|Year : 2015 | Volume
| Issue : 2 | Page : 46-49
Comparative Study of thyroidectomy wound closure using tissue glue versus subcuticular suture
Vinay V Rao1, Caren D'Souza2, Saurabh Kumar3, Ashwin Kumar2
1 Department of Ear, Nose and Throat, Father Muller Medical College, Mangalore, Karnataka, India
2 Department of General Surgery, Kawdoor Sadananda Hegde Medical Academy, Mangalore, Karnataka, India
3 Department of Community Medicine, Father Muller Medical College, Mangalore, Karnataka, India
|Date of Web Publication||8-May-2015|
Vinay V Rao
Department of Ear, Nose and Throat, Father Muller Medical College, Mangalore 575 002, Karnataka
Source of Support: None, Conflict of Interest: None
Background: The purpose of this study is to compare closure of thyroidectomy incisions using octyl-cyanoacrylate (OCA) and traditional subcuticular suturing in terms of wound morbidity and patient satisfaction outcomes. Study Design: A prospective randomized study was performed on adult patients scheduled for thyroidectomy surgery in a tertiary referral center. Patients were randomized to have closure of thyroidectomy incisions using either OCA or subcuticular sutures. Patients were evaluated for scar appearance and pain at the operated site on 1 st and 3 rd postoperative week. Results: Seventy-four patients were enrolled in the study. They were randomly divided into two groups, group 1 (N-36):
OCA was used and group 2 (N-38): Subcuticular sutures were used. Scar appearance was better and pain was relatively less in group 2 in early postoperative phase. Subjective sensation of pain at the operated site in the first postoperative week was more in patients in group 1, which was the only statistically significant finding (P value 0.010). Conclusion: OCA is as effective as conventional method of wound closure. Early postoperative changes of pain and appearance do not vary much. Cost is the major limiting factor in widespread usage.
Keywords: Octyl-cyanoacrylate, pain, scar appearance, subcuticular suture
|How to cite this article:|
Rao VV, D'Souza C, Kumar S, Kumar A. Comparative Study of thyroidectomy wound closure using tissue glue versus subcuticular suture. Thyroid Res Pract 2015;12:46-9
|How to cite this URL:|
Rao VV, D'Souza C, Kumar S, Kumar A. Comparative Study of thyroidectomy wound closure using tissue glue versus subcuticular suture. Thyroid Res Pract [serial online] 2015 [cited 2020 Feb 28];12:46-9. Available from: http://www.thetrp.net/text.asp?2015/12/2/46/156717
| Introduction|| |
Closure of wounds to achieve an esthetically pleasing scar has always been a challenge. Since time immemorial, surgeons have strived to produce "invisible scars". Wound closure techniques have evolved from the earliest suturing materials to resources that include synthetic absorbable sutures, staples, tapes, and adhesive compounds. The ideal method of incision closure should be simple, safe, rapid, inexpensive, painless, bactericidal, and result in optimal cosmetic appearance of the scar.
The use of octyl-cyanoacrylate adhesives (OCA) has been extensively studied for nearly four decades for diverse applications including tissue adhesion, wound closure, hemostasis, closure of cerebrospinal fluid (CSF) leaks, vascular embolization and application of skin grafts. ,
Keeping in mind the changing cosmetic expectations of patients this study was designed to compare the efficacy of OCA with that of the conventional sutures, in closure of thyroidectomy scars.
| Materials and methods|| |
This prospective randomized comparative study was conducted in K S Hegde Medical Academy, Mangalore under the department of Otolaryngology and General Surgery from February 2012 to January 2013. In this period, 142 cases of thyroidectomy were performed. Total of 107 patients were considered eligible to be included in the study, out of which 86 consented to be enrolled, 12 patients were lost in follow-up. The study group (N-74) was randomly divided into two groups; in group 1 (N-36), OCA was used for skin closure. In group 2 (N-38), conventional subcuticular sutures were used.
All patients undergoing total thyroidectomy.
Patients undergoing total throidectomy for malignancy with neck dissection/recurrence/partial excision. Patients with insulin-dependent diabetes mellitus, known bleeding diathesis, known personal or family history of keloid formation or scar hypertrophy or a known allergy to cyanoacrylate compounds or formaldehyde.
Octyl-cyanoacrylate adhesive (Marvilyte) was used by using an applicator.
Ethilon 3-0 subcuticular sutures applied.
The patients were assessed on 1 st and 3 rd post operative week for appearance of the scar using Stony Brook scar evaluation scale (SBSES) and pain using visual analogue Scale (VAS) as shown in [Table 1] and [Figure 1] respectively. , The collected data was analyzed using Statistical Package for the Social Sciences (SPSS software version 12.0.).
|Figure 1: Visual Analogue Scale (VAS)* *Of the various methods for measuring pain the visual analogue scale seems to be the most sensitive|
Click here to view
| Results|| |
A total of 74 patients were randomly divided into two groups. Group 1 (N - 36) consisted of patients where wounds were closed using cyanoacrylate adhesives. Subcuticular sutures were used for closure in Group 2 (N-38) patients. First evaluation was done at the end of 1 st post operative week at the time of discharge. Second evaluation was done at the end of 3 rd postoperative week at the time of first follow-up. Out of the 74 patients, 11 were males and 63 were females [Table 2]. One patient, in group 1, had immediate postoperative wound dehiscence after application of adhesive.
The test results between the two groups were compared for scar appearance and pain using Mann-Whitney U-test and Wilcoxon test for non-normal distribution.
There is no significant difference in the scar healing in the immediate and early postoperative period with either of the technique. Significant difference was observed in the mean ranks of pain score using visual analog scale (VAS) between OCA and subcuticular in the immediate postoperative period [Table 3].
The scar appearance has improved over the period of 3 weeks with both the closure techniques. There was significantly higher pain in the early postoperative period in comparison to the immediate postoperative period with both the techniques [Table 4].
The cost effectiveness in both the groups was also measured and it was found that cost of the material in the case of group 1 was higher.
The time required for closure with OCA could not be compared with the suture closure as it greatly varied based on the expertise of the surgeon.
| Discussion|| |
"Surgeon is known by the scar he gives"; this is a quote, we are quite familiar with. With changing times one thing has not changed much and that is the desire to look better. Since time immemorial, surgeons have strived to produce "invisible scars". Over the time wound closure techniques have evolved from the earliest suturing materials to resources that include synthetic absorbable sutures, staples, tapes, and adhesive compounds. The ideal method of incision closure should be simple, safe, rapid, inexpensive, painless, bactericidal, and result in optimal cosmetic appearance of the scar. 
Thyroidectomy is a surgery commonly performed across the country, in both large volume centers and small hospitals. The incision used for thyroid surgery has become shorter overtime, from the classical 10 cm long Kocher incision to the shortest 15 mm access achieved with minimally invasive video-assisted thyroidectomy. This is mainly to achieve a good cosmetic outcome along with less postoperative morbidity. As this surgery is well described and standardized, we based our study on this surgery to reduce interoperative variations.
Early and uncomplicated wound healing has been a subject of interest over the ages. In general, wound closure biomaterials are divided into three major categories: Suture materials, staples and tissue adhesives. Suturing has been the most widely used method for wound closure because of high reliability of suture materials. However, alternative techniques have long been sought, since suturing technique requires skill and experience, a relatively longer time and the need for its removal. Due to these reasons, surgeons are increasingly using tissue adhesives over sutures for wound closure. 
Although most facial wounds heal without complications, owing to the abundant blood supply of the region, mismanagement may result in infection, wound dehiscence, and unsightly and dysfunctional scar. 
The clinical usage of tissue glue (octyl-cyanoacrylate adhesives) has been extensively studied for diverse applications including tissue adhesion, wound closure, hemostasis, closure of cerebrospinal fluid (CSF) leaks, vascular embolization and application of skin grafts. Developed in 1949, the cyanoacrylate adhesives are applied topically to the outermost skin layer as monomers in a liquid form. On contact with tissue anions, they polymerize forming a strong bond that holds the apposed wound edges together. The cyanoacrylate adhesives usually slough off with wound re-epithelialization within 5-10 days and do not require removal. 
OCA have a number of advantages over conventional sutures like their fast and painless application, rapid setting, which reduces the total operating time and their antibacterial properties. OCA itself acts as a waterproof dressing and helps in reduction in the number of follow-up visits. As they do not require any needles, accidental needle stick injuries are prevented. However, there are certain disadvantages of OCA like their less tensile strength and chances of adhesive seepage, if edges are not properly approximated. ,
Multiple studies showed superior outcome with tissue adhesives as compared to skin sutures. ,,,, however; it is important to remember that dermal suture support is still needed (in wounds that traverse the full thickness) and skin must be held together as the adhesive is applied to prevent the deposition of the cyanoacrylate polymer into the wound, potentially delaying or preventing the healing.  Bernard and coworkers in their prospective comparison of octyl cyanoacrylate tissue adhesive (dermabond) and suture for the closure of excisional wounds in children and adolescents found that the cosmetic outcome of cutaneous excisional surgery wounds closed with standard suturing was found to be superior to that of wounds closed with OCA; , this is supported by Handschel and coworkers in their study on facial wound closures.  David Greene and coworkers in their study found no differences in wound complications, duration of healing, inflammation, or final incision appearance between glue and suture.  In our study, we did not find significant difference between the two techniques, scar appearance was marginally better in patients in whom OCA was used but relatively they experienced greater pain in early postoperative period. One of our patients had wound dehiscence, in whom OCA was used, which is well discussed in various studies, and this could have been due to faulty technique. , None of the wounds got infected thus, rendering the use of tissue glue quite safe. Quinn and co associate, in their study showed that contaminated wounds closed with sutures had higher infection rates compared with those repaired with topical tissue adhesive.  Studies have shown that simple wounds closed by tissue adhesives incur a higher cost but may be preferred by the patients, who show apprehension towards conventional suturing and who are not willing for follow-up for suture removal. 
Cost of OCA has often been mentioned as one of the factors or perhaps differences between the two; in a developing country like ours this subtle difference might appear very significant and can sometimes add burden to the surgical cost. Usage of OCA is as easy and convenient as subcuticular suturing hence; its use is entirely preferential and not mandatory. Studies having long-term follow-up and larger number of patients can give us more insight in use of OCA; however, this study can pave the road in realizing that.
| Conclusion|| |
Octyl-cyanoacrylate adhesive are quite effective and novel technique of wound closure. When compared with conventional suturing for throidectomy wounds, not much variation was found in terms of pain and scar appearance in early postoperative period. Cost is the major deterrent in usage of tissue glue; however, wide spectrum of clinical application can be exploited.
| References|| |
Singer AJ, Thode HC Jr. A review of the literature on octylcyanoacrylate tissue adhesive. Am J Surg 2004;187:238-48.
Coulthard P, Esposito M, Worthington HV, van der Elst M, van Waes OJ, Darcey J. Tissue adhesives for closure of surgical incisions. Cochrane Database Syst Rev 2010;12:CD004287.
Fearmonti R, Bond J, Erdmann D, Levinson H. A review of scar scales and scar measuring devices. Eplasty 2010;10:e43.
Huskisson EC. Measurement of pain. Lancet 1974;2:1127-31.
Shivamurthy DM, Singh S, Reddy S. Comparison of octyl-2-cyanoacrylate and conventional sutures in facial skin closure. Natl J Maxillofac Surg 2010;1:15-9.
Toriumi DM, O'Grady K, Desai D, Bagal A. Use of octyl-2-cyanoacrylate for skin closure in facial plastic surgery. Plast Reconstr Surg 1998;102:2209-19.
Bernard L, Doyle J, Friedlander SF, Eichenfield LF, Gibbs NF, Cunningham BB. A prospective comparison of octyl cyanoacrylate tissue adhesive (dermabond) and suture for the closure of excisional wounds in children and adolescents. Arch Dermatol 2001;137:1177-80.
Jallali N, Haji A, Watson CJ. A prospective randomized trial comparing 2-octyl cyanoacrylate to conventional suturing in closure of laparoscopic cholecystectomy incisions. J Laparoendosc Adv Surg Tech A 2004;14:209-11.
Man SY, Wong EM, Ng YC, Lau PF, Chan MS, Lopez V, et al
. Cost-consequence analysis comparing 2-octyl cyanoacrylate tissue adhesive and suture for closure of simple lacerations: A randomized controlled trial. Ann Emerg Med 2009;53:189-97.
Handschel JG, Depprich RA, Dirksen D, Runte C, Zimmermann A, Kübler NR. A prospective comparison of octyl-2-cyanoacrylate and suture in standardized facial wounds. Int J Oral Maxillofac Surg 2006;35:318-23.
Greene D, Koch RJ, Goode RL. Efficacy of octyl-2-cyanoacrylate tissue glue in blepharoplasty. A Prospective controlled study of wound-healing characteristics. Arch Facial Plast Surg 1999;1:292-6.
Singer AJ, Quinn JV, Hollander JE. The cyanoacrylate topical skin adhesives. Am J Emerg Med 2008;26:490-6.
Dragu A, Unglaub F, Schwarz S, Beier JP, Kneser U, Bach AD, et al
. Foreign body reaction after usage of tissue adhesives for skin closure: A case report and review of the literature. Arch Orthop Trauma Surg 2009;129:167-9.
Quinn J, Maw J, Ramotar K, Wenckebach, Wells G. Octylcyanoacrylate tissue adhesive versus suture wound repair in a contaminated wound model. Surgery 1997;122:69-72.
[Table 1], [Table 2], [Table 3], [Table 4]