Primary Closure Versus Delayed Primary Closure of Class III and IV Surgical Wounds Following Emergency Laparotomy: A Prospective Comparative Study.

Abstract

Introduction Emergency surgery has a high risk of complications due to the detrimental effect of perioperative sepsis and the relative lack of preoperative optimization of patients. Despite advances in critical care for the management of sepsis, its prevention is dependent on various patient and surgeon factors. Surgical site infection continues to be a major determinant of morbidity and mortality following emergency abdominal surgery, especially in contaminated or dirty wounds. This study aims to compare two techniques of abdominal wall closure, primary closure with subcutaneous suction drains and delayed primary closure following negative pressure wound therapy, in terms of incidence of surgical site infection and morbidity. Materials and methods The study was a prospective comparative study including 50 patients with an acute surgical abdomen requiring laparotomy. The patients were randomized into two groups, Group A (n=25) who underwent primary closure, and Group B (n=25) who underwent delayed primary closure. In Group B patients, a vacuum-assisted closure device was applied in the subcutaneous space for five days prior to the closure of the skin. Outcomes were compared in terms of the incidence of superficial and deep surgical site infection, its association with diabetes mellitus, and the total duration of hospital stay. A chi-square test and an unpaired t-test were used for the test of significance. Results A total of 50 patients, comparable in age, were included in the study. The overall incidence of surgical site infection was significantly higher in patients of Group A as compared to Group B (p=0.0046). There was a positive correlation between diabetes mellitus and the occurrence of wound infection in both groups with the odds ratio being 2.67 and 2.38 respectively. The incidence of superficial wound infection was significantly higher in Group A when compared to Group B (52% versus 24%; p=0.04). Deep surgical site infection was higher in patients of Group A (20% versus 8%) but was not statistically significant (p=0.22). The average duration of hospital stay was 41.56 ± 6.96 and 37.86 ± 6.68 days for patients who developed complications fromGroups A and B respectively, while it was nearly two and a half times lower in uncomplicated cases of Groups A and B (11.71± 1.70 days and 16.58± 1.06 days respectively). The one-tailed unpaired t-test showed a significant difference in means of hospital stay between patients with and without complications (T: 17.06, critical value: 1.677). Conclusion Delayed primary closure is an effective method of managing contaminated and dirty wounds following emergency laparotomy. Negative pressure wound therapy is one technique for preventing wound bed infection and accelerating wound healing in such cases. By combining the above in emergency surgeries, the incidence of surgical site infection and duration of hospital stay can be significantly reduced.