Traditionally preoperative hair removal has been carried out as skin preparation method to reduce exposure to bacteria which may lead to surgical site infections (SSI) (Gottrup et al 2005). SSI’s are defined by Centres for Disease Control (CDC) as superficial, deep incision and organ infection. According to Miller (2001) hair has been removed for such reason as wound asepsis, suitable placement of bandages, and access to operative site and accurate approximation of wound edges. Though preoperative hair removal has been in practice since 18th century its impact on the wound site has been under contention and therefore attracted the author’s interest in seeking ways of hair removal without skin damage. However there are concerns that hair removal increases rather than reduces infection, in a study carried out by Astegnau et al (2001) to identify mortality and morbidity related to surgical site infection suggested that shaving increased the risk of infection by facilitating colonisation of bacteria in the operating site. Many organisations, Association of Perioperative Registered Nurses (AORN2006) and Association for Perioperative Practise (AFPP2007) have moved away from hair removal.
There is no clarity in literature as to the origin of preoperative hair removal, but researchers conclude to the fact that the surgeons of the time believed that wounds might heal more quickly if hair could be prevented from becoming entangled in the sutures and wound during closure (Miller et al 2001). Shaving with a razor substantiated the emergence of preoperative hair removal in a systematic literature review by Kjonnisken et al (2002) as an established practice based on assumption of preventing surgical site infection. Some other methods, electric clipping and depilatory creams have been highlighted as having lower postoperative wound infection rates.
Hair is associated with poor hygiene habits because it harbours bacteria and removing it is thought to reduce surgical infections (Kumar 2002). Hair removal is done by shaving with either a razor or a clipper which are believed to cause both visible and microscopic injuries (Briggs1997). The damage caused by a razor or a clipper can release flora-providing access to serous exudates on which micro organisms may grow (Small 1996). Skin is always a hunting ground for microbes. Once the skin’s protective barrier is diminished primarily by a surgeons incision, microbes can potentially contaminate the wound. Loius Pasteur in confirmation of the existing understanding into the world of infection hypothesized in his germ theory that invisible bacteria could cause surgical infection if they gained entry through the broken skin (Fogg 2003).
A national audit in 2004 suggests that surgical site infections increases patients’ hospital stay, and increases health care cost by delaying wound healing, this causes major physical limitations and reduced quality of life (Whitehouse et al 2002). If occurring after discharge the patient is likely to be readmitted which is a burden to the patient and can even cause death (Plowman 2000). Surgical site infections occurs within 30 days after surgery, exudes pus and shows one of the following symptoms pain, localised swelling and redness according to the Centre for Disease Control (1999).
While once accepted as a standard practise for surgical procedures, hair removal is now being considered in great depth in the research. This essay will review the role of hair removal in the perioperative setting and its impact on surgical site infections. The author will discuss research regarding nurses and doctors knowledge on recommended guidelines on hair removal methods, comparison and timing of hair removal methods and their relationship to incidences of surgical site infections.
Keywords used for the search are preoperative skin preparation, hair removal, preoperative razor shaving, electric clipping, depilatory creams and surgical site infections. The databases utilised were CINAHL, Cochraine database of systematic reviews, Health Source Nursing and Allied Health Science. The studies were done in USA, UK, Canada and Turkey.
Hair Removal Methods
Razor shaving is the cheapest and most commonly used hair removal method (Tanner et al. 2007). Using a sharp blade held with the head of the razor that is drawn to the patients’ skin to cut hair close to the skin surface. Razor shaving increases bacterial infection rates (Basevi & Lavender 2001). Another method entails the use of clipper that uses fine teeth to remove hair close to the skin leaving stubble of usually one millimetre in length. Heads are disposable and handles are disinfected between patients to minimise risk of cross infection (Tanner et al. 2006). A further method is the use of depilatory creams that utilises chemicals, which dissolves the patient’s hair. Cream has to be in contact with the hair for between 5-20 minutes. A patch test should be done 24 hours before using the cream as some patients can develop allergic reactions and some have sensitive skins (Kjonnisken et al .2002).
Miller et al. (2001) conducted a retrospective study comparing all patients who underwent intracranial procedures in the last two and half years where hair was not shaved, to patients done three and half years back that were shaved, to determine whether no hair removal increase post operative infection rate. Results were documented as minor, moderate and severe. Of the 250 subjects used 150 patients were not shaved and 7% developed post operative wound infection compared to 6.6% infections in the shaved group. There was no statistical significance in these findings though the sample size is large for an organisational setting however the finding could not be generalised based on this number. An experimental study was performed on 82 patients who underwent abdominal surgery between November 30th – May 2005 to determine the effect of preoperative hair removal on post operative wound infection. Patients were told the aim of the study and they signed consents. Inclusion criteria were patients who had not been hospitalised within the last 30 days and didn’t have infections while being admitted. Control group with 39 patients were razor shaved and on 43 for study group clippers were used. Patients were observed for signs of SSI two days post operatively and 7% of the study group developed SSI compared to 25.6 % in the control group. The results are statistically significant but the sample size is small and the fact that abdominal surgeries are viewed dirtier than lower limbs makes findings hard to generalise however the length of time and the study design utilised would have enabled the establishment of rigor for the findings to be reliable. The study uptake therefore will be better with an increased sample size. Though the latest studies are endorsing hair clipping (Tanner et al 2006). (Boyce & Pittet 2002), more studies need to be carried out.
A double-blind prospective study was carried out between 2000-2004 for all patients undergoing spinal surgery (Celik et al. 2007 ) to determine the effect of razor shaving and increased rate of postoperative site infection compared to no hair removal. The shaved group consisted of 371 subjects and the unshaved group comprised of 418 subjects. Patients were fully informed about the study and consents obtained. The subjects were randomly allocated according to pre-surgical shaving status. Exclusion criteria involved patients with skin conditions acne, furuncle and sebaceous cyst, patients with nutritional deficiency and medical conditions like diabetes and cancer. Same skin preparations were done in both groups. Both subjects received prophylactic antibiotics.
Postoperatively, both groups were observed for signs of infection redness swelling and purulent discharge and bloods taken to check erythrocyte sedimentation rate. Infection was higher in the shaved group (p=.01) 4 patients in a shaved group (1.07%) developed infection and in only 1 patient in the unshaved group (0.23%). The findings suggest that preoperative hair removal increases postoperative infections. This study was ethically approved and both methodology and aim were clear and concise. These all confirm its reliability however giving antibiotics during procedures may mask the results causing the study to be unreliable.
A randomised control study was conducted by (Menendez et al. 2004) aiming to assess the effects of preoperative shaving of pubic hair on postoperative bacterium after urological surgery. A sample size of 300 patients was used. 149 patients were shaved and 151 were not shaved. In both groups urine samples were taken for culture before being given prophylactic antibiotic and again at one week before the catheter was removed. In the shaved group 19.5% developed infection as compared to 16.6% in the non-shaved group. The difference was found not to be statistically significant. The results were based on testing urine samples than in the wounds making the study invalid. There is no clarity about ethical considerations and if the aim and purpose of the study was explained to the subjects and whether the consent obtained was informed. The prophylactic administration of the antibiotics makes the study to be unreliable and not valid.
In Cochraine collaboration review data Tanner et al. (2007) conducted eleven randomised controlled trials to evaluate the effects of routine preoperative hair removal with razor as opposed to no hair removal in postoperative infection. The authors concluded that there is no sufficient evidence to prove that hair removal causes an increased risk of surgical site infections. However the study suggested the use of clippers or depilatory cream when necessary to remove hair with an idea that both methods results in fewer surgical site infections.