Closure of abdominal incisions with subcutaneous catheters. A prospective randomized trial

A preliminary report from our institution suggested that closure of abdominal incisions with subcutaneous, closed-suction catheters intermittently irrigated with antibiotic resulted in decreased wound infection rates. To test this hypothesis, a prospective, randomized, controlled trial was undertaken to compare the results of primary closure, subcutaneous catheter irrigated with saline or antibiotic, and subcutaneous catheter alone. During the two-year trial, 3,282 incisions (type II, III, or IV) were analyzed. Subcutaneous catheter placement alone or with antibiotic or saline irrigation was not superior to primary closure for type II or III incisions. A trend favoring subcutaneous catheter and antibiotic irrigation was observed for type IV incisions. This finding suggests that further clinical trials designed to assess the role of subcutaneous catheter placement and antibiotic irrigation in decreasing wound infection rates are warranted in type IV incisions.     

Use of negative pressure wound therapy over clean, closed surgical incisions

The literature has reported that surgical site infections account for 17-22% of health care-associated infections, while surgical wound dehiscence rates range from 0.25% to 3.0% (post laparatomies), 1.6% to 42.3% (post-caesarean incisions) and 0.5% to 2.5% (sternal incisions). These types of incisional complications can become a significant cost burden to the health care system because of lengthy hospital stays and readmissions, additional nursing care and added surgical procedures. Therefore, the type of therapy used for surgical incisions plays a critical role in the healing process. The success of negative pressure wound therapy (NPWT; V.A.C.? Therapy; KCI USA, Inc., San Antonio, TX) for open wounds has been well documented and has led to its use over clean, closed surgical incisions. This review will focus on clinician experience and literature review of incisional NPWT and will include clinical cases describing NPWT's successful use over surgical incisions.     

V.A.C.-instill therapy in periprosthetic infection of hip and knee arthroplasty

Periprosthetic infection represents a main complication of arthroplasty. In case of an early infection the implant often can be left in place. Whether instillation of antiseptic solution using a reticulated sponge in combination with negative pressure wound therapy (V.A.C.-Instill) can be useful was the aim of our investigation. Up to now the instillation of Lavasept in combination with negative pressure wound therapy could be performed in three patients. In two cases an early infection of a hip prosthesis and one infected knee implant had to be treated. Following surgical debridement V.A.C.-Instill therapy was performed for 4-7 days followed by closure of the wound or a repeated application. Lavasept was used for irrigation. In all three cases retention of the primary implant could be achieved. The follow up now is 8 to 22 weeks. No recurrence of the infection occurred. After salvage of the prosthesis the joint allowed full load bearing and painfree mobilisation. The V.A.C.-Instill system proved to be easy to use. With this system early periprosthetic infection with antiseptic irrigation in combination with negative pressure wound therapy decreasing the bacterial burden, salvage of prosthesis seems to be possible. The therapy is applicable in hip and knee prosthesis. Final conclusions about this therapy however can be done only after a larger series of patients.     

Efficacy of debridement and primary closure of contaminated wounds: a comparison of methods

Proper management of highly contaminated traumatic wounds frequently requires delayed primary closure of healing by secondary intention to prevent subsequent infection. This animal study compares the efficacy of various wound debridement methodologies to prevent infection following primary closure of treated contaminated wounds. Forty-four Sprague-Dawley rats with uniform, paravertebral incisions were studied. Each wound was inoculated with a standard amount of Staphylococcus aureus bacteria and allowed to remain open for two hours. Each wound was treated before wound closure by one of four debridement methods: (1) surgical scrubbing, (2) high-pressure irrigation, (3) ultrasonication, or (4) soaking. The control animals' wounds were closed without debridement. At 7 days, each animal was evaluated for the presence of gross infection and wound induration. Ultrasound, with a 25% incidence of gross infection, compared with irrigation (75%), scrubbing (82%), and soaking (89%) provided significant protection from subsequent abscess formation. The control group uniformly developed infection (100%). The average amount of induration after ultrasonication (1.35 +/- 0.56 cm) was also significantly less than irrigation (2.07 +/- 0.75 cm), scrubbing (1.95 +/- 0.34 cm), and soaking (1.73 +/- 0.22 cm). Our data demonstrate that ultrasonic wound debridement has exciting potential as a new debridement technique for contaminated traumatic wounds.     

Evaluation of negative pressure wound therapy to closed laparotomy incisions in acute care surgery

Background

Surgical site complications in the form of wound infections are a major burden to the healthcare system. Negative pressure wound therapy (NPWT) as delivered by a surgical incision management system (SIMS) is a novel approach to improve wound healing when applied to closed incisions. However, data is limited in its application to laparotomy incisions in the acute care surgery setting.

The enhanced healing of a high‐risk,clean, sutured surgical incision by prophylactic negative pressure wound therapy as delivered by Prevena™ Customizable™: cosmetic and therapeutic results

According to the literature, incisional closure complications may range from postoperative surgical site infections, representing 17–22% of health care‐associated infections, surgical wound dehiscence and formation of haematomas or seromas, and can lead to delayed or impaired incision healing. These kinds of situations are more common when wounds are closed under tension or in specific patient morbidities. Obesity, in particular, is associated with an impaired blood flow to tissues, predisposing the patient to increased risk of wound complications by various mechanisms. Incisional complications can become relevant economic burdens for health care systems because of an increase in the average length of hospital stay and readmissions, and additional medical and surgical procedures. Thus, a preventive therapy may have a critical role in the management of healing. Negative pressure wound therapy (NPWT) technology as delivered by Prevena? Customizable? (Kinetic Concepts Inc., San Antonio, TX) has recently been the focus of a new investigation, as a prophylactic measure to prevent complications via immediate postoperative application in high‐risk, clean, closed surgical incisions. The authors present a 62‐year‐old class II obese female, who underwent bilateral inguinal dermolipectomy. Prophylactic NPWT as delivered by Prevena? was performed successfully over surgical incisions. Cosmetic and therapeutic results are shown.     

Comparison of wound-healing characteristics with feedback circuit electrosurgical generators in a porcine model

The type of incisional instrument used to create a surgical wound can influence the rate of wound healing and overall wound strength. The purpose of this study was to evaluate several facets of wound healing within incisions created in the small intestine, uterus, and skin in a porcine model by using feedback circuit electrosurgical generators and a standard steel scalpel blade in a porcine model. Eighteen pigs were evaluated by creating surgical incisions in the skin, uterus, and small intestine utilizing 2 computerized electrosurgical generators (FX, ValleyLab, Boulder, CO, and PEGASYS, Ethicon Endo-Surgery, Inc., Cincinnati, OH) and a scalpel blade. All incisions were reapproximated with absorbable suture. Incision sites were evaluated histologically at 3, 7, or 14 days postincision according to randomization. The skin and small intestine samples were tested for wound tensile strength at 7 and 14 days. There were no statistically significant differences demonstrated with tensile strength testing comparing the electrosurgical devices to the scalpel-blade incisions for skin or small intestine at all time points. The only significant difference detected with respect to wound tensile strength was when different organ types were compared, regardless of device used (i.e., skin, 19.5 N/cm2 vs. small intestine, 5.78 N/cm2). Histologic evaluation demonstrated that the wounds created by the electrosurgical generators displayed decreased overall wound healing at 3, 7, and 14 days compared to the scalpel group. These findings indicate that the electrosurgical devices tested delay wound healing at the surgical site, but fail to demonstrate any significant difference in overall wound tensile strength. Wound healing may occur at a more rapid rate when a traditional scalpel blade is used to create the surgical incision, but no difference in global wound dynamics could be detected.     

Surfactant wound irrigation for the treatment of staphylococcal clinical isolates

Deep wound infection involving an implanted biomaterial is a devastating complication in orthopaedic surgery. Two-thirds of such infections are monomicrobial and the most commonly isolated bacteria in human osteomyelitis and orthopaedic device infection are Staphylococcus aureus and Staphylococcus epidermidis. The purpose of the current study was to examine the effectiveness of the previously reported sequential surfactant irrigation protocol against human-isolated clinical strains of Staphylococcus aureus and Staphylococcus epidermidis in the rat model of orthopaedic implant contamination. The infectivity rate of human-isolated clinical strains of Staphylococcus aureus in a contaminated complex orthopaedic wound was reduced effectively by a sequential surfactant irrigation protocol. Also, in this model, the infectivity of Staphylococcus epidermidis was reduced by normal saline irrigation alone when compared with no irrigation. Therefore, the sequential surfactant irrigation protocol may represent an effective method of wound irrigation in monomicrobial Staphylococcus aureus orthopaedic implant contamination, and normal saline irrigation may suffice in cases of monomicrobial Staphylococcus epidermidis contamination. Additional studies are necessary to determine the clinical use of surfactant irrigation.     

Systematic review and meta-analysis of electrocautery versus scalpel for surgical skin incisions

BackgroundThe creation of surgical skin incisions has historically been performed using a cold scalpel. The use of electrocautery for this purpose has been controversial with respect to patient safety and surgical efficacy. A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to compare skin incisions made by electrocautery and a scalpel.Data sourcesA systematic electronic literature search was performed using 2 electronic databases (MEDLINE and PubMed), and the methodological quality of included publications was evaluated. Six RCTs were identified comparing electrocautery (n = 606) and a scalpel (n = 628) for skin incisions.ConclusionsNo significant difference in wound infection rates or scar cosmesis was identified between the treatment groups. Electrocautery significantly reduced the incision time and postoperative wound pain. A trend toward less incisional blood loss from skin incisions made with electrocautery was noted. Electrocautery is a safe and effective method for performing surgical skin incisions.     

Reversal of impaired wound healing in irradiated rats by platelet-derived growth factor-BB

This study examined the potential influence of platelet-derived growth factor-BB homodimers (PDGF-BB) on surgical incisions in irradiated animals with depressed wound healing. Rats were irradiated with either 800 rads total body or 2,500 rads surface irradiation. Parallel dorsal skin incisions were made 2 days later, and PDGF-BB was applied topically a single time to one of two incisions. In total body-irradiated rats, bone marrow-derived elements were severely depressed, wound macrophages were virtually eliminated, and PDGF-BB treatment was ineffective. However, in surface-irradiated rats, PDGF-BB treatment recruited macrophages into wounds and partially reversed impaired healing on day 7 (p less than 0.005) and day 12 (p less than 0.001). PDGF-BB-treated wounds were 50 percent stronger than the paired control wounds. The results suggest PDGF requires bone marrow-derived cells, likely wound macrophages, for activity and that it may be useful as a topical agent in postirradiation surgical incisions.     

Effectiveness of prophylactic application of negative pressure wound therapy in stopping surgical site wound problems for closed incisions in breast cancer surgery: A meta-analysis

We performed a meta-analysis to evaluate the effect of prophylactic application of negative pressure wound therapy in stopping surgical site wound problems for closed incisions in breast cancer surgery. A systematic literature search up to April 2022 was performed and 2223 women with closed incisions in breast cancer surgery at the baseline of the studies; 964 of them were using the prophylactic application of negative pressure wound therapy, and 1259 were using standard dressings. Odds ratio (OR) with 95% confidence intervals (CIs) were calculated to assess the effect of prophylactic application of negative pressure wound therapy in stopping surgical site wound problems for closed incisions in breast cancer surgery using the dichotomous method with a random or fixed-effect model. The prophylactic application of negative pressure wound therapy women had a significantly lower total wound problems (OR, 0.62; 95% CI, 0.43-0.90, P = .01), lower surgical site wound infection (OR, 0.59; 95% CI, 0.36-0.96, P = .03), lower wound dehiscence (OR, 0.54; 95% CI, 0.39-0.75, P < .001) and lower wound necrosis (OR, 0.44; 95% CI, 0.27-0.71, P < .001), in women with closed incisions in breast cancer surgery compared with standard dressings. However, prophylactic application of negative pressure wound therapy did not show any significant difference in wound seroma (OR, 0.73; 95% CI, 0.32-1.65, P = .45), and hematoma (OR, 0.73; 95% CI, 0.33-1.59, P = .001) compared with standard dressings in women with closed incisions in breast cancer surgery. The prophylactic application of negative pressure wound therapy women had a significantly lower total wound problems, surgical site wound infection, wound dehiscence, and wound necrosis and no significant difference in wound seroma, and hematoma compared with standard dressings in women with closed incisions in breast cancer surgery. The analysis of outcomes should be with caution because of the low sample size of 5 out of 12 studies in the meta-analysis and a low number of studies in certain comparisons.     

固体硅胶隆鼻术并发症及其防治措施

目的为了预防固体硅胶隆鼻术的并发症，提高隆鼻术的效果。方法在分析并发症发生原因的基础上，提出预防措施及注意事项。结论预防并发症的关键措施在于讲求为切口选择，假体置入隧道及置入层次，假体雕刻、长度及缝合张力，改进固定方法等。结果鼻翼软骨内脚缝合固定假体以及在假体尖端加小片自体软骨保护固定者，未发现鼻尖顶处穿破。     

Incisional vacuum-assisted closure therapy

Postoperative swelling and prolonged drainage from surgical incisions result in both practical and medical burdens, such as increased need for dressing changes and potentially higher rates of surgical wound infection. This article presents a technique to apply a vacuum-assisted closure therapy sponge as a postoperative dressing to provide a clean, dry wound environment in the immediate postoperative period.     

Delayed primary closure in colon operations.

Secondary closure of incisions by tape is a simple, safe procedure. In a retrospective series of 179 contaminated surgical wounds (incisions for colon operations) delayed wound closure resulted in a lower incidence of wound infection (5.8%) than did primary closure of similar wounds (11.8%). Although wounds left open do become infected, the acute swelling and systemic signs typical of an infection in a closed wound never develop. Delayed closure facilitated wound healing in hospital: only 3.8% of patients thus treated left hospital with open wounds, but 9.5% of patients whose wounds were closed primarily left hospital with wounds that were partially or completely open.     

Comparison of castile soap, benzalkonium chloride, and bacitracin as irrigation solutions for complex contaminated orthopaedic wounds.

OBJECTIVE: The purpose of the present study was to determine the effects of cleaning a contaminated orthopaedic wound with different classes of wound irrigation solutions. STUDY DESIGN: Rats with a contaminated orthopaedic wound were randomized into treatment groups: normal saline (NS), castile soap (CS), benzalkonium chloride (BzC), bacitracin (Abx), or sequential irrigation with BzC, CS, and NS. INTERVENTION: Pseudomonas aeruginosa [P. aeruginosa; 1 x 10(6) colony-forming units (CFU)], or Staphylococcus aureus (S. aureus; 1 x 10(6) CFU) were placed into a paravertebral wound (containing a wire implant placed through a spinous process) and allowed to incubate for fifteen minutes. The wound was then irrigated with three liters of either NS, 0.05 percent CS, 0.03 percent BzC, Abx (33,000 units per liter) or underwent a sequential irrigation treatment (one liter each of BzC, CS, NS). MAIN OUTCOME MEASUREMENTS: The animals were observed daily for wound complications for fourteen days and then killed, and cultures of the wound were obtained. RESULTS: Pseudomonas aeruginosa: Both CS and the sequential irrigation treatment significantly lowered the rate of positive wound cultures when compared with NS (p < 0.05). Irrigation with BzC resulted in a higher rate of positive wound cultures and complications. The sequential irrigation treatment prevented the wound complications associated with irrigation with BzC alone. Staphylococcus aureus: Only BzC irrigation significantly lowered the rate of positive wound cultures when compared with NS (p < 0.05). CONCLUSION: The rate of positive wound cultures due to P. aeruginosa is effectively reduced by irrigation with CS alone or by the sequential irrigation treatment. When used alone, the antiseptic BzC results in a higher rate of positive wound cultures and wound complications. The wound complications seen with irrigation with BzC alone are prevented by the sequential irrigation treatment (BzC followed by CS and NS). The rate of positive wound cultures in this model due to S. aureus is not decreased by irrigation with CS; however, the rate of positive wound cultures is safely and effectively decreased with the use of BzC.     

应用透视图像导航(Fluoro-Navigation)进行Gamma-AP钉手术的早期临床经验

目的 报告在Gamma钉固定转子周围骨折手术中应用透视图像导航的早期临床经验。方法 应用连接在标准Gamma钉器械上的新型适配器(adapters)，透视图像导航可辅助完成手术中的髓内通道的人点选择、髓内针置人、头钉置人、还有远端锁钉的置人。结果 54例转子周围骨折的早期应用结果是令人鼓舞的。平均手术时间为41．7min，平均X线图像采集12．5次。平均切口长度为7．26cm。在手术中和手术后无并发症发生。结论 肯定了透视图像导航在Gamma钉手术中应用的可行性，它可以减少X线照射量和精确置人定位。通过更小的切口，使手术创伤进一步减小，对手术技术和预防方面的进一步改进措施也进行了讨论。     

The neurosurgical wound and factors that can affect cosmetic,functional, and neurological outcomes

Surgically accessing pathological lesions located within the central nervous system (CNS) frequently requires creating an incision in cosmetic regions of the head and neck. The biggest factors of surgical success typically tend to focus on the middle portion of the surgery, but a vast majority of surgical complications tend to happen towards the end of a case, during closure of the surgical site incisions. One of the most difficult complications for a surgeon to deal with is having to take a patient back to the operating room for wound breakdowns and, even worse, wound or CNS infections, which can negate all the positive outcomes from the surgery itself. In this paper, we discuss the underlying anatomy, pharmacological considerations, surgical techniques and nutritional needs necessary to help facilitate appropriate wound healing. A successful surgery begins with preoperative planning regarding the placement of the surgical incision, being cognizant of cosmetics, and the effects of possible adjuvant radiation therapy on healing incisions. We need to assess patient's medications and past medical history to make sure we can optimise conditions for proper wound reepithelialisation, such as minimizing the amount of steroids and certain antibiotics. Contrary to harmful medications, it is imperative to optimise nutritional intake with adequate supplementation and vitamin intake. The goals of this paper are to reinforce the mechanisms by which surgical wounds can fail, leading to postoperative complications, and to provide surgeons with the reminder and techniques that can help foster a more successful surgical outcome.     

Septic necrosis of the midline wound in postoperative peritonitis. Successful management by debridement, myocutaneous advancement, and primary skin closure.

Wound management following laparotomy for postoperative peritonitis and varying degrees of parietal necrosis remains a challenging and controversial problem. Because maintained peritoneal integrity and primary wound closure offer the best opportunity for survival, an original technique involving bilateral incisions to relax skin and rectus fascia is proposed. This technique permits medial myocutaneous advancement and primary tension-free skin closure of midline laparotomy incisions. Sixty-nine patients with severe postoperative peritonitis were treated according from 1980 through 1985. Nine of these patients died of advanced multiple organ failure soon after referral, and eight more died after prolonged treatment. Fourteen patients had one or more reoperations for complications. Only nine wound failures resulted, including five eviscerations and four wound infections followed by progressive dehiscence. The bilateral relaxing incisions healed secondarily without complication. Survivors developed midline wound hernia; ten of the 52 surviving patients have had these repaired. This method of primary closure is safe when performed in conjunction with rigorous surgical care of intraperitoneal infection and may enhance survival. We recommend the technique to surgeons who treat severe postoperative peritonitis and septic necrosis of midline laparotomy wounds.     

Use of semiocclusive, transparent film dressings for surgical wound protection: experience in 3637 cases.

During an eight-year period, the author used a semiocclusive, transparent film surgical dressing as a protective cover for 3637 surgical incisions. The wet environment facilitated healing, and no patient exhibited any symptoms of wound infection. Compared with traditional methods, the semiocclusive dressing resulted in faster wound healing, decreased pain, and less scarring. It also permitted visual assessment of wound healing, as well as promoting patient mobility and hygiene.     

Surgical treatment of calcaneal fractures with bioabsorbable screws

There is no consensus for the best surgical treatment of intra-articular calcaneal fractures. Bioabsorbable implants have been recommended for the treatment of some fractures. The aim of this study was to estimate the outcome and complications of surgical treatment of calcaneal fractures using bioabsorbable screws. We retrospectively reviewed 58 patients who underwent surgical treatment using bioabsorbable screws. The minimum follow-up was 15 months (mean, 23 months; range, 15–32 months). Fifty-five of 58 patients healed without additional complications. The mean adjusted American Orthopaedic Foot and Ankle Society ankle-hindfoot score was 73.6 ± 22.4, the mean foot function index score was 23.9 ± 7.1, and the mean calcaneal fracture scoring system score was 77.2 ± 8.5. One patient had a superficial wound infection which healed after irrigation and debridement without removal of the implant. Two patients had consistent effusion from the wound for two weeks which healed after drainage and elastic dressing. We identified no evidence of soft tissue irritation or other complications directly attributed to the bioabsorbable screws. Our observations indicate that bioabsorbable screws provide sufficient stabilisation to allow for calcaneal fracture union with the advantage of no implant removal needed.