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Original Article

Evidence-based adoption of purse-string skin

closure for stoma wounds

Nilotpal Behuria a, Jayant Kumar Banerjee b, Sita Ram Ghosh c,

Shrirang Vasant Kulkarni d, Ramanathan Saranga Bharathi d,*
a
Graded Specialist (Surgery & Gastro-intestinal Surgery), INS Patanjali, Karwar, India
b
Professor (Gastro-intestinal Surgery), Bharati Vidyapeeth Medical College, Pune, India
c
Consultant (Surgery), Command Hospital (Southern Command), Pune 411040, India
d
Classified Specialist ( (Surgery) & Gastro-intestinal Surgeon), Command Hospital (Central Command), Lucknow,
India

article info abstract

Article history: Background: Opinion is divided on the optimal technique of skin closure after stoma
Received 3 March 2018 reversal as most conventional techniques compromise either on speed/neatness of wound
Accepted 22 February 2019 apposition or on the incidence of surgical site infection (SSI). Evidence suggests that purse-
Available online xxx string skin closure (PSSC) may achieve both objectives. This study aims to compare con-
ventional primary closure (PC) with PSSC to determine the efficacious technique for stoma
Keywords: wound closure.
Surgical site infection Methods: Patients undergoing stoma reversal between April 2015 and September 2017 were
Purse-string skin closure prospectively studied. Patients were divided into two groups based on the technique of skin
Suture techniques closure (PC or PSSC). The following parameters were assessed: SSI, hospital stay, additional
Abdominal wound closure tech- outpatient visit, wound healing time and patient satisfaction based on a standardised
nique questionnaire.
Surgical stomas Results: Forty one patients underwent stoma reversal (20 PSSC vs 21 PC). Wound infection,
need for wound care, length of hospital stay, healing time and scar size were significantly
less, whereas average patient wound satisfaction scores were significantly more in the
PSSC group.
Conclusion: Purse-string skin closure (PSSC) proves efficacious and hence merits adoption as
the technique of choice for closure of stoma wounds.
© 2019, Armed Forces Medical Services (AFMS). All rights reserved.

* Corresponding author.
E-mail address: sarangabharathi@gmail.com (R. Saranga Bharathi).
https://doi.org/10.1016/j.mjafi.2019.02.009
0377-1237/© 2019, Armed Forces Medical Services (AFMS). All rights reserved.

Please cite this article as: Behuria N et al., Evidence-based adoption of purse-string skin closure for stoma wounds, Medical Journal
Armed Forces India, https://doi.org/10.1016/j.mjafi.2019.02.009
2 medical journal armed forces india xxx (xxxx) xxx

constitutes contaminated surgery. Hence, it is associated with

Introduction significant incidence (up to 41%) of surgical site infection (SSI)
and its sequelae, such as prolonged wound discharge, wound
Temporary stomas are created for a myriad of surgical con- herniation and scarring.2e8 These adversely affect patient
ditions.1 Subsequent stoma reversal, although simple,

Fig. 1 e (a) Primary closure. (b) Purse-string skin closure. (c) Primary closure seen after 10 days. (d) Purse-string skin closure
seen after 10 days with scab at the orifice.

Fig. 2 e (a) Infected primary closure wound. (b) Infected and partially cut through purse-string skin closure wound. (c)
Infected primary closure wound laid open with some granulation. (d) Infected purse-string wound with smaller size and
good granulation.

Please cite this article as: Behuria N et al., Evidence-based adoption of purse-string skin closure for stoma wounds, Medical Journal
Armed Forces India, https://doi.org/10.1016/j.mjafi.2019.02.009
 medical journal armed forces india xxx (xxxx) xxx 3

morbidity, hospital stay, cost and cosmesis.2e8 Therefore, it is

imperative that SSI be minimised while ensuring early and Materials and methods
neat wound apposition.
Conventional techniques of skin closure, such as primary/ All patients undergoing stoma reversal, between April 2015
loose/delayed primary closure with or without drain or sec- and September 2017, at a tertiary care hospital, were included
ondary suturing, compromise on either of the two in this prospective cohort study, after written informed con-
objectives.9e17 Therefore, there is a felt need for adopting an sent of the patients and approval of the Armed Forces Medical
alternative technique that optimally combines the benefits of Research Ethics Committee. This study is registered with the
primary and secondary closure, without the disadvantages of Research Registry (United Kingdom) and bears the unique
either. Purse-string skin closure (PSSC) has been advocated as identity (research registry 3511).
a viable alternative.18,19 Patients underwent either PC or PSSC depending upon the
This study aims to compare conventional primary closure practice of the surgical unit to which patients reported to,
(PC) with PSSC to determine the optimal technique of skin thereby forming two groups for comparison. However, all the
closure for stoma wounds. patients were operated upon by surgeons with equitable
operative experience of more than a decade.
Patients were given clear fluid diet for 24 h before surgery,
and distal bowel wash was administered an evening before
Table-1 e Patient wound healing satisfaction scale. surgery. Part preparation was carried out using depilatory skin
cream. Prophylactic injectable antibioticsdciprofloxacin
Cosmetic aspect
What do you think about the appearance of your scar? 200 mg and metronidazole 500 mgdwere administered at the
1. It looks horrible, it is so disgusting. induction of general anaesthesia, and two more doses were
2. It looks very ugly, I hate it. administered, subsequently, within 24 h. The operative tech-
3. It looks ugly, I don't hate it. niques are outlined in the following section.
4. It is not that great, it doesn't look good.
5. It doesn't bother me, it looks ok.
Operative technique
Patient's satisfaction
Is the appearance of your scar different than what you expected
before surgery? A skin incision was made at the mucocutaneous junction of
1. It looks remarkable worse. the stoma, which was sharply taken down through the ante-
2. It looks worse. rior abdominal wall into the peritoneal cavity. After adhe-
3. This scar is what I expected before surgery. siolysis, end-to-end or side-to-side bowel anastomoses were
4. It looks better. performed using sutures or staples, respectively, and the
5. It looks remarkably better.
bowel was returned into the peritoneal cavity. Transverse
Postoperative pain
fascial closure was performed using No. 1 or I’0 poly-
How did you assess the severity of your pain after the surgery
from the time of surgery until the wound healed? Use a scale of diaxonone suture. Wound was thoroughly washed, and the
5e1, five for slight pain and one for excruciating pain. skin was apposed by either of the following two techniques:
Time of healing
Did your wound heal as fast (or as slow as) you expected.
1. It healed remarkably longer tan I expected.
2. It healed longer than I expected. Table 2 e Demographic and laboratory variables.
3. It healed as fast as I expected.
Variable Purse-string Primary closure p-value<
4. It healed faster than I expected.
skin closure n¼21
5. It healed remarkably faster than I expected.
n¼20
Wound care
Did you have problem with the dressing change? Age in years 52.85 (29e84) 53.05 (25e81) 0.97
1. Yes, it was a nightmare, it paralysed my life, I hated it so Sex (M/F) 16/4 16/5 0.99
much. ASA 0.35
2. Yes, it was so cumbersome and annoying, I hated it. I 8 7
3. Yes, I didn't like it, it bothered me. II 10 14
4. Ni, I didn't like it but it was not a big deal, it was OK. III 2 0
5. No, it was so easy. Anaemia 1 2 1.00
Activity DM type 2 1 3 0.60
After the surgery, did you have to limit your daily activities (eg. Hypertension 2 3 1.00
Grocery shopping, laundry etc.) because of your wound, DM þ hypertension 2 3 1.00
whether it was pain, discomfort, having a dressing, oozing CAD 1 0 0.48
from the dressing or any other reason? BMI in kg/m2 22.5 (14.8e28) 23 (15.3e24) 0.325
1. Very severely limited my activities (could not do anything) Laboratory tests
2. Remarkably limited my activities. Haemoglobin 13.32 (9.9e16.2) 13.53 (9.1e15.3) 0.716
3. Moderately limited my activities. Albumin 3.35 (2.9e3.7) 3.37 (3.1e3.7) 0.705
4. Slightly limited my activities. Creatinine 0.8 (0.4e1.2) 0.86 (0.4e1.1) 0.358
5. Not at all (I did whatever I wanted to do).
Haemoglobin and serum albumin expressed in grams/dL. Serum
1 to 5 are the numerical score for each response. Higher score de- creatine expressed in mg/dL. Values in brackets denote the range.
notes better satisfaction. Total score is calculated by summing up DM, diabetes mellitus; CAD, coronary artery disease; BMI, body
the individual scores of each response. mass index.

Please cite this article as: Behuria N et al., Evidence-based adoption of purse-string skin closure for stoma wounds, Medical Journal
Armed Forces India, https://doi.org/10.1016/j.mjafi.2019.02.009
4 medical journal armed forces india xxx (xxxx) xxx

Table-3 e Surgical and outcome variables. Table- 4 e Studies on stoma wound closure techniques.
Variable PSSC (n-20) PC (n ¼ 21) p-value< Study Year Study No. of SSI
arms patients (n [%])
Type of ostomy 0.669
Ileostomy 14 16 A. Single cohort studies
Colostomy 5 3 Feinberg et al. 9 1987 PC 99 3 (3%)
Jejunostomy 1 2 Lewis et al. 10 1990 PPC 40 1 (3%)
Timing of stoma 23.61 (9.9e16.2) 22.48 0.771 Khoo et all 11 1994 PC 201 1 (0.5%)
closure (weeks) (8e46) Wexner et all 12 1993 SH 66 0 (0%)
Operative time 99.05 (88e110) 99.24 0.907 Garcia-Botello et all 13 2004 PC 109 20 (18.3%)
(minutes) (90e107) Sutton et all 19 2002 PSSC 52 0 (0%)
Complications B. Comparative studies ofconventional closures
Wound infection 1 9 0.0089 Pittman et al. 14 1985 PC 42 8 (19%)
Suture cut through 1 0 0.999 SH 70 2 (2.8%)
Midline sepsis 0 4 0.107 DPC 14 3 (21.4%)
Anastomotic leak 0 1 0.999 Van de Pavoordt 5 1987 PC 26 1 (3.8%)
Incisional hernia 0 1 0.999 PPC 25 2 (8%)
Mean hospital stay 5.8 (4e12) 7.90 (5e12) 0.002 SH 242 5 (2.1%)
(days) Hackam et al. 2 1995 PC 54 22 (41%)
Healing time (days) 22.85 ± 4.26 34.24 ± 6.24 0.001 SH 41 6 (15%)
Additional 1 6 0.0931 Phang et al. 3 1999 PC 315 47 (14.9%)
Outpatient PPC 24 1 (4%)
visits Wong et al. 4 2005 PC 194 18 (9.3%)
Wound satisfaction scale PPC 579 3 (0.4%)
SH 731 2 (0.4%)
Components Ustat Ustat Significance
Lahat et al. (RCT) 16 2005 PC 20 2 (10%)
Cosmetic aspect 388 32 Significant DPC 20 4 (20%)
Patient's 233.88 188.62 Not significant Vermulst et al. 15 2006 PC 25 9 (36%)
expectations SH 37 2 (5%)
Postoperative pain 282 138 Not significant C. Comparative studies with PSSC
Time of healing 365 54.5 Significant Milanchi et al. 21 2009 PC 25 10 (40%)
Wound care 475 24 Significant PSSC 24 0 (0%)
Activity 222.56 155 Not significant Reid et al. (RCT) 22 2010 PC 31 12 (38.7%)
Average patient 398.5 20.5 Significant PSSC 30 2 (6.7%)
satisfaction Marquez et al. 23 2010 PC 61 14 (22.9%)
score PSSC 17 0 (0%)
Values in brackets denote the range. Healing time is expressed as Lee et al. 24 2011 PC 30 5 (16.7%)
mean ± standard deviation. ManneWhitney U test used for wound PSSC 18 1 (5.6%)
satisfaction scale: a ¼ 0.05 (two tailed); U critical ¼ 134. Mirbagheri et al. 25 2012 PC 28 5 (17.9%)
PSSC, purse-string skin closure; PC, primary closure. PC (Penrose 86 9 (10.5%)
drain)
PSSC 28 1 (3.6%)
Camacho-Mauries et al. 26 2013 PC 30 11 (36.6%)
PC: the wound was refashioned into an ellipse, for pre- PSSC 31 0 (0%)
Dusch et al. (RCT) 27 2013 PC 41 10 (24%)
venting dog-earing and closed linearly using interrupted 20 0
PSSC 43 0 (0%)
prolene/nylon (Fig. 1A).
Klink et 28 2013 PC 96 16 (17%)
PSSC: continuous subcuticular 20 0 prolene/nylon suture PSSC 44 2 (5%)
was placed circumferentially around the wound and tight- Li LT et al. 29 2014 PC 40 17 (43%)
ened/tied to leaving a 5e10 mm gap in the middle, which was PSSC 18 1 (6%)
packed with a moist gauze wick (Fig. 1B). SS 68 11 (16%)
Dressings were applied on top, in both techniques, which Loose PC 20 3 (15%)
Habbe et al. 30 2014 PC 81 10 (12.3%)
were removed on the second postoperative day to allow
PSSC 33 0 (0%)
inspection. Lee et al. 31 2014 PC 58 8 (15%)
Patients were administered intravenous fluids for 48e72 h. PSSC 55 1 (2%)
Oral clear fluids were allowed after 6 h of surgery, as per pa- Yoon et al. 32 2015 PC 14 3 (21.4%)
tients’ comfort/desire. Patients were hospitalised until they PSSC 34 0
resumed complete oral nutrition, had return of bowel function Wada et al. 33 2015 PC- (Penrose 29 4 (13.8%)
drain)
and were free of sepsis.
PSSC 26 0 (0%)
Wound was examined from the second postoperative
Alvandipour et al. 34 2016 PC 32 7 (21.8%)
day, daily, until the end of hospitalisation, and patients PSSC 34 1 (2.9%)
were followed up, subsequently, on outpatient basis (Fig. 1C
PSSC, purse-string skin closure; PC- primary closure; PPC- partial
and D). Sutures were removed at 2 weeks after surgery.
primary closure; DPC, delayed primary closure; SH- secondary
Wound infection was treated with removal of affected su- healing; SS- secondary suturing; SSI, surgical site infection.
tures, wound irrigation, antiseptic dressings and, if needed,

Please cite this article as: Behuria N et al., Evidence-based adoption of purse-string skin closure for stoma wounds, Medical Journal
Armed Forces India, https://doi.org/10.1016/j.mjafi.2019.02.009
 medical journal armed forces india xxx (xxxx) xxx 5

oral/parenteral antibiotics (Fig. 2A and B). Once the wound
was healthy and granulating well (Fig. 2C and D), it was
sutured secondarily, or if the wound was small enough, it
was allowed to heal on its own.
Parameters assessed were
i.SSI as per Centre for Disease Control guidelines.20
ii.Hospital stay
iii.Additional outpatient visit
iv. Healing time determined by confirming stable wound
reepithelialization.
v. Patients' satisfaction based on a validated question-
naire, which was administered by the interviewer at 3
months after surgery (Table .1).21
Statistical analysis
The minimum sample size for detecting the difference in
wound healing time and SSI, calculated based on confidence
level of 95%, absolute error margin of 5% and power of 80%,
was 20 and 16, respectively, in each arm. This was calculated
based on the data provided by Camacho-Mauries et al.26
Hence, this study compares 20 patients in the PSSC arm
with 21 patients in the PC arm.
Data were checked for normal distribution using Kolmo-
goroveSmirnov test.
Nominal variables were analyzed using Fisher's exact test;
means were compared using Student's T-test. p value < 0.05
was considered significant.
Ordinal variables were analyzed using ManneWhitney U
test. Ustat  U critical was considered significant.
Statistical analysis was performed with SPSS, version 15.0.
Results
Forty-one patients (32 male, 9 female) with a mean age of 53
years (range: 25e84) and mean body mass index of 22.75 kg/m2
(range: 14.8e28) underwent stoma reversal. Twenty patients
underwent skin closure by PSSC and 21 patients by PC. There
were no differences in the demographic/laboratory variables,
types of ostomies, time of closure and operating time between
the two cohorts; hence, both groups are very well comparable
without any confounding bias. Wound infection (p < 0.0089),
need for wound care, length of hospital stay (p < 0.002),
healing time (p < 0.001) and scar size were less, whereas
average patient wound satisfaction scores were significantly
more in the PSSC group.
The results are summarised in Tables 2 and 3.
Discussion
Stomas are reversed commonly in the clinical background of
previous malignancy, inflammation, steroid use, anaemia and
transfusions, which render the contaminated procedure
further prone to sepsis.21 Hence, numerous conventional
techniques of wound closure have been assessed (Table 4A)

Fig. 3 e (a) Purse-string wound healing from below with granulation tissue. (b) Healed purse-string wound scar akin to the
drain site scar. (c) and (d) Healed midline and primary closure stoma wound scars.

Please cite this article as: Behuria N et al., Evidence-based adoption of purse-string skin closure for stoma wounds, Medical Journal
Armed Forces India, https://doi.org/10.1016/j.mjafi.2019.02.009
6 medical journal armed forces india xxx (xxxx) xxx
and compared (Table 4B) for their efficacy in minimizing
SSI.2e7,9e17 Not surprisingly, most have found leaving the
wound open, either completely or partially, to be effective in
reducing SSI, with the least SSI in wounds left to heal by
secondary intention. However, the need for wound care, pa-
tient discomfort with discharging wounds and ghastly scar
formation preclude their wide use, in favour of PC, for quick
and neat wound apposition, despite higher incidence of
SSI.27,917
With the introduction of PSSC for stoma wounds,18 studies
have compared its efficacy vis a vis conventional closure
techniques (Table 4C) and have found it to be superior in
reducing SSI, as echoed by our results.19,2134 This is again not
surprising as the technique is quintessentially healing by
secondary intention.21,24 The wound heals by granulating
from below (Fig. 3A). The small skin defect heals leaving
behind a small circular scar mark, as is seen at drain sites
(Fig. 3B).24 Hence, it provides the benefit of secondary healing
while providing the apposition akin to PC.35 The central
opening ensures drainage of exudates and allows irrigation of
wounds.21,24,26,35 Even when the purse string partially cuts
through before time, it leaves behind a nicely granulating
wound which has shrunken to fraction of its original size
(Fig. 2 B & D). This renders the wound easier to manage, and
the final scar is much smaller.
PC necessitates enlargement of the wound into an ellipse to
avoid dog-earing.35 When it gets infected (Fig. 2A), dressings
become tedious as sutures have to be removed to express the
exudates.26 Most often, the wounds have to be laid open for
effective wound toilet (Fig. 2C). This renders the wound man-
agement painful, time-consuming, costly and ghastly, as
opposed to PSSC which can well be managed by the patient
himself/herself.26,27 This is reflected by the difference in wound
care scores and hospitalization time in favour of PSSC.21,24
Although healing is quicker in PC than in PSSC, however, only
if not infected.25 When taken as a cohort, the healing time in
PSSC is significantly less, as evident from our results.19,35
Although not assessed in this study, it is obvious that this
would translate into lower cost and less loss of work days.
As regards postoperative pain, there was no difference in
the pain perceived by the patients in either cohort. This is so
because, other than skin closure, the technique and extent of
surgery are essentially the same in both cohorts.
Patients’ perception of wound cosmesis favoured PSSC, as
was objectively evident from smaller eventual scar formation
in PSSC, as compared to PC (Fig. 3).18,24,33,35 Overall, the pa-
tients were satisfied more with PSSC than PC.
Conclusion
PSSC evidently scores over PC by reducing SSI, hospital stay,
need for wound care, healing time and size of the resultant
scar. Hence, PSSC merits adoption as the method of choice for
closure of stoma wounds.
Conflicts of interest
The authors have none to declare.
Please cite this article as: Behuria N et al., Evidence-based adoption of purse-string skin closure for stoma wounds, Medical Journal
Armed Forces India, https://doi.org/10.1016/j.mjafi.2019.02.009
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.mjafi.2019.02.009.
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