Lower Wound Infection Rate Research Articles

Value of Laparoscopic Appendectomy in Perforated Appendicitis

The purpose of this clinical study was to evaluate the efficacy of laparoscopic appendectomy in patients with perforated appendicitis. This study involved a total of 73 consecutive patients who had undergone appendectomy for perforated appendicitis between January 1999 and December 2004. While 39 patients underwent open appendectomy (OA) during the first 3 years, the remaining 34 patients underwent laparoscopic appendectomy (LA) during the last 3 years. There was no case of LA converted to OA. No significant difference was found in the operating time between the two groups. Laparoscopic appendectomy was associated with less analgesic use, earlier oral intake restart (LA, 2.6 days; OA, 5.1 days), shorter median hospital stay (LA, 11.7 days; OA, 25.8 days), and lower rate of wound infections (LA, 8.8%; OA, 43.6%). These results suggest that LA for perforated appendicitis is a safe procedure that may prove to have significant clinical advantages over conventional surgery.

Outcomes Following Laparoscopic Versus Open Repair of Incisional Hernia

The purpose of this study was to compare short- and long-term outcomes for patients undergoing laparoscopic or open surgery for incisional hernia repair using meta-analytical techniques. A literature search was performed to identify comparative studies reporting outcomes on laparoscopic versus open surgery for incisional hernia repair. A random-effect meta-analytical model was used and subgroup analysis performed on high-quality studies, those reporting on more than 30 patients, and those published since 2000. Five studies, with a total of 351 patients, satisfied the inclusion criteria. Laparoscopic surgery was attempted in 148 (42.2%) patients. Overall, in the laparoscopic group, operative time was significantly longer--by 12.0 minutes (P = 0.03) and length of stay reduced by 3.3 days (P < 0.003) although this finding was associated with significant heterogeneity between studies (P < 0.001). There was no difference in the short-term adverse events between the groups, but there were fewer wound infections for laparoscopic patients in high-quality studies [odds ratio (OR) = 0.22, 95% confidence interval (CI): 0.05, 0.85, P = 0.03] and those reporting on more than 30 patients (OR = 0.19, 95% CI: 0.04, 0.84, P = 0.03). No difference in hernia recurrence was shown in the overall or subgroup analysis. Laparoscopic incisional hernia repair was associated with a reduced length of stay and lower wound infection rate. The impact on post-operative quality of life and financial implications needs further prospective, validated evaluation.

Staged Management of High-Energy Proximal Tibia Fractures (OTA Types 41)

This study evaluated the use of a staged protocol involving temporary spanning external fixation and delayed formal definitive fixation in the management of high-energy proximal tibia fractures (OTA types 41) with regard to soft-tissue management, development of complications, and functional outcomes. Two level-one trauma centers and a tertiary care orthopaedic center. Fifty-three patients with 57 high-energy tibial plateau fractures. The authors instituted a protocol of immediate placement of knee spanning external fixation with management of soft-tissue injuries for all high-energy proximal tibia fractures. Between August 1999 and May 2002, 62 consecutive patients with 67 high-energy proximal tibia fractures (OTA types 41A, B, C) underwent temporary knee spanning external fixation on the day of admission. Nine patients with 10 fractures who transferred care after initial stabilization or sustained an extraarticular fracture were excluded. The remaining 53 patients with 57 fractures underwent repair of articular fractures and meta-diaphyseal fracture repair with plates and screw constructs or conversion to a ring fixator. These patients had a mean age of 47 years (standard deviation (SD), 14). Of these 53 patients, 42 (79%) were men and 11 (21%) were women. Characteristics of the 57 fractures were: 42 Schatzker VI (74%), 12 Schatzker V (21%), 2 Schatzker IV (4%), and 1 Schatzker II (2%). There were 41 closed fractures and 16 open fractures. (One patient had bilateral fractures with 1 extremity open and 1 closed). Orthopaedic evaluation at latest follow-up included a clinical and radiographic examination and functional outcome measurement with the Western Ontario McMaster functional knee score (WOMAC). Eight patients with 8 fractures were lost to follow-up. This left 45 patients with 49 fractures with a mean follow-up of 15.7 (SD, 5.7; range, 8-40) months. Complications included 3 (5%) deep wound infections, 2 (4%) nonunions, and 2 patients (4%) with significant knee stiffness (<90 degrees). Nine patients (16%) underwent additional surgery after definitive skeletal stabilization related to their injury. Range of knee motion at final follow-up was 1 degrees (SD, 4) to 106 degrees (SD, 15). The mean WOMAC was 91 (SD, 55). Poor results did not correlate with demographic or injury characteristics. We had a relatively low rate of wound infection in these complex injuries (5% overall). There was only 1 wound problem in our subset of patients with closed fractures and 2 infections in those with open fractures. One downside of this technique may be residual knee stiffness. The benefits of temporizing spanning external fixation include osseous stabilization, access to soft tissues, and prevention of further articular damage. Our relatively low rates of complications in patients who sustain high-energy proximal tibia fractures and the access this technique affords in open fractures and those with compartment syndrome lead us to recommend this technique in all high-energy intra-articular and extra-articular fractures of the proximal tibia. This study supports the practice of delayed internal fixation until the soft-tissue envelope allows for definitive fixation.

Ist die offene Appendektomie noch zeitgemäß?

The acceptance of the laparoscopic technique for appendectomy can't be compared with the success in laparoscopic cholecystectomy. The discussion is still controversial. A lower rate of wound infection in comparison to open appendectomy has been proven statistically in many studies. There is no evidence of a higher rate of complications. Postoperative pain may be reduced and return to work is often earlier. Cosmesis shows better results. Operation time and hospital stay are comparable to open appendectomy. The total of direct and indirect costs is not higher with laparoscopic than with open appendectomy. Excellent indications for laparoscopic appendectomy are atypical pain in the right lower abdomen, uncertain diagnosis in fertile and elderly women, obesity and complicated appendicitis. Controlled double-blinded randomized studies are necessary in the future to define the advantages and further indications.

Antibiotic prophylaxis revisited

Antibiotic prophylaxis for cutaneous surgery is a controversial but important area for dermatologists. Five key issues are addressed: why prophylax, whom to prophylax, when to prophylax, how to prophylax, and why NOT to prophylax. The goal of prophylaxis is to prevent infection. Infection can manifest as localized (limited to wound) or systemic (bacteremia leading to endocarditis or prosthesis infection). Guidelines for prophylaxis to prevent wound infection come from the general surgery literature and may not be applicable to cutaneous surgery. Dermatologic procedures are generally short in duration and have a low rate of wound infection (2–4%). Many factors contribute to the development of wound infection, including anatomic location, variations in practice of aseptic technique, characteristics of the lesion to be excised, surgical technique, and overall status of the patient. Similarly, some patients are at higher risk of developing endocarditis following a bacteremia-producing procedure than others. The gold standard guidelines for antibiotic prophylaxis come from the American Heart Association (AHA). Joint guidelines from the American Dental Association and the American Academy of Orthopaedic Surgeons were reviewed as well. Cutaneous surgery is not specifically addressed by any of these guidelines but AHA guidelines state that “incision into surgically scrubbed skin does not require antibiotic prophylaxis.” Various studies have shown that the incidence of bacteremia after surgical procedures on non-infected skin is low (0–7%). Antibiotic prophylaxis should be initiated just prior to surgery and need not be continued for an extended period. Antibiotic use is not without risk; potential side effects range from GI distress to anaphylaxis. Methods to decrease reliance on oral antibiotics include increased use of sterile technique, meticulous wound care, and intra-incisional antibiotics. In general, management of each patient should be considered on a case-by-case basis.

Pyloromyotomy through circumbilical incision with fascial extension.

Extending the fascial incision underlying the circumbilical approach to the shape of an 'inverted T' permits easy delivery of the pyloric tumour for Ramstedt's pyloromyotomy. This modification was used in 51 consecutive infants (42 male, 9 female) with a mean age of 4.7 weeks. Extension of the skin incision or conversion to the right hypochondrium approach was not necessary in any patient and the mean operating time was 31.4 min. Mild wound infection occurred in two infants (3.9%) that resolved with antibiotic treatment. Follow-up at 3 months did not detect any incisional hernia. This modification allows delivery of small or large pyloric tumours, is associated with a low rate of wound infection and does not alter the excellent cosmetic finish.

Wound Management after Colon Injury: Open or Closed? A Prospective Randomized Trial

It is unknown whether leaving the skin wound open to heal by secondary intention is associated with a lower rate of wound infections compared with primary skin-wound closure after operations for colon injuries. From June 1998 to December 2000 at our Level I academic trauma center 48 patients entered into a randomized controlled trial (RCT) and were randomized to have their skin wound primarily closed (CLOSED-RCT) or left open (OPEN-RCT). At the same time patients not included in the RCT were followed prospectively. At the discretion of the surgeon their skin wounds were managed by primary closure (CLOSED-nonRCT) or were left open (OPEN-nonRCT). Univariate and multivariate analysis was done to identify independent risk factors of wound infection, wound dehiscence, and necrotizing soft tissue infection. Wound infection developed in 65 per cent of CLOSED-RCT and 36 per cent of OPEN-RCT patients (P = 0.04) and wound dehiscence in 31 per cent and 14 per cent respectively (P = 0.18). No remarkable differences were noted in any other variable including length of hospital stay. Wound infection developed in 29 per cent of CLOSED-nonRCT and 15 per cent of OPEN-nonRCT patients (P = 0.46). There were three independent risk factors of wound infection: primary wound closure [odds ratio (OR) = 5.5, 95% confidence interval (CI) = 1.8-19.4], colectomy (OR = 3.4, 95% CI = 1.2-10.4), and intraabdominal infection (OR = 5.3, 95% CI = 1.3-24.2). There were two independent risk factors for wound dehiscence and/or necrotizing soft tissue infection: wound infection (OR = 20.9, 95% CI = 4.9-152.3) and intra-abdominal infection (OR = 19.3, 95% CI = 4.0-146.9). Primary closure of the wound almost doubles the rate of wound infection compared with leaving the wound open in operations for colon injuries. Primary wound closure is a risk factor for wound infection and wound infection is a risk factor for wound dehiscence or necrotizing soft tissue infection. Because of the complexity of evaluating the real clinical significance of superficial wound infection larger studies on trauma patients are required.

Subjective patient outcomes following coronary artery bypass using the radial artery: results of a cross-sectional survey of harvest site complications and quality of life.

To assess patient-based outcomes following radial artery harvesting for coronary artery bypass surgery (CABG). A cross-sectional telephone survey of 127 patients who underwent radial artery grafting was undertaken. The parameters assessed included symptoms related to the radial artery harvest site (functional impairment, sensory symptoms, and wound infection) and health related quality of life. A high percentage of patients (67.7%) reported altered sensation, in the hand, in particular around the thenar eminence, in the forearm, or in relation to the incision; this was self-limiting and clinically insignificant in the vast majority of patients. Twelve patients reported residual insignificant symptoms after a median follow-up of 17.5 months. Four patients reported a subjective decrease in grip strength. Patients reported a good quality of life, and there was no association between this and the presence or absence of symptoms related to radial artery harvest. Some patients volunteered a 'preference' for the radial artery harvest site when compared with concomitantly harvested long saphenous vein (LSV), and there was a lower wound infection rate at radial artery harvest sites compared with vein harvest sites (6 vs. 15%). Sensory symptoms following radial artery procurement occur more frequently than previously reported, but are largely self-limiting and are usually clinically insignificant. Patients appear to have a good quality of life following CABG using the radial artery. Radial artery harvest may be associated with lower wound infection rates and greater patient satisfaction than LSV harvest, however, the presence of residual sensory symptoms may be of relevance when obtaining informed consent.

Surgical capability and surgical pathology in Papua New Guinea in the year 2000.

Papua New Guinea (PNG) is a country of 4.5 million people with an annual health budget of only 96 million Kina (1K = US$0.35). There are 19 hospitals in the country and national surgeons are now staffing most of these hospitals. This review aims to describe the surgical pathology in the year 2000 and the capability of PNG surgeons to manage it. A review of publications, reports and surgical audit data on surgery in PNG was conducted. Surgical audit has been computerized for over 5 years. The review also draws on personal experience and data from MMed theses submitted to the University of Papua New Guinea. Surgical pathology Surgical practice in PNG remains very general. Late presentation and advanced disease are common. Trauma, infection, malignancy and congenital anomalies dominate the surgical scene. The pattern of disease is different from what is found in the West. Western diseases are emerging with the incidence of appendicectomy rising from 5/100,000 to 75/100,000 in the past 30 years. The incidence of diabetes and gallstones has also risen. Osteoporosis, Colles' and neck of femur fractures are rare. Surgical capability The standard of surgical care is acceptable with a low wound infection rate for clean and clean-contaminated abdominal surgery of 0.9% and an anastomotic leak rate of 1.6%. Transurethral prostatectomy is also being performed to a satisfactory standard for head injuries admitted with a Glasgow Coma Score of 6-8 and a good outcome is achieved in over 70% of cases. Hospital mortality for surgical admissions is 3.7%. Subspecialties in orthopaedics, urology and head and neck surgery have been established. Neurosurgery, paediatric and cardiac surgery are being developed. Priorities for the next decade Papua New Guinea needs to continue to develop surgical subspecialties, particularly paediatric and neurosurgery, while maintaining a broad competence in general surgery. Services for burns, spinal injuries, rehabilitation and oncology need to be improved. Surgeons need to be more involved in rural health and teaching basic skills to primary health-care workers. Acquisition, maintenance and repair of surgical equipment needs to be improved so that PNG's well-trained surgeons can have the right tools for their trade. Papua New Guinea offers a wide range of surgical pathology. The standard of surgery in PNG is reasonable but there are many areas that need development during the period of the next national health plan, 2001-2010. Australasian surgery has many opportunities to assist surgeons in PNG to achieve their objectives.

Tension-free hernioplasty in primary inguinal hernia. A series of 2054 cases

This was a prospective study to analyze the results of tension-free hernioplasty in a center no specially dedicated to hernia surgery. We reviewed data of 1761 patients with 2111 primary hernias. Tension-free hernioplasty (Lichtenstein procedure) was performed in 2054 hernias and herniorrhaphy i (Marcy or Bassini repair) in 57. Loco-regional anesthesia was used in 65% of the patients. The most common complication was hematoma of the wound (1.6%). There was a very low rate of wound infection (0.1%) and in no case was necessary to remove the prosthesis. Median follow-up was 5 years. There were 5 recurrences in the Lichtenstein procedures (0.24%). Three were at the pubic tubercle and two were a disruption of the lower edge of the mesh from the inguinal ligament. All of these were at the beginning of the series.

Laparoscopic surgery for stage III colon cancer

The role of laparoscopic surgery in the management of colorectal cancer is controversial. This study was undertaken to determine the oncological adequacy, in terms of margins of resection, lymph node harvest, and anastomotic and locoregional recurrence of laparoscopic colectomy in patients with stage III (node-positive) colorectal cancer. The results of laparoscopic colectomy in 50 consecutive patients with stage III colorectal cancer operated on at a single hospital between 1991 and 1998 were analyzed with respect to postoperative morbidity, mortality, and long-term survival by the Kaplan-Meier method. Methodical patient follow-up was the mainstay of the study. There were 31 men (52%) and 19 women (38%) with a mean age of 67.7 years (range, 40-88). Low anterior resection was performed in 17 cases, abdominal perineal resection in five cases sigmoid colectomy in 10 cases, left hemicolectomy in six cases, right hemicolectomy in seven cases, transverse colectomy in one case, and subtotal colectomy in four cases. Conversion was necessary in three cases (6%). Major complications included one leak, one pelvic abscess, one perineal wound infection, and three anastomotic strictures early in the experience, with none in the past 4 years. One early death occurred due to massive stroke. Median length of stay was 6 days (range, 3-37). Forty-six patients were staged as CII and four as CI colon cancer. The average number of positive nodes was 5.1 (range, 3-58). The margins of resection were adequate in all patients. Follow-up ranged from 3 to 75 months (average, 29.3; median, 24). Overall cancer-related mortality was 34% (17 patients); three patients died of unrelated causes with no detectable cancer. All who died of cancer had distant disease; three of them also had pelvic recurrence. Mean time of death was 21.7 months. There were no anastomotic recurrences or trocar site implants. Overall 3- and 5-year survival was 54.5% and 38.5%, respectively; cancer-adjusted survival was 60.8% and 49.1%. Based on this study, laparoscopic colectomy in patients with stage III colorectal cancer is oncologically adequate. It results in a long-term outcome comparable to that of traditional open surgery and is associated with low perioperative mortality and morbidity (lower wound infection rate, lower wound recurrences at trocar sites) and a shortened length of stay.

Prevention of Infections During Neurosurgery

Infections associated with neurosurgery can be disastrous. Ample evidence supports the routine use of prophylactic antibacterials in clean, nonimplant neurosurgical procedures to reduce the risk of wound infections. A recently performed meta-analysis suggests that even in neurosurgical units that do not use antibacterial prophylaxis and have a low wound infection rate, prophylaxis may still be beneficial. Since comparative studies are lacking, selection of one prophylactic regimen over another is somewhat arbitrary. In neurosurgical units where the prevailing pathogens are still antibacterial-sensitive Gram-positive cocci, the regimen selected should be aimed at these pathogens. Antistaphylococcal antibacterials, of which the most frequently studied agents are various first or second generation cephalosporins, are suitable for this purpose. Future studies should compare proposed new antibacterial regimens with one of those already demonstrated to be effective.

Toward Further Reducing Wound Infections in Cardiac Operations

Background. Serious wound infections such as mediastinitis still occur at a rate of 0.8% to 2.0%, according to the most recently published cardiac operative series. Methods. Data from careful surveillance for infection have been collected prospectively during a 4.5-year period on 1,717 patients who underwent cardiac operations performed under direct ultraviolet C radiation. Results. The rate for mediastinitis was 0.23%, and for deep incisional infection without mediastinitis, 0.12%; these rates are significantly lower than those for eight of nine of the most recently published cardiac series. When our infection rates were stratified using the National Nosocomial Infection Surveillance risk index, they were also significantly lower in the most important risk categories than the corresponding stratified rates collected from the participating hospitals of the Centers for Disease Control and Prevention National Nosocomial Infection Surveillance system. Conclusions. Though we lack the proof that only a large, randomized study might provide, certainly, one possible explanation for our lower wound infection rate was the use of bactericidal ultraviolet C radiation during operation. This is a simple and effective means of minimizing operating room airborne bacteria as one possible source of these infections.

A prospective evaluation of risk factors for infections from dog-bite wounds.

To define risk factors for infections from dog- bite wounds and to model the probability of wound infection in patients presenting without infection who are treated as outpatients. A prospective survey of 769 consecutive dog-bite victims presenting over a two-year period to a community hospital emergency department (ED) with an emergency medicine residency program. A standardized wound-cleaning protocol was used, which included debridement and wound closure when indicated. Wounds were examined for infection at follow-up. Variables analyzed included demographic data (patient age, gender, race); wound information (wound age, type, number, location, depth); and treatment (prior to hospital, ED debridement, suturing, tetanus or rabies shots, antibiotics). There were 734 patients with complete records. These patients had a mean age of 13.4 +/- 13.2 years (range, 4 months to 71 years). Infection was evident in 2.5% of the wounds upon presentation. There were 704 patients (765 wounds) managed as outpatients and without wound infection upon presentation. Wounds were distributed as follows: 26.7% head/neck, 20.4% hand, 15.7% arm, 10.1% trunk, 9.5% thigh, 15.9% leg, and 1.7% foot. There were 32.9% puncture, 39.9% full-thickness, and 60.1% partial-thickness wounds. Wound infections were diagnosed in 2.1% Of these wounds at follow-up. Wounds requiring surgical debridement had a sevenfold higher infection rate (p = 0.01). Patients more than 50 years of age had a sixfold higher infection rate than younger patients (p = 0.05). Stepwise logistic regression found the following variables to be the best predictors for wound infection: full-thickness [p = 0.006, odds ratio (OR) = 6.23], female gender (p = 0.048, OR = 2.88), and wound debridement (p = 0.024, OR = 5.01). Combinations of these three variables predict infection rates from 0.35% to 23.9%. A low wound infection rate was seen in this cohort of dog-bite victims who were treated on an outpatient basis. Wound depth, patient gender, and wound debridement were the clinical variables that best predicted the likelihood of developing infection. Future interventional studies should concentrate on wounds with high probabilities of infection.

Paper Tape in the Closure of Abdominal Wounds

Wounds closed by adhesive tapes have less inflammatory reaction, a lower rate of wound infection, greater tensile strength and better cosmetic results than sutured or stapled wounds. Special backing tapes, such as Steri-Strip, have been reported to have satisfactory results in closing laparotomy wounds. However, they are more expensive than paper tape. Sterile paper tape had adequate adhesive and supporting strength in the closure of abdominal wounds. The wounds closed with paper tape healed well and had satisfactory cosmetic results. Paper tape is a nonexpensive and convenient alternative to close abdominal wounds.

The management of infected penile implants

Penile prosthesis implantation is associated with a relatively low rate of wound infection (3%). The most common organism in most reported series isS. epidermidis, followed by the gram-negative coliforms. Strict adherence to antiseptic principles, together with the use of prophylactic antiseptic principles, together with the use of prophylactic antibiotics, keeps the incidence of infection low. If an infection occurs, either the prosthesis should be promptly removed or a salvage or rescue procedure should be considered by which the device is removed, the wound cleansed, and a new prosthesis inserted.

Retroperitoneal colopexy for adult rectal procidentia. A new procedure.

Nonresective fixation procedures are superior to resections in the management of rectal procidentia. A new operative procedure of retroperitoneal fixation of the redundant rectum and sigmoid after mobilization of the rectum up to the pelvic floor is described. The procedure was performed in 32 patients. In a follow-up ranging up to 11 years, only one recurrence of mucosal prolapse was seen. Rectal, bladder, and sexual functions were normal. There was a low wound infection rate and no mortality. The procedure appears superior to conventional operations for rectal procidentia and, at the same time, avoids usage of prosthetic materials for fixation with their known risk of complications.

Closed-suction versus Penrose drainage after cholecystectomy: A prospective, randomized evaluation

Closed-suction drainage was compared prospectively to open, passive drainage (Penrose drains) in 128 patients undergoing cholecystectomy. Patients were randomized at the time of operation to receive either closed-suction drains (Group I, 67 patients) or Penrose drains (Group II, 61 patients). The preoperative clinical parameters of the two groups were similar. The patients in Group I when compared with those in Group II had a shorter duration of drainage (3.3 days and 4.1 days, respectively, p < 0.01), a lesser volume of drainage in the first 48 hours postoperatively (78 ml and 132 ml, respectively, p < 0.001), a decreased incidence of fever on the night of operation (24 of 67 patients and 39 of 61 patients, respectively, p < 0.05) and on the first postoperative day (26 of 67 patients and 32 of 61 patients, respectively, p < 0.05), and a lower leukocyte count on the first postoperative day (12,000 cells/mm 3 and 14,100 cells/mm 3, respectively, 0.05 < p < 0.1). Patients in Group I tended to have a lower rate of wound infection (1 of 67 patients versus 5 of 61 patients in Group II, 0.05 < p < 0.1) and had a much lower incidence of drain site tenderness (8 of 67 patients in Group I versus 24 of 61 patients in Group II, p < 0.05). This study demonstrates the superiority of closed-suction drains over open, passive drains after cholecystectomy.

THE VALUE OF DELAYED PRIMARY WOUND CLOSURE IN COLONIC AND RECTAL SURGERY

The technique of delayed primary wound closure was employed in 82 out of 100 consecutive colorectal operations. Problems with wound healing occurred in seven patients, but in only three of them was it a wound infection. The value of delayed primary wound closure has been demonstrated by this low rate of wound infection (3.7%).

A COMPARISON OF THE INCIDENCE OF WOUND INFECTION FOLLOWING THE USE OF PERCUTANEOUS AND SUBCUTICULAR SUTURES: AN EXPERIMENTAL STUDY

This is a study in which the results have shown that the use of subcuticular sutures in the pig is associated with a lower rate of wound infection when compared with that following percutaneous sutures.