Preoperative hair removal—a systematic literature review

AORN Journal,  May, 2002  by Inge Kjonniksen,  Bjorg Marit Andersen,  Valbjorg G. Sondenaa,  Leidulf Segadal

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Preventing postoperative surgical site infections (SSIs) through preoperative skin preparation has a long history. One measure for preventing SSIs has been to remove patients' hair in the surgical field via a safety razor. In the 1970s and 1980s, clinical investigations indicated that shaving increased the frequency of SSIs and that depilation or electric clippers were preferable if hair removal was necessary. (1) A 1999 guideline from the Centers for Disease Control and Prevention (CDC) provides recommendations on preoperative hair removal. The guideline strongly recommends that hair should not be removed preoperatively unless the hair at or around the incision site will interfere with the surgical procedure. If hair is removed, however, it should be done immediately before surgery, preferably with clippers. (2)

When the CDC released its guideline, the Norwegian Centre for Health Technology Assessment, Oslo, was in the process of reviewing evidence on the necessity of several preoperative and perioperative hygienic procedures. A question was raised regarding to what extent the CDC guideline was a result of a systematic search of all relevant literature and a subsequent critical literature appraisal. The working methods and search strategies used to generate the CDC guideline were not described, so before implementing the recommendations, staff members at the Norwegian Centre for Health Technology Assessment wanted to systematically search and appraise relevant scientific literature on some topics to compare the Centre's and the CDC's conclusions. Team members chose to first assess preoperative hair removal and the subsequent incidence of SSIs.

LITERATURE SEARCH AND ASSESSMENT

Scientific articles were identified by searches of the following electronic databases:

* Cochrane Trial Register--Issue 3, 1999;

* Medline--1966 to 1999;

* Embase--1974 to 1999;

* CINAHL--1982 to 1999;

* Database of Abstracts of Reviews of Effectiveness;

* National Health Service Economic Evaluation Database; and

* Health Technology Assessment Database. Searches were terminated in December 1999. Search terms that were used included surgical site infection/s or surgical wound infection/s and depilation, or hair, or shaving.

All articles dealing with conventional surgical procedures in ORs and that reported on the relationship between preoperative hair removal and SSIs were included. Team members considered both randomized and observational studies. All endoscopic, transurethral, catheterization, and interventional radiology procedures were excluded--in accordance with the CDC guideline--together with studies concerning pilonidal cysts. Two team members independently read and evaluated all titles and summaries retrieved electronically for inclusion in the study. The reference list of relevant articles published in the 1990s was hand searched, and team members obtained articles thought to be relevant. These articles also were read independently for inclusion. Team members also retrieved references cited in the CDC guideline on preoperative hair removal. Each article was assessed and graded based on modified recommendations provided by the US Agency for Healthcare Research and Quality (Table 1). (3) All 10 members of the team assessed all included articles and decided in plenary the relevance and quality of each article.

RESULTS

Electronic searches identified 120 articles dealing with preoperative hair removal and SSIs. Six articles were identified in reference lists. Articles cited in the CDC guideline that were not found in our searches also were included and assessed. No relevant health technology assessments or systematic reviews were found. Studies were divided into groups, including

* shaving compared to no hair removal,

* shaving compared to clipping,

* shaving compared to depilation,

* timing of preoperative hair removal with razor or clippers, and

* wet and dry shaving (Table 2).

Shaving compared to no hair removal. In a randomized study, one researcher found that 17 of 137 (ie, 12.4%) shaved patients developed SSIs compared to 11 of 141 (ie, 7.8%) unshaved patients, which is not statistically significant. (4) In another small study, no patients developed wound infection. (5) In another study, shaved patients received a different preoperative skin treatment compared to nonshaven patients; therefore, results are difficult to relate to hair removal alone, and the study was not emphasized in the assessment. (6)

An observational research study recorded that 4.6% of shaved patients in the study developed wound infections compared to 1.5% of unshaved patients (P < .05). (7) One researcher showed significant differences in favor of no hair removal (P < .05) for subgroups of wounds.8 Other researchers found a reduction in infection rates when performing shaveless neurosurgical procedures compared to corresponding procedures with shaving (P < .05); however, treatments were somewhat different between the groups. (9) Another research study could not demonstrate significant reduction in wound infections (ie, 6.9% in historical controls compared to 3.3% after changing practice to shaveless procedures). (10) Shaving was associated with higher incidences of postoperative site infections compared to procedures performed without hair removal (ie, 2.5% compared to 0.9%) in a 10-year study that included more than 60,000 wounds. (11) Another study showed that neurosurgical procedures could be performed without hair removal and with low incidence of SSIs compared to corresponding procedures with shaving; however, this study was performed without controls. (12)