Emergency surgeryProphylactic Negative-pressure Dressings Reduce Wound Complications and Resource Burden After Emergency Laparotomies
Introduction
Emergency laparotomy carries a high risk of wound complications.1 These adverse events, which include surgical site infection (SSI), wound breakdown, and hematoma formation, incur significant patient morbidity and health care costs.2 To date, multiple strategies to minimize wound complications have been proposed. These include prophylactic antibiotics, wound lavage, innovative closure techniques, and use of tissue repair stimulants.3, 4, 5 Despite these advances, most have limited utility, and wound complications remain a significant issue.6, 7, 8
For a variety of elective surgeries, the use of negative-pressure dressings (NPDs) on closed incisions has been shown to reduce wound complications rates, improve patient quality of life, and save costs.5,9 Mechanistically, NPD removes excessive fluid and toxic inflammatory mediators from subcutaneous tissues. This facilitates cell-mediated immune response, fibroblast proliferation, angiogenesis, and granulation tissue formation,10 which are crucial for successful wound healing.11
Despite mounting evidence supporting the prophylactic use of NPD for elective laparotomies,12 there is a paucity of data in the emergency setting. It is widely recognized that emergency abdominal surgery carries a significantly higher risk of wound complications compared with elective surgery.13, 14, 15 This is due to a combination of unoptimized patient risk factors, increased likelihood of wound contamination,16 and systemic inflammation that may circumvent tissue repair.17 Therefore, patients who undergo emergency laparotomy and have a closed wound may potentially benefit from NPD. However, the factors that predispose to wound complications may overwhelm its prophylactic benefit. To address this question, this study examined whether prophylactic NPD reduces wound complication rates after emergency laparotomy with closed incisions.
Section snippets
Study design
A retrospective review was performed for consecutive patients who underwent emergency laparotomy from January 1, 2018 to October 31, 2019 at the Northern Hospital, Victoria, Australia. Patients were identified from the hospital's administrative database using the Australian Classification of Health Interventions procedural codes (Supplementary Table 1). These patients were cross-referenced with surgeons' logbooks to ensure that all cases were captured. We excluded patients under 18 y of age,
Characteristics of patients
In total, 227 patients underwent emergency laparotomy. The most common indication for surgery was adhesive small bowel obstruction that failed nonoperative management. This was followed by surgery for malignant large bowel obstruction, incarcerated or strangulated hernias, complicated diverticulitis, perforated viscus, malignant small bowel obstruction, and peritonitis resulting from anastomotic leaks after gastrointestinal surgery. Together, these accounted for over 70% of emergency cases (
Discussion
This is the first comparator study to specifically examine the prophylactic benefit of NPD on SSI and wound breakdown for closed emergency laparotomy incisions. The key findings were significantly lower rates of SSI and wound breakdown after NPD placement. This is despite relatively higher rates of wound contamination, colorectal cancer resections, and SIRS within the NPD cohort. Furthermore, use of NPD reduced hospital stay and wound-related readmissions. These findings reflect those
Conclusions
Prophylactic NPD significantly reduced the rate of wound complications after emergency laparotomy. This was associated with a substantial health resource saving. NPD should be considered in high-risk patient populations. Randomized trials are ongoing to evaluate this further.
Acknowledgment
Authors contributions: D.S.L. contributed to Conceptualization, Methodology, Investigation, Formal analysis, Data curation, Writing – original draft. C.C. contributed to Conceptualization, Investigation, Data curation, Writing – review & editing. R.I. contributed to Conceptualization, Investigation, Writing – review & editing. M.T. contributed to Conceptualization, Methodology, Formal analysis, Writing – review & editing. A.S. contributed to Conceptualization, Writing – review & editing. D.L.
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Cited by (9)
Prophylactic use of incisional negative pressure wound therapy for the prevention of surgical site occurrences in general surgery: Consensus document
2023, Surgery (United States)Citation Excerpt :No differences were detected in morbidity and mortality at 30 days, Clavien-Dindo grade, length of hospital stay, or reoperation between the 2 groups. Finally, Liu et al49 examined 227 consecutive emergency laparotomies (70 treated with prophylactic incisional NPWT and 157 treated with standard dressings). An SSI occurred in 33 (21.0%) patients in the control group versus 6 (8.6%) of those receiving NPWT (OR: 0.35, 95% CI: 0.15–0.85, P = .022).
Prophylactic negative pressure wound dressings reduces wound complications following emergency laparotomies: A systematic review and meta-analysis
2022, Surgery (United States)Citation Excerpt :Whilst consensus has been established for the use of prophylactic NPWD in the elective general surgical setting,12,13 no consensus has been reached in the emergency setting.9 Emergency surgery carries greater risk of postoperative wound infection due to higher likelihood of both wound contamination and impaired physiological condition.4,20 Therefore, the scope for NPWD to reduce rates of SSI amongst patients undergoing emergency surgery is significant.
Closed incision negative pressure wound therapy is associated with reduced surgical site infection after emergency laparotomy: A propensity matched–cohort analysis
2021, Surgery (United States)Citation Excerpt :This reflects the mechanism of action of CINPT, which is targeted at the abdominal wall and does not extend beyond the fascial layer, and therefore would not be expected to effect organ space infection rates. Furthermore, organ space infection rates are not typically reported in this setting.18–20 The higher rate of organ space infection is likely to reflect the higher rate of colorectal resections undertaken in the CINPT arm compared to the standard dressing arm, with rates of 51.8% and 34.7%, P = .01, respectively.
ECLAPTE: Effective Closure of LAParoTomy in Emergency—2023 World Society of Emergency Surgery guidelines for the closure of laparotomy in emergency settings
2023, World Journal of Emergency Surgery