Non-suture closure of wound using cyanoacrylate.
Basic and vitally important procedures in surgical operations are techniques of joining and uniting tissues. Among these, suturing with the needle is still the most commonly practised method. However, it is time consuming. The final appearance of the healed wound is not always satisfactory e.g. cross-hatching of the stitches. To overcome these disadvantages, various other methods like clips, adhesive strips and plastic adhesives have been investigated.
In the present study, cyanoacrylate, a plastic adhesive, was used in skin closure of various operations with an aim to find out (i) time consumed, (2) incidence of infection (iii) cosmetic result.
Use of cyanoacrylate in skin closure was studied in 30 cases, in the age group of 16 to 65 years, undergoing routine planned surgery over a period of six months from September 1983 to March 1984. Twenty five other patients in the same age group undergoing similar procedures were taken as control in whom skin was closed with 4/0 monofilament (nylon) polyamide using simple surgical sutures. The operations undertaken were herniorrhaphy, appendicectomy, exploratory laparotomy, cervical lymph node biopsy, submandibular lymph node excision, hemithyroidectomy, myomectomy, lipoma excision, varicocele, tubal ligations, closure of leak following exteriorisation of ileal perforation and suprapubic fistula. The incisions were located on all Darts of the body and varied between 3 and 17 cm in length.
Procedure of closing incision
In closing the incision, following criteria were fulfilled prior to the application of the adhesive on the approximated skin edges (1) absolute haemostasis, (2) use of absorable material for the subcutaneous layer, (3) good approximation of skin edges and dry field prior to the closure of the skin.
After the deeper layers were sutured in individual cases, complete haemostasis was achieved in the subcutaneous plane. This was followed by meticulous suturing of the subcutaneous layer by 3/0 chromic catgut to obtain good approximation of the skin edges. The operative field was then cleaned with saline and allowed to dry.
In the control group the skin was sutured with 4/o monofilament polyamide using simple sutures.
In the study group, the ends of the skin incision were held with a forceps so as to appose the skin edges. The compound N-butyl-cyanoacrylate was applied directly over the edges in droplet form. The apposition of the edges was maintained with the forceps till polymerization of the cyanoacrylate was completed as indicated by the opacification of the adhesive. This process of polymerization took at an average 30-45 seconds. Time was measured from the start of skin closure to its completion.
Clean and dry dressings were applied. The wounds were evaluated after 48 hours and at discharge, except in infected cases.
The sutures as well as the adhesive were removed at the end of the 7th day or the 10th day depending on the procedure. The adhesive was removed by the application of ether or acetone. Resultant scar was seen after 4 weeks of surgery.
(A) Time taken for skin closure
[Table - 1] shows the time taken for closure of the skin. It was persistently seen that the time taken for closure of the skin incision was less when cyanoacrylate was used. Longer the incision greater the time difference was seen.
(B) Incidence of infection
In the control group of 25 cases where the suture technique was used, 8 showed inflammatory reaction (32%). In 4, there was a serous discharge on the fifth postoperative day (16%). In the study group where cyanoacrylate was used, 2 out of 28 cases showed evidence of inflammation (7.14%). One case of discharge from the wound was seen (3.57%). Only 1 of the 28 cases using cyanoacrylate showed evidence of frank infection and required secondary suturing (3.57%). Three out of the 25 cases which were sutured showed evidence of infection (12%).
(C) Cosmetic results
Single beautiful linear scar was seen after cyanoacrylate [Fig. 1] as compared to the cross hatching of suture marks which were seen after the use of suture material.
Closure of the ileal leak following exteriorization of the ileal loop for perforation using cyanoacrylate seemed to be successful till 48 hours when it gave way. However, successful closure of the suprapubic leak using cyanoacrylate was seen after its applications on the approximated skin edges.
Advances in anaesthesia and surgery have not been paralleled by the advances in the treatment of wound problems. Skin closure is one of the many factors that are involved, in wound problems. This work was carried out to study the efficacy of cyanoacrylate as an adhesive in the skin closure as compared to the conventional suture technique.
The results of the study clearly demonstrate that cyanoacrylate has a definite place in skin closure and that it is better with regards to (1) time consumption (2) incidence of infection (3) cosmetic result. Kaplan, in his experimental study has shown that the time required to close the incision using the adhesive is 4th as compared to the suture technique.
Incidence of infection
If primary healing is to be intended, mechanical means are necessary to keep the wound edges in apposition until the healing process has reached a certain stage. It is essential that the method of closure itself does not disturb the healing process. The conventional technique for wound closure with sutures may cause disturbance of healing process by stitch infection, foreign body reaction, increased inflammatory reaction and interference to circulation' within the wound.
Wound infection has been shown to be more in suture technique. Sutures provide an extra source of contamination via suture canal, perisutural cuff of dead epidermis, dermis and subcutaneous fat. It provides all the factors necessary to initiate infection in following ways: by (1) providing route of entry from skin to subcutaneous tissue, (2) providing route of entry from intradermal structures, hair follicles, sebaceous glands etc, (3) maintaining patency of tract for 5-10 days, (4) causing foreign body reaction with associated local tissue autolysis, so that sutures can break down the tissue barrier into more infected intradermal structures (e.g. sebaceous gland) which were not open at the time of initial passage of suture and (5) due to foreign body reaction and local tissue autolysis, likelihood of suture to be bathed in liquified protein which will both proliferate and increase the activity of bacteria.
Carpendale and Sereda, in their studies, showed that wound infection is higher with suture material as compared to use of adhesive tapes working on the same principle as cyanoacrylate. They tied sutures to nonincised skin and showed 10.8% infection rate. Tissue adhesive like cyanoacrylate leaves no such tract for infection to traverse in the subcutaneous tissues. There is no intradermal invasion or significant foreign body reaction produced. Brunius and Zederfeldt in their study on white rats showed that tensile strength of incisions with non-suture technique was higher than that of sutured wounds for a healing period of 7-60 days. There was less degree of inflammatory reaction and evidence of early maturation of scar in the non-suture technique.
In our study, excellent cosmetic results were obtained using cyanoacrylate. Similar observations have been made by various other authors., , , 
Bromberg, et al have effectively used the adhesive on experimental animals to anastomose blood vessels. Weilbalche et al have effectively used this monomer in gastrointestinal anastomosis in experimental animals. The adhesive has also been used in (1) pyelolithotomy-to close renal pelvis (ii) ureterotomy-to close incisional opening (iii) nephrectomy-for adhesions of the renal parenchyma.