Received: 29 May 2019 Revised: 3 August 2019 Accepted: 21 September 2019

DOI: 10.1111/vsu.13344

ORIGINAL ARTICLE - CLINICAL

Effect of subcutaneous closure technique on incisional

complications and postoperative pain in cats undergoing midline
celiotomy: A randomized, blinded, controlled trial

Daniel J. Lopez DVM | Galina M. Hayes PhD, DACVECC, DACVS | Gilad Fefer BS |
Sarah A. McCalla DVM | Denise F. LaLonde-Paul LVT, BS, MPS |
James A. Flanders DVM, DACVS | Julia P. Sumner BVSc, DACVS
Department of Clinical Studies, Cornell
University Hospital for Animals, Ithaca,
Abstract
New York Objective: To compare the effect of three methods of subcutaneous tissue closure
on postoperative incisional complications and pain in cats.
Correspondence
Galina M. Hayes, Department of Clinical Study design: Single-center, randomized, blinded, controlled trial conducted in a
Studies, Cornell University Hospital for veterinary teaching hospital.
Animals, 930 Campus Rd, Ithaca, New York
Animals: Two hundred ninety-seven cats undergoing midline celiotomy for
14853.
Email: [email protected] ovariohysterectomy (n = 280) or other abdominal procedure (n = 17).
Methods: Cats (n = 297) were assigned to one of three subcutaneous
Funding information
Cornell Feline Health Center, Grant/Award
closure methods: simple continuous apposition with tacking to the rectus
Number: 4808859 fascia (n = 108, quilting [Q] group); simple continuous apposition (SC;
n = 94); no subcutaneous closure (NC; n = 95). Primary outcomes were
incidence of seroma formation, postoperative pain, and surgical site infection
or dehiscence. Active follow-up was obtained at 10 and 30 days
postoperatively.
Results: Baseline characteristics did not differ between groups. Seroma was less
common in the Q group (13.0%) than in the NC (27.3%) and SC (25.9%) groups
(P = .03). Compared with the other two groups, the relative risk of seroma forma-
tion in the Q group was 0.49 (95% CI = 0.28-0.86, P = .01). Median mechanical
pain thresholds were higher (indicating greater comfort) in cats with subcutaneous
sutures (Q and SC = 1.23 [interquartile range (IQR), 0.2-2.6 N], NC = 0.83 [IQR,
0-1.87 N], P = .04) on the day after surgery.
Conclusion: Closing subcutaneous tissues with a quilting closure pattern reduced
seroma formation in cats undergoing celiotomy.
Clinical significance: Placing a quilting suture pattern in the subcutaneous tissues
after celiotomy is a simple low-cost measure that reduces seromas in cats.
Abstaining from subcutaneous closure cannot be recommended because of
increased seroma formation and pain.

Veterinary Surgery. 2019;1–8. wileyonlinelibrary.com/journal/vsu © 2019 The American College of Veterinary Surgeons 1
2 LOPEZ ET AL.

1 | INTRODUCTION tissue closure. However, the paucity of studies on this topic

precludes evidence-based recommendations of one closure
Midline celiotomy is among the most commonly performed method rather than another. This study sought to compare
surgical approaches in cats undergoing surgery; it is used for the effects of three methods of subcutaneous tissue closure
almost all nonelective abdominal procedures as well as elec- on seroma formation, severity of postoperative pain, inci-
tive open ovariohysterectomy.1 Common incisional compli- dence of SSI or dehiscence, incisional appearance, and
cations after feline celiotomy include seroma formation, incisional closure time. The null hypothesis was that there
surgical site infection (SSI), and surgical site dehiscence.2 would be no difference between the different closure
Seromas occur secondary to the disruption of lymphatics methods for these outcomes.
during surgical dissection and disruption of tissue planes
creating a dead space for fluid accumulation.3 Fluid accumu-
2 | METHODS AND MATERIALS
lation stretches the skin and surrounding tissues resulting in
discomfort; in human patients this has been associated with
2.1 | Trial design
increased risk of SSI.3 While seromas are considered a
minor complication, their development may be a source of A single-center (Cornell University Hospital for Animals),
anxiety to owners, increase visits to the emergency room, randomized, blinded, controlled trial was conducted. Cats
and result in increased cost of care. were considered eligible for inclusion when they were
Tacking the subcutaneous tissues to the deep fascia dur- undergoing midline celiotomy for any reason. After owner
ing subcutaneous tissue closure, also known as a quilting consent via standardized consent forms and enrollment, cats
pattern, has been found to reduce the risk of seroma forma- were randomly assigned in a 1:1:1 ratio to closure of the
tion in man and dogs. This practice stabilizes the tissue subcutaneous tissues with either a simple continuous apposi-
layers relative to one another and obliterates dead space.4-14 tional pattern using a tacking component (quilting group Q),
The use of a quilting pattern in dogs has been reported to simple continuous appositional closure without a tacking
reduce both postoperative pain and the seroma incidence component (SC group), or no closure (NC group). The quilt-
compared with a standard appositional closure.13 However, ing pattern is illustrated in Figure 1 and consisted of a simple
outcomes in man and dogs may not apply to cats because of continuous line with the addition of an anchoring bite taken
interspecies differences in wound healing. Cats have reduced to the rectus fascia on every third pass. Any closure of the
wound perfusion in the acute phase of healing, a lower den- subcutaneous tissue used 3-0 poliglecaprone 25. The linea
sity of subcutaneous collateral blood vessels, lower wound alba was closed with 2-0 or 3-0 polydiaxanone in a simple
tensile strength, and greater dependence on the subcutaneous continuous pattern, and the skin was closed with 3-0
tissues for wound healing compared with dogs.15,16 The rela- poliglecaprone 25 in an intradermal pattern. Cats were
tive lymphatic density in the subcutaneous tissues and com- excluded when any of the following criteria applied: age less
parative tendency to seroma formation between cats and than 4 months, had a prior celiotomy within 30 days of
dogs is unknown.
Methods of subcutaneous tissue closure in cats have not
been rigorously compared. Omitting closure of the subcuta-
neous tissues decreased incisional line inflammation but
increased seroma formation in a randomized clinical study
of 99 cats undergoing celiotomy.17 The incidence of seroma
formation was six of 48 (13%) when subcutaneous closure
was omitted and one of 51 (2%) when subcutaneous tissues
were closed (P = .06). However, the authors are aware of
recommendations against closing the subcutaneous tissue in
cats because of the reported increased incisional inflamma-
tion. For women undergoing cesarean section celiotomy, the
lack of subcutaneous tissue closure did not affect the appear-
ance of the incision line or seroma incidence but was associ-
ated with an increased risk of hematoma.18
Current variants in routine use for subcutaneous tissue F I G U R E 1 Illustration of the quilting suture pattern placed in the
closure in cats include appositional closure with a simple subcutaneous tissue of cats in the quilting group. The pattern consisted
continuous or interrupted suture pattern, an appositional clo- of a simple continuous pattern with the addition of an anchoring bite
sure with a quilting pattern, or abstaining from subcutaneous taken to the rectus fascia on every third pass
LOPEZ ET AL. 3

admission, a drain or vascular access port was placed in the were blinded to treatment group assignment (D.J.L., D.F.L-P.).
subcutaneous tissues, the cat was severely fractious limiting The US Centers for Disease Control and Prevention criteria for
handling, or lack of informed owner consent. Perioperative SSI were used.21 Diagnosis of seromas was based on physical
analgesia was administered in all cases with medication examination findings of a focal area of fluctuant fluid swelling
selection at the discretion of the supervising clinician at the incision site with an intact body wall and absence of
acording to institutional protocols. The clinician was blinded heat/redness. When required, ultrasound examination or fine-
to group assignment. The study was approved by the Cornell needle aspiration cytology was used to differentiate seromas
University Hospital for Animals Institutional and Animal from herniations or incisional abscesses.
Care Use Committee (No 2017-0062). Pain was assessed within the first postoperative day by
Cats were enrolled through the Cornell University Hospital using the feline composite pain scale (FCPS)22 and peri-
for Animals Soft Tissue Surgery Service for senior veterinary incisional mechanical threshold testing with a force algometer
student ovariohysterectomy or resident/faculty-performed with a 2-mm diameter probe head23 (Prodplus; Topcat
abdominal procedures, through the second-year veterinary stu- Metrology, Little Downham, Cambridgeshire, United King-
dent ovariohysterectomy laboratory, or through Shelter Out- dom). Systolic blood pressure was measured by using a
reach Services (Ithaca, New York) ovariohysterectomy clinics. 9.7-MHz doppler ultrasound infant style probe and unit
Power analysis identified a group size of 89 as sufficient (Model 811-BTS; Parks Medical Electronics, Las Vegas,
to provide 80% power to detect a seroma incidence differ- Nevada). Incisional appearance was assessed by using a 0 to
ence of 2% vs 13%. Randomization was performed with a 100-mm modified cosmesis visual analog scale (VAS)24 that
computer-generated random treatment assignment (GMH, evaluated degree of skin apposition, incisional inflammation/
STATA; StataCorp, College Station, Texas), with stratifica- swelling, and incisional discharge. With this scale, a score of
tion based on the admitting service. Randomization was 0 represented the most undesirable situation, and a score of
stratified in this manner to ensure that no treatment group 100 represented the most desirable situation. Evaluators (D.J.
experienced significant differences in surgeon type. Inter- L., G.F., S.A.M.) were blinded to the intervention group.
vention group assignment was revealed via premade sealed The total surgical duration for the procedure (skin inci-
envelopes at the time of surgery. sion to final skin suture) and the duration for the incisional
closure (start of the linea to final skin suture) were recorded
intraoperatively.
2.2 | Data collection and outcomes
The primary outcomes were the incidence of seroma and
SSI/dehiscence within the follow-up period and postopera-
2.3 | Statistical analysis
tive pain severity assessed on the first postoperative day. Continuous data were assessed for normality by using a Sha-
Secondary outcomes were the surgical time required for piro Wilk test. Normal data are reported as mean ± SD, and
incisional closure and incisional appearance assessed on the nonnormal data are reported as median (interquartile range
first postoperative day. Baseline data on cat age, body condi- [IQR]). Differences between all three treatment groups in con-
tion score (BCS), blood pressure, weight, illness severity tinuous baseline or outcome data were assessed by using an
(APPLE [acute patient physiologic and laboratory evalua- ANOVA test when data were normal or a Kruskal Wallis
tion] score),19 abdominal procedure performed, and surgeon equality of populations rank test where data were not normal.
experience were collected. Post hoc two-group comparisons were made by using a t test
Active follow-up to document incisional complications was when data were normal or a Wilcoxon rank-sum test when
performed at 10 and 30 days postoperatively with owners and data were not normal. Differences in categorical outcomes
referring veterinarians. At the 10-day time point, owners were between treatment groups were evaluated by using the χ2 test
encouraged to return to the hospital for in person administration when cell numbers were >5 and Fisher's exact test when cell
of a previously validated questionnaire20 and direct evaluation numbers were ≤5. The Wald approximation was used to cal-
of the incision. Owners unable to return were contacted by tele- culate 95% confidence intervals (95% CI) for proportions. All
phone, and the questionnaire was administered. A total of five analyses were performed in Stata 15 (StataCorp).
attempts at contact were made before an animal was considered
lost to follow-up. When the cat received treatment with the pri-
mary care veterinarian during the postoperative period, the vet-
3 | RESULTS
erinarian was contacted, and the details of findings and care
3.1 | Recruitment, participants, and follow-up
administered were obtained. The investigator applying the
questionnaire as well as the owner/caregiver and referring vet- Cats were recruited from Sept 12, 2017 until April 10, 2019
erinarians responsible for care during the postoperative period (Figure 2). The study was concluded after sufficient
4 LOPEZ ET AL.

FIGURE 2 CONSORT (Consolidated Standards of Reporting Trials) flow diagram of cat enrollment, treatment allocation, follow-up, and
analysis during the study period

enrollment to satisfy power calculations. Cats were recruited (NC) group vs eight of 108 (7.4%) and nine of 94 (9.6%)
from three sources: (1) cats presenting to the Cornell Univer- in the quilting (Q) and simple continuous (SC) groups
sity Hospital for Animals Soft Tissue Surgery Service for (P = .01), respectively. There were no group differences in
either elective ovariohysterectomy by a fourth year veteri- loss to follow-up by the 30-day time point, with loss of
nary student (n = 79) or for other nonspay abdominal proce- 32 of 108 (29.6%) in the Q group, 30 of 95 (31.5%) in the
dure performed by a resident or boarded surgeon (n = 17); NC group, and 34 of 94 (36.2%) in the SC group
(2) cats presenting for a second-year ovariohysterectomy (P = .60). Loss to follow-up resulted from either cat death
teaching laboratory (n = 89); or (3) cats presenting for prior to the 10-day evaluation or inability to contact the
ovariohysterectomy performed by either an experienced owner. The two deaths that occurred were unrelated to
shelter clinician, resident, or board-certified surgeon incisional complications and resulted from (1) euthanasia
(n = 112) in association with Shelter Outreach Services. secondary to hypovolemic shock and gastric outflow
Postoperative outcomes were assessed a median of 17 hours obstruction after pyloric mass removal and (2) euthanasia
(IQR, 15-19) after surgery. After hospital discharge, follow- secondary to unresponsive vasodilatory septic shock post
up occurred at a median of 10 days (IQR, 10-12) and cholecystectomy.
32 days (IQR, 31-42) postoperatively. The baseline characteristics of each treatment group are
No animals received a closure pattern that differed from presented in Table 1. There were no between-group differ-
study protocol; all analyses were by intent-to-treat. No cats ences in age, BCS, weight, illness severity, or baseline sys-
received a postoperative bandage of the surgical site. tolic blood pressure. There were no between-group
Treatment allocation by group stratification and follow-up differences in procedure type or urgency, whether prophy-
at 10-days and 30-days postoperatively are presented in lactic antibiotics were given, or the experience level of the
Figure 2. There were no group differences in the propor- surgeon.
tion of cases receiving veterinary evaluation at 10 days
postoperatively compared with owner evaluation (P = .28;
3.2 | Primary outcomes
Table 1). There were group differences in the proportion
of cases lost to follow-up at the 10-day time point, with Primary outcomes, including incisional complications and
the loss of 18 of 95 (18.9%) animals from the no closure postoperative pain measurements, are presented in Table 2.
LOPEZ ET AL. 5

TABLE 1 Baseline characteristics of cats in the quilting, no closure, and simple continuous subcutaneous closure groups

Variables Quilting, n = 108 No closure, n = 95 Simple continuous, n = 94 P-value

Demographics
Age, y 0.7 (0.4-2) 0.7 (0.4-1) 0.8 (0.4-1.6) .67
BCS, scale 0-5 2.7 ± 0.7 2.8 ± 0.7 2.7 ± 0.7 .62
BW, kg 2.8 ± 1.1 2.7 ± 1.0 2.7 ± 1.0 .93
Feline APPLE, scale 0-40 12.4 ± 3.7 12.7 ± 3.9 13.4 ± 3.9 .33
Baseline SBP, mm Hg 110 (100-120), n = 76 110 (100-130) n = 64 110 (100-130) n = 67 .78
Procedure characteristics
Elective spay, n 104 91 85 .20
Emergency procedure, n 3 2 6 .31
Prophylactic antibiotics given, n 91 85 80 .52
Student surgeon, n 58 57 53 .67
Follow-up characteristics
Direct physical evaluation, n (%) 60/100 (60) 52/77 (67.5) 47/85 (55.3) .28

Note: Data are mean ± SD or median (IQR) except when indicated otherwise.
Abbreviations: APPLE, acute patient physiologic and laboratory evaluation; BCS, body condition score, BW, body weight; IQR, interquartile range; SBP, systolic
blood pressure.

TABLE 2 Effect of subcutaneous closure group on primary outcomes

Variables Quilting No closure Simple continuous P-value

Postoperative pain, median (IQR)
PROD algometer (N) 1.37 (0.07-2.87) 0.83 (0.1-1.87) 1.1 (0.2-2.17) .11
FCPS 2 (0-5) 2 (0-4) 2.5(1-4) .31
Seroma, n (%)
Seroma at 10 d 13/100 (13.0) 21/77 (27.3) 22/85 (25.9) .03
Seroma at 30 d 13/74 (17.8) 21/65 (32.3) 22/59 (37.3) .03
SSI/dehiscence, n (%)
SSI/dehiscence at 10 d 1/100 (1.0) 1/77 (1.3) 3/85 (3.5) .53
SSI/dehiscence at 30 d 1/74 (1.4) 2/65 (3.1) 3/59 (5.1) .45

Abbreviations: FCPS, feline composite pain scale; IQR, interquartile range; N, Newtons; PROD, Prodplus; Topcat Metrology; SSI, surgical site infection.

All seromas were identified within 10 days of surgery. mechanical threshold was higher in the sutured (1.23 N
The incidence of seroma was lower in the Q group [IQR, 0.2-2.6] compared with the unsutured (0.83 N [IQR,
(13.0%, 95% CI = 6.4-19.6) compared with the other two 0-1.87] group (P = .04). No between-group differences in
groups (NC = 27.3%, 95% CI = 17.3-37.2; SC = 25.9%, feline composite pain scale were identified. There was no
95% CI = 16.6-35.2). When compared with the NC and difference between treatment groups in the incidence of
SC groups combined, the Q group had a relative risk for SSI/dehiscence at any time point.
seroma of 0.49 (95% CI = 0.28-0.86; P = .01). The inci-
dence of seroma in the NC and SC groups was similar,
with a relative risk for seroma in the SC group of 0.95 3.3 | Secondary outcomes
(95% CI = 0.57-1.58; P = .84) compared with the NC
group. The secondary outcomes are presented in Table 3. Apposi-
There was some variation in median mechanical pain tion scores were lower for the Q group compared with the
thresholds between the three treatment groups (P = .11). NC and SC groups (P = .02). No other differences were
However, when sutured techniques (Q and SC) were com- noted in wound scores. There was no difference in incisional
pared with the unsutured technique (NC), median closure time between groups.
6 LOPEZ ET AL.

TABLE 3 Effect of subcutaneous closure group on secondary outcomes

Variables Quilting No closure Simple continuous P-value

Perioperative variables, median (IQR)
Surgical time, min 67 (14-114) 68 (11-113) 81.5 (19-115) .54
Incision closure time, min 28 (6-52) 23 (5-53) 31 (8-56) .36
Postoperative incisional appearance (VAS score), mean
± SD
Drainage 48.2 ± 16.0 51.3 ± 18.3 51.5 ± 18.6 .33
Apposition 51.7 ± 15.9 57.3 ± 16.8 57.7 ± 17.1 .02
Swelling/ inflammation 50 ± 13.2 50.8 ± 14.2 50.3 ± 13.6 .91

Abbreviations: IQR, interquartile range; VAS, visual analog scale.

TABLE 4 Association between the incidence of seroma and surgeon experience within treatment subgroups

Variables Quilting No closure Simple continuous P-value

Seroma at 10 d, student surgeon, n (%) 7/53 (13.2) 13/45 (28.9) 12/45 (26.7) .13
Seroma at 10 d, nonstudent surgeon, n (%) 6/47 (12.8) 8/32 (25.0) 10/40 (25.0) .27
Incision closure time, nonstudent surgeon, median (IQR), 6 (2-10) 4 (2-6) 7 (4-12) .02
min

threshold for pain (P = .01) compared with cats under-

TABLE 5 Comparison of postoperative pain outcomes in cats
going ovariohysterectomy by a nonstudent surgeon
undergoing ovariohysterectomy performed by a student or a nonstudent
(Table 5).
surgeon

Nonstudent
Student surgeon, P- 4 | DISCUSSION
Pain variable surgeon, n = 168 n = 112 value
Pain score 3 (2-5) 0 (0-1.5) <.001
In this study, we evaluated the effect of various subcutane-
ous closure techniques on incisional complications and post-
PROD 0.81 (0.08-1.75) 1.5 (0-2.87) .01
algometer (N) operative pain in cats undergoing celiotomy using a
randomized, blinded, controlled, clinical trial. The trial was
Note: Data are median (IQR).
appropriately powered with well-balanced treatment groups
Abbreviations: N, Newtons; PROD, Prodplus; Topcat Metrology.
and was performed in a setting that included a diverse set of
surgical skill levels (students, residents, board-certified sur-
3.4 | Subgroup analysis
geons, and shelter clinicians). Use of a quilting pattern in the
Analysis of treatment subgroups within categories of sur- subcutaneous tissues was found to reduce in half the inci-
geon experience is presented in Table 4. Point estimates of dence of seroma in cats undergoing midline celiotomy com-
seroma incidence in the Q group remained approximately pared with other closure techniques, with minimal
50% of those in the NC and SC groups, regardless of associated increase in surgical time.
whether the surgeon was a student or an experienced clini- The quilting pattern has been previously evaluated in
cian. Reduction in group size due to stratification led to loss human patients undergoing surgery for ventral hernia
of power to maintain significance (P = .13) for this outcome. repair,4 abdominoplasty,5,12 port site closure after single port
When procedures were restricted to those performed by an laparoscopy,6 latissimus dorsi breast reconstruction,7,9 mas-
experienced clinician, the median incisional closure time tectomy and axillary lymph node dissection,8,10,14 and man-
was 2 minutes shorter in the NC group at 4 minutes com- agement of traumatic skin avulsion injuries,11 with findings
pared with the Q (6 minutes) and SC (7 minute) groups similar to those of this study. These cited researchers found
(P = .02). When treatment groups were combined, cats that the quilting pattern reduced seroma incidence and sever-
undergoing ovariohysterectomy by a student surgeon had ity compared with standard appositional closure and reduced
higher pain scores (P < .001) and a lower mechanical the requirement for postoperative closed suction drainage. A
LOPEZ ET AL. 7

previous study in which the quilting pattern was compared The strengths of this study are inherent to the randomized
to standard apposition for closure of subcutaneous tissues blinded design, which provides a high level of evidence.
after celiotomy in dogs also provided evidence of a reduc- Groups were well balanced on all measured variables, which
tion in seromas and postoperative pain.13 While the current makes it less likely that a silent variable influenced our
study found that subcutaneous tissue closure by any method results. Group size was driven by power analysis. However,
reduced postoperative pain compared with no closure, the despite these strengths, several limitations should be noted.
best method of subcutaneous closure for optimizing that Differential loss to follow-up at 10-days was unexpectedly
benefit could not be confirmed. The mechanism of pain identified in the NC group and may have introduced infor-
reduction with suturing is unknown but may reflect mation bias if the loss was related to the presence or absence
decreased movement and stretch of the subcutaneous relative of incisional complications. Incisional complications were
to the surrounding tissues. Withholding subcutaneous tissue identified through a combination of physical examinations
and/or owner questionnaires, which could have resulted in
closure resulted in an increased incidence of seroma, and
variation in the sensitivity of detection of complications
pain and cannot be recommended. The results of this study
within groups. However, group bias is an unlikely con-
appear to provide evidence to counter the commonly held
founder in this study because all parties were blinded to
misconception that feline subcutaneous fat should not be
group assignments. A high proportion of the cats in this
apposed because of the risk of steatitis.
study were operated on by student surgeons, which may
The suture pattern illustrated in Figure 1 was selected to
limit extrapolation of findings to cats undergoing other
allow implementation in a clinical setting, balancing speed,
abdominal procedures with experienced surgeons. However,
and clinical familiarity, while achieving the goal of anchor-
incisional lengths of student surgeons may more accurately
ing the superficial to deep layers. However, dead space
represent an exploratory celiotomy for experienced sur-
could likely be obliterated with other suture configurations.
geons, and point estimates of treatment group seroma inci-
The mechanism of action for reduction of seroma formation
dence varied minimally between student surgeons vs
with a quilting pattern likely involves the reduction of dead
nonstudent surgeons. This finding provides evidence that the
space between the external rectus fascia and the subcutane-
effect of subcutaneous tissue closure technique may be
ous tissues by apposition and stabilization of the two layers-
maintained across incision size and experience; however,
a principal that dates back to Halsted.25 Other preventive
lack of power within subgroups limits the ability to defini-
strategies include closed suction drainage, use of fibrin glue,
tively confirm this effect. Finally, the low incidence of
and bandaging.5,7 While drains may result in harm through
SSI/dehiscence in this population resulted in the loss of
increased SSI risk,26 quilting is a low cost, simple interven-
power to detect differences between treatment groups to a
tion that does not increase the requirement for postoperative
post hoc power of 31%.
care in the way that drains and bandages may. The lower
In conclusion, a quilting suture pattern of the subcutane-
cosmetic apposition visual analog score assigned to incisions
ous tissue reduced seroma formation with minimal increase
with a quilting pattern was contrary to our clinical impres-
in surgical time compared with other techniques in cats
sion, and we were unable to identify a plausible explanation.
undergoing midline celiotomy. Failing to close the subcuta-
The statistical difference detected between groups may not
neous tissues cannot be recommended because this practice
be clinically significant, reaching only 6 of 100 points on the
resulted in the highest point estimates of seroma incidence at
scale of 0 to 100. Indeed, the minimal clinically important
10 days postoperatively and increased postoperative pain the
difference on a similar wound cosmesis scale has previously
day after surgery. Widespread application of a quilting pat-
been recommended at 15 points.27 In addition, the difference
tern to cats undergoing celiotomy may improve animal wel-
observed in our study did not appear to impact clinical
fare and reduce client emotional distress. Quilting patterns
healing because the incidence of SSI/dehiscence did not dif-
may also be indicated for other procedures, particularly
fer between the three groups.
those in which there is risk for seroma formation.
The higher pain scores after procedures performed by
student surgeons compared with experienced surgeons may
be intuitive but has not been previously identified in cats. In C O N F L I C T O F I N T ER ES T
a randomized trial of ovariohysterectomy in dogs random-
ized to experienced vs student surgeons, duration of surgery, The authors declare no conflicts of interest related to this
blood loss, and C-reactive protein levels were all greater in study.
the inexperienced group.28 The increased pain noted in cats
operated on by student surgeons may have been associated
with longer incisions, a variable unfortunately not measured OR CI D
in this study. Galina M. Hayes https://orcid.org/0000-0002-1365-3284
8 LOPEZ ET AL.

R E F E REN CE S 15. Bohling MW, Henderson RA, Swaim S, Kincaid SA, Wright JC.
Cutaneous wound healing in the cat: macroscopic description and
1. Boothe HW, Slater MR, Hobson HP, Fossum TW, Jung C. comparison with cutaneous wound healing in the dog. Vet Surg.
Exploratory celiotomy in 200 nontraumatized dogs and cats. Vet 2004;33:579-587.
Surg. 1992;21:452-457. 16. Bohling MW, Henderson RA, Swaim S, Kincaid SA,
2. Kennedy KC, Tamburello KR, Hardie RJ. Perioperative morbidity Wright JC. Comparison of the role of subcutaneous tissues in
associated with ovariohysterectomy performed as part of a third- cutaneous wound healing in the dog and cat. Vet Surg. 2006;
year veterinary surgical-training program. J Vet Med Educ. 2011; 35:3-14.
38:408-413. 17. Freeman L, Pettit G, Robinette J, Lincoln JD, Person MW. Tissue
3. Ouldamer L, Bonastre J, Brunet-Houdard S, Body G, reaction to suture material in the feline linea alba. Vet Surg. 1987;
Giraudeau B, Caille A. Dead space closure with quilting suture 16:440-445.
versus conventional closure with drainage for the prevention of 18. Husslein H, Gutschi M, Leipold H, Herbst C, Franz M, Worda C.
seroma after mastectomy for breast cancer (QUISERMAS): proto- Suture closure versus nonclosure of subcutaneous fat and cosmetic
col for a multicenter randomized controlled trial. BMJ Open. 2016; outcome after cesarean section: a randomized controlled trial.
6:1-8. https://doi.org/10.1136/bmjopen-2015-009903. PLoS One. 2014;9:1-12. https://doi.org/10.1371/journal.pone.
4. Alhussini MA, Awad AT, Kholosy HM. Using quilting sutures in 0114730.
deceasing seroma formation after managing large ventral hernia: a 19. Hayes G, Matthews K, Doig G, et al. The feline acute patient
comparative study. Hernia. 2018;1-6. https://doi.org/10.1007/ physiologic and laboratory evaluation (feline APPLE) score: a
s10029-018-1850-9. severity of illness stratification system for hospitalized cats. J Vet
5. Bercial ME, Sabino Neto M, Calil JA, Rossetto LA, Ferreira LM. Intern Med. 2011;25:26-38.
Suction drains, quilting sutures, and fibrin sealant in the prevention 20. Turk R, Singh A, Weese JS. Prospective surgical site infection sur-
of seroma formation in abdominoplasty: which is the best strategy? veillance in dogs. Vet Surg. 2015;44:2-8.
Aesthetic Plast Surg. 2012;36:370-373. 21. Centers for Disease Control and Prevention. Surgical Site Infec-
6. Chang JW, Oh J, Jung US. Umbilical quilting suture technique tion. https://www.cdc.gov/infectioncontrol/guidelines/ssi/index.html
during single-port laparoscopic surgery. JSLS. 2018;22(1): Accessed October 16, 2019.
e2017.00088. https://doi.org/10.4293/JSLS.2017.00088. 22. Brondani JT, Luna SP, Padovani CR. Refinement and initial vali-
7. Hart AM, Duggal C, Pinell-White X, Losken A. A prospective dation of a multidimensional composite scale for use in assessing
randomized trial of the efficacy of fibrin glue, triamcinolone acute postoperative pain in cats. Am J Vet Res. 2011;72:174-183.
acetonide, and quilting sutures in seroma prevention after 23. Dixon MJ, Taylor PM, Slingsby L, Hoffmann MV, Kästner SBR,
latissimus dorsi breast reconstruction. Plast Reconstr Surg. 2017; Murrell J. A small silent low friction linear actuator for mechanical
139:854e-863e. https://doi.org/10.1097/PRS.0000000000003213. nociceptive testing in veterinary research. Lab Anim. 2010;44:
8. Khater A, Elnahas W, Roshdy S, et al. Evaluation of the quilting 247-253.
technique for reduction of postmastectomy seroma: a randomized 24. Quinn JV, Drzewiecki AE, Stiell IG, Elmslie TJ. Appearance
controlled study. Int J Breast Cancer. 2015. https://doi.org/10. scales to measure the cosmetic outcomes of healed lacerations.
1155/2015/287398. Am J Emerg Med. 1995;13:229-231.
9. Lee J, Bae Y, Jung JH, et al. Effects of quilting suture interval on 25. Osborne MP. William Stewart Halsted: his life and contributions
donor site seromas after breast reconstruction with latissimus dorsi to surgery. Lancet. 2007;8:256-265.
muscle flap. A randomized trial. Clin Breast Cancer. 2016;16: 26. Bristow PC, Halfacree ZJ, Baines SJ. A retrospective study of the
e159-e164. https://doi.org/10.1016/j.clbc.2016.05.017. use of active suction wound drains in dogs and cats. J Small Anim
10. Mazouni C, Mesnard C, Cloutier A, et al. Quilting sutures reduces Pract. 2015;86:325-330.
seroma in mastectomy. Clin Breast Cancer. 2015;15:289-293. 27. Quinn JV, Wells GA. An assessment of clinical wound evluation
11. Read J, Price CE, Adams S, Hudson DA. Morel-Lavallée lesion scales. Acad Emerg Med. 1998;5:583-586.
contour deformity: quilting sutures to prevent recurrent seroma 28. Michelsen J, Heller J, Wills F, Noble GK. Effect of surgeon expe-
after resection. Plast Reconstr Surg Glob Open. 2017;5:e1267. rience on postoperative plasma cortisol and C-reactive protein con-
https://doi.org/10.1097/GOX.0000000000001267. centrations after ovariohysterectomy in the dog: a randomised
12. Sforza M, Husein R, Andjelkov K, Rozental-Fernandes PC, trial. Aust Vet J. 2012;90:474-478.
Zaccheddu R, Jovanovic M. Use of quilting sutures during
abdominoplasty—are they really effective? Aesthet Surg J. 2015;
35:574-580.
13. Travis BM, Hayes GM, Vissio K, Harvey HJ, Flanders JA, How to cite this article: Lopez DJ, Hayes GM,
Sumner JP. A quilting subcutaneous suture pattern to reduce ser- Fefer G, et al. Effect of subcutaneous closure
oma formation and pain 24 hours after midline celiotomy in dogs:
technique on incisional complications and
a randomized controlled trial. Vet Surg. 2018;47:204-211.
postoperative pain in cats undergoing midline
14. Wolde BT, Wildenberg F, Keemers-Ges ME, Polat F, Strobbe L.
Quilting prevents seroma formation following breast cancer sur- celiotomy: A randomized, blinded, controlled trial.
gery: closing the dead space by quilting prevents seroma following Veterinary Surgery. 2019;1–8. https://doi.org/10.
axillary lymph node dissection and mastectomy. Ann Surg Oncol. 1111/vsu.13344
2014;21:802-807.