Closing 5mm trocar holes

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Kind of trivial topic, but...What do you do for these?

At my med school we used to just pinch and use glue.
During residency I've seen a few ways with monocryl...
1. Single buried suture
2. Single horizontal mattress
3. Untied Subcuticular suture with ends cut after glue

I tend to prefer the glue only option on fatter people with redundant skin and no tension, and if my attendings insist on suture I like the horizontal mattress.

My least favorite is the buried suture because I can never get the edges to get close enough.

I do the single inverted suture, however, you have to make sure your tails of the suture aren't crossed, otherwise the edges won't come together. I complete it with a steristip and tell the patients not to remove the steristrips for at least 2 weeks.

Originally Posted by filter07

Kind of trivial topic, but...What do you do for these?

At my med school we used to just pinch and use glue.
During residency I've seen a few ways with monocryl...
1. Single buried suture
2. Single horizontal mattress
3. Untied Subcuticular suture with ends cut after glue

I tend to prefer the glue only option on fatter people with redundant skin and no tension, and if my attendings insist on suture I like the horizontal mattress.

My least favorite is the buried suture because I can never get the edges to get close enough.

I close 5mm trocar incisions with an inverted subcuticular using a 4-0 monocryl, and I've been very happy with the short and long-term cosmetic outcomes. I do believe that dermabond is almost as good, although it's difficult to evert the edges with that.

The main reason I don't do dermabond is because this is the medical student's time to shine. They look forward to closing those small incisions, and they put a lot of TLC into the closure...I'm not going to take that away from them.

Most places I have been let me close with the single buried stitch, then throw dermabond over it so the patient doesn't see how bad it looks until they leave the hospital.

I've used both a single burried stitch and a SubQ with good results. I had some trouble with good approximation early on but realized that I when I throw my knots that if I pull the suture parallel with the incision I get good results. Early on I was pulling the knot tight by pulling the free ends perpendicular which always left me with a big gap for those pesky small trocar holes. Throw some tegaderm over that and even questionable technique looks decent, med students best friend so far.

Keep in mind that each ampule of Dermabond is $27 and a Monocryl or Vicryl is about $7/pack (Nylon is ~ $4.75). Dermabond is a significant and unnecessary expense. Your fixed costs for procedures are going to be increasingly tracked, and you need to pay attention to these things. All methods for paying you in the future being discussed involve cost-sharing incentives that will penalize you for every cost involved in your procedures. Something to think about.

I started out using a single buried 4-0 , but lately have switched to a horizontal mattress, I feel like I get better purchase out of the suture in terms of wound closure and it removes the need to use dermabond excessively like droliver alluded to.

Originally Posted by droliver

Keep in mind that each ampule of Dermabond is $27 and a Monocryl or Vicryl is about $7/pack (Nylon is ~ $4.75). Dermabond is a significant and unnecessary expense. Your fixed costs for procedures are going to be increasingly tracked, and you need to pay attention to these things. All methods for paying you in the future being discussed involve cost-sharing incentives that will penalize you for every cost involved in your procedures. Something to think about.

How much is mastosol and steristrip? That would work just as effectively, I would think.

The single buried stitch is hard to get perfect but it is all in how much tissue you grab as you are turning your wrist. Too much or too little and it looks like crap. The horizontal mattress is ok as long as you place it well. Too much tissue and it bunches, too little and it isn't closed. I assume no one does something external (like an interrupted nylon) but why not. If it is just about not wanting to bring them back to take out the stitch what about a monocryl interrupted (we do this to close the stab incision for a tunneled dialysis cath to avoid any chance of catching the tube-when the inside absorbs the outside falls off, but I haven't tried it for a port site ever). As for the cost difference, I think you would have to take into account the difference in OR time. Closing plus dermabond would be more expensive obviously, but I wonder if dermabond only would save you enough OR time that the costs would even out? Or steri strip only for that matter (and do you really need the mastisol or benzoin? I use mastisol when I place steris in the OR because we have it nearby and it is habit, but when I use it elsewhere and don't want to find it I just use them plain and it seems to be fine as long as there isn't tension.

Originally Posted by Jambo1

I started out using a single buried 4-0 , but lately have switched to a horizontal mattress, I feel like I get better purchase out of the suture in terms of wound closure and it removes the need to use dermabond excessively like droliver alluded to.

The secret to a good inverted subcuticular stitch is to make a large tissue purchase. Little wimpy bites lead to the figure-of-eight look. Also, I tend to take the dermal bite as close as I can to the surface without causing dimpling.

My main issue with the "U-stitch" that I think you're describing is that the knot is at skin level, and patients are often irritated by this. They complain that it itches or feels weird. In general, since they can see it and can feel it, it generates more questions and more patient unhappiness. I also think the immediate cosmetic outcome is better with the buried stitch.

droliver, as our main plastics contributor, I'd be interested to hear what you think about the longer-term cosmetic outcomes of these different closure methods (buried subcuticular, u-stitch, knots vs. knotless, dermabond, staples, simple prolenes). Does it make a difference, or do they all look the same in a few months?

One of our plastics guys claims you could use staple to close the face even and it would look fine as long as you took the out soon enough (and had appropriate deep closure)

Originally Posted by dpmd

One of our plastics guys claims you could use staple to close the face even and it would look fine as long as you took the out soon enough (and had appropriate deep closure)

The OB/GYN literature would agree with this. They've shown similar short and long-term cosmetic outcomes when comparing staples to subcuticular stitches....but they also take their staples out way faster than we do.

The Gyn literature has also shown a decreased rate of SSI when you close the subcutaneous fat (versus just fascia and skin). To be honest, I tend to ignore the OB/GYN literature....some of their stuff is a little off-the-wall.

Originally Posted by SLUser11

The OB/GYN literature would agree with this. They've shown similar short and long-term cosmetic outcomes when comparing staples to subcuticular stitches....but they also take their staples out way faster than we do.

The Gyn literature has also shown a decreased rate of SSI when you close the subcutaneous fat (versus just fascia and skin). To be honest, I tend to ignore the OB/GYN literature....some of their stuff is a little off-the-wall.

If we closed a layer in betwen fascia and skin then in theory we coud the staples out earlier (deep dermal, not sure actual sub q would help). For a outpt surg it would mean sooner f/u though for removal

Originally Posted by SLUser11

The OB/GYN literature would agree with this. They've shown similar short and long-term cosmetic outcomes when comparing staples to subcuticular stitches....but they also take their staples out way faster than we do.

Yeah I was surprised to find this out when they took out my wife's staples on POD 3 after a C-section.

Originally Posted by Dirt

Yeah I was surprised to find this out when they took out my wife's staples on POD 3 after a C-section.

I think pfannenstiel incisions are more forgiving. Sure, there are more young healthy ladies getting c-sections than big abdominal operations, but little old ladies getting the TAH/BSO do well with the pfannies as well.

Since starting fellowship, I've become a huge fan of the low-transverse incision. It can be used for specimen extraction or for hand-assist during Lap totals/sigmoids/LARs/pouches. If the case gets too tough laparoscopically, you can do the rectal dissection with an open technique through the pfannie as well. The scars look really nice and hide well.

Originally Posted by dpmd

The single buried stitch is hard to get perfect but it is all in how much tissue you grab as you are turning your wrist. Too much or too little and it looks like crap. The horizontal mattress is ok as long as you place it well. Too much tissue and it bunches, too little and it isn't closed. I assume no one does something external (like an interrupted nylon) but why not. If it is just about not wanting to bring them back to take out the stitch what about a monocryl interrupted (we do this to close the stab incision for a tunneled dialysis cath to avoid any chance of catching the tube-when the inside absorbs the outside falls off, but I haven't tried it for a port site ever). As for the cost difference, I think you would have to take into account the difference in OR time. Closing plus dermabond would be more expensive obviously, but I wonder if dermabond only would save you enough OR time that the costs would even out? Or steri strip only for that matter (and do you really need the mastisol or benzoin? I use mastisol when I place steris in the OR because we have it nearby and it is habit, but when I use it elsewhere and don't want to find it I just use them plain and it seems to be fine as long as there isn't tension.

How about the pediatric surgery X-stitch? I don't know what it's actually called, but it's the deep-->superficial, deep-->superficial stitch that everts the edges.

Originally Posted by droliver

Keep in mind that each ampule of Dermabond is $27 and a Monocryl or Vicryl is about $7/pack (Nylon is ~ $4.75). Dermabond is a significant and unnecessary expense. Your fixed costs for procedures are going to be increasingly tracked, and you need to pay attention to these things. All methods for paying you in the future being discussed involve cost-sharing incentives that will penalize you for every cost involved in your procedures. Something to think about.

The flip side is that it might save you a minute or two in the OR, and I've been quoted a rate of $60/minute for OR time.

Originally Posted by SLUser11

I think pfannenstiel incisions are more forgiving. Sure, there are more young healthy ladies getting c-sections than big abdominal operations, but little old ladies getting the TAH/BSO do well with the pfannies as well.

Since starting fellowship, I've become a huge fan of the low-transverse incision. It can be used for specimen extraction or for hand-assist during Lap totals/sigmoids/LARs/pouches. If the case gets too tough laparoscopically, you can do the rectal dissection with an open technique through the pfannie as well. The scars look really nice and hide well.

Yeah, I've only done one general case through a Pfannenstiel, but I wish we had more use for it.

Originally Posted by TheProwler

The flip side is that it might save you a minute or two in the OR, and I've been quoted a rate of $60/minute for OR time.

That calculation for true costs is an exercise in theoretical bull**** in the real world, as that kind of productivity hit is impossible to quantify and makes assumptions about time management that don't really exist. Loses of small blocks of time are not really addable in a meaningful way to merely state that your gain/loss in productivity is just the sum of those events. If you can't show it on an invoice or balance sheet, it really doesn't exist to an administrator. Watch your OR director roll their eyes the next time you promise them some new toy will save them time and pay for themselves!

ie..... your hypothetical 1-2 minutes per case (which is inaccurate IMO as by the time you have to wait for the glue to completely dry you've usually taken longer for a short suture and dressing to be applied) doesn't really produce a meaningful gain in OR or employee utilization at the end of the day the way hospital schedules and staffing shifts run. You're not going to save enough time from something like that to move the needle enough to do more cases in a day per room or require fewer hospital staff. The gains in time have to be independent events (as opposed to a bunch of little separate ones) with bigger chunks (10-20 mins) to materially affect your costs on a predictable basis.

Originally Posted by SLUser11

droliver, as our main plastics contributor, I'd be interested to hear what you think about the longer-term cosmetic outcomes of these different closure methods (buried subcuticular, u-stitch, knots vs. knotless, dermabond, staples, simple prolenes). Does it make a difference, or do they all look the same in a few months?

So much of what makes a good scar is out of your direct control (ie. location of an incision or a person's biologic propensity for inflammation) that I'm coming to peace with the idea that it's really not all in my hands.

1. It's my impression that the smallest gauge absorbable suture (I usually use monocryl) you can get away with for dermal and subcuticular closures tends to scar better, presumably from less residual inflammation of the suture material.

2. I like glue as a dressing after I've already closed things because they can shower immediately. I'm not really convinced it makes a scar better.

3. staples are bad karma, and frequently produce a lot of hatch marks. About the only place they're preferable is on the scalp as it produces less scar alopecia then sutures. They're also a pain in the ass to take out, an important consideration in what you'll choose to put on a patient.

4. braided absorbables (vicryl and dexon) scar worse when used for subcuticular closure as they cause more inflammation. They are fine for deeper dermal closure, but they will spit a lot more then monofilaments absorbable.

5. steristrips/paper tape or silicone sheeting of incisions are really the only interventions that have much evidence they affect scarring much. Everything else (scar gaurd, mederma, etc...) is pretty soft evidence-wise. Paper tape is by far the cheapest material for this.

Originally Posted by droliver

steristrips/paper tape or silicone sheeting of incisions are really the only interventions that have much evidence they affect scarring much. Everything else (scar gaurd, mederma, etc...) is pretty soft evidence-wise. Paper tape is by far the cheapest material for this.

I was on plastics shortly after my thyroidectomy so I asked for recs on my incision. He grabbed a roll of paper tape and cut me a little strip to cover it with. I sort of thought he was crazy until later when I realized how faint my scar was. Between that and a determination to avoid sun exposure there for a year (scarves became my friends) it kept me from having my typical hyperpigmented scar. Now I pass those tips on to my patients who ask or are having an incision on a noticeable place.

Originally Posted by droliver

paper tape

That's pretty interesting. Do we just put a piece of paper tape over the incision after suture closure (i.e. no dermabond)? Do we put any tension on it to bring the wound edges together? How long should it stay on there? Can it be replaced or reinforced if soiled?

Originally Posted by droliver

That calculation for true costs is an exercise in theoretical bull**** in the real world, as that kind of productivity hit is impossible to quantify and makes assumptions about time management that don't really exist. Loses of small blocks of time are not really addable in a meaningful way to merely state that your gain/loss in productivity is just the sum of those events. If you can't show it on an invoice or balance sheet, it really doesn't exist to an administrator. Watch your OR director roll their eyes the next time you promise them some new toy will save them time and pay for themselves!

If you use Dermabond, isn't the patient being billed for the cost? As long as it's a reimbursable item, why is the manager going to give you grief?

Originally Posted by TheProwler

If you use Dermabond, isn't the patient being billed for the cost? As long as it's a reimbursable item, why is the manager going to give you grief?

It's not a reimbursable item, but comes out of the global DRG payment they get. Everything is itemized for charges and they can track your supplies on cases. Hospitals already put pressure on us for supplies, dressings, trochars, implants etc... on a cost basis reflecting this.

Coming soon, the whole idea of cost sharing b/w providers and hospitals is going to be coming down over how to split the lump sum (which will go to the hospital BTW). On planet earth, we're NOT going to get paid more for using less resources, but we WILL be penalized for using more. ie. using Dermabond will get you paid $X less as you fee is capitated before expenses.

Originally Posted by droliver

It's not a reimbursable item, but comes out of the global DRG payment they get. Everything is itemized for charges and they can track your supplies on cases. Hospitals already put pressure on us for supplies, dressings, trochars, implants etc... on a cost basis reflecting this.

Are there any broad categories you can lump things into in terms of what is a reimbursable item and what is not? E.g., staplers are, PTFE graft is, but suture isn't.

Coming soon, the whole idea of cost sharing b/w providers and hospitals is going to be coming down over how to split the lump sum (which will go to the hospital BTW). On planet earth, we're NOT going to get paid more for using less resources, but we WILL be penalized for using more. ie. using Dermabond will get you paid $X less as you fee is capitated before expenses.

wish I were surprised...

Originally Posted by SLUser11

That's pretty interesting. Do we just put a piece of paper tape over the incision after suture closure (i.e. no dermabond)? Do we put any tension on it to bring the wound edges together? How long should it stay on there? Can it be replaced or reinforced if soiled?

I'm a medical student, but in the OR, we would use the steri-strip rather than paper tape, I'm guessing because the first dressing is sterile. After leaving the OR, paper tape can be used because sterility is no longer a concern. I believe the whole point of this intervention is to take the tension off of the scar and be put onto the steri-strip or paper tape so that the scar doesn't widen. So you place the tape on one side and pull that over and tape to the other side so the tension of the scar in keeping the skin on either side together is now on the tape. My understanding from plastics rotations is this can be done for as long as up to 6 months or a year but is usually until the patient can tolerate. The ones that are better about this seem to have less scar widening and a better result, though of course not drastic due to all the other factors involved and I would guess this is probably why time is not spent to preach this for every incision. Of course it can be replaced or reinforced if soiled, I think the point is to have the tension off of the scar as much as possible during the initial time period so there is less widening and it remains faint.

I would think if you put dermabond in the OR so the patient could go ahead and shower you would just start with the paper tape/steri-stripping whenever afterwards. I don't think I've seen steri-strip over dermabond ever. I don't think it'd be a problem but just because it doesn't seem like there was a point to the dermabond if you're going to still cover it.

Taping a wound provides compression, which is good for scar reduction.

I agree with droliver. Most of scarring is out of our control. A laparotomy incision will always look worse than a thyroidectomy incision. Skin thickness and mobility have much more do to with the final result than choice of suture.

I'm an ENT and most of my incisions are on the face or neck and they usually look great. Occasionally, I'll get asked to remove something from the upper back or shoulders and those scars usually look terrible. It is not really because I'm such a great surgeon on the face and then suddenly a terrible surgeon on the upper back. The scar potential is just vastly different between say an upper blepharoplasty incision and mole excision from the shoulder.

Originally Posted by SLUser11

That's pretty interesting. Do we just put a piece of paper tape over the incision after suture closure (i.e. no dermabond)? Do we put any tension on it to bring the wound edges together? How long should it stay on there? Can it be replaced or reinforced if soiled?

I found some literature:
RCT comparing paper tape to no intervention

Rat study that addresses the physiology

Haven't read this one yet

It sounds cheap and effective. This may change my practice...

Where is the evidence that says a patient can't shower after being sutured as opposed to dermabond?

Originally Posted by mrblair020

Where is the evidence that says a patient can't shower after being sutured as opposed to dermabond?

I've heard that it takes 48 hours for the wound to epithelialize, so you don't want to be putting tap water in there before that.

Originally Posted by TheProwler

I've heard that it takes 48 hours for the wound to epithelialize, so you don't want to be putting tap water in there before that.

I have heard this, followed this, and taught this to other people but I have no real evidence that this is how things should be done. I'm thinking of all the times I have cut myself on accident and how I didn't hesitate to clean with soap and water immediately and ad lib afterward. The one time I was cut bad enough to need stitches though I kept that puppy dry for a while. Something about the foreign bodies sitting there that is worrisome I guess. I would like to see a study comparing a same day shower (with normal soap) versus waiting a couple of days. Some of my patients would really benefit from an early shower (or at least those around them would).

Originally Posted by dpmd

I have heard this, followed this, and taught this to other people but I have no real evidence that this is how things should be done. I'm thinking of all the times I have cut myself on accident and how I didn't hesitate to clean with soap and water immediately and ad lib afterward. The one time I was cut bad enough to need stitches though I kept that puppy dry for a while. Something about the foreign bodies sitting there that is worrisome I guess. I would like to see a study comparing a same day shower (with normal soap) versus waiting a couple of days. Some of my patients would really benefit from an early shower (or at least those around them would).

It's different with an open wound though - you can definitely wash that. It's just like washing a lac on a trauma patient before you close it.

I got in trouble as a resident for letting patient shower like on POD #5.

I and most of my PRS colleagues here allow patients to shower 24-48 hours post-op. So far we haven't seen an excess of infections/dehiscence etc from dreaded tap water getting into the incisions (which are typically covered with Proxi-strips).

By POD #5, we're usually encouraging our patients to shower. I think 24-48 hours is probably our standard.

Originally Posted by TheProwler

By POD #5, we're usually encouraging our patients to shower.

I know...that attending was just a crazy bitch. Everyone else was POD #5 dressing down, shower. One, who was a Hopkins grad, insisted on POD #2.

I think 24-48 hours is probably our standard.

Its what I see in practice as well.

In residency, we took all dressings down POD 2 and left them open to air.

In my PP now, the nurses where I work are used to changing the dressing on POD 2 to a sterile, waterproof dressing and showering patients after the new dressing is on. My wound infection rate is ridiculously low so maybe there is something to it.

When I had a reconstructive surgery on my ear, initially the gs teaching nurse told me I wouldn't be able to wash my hair for FIVE days (I jokingly told my PD I wouldn't come back til I could wash my hair). I was delighted to wake up post op and have the plastics residents tell me I could was my hair the next day. Anectdotally, nothing bad happened.