;102:234-40.