Meta-Analysis: Skin Closure Methods in Laparoscopic Surgery

This report presents a meta-analysis comparing skin closure methods—sutures, skin glue, and skin clips—following laparoscopic surgery. The study aims to determine which method provides better results in terms of pain and cosmetic outcomes. The methodology involves a critical review of existing l...Read More

All applications must be completed in line with the guidance notes attached as Appendix I.
Applications must be submitted no later than the deadlines stipulated. Contact the Research
Administrator for dates.
Late applications will not be considered.
School of Healthcare Sciences
Research Proposal Form
2016/17
1, Personal Details
Name of applicant:
Please tick where appropriate;
Student: ☐ Full time: ☐ Part Time:☐
Title of Course:
Student Number:
Contact Address:
Email address:
Contact telephone number:
Staff: Department:
Email address:
Proposed start date of Study (m/y):
Proposed end date of study (m/y):
Title of Project: A comparison of the use of skin closure by glue, clip and suture in laparoscopic
surgery

Operative laparoscopy is the common choice in gynaecologic surgery as it is considered
as a minimally invasive procedure (Chen et al. 2010). When compared with traditional open
surgery, laparoscopy surgery scores high in the ground of reduced pain, rapid resumption of
oral intake, improved cosmetic results and shorter span of hospitalization (Chen et al. 2010).
Sutures are most commonly used process for skin closure after surgery. This effective
method of skin closure is time consuming and at times leads to needle-stick injuries for the
surgeon and also demands additional intervention for removal. In order to eliminate these
disadvantages, advanced and alternative skin adhesive method was formulated cyanoacrylate
(Chow et al. 2010). This is a liquid monomer that undergoes exothermic reaction when it comes
in contact with the basic or fluid medium and thus leading to polymerization and subsequent
bonding with skin. Such tissue adhesives negate the requirement hospital visit post release for
removal of stitches and hence considered to be effective in case of paediatric surgery.
However, use of tissue adhesive may substantial increase in wound dehiscence in case if
traumatic lacerations (Chow et al. 2010).
Background of the study
2, Additional Information
Where the project is part of an undergraduate or postgraduate course
Full name of academic supervisor:
Address:
Where the research is being carried out by a member of staff please provide details of co-
investigators
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3, Project Details
3.1 Lay Summary
Operative laparoscopy is now popular in surgery field and is regarded as minimally invasive.
Sutures are most commonly used process for skin closure after laparoscopy surgery. However, this
effective method of skin closure is considered to be time consuming painful and demands superior
expertise. After suture, there came skin clips, this negated requirement for superior expertise in
hand skills. But it too has certain share of disadvantages. In order to eliminate this disadvantages,
advanced and alternative skin adhesive method was formulated, cyanoacrylate. However, use of
tissue adhesive may substantially increase wound dehiscence. In order to ascertain the efficacy of
each of the these methods of wound closure, this study aims to perform a meta-analysis of the
research articles based on the laparoscopic surgery and wound closure via skin clips, suture and
skin adhesive or glue. The research results will help to get a detailed picture of the efficacy of each
process of wound closure with a comparative overview. The end results will also help to elucidate
the best possible method for wound closure in laparoscopic surgery.
3.2 Background and Objectives of Study
Introduction

In order to check the efficacy of skin adhesive, Chen et al. (2010) performed a
randomised control trial. The study showed that laparoscopic port sites at the lower portion of
abdomen sealed with OCT (octyl-cyanoacrylate tissue adhesive) has minimal complications
along with better cosmetic outcomes in women. Identical results were demonstrated in the study
of Jan et al. (2013). The RCT of Jan et al. showed that LiquiBandSurgical S (LBSS) (new
formulation of monomeric n-butyl and 2-OCT) promotes faster laparoscopic skin closure in
comparison to sutures. However, according to NICE UK, sutures when used with TopClosure
Tension Relief System provide better results with wounds having high mechanical stress (NICE
2017). In the regards to skin clips, the study published by Ates et al, (2012) showed that in
laparoscopic appendectomy, the application of titanium endoclip to standardise and control the
appendiceal stump is safe and require shorter time span. Ates et al. (2012) also opined that the
use of skin clips simplifies the overall procedure and can be used as an alternative to
intracorporeal knot tying for appendiceal stump closure.
Problem statement
Reports published in Chen et al. (2010) showed that transcutaneous suture is preferred
in comparison to laparoscopic trocar wounds in comparison to subcuticular suture (absorbable
suture). Chen et al. (2010) also demonstrated several advantages of using adhesive in closure
of laparoscopic incision nut several other studies have highlighted certain disadvantages of use
OCA. According to Matin (2003), the major disadvantages of OCA are difficulty in attaining
familiarity with the exact application of the product. Moreover, OCA can only be applied over dry
and well-approximated incisions. Serious negative foreign body reactions entails if OCA seep
within the incision. Such reaction results in the formation of inflammation, similar to that of
invasive infection reaction. There lies probable risk in application as accidental contact of
surgical gloves and instruments with the adhesive leads to permanent adhesion as the glue
dries extensively fast. So this particular research topic is important in present day scenario at it
aims to provide a comparative overview of the laparoscopic port closed with skin adhesive, skin
clips and suture.
Aim to the study
Extended literature review will be conducted in this study to investigate which form of wound
closure like glue, skin clips and suture is more effective in terms of laparoscopic surgery.

3.3 Principal Research Question
Which form of wound closure namely skin closure by glue, skin clips or suture) provides better
results in terms of pain and cosmetic outcomes in case of laparoscopic surgery?3.4 Methodology
This study will solely be based on the meta-analysis of the secondary data generated as a
result of critical review of literature. Critical review of literature will follow the analysis of the articles
via their steps in the research process which are directed towards testing the effectiveness of the
skin closure methods (skin clips, glue or suture) in closure of laparoscopic wounds. The review of
literature should be framed in such a way that it sets out to answer the focused research questions
(Moher et al. 2015). The meta-analysis will be reported in accordance with the Preferred Reporting
Items for Systemic Reviews and Meta Analyses (PRIMSA Statement) (Moher et al. 2015).
The resources of the Cardiff University library will be extensively used for searching
authentic, relevant and recent research articles which are published in scientific journals. The main
databases that will be used to research research paper include CENTRAL, ScienceDirect,
MEDLINE, Scopus, SciELO, LILACS, ClinicalTrials.gov. In addition, the following grey literature
databases will also be used: ClinicalEvidence.com, OpenGrey.eu, DissOnline.de and NYAM.org.
Moreover, no specialist in the field will be contacted in order to avoid the chances of citation bias.
The selection of the research paper will be included terms related to the intervention.
Boolean search approach will be used in all data bases via using the keywords: “tissue glue”,
“cyanoacrylate”, “ dermabond”, “skin clips”, “closure”, “closure method”, “laparoscopic port”, OR
“Laparoscopy”, and “suture” AND “surgery”. These keywords are specifically selected because they
were stringently derived from the research question and they are utilised in the majority of the
articles, abstracts and titles. Apart from this, other related terms like “skin adhesive”, “wound” will
be used in order to use the sensitivity of the search (Robinson and Dickersin 2002).
The research articles published during the 2000 to 2018 will be considered for the study.
This is because before 2000 there was minimal access towards the laparoscopic surgery (Mayol et
al. 1997). Moreover, this secondary research study will also consider data published in the
government websites of UK like NICE (The National Institute for Health and Care Excellence) and
NHS (National Health Science). The reason for choosing government website is it provides latest
update in the methodology and advancement in the research procedures along the price and the
guidelines for the protocol. The mechanism that will be used for reviewing literature for critical will
be in the form of critical appraisal via using critical appraisal tool (CASP tool: Critical Appraisal Skills
Programme checklist) that will be derived from CASP UK. UK
3.5 Location of study and access arrangements
Location of the study will be University of Cardiff. University of Cardiff, UK has got a hue health
library will comprehensive learning resources in their Cochrane building which is accessible round
the clock for its students. Moreover, home will be the best suited place to learn and study the
literatures thoroughly after extracting the same from the university library. At home, internet is
accessible 24x7 and the administration of Cardiff University enables its students a steady internet
access to browse through the online university library, other databases and recourses.
Has informal consent been obtained to access these facilities/participants?
Yes ☐ No☐ (Please tick where appropriate)
3.6 Resource Implications
(Staff should also stipulate the source of funding for the research)
The laptops and computers are readily available round the clock for all the students at the health
library of Cardiff. The University of Cardiff also allows its students to make print of photocopy of the
research paper. However, the generation of hard cope can only be made via the access through the
student’s account via adding credit to it. Optimal duration of time will be allocating for search and
review of the research papers.

3.8 Project Milestones and Timescales
3.7 Ethical Considerations
Outline the potential ethical issues of the proposed research and how you intend addressing
these issues.
Since the entire study is solely based on the meta-analysis of the randomised control trail and the
data are solely secondary, approval coming from the ethical committee is not required. Zero contact
with the patients’ further rule out the requirement of approval coming from ethical committee.
However, this research will be unique and un-plagiarised and providing plagiarised content is also
considered to be unethical.
Is NHS R & D approval required? Yes ☐ No ☐
If so which Trusts will be required to give approval?
Is NHS Research Ethics Service approval required? Yes☐ No ☐
Does your research involves children and young people? Yes☐No☐
If yes, please indicate whether, or not, you have read and understood the University’s
Safeguarding Children and Vulnerable Adults Policy
A copy of which can be found at: http://www.cardiff.ac.uk/racdv/ethics/guidelines/FINAL
%20Safeguarding%20Children%20&%20VAs%20Policy%202010.doc
Yes- I have read and understand the Policy☐
No – I have not read or understood the Policy☐
(Tick where appropriate)

Activity Start Date Completion Date
(Estimated)
Providing idea to module leader about the
topic
February February
Data collection from secondary sources March March
Drafting the research proposal April April
Discussing topic with supervisor May May
Submission of the proposal form after
approval
May May
Searching articles for the literature review June June
Showing retrieved articles to the supervisor July July
Initiating reading to the selected articles July August
Planning reviewing of literature August September
Writing introduction and verifying the same
with the professor
September October
Drafting methodology October October
Writing literature review October November
Showing the professor the progress November November
Writing the conclusion November December
Proof-reading and final submission December December

3.8 References
Ates, M., Dirican, A., Ince, V., Ara, C., Isik, B. and Yilmaz, S., 2012. Comparison of intracorporeal
knot-tying suture (polyglactin) and titanium endoclips in laparoscopic appendiceal stump closure: a
prospective randomized study. Surgical Laparoscopy Endoscopy & Percutaneous
Techniques, 22(3), pp.226-231.
Aveyard, H. 2014. Doing a literature review in health and social care: a practical guide. 3rd ed.
Maidenhead: McGraw-Hill Education.
Chen, K., Klapper, A.S., Voige, H. and Del Priore, G., 2010. A randomized, controlled study
comparing two standardized closure methods of laparoscopic port sites. JSLS: Journal of the
Society of Laparoendoscopic Surgeons, 14(3), p.391.
Chow, A., Marshall, H., Zacharakis, E., Paraskeva, P. and Purkayastha, S., 2010. Use of tissue glue
for surgical incision closure: a systematic review and meta-analysis of randomized controlled
trials. Journal of the American College of Surgeons, 211(1), pp.114-125.
Gerrish, K. and Lathlean, J. 2015. The research process in nursing. 7th ed. Oxford: Wiley-Blackwell.
Greenhalgh, T. 2014. How to read a paper: the basics of evidence-based medicine. 5th ed. Oxford:
Wiley-Blackwell.
Jan, H., Waters, N., Haines, P. and Kent, A., 2013. LiquiBand® Surgical S topical adhesive versus
sutures for the closure of laparoscopic wounds.A randomized controlled trial. Gynecological
surgery, 10(4), pp.247-252.
Matin, S.F., 2003. Prospective randomized trial of skin adhesive versus sutures for closure of 217
laparoscopic port-site incisions. Journal of the American College of Surgeons, 196(6), pp.845-853.
Mayol, J., Garcia-Aguilar, J., Ortiz-Oshiro, E., Jose, A. and Fernandez-Represa, J.A., 1997. Risks of
the minimal access approach for laparoscopic surgery: multivariate analysis of morbidity related to
umbilical trocar insertion. World journal of surgery, 21(5), pp.529-533.
Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., Shekelle, P. and Stewart,
L.A., 2015. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P)
2015 statement. Systematic reviews, 4(1), p.1.
Moule, P. and Goodman, M. 2013. Nursing research: an introduction. 2nd ed. London: SAGE
Publications.
Parahoo, K. 2014. Nursing research: principles, process and issues. 3rd ed. London: Palgrave
Macmillan.
Parahoo, K. 2014. Nursing research: principles, process and issues. 3rd ed. London: Palgrave
Macmillan.
Rees, C. 2011. An introduction to research for midwives. 3rd ed. Edinburgh: Churchill Livingstone
Robinson, K.A. and Dickersin, K., 2002. Development of a highly sensitive search strategy for the
retrieval of reports of controlled trials using PubMed. International journal of epidemiology, 31(1),
pp.150-153.
TopClosure Tension Relief System for wound closure. 2017. [ebook] England: National Institute for
Health and Care Excellence, p.2. Available at: http://nice.org.uk/guidance/mib97 [Accessed 4 Feb.
2018].

4, Signatures
In signing this form the applicant confirmsthat the relevant health and safety measures,
in accordance with University Policy and School requirements, have been taken into
account for the proposed research.
Applicant:
Name: Date: Signature:
Academic Supervisor:
Name: Date:
Signature:
Clinical Supervisor:
Name: Date:
Signature:
For completion by staff applicants only
Project Mentor
(where applicable)
Name: Date:
Signature
Head of Department
Name: Date:
Signature:

Bibliography
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Robertson, D., Lefebvre, G., Leyland, N., Wolfman, W., Allaire, C., Awadalla, A., Best, C.,
Contestabile, E., Dunn, S., Heywood, M. and Leroux, N., 2010. Adhesion prevention in
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Sajid, M.S., Ladwa, N., Kalra, L., McFall, M., Baig, M.K. and Sains, P., 2013. A meta-analysis
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