JIIMS final.cdr 35 ORIGINAL ARTICLE ABSTRACT Objective: To determine the frequency of wound infection with skin closure by removable subcuticular sutures in non complicated open appendectomy wound. Study Design: Descriptive case series Place and Duration of Study: Department of Surgery Railway Hospital Rawalpindi, Seven months and ten st th days, from 1 Nov, 2009 to 10 June, 2010. Materials and Methods: The study was carried out after taking approval from the hospital ethics committee. Seventy three adult patients of either sex admitted in department of surgery with diagnosis of acute appendicitis were included in the study by non probability consecutive sampling. All the patients were explained about the procedure and an informed written consent was obtained. Right grid iron abdominal incision centred over the Mc Burney's point was used to open the abdomen. Appendicectomy was done. In all patients subcuticular stitches rd th by using polypropylene 2/0 were applied to close the skin. All the patients were followed on 3 , 7th and 30 post operative day for examination of wound . Data was entered in the predesigned Proforma (annexed) for analysis. Results: Out of 73 patients 6(8.2%) suffered from wound infection. Successful open management of the infected wounds was done. Rest of the patients had uneventful recovery. Conclusion: Frequency of wound infection is negligible with removable subcuticular skin suture in non complicated open appendicectomy wound. Key words: Appendicitis, open appendicectomy, subcuticular skin closure, wound infection. Introduction The vermiform appendix is a blind ended long, narrow, muscular tube arising from the posteromedial aspect of the caecum, about 1 inch (2.5 cm) inferior to the ileocaecal 1,2valve. Acute appendicitis is one of the most common abdominal emergencies for which patients attend the emergency 3department. Appendicectomy is the most commonly performed surgical operation all 1,4,5over the world. Different etiological and pathological factors are considered in acute appendicitis ranging from infection of appendix to occlusion of the appendicular l u m e n d u e t o f e c o l i t h , l y m p h o i d h y p e r p l a s i a , p a r a s i t e s a n d 6t u m o r. Appendicitis can be divided into acute non perforated appendicitis and perforated appendicitis. Non perforated appendicitis can be further classified into non gangrenous and gangrenous. Typically the patient of acute appendicitis presents with complaint of migratory pain to right iliac fossa, which means the pain initially starts in the 7,8 epigastrium or pararumbilcal region. Most of the times this pain is associated with anorexia, nausea and vomiting with gaurding, rigidity and rebound tenderness 5 , 9 , 1 0on palpation. Diagnosis of acute appendicitis is basically done on clinical grounds. However different laboratory and r a d i o l o g i c a l i n v e s t i g a t i o n s h e l p i n 11,12supporting the diagnosis. The surgical management of acute appendicitis is 13appendicectomy. This can be done as traditional open appendicectomy, mini appendicectomy or by laparoscopic approach. In cases of non complicated --------------------------------------------------------- Removable Subcuticular Skin Sutures in Open Appendicectomy; Surgeons Fear Hamid Rasheed Goreja, Salman Najam Sheen, Khalid Farooq Danish, Salma Naz Correspondence: Dr. Hamid Rasheed Goreja Senior Registrar Surgery Department Islamic International Medical College & Trust Pakistan Railway Hospital, Rawalpindi E-mail: hamidgoreja@Yahoo.com 35 36 appendicitis, after open appendicectomy the skin can be closed by silk,which is 14applied in interrupted fashion. Conversely prolene or vicryl can be used to close the skin 15as subcuticular running suture. Choice of suture material depends upon a lot of factors including the patient, tissue, anatomical area, surgeon, and economic factors. In this new era a lot of new materials have been invented which make a surgeon's job 17difficult to choose any material for closure. Skin can be closed using sutures in interrupted, subcuticular or mattress fashion using absorbable or non absorbable 18materials. Although the outcomes of surgical skin closure may be influenced by the indication for the procedure, the location of the surgical site, and associated I n t r a o p e r a t i v e a n d p o s t o p e r a t i v e complications, the goal of any skin closure technique is to produce appropriate skin approximation and adequate healing with minimal wound complications, scarring, 16,17pain, and cost. Infections occurring in surgical incisions were initially called wound infections, but 7now called as surgical site infection. Multiple etiological factors are involved in the development of SSI. Efforts should be made to adjust the modifiable risk factors. Cigarette smoking, old age and obesity, choice of suture material and suturing technique are known etiological factors for 20SSI along with the bacteria. T h e m o s t c o m m o n o r g a n i s m i s 21staphylococcus aureus. Surgical site infection is a serious issue which needs to be addressed and efforts should be made at every level starting from the ward, hospital 19,20policy and national level to prevent them. Since appendicectomy is considered as a clean contaminated surgery, therefore most surgeons have a fear of closing the wound in a subcuticular fashion due to high risk of wound infection. This study is planned to alleviate this fear of increased risk of wound i n f e c t i o n i n n o n c o m p l i c a t e d o p e n appendicectomy wound having skin closure with removable subcuticular stitches. A descriptive study was conducted in the Department of Surgery at Pakistan Railway Hospital from 1st Nov, 2009 to 10th June, 2010. Seventy three adult patients of either sex admitted with the diagnosis of non complicated appendicitis were included in the study with convenient sampling technique. Sample size was calculated by using WHO sample size calculator taking confidence level of 95%, population proportion 5% and absolute precision 5%. All male and female adult patients admitted in surgical department who had undergone o p e n a p p e n d i c e c t o m y f o r a c u t e appendicitis and their appendix was non gangrenous and non perforated were included in the study. Exclusion criteria Known diabetic patients, Patients with malignant disease. Patients with chronic liver disease. Patients with chronic renal failure. Patients on steroids. Data Collection All patients were explained about the procedure and an informed written consent was obtained. Right grid iron abdominal Materials and Methods � � � � � incision was used to open the abdomen. Appendicectomy was done. Peritoneum was closed by vicryl 2/0.Interrupted and continuous sutures by vicryl 1 were applied 36 37 to the internal oblique muscle and external oblique appaneurosis respectively. Sub cutaneous tissue was closed by vicryl 2/0 interrupted stitches. In all patients s u b c u t i c u l a r s t i t c h e s b y u s i n g polypropylene 2/0 were applied to close the skin. All the patients received 3 doses of antibiotics (ceftriaxone and metronidazole), 1 at the time of induction of anesthesia and 2 doses post operatively at 12 hour interval. P a t i e n t s w e r e d i s c h a r g e d o n 3 r d postoperative day after examination of the wound. Stitches were removed at 7th post operative day. All the patients were followed on 7th and 30th post operative day for examination. Data was entered in the preformed Proforma (annexed) for analysis. Data was analyzed by using SPSS version 10. Frequency and percentage was used for qualitative variables i.e. wound infection, pain or tenderness, swelling, redness or heat and pus discharge from the incision on 3rd, 7th, and 30th post operative day. Out of 73 patients 6(8.2%) suffered from w o u n d i n f e c t i o n . S u c c e s s f u l o p e n management of the infected wounds was done. Rest of the patients had uneventful recovery. Appendicectomy is considered as a clean contaminated surgery, therefore most surgeons have a fear of closing the wound in Results Discussion a subcuticular fashion due to high risk of wound infection. This study was planned to alleviate this fear of increased risk of wound i n f e c t i o n i n n o n c o m p l i c a t e d o p e n appendicectomy wound having skin closure with removable subcuticular stitches.Our study supports that the wound a f t e r o p e n a p p e n d i c e c t o m y i n n o n perforated non gangrenous appendix can be closed by subcuticular removable sutures by prolene. In our study wound infection occurred in 6 patients (8.2%) only. A randomized controlled trial was conducted by Hamid Ghaderi et al in Imam Khomeini hospital Tehran in 2010 to compare the wound infection rate after open appendicectomy in non complicated appendicitis. They took 278 patients admitted via emergency department and divided them in two groups. In one group the wound was closed by interrupted method and second group wound was closed by subcuticular prolene stitch. They did not find any gross difference in wound infection, 08 patients in interrupted group and 05 patients in subcuticular group with a p value of 0.415. So they concluded that frequency of wound infection doesn't increase with application of non absorbable suture in non open appendicectomy 15wounds. Fashina IB, and associates in 2009 conducted a prospective study in 250 cases of appendicitis in Department of Surgery, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Idi-araba, Lagos, Nigeria. They analyzed the w a y o f p re s e n t a t i o n , m a n a g e m e n t , operative findings and management Figure 1: Frequency of Wound Infection in Study Group (n= 73). wound infection 37 38 outcome in patients of acute appendicitis. They found that 08 % of the patients had 22wound infection. It was controlled clinical trial in which they divided the patients in two groups. In one group the wound was closed interrupted method and other by subcuticular method. They concluded that there is no significant increase in the wound infection rate when wound is closed with 22subcuticular technique. Another study done by A. Hussain and associates to evaluate the wound infection incidence in patients with acute non complicated appendicitis and perforated and gangrenous appendicitis. This was an observational study which was carried out on 400 patients with gangrenous or perforated (50%) and simple appendicitis (50%). Both groups underwent primary wound closure. Wound infections were observed in 15 patients (3.7%), including 6 cases of simple and 9 cases of gangrenous appendicitis which was not statistically 14significant. Frequency of wound infection is 8.2% with removable subcuticular skin suture in non complicated open appendicectomy wound. The result of this study is comparable to studies conducted elsewhere in clean c o n t a m i n a t e d s u r g e r i e s l i k e appendicectomys the wound nfection is 5 10 %. So it is concluded that by using prolene in subcuticular fashion the rate of wound infection does not rise. It implies that the fear of surgeons to close the appendicectomy wounds by subcuticular closure is baseless. It is recommended that the skin should be closed with removable subcuticular sutures in non complicated open appendicectomy Conclusion Recommendations wound as it does not increase the rate of wound infection. References 1. Humes D, Simpson J. Acute appendicitis. BMJ 2006; 333: 530-4. 2. O g u n t o l a A , A d e o t i M , O y e m o l a d e T. Appendicitis: Trends in incidence, age, sex, and seasonal variations in South-Western Nigeria. Ann Afr Med 2010; 9: 213-7. 3. Evans SRT. Appendicitis 2006. Ann Surg 2006; 244: 661-2. 4. Lansdown MRJ, Gray AJG, Treasure T, Layer GT. Appendicectomy: who performs it, when and how? Ann R Coll Surg Engl 2006; 88: 530-4. 5. Chamisa I. A clinicopathological review of 324 appendices removed for acute appendicitis in Durban, South Africa: a retrospective analysis. Ann R Coll Surg Engl 2009; 91: 688-92. 6. Akbulut S, Tas M, Sogutcu N, Arikanoglu Z, B a s b u g M , U l k u A , e t a l . U n u s u a l histopathological findings in appendectomy specimens: A retrospective analysis and literature review. World J Gastroenterol 2011; 17: 1961-70. 7. Adisa A, Omonisi A, Osasan S, Alatise O. C l i n i c o p a t h o l o g i c a l r e v i e w o f schistosomalappendicitis in south western Nigeria. Trop Gastroenterol 2010; 30: 230-2. 8. Lin CH, Chen JH, Li TC, Ho YJ, Lin WC. C h i l d re n p re s e n t i n g a t t h e e m e rg e n c y department with right lower quadrant pain. Kaohsiung J Med Sci 2009; 25: 1-9. 9. Hansson LE, Laurell H, Gunnarsson U. Impact of time in the development of acute appendicitis. Digestive surgery 2008; 25: 394-9. 10. Morishita K, Gushimiyagi M, Hashiguchi M, Stein GH, Tokuda Y. Clinical prediction rule to distinguish pelvic inflammatory disease from acute appendicitis in women of childbearing age. Am J Emerg Med 2007; 25: 152-7. 11. Jamal S, Amin M, Salim M, Mehmood A. C l i n i c o p a t h o l o g i c a l d i a g n o s i s o f a c u t e appendicitis after emergency appendicectomy Rawal Med J 2005; 30: 56-8. 12. Salari AA, Binesh F. Diagnostic value of anorexia in acute appendicitis. Pak J Med Sci 2007; 23: 68-70. 38 39 13. M o h a m e d F , K h o o K K . A c u t e a p p e n d i c i t i s : L e a v i n g n o r m a l l o o k i n g appendices. BMJ 2006; 333: 652. 14. Hussain A, Mahmood H, Geddoa E, James A.Three none: A A new technique for open appendectomy. Prospective non-randomized comparative study. European Surgery 2008; 40: 125-9. 15. Ghaderi H, Shamimi K, Moazzami F, Aminian A, Jalali SM, Afghani R, et al. A new look at an old dogma: wound complications in two methods of skin closure in uncomplicated appendicitis. TUMJ 2010; 68: 54-8. 16. Tajirian AL, Goldberg DJ. A review of sutures and other skin closure materials. J Cosmet Laser Ther 2010; 12: 296-302. 17. Hochberg J, Meyer KM, Marion MD. Suture choice and other methods of skin closure. Surg Clin North Am 2009; 89: 627-41. 18. Gaertner I, Burkhardt T, Beinder E. Scar appearance of different skin and subcutaneous tissue closure techniques in caesarean section: a randomized study. Eur J Obstet Gynecol Reprod Biol 2008; 138: 29-33. 19. Wenzel RP. Minimizing surgical-site infections. N Engl J Med 2010; 362: 75-7. 20. Woodfield JC, Beshay NMY, Pettigrew RA, Plank LD, Van Rij AM. American Society of Anesthesiologists classification of physical status as a predictor of wound infection. ANZ J Surg 2007; 77: 738-41. 21. Anderson DJ, Kaye KS. Staphylococcal surgical site infections. Infect Dis Clin North Am 2009; 23: 53-72. 22. Fashina I, Adesanya A, Atoyebi O, Osinowo O, Atimomo C. Acute appendicitis in Lagos: a review of 250 cases. Postgrad Med J 2009; 16: 268- 73. 39