Analysis of the effectiveness of wound closure techniques among surgeons and emergency physicians in Mecca Hospitals: Retrospective Cohort Study

Objective: Wound suturing is a procedure performed at many medical specialties. This study aims to analyze the effectiveness of wound closure techniques by recognizing the common suturing techniques and materials that used in different type of wounds among surgeons and emergency physicians and to assess the rate of scars formation among their patients in-Mecca City Hospitals, Saudi Arabia. Results: Every participant selects and prefers some methods in wound closure over other methods. Choosing the simple interrupted technique exceeded 50% for all types of studied wounds. The other most common techniques among participants were subcuticular and vertical mattress respectively, also using stabler was limited to some wound types with less percentage than other suture techniques. Regarding suturing material, there are many materials alternatives were selected for the studied wounds such as 23% of participants used Monocryl for eyelid wounds, and 6% for breast wounds, also 9% of participants were using Polypropylene for scalp wounds and 8% for eyelids wounds. This study showed a high level of awareness among participants with a signicant p-values regarding the important factors affecting wound healing and scare formation.

techniques among participants were subcuticular and vertical mattress respectively, also using stabler was limited to some wound types with less percentage than other suture techniques. Regarding suturing material, there are many materials alternatives were selected for the studied wounds such as 23% of participants used Monocryl for eyelid wounds, and 6% for breast wounds, also 9% of participants were using Polypropylene for scalp wounds and 8% for eyelids wounds. This study showed a high level of awareness among participants with a signi cant p-values regarding the important factors affecting wound healing and scare formation.

Introduction:
Wound suturing and laceration closure are frequent procedures performed at many surgical and Emergency departments. Different suturing techniques are used to treat patients who are undergoing any surgical closure such as skin suture, adipose, tendon, and muscle, either wound injury conditions or surgical operations. Skin and any wound defects can be repaired via several suture techniques and materials which are available for surgeons and medical practitioners. The selection of which depends on many different variables that affect the outcome of the procedure. A lot of verities of suturing materials and needles are available. The choice of sutures and needles is determined by the location of the lesion, the type and the thickness of the tissue at that location, and the amount of tension exerted on the wound (1). Several studies compared between different techniques according to certain variables and their effect on the outcomes, some of these variables are wound complication, speed of repair, cosmoses, patient and physician satisfaction, and cost of repair (2). The good suturing techniques depend mainly on eliminating dead space in subcutaneous tissues. minimizing tension that causes wound separation. also, involving correct wound placement concerning relaxed tension lines. (3) many studies have been conducted to compare different suturing techniques. A study investigated different suture methods for patient satisfaction, wound healing, and treatment cost in patients with scalp laceration, found There are many alternatives such as adhesions and staples that have more advantages than simple suture (4,5).
Other studies showed that cosmetic pleasing and patient satisfaction which they signi cantly better in the running horizontal matters and running subcuticular sutures technique than the traditional simple interrupted-are considered as important factors that assess the effect of the suture technique. (6,7,8).
Another randomized controlled trial of subcuticular versus interrupted skin suturing aimed to compare the super cial incisional surgical site infection rate after cesarean section (CS) in obese women and the result was "Subcuticular skin closure during CS was signi cantly associated with better short-term cosmetic outcome, less skin closure time". (9) This study aim is to analyze the effectiveness of wound closure techniques by knowing the common suturing technique and the common types and materials of sutures that used in the closure of Eyelids wound, Scalp wound, Facial wound, Breast wound, Buttocks wound, Skin wound (other than those mentioned above), and Fascial Plication that used among surgeons and emergency physicians in Mecca City Hospitals, Saudi Arabia. And to know the rate of scars formation among the surgeons and EM physicians during their practice of wound closure.

Method:
A retrospective cohort study was conducted among general surgery (GS) and Emergency (EM) physicians of surgical and Emergency departments who were enrolling and preforming any suture procedure to investigate their practice of suturing on their patients who underwent any wound closure procedure for different skin wounds at the last year in the seven different hospitals of Mecca, Saudi Arabia. Research committee approval was obtained, and a sample of 172 surgeons and EM physicians were calculated to give us 80% power with an alpha level of 5%. A random generator software was used for randomization.
A strati ed random sampling technique was applied to an equal number of surgeons and EM physicians from both departments of the seven different hospitals of Mecca City. they were asked about their practice regarding their suturing technique and the type of materials for the different wound types which included eyelid wounds, Scalp wounds, Facial wounds, Breast wounds, Buttocks wounds, Skin wound (other than those mentioned above), and Fascial Plication. During 2 months of period, the data was collected by using a self-administered questionnaire on an electronic sheet that included demographic information, suture techniques, and materials about different wound types, and the factors affect the rate of scars. Practice on patients with certain conditions was not be included in the study such as patients with hematological disorders, autoimmune disease, liver diseases, diabetes mellitus, thyroid diseases, renal diseases, and immunode ciency. Verbal and written consent was obtained from all participants.
However, those who did not participate in lling up the survey were respected. Statistical analysis was performed using SPSS software. sample descriptive statics (mean, median, SD range) were applied on demographic data, and deferent suturing techniques and materials. Chi-square and T-test were used to assess the level of awareness for surgeons and ER physicians about the factors that have a role in the rate of scar formation which was assessed via a Likert scale.

Results:
In our study, we surveyed a total of 172 participants and we summarized the nding on Figure1 which is showing the common types of suturing techniques. Most of the responses were about using the simple interrupted technique in a different type of wounds that mentioned in the study. Moreover, the number of participants who choose the simple interrupted technique among other types of techniques exceed 50% for all types of the mentioned wounds. The second and the third common techniques were used among participants were subcuticular and vertical mattress respectively, depending on the type of the wound. However, the use of stabler was limited just to some of the wound types with less percentage than in other suture techniques.
Figure2: It shows the uses of different types of suturing material, 23% of participants use Monocryl for eyelids wounds, and 6% for breast wounds. Polypropylene is chosen to be used in different types of wounds 9% of participants using it for scalp wounds and 8% for eyelids wounds. Silk suture was one of the most commonly used suture materials among our participants especially for facial wounds 13%. Fascial Plication was commonly closed by Polylactic acid sutures which represent 10% of its uses. There is also the polyglycolic acid which was commonly used over the other materials.
However, the wound healing has many stages to be successful; any factor that will interfere during this process will result in improper healing. This study assessed the awareness of the surgeons and EM physicians about how much these factors (which include: Wound Position, Wound tension, Using the proper suturing technique, Using the proper suturing material, Nutritional de ciencies, Systemic diseases: (Diabetes mellitus), Age of the patient.) will have a strong impact on the rate of scar formation. In gure 3 the results show a high level of awareness with a signi cant p-value less than 0.01 for (Wound Position, wound tension, using the proper suturing technique, Using the proper suturing material, nutritional de ciencies) and equal to 0.017 for (Systemic diseases) and 0.044 for (Age of the patient).

Discussion:
The present study was conducted to analyze the effectiveness of wound closure techniques by knowing the common suturing technique and the common type and materials of sutures that used in the closure of Eyelids wound, Scalp wound, Facial wound, Breast wound, Buttocks wound, Skin wound (other than mentioned above), and Fascial Plication that used among surgeons and emergency physicians in Mecca Hospitals, Saudi Arabia. The nding of this study represents that there are no certain methods used from all participants in their practice of suturing regarding the speci c types of wounds that have been mentioned in the study. Every surgeon and EM physician select and prefer some methods in wound closure over other methods which may affect wound closure outcomes among practitioners. However, the previous studies also showed that many suture techniques used nowadays, some of them used more frequently than others due to their advantages and suitability. the most common and fundamental technique of wound closure is a simple interrupted suture. (3) This is similar as in our participants were most of them choose the simple interrupted technique among other types of techniques with a percentage of using that to exceed 50% for all types of the mentioned wounds, consequently, this lead us to the urgent need for increased education and awareness for selecting this type of technique just in designated site of the skin and avoiding other sites especially in face or breast. The interrupted sutures are easy to place, possess greater tensile strength, and have less potential to cause wound edema and impaired circulation. (3) However, subcuticular suture technique which resembles the second most common technique in our study is used more frequently in breast and facial wound, the literature showed that this technique is used more than the traditional simple interrupted to enhance the cosmetic result and showed its effectiveness, it is also useful for closing wounds with equal tissue thickness in which virtually no tension exists. (6,9) Another suture technique is vertical mattress suture which was the third most common technique in this study and used more frequently in buttock wound, also the literature showed that it is a very common technique and useful in maximizing the wound eversion, reducing dead space and minimizing tension across the wound. (3) The use of staplers in the closure of scalp wounds have more advantages than simple suture in regards to patient satisfaction, wound healing, and treatment cost. (4) however, in our study, 5.20% of the participants choose staplers in scalp wounds which are a very low percentage in comparison to 77.90% who are choosing the simple interrupted technique in scalp wounds which is not considered as the best technique for scalp wound according to the previous studies. (5) Moreover, there are much different suturing material can be used in different types of wounds, apart from what is the most suitable types of material, the selection of good material in wound closure may contribute in satisfactory outcomes ether in wound healing processes, cosmetic pleasing or any other expected outcomes. This study has not shown certain types of material that are used from all participants in their practice, but some materials are more frequently used than other such as polyglycolic acid, Silk, Polylactic acid, Monocryl, Polypropylene, and catgut. Therefore, there must be awareness and intensive education regarding the proper use of material with the area and the level of the wound, because it seems there is a wide verity of using material without strict guidelines. On the other hand to know the rate of scars formation among the surgeons and ER physicians during their practice of wound closure the study evaluates their awareness about the factors that affect the rate of scar formation. The results showed very satisfactory signi cant p values for their high level of awareness about all the mentioned factors in the study which is going to re ect their practice attitude about the scar formation. Still, the lack of evidence and guidelines for selecting the proper type of suture technique and materials lead to some limitation in analyzing the effectiveness of the most common suture technique and materials, this study depends in its comparison upon different previous studies that were studying few methods which have been mentioned, whereas the other methods have not been studied yet. So our recommendation is to consider new criteria for selecting the most proper type of suture technique and material that can be applied to all the different types of wounds by surgeons and EM physicians to have the optimum outcomes in any wound closure procedure.

Conclusions:
This study provides an insight into the most common suture methods used among surgeons and emergency physicians in Mecca Hospitals. The results suggest that there are different suture techniques and materials used in different types of wound closure, some of the techniques and materials are better and frequently used than others in different wound conditions. Besides, there are wide variations in selecting these techniques and materials among surgeons and emergency physicians which is going to re ect on the outcome result of wounds suture among them. However, intensive education and awareness must be conducted regarding the proper use of techniques and materials in skin suturing and closure, while it has been noticed signi cantly that the awareness of the factors which lead to scar formation has been addressed already.

Limitation:
The limitations of this study were represented in the potential for information bias during data collection in receiving answers by using online questionnaire rather than submitting the questionnaire physically and this study was conducted among participants from limited hospitals.

Figure 1
The different types of suturing techniques regarding certain types of wounds.  The different types of suturing material regarding certain types of wounds.