Letters to the Editor
Sir,
Re: A simple technique for the retention of a subcuticular suture. Singh-Ranger D. Surg J R Coll Surg Edinb Irel 2003; 1 (3): 149-51.
I agree with Mr Sing-Ranger that it is difficult in the first instance to acquire the skills to perform an adequate subcuticular closure. There are alternatives for the novice. A good absorbable subcutaneous suture, i.e. Vicryl, which is anchored deeply to the lower edge of the subcuticular tissue and subcutaneous fat allows the initial knot to be adequately buried. This is followed by a continuous suture through the above-mentioned layers. These edges are approximated and a distal knot tied and buried in the Aberdeen fashion. This is followed by the ubiquitous metal clips. The leading edge of each clip travels deep to encompass the superficial edge of the subcuticular tissue with the dermis becoming slightly everted. No dog ears, bulky knots or gaping wound edges.
Yours Faithfully,
M.P. Maguire,
Royal Preston Hospital,
Lancashire, U.K.
Sir,
Re: A simple technique for the retention of a subcuticular suture. Singh-Ranger D. Surg J R Coll Surg Edinb Irel 2003; 1 (3): 149-51.
I read with interest the technique of subcuticular wound closure described by Singh-Ranger in your journal. While otherwise well-described, there is an important ambiguity which is also of practical significance to operative surgery. Figure 1b describes the creation of a loop by passing the suture through the dermis perpendicular to the initial suture exit point. However, the text does not specify whether in doing this the suture line for the loop is passed proximal or distal to the initial dermal suture line formed and shown in Figure 1a.
In my experience with this technique it is near impossible to be certain that the second suture line (which is being used to form the loop) is passed in a horizontal dermal plane so as to also coincide with that of the initial suture exit point. This is because continuous sutures are rarely visible save for their entry and exit points. Furthermore, use of a curved needle means the first suture line is not exactly vertical. There is therefore, ample room for passing the loop’s suture line either proximal or distal to the first suture line. Thus, is the author recommending that the second suture line (that for the loop) be passed proximally or distally to the first suture line? Examining Figure 1b, the hashed lines show the loop’s suture line overlapping the initial suture exit point, marked with an asterisk that is not explained by the author. This diagram suggests that the two horizontal dermal planes of the two suture lines overlap at the initial suture’s exit point. In itself this might also suggest that the author recommends the loop’s suture line be passed proximally as, using the diagram, to pass it distally would become a purposeless manoeuvre bringing it anterior to the needle’s initial exit point. However, using this technique during my training I have passed the loop’s suture line distal to the first suture line on several occasions over the years - though clearly always slightly above or below the initial exit needle - yet remaining near its horizontal dermal plane, to produce a secure and cosmetically satisfactory wound.
I have found that there is further practical significance as to whether the loop’s suture line is passed proximally or distally. The latter can form a neater knot as there is no ‘drag’ from the first suture line which can occur if the physical gap between suture lines is minimal, such as when the first suture line cuts through the dermis toward the wound when skin is under tension. Thus, passing the loop’s suture line distally may be preferred for small wounds in areas of cosmetic importance and with little tension. This is important as the author recommends the technique he describes, especially for small wounds, though Figure 1b might suggest he recommends passing it proximally. In my experience the passing of the loop’s suture line proximally is more suitable for large wounds and/or those under tension as it involves more ‘bite’ though, depending on how much proximity there is to the first suture line, a slightly less tidy knot as there is potentially also more drag on it.
Yours Faithfully,
F.H. Zaidi,
Imperial College,
London, U.K.
Sir,
I am grateful to Maguire and Zaidi for taking an interest in the article. Whist I agree with Mr Maguire that there are alternative methods for the novice, the aim of this article was to demonstrate a technique that is simple and easy to master without the use of additional materials to manage wound gaping. With regards to the effective use of resources, metal clips incur an increased cost over subcuticular suture.1,2 There is a vast body of literature that compares the use of metal clips and absorbable subcuticular suture. Metal clips tend to cause more pain on subsequent removal. In one study, when compared with subcuticular suture, metal clips resulted in more pain and increased analgesic requirement in the postoperative period.2
With regards to minimally invasive surgery, where the skin wounds are small, use of subcuticular suture causes less pain than other methods of closure.3 The technique described can be used for small wounds, where perhaps the use of metal clips may not be ideal.
With the described technique, subcuticular suture is, from ‘start to finish’, performed in the same plane and may be the reason why additional materials are not necessary to contend with wound gaping.
I thank Mr Zaidi for his comments. To clarify matters, the technique described can be used with both curved and straight needles. The use of a curved needle in the diagrams were to illustrate, with clarity, the demarcation between suture and needle.
I am sure that there are many other ways of performing this loop including the one mentioned by Mr Zaidi. However, if the whole process of subcuticular suture is performed in the same plane, then I suspect that the issue of drag (and its effect on wound size) becomes insignificant.
REFERENCES
1. Chughtai T, Chen LQ,
Salasidis G et al. Clips versus
suture technique: is there a
difference? Can J Cardiol
2000;16 (11): 1403-7.
2. Ranaboldo CJ, Rowe-Jones
DC. Closure of laparotomy
wounds: skin staples versus
sutures. Br J Surg 1992; 79
(11): 1172-73.
3. Rosen DM, Carlton MA.
Skin closure at laparoscopy. J Am Assoc Gynecol Laparosc
1997; 4 (3): 347-51.
Yours Faithfully,
Mr D. Singh-Ranger,
Northwick Park and St Mark’s Hospitals,
Watford Road,
London, U.K.
Sir,
Re: General surgery units, asymptomatic gallstones and benign prostatic hypertrophy
With the advent of ultrasonography, diagnosis and surgery of asymptomatic gallstones have increased, especially in developing countries. In the central government hospital in Nepal, cholecystectomy is the number-one surgical procedure.1 Ease of detection of gallstones by ultrasonography is one obvious reason for the increase in surgery for cholelithiasis, but this is not the complete explanation. Certain surgical procedures (e.g. vagotomy or partial gastrectomy) are done infrequently and others (e.g. open prostatectomy), previously performed by general surgeons, have been taken over by other subspecialties and/or procedures. But even with the decreased major surgical cases, the operation theatre slots remain the same and more surgical trainees are being produced. It is not surprising that general surgical units operate on asymptomatic gallstones. Unless we provide sufficient major surgical cases to surgeons no amount of guidelines would be effective in minimising unnecessary gallstone surgery.
By contrast, there are long waiting lists for surgery for benign prostatic hypertrophy. Patients frequently wait for months with indwelling catheters. In the central government hospital in Nepal, there is only one urologist, 18 beds, and two operation days per week for the urology unit. In the general surgery units, there are six general surgeons along with other surgical trainees, 48 beds and 4.5 operation days per week.1 But the total outpatient attendance in the urology units is almost half of those at lively general surgery units; for example, two years ago the numbers were 8458 and 16,283, respectively.2 No wonder patients are on queue waiting for urology surgery for more than six months.3 The scarcity of urology service and redundancy of general surgical service seen here reflects the situation in other developing countries. With increasing longevity of the population, the problem is likely to be aggravated.
It is not possible to immediately either increase the urology service or decrease the general surgical service. Should we not place transurethral resection of the prostate, under the care of the general surgery units, leaving other urological conditions to be dealt with by urology units? In general surgery units, consultants and higher specialist trainees, not the basic surgical trainees like those qualifying for MRCS or equivalent could perform cystoscopies and operate on the prostate. This would not only provide relief to the long waiting lists of prostate surgery but also fill the major surgery lists in the operation theatre, thereby, hopefully reducing the unnecessary surgery of asymptomatic gallstones. The domain of general surgery units (particularly in Nepal) may need to be redefined by the availability and requirement of the services for the population. Consideration of patients, not the arbitrary, watertight division of service providers, is the priority. In issues like these, which are linked with global training practice and, thus, promoted worldwide, local suggestions for change alone are unlikely to be effective. Unless international experts address the issue, patients with benign prostatic hypertrophy and asymptomatic gallstones may continue to receive less than optimal service, particularly in developing countries.
REFERENCES
1. Shrestha ML, Shrestha S, Shrestha AK. General surgery unit - footprints of
the last year. Annual Report of Bir Hospital 2002: 37-39.
2. Malla M. Surgical services in Bir Hospital. Annual Report of Bir Hospital
2001: 11-12.
3. Bhatta AD. Activities and constraints of the urology unit. Annual Report of Bir Hospital
2001: 32-33.
Yours Faithfully,
Madhur Dev Bhattarai,
Department of Medicine,
Bir Hospital,
Post Box: 3245,
Kathmandu, Nepal