|Year : 2020 | Volume
| Issue : 1 | Page : 32-38
Assessment of local wound healing complications after groin surgery: a comparative study between two wound closure techniques
Ikechukwu Bartholomew Ulasi1, Olakayode Olaolu Ogundoyin2
1 Department of Surgery, University College Hospital, Ibadan, Nigeria
2 Department of Surgery, University College Hospital; Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria
|Date of Submission||20-Apr-2020|
|Date of Acceptance||28-Jul-2020|
|Date of Web Publication||17-Sep-2020|
Olakayode Olaolu Ogundoyin
Department of Surgery, College of Medicine, University of Ibadan, Ibadan
Source of Support: None, Conflict of Interest: None
Background: Scars are inevitable sequelae of any surgical procedure. Wound closure method has been shown to affect the post-operative scar outcome. This study compared the post-operative scar of two wound closure techniques in paediatric groin surgeries. Methods: This was a prospective comparative analytical study involving 60 paediatric surgical patients randomized into two groups. After a groin procedure in patients who met the inclusion criteria, patients in Group A had only the skin layer closed whereas both skin and subcutaneous tissue were closed in Group B. Scar assessment was done using the Patient and Observer Scar Assessment Scale (POSAS) at 1 week, 3 weeks and 6 weeks after surgery. Results: The mean POSAS score was 108.44 ± 20.32 and 113.91 ± 26.18 for groups A & B respectively (P = 0.379) while the overall opinion score for groups A & B were 19 (IQR = 4) and 21(IQR = 10) (P = 0.392) respectively. The average duration of surgery was 35 minutes in each group. There was equal distribution of seroma formation among the two wound closure groups. Among the patients that developed wound dehiscence, 25% were in group A, while 75% were in group B. Ninety-five percent of the wounds healed with fine linear scar. Conclusion: Majority of paediatric groin wounds heal with fine linear scars. Although no statistically significant association exists between wound closure technique and scar assessment scores, patients who had two-layer wound closure recorded worse scar assessment scores compared to those who had one-layer closure.
Keywords: Assessment, paediatric, scar, wound closure
|How to cite this article:|
Ulasi IB, Ogundoyin OO. Assessment of local wound healing complications after groin surgery: a comparative study between two wound closure techniques. Nigerian J Plast Surg 2020;16:32-8
|How to cite this URL:|
Ulasi IB, Ogundoyin OO. Assessment of local wound healing complications after groin surgery: a comparative study between two wound closure techniques. Nigerian J Plast Surg [serial online] 2020 [cited 2023 Mar 30];16:32-8. Available from: https://www.njps.org/text.asp?2020/16/1/32/295257
| Introduction|| |
Wound closure after surgical incisions marks the end, yet an important part, of a surgical procedure. An ideal wound closure device or technique should be easy to use, fast and painless; provides excellent cosmetic appearance; be cost effective and have good patient acceptability.,,,,,, In the past, this was achieved using insect tick, jaws of black ant, hemp, flax and animal fibers with the resultant post-operative morbidities including abnormal scars.
Presently, different methods of wound closure have been developed ranging from simple to more complex techniques with the aim of not just closing the wounds effectively but also to achieve minimal complication and acceptable cosmetic outcome., The factors that determine a surgeon’s preference for a particular wound closure method over another include patient-related factors (age, sex, obesity), surgeon-specific factors (expertise, preference, location of incision, speed of use) and post-operative outcome associated with a particular wound closure method.,, Hence, no wound closure technique is ideal for all situations and so the surgeon decides what best suits a particular closure.
One of the most important late post-operative sequelae of skin injuries (whether surgical or non-surgical in origin) is the resultant scar., Scars are dermal fibrous replacement tissue from a wound that healed by resolution rather than regeneration., Cutaneous scarring is said to be inevitable following damage to more than 33.1% of the thickness of the skin either through trauma or surgery.,,
Suture type and wound closure technique are significant factors known to affect wound closure outcomes. Studies on the post-operative outcome of the common wound closure techniques in a paediatric population in our environment are limited and those assessing the scar outcome with respect to closure and non-closure of the subcutaneous fat during wound closure in children are either scarce or non-existent.
This study therefore sought to compare the outcomes between wounds closed by apposing only the skin leaving the subcutaneous layer unopposed, with those in which both skin and subcutaneous layer were closed among paediatric surgical patients in a tertiary health institution in South-West Nigeria.
| Methods|| |
This is a prospective, analytical, comparative study conducted on consecutive paediatric patients booked for elective groin surgeries from 1st September, 2018 to 31st March, 2019 in the Surgical Outpatient of University College Hospital (UCH) Ibadan, Nigeria. All children aged 15 years and below who have been diagnosed with uncomplicated groin swellings like hernias, hydroceles and undescended testis and presenting through the surgical out-patient department of the hospital were included in the study. Parents’ refusal to give consent for the study, history of keloids and (or) presence of keloids on physical examination, recurrent inguinoscrotal swellings and complicated inguinoscrotal swellings like strangulated inguinal hernias formed the criteria for exclusion from the study.
A computer-generated blocked randomisation sequence was used to randomise the patients into two groups. Informed consent for participation in this study was obtained on the day of the proposed surgery. Required basic information on socio-demography was obtained. The family social class of the patients was categorized as Class I (Upper), Class II (middle) and Class III (low) using the socio-economic classification scheme by Oyedeji.
Pre-operative evaluation of all patients included a detailed history, physical examination and routine investigations. All patients recruited for the study had general anaesthesia as is the usual practice in the division for all children scheduled for surgery. Groin skin preparation was done using Clorhexidine and Cetrimide solution (Savlon), Povidone iodine and Methylated Spirit. Skin incision was made along the line of skin crease. The relevant procedures were carried out using standard technique. The thickness of the subcutaneous fat was measured using a sterile paper tape.
During wound closure, sealed envelopes containing the information regarding group allocation were drawn and shown to the surgeon. Patients in Group A had only a continuous subcuticular suturing of the skin, with the subcutaneous layer not apposed, whereas in Group B patients, closure of both the subcutaneous layer and skin with simple interrupted and continuous subcuticular sutures respectively was performed. Wound closure was achieved using 3-0 Polyglactin-910 (Vicryl®) for all patients. Meticulous haemostasis was achieved before closure of the wound. The wound was covered with padded sterile occlusive dressing with micropore. Involved in the surgery were three consultants and two trainee surgeons (Senior Registrar).
Patients were reviewed for scar outcome in the out-patient clinic on the 1st, 3rd and 6th week post operatively using the Patient and Observer Scar Assessment Scale (POSAS). The POSAS consists of a Patient Scar Assessment Scale (PSAS) and an Observer Scar Assessment Scale (OSAS). The observer scores six items: vascularization, pigmentation, thickness, surface roughness, pliability, and surface area whereas the patient scores six items: pain, pruritus, colour, thickness, relief, and pliability. All included items are scored on the same 10-point scale, in which a score of 1 is given when the scar characteristic is comparable to ‘normal skin’ and a score of 10 reflects the ‘worst imaginable scar’. Both OSAS and PSAS have a 7th item about the overall opinion graded on a 10-grade scale as well. All items are summed to give a total scar score, and therefore, a higher score represents a poorer scar quality. The PSAS scoring was done by the parents/guardians of the patients whereas an independent assessor (Paediatric Surgery trainee) blinded to the type of skin closure carried out the OSAS component of the POSAS scale.
Other post-operative data collected included wound-related complications and length of hospital stay between the two groups. All these information were gathered from each of the patients over a period of 12 months from the time they had surgery.
The mean POSAS score, the mean Patient and Observer Overall Opinion (POOO) score in the first week and the mean POSAS scores over the 6-week period were compared between the two groups using the student t-test while the Mann-Whitney U test was used to compare the rest of the scores all of which were not normally distributed. The χ2 and Fisher’s exact tests were used to analyse categorical variables. Statistical significance was set at a P-value of <0.05. IBM Statistical Package for Social Sciences Software for Windows Version 23.0 was used to analyse all data obtained from the study. Ethical approval for the study was obtained from the joint University of Ibadan/University College Hospital Ethical Review Committee.
| Results|| |
A total of 60 paediatric patients were recruited for the study. There were 58 (97%) males and 2 (3%) females. A large proportion of the patients (46, 76.7%) were below the age of 5 years with a median age of 3years (IQR = 3.3). All the parents were educated with majority (Fathers − 68.3%, Mothers − 71.7%) educated up to the tertiary level [Table 1]. A large proportion of the patients (41, 68.3%) belonged to socio-economic Class II, whereas, 18(30.0%) patients were in class I, and 1 (1.7%) in class III [Figure 1].
Groin hernia was the most common diagnosis observed in 27 (45%) patients, undescended testis in 21 (35%), hydrocele in 11 (18.33%) patients and only 1 (1.67%) patient had testicular atrophy [Figure 2]. One-layer closure of the wounds was performed on 27 (45%) patients (Group A) whereas 33 (55%) patients (Group B) had two layer wound closure.
The duration of surgery (35 minutes) and duration of hospital stay (9 hours) were similar in both Group A (IQR = 16 & 3 respectively) and Group B (IQR = 12 & 3 respectively).
The mean POSAS score in Group A was 108.44 ± 20.32, and 113.91 ± 26.18 in Group B (P = 0.379). The cumulative opinion score of both the patients and the observer showed that out of a maximum score of 60, participants in Group A and Group B had a score of 19 and 21 respectively [Table 2] with no statistically significant difference observed between participants in both groups (P = 0.392). No statistically significant difference in POSAS score and overall patient and observer opinion scores exists between the two groups both at weeks 1, 3 and 6.
Overall, wound-related complications were observed more in patients in nine (15.0%) patients with two (3.3%) patients in Group A and 7 (11.7%) in Group B. The wound-related complications included seroma in two (3.3%) patients with one patient in each group; wound dehiscence in one patient in Group A and three in Group B, whereas ninety-five percent of the study participants had a fine linear scar and only three (5%) patients (all in Group B), had hypertrophic scars [Table 3].
| Discussion|| |
The aesthetic appearance of an operative scar following wound healing is of cosmetic significance to the parents of children who have just had surgery; indeed, it is more significant to the child when he grows up because of an increase in the size and extent of the scar following increase in body size.
In evaluating the quality of post-operative scars in children, it is important to note that wounds in human foetuses heal without scars and beyond 24 weeks of gestation, scarring of wounds begins.,, Although Morrison et al reported the presence of a visible scar in three infants with a prenatal history of injury during amniocentesis at 16-20 weeks. Most reports on scar evaluation have been on burn wounds with fewer literatures on post-operative scar evaluation.,
The study site being a tertiary health institution may explain why most of the patient fell into classes I and II (upper and middle) socio-economic class with only 1.7% being in class III (low) social class. In this hospital and other major tertiary centres in the country patients usually pay out of pocket which could be too expensive for patients in Class III to afford. Also, many of them are not educated well enough to appreciate and enrol into the health insurance programme to assist them in financing their healthcare.
Inguinoscrotal anomalies necessitating groin surgeries were purposively selected for this study because the surgical incisions for these procedures are usually transverse along the skin crease in the lower abdomen and they are small incisions that can easily be studied as day case procedures. The choice of these clinical conditions may explain the predominance of males over females as inguinoscrotal anomalies are much more common in boys than girls.
Closure of groin wounds following surgery usually involves layered closure of both the subcutaneous layer and the overlying skin. Some surgeons have advocated for a single layer closure based on the argument that it reduces cost incurred by use of extra sutures in addition to decreasing operative time in comparison to the conventional 2-layer closure., The proponents of a 2-layer closure however argue that it results in superior cosmetic outcome and lower post-operative complications. Although the benefit or otherwise of closure of subcutaneous layer in paediatric groin procedures has not been documented prior to this study, it was observed that patients who had closure of their subcutaneous layer had worse scar assessment scores but this was not statistically significant.
It has been reported that closure of the subcutaneous tissue after abdominal hysterectomy lowers the overall rate of complications like wound disruption however, patients in the non-closure group have higher incidence of seroma and hematoma formation with consequent wound disruption. The reported observed benefit of subcutaneous tissue closure was in women with a subcutaneous fat thickness of at least 2.5cm. This fact was emphasized in a meta-analysis involving six studies which showed that subcutaneous tissue closure during caesarean delivery results in 34% less risk of wound disruption in women with fat thickness greater than 2 cm. However, findings of two of the studies that assessed outcomes in patients with subcutaneous thickness of 2 cm or less did not suggest any effect in these patients. In other studies involving non caesarean surgical procedures, it was observed that non-closure of subcutaneous fat tissue does not increase the occurrence of infectious or non-infectious wound complications., In children, the fatty layer of the subcutaneous tissue is not thick and may be less than 2 cm except in obese children; this may explain the lack of statistically significant difference observed between the two groups studied.
Also, it was observed that there was no significant difference in duration of surgery between the two groups studied, although the sizes of the wound may be small as expected in groin surgeries for children in comparison to adult surgical procedures. Thus, there was no significant difference between the two groups in terms of SSI and wound complications. This may not reflect the true difference between the two groups since the whole duration of surgery (which may be affected by other intra-operative factors that cause delays) − and not the duration of wound closure only − was calculated. This finding was similar to previous report which observed that the duration of wound closure was shorter in diabetic women undergoing caesarean section when the subcutaneous tissue was not closed with no significant difference between the two groups in terms of wound-related complications.The observed non-significant difference in the POSAS and Observer opinion scores in the two groups may be attributed to so many factors which may include the size of the wound, the thickness of the subcutaneous tissue and possibly the age of the cohort group of patients studied. However, the observed long-term cosmetic benefit of non-closure of the subcutaneous tissue versus suture closure of the subcutaneous tissue is similar to the findings in a previous report in which there was no significant difference in the POSAS and Vancouver Scar Scale (VSS) Scores in 116 women who underwent caesarean section.
| Conclusion|| |
The cosmetic benefit of both single- and double-layered wound closure and the duration of wound closure in both techniques are similar. Although majority of paediatric groin wounds heal with fine linear scars, immediate wound-related complications like hypertrophic scars are more in the double-layered closure.
Ikechukwu Bartholomew Ulasi contributed in design, definition of intellectual content, literature search, clinical studies, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing and manuscript review.
Olakayode Olaolu Ogundoyin contributed to concept, design, definition of intellectual content, literature search, clinical studies, manuscript preparation, manuscript editing and manuscript review.
Declaration of Consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
We declare that we do not have conflict of interest either financially or otherwise in the course of carrying out this study. The study was solely funded by the authors.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]