Clean Surgical Wounds Research Articles

Is Catgut Really Obsolete? Experience with Buried Subcuticular Catgut Sutures in Operative Wounds.

A good scar after surgery is desirable. Skin closure with subcuticular sutures is known to give better scars. Absorbable sutures reduce suture track infection. Catgut is a monofilament absorbable suture, which has not been generally recommended for skin for fear of infection and dehiscence. Buried subcuticular sutures using catgut were given in 350 cases after surgery. Disorders known to impair wound healing were excluded. Infection and dehiscence was noted in only 4.3% cases. Dehiscence in the absence of wound infection was seen in only two cases (0.6%). Excellent healing with fine linear scars was the result in 92% patients. Catgut can be safely used for skin closure by the described technique of buried subcuticular sutures in clean surgical wounds with gratifying results. It has advantages over its synthetic counterparts of easy availability, economy and good handling. The fear of poor result with catgut as a skin suture is unfounded.

Prevention of orthopaedic wound infections: a quality improvement project.

Using clinical practice improvement methodology, a project was undertaken to reduce the incidence of surgical wound infections following elective hip and knee replacement surgery. A team was established, key measures for improvement were identified, strategies for change were developed and an action plan was implemented. Outcomes for this project included a reduction in the rate of clean surgical wound infection for joint replacement surgery from 28% to zero. Average length of stay for total hip replacement surgery was reduced from 13.9 to 9.3 days and from 14.6 to 10.4 days for total knee replacement surgery. Guidelines for patient selection were developed along with a protocol for the management of preparation to prevent urinary tract infections. Post-discharge surveillance and a preoperative rehabilitation and exercise programme have been implemented. There is potential for wider uptake and implementation of the quality principles described herein.

Clean surgical wounds: prevention of infection.

Nurses need to be aware of the principles of infection control and the factors affecting wound infection to develop effective strategies to prevent infection and cross-infection.

The effects of perioperative hypothermia and the duration of anesthesia on postoperative wound infection rate in clean wounds: a retrospective study.

To determine the effects of hypothermia and duration of anesthesia on the infection rate in clean wounds in dogs and cats. Retrospective clinical study. Seven hundred seventy-seven dogs and cats undergoing clean surgical procedures. Records of animals prospectively evaluated for postoperative wound infection were retrospectively evaluated for the prevalence of perioperative hypothermia. Body temperatures during the perioperative period and the duration of surgery and anesthesia were recorded. Data were analyzed to identify differences between animals with infected and uninfected wounds and multiple logistic regression modeling was used to evaluate the independent contribution of risk factors to the incidence of postoperative wound infection. No statistically significant differences were found in the analysis of temperature data between animals with infected and uninfected wounds. Duration of anesthesia was significantly greater in animals with wound infections (P = .01). Multiple logistic regression modeling identified duration of anesthesia as a risk factor for postoperative wound infection independent of the duration of surgery. In animals with clean surgical wounds, mild perioperative hypothermia is not a significant risk factor for postoperative wound infection. The duration of anesthesia, however, is a significant risk factor independent of the duration of surgery. To decrease the incidence of postoperative wound infection, the duration of anesthesia should be minimized. Surgical time, as well as the time required for ancillary diagnostic tests while under anesthesia should, therefore, be kept to a reasonable minimum.

The association of propofol usage with postoperative wound infection rate in clean wounds: a retrospective study.

To determine if the use of propofol influences the postoperative infection rate of clean surgical wounds in dogs and cats. Retrospective study. 863 dogs and cats undergoing clean surgical procedures. Medical and anesthetic records of surgical cases used as part of a previously described epidemiologic study on postoperative wound infection rates were reviewed. The records of all animals with clean surgical wounds were reviewed to determine if propofol had been used for anesthetic induction or maintenance during the procedure. To determine the effect of propofol use on wound infection rate, data were analyzed using Fisher's exact test, followed by multiple logistic regression to adjust for various factors, including surgery time, time from clipping to surgery, antibiotic usage, coexisting distant infection, endocrine disease, and the use of immunosuppressive drugs in the perioperative period. Of 863 dogs and cats with clean surgical wounds, 46 received propofol as part of the anesthetic protocol. A total of 6 of 46 animals (13%) receiving propofol developed postoperative wound infections, compared with 33 of 817 animals (4%) not receiving propofol (P = .014; % difference = 9%; 95% CI = 0.5% to 24%). Adjusting for all other factors evaluated, animals receiving propofol were 3.8 times more likely to develop postoperative wound infections compared to animals not given propofol (95% CI = 1.5-9.9). Propofol is a lipid-based emulsion capable of supporting microbial growth. Administration of a potentially contaminated solution may contribute to surgical wound infection or other patient morbidity or mortality. Strict aseptic technique in the preparation of the solution and prompt disposal of unused drug are imperative to curtail the potential for extrinsic contamination.

The effect of surveillance on surgical wound infection rates

The clean wound infection rate is the most valuable reflection of surgical care in any hospital. Wound infection rates are seen as indicators of quality in terms of negative outcome measures. A nurse was appointed by Hairmyres and Stonehouse Hospitals NHS Trust for the purpose of surveillance of the clean surgical wound infection rate. The surveillance is based on a previous study in the USA showing that feedback of infection rates to surgeons can lead to a reduction in these rates. The specifications for surveillance were that all clean surgery would be followed up for 30 days post-operatively and that wounds with implants, i.e. vascular grafts, would be followed up for 1 year post-operatively to produce infection rates for the surgeons, wards, theatres and the infection control team. Data collection commenced in October 1995 and so far 1851 clean surgical cases have been followed up for 30 days post-operatively. All patients were monitored until discharge, then at 30 days post-operatively, and the wound scored for signs of infection. Day cases were seen within week 1 and at day 30. General practitioner and district nurse liaison enabled detection of problems at other times. The patients were given a telephone number they could use to report problems after surgery. The results show that this type of surveillance is an effective way of collecting accurate data on wound infection rates. It has enabled the early identification of problem areas in practice. The audit has also been used to facilitate the adoption of evidence-based practice, through recommendations for clean surgery, to reduce the extrinsic risk factors for wound infection. As a result of the surveillance, there has been a significant reduction (P < 0.05) in the clean wound infection rate.

Evaluation of artificial skin (Integra) in a rodent model

The biocompatibility of artificial skin (Integra) has been investigated in clean surgical wounds of 20 guinea-pigs. A rectangular 3 × 3 cm full-thickness skin defect with excision carried down to the panniculus carnosus was prepared on the dorsal area of the guinea-pig. A thin layer of silver sulfadiazine cream was applied and artificial skin was placed to cover the wound. At day 14, the uppermost silicone layer was removed. Good take of the artificial skin was observed in 18 of 20 animals. Microscopy showed good vascular ingrowth in 14 of the 18 animals. The remaining four animals showed necrotic tissue, absence of vascularization and haemorrhage in the wound bed. Two of the 20 wounds showed purulent discharge. In this animal model, clinical ‘take’ of the neodermis was achieved in frcase|18/20 animals (90 per cent), while vascular ingrowth was observed in only frcase|14/20 animals (70 per cent). These results suggested that artificial skin in clean surgical wound is readily biologically incorporated into surrounding viable tissue.

Intrastromal corneal suture for small incision cataract surgery

Proper wound closure is important in preventing postoperative endophthalmitis. We developed an intrastromal corneal suture technique that uses some principles of the running, locked, intradermal suture for light-tension skin wounds. It achieves close approximation of the wound edges, reduces postoperative wound care and the risk of wound infection in clean surgical wounds, and obviates suture removal. It may also help prevent endophthalmitis and early against-the-rule astigmatism without the complications associated with external suture exposure.

Classification of the Surgical Wound: A Time for Reassessment and Simplification

Classification of the surgical wound in the operating room by surgeons and nurses is a time-honored routine that has been practiced for at least 30 years, since the time of the National Academy of Sciences National Research Council study on the influence of ultraviolet irradiation on surgical wound infection.1 This traditional method uses four classes of wounds based on the risk level and type of contamination expected or observed at operation.2-3 Clean surgical wounds (Class I) are those in which only exogenous (airborne) contamination is expected or observed and the predicted wound infection rate is approximately 2%, largely due to gram-positive microorganisms such as Staphylococcus aureus. Clean-contaminated (Class II) wounds are those in which generally both exogenous and endogenous (aerobic-anaerobic) bacterial contamination occur during elective operations. The infection rate in this category is estimated at 5% to 15% and is usually due to the polymicrobic endogenous flora. Contaminated wounds (Class III) are those with early endogenous leakage or delayed exogenous contamination in the absence of established clinical infection and carry a greater than 15% infection rate. In dirty wounds (Class IV) where active infection is encountered during operation, a postoperative infection rate of greater than 30% is anticipated. During the last decade, there have been problems identified with the use of this traditional wound classification system and the accuracy of the predicted infection rates in each category. The major limitation lies in the lack of attention to the varying risk of infection among subjects in each class of wound.3 Haley et a14 at the Centers for Disease Control and Prevention were among the first to publish on the importance of identifying the varying individual risks for infection among patients in each of the traditional four categories of wounds. Using stepwise multiple logistic regression in nearly 59,000 patients, they developed a new predictive index using four risk factors that, when studied in an equally large group of surgical patients, was able to accurately predict the incidence of wound infection. They identified three different risk groups (low, medium, and high) in both the clean and clean-contaminated wound classes and only two risk groups (medium and high) in the contaminated and dirty classes. There were surprisingly close similarities of predicted infection rates among Class I and II and in Class III and IV wounds. The infection rates in Class I wounds were reported as 1.1% (low risk), 3.9% (medium risk), up to 15.8% (high risk) with an overall rate of 2.9%, while they were predicted as 0.6% (low), 2.8% (medium), up to 17.7% (high), with an overall 3.9% in Class II wounds. The infection rates in Class III wounds, where no low-risk group was identified, were 4.5% (medium) and up to 23.9% (high) with an overall rate of 8.5%, while in Class IV wounds, also without a low-risk group, they were predicted at 6.7% (medium), up to 27.4% (high), and 12.6% overall.

The Running Locked Intradermal Suture: A Cosmetically Elegant Continuous Suture for Wounds Under Light Tension

A new suture technique, the running locked intradermal suture, is introduced. The suture is continuous and buried, and is designed for closing simple elliptical wounds under light tension in which a good cosmetic result is desired. It is used in conjunction with a topical antibiotic and a transparent dressing. This technique reduces the dermal dead space, achieves close approximation of the epidermal wound edges, has a good cosmetic appearance soon after surgery, reduces necessary postoperative wound care, reduces the risk of wound infection in clean surgical wounds, and obviates suture removal. Three examples of its application on the face are presented. It is compared with frequently used standard wound closure methods are discussed.

Determinants of clean surgical wound infections for breast procedures at an oncology center.

To determine the clean surgical wound infection rate for breast procedures and the risk factors predisposing patients to these infections. A survey study. Oncology center. A consecutive sample of adult female patients who underwent surgical breast procedures for suspected carcinoma of the breast. Patients undergoing excisional biopsy, lumpectomy, or mastectomy from January 1985 to January 1987 were included in the study. Clean surgical wound infection rates were derived overall and for each procedure type. The medical records of all patients were then reviewed to extract data on patient characteristics and operative information in order to assess the risk factors for infection. Among the breast procedures performed on 448 patients, the overall clean surgical wound infection rate was 8.7% (39/448). The clean surgical wound infection rate for each procedure type was as follows: biopsy 2.3%, lumpectomy 6.6%, and mastectomy 19%. In addition to the type of procedure, factors significantly (p less than .05) associated with the development of clean surgical wound infection in the univariate analysis included: presence of surgical drains (p less than .01); closed suction drainage (odds ratio [OR] = 16.5, 95% confidence interval [CI95] = 5.0-54.7); location of the drain (OR = 3.3, CI95 = 1.7-6.6); prolonged preoperative stay (OR = 1.2, CI95 = 1.0-1.5); length of surgery (OR = 2.2, CI95 = 1.7-3.0); and greater mean age (OR = 1.6, CI95 = 1.2-2.1). Clean surgical wound infections are not uncommon in patients undergoing breast procedures. Factors relating to both the patient and operative techniques contribute to the clean surgical wound infection rate. Further consideration should be given to perioperative antibiotic prophylaxis for selected breast procedures, and the role of surgical drains should be reassessed.

Determinants of Clean Surgical Wound Infections for Breast Procedures at an Oncology Center

Determinants of Clean Surgical Wound Infections for Breast Procedures at an Oncology Center

Non-sporing anaerobic bacteria : Benediktsdottir E. and Kolstad K. (1984) Non-sporeforming anaerobic bacteria in clean surgical wounds. J. Hosp. Infection5, 38

Non-sporing anaerobic bacteria : Benediktsdottir E. and Kolstad K. (1984) Non-sporeforming anaerobic bacteria in clean surgical wounds. J. Hosp. Infection5, 38

Non-sporeforming anaerobic bacteria in clean surgical wounds—air and skin contamination

The contamination of clean surgical wounds with anaerobic and aerobic bacteria was studied in 52 hip operations. In addition to wound samples, samples from air and the patients' skin were taken. The median of the total number of bacteria isolated from the wounds was 26 colony-forming units (cfu). The median percentage of anaerobic bacteria in the wound counts was 30. Propionibacterium spp. were found in 71 per cent of the wounds and anaerobic or microaerophilic cocci, most often Peptococcus spp., were found in 23 per cent. In six of 43 patients the same bacterial flora was seen in the skin samples and wounds. The geometric mean of the total number of bacteria in the air was 70·3 cfu/m 3. Of these the median percentage of anaerobic bacteria was 30·3. When operating clothing of a disposable fabric (Barrier 450 ®, Johnson & Johnson) was used, the counts of airborne bacteria were a little less than half those found when conventional cotton clothing was worn. Probably because of the overall low air counts in the operating theatre and the great variability in the individual bacterial counts from the operation wounds, a significant decrease in wound contamination was not observed. A positive correlation was found between the duration of operation and wound contamination.

Postoperative wound infections in a children's hospital.

A prospective study was made of postoperative wound infections at Milwaukee Children's Hospital for 1 year. Essentially all procedures requiring a skin incision were included. The clean surgical wound infection rate was 3.1% (26 infections in 849 cases). There were no significant differences in clean wound infection rates among the individual surgeons or among the four busiest surgical services. The occurrence of postoperative wound infections was associated with administration of prophylactic antibiotics, longer duration of surgical procedures and longer hospital stay before and after surgery. About 50% of patients having a clean surgical procedure were given prophylactic antibiotics. Prophylactic antibiotic were given for 4 days or more in about half the cases.

Isolation of anaerobic and aerobic bacteria from clean surgical wounds: an experimental and clinical study

A pad imprint method was evaluated for quantitative sampling of anaerobic and aerobic bacteria from clean surgical wounds. The best recovery of bacteria from the pads was obtained when they were treated with a rinsing solution in a ‘Stomacher’ ® apparatus. Pads of three different fabrics were compared, but no difference was noted in their efficiency in sampling anaerobic and aerobic bacteria from clean surgical wounds. Sampling of known quantities of Staphylococcus aureus from experimental wounds in rabbits performed with the pad method gave a threefold better recovery than with a swab. The pad method was superior to the wound wash-out method when sampling wounds in hip surgery.

Basic physiology of wound healing in the horse.

Wound healing is part of the normal general repair process of the body. Its efficient completion depends on many factors, some physical, eg, pH, oxygen tension and tissue tension, and some biological, eg, cell-cell interaction and feedback of extracellular matrix on to the cells which produce it. The factors which affect healing are discussed and failures and anomalies in the process described. New techniques which may improve the quality of healing in specialised tissues are explained. Recent research on wound healing has concentrated on the role of the different cell types in the process and also on the effects of micro-environment on the enhancement or inhibition of cellular activity. The wound is a situation in which cells are apparently operating at the limits of their powers of survival and very slight modification of the micro-environment can render the tissue either unduly hostile to the cell or can enhance cellular activity. While it is not possible to increase the rate of healing of a clean surgical wound to any useful degree, an understanding of the mechanics of wound healing is essential to a rational treatment of simple or indolent wounds. It is especially important that surgical or medical treatment should complement, rather than compete with, the natural process. Tight bandages, which compress circulation, or excessive washing, which may remove macrophages and dilute bacteriostatic or chemotaxic agents, should be avoided.

Contraction and Relaxation in Split Skin Autografts—A Human Study

Summary1. Intermediate skin grafis were applied in 30 patients after obtaining a clean surgical wound.2. Detailed measurement studies have revealed that such grafts contract during the first four weeks post-operatively.3. Relaxation begins after 4 to 8 weeks so that the ultimate area of skin graft is larger than during its period of maximum contraction.4. Some skin grafts relax/grow to a larger size than the original area of the skin graft applied at time of operation.5. Most skin grafts, however, do not regain the original area.

Laser surgery of the vocal cords. An experimental study with carbon dioxide lasers on dogs.

AbstractIn experiments on dogs, a focused beam from a continuous wave surgical carbon dioxide laser integrated with an operating microscope was used selectively to evaporate predetermined amounts of normal vocal cord tissue through a laryngoscope. This mode of tissue removal was precise, rapid and practically bloodless. Microscopic laryngoscopy examinations and histological work‐up one, two and three weeks postoperatively indicated normal healing similar to that of clean surgical wounds.

Prevention of likely wound infections. Prophylactic closed antibiotic-detergent irrigation.

Wound infections continue to plague the surgeon, despite the development of antibiotics and improved aseptic technique. The development of infection in clean surgical wounds depends upon many factors, not the least being the presence of pathogenic bacteria. Probably wound infection is the result of the interaction of many local environmental factors such as the blood supply, modified by the trauma of surgery, the general condition of the patient, the contamination of the ambient air, the suture material used, and surgical skill. Since the basis of all wound infection is bacteria, infection could theoretically be eliminated if the organisms could be totally eradicated. Systemic prophylactic antibiotics have fallen into disrepute and are used by most surgeons only in selected circumstances. In presenting this paper, the literature has been reviewed and a case is presented in order to emphasize the efficacy of topical antibiotic detergent irrigation in the prevention of wound infection