Preoperative hair removal to reduce surgical site infection.

BACKGROUND Although preparation of people for surgery has traditionally included removal of hair from the incision site, some studies claim that preoperative hair removal is harmful, causes surgical site infections (SSIs), and should be avoided. OBJECTIVES To determine if routine pre-operative hair removal (compared with no removal) and the timing or method of hair removal influence rates of SSI.. SEARCH METHODS For this second update we searched the Cochrane Wounds Group Specialised Register (searched 12 August 2011); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3); Ovid MEDLINE (1950 to August Week 1 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations August 11, 2010); Ovid EMBASE (1980 to 2011 Week 31) and EBSCO CINAHL (1982 to 11August 2011). No date or language restrictions were applied. SELECTION CRITERIA Randomised controlled trials (RCTs) or quasi randomised trials (QRCTs) that compared:1) hair removal with no hair removal; 2) different methods of hair removal; 3) hair removal at different times before surgery; and, 4) hair removal in different settings (e.g. ward, anaesthetic room). DATA COLLECTION AND ANALYSIS Three authors independently assessed relevance and quality of each trial. Data were extracted independently by two authors and cross-checked. MAIN RESULTS We included 14 trials (17 comparisons) in the review; three trials involved multiple comparisons. Six trials, two of which had three comparison arms, (972 participants) compared hair removal (shaving, clipping, or depilatory cream) with no hair removal and found no statistically significant difference in SSI rates however the comparison is underpowered. Three trials (1343 participants) that compared shaving with clipping showed significantly more SSIs associated with shaving (RR 2.09, 95% CI 1.15 to 3.80). Seven trials (1213 participants) found no significant difference in SSI rates when hair removal by shaving was compared with depilatory cream (RR 1.53, 95% CI 0.73 to 3.21), however this comparison is also underpowered. One trial compared two groups that shaved or clipped hair on the day of surgery compared with the day before surgery; there was no statistically significant difference in the number of SSIs between groups however this comparison was also underpowered.We identified no trials that compared clipping with depilatory cream; or investigated application of depilatory cream at different pre-operative time points, or hair removal in different settings (e.g. ward, anaesthetic room). AUTHORS' CONCLUSIONS Whilst this review found no statistically significant effect on SSI rates of hair removal insufficient numbers of people have been involved in this research to allow confidence in a conclusion. When it is necessary to remove hair, the existing evidence suggests that clippers are associated with fewer SSIs than razors. There was no significant difference in SSI rates between depilatory creams and shaving, or between shaving or clipping the day before surgery or on the day of surgery however studies were small and more research is needed.

[1]  F. Cheater,et al.  Pre-operative shaving in gynaecology. , 1992, Nursing standard (Royal College of Nursing (Great Britain) : 1987).

[2]  J. Mylotte,et al.  Surveillance of surgical wound infections following open heart surgery. , 1991 .

[3]  P. Hoffman,et al.  Behaviours and rituals in the operating theatre. A report from the Hospital Infection Society Working Party on Infection Control in Operating Theatres. , 2002, The Journal of hospital infection.

[4]  S. Dogan,et al.  The Effect of Hair on Infection after Cranial Surgery , 2001, Acta Neurochirurgica.

[5]  L. Bt,et al.  Pre-operative preparation of the skin with a depilatory. , 1975 .

[6]  J. Gilsbach,et al.  Incidence of wound infection in patients undergoing craniotomy: Influence of type of shaving , 2005, Acta Neurochirurgica.

[7]  K. Winston.  Hair and neurosurgery. , 1992, Neurosurgery.

[8]  J. Tanner,et al.  Preoperative Hair Removal: A Systematic Review , 2007, Journal of perioperative practice.

[9]  O. Isom,et al.  Effects of shaving methods and intraoperative irrigation on suppurative mediastinitis after bypass operations. , 1992, The Annals of thoracic surgery.

[10]  E. Barnes,et al.  A clinical study of Sudocrem in the management of dermatitis due to the physical stress of incontinence in a geriatric population. , 1987, Journal of advanced nursing.

[11]  L. Wahlqvist,et al.  Wound healing after depilation with a keratolytic cream. A tensiometric and histological study in the rat. , 1967, Acta chirurgica Scandinavica.

[12]  M. Phippen,et al.  Patient care during operative and invasive procedures , 2000 .

[13]  Court-Brown Cm.  Preoperative skin depilation and its effect on postoperative wound infections. , 1981 .

[14]  Nichols Rl,et al.  Preoperative hair removal: a random prospective study of shaving versus clipping. , 1982 .

[15]  S F Mishriki,et al.  Factors affecting the incidence of postoperative wound infection. , 1990, The Journal of hospital infection.

[16]  J. Howell,et al.  Scalp laceration repair without prior hair removal. , 1988, The American journal of emergency medicine.

[17]  W R Jarvis,et al.  Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. , 1999, Infection control and hospital epidemiology.

[18]  R. McCloy,et al.  Shaving patients before operation: a dangerous myth? , 1994, Annals of the Royal College of Surgeons of England.

[19]  V. López,et al.  Sobre la necesidad del rasurado de la región púbica en los pacientes que van a ser sometidos a cirugía urológica endoscópica , 2004 .

[20]  C. Chan,et al.  Cosmesis in neurosurgery: is the bald head necessary to avoid postoperative infection? , 2002, Annals of the Academy of Medicine, Singapore.

[21]  S. Mason.  Type of soap and the incidence of skin tears among residents of a long-term care facility. , 1997, Ostomy/wound management.

[22]  S. Danchaivijitr,et al.  Pre-operative shaving and wound infection in appendectomy. , 1992, Journal of the Medical Association of Thailand = Chotmaihet thangphaet.

[23]  C. Dealey.  Pressure sores and incontinence: a study evaluating the use of topical agents in skin care. , 1995, Journal of wound care.

[24]  M. Elía,et al.  Is It Necessary to Shave the Pubic and Genital Regions of Patients Undergoing Endoscopic Urological Surgery? , 2004, Infection Control & Hospital Epidemiology.

[25]  M. Uchino.  Surgical Site Infection (SSI) Following Surgery for Inflammatory Bowel Disease (IBD) , 2008 .

[26]  M. Finch.  Assessment of skin in older people. , 2003, Nursing older people.

[27]  J. Rothrock,et al.  Alexander's Care of the patient in surgery , 1972 .

[28]  M. Sasako,et al.  [Preoperative skin preparation. A prospective study comparing a depilatory agent in shaving]. , 1987, Presse medicale.

[29]  B. Scherpereel.  [No hair shaving]. , 1993, Neuro-Chirurgie.

[30]  A. Adeleye,et al.  Nonshaved cranial surgery in black Africans: a short-term prospective preliminary study. , 2008, Surgical neurology.

[31]  E. Kovavisarach,et al.  Randomised controlled trial of perineal shaving versus hair cutting in parturients on admission in labor. , 2005, Journal of the Medical Association of Thailand = Chotmaihet thangphaet.

[32]  Sanguansin Ratanalert,et al.  Nonshaved cranial neurosurgery. , 1999, Surgical neurology.

[33]  J. Sutcliffe,et al.  The preoperative skin shave in neurosurgery: is it justified? , 1998, British journal of neurosurgery.

[34]  Rick Wiechula,et al.  The JBI model of evidence-based healthcare. , 2005, International journal of evidence-based healthcare.

[35]  K. Clever,et al.  Evaluating the efficacy of a uniquely delivered skin protectant and its effect on the formation of sacral/buttock pressure ulcers. , 2002, Ostomy/wound management.

[36]  Sanguansin Ratanalert,et al.  Nonshaved ventriculoperitoneal shunt in Thailand , 2005, Journal of Clinical Neuroscience.

[37]  L. Barrou,et al.  L'infection postoperatoire apres craniotomie chez l'adulte , 2004 .

[38]  T. Coggins,et al.  No-rinse, one-step bed bath: the effects on the occurrence of skin tears in a long-term care setting. , 2003, Ostomy/wound management.

[39]  W. B. Conolly,et al.  THE USE OF A DEPILATORY CREAM IN SURGERY , 1966, The Medical journal of Australia.

[40]  B. Reynolds,et al.  Wound infections after preoperative depilatory versus razor preparation , 1971 .

[41]  J. Piatt,et al.  Shaving of the scalp may increase the rate of infection in CSF shunt surgery. , 1996, Pediatric neurosurgery.

[42]  K. Whittingham,et al.  Cleansing regimens for continence care. , 1998, Professional nurse.

[43]  R. Nambiar,et al.  Is preoperative shaving really necessary? , 1985, Annals of the Academy of Medicine, Singapore.

[44]  I. Fraser,et al.  Should patients be shaved prior to transurethral surgery? , 1978, British journal of urology.

[45]  Paul Thur de Koos,et al.  Shaving versus skin depilatory cream for preoperative skin preparation. A prospective study of wound infection rates. , 1983, American journal of surgery.

[46]  C. Howie.  A flow of good ideas. , 1983, Nursing times.

[47]  A. Houlker.  Alexander's care of the patient in surgery , 1988 .

[48]  M. Brazzelli,et al.  Absorbent Products for Containing Urinary and/or Fecal Incontinence in Adults , 2002, Journal of wound, ostomy, and continence nursing : official publication of The Wound, Ostomy and Continence Nurses Society.

[49]  S. Small.  Preoperative hair removal: a case report with implications for nursing. , 1996, Journal of clinical nursing.

[50]  J. Alexander,et al.  The influence of hair-removal methods on wound infections. , 1983, Archives of surgery.

[51]  S. Beck,et al.  Implementation of the AORN Skin Shaving Standard , 1993 .

[52]  M. Bumbasirevic,et al.  Surgical site infections in orthopedic patients: prospective cohort study. , 2008, Croatian medical journal.

[53]  Choo Ht,et al.  Post-operative wound infection following gynaecological operations. , 1984 .

[54]  M. Abouzari,et al.  Re: Nonshaved cranial surgery in black Africans: a short-term prospective preliminary study (Adeleye and Olowookere, Surg Neurol 2008;69-72) Effect of hair on surgical wound infection after cranial surgery: a 3-armed randomized clinical trial. , 2009, Surgical neurology.

[55]  S. Sgouros,et al.  The Influence of Hair Shave on the Infection Rate in Neurosurgery , 2001, Pediatric Neurosurgery.

[56]  V. Ilankovan,et al.  Preoperative shaving: patient and surgeon preferences and complications for the Gillies incision. , 1992, Journal of the Royal College of Surgeons of Edinburgh.

[57]  S. Beck,et al.  EVALUATION OF A PLANNED CHANGE , 1993 .

[58]  S. Çelik,et al.  Does Shaving the Incision Site Increase the Infection Rate After Spinal Surgery? , 2007, Spine.

[59]  C M Sheppard,et al.  The effects of bathing and skin care practices on skin quality and satisfaction with an innovative product. , 2000, Journal of gerontological nursing.

[60]  M. Kelsey,et al.  The Second National Prevalence Survey of infection in hospitals--overview of the results. , 1996, The Journal of hospital infection.

[61]  James A. Roberts,et al.  Socio-economic burden of hospital acquired infection , 1999 .

[62]  C. Kopac,et al.  Skin tears in institutionalized elderly: an epidemiological study. , 1998, Ostomy/wound management.

[63]  L. Segadal,et al.  Preoperative hair removal--a systematic literature review. , 2002, AORN journal.

[64]  P. Cooper,et al.  Comparison of two skin care regimes for incontinence. , 2001, British journal of nursing.

[65]  D. Arkell,et al.  Preoperative skin preparation: clinical evaluation of depilatory cream. , 1976, British medical journal.

[66]  J. Clarke.  Theatre nursing. The effectiveness of surgical skin preparations. , 1983, Nursing times.

[67]  M. Briggs.  Principles of closed surgical wound care. , 1997, Journal of wound care.

[68]  R. Nichols.  Surgical wound infection. , 1991, The American journal of medicine.

[69]  John Ramey,et al.  Intracranial Surgery: To Shave or Not to Shave? , 2001, Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology.

[70]  U. Winfield.  Too close a shave? , 1986, Nursing times.

[71]  V. Braun,et al.  Shaving the hair — Is it always necessary for cranial neurosurgical procedures? , 2006, Acta Neurochirurgica.

[72]  N. Black,et al.  The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. , 1998, Journal of epidemiology and community health.

[73]  G. Mehta,et al.  Computer assisted analysis of wound infection in neurosurgery. , 1988, The Journal of hospital infection.

[74]  R. Penzer,et al.  Promoting healthy skin in older people. , 2001, Nursing older people.

[75]  Y. Sumiyama,et al.  [Surgical site infection: SSI]. , 2002, Nihon rinsho. Japanese journal of clinical medicine.

[76]  P. W. Vestal.  Preoperative preparation of the skin with a depilatory cream and a detergent. , 1952, American journal of surgery.

[77]  M. Carrieri,et al.  Risk factors for surgical wound infections in clean surgery: a multicenter study. Italian PRINOS Study Group. , 1996, Annali italiani di chirurgia.

[78]  K. Westermann,et al.  [Does preoperative shaving cause disturbance of wound healing? (author's transl)]. , 1979, Unfallheilkunde.

[79]  C. Lyder,et al.  STRUCTURED SKIN CARE REGIMEN TO PREVENT PERINEAL DERMATITIS IN THE ELDERLY , 1992, Journal of ET nursing : official publication, International Association for Enterostomal Therapy.

[80]  P. Ryan,et al.  Effects of incontinence care cleansing regimens on skin integrity. , 1995, Journal of wound, ostomy, and continence nursing : official publication of The Wound, Ostomy and Continence Nurses Society.

[81]  T. Horan,et al.  Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. , 1999, American journal of infection control.

[82]  Peter J. E. Cruse,et al.  A five-year prospective study of 23,649 surgical wounds. , 1973, Archives of surgery.

[83]  S. Milo,et al.  Surgical site infection rates following cardiac surgery: the impact of a 6-year infection control program. , 2005, American journal of infection control.

[84]  R. F. Morgan,et al.  Bacteriologic evaluation of electric clippers for surgical hair removal. , 1984, American journal of surgery.

[85]  H. Hamilton,et al.  Preoperative hair removal , 1977, Canadian journal of surgery. Journal canadien de chirurgie.

[86]  B. J. Bird,et al.  Extensive pre-operative shaving: a costly exercise. , 1984, The New Zealand medical journal.