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HC30761 Database Searching

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HC30761 Database Searching

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Course Code: HC30761
University: Central Queensland University

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Country: Australia

Question:

Does listening to music help surgical patients?
In patients undergoing surgery under regional anaesthesia does listening to music compared with no music or white noise reduce anxiety and increase patient wellbeing?
Does the job you do affect how long you live?
In people aged 50 or more is being unemployed or in a poorly paid job compared with being in a highly paid job associated with a shorter life?
How do day surgery patients deal with stress?
Identify relevant indexed terms

Indexed terms/subject headings

– Identify key concepts/topics
– Vary between databases
–Not all databases have them!

Match keywords to terms

Answer:

Introduction
Laparoscopic surgery is a form of surgery which is minimally invasive; the surgeon uses a key hole to assess the desired body organ (Robinson et al 2004). It is a modern surgical method whereby operations are undertaken via small incisions (normally 0.5 to 1.5 centimeter) elsewhere in the body. Laparoscopic surgery an advantage over common, open procedure, because both hemorrhaging and pain are decreased as a result of smaller incisions alongside shorter recovery time (Rosen et al 2005). The use laparoscope is the key element in this laparoscopic surgery together with a long fiber optic cable system that allows the affected area to be viewed through a snaking cable from a distant, yet more effortlessly accessible destination. The laparoscopic surgery entails operations within pelvic and abdominal cavities while the keyhole surgery undertaken on chest and thoracic cavity is known as thoracoscopic surgery. The laparoscopic surgical surgery wound closure can be done using glues, clips and sutures (Singer et al 2004). The glue is never put in wound but on a wound (outside the wound) whereby the surgeon pinches the skin edges together when they are dry and placing a drop of glue on the top of the wound (Chow et al 2010). This glue has tiny threads that make it stronger as fiberglass therefore it prevents gaping and eliminates bandaging. A suture is a threadlike substance used by surgeons to hold tissues together following the surgery. Suturing entails use of a needle with attached length thread. There are both absorbable and non-absorbable sutures based on the degradeability of the materials used to make the suture by the body. Examples of absorbable sutures are original catgut and newer synthetics polylactic acid, polyglycolic acid, caprolactone and polydioxane. Examples of non-absorbable sutures are made of silk or synthetic polyester, nylon or polypropylene. Clips have “teeth’ that offer better clamping and wound closure of skin. The clips are also easy to remove following recovery and have less trauma and usable with existing 9mm removers and applies. They are perfect for swiftly closing wounds as they provide maximum holding force with fewer traumas, and remain much easier and swifter to use as opposed to traditional sutures.
This extended literature review is designed to critically review the existing literature and compare the use of skin closure by glue, clip, and suture in laparoscopic surgery to determine the safety as well as the efficacy of the three materials. A review of ten RCT studies is done to compare all these wound closure substances.
In essence, a surgical incision closure method has to be economical, time saving, simple to perform, as well as provide an optimal cosmetic outcome. Albeit sutures are frequently used in surgery, unlimited number of reviews are available in the field which compares or even assessment the qualities and attributes of the sutures.  Over the decades, the study on critical wound healing has culminated in the technological advamncement of staples and tissues adhesive methods. Scientist and medical researchers have conducted studies to analyze the different types materials used for wound closure including laser assisted tissue bonding (Simohon, Gabay and Shpolyansky et al,,, 2015).
Research Question: 
Which are the most effective wound closure methods (glue, clip, or sutures) in laparoscopic surgery?
Aim and objectives of the study:
This study is aimed at investigating which wound closure technique is most effective during laparoscopic surgery
Specific objectives:

To determine which closure technique leads to optimal cosmetic appearance and less wound complications.
Identifying which wound closure technique (suture, glue or clip) provide the most patient satisfaction after laparoscopic surgery.
Investigating which wound closure technique leads to the quickest wound healing duration

Tissue Adhesives: 
Many methods are available for wound closures like glues, clips and sutures (Ebersole and Choudhury 2018). However, the most commonly used material is sutured(Norton and Ischy 2017). Nevertheless, new techniques have been introduced such as tissue adhesives and adhesive paper tape. In the year 1949, a cyanoacrylate tissue adhesive was developed by a German chemist which was utilized for the first time in 1959 by a British plastic surgeon (Buchweitz et al. 2016).  In 1998, Food and Drug Association (FDA) approved Octyl-2-cyanoacrylate or OCA for use in wound closure. It often begins to work upon being applied within ten seconds. The stabilizer gets neutralized by partly ionized water molecules on the surface of the skin that eventually trigger polymerization of molecules (Antoniou et al. 2016). The OCA, interestingly, breaking strength is almost 5-times that of monofilament nylon sutures. The HVOCA (high-viscosity octyl-2-cyanoacrylate) is a newer formulation which is thicker as opposed to the initial OCA (Buchweitz et al. 2016). The high-viscosity has an advantage of risk reduction; the adhesive is applied away from the wound, there-by enhancing the cosmetics of the skin. Under five-ten days, the adhesive sloughs of generally as the wound re-epithelialize (Chen et al. 2010). Premature sloughing of the adhesive could arise from topical ointment alongside frequent wound cleansing when it is treated with OCA. Many new reports have illustrated the OCA effectiveness of skin closure in a broad range of clinical context as well as surgical subspecialists (Park et al.  2015). The wound has to be evaluated before the application of the adhesive for the subcutaneous sutures placement to reduce the tension of the wound, elimination of subcutaneous dead space as well as maximization of skin edge eversion (Buchweitz et al. 2016).   
Uses, pros, and cons of tissue adhesives (glue)
Uses 
Tissues adhesives have already been utilized for decades in both major and minor skin closure procedures. These materials have widespread applications and indications and have been utilized for tissue adhesion, implants fixation, cerebrospinal fluid leaks closure as well as blood vessels’ embolization (Buchweitz et al. 2016).  Besides, these materials are currently being utilized for groin wounds, facial wounds, laparoscopic surgical wounds, blepharoplasty, hand surgery, and lacrimal punctum closure as well as hair transplantation.    
Pros: 
Many pros of tissue adhesives have been identified in comparison to skin sutures and other techniques of closure of wounds, like reduced rate of infection, minimal time in operation room, better cosmetic outcomes, cost-effectiveness, easy to use, instant sealing of wound, swifter return to work and athletic activities, needle-stick injuries elimination alongside removal of the need for post-operative suture removal (Kane et al. 2018). These tissue adhesives are further easier as well as more friendly when children are the subjects (Buchweitz et al.  2016). Furthermore, OCA has an undoubted safety record; as no report of adverse effects or even carcinogenicity has been reported. Recent studies have interestingly demonstrated that OCA utilization bars growth of bacteria and further preventing the Gram-positive bacterial wound infections (Dowson et al. 2006). Moreover, the OCA remains a good technique for closure of wound for patients at high risk of hypertrophic or keloid scar formation. Hence, surgical doctors could consider tissue adhesive as the substitute technique to sutures.  
Cons: 
Some limitations have been discovered on the use of OCA notwithstanding its costs that might be more than 4 times as costly as sutures. Besides, OCA requires effective patient selection as well as is solely for the exterior use (Matin 2003). Furthermore, OCA utilization calls for a meticulous method, because there is a need for no gap between the margins of skin and the bleeding. Even in the presence of small gaps, the adhesives could seep through and hence preventing the epithelialization, eventually disrupting the healing of the wound (Matin 2003)
Contraindication:
The tissue adhesives complications are the increased susceptibility to infections, ulceration/gangrene, oozing or bleeding from incision (Chen et al. 2010). Others include incision under massive tension calling for sutured approximation or even edematous wound edges, burns, partly-thickness skin loss, animal bites, across muco-cutaneous junction or mucosal surfaces, high moisture area or dense hair, as well as high tension areas like joints (Chen et al. 2010). Tissue adhesives remain contraindicated further in patients at high risk of delayed healing of wound including diabetic and collagen vascular illness and also among the OCA-allergic patients.
Comparison: 
The initial prospective RCT was undertaken by Maartense et al. that compared the techniques of closure by use of OCA, adhesive paper tape/poliglecaprone in the elective laparoscopic surgery (Maartense et al. 2002). This study discovered that laparoscopic trocar wounds closure with OCA reduces the duration of the surgical procedure however; it was the most costly of the three techniques. Adhesive paper tape stood the fastest, cheapest as well as most cost-effective technique. The cosmetic outcome stood significant better for OCA as opposed to adhesive paper tape (Mueller, Kenton, and Anger, et al 2016). Moreover, OCA was attributed to fewer infections of the wound compared to sutures. Additional subsequent studies have further demonstrated the antimicrobial influences of tissue adhesives. A recent research/Cochrane review indicated that no variation in the wound infections rates or wound dehiscence between the sutures and HVOCAs (Barto 2003).
A RCT undertaken by (Zempsky et al 2014) accomplished similar cosmetic outcomes with decreased cost utilizing adhesive tape closure as opposed to tissue glue in facial lacerations amongst children. The study conducted by (Brown et al 2009) shown that an enhanced cosmetic result when suturing was utilized to close wounds engaging tissue excision, leading to higher tension of wound. The corresponding cosmetic outcome with OCA alongside sutured closure utilization was satisfactory. A prospective RCT indicated that skin closure in the traumatic wounds utilizing 2-OCA produced outcomes that were comparable to those of the standard sutured closure in respect of rates of infection, long-term cosmetic outcome and dehiscence (Maartense et al. 2002).
Adhesive Tapes: 
The surgical adhesive tapes often entail an adhesive backing entailing iso-octo-acrylate together with n-vinyl-pryolidone. The ideal surgical adhesive tape needs to be non-allergic, water-resistant, non-irritating, vapor permeable as well as have to be strictly adhered to skin (Buchweitz et al. 2016). Adhesive tapes are utilized most often as adjunctive wound assistance/support following staples or even sutures removal, together with buried dermal sutures, or even with absorbable running subcuticular sutures in the less-tension wounds (Buchweitz et al. 2016). The application of surgical adhesive tapes in the parallel, non-overlapping fashion following coating the whole area of application with the adjuvant adhesive remains the optimal application method which showed the best adherence over a period of time, as well as several significant variables in tape application have been noted encompassing dry skin acute edges’ apposition, strict homeostasis as well as utilization of an adhesive adjunct; besides, tension has to be disseminated along the whole tape to bar blisters (Maartense et al. 2002).
Uses, Pros and Cons
Uses   
Suture-less skin closure using adhesive tape is able to bar local skin tension, reduce overall cost as well as decrease time consumed in operating room. (Maartense et al 2002). Furthermore, this method permits swifter tensile strength equal restoration or eve superior at ten days as opposed to sutured wounds. Tension of skin equal in the entire length of incision as well as this technique helps evade post-operative “railroad track” scaring for the sutures (Chen et al. 2010). The micro porous strips permits passage of water and gas from the surface of skin that makes environment unfavorable for the proliferation of bacteria and hence leading to lower infection of the wound (Chen et al. 2010). The study conducted by (Gohil, Lakhawala and Patel 2018) study showed that wounds sealed with skin tapes stood resistant to infection. Moreover there is reduced infection rate of the taped wounds at 3.8% against 14.0% for the wounds closed by skin sutures in those patients with clean adulterated wounds (Matin 2003)
Cons: 
The use of tapes is not highly recommended because of the poor reliability in their adhesive features (Dowson et al. 2006). They are prone to losing their adhesiveness as time passes by hence culminating in wound dehiscence. The adhesiveness variability is linked to the variation in knowledge and skills of operator utilizing the tape (Kane et al. 2018). The main cons of the tape ae the difficulties in ensuring accurate skin edge apposition as well as skin edge eversion. Moreover, the operating room time-saving pros is in increased doubt (Gibson et al 2011). Furthermore, it has been discovered that skin edges stood usually challenging to accurately estimate (Park et al.  2015). In order to guarantee tape adhesiveness, skin edges have to remain dry and strict hemostasis has to stay absolute (Siu et al. 2002). These tapes can as well trigger injury to epidermis in the course of placement as well as removal. A research undertaken by Sarifakioglu et al., undertook the comparison between the adhesive strength of tincture of benzoin as well as transparent film dressing spray, and the authors visibly illustrated that tincture of benzoin surges the adhesiveness of these tapes by nearly seven times, while merely two-fold surge was recorded with transparent film dressing spray (Park et al.  2015)
Sutures: 
Suturing has been classified as the oldest method of suturing. Wound closure by sutures is described by the Egyptian Scroll that traces back to 3500 BC (Chen et al. 2010). The use tendons of animals, strips of leather, horsehair, vegetable fibers, strips as well as human hair are the oldest forms of suture materials that were used in the medieval age.
In the new age sutures were made from silk which is a biologic material for example catgut. Today sutures are made synthetically they can be absorbable or non-absorbable (Chen et al 2010). In surgical literature, debates have existed relating to the “ideal suture substance”. For the repair of skin, the ideal substance needs to be unreactive in tissue, inject no foreign reaction to the body, have a fine caliber alongside smooth surface, as well as remain strong alongside easy to handle(Chen et al. 2010). Moreover, it has to have secure knotting attributes alongside minimum trauma must arise from its insertion. Moreover, suturing substance has to contain some qualities of handling to be used effectively. Suture infection risk, strength, power of tissue-holding, type of incision alongside suturing method remain significant variables for making a decision on what particular suture type for closure of wound(Buchweitz et al. 2016). Staples/sutures are commonly used since they avail the desired mechanical support. A broad range of suture substances stay accessible to the present-day surgeons (Buchweitz et al. 2016). The suture choice of a given procedure must be anchored on known biological alongside physical attributes of suture substance, technique as well as sutured tissues’ healing properties (Buchweitz et al. 2016). Nevertheless, the suture materials’ availability alongside the surgeon personal preferences has key roles to play.
Types of Suture: 
Suture are categorized as absorbable or permanent, natural or synthetic as well as multi-filament or monofilament. The multi-filament suture as the easiest to handle and have preferable knot-tying attributes (Buchweitz et al. 2016). Nevertheless, bacteria are able to make their way in the braided interstices and thus escaping phagocytosis culminating in suture infection, sinuses and granulomas. Conversely, monofilament sutures trigger substantially less tissue reactions and remain easily glided via the tissue (Buchweitz et al. 2016). Their cons encompass high package shape retention, hard to handle, insecurity in knotting, and cutting via the tissue.
Absorbable Suture Materials
The main characteristic of absorbable sutures is the reduction of elasticity within 60 days after  placement (Al-mubarak and Al-haddad 2013). They need to be absorbed with little or even no tissue reaction at an anticipated rate suitable for the period of the desired tissue support. They are utilized mainly as buried sutures for closing dermis as well as subcutaneous tissue alongside in the reduction of wound tension (Antoniou et al. 2016). These absorbable sutures conventionally have never been recommended for closure of skin, mainly because of unsightly formation of railroad track. The solely natural absorbable suture recommendable is surgical gut/catgut sutures. The synthetic multi-filament substances encompass polyglycolic acid (Antoniou et al. 2016). On the other hand, the monofilaments forms encompass polydioxanone (Buchweitz et al. 2016). The table below summarizes the types of the sutures and absorbable sutures:
Commonly used Absorbable sutures    
Non-absorbable sutures are known for their resistance to degradation by living tissues as well as for being most helpful in percutaneous closures (Buchweitz et al. 2016). The surgical silk, steel, line and cotton remain among the typical natural examples of these materials. Synthetic non-absorbable monofilament sutures are commonly utilized in cutaneous processes and encompass polypropylene, nylon as well as polybutester (Maartense et al. 2002). Synthetic non-absorbable multi-filament sutures comprised of polyester and nylon are commonly utilized in dermatologic surgery.  
Commonly used non-absorbable sutures
Generally, braided sutures potentiate high infections as opposed to non-braided ones. The contaminated wounds with braided Vicryl suture closure leads to one hundred percent rate of wound infection (Chen et al. 2010). Conversely, contaminated wounds that are non-braided suture-closure indicate a substantially lowered wound infection incidence. Several surgeons favor non-absorbable monofilament sutures due to their gliding ease through the tissue, ease of handling, and minimum inflammatory response alongside unlikeliness of premature break (Chen et al. 2010). Others favor absorbable ones as a result of needless of future removal alongside time-saving and lowered patient discomfort and anxiety. The major disadvantage of non-absorbable sutures is they have to be removed between five and ten days following placement (Bou et al. 2015). Such a need necessitates another visit by physician, usually culminating in missed work as well as higher costs.
Absorbable sutures have an increased ease of handling, reduced reactivity alongside effective tensile strength, as well as cost less compared to the non-absorbable sutures (Chen et al. 2010). Various additional studies have compared absorbable and non-absorbable sutures and have subsequently showed no significant differences in regards to wound appearances alongside rates of infection and hence concluded that clean facial wounds were linked to low rates of infections irrespective of the technique of repair (Matin 2003).      
Studies conducted indicate that no clinical significant variations in cosmetic appearance between non-absorbable and absorbable sutures following 90 days after placement (Dowson et al. 2006). It is reported that there is no clinical difference in scores of cosmetics between plain catgut against nylon sutures within pediatric lacerations following four to five months of placement (Chow et al. 2010). It was revealed that 3-point corner stich had the greatest capillary blood flow at tip in the initial post-operative time (Kane et al. 2018). When compared to absorbable sutures, monofilament nylon type decreased the risk of hypertonic scaring primarily in the sternotomy scars. 3 out of 5 RCT trials that compared staples with sutures unraveled that the rate of complication was much lower with sutures (Kane et al. 2018). Excitedly, 2/5 of studies noted that sutures were superior cosmetically. Higher complication rates were experienced in superficial wounds that were closed using metallic staple as opposed to the ones closed with subcuticular vicryl (Kane et al. 2018). No difference in long-run cosmetics outcomes of repair using absorbable or non-absorbable suture substances in adults patients that had clean wound on neck or face (Dumville et al. 2014). This new formulation’s tensile strength is decreased by fifty percent following five days as opposed to initial Vicryl that has thirty-five reduction at fourteen days; moreover, no traction is left following the fourteen days ( Sarifakioglu and Sarifakioglu 2006).
Clips: 
In long skin incision, skin staples are an effective method for wound closure compared to staples because they are cost effective and time effective during closure (Shetty et al 2004). Staples require more time during removal (Tajirian and Goldberg 2010). Studies show that metal staples lead to a faster healing compared to other forms of wound closure, but they increase the risk of developing infection (Shetty et al., 2004; Joshi et al., 2007; Cross et al., 2009). Staples are associated with cosmetic dissatisfaction because they are not accepted as suture (Singh et al., 2006).
Clips have also been successfully used in wound closure. However, they have a challenge of failure due slippage or cellophane breakage long after the clip has been inserted (Kane et al. 2018). Albeit surface area contact has been discoursed as a variable in the study of metallic clips, it seems as though the much larger influence in clip strength is the flexibility (Buchweitz et al 2016).  This probably further combines with Hemo clip having the greater coefficient of the friction as opposed to the Hem-o-lok clip, although further test could be required to have the eventual conclusion in this area (Park et al.  2015). Slippage has been discussed in various studies as being the major method of failure of the hemo clip, the manner they might slip has never been discussed in any previous studies.
In a wide array of instances, the clips slipped one after another in the cellophane branding tensile tests (Park et al.  2015) which is probably a result of the vertical extension of circular jaw stretching out cellophane, hitting each clip independently (Chen et al. 2010). In many samples, the clips were never originally touching one another when applied, thus, when one clip slipping, it would then join with the adjacent one, surging the slip force of each subsequent number of clips (Chen et al. 2010). In a single slip case, the clips are often put closer together, culminating in a slip of all the clips at a go (Chen et al. 2010). Occasionally, this has been of higher value as opposed to multiple slip instances, however, they have just been as often lower as the multiple slips, and remain far less common (Chen,  Klapper, and Voige et al 2008).
It remains likely that the clip type has no general effect on the load which ligation clips are able to bear. The stainless steel Hemoclip has been found to remain stronger than the polymer Hem-o-lok clips (Chen et al. 2010). This has shown to be statistically significant. The clips did not break, and cellophane solely broke following clips had already slipped, hence it is not likely that there was a failure of material itself, but instead the interactions between the cellophane and the clips (Buchweitz et al. 2016). This interaction is attributable to coefficient of friction between the material of the clip and the cellophane alongside the grip mode on the cellophane (Antoniou et al. 2016). The Hemoclip depends wholly on the surface area alongside its stiffness to usher a frictional grip. Since it makes full contact with band and is able undergo comprehension into the thick triple layer of cellophane, it is able to maintain the loading to the tune of 11.5 Newton for bigger clips (Antoniou et al. 2016)
The present study uses the systematic critical review of literature design. The literature review permits the researchers to systematically retrieve and subsequently analyze the existing literature on the particular topic in healthcare. The literature review used in this study remains consistent with the Evidence-Based Care (Crochet, Aggarwal and Knight et al 2017). This is because it enables the healthcare providers to utilize information drawn from published research when selecting the kinds of closure techniques and materials for the patient who under surgical procedures and process in the operation room.
Searching Techniques: 
The Randomized Control Trial studies for this present study were drawn from PubMed database(Greco, Carpreeti and Beretta et al 2014).It is a credible database to retrieve the healthcare or medical sources. It contains nursing and allied health journals with million health-linked literature citations.
Subject Identification: 
The keywords were utilized in this study to facilitate the search procedure and process leading to the identification of suitable sources on the topic. The utilization of keywords have been identified by (Aveyard 2014) as being helpful to scholars in retrieving studies that provide suitable information to the aims and the topics of the current study. The search used the following keywords wound healing, surgery, skin suture, skin staple, skin adhesive, patient satisfaction, cosmetic appearance, surgery wound, and healing time. The keywords utilized in this literature were merged using Boolean Operators to form the search terms. The table below denotes the outcome of the merger of the keywords from the database.

Search Terms

PubMed (no. of hits)

(Surgery wound) AND (suture OR staple) AND adhesive AND (healing time)

45

Surgery AND skin suture OR skin adhesive AND cosmetic appearance

20

Surgery AND wound healing AND skin suture AND skin adhesive AND skin staple

15

Surgery AND wound healing AND skin suture AND skin adhesive AND skin staple AND patient satisfaction

20

Total number of Hits

100

Limiting the Search
The criteria for exclusion and inclusion were employed in this study to enhance the process of search. Only sources that were published using English language were included in the review in the period between 2000 and 2018. This timeframe is long enough for retrieving required information on in order to effectively compare how each method has been use in laparoscopic surgery to determine the best method. The articles that examined any or all of the primary wound closure outcomes for the patients undergoing the laparoscopic surgery were include for review. The inclusion criteria also allowed the studies examining patients that were undergoing different surgical procedures. Studies carried out in the United Kingdom and overseas were further allowed in the literature review. The inclusion criteria made sure that a broad array of quality studies was included. The expert opinion sources were also excluded because they rank least in the evidential hierarchy.   The restrictions were further made in the age group of patients recruited in the RCT. The review of the literature solely included the RCTs. This is because RCTs are more valid, credible, reliable and trustworthy sources and rates high in the evidence hierarchy only when the literature review is well conducted (Greenhalgh, 2010). The studies published in foreign language were further excluded in the literature review this is because, the review team was only conversant with English and hence inclusion of foreign language is expensive to translate.
Literature Type: 
The literature type for this extended literature review was from Randomized Controlled Trial sources. This is because they provide more vigorous findings as opposed to other kinds of quantitative studies (Polit et al., 2013). Both random selection and allocation of subjects to the RCTs experimental group enhance the RCTs’ robustness where by all clients have an equal chance of being allocated to either control or experimental cohort (Polit et al., 2013). Moreover, the RCTs probed the effectiveness of intervention on a cohort of patients. Therefore, this literature review remains restricted to RCTs because the purpose of the current review is to determine the most effective closure technique amongst glue, clip and suture during the laparoscopic surgery procedure.
Result selection
100 full text articles were retrieved from the PubMed database for the current literature review which talked about surgical wound closure. In this phase of the review, all the titles of the articles were first reviewed; this lead to the determination of whether the article focused on the three techniques of closing wound. Following a careful review, 80 articles were included in the literature review, 20 of the articles did not talk about the three technique of wound closure. The full text copes of the balance studies were subsequently retrieved; this represented the 65 articles published since 2000 that met the inclusion criteria. Every article was evaluated to determine whether they met the inclusion criteria of the review as already outlined above. 15 articles were excluded because they did not meet the inclusion.
Framework for Critique
The RCTs were reviewed critically utilizing the CASP, Critical Appraisal Skills Programme (2013) tool for the RCTs. The CASP tool been validated in the previous studies and are broadly utilized in the determination of the qualitative and quantitative studies. The CASP tool has eleven questions that aid the scholars to appraise their corresponding articles in terms of quality of evidence that RCTs present. The CASP tool has questions on reliability and validity of the methods utilized in the study alongside the study outcomes. It is further helpful for healthcare providers in determining whether the RCT has offered a precisely focused question. The CASP help the researchers to determine whether adequate rigor has been accomplished in the selection of the subjects.
RESULTS
The results and findings of the literature review were classified in three key areas based on what was being tested or reviewed. The first category of was in relation to the wound closure time and complication (Al-mubarak and Al-haddad 2013). The second category was in relation to cosmetic appearance and the third category was based on the surgical patients’ satisfaction. The current study review finding in relation to time was based on the mean closure time between tissue adhesive, clips and skin sutures (Al-mubarak and Al-haddad 2013). The investigators of the previous studies came to findings that, tissues adhesive wound closure was perfect compared to clip closure and skin sutures at the initial stages of wound closing by surgeons and nurses. Findings for these were derived from a search of 100 which talked about surgical wound closure, 80 of these articles were included in the study and 20 were excluded because they were not about laparoscopy. Of the 80 included 65 of the articles meet the inclusion criteria and they were published since 2000.
Moreover, the investigators conducted a three months patient’s follow up where they came realize that there were close similarities in terms of complications and cosmetic wound appearances within the selected three months for both skin closure using glue, clip and adhesive (Maartense et al. 2002). Significantly, the previous study investigators found that there were more dressings required by clip and suture groups compared to tissues adhesive patients groups.  This meant that clips and sutures needed more time to complete the closure compared to skin closure by glue or tissue adhesive wound closer which required very minimal dressings immediately after the laparoscopic port surgeries (Maartense et al. 2002). The findings of the study shows that in only 21% of the patient with skin closure using glue required immediate wound dressing while approximately 88% of the patient who went through clip closure and skin sutures (Chen et al. 2010). According the previous findings, the current study review suggested that, tissue adhesive wound closer method required less wound dressings immediately after surgery compared to clip closure and tissue sutures require several dressings immediately after surgery.
Category One: Wound Closure Time and Wound Complication Results
In relation to wound closure complications, previous study investigators found that, time taken while using tissues adhesive wound closer method was less compared to clip and skin sutures thus minimum complications (Chen et al. 2010). This study review based on the previous study findings suggested that wound infection risks and complication are always high when operation time is long than when it is short. This meant that there were minimum wound infection risks and complications while using tissues adhesive wound closure method compared to clips and skin sutures (Matin 2003).  It was concluded by the investigators that, wound closure time is directly related to wound complications and infections. The current study review in relation to previous study findings concluded that the shorter the closure time the lesser the complication and wound infections (Dowson et al. 2006). Hence, skin adhesive proved to me more appropriate surgical wound closer method compared to clip closure method and skin sutures.
Category Two: Results of Wound Cosmetic Appearance
The cosmetic satisfaction was assessed by previous investigators where they came to find no statistically significant difference found between tissue adhesive closure method and clips as well as skin sutures (Bisgaard, Klarskov, Kehlet and Rosenberg 2003).  The current study based on previous studies suggested that surgical doctors and nurses could use either of the wound closure methods to achieve optimal cosmetics of a surgical wound. However, previous studies proved that the cost of wound closure by tissue adhesive closure method is higher compared to clips and skin sutures (Dowson et al. 2006). Current studies suggest that the issue of wound closure should be reviewed as both methods have no significant different when it comes to cosmetic wound appearances.  
Majority of the reviewed articles indicated that wound cosmetic appearances are similar for both tissue adhesive method, clips closure method and skin suture methods (Kane et al. 2018). However, one of the studies indicated small difference between wound cosmetic appearances scars close using two different methods of wound closer methods.  The surgeon in the study who used tissues adhesive method was given a score of 45.1 %while the other doctor who used skin suture method was given a score of 22.45% after observing pictures of the wounds after seven (Park et al.  2015) this was however regarded as biased observation as majority of other studies found no significant differences in when either of the wound closer methods is used. The current study found some contradicting opinions regarding wound cosmetic appearance, thereby recommending future studies to be focused on the wound cosmetics (Park et al.  2015).
Category Three: Patients’ Satisfaction Results
 The study results regarding patients’ satisfaction were found after reviewing findings in the selected previous studies.  The reviewed findings from the articles revealed that at the time of discharge, there was no difference in the wound cosmetic and scar appearance thus nor does significant patient satisfaction among the three group (Park et al.  2015). However, the study results changed after six weeks follow up of the three patients groups. After six weeks recovery, the current study review based on the previous findings found that there was high patient satisfaction among the skin closure by glue compared to clips group and skin suture group (Chen et al. 2010). This study suggested that high patients’ satisfaction among the tissue adhesive group was a result of shorter wound healing period, optimal wound appearance after surgery and working scars.  One of the study review investigators also found that there was a close match between the skin colour and the surgical wound scars in tissue adhesive group with reduced wound visibility (Chen et al. 2010). The study concluded that in terms of healing and wound appearance skin closure by glue resulted in to increased patient compared to the other two wound closer methods.
The creation of the topical skin adhesives including the monomer 2-ocytylcyanoacrylate, surgical staples alongside tapes to replace sutures has supplemented the wound closure method armamentarium. Aesthetic closure of laparoscopic surgery wound closure, if traumatic/surgically induced, is anchored on the knowledge of healing mechanism as well as skin anatomy alongside the appreciation of suture substances besides closure technique. Selecting the proper material for wound closure guarantees optimal healing after the laparoscopic surgery (Buchweitz et al. 2016).
The efficacy of the OCA tissue adhesive has been investigated in the previous studies and compared with the non-absorbable monofilament sutures in the laparoscopic port sites’ closure (Dowson et al. 2006). The prospective, RCT design was used whereby 78 patients were included in the study. All the subjects were taken through elective laparoscopic procedures. The patients were assigned to the wound closure with suture or tissue adhesives groups at random. The wound dressing requirements, wound complications, cosmetics and skin closure time were used as the study endpoints (Buchweitz et al. 2016). The result of the study were then measures at weeks 4; 6; and at 3 months following the discharge. A critical review of this study demonstrate that suitable sample of (n=78) in suture group and (n=76) in the tissue adhesive cohort stood included for the comparison of the effectiveness between adhesives and sutures (Buchweitz et al. 2016).
Significantly, the authors highlighted that they carried out power calculations in determining the effects of treatment in the study. It has been reported that the pilot data presented in this study was useful in the computation of sample size.  The authors managed to detect the a fifty percent decrease in the wound closure time at 2 minutes when tissues adhesive was used and 4 minutes when sutures were employed using a two-tailed significance level of 0.05 and the CF of 95% (Maartense et al. 2002). This indicates the effectiveness of tissue adhesives (glues) over sutures based on assumption of having eighty-four patients in every arm of treatment. The utilization of the a prospective RCT design in this study further made sure that there was a reduction in allocation bias because all patients were assigned at random in skin adhesive or suture cohorts (Maartense et al. 2002). This randomization should effective as it provided every patient an equal opportunity of being allocated to control or intervention cohort.
A prospective study design was thus helpful in this study in allowing comparison of endpoints across the time. Because the primary aim of this current study by Dowson above was to compare the comparative effective of tissue adhesive or skin suture as methods of wound closure, the authors would have assessed improvement over a period when measuring endpoints. However, the study design selected in this study stays consistent with both objectives and aims of the present study (Maartense et al. 2002). The randomization of patients ensured that allocation bias is minimized and the use of patients with identical baseline features was effective in aiding the comparison. The outcome of the study was thus related to the interventions that the subjects were recceing and they were never influenced by the variation in the features of the patients.
The findings are thus generalizable with a guaranteed credibility and reliability since the study used a RCT design which ranks highest in terms hierarchy of evidence purely because the generalizability as well as transferability of study is surged (Chen et al. 2010). The outcome from this review clearly showed that average closure time varied between adhesives and skin sutures. It was noted that the average time was extensive in sutures than it was in tissue adhesive hence a confirmation of the effectiveness of adhesives over sutures (Maartense et al. 2002). For example, the average time for closure was 220 seconds with suture against 125 seconds in tissue adhesive with a p-value less than 0.0001. This implies that where laparoscopic surgeon uses tissues adhesives, it will be more effective in earlier closure of wound relative to sutures (Chen et al. 2010). Significantly, no significant variation in cosmetics or even wound complications at weeks 4 and 6 noted following the laparoscopic surgery or at the third month when the follow-up was done.
Significantly, the authors discovered that fewer dressings were needed when tissue adhesive was used at twenty-one percent immediately following the laparoscopic surgery, relative to suture that stood at 97 percent. The variation in the number of required dressing by the suture and adhesive cohort stood significant at a p-value less than 0.001 (Chen et al. 2010). In the course of the discharge, statistical test showed a significant variations in dressings needed by each group with twenty-four percent being noted in tissue adhesive cohort against the 84 percent in the suture cohort at a p-value of less than 0.001(Dowson et al. 2006). The outcome of this study by Dowson presents a precise suggestion that tissue adhesive led to fewer dressing as opposed to sutures following the laparoscopic port site closure thus confirming its effectiveness against the sutures (Dowson et al. 2006). Moreover, the outcome of Dowson study recommends potential savings from the utilization of OCA tissue adhesives because wound closure time stood shorter while wound complication is shortened as well. On the basis of these outcomes, potential saving might be produced by the requirements for fewer dressings when the surgeon uses tissue adhesive in laparoscopic port site closure.
The review of the Dowson study indicates that patients stood blinded to the intervention applied in wound closure. Nevertheless, the authors were never blinded to the study. Authors who do not understand the intervention utilized in a research might interpret the outcome subjectively (Kane et al. 2018). A review of the methodology of the study indicates that taking photographs of wounds and permitting assessor’s independently in determination of the wound cosmetics might have blinded the authors to wound closure technique applied in the study. Therefore, when the subjects or researchers are blinded in the study, the risk of bias reporting is curtailed.          
Moreover, the data interpretations as well as statistics utilized were presented thus giving a transparency which minimizes the interpretation bias. Seventy-eight patients were recruited in the suture cohort and 76 patients recruited in the tissue adhesive cohort. This never contributed to the selection bias of the patient because the dropout rate was never high. Moreover, the both cohorts had identical features at baseline thus reducing the bias in selecting patients (Kane et al. 2018). A suitable sample size is necessary in the establishment of rigor and making sure that the outcome is generalizable to a bigger and more heterogonous cohort of patients. It is worth noting that tissue skin adhesive showed comparable outcome based on cosmetics appearance as well as wound cosmetic besides rates of complication. The primary advantage of tissue skin adhesive seems to be lower cost of utilizing tissue skin adhesives as opposed to costly sutures. The application of tissue adhesives in laparoscopic surgery leads to potential savings whereas still enhancing the cosmetic of the wounds (Kane et al. 2018). The strength of this study depends on the number of recruited patents because an adequately powered sample size implies that its outcome is generalizable to the bigger population of patients who undergo laparoscopic port site closure. Nevertheless, the outcome of this study is restricted to patients who are undergoing other surgical processes or procedures. Skin adhesive, for example, is never suitable for gangrenous wound.
The study by (Krishnamoorthy et al. 2009) also gives useful comparison between wound closure time and tissues adhesives Dermabond and the conventional subcuticular sutures after the saphenous vein harvesting in the patients who underwent CABG (coronary artery bypass grafting).  The outcomes of this research shows that wound closure time stood shorter in Dermabond cohort relative to suture group at a p-value equals to 0.017 (Park et al.  2015). In suture cohort, the media closure time stood at thirteen minutes and 20 seconds. In comparison, the median wound closure time in Dermabond cohort stayed at merely ten minutes and 45 seconds. This shows that Dermabond stays effective in the reduction of time of wound as opposed to the conventional subcuticular sutures when used in the laparoscopic surgery (Park et al.  2015).
(Basha et al 2009) and (Figueroa et al 2013) studies have showed that wound complications rates stood higher in surgical clip cohort as opposed to subcuticular suture cohort. It is worth noting that none of the above studies unearthed that any significant variations in patient cosmetic satisfaction at 4 to 6 weeks following the laparoscopic surgery. Nevertheless, higher rates of complications were recognized in surgical clips cohort at discharge in both articles (Park et al.  2015). The incidence of wound disruption or even infection during discharge in 3 to 4 days stood at 7.1 percent in surgical clip cohort in (Figueroa et al 2013) as opposed to 0.5 percent in suture cohort. The variations in wound disruption or even infection rate between the cohorts stood significant with p-value less than 0.001, comparative risk stayed at 14.1 CF: 95% of 1.9 t 106 (Chen et al. 2010). In the course of follow-up, at 4 to 6 weeks, the cumulative risk for wound disruption stayed higher in clip at 14.5 percent as opposed to suture cohort being 5.9 percent.
The variations in wound disruptions rates stood further significant at a p-value equals to 0.008, relative risk being 2.5 percent and 95% CI, 1.2-5.0.  The statistical tests stood utilized in establishing significant differences in results of two cohorts. (Basha et al 2015) examined the correlation between laparoscopic surgery using clip and a 4-fold surges risk of wound separation stood noted (adjusted odds ratio being 4.65; 95% CI of 2.070-10.52, p-value less than 0.001) when contrasted with subcuticular suture. Therefore, from the outcomes of (Figueroa et al 2013), together with (Basha et al 2010), it is clear that subcuticular suture is suitable than clip sine the risk of wound complication is substantially decreased as opposed to surgical clip. Conversely, wound complication rates are identical when skin adhesive (glue) or surgical clip are utilized for the surgery. No significant variations in rates of complication of wound at the third months of follow-up after the surgery. Nevertheless, skin clips were discovered to be highly convenient in wound closure and swifter to apply as compared to adhesives (Chen et al. 2010). Moreover, cost of skin clips stood lower, albeit, the investigators explicated that the cost of skin clips stood lower as opposed to costly skin adhesives.
To sum up, these studies have compared effectiveness of tissues adhesive to clips with subcuticular sutures, in the reduction of wound complications and increasing would closure time in diverse cohorts of patients. The effectiveness of tissue adhesive specifically LiquiBand was compared with non-absorbable monofilament suture in laparoscopic port sites closure (Park et al.  2015). The outcome of this study presents a suggestion that the utilization of tissue adhesives culminated in swifter wound closure time alongside lower rates of complications as opposed to monofilament suture.  
The discussion can also be understood based on the cosmetic appearance. Dowson et al. (2006) study indicated that cosmetic result of utilizing tissue adhesives stood relative to the use of non-absorbable monofilament sutures for laparoscopic surgery closure of port sites. When employed in nursing practice, the healthcare providers might either utilize tissue adhesive or even suture for optimal cosmetic of the skin (Dowson et al. 2006). Nevertheless, when the closure method’s cost is taken into account, the healthcare providers could favor OCA tissue adhesive or LiquiBand rather than sutures. This finding has been bolstered by the outcomes of the Krishnamoorthy et al. (2009) that compared the tissue adhesive (Dermabond) effectiveness with conventional subcuticular suture for patients in the improvement of closure of wound time, cosmetic appearance alongside satisfaction of patients (Dowson et al. 2006) . It is imperative to highlight that the 2 independent researchers examined the patients wound’s photographs taken 1.5 weeks following the surgery. They were blinded to the wound closure technique displayed in the photographs.
These photographs allowed them to form the view on the cosmetics appearances of scars following six weeks. Blinding of these surgeon researchers increased the credibility and reliability of the findings of study. It further decreased the reporting of bias risk which is common when investigators are unblended to the intervention. The wound cosmetic appearance was thus rated by these two authors using the visual analogue scale (Dowson et al. 2006). There were statistical tests that revealed substantial differences between scores in Dermabond cohort and in conventional subcuticular suture cohort with p-values less than 0.001. It is also imperative to recognize that none of the wounds of the patients in suture cohort had a score of zero denoting optimal cosmetic satisfaction. Because the two standalone surgeons scored the wounds using distinct scenarios, it is essential to probe the inter-observer variations.
The outcomes of statistical tests demonstrated that there were no significant with p-value equals to 0.045 inter-observer variations between two standalone surgeons. This indicated that the outcome stood valid as well as reliable. At follow-up in week six, the cosmetic appearance of wounds in the Dermabond group and suture cohort stood were compared by use of Vancouver Scale. The authors used the Fisher exact test in the analysis of the variations in cosmetic appearance of wounds in both cohorts. Such a test is employed in examining when the sample size is comparatively small (Dowson et al. 2006). The test is useful in the examination of the non-random relationships between two categorical factors like cosmetic appearance. The outcomes of Fisher exact test showed that cosmetic appearance or wound scores in Dermabond cohort was higher significantly with a p-value equals to 0.001 as opposed to those in the suture cohort.
After performing the postoperative examination, the pigmentation of skin of scar area stood less visible in the Dermabond cohort, as opposed to suture cohort. In comparison, the hyperpigmentation stood noticed in all patients’ wounds in subcuticular suture cohort. The standalone surgeons as well as nurses were further included in this study, blindly to enable the comparison between hyperpigmentation of scars in both suture and Derma bond cohorts (Dowson et al. 2006). The inter-observer differences were never significant at a p-value equals to 0.130. This indicated that observations of nurses alongside surgeons tool not only valid but also reliable. These studies have compared skin clip to subcuticular suture for closure of wound following laparoscopic surgery but did not find any variations in cosmetic of the wounds in both cohorts (Dowson et al. 2006). This indicates that either skin clip or subcuticular sutures based on cosmetic appearance might be utilized after laparoscopic surgery port sites. Moreover, (Liversey et al. 2009) probed the skin adhesive effectiveness against the clips for skin closure after the laparoscopic surgery (Buchweitz et al. 2016). This study regarded cosmetic appearance of scar of patients at 3 months following surgery. The authors used visual analogue scale to assess cosmetic appearance of wounds. Significantly, power computations were undertaken to determine the size of the sample. The use of power calculations guarantees suitable sample size in the RCT (Buchweitz et al. 2016). Patients of seventy-four were needed to detect a variation between the effectiveness of skin clips and adhesives for closure after the surgery. A p-value of 0.05 alongside eighty percent power stood observed in study.
The (Ridgway et al. 2007) study probed the skin clip and tissue glue for skin closure in patients that needed collar line incision. The authors recruited 29 patients in the study using random allocation to tissue glue with n=14 or skin clip of n=15. 14 of the patients had hemithyroidectomies whereas six had sub-total thyroidectomies (Buchweitz et al. 2016). Five patients had complete thyroidectomies while four patients were taken through parathyroidectomies. The outcome of this study suggested that closure of wound utilizing tissue glue took extended period as opposed to when clips were used with mean time closure of 95 seconds in tissue glue cohort as opposed to twenty-eight seconds in clip cohort (Buchweitz et al. 2016). The variations in closure between the two cohorts stood significant with a p-value greater than 0.001. The outcome of the study indicated that cosmetic appearance at 6 weeks after surgery stood comparable at the p-value equals to 0.898 in both groups. The patient indicated levels of satisfaction at the appearance of their wound that was identical in each group at the mean of 1.70 in tissue glue cohort and 1.80 in click cohort. The standalone assessment of appearance of the wound demonstrated that mean cosmetics scores in tissue glue cohort was 1.140 and click cohort with mean of 1.90 were never significantly different with p-value of 0.365 (Buchweitz et al. 2016). The mean scores in tissue glue cohort stood at 2.60 against 2.3 in clip cohort following the rating of appearance of wounds by surgeons. The variations were never significant a p-value of 0.898. This study clearly indicates that wound evaluation methods presented and outcome responded to the aims and objectives of the study.  The study conducted by (Gray 2009) stress that the objectives and aims must be stated clearly to minimize the study ambiguity.
Patient satisfaction metric can also be used to compare the methods of wound closure. For instance the study conducted by (Krishnamoorthy et al 2009) included patient satisfaction amongst the health results being measured. This study compared the Dermabond effectiveness as topical skin adhesive, with the traditional sutures for the closure of surgical wound. A total of 106 patients that underwent CABG, stood included as well as randomized to skin glue of n=53 alongside subcuticular sutures of n=53 cohorts after the harvesting of the saphenous vein. There major outcomes measured in the research. Cosmetic appearance, wound closure time as well as complications alongside patient satisfaction.
Krishnamoorthy study demonstrated no significant variations between two cohorts at discharge based on the satisfaction of the patient with a p-value of greater than 0.990, however at the 6-week follow-up; satisfaction of patients was significantly higher than the suture cohort. Such a level of satisfaction could be attached to shorter duration of healing of wound following the utilization of tissue adhesive alongside optimal cosmetic purpose. It was also noted that the color of the scar closely matched skin color of patients in tissue adhesive cohort whereas visibility o scar was decreased (Buchweitz et al. 2016). Nevertheless, the satisfaction of the patient with scar size never differed significantly at a p-value of 0.067 between the two cohorts. It is worth noting that Dermabond has always been utilized for different kinds of surgery, like pediatric surgery alongside neck surgery because it was easy to use. (Krishnamoorthy et al 2009) was among the first studies to probe the cosmetic satisfaction of the client, complication of wound and closure time of the wound after the utilization of conventional subcuticular suture group.     
Conclusion
 The most ultimate objective of surgical wound closure is to ensure that the patient scar is cosmetically acceptable, functional and infection free.  There are various ways of skin closure methods as discussed within the content; however, the effectiveness of each wound closure method depends on the kind of surgical operation performed on the patient (Al-Mubarak and Al-Haddab 2013).  The study reveals that use of tissue adhesive or skin closure by glue for patients laparoscopic port surgery results into a quick wound healing compared to clips as well as surgical suture methods.  There were a lot of benefits wound closure by skin glue in the study compared to clips and sutures.
Use of glue for skin closure proved to be taking minimum and time and less technically challenging as clips and suture.  The study also indicted that skin closure using tissues adhesive is simple and easy to re-approximate, cost effective as well as rapid.  Skin closure using glue is increasingly being used as in the study results compared to clips and sutures since it seals laparoscopic surgical wounds immediately reducing infection risks (Aveyard 2014).  Laparoscopic surgeries take longer time compared to other open surgeries and this makes various surgeons and nurses to increasingly use tissues adhesive wound closure which reduces operating room time.  Thus, the content of this current review recommends skin closure by glue for patients undergoing laparoscopic surgery based on its benefits.
 As evident within the content of the current study review, laparoscopic wound closure using clips and sutures takes a longer time compared to tissues adhesion method (Buchweitz et al. 2016).  Increased time during surgical operations may account for increased rate of wound infection risks as well as complications with the use of other closure methods such as clips and sutures in laparoscopic surgeries. However, both clips and sutures proved to be easy to use and cost effective even though take the same time for patients undergoing hip surgery (Basha, Rochon, and Quiñones, et al 2010). In addition, both clips and suture wound closure methods also shown to us less skins compare to tissues adhesive which costs as high as four times the cost of sutures in caesarean surgery. However patients undergoing caesarean delivery show high satisfaction rate when treated using tissues adhesive method (Buchweitz et al. 2016). According to the current review, skin closure by glue is crucial and recommended for patients undergoing laparoscopic and caesarean based time and minimum wound infections but not recommended for patients with financial constrains based on its high cost (Beam 2008).  Clips and sutures are cost effective and affordable thus different to tissue adhesive which is charged so high as a result of the reduced risks of infections.    
Apart from operating time and minimal infection risks involves with tissue adhesive wound closer method, the current review also shows advantages of skin closure by glue in relation to patients satisfaction. As seen within the content of the review, skin closure by resulted into high patients’ satisfaction rate for patients who underwent laparoscopic surgeries (Brown et al. 2009). However, almost similar satisfaction response was evident for caesarean patients who undergone wound closure by use of clips and sutures. However, tissue adhesive wound closure method approved to be more satisfying when it comes to laparoscopic surgeries compared to clip and sutures (Quinn, Coran and Hirsch 2009).  The benefits of skin adhesive resulted in many patients’ acceptance and satisfaction. The current study review found that high patient acceptance and satisfaction comes and increases when laparoscopic patients heal faster.
The current review findings further suggest that patient’s satisfaction rate increased as a result of optimal cosmetic appearance after surgery and working scars. In addition, skin by glue resulted into optimal cosmetic wound appearance compared to other skin tissue adhesive method of wound closure (Charters 2000).  According to cosmetic appearance results, it concluded be concluded that tissue adhesive wound closure is better than clips and sutures for patients undergoing laparoscopic surgeries. Hence, tissue adhesive wound closure method is suggested by this review the most recommended method of wound closer for patients undergoing laparoscopic surgeries.
Moreover, considering the general benefits of the three closure methods, the current review suggests that tissues adhesive can be used by patients undergoing various types of surgeries laparoscopic surgeries, caesarean delivery and coronary artery bypass grafting (CABG) (Buchweitz et al. 2016). In addition, previous review studies show that, even though there is a closer rate of patient’s satisfaction with regards to hip replacements surgeries, patients’ satisfaction is the same for patients undergoing complete hip replacement surgeries when surgeons use either surgical clips or skin closure by glue (Carbajo 2009). In relation to similarities when it comes to adhesive and clips wound closure methods for patients undergoing hip replacement, the study suggests that medical doctors can advise patients on either of the methods. However, the findings of the study show that tissue adhesive wound closure method is the most preferable method for patients undergoing laparoscopic surgeries based on its benefits.  Health practitioners should therefore advice patients undergoing laparoscopic surgery to consider tissue adhesive instead of clips and sutures.
Finally, literature reviews as well as previous studies show that use of adhesive method for patients undergoing laparoscopic surgery, leads to quick healing and faster wound closure which also results into a working scar, optimal cosmetic wound appearance, minimum wound infection risk and patient satisfaction (Chow, Marshall, and Zacharakis, et al 2010).  The tissue adhesive method of skin closure can be suggested for patients undergoing various types of surgeries like caesarean, CABGs and hip replacement, however, this method is method is most suggested for patients undertaking laparoscopic port surgeries (Buchweitz et al. 2016).  Tissue adhesive has various benefits which will make it more accepted by majority of patients, surgical doctors and nurses (Antoniou et al. 2016). Although tissue adhesive wound closure method has various benefits over clip closure method and skin sutures, this method is not for very surgical wound closure. Tissue adhesive is more expensive compared to clips and skin sutures thus not affordable for every patient (Chow, Marshall, Zacharakis, Paraskeva and Purkayastha 2010). This review therefore suggests that the cost of skin closer by glue should be reviewed as patents’ satisfaction for both methods are almost similar. The effectiveness of surgical wound closure methods vary in relation to type of surgery undertaken by a patient. However, skin closure by glue of tissue adhesive remains the most appropriate wound closure method for patients undertaking laparoscopic surgery.  
In summary, tissue adhesive results into optimal wound appearance, minimal wound infection risks and high patient satisfaction. Even though, tissue adhesive wound closure method has several benefits for patients undergoing laparoscopic surgery, clips and skin sutures have also proved to be effective for patients undertaking other types of surgeries (Jones, Samy, and Boom et al 2017). This current study suggests and recommends for a randomized controlled trial for future studies in order to examine the benefits of the three surgical wound closure methods. This will ascertain the benefits of clips closure method, tissue adhesive wound closer method and skin sutures in relation to surgical patients’ satisfaction, cosmetic wound appearance and wound healing period (Coughlan, Cronin and Ryan 2007). Lastly, the study review recommends for future primary studies or systematic study reviews should be performed in order to look into healthcare costs of tissue adhesive as a method of wound closure.
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Mayhew, P.D. and Brown, D.C., 2007. Comparison of three techniques for ovarian pedicle hemostasis during laparoscopic?assisted ovariohysterectomy. Veterinary Surgery, 36(6), pp.541-547.
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Mueller, E.R., Kenton, K., Anger, J.T., Bresee, C. and Tarnay, C., 2016. Cosmetic appearance of port-site scars 1 year after laparoscopic versus robotic sacrocolpopexy: a supplementary study of the ACCESS Clinical Trial. Journal of minimally invasive gynecology, 23(6), pp.917-921.
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Ridgway, D.M., Mahmood, F., Moore, L., Bramley, D. and Moore, P.J., 2007. A blinded, randomised, controlled trial of stapled versus tissue glue closure of neck surgery incisions. The Annals of The Royal College of Surgeons of England, 89(3), pp.242-246.
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