Abstract
BackgroundLaparotomy incisions with contamination have a high incidence of surgical site infection (SSI). One strategy to reduce SSI has been to allow these wounds to heal by secondary intention; however, this results in an ongoing need for wound care after discharge.MethodsA prospectively maintained Acute and Critical Care Surgery database was queried for patients who underwent exploratory laparotomy during 2008-2018. Patients were stratified into two groups: 2008-2015 (no protocol [NP]) and 2016-2018 (closure protocol [CP]). CP patients were operated on by a single surgeon utilizing a multi-modal high-risk incisional closure protocol, which included dilute chlorhexidine lavage, closed suction drains for incisions deeper than 3 centimeters, and incisional negative-pressure wound therapy (iNPWT). The CDC (Centers for Disease Control and Prevention) guidelines were used to determine wound classification and SSI based on chart review. Groups were compared using univariate and multivariate analysis.ResultsA total of 139 patients met the study criteria. The overall SSI rate, including superficial and deep space infections, was no different in NP versus CP (21.6 vs. 24.1%; p=0.74). The rate of superficial SSI was similar between NP and CP (11.8 vs. 8.4%; p=0.53). Rates of wound closure at discharge were higher in the CP group than the NP group across wound classes, with the greatest difference among dirty wounds (50.0% NP vs. 94.9% CP; p<0.01). CP significantly increased the likelihood of wound closure (OR=179.2; p<0.001) even after controlling for body mass index, wound classification, ASA (American Society of Anesthesiologists) status, and initially open abdomen.ConclusionsBy addressing both tissue factors and bacterial burden through the use of a multi-modal high-risk incisional closure protocol involving iNPWT, all wounds can be considered for closure without increasing the risk of SSI.
Highlights
Surgical site infections (SSIs) represent both the most prevalent and most costly form of nosocomial infection in the United States, occurring after 2-5% of all operations and more than 16% of abdominal operations annually [1,2]
One strategy to reduce surgical site infection (SSI) has been to allow these wounds to heal by secondary intention; this results in an ongoing need for wound care after discharge
CP significantly increased the likelihood of wound closure (OR=179.2; p
Summary
Surgical site infections (SSIs) represent both the most prevalent and most costly form of nosocomial infection in the United States, occurring after 2-5% of all operations and more than 16% of abdominal operations annually [1,2]. Efforts to reduce SSI are common in the surgical literature but vary based on wound classification. Healing by secondary intention is often used in high-risk wounds to decrease rates of SSI [5]. Healing by secondary intention reduces SSI, it increases healthcare costs [6,7]. Delayed primary closure has been used to mitigate the risk of SSI in contaminated or dirty wounds by avoiding closure at the initial operation when the bacterial burden is higher, while still eventually achieving a primarily closed wound [8,9]. Laparotomy incisions with contamination have a high incidence of surgical site infection (SSI). One strategy to reduce SSI has been to allow these wounds to heal by secondary intention; this results in an ongoing need for wound care after discharge
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