September 9, 2021

There are plenty of reasons to consider ditching sutures and staples.

SCAR ERASER The use of alternative wound closure technology made the scars from this patient’s knee arthroscopy barely visible two weeks after surgery.

Most skilled surgeons will tell you there’s nothing superior about using sutures and staples to close wounds. Those same surgeons will likely also tell you that many of the alternative wound-closure devices on the market come pretty darn close to matching their performance, and in fact carry a host of their own advantages, such as:

Patient satisfaction. Many surgical procedures still rely on staples, which require in-person follow-up appointments for removal that are, at best, inconvenient for patients and, at worst, a source of genuine fear. "With a knee revision, we're talking about 30, 40 or 50 staples we need to remove." says Asit K. Shah, MD, PhD, an orthopedic surgeon at Englewood (N.J.) Hospital. Not only can non- or less-invasive adhesive wound closure alternatives remove the need for follow-up staple-removal appointments, but they can also improve patients’ overall impression of your facility. "Patients who see that a surgeon is on the cutting edge and using these staple-free devices will likely tell their friends and family about the facility," says Dr. Shah.

Staff and patient safety. It's fairly common for physicians to get pricked in the process of using sutures, which remain one of the top sharps injury risks. "I was working side by side with a resident," says Richard Vagley, MD, FACS, of Spectrum Aesthetics in Coral Gables, Fla. "I zigged, he zagged, and I wound up with a needle in my finger." Patients are also vulnerable with traditional closing methods, particularly those that employ staples. "With staples, you’re leaving little holes in the body," says Dr. Shah. "That's a possible source of infection. It hasn’t been clinically proven, but it’s always a concern for surgeons."

Ease of use. Many alternative wound closure technologies are simple and intuitive enough to use that surgeons can delegate the process to a surgical assistant, which can greatly benefit your facility’s bottom line. "If you’re operating in two rooms at a busy facility, and you can delegate the closure to an assistant," says Dr. Vagley, "there's potential to complete more cases per day."

Much like NPO and other long-held practices, sutures and staples continue to be used because that's what many surgeons have always done. Administrators now can suggest that their surgeons make the switch to alternative closure methods that are backed by evidence and have proven successful in the field.

These small steps can make a big impact on your facility’s efforts to prevent SSIs.

HOLD ON THERE! Dated stickers constantly remind patients not to give into the temptation to remove dressings or peek underneath at the wound.

A surgeon's wound closure skills certainly play a primary role in preventing post-op infections, but more can be done to decrease the risks. Surgical staff and other personnel can help surgeons protect patients and their healing wounds from harm. Here are two examples:

"Do Not Remove" stickers. At the Yale School of Medicine in New Haven, Conn., surgical patients are sent home with SSI prevention bundles that include "Do Not Remove Until" stickers stuck to surgical wound dressings that remind them to keep the skin underneath fully covered for at least a full day after they leave the facility. This extra reminder helps to ward off the natural human instinct to sneak a peak at what's under the bandage or, worse, remove their bandages in the shower, says Kimberly Davis, MD, MBA, FACS, FCCM, professor of surgery (trauma) at Yale School of Medicine.

In the Yale PACU, nurses write the next day’s date on the stickers, which Dr. Davis says online office supply retailers can make for your facility, before placing them on the patient's wound dressings. "The stickers serve as on-the-spot reminders for tempted patients to keep dressings in place until wounds begin to close," she says.

Plastic wound protectors. At Abington (Pa.) Jefferson Health, staff recently added a number of steps to reduce the infection rate among colon resection patients. One focused on protecting vulnerable anatomy. "We place a plastic wound protector, which goes in the body and looks like the lid to a Tupperware container, in the patient's wound to hold the skin back and keep the abdomen walls clean," says Jodi Rennie, BSN, RN, CNOR, operating room team coordinator at the facility.

These small interventions, often springing from the imaginations of dedicated providers, can provide enormous benefits to surgical patients and facilities alike.

Surgeons follow the "reconstructive ladder" to achieve primary closure of wounds for safe surgical outcomes.

Credit: Synovis Micro Companies Alliance, Inc. a subsidiary of Baxter International Inc.
DERMACLOSE Case Type Ladder.

Wound management is an important part of the surgery process as teams work to keep patients safe during surgery and send them home for postoperative recovery. A recent article, "Multidisciplinary Application of an External Tissue Expander Device to Improve Patient Outcomes: A Critical Review," offers an important review of continuous external tissue expansion (CETE). This is a versatile tool in soft tissue injury management that could be an addition to the traditional "reconstructive ladder" in surgery.¹

Although CETE is becoming more widely used by surgeons from different specialties, information and recommendations regarding its use are limited. Using the correct technique results in fewer complications and improved outcomes for patients.

The hierarchy of surgical techniques traditionally used by reconstructive surgeons is depicted in the "reconstructive ladder."² According to the authors, “Surgical developments, like CETE, may provide opportunities to add new rungs to the traditional reconstructive ladder. Furthermore, the simplicity of these devices makes them accessible to subspecialties outside plastic surgery."¹

CETE uses the viscoelastic properties of the skin. Mechanical strain induces cellular proliferation, leading to an increase in tissue surface area through generation of new tissue. The authors note, "Although the exact mechanism by which mechanical strain induces proliferation of new tissue is still being elucidated, several factors have been linked to stress and/or mechanical strain."³

The authors discuss the principles and application of CETE, covering a company-sponsored consensus meeting on this emerging technology and highlighting the DermaClose (Synovis Micro Companies Alliance, Inc., Birmingham, AL) device’s unique approach to soft tissue injury management.

According to the authors, "There is clinical evidence to support the use of CETE in the management of a number of wound types, including fasciotomy, trauma, amputation, and flap donor sites. The device can be applied to open wounds, potentially avoiding the need for a skin graft or other more complex or invasive reconstruction options. DermaClose applies constant tension without restricting blood flow and does not require repeated tightening."¹

Furthermore, they say, "Given the paucity of published data, this critical review may serve as a meta-analysis for CETE as it details methods for CETE application, clinical evidence for its use in a number of settings, and the authors’ recommendations, specifically related to DermaClose, based on their clinical experience."¹

The authors note, "CETE can be used for wound management in multiple settings, and could be an addition to the traditional reconstructive ladder. Unlike other systems and devices, DermaClose applies constant tension and does not require tightening. There is clinical evidence supporting the use of this device in a number of wound types, and its use could avoid the need for a skin graft or other more invasive procedures."¹

Study shows adding saline instillation leads to significantly better healing.

Negative pressure wound therapy (NPWT) is a powerful infection prevention tactic in its own right, but adding normal saline irrigation to the treatment could significantly improve healing for patients with acute or chronic wounds. That’s one of the major findings from recent literature comparing this combination to conventional NPWT.

NPWT — a method of drawing out fluid from a wound to bolster healing by sealing a special dressing over the wound and attaching a vacuum pump — is a widely used tactic for managing acute and chronic extremity wounds. The study, published earlier this year in Annals of Medicine and Surgery, sought to determine the effects of adding normal saline instillation to NPWT (a process they dubbed NPWTi) in aiding the wound-healing processes of extremity ulcer patients who initially underwent surgical debridement.

Characterizing their study as the first prospective randomized controlled trial comparing the two methods, researchers separated patients into two groups: 25 with NPWTi, and 23 with NPWT only. Tissue samples taken on Day 1 and Day 10 were compared. The study found that histological parameters of wound healing (assessed as surface epithelium, granulation, inflammatory cells, proliferative blood vessels and fibroblasts) were "significantly better" in the NWPTi group. One drawback with the NPWTi group, however, was skin maceration around the ulcer, which was successfully managed.

The researchers conclude, "Our findings suggest that wound healing is significantly better when saline instillation is combined with NPWT. It can aid in complex extremity ulcers management by reducing the size of the wound with healthier looking granulation tissue."

Technology should never supplant the use of tried-and-true techniques.

As technological innovations continue to transform infection prevention practices, surgical leaders need to remember that high-tech solutions should complement their rigorous manual processes — not replace them.

Bernard Camins, MD, the medical director of infection prevention for the Mount Sinai Health System and a professor of medicine and infectious disease at Icahn School of Medicine at Mount Sinai in New York City, is a big proponent of maintaining an old-school approach to infection prevention. "We've all become so focused on turnover times and surgical throughput that some of the basic, tried-and-true protocols fall by the wayside," he says.

"Technology has evolved, and infections are rare — but they still happen," says Dr. Camins. "Let's step back and look at how thorough we're being with surface disinfection. Let's make sure surgical attire is properly washed, providers remove jewelry before they enter the OR and hand hygiene is performed as often as possible."

The pandemic has shone further light on this issue. "We're all paying much closer attention to the little things," says Dr Camins. "We're wiping surfaces more often and washing our hands more frequently. We're also masked all the time, something I hope continues well into the future — even after life looks more like it did pre-pandemic." Moving forward, Dr. Camins favors some type of universal masking during flu season because, as we saw this year with the record-low number of flu cases, simple protocols work when everyone is following them.

Another "positive" of the pandemic, says Dr, Camins, is an increased interest from younger generations in infection prevention careers. "The 'Fauci Effect' has resulted in more people being interested in careers in medicine in general and in epidemiology and infection prevention specifically," he notes. "This is wonderful news for my field because, before COVID-19, we were facing a shortage of infectious disease physicians. But thanks to the increased exposure of prominent epidemiologists like Dr. Fauci, we’re now experiencing an increase in applicants."

In a world where little seems certain, the hard work of infection prevention goes on.