Incisional negative-pressure wound therapy versus conventional dressings following abdominal wall reconstruction: a comparative study

A Comparative Trial of Incisional Negative-Pressure Wound Therapy in Abdominoplasty

The risk for minor local complications for abdominoplasty remains high despite advances in strategies in recent years. The most common complication is the formation of seroma with reported rates ranging from 15% to 40%. The use of incisional negative-pressure wound therapy (iNPWT) on closed surgical sites has been shown to decrease the infection, dehiscence, and seroma rates. Thus, this article aims to determine whether an iNPWT dressing, Prevena Plus, is able to reduce postoperative drainage and seroma formation in patients who undergo abdominoplasty. Sixteen consecutive patients who underwent abdominoplasty by a single surgeon were dressed with standard dressings and iNPWT dressings. Total drain output, day of drain removal, and adverse events were compared between cohorts with a minimum follow-up of 6 months. The iNPWT group demonstrated a significantly less amount of fluid drainage with a mean total fluid output of 370 ± 275 ml compared to 1269 ± 436 ml mean total drainage from controls (P < 0.001). Time before removal of both drains was almost halved in the iNPWT group with an average of 5.3 ± 1.6 days, which was significantly less than the average time of 10.6 ± 2.9 days seen in control patients (P < 0.001). No observed adverse events were recorded in either group. Our findings show that iNPWT for a closed abdominoplasty incision decreases the rate of postoperative fluid accumulation and results in earlier drain removal.

Management of Surgical Incisions Using Incisional Negative-Pressure Therapy

Use of negative-pressure therapy (NPT) is a well-established therapy for chronic, open, contaminated wounds, promoting formation of granulation tissue and healing. The application of NPT after primary closure (ie, incisional NPT) has also been shown to reduce surgical site infection and surgical site occurrence in high-risk procedures across multiple disciplines. Incisional NPT is believed to decrease edema and shear stress, promote angiogenesis and lymphatic drainage, and increase vascular flow and scar formation. Incisional NPT may be considered when there is a high risk of surgical site occurrence or surgical site infection, particularly in procedures with nonautologous implants, such as hernia mesh or other permanent prosthetics. Here we discuss the proposed physiologic mechanism as demonstrated in animal models and review clinical outcomes across multiple specialties.

Use of Closed-Incision Negative-Pressure Therapy in Aesthetic Surgery

BACKGROUND

Recently published studies have demonstrated clinical effectiveness of closed-incision negative-pressure therapy (ciNPT) in many fields of surgery including vascular, cardiac, colorectal, orthopedic, and reconstructive surgery. A review of current literature was conducted to determine whether the application of negative-pressure therapy to closed incisions post aesthetic procedures was beneficial.

METHODS

The PubMed/MEDLINE databases were searched for preclinical and clinical studies published through June 2018. Higher quality publications that met the following criteria were included: adult patients undergoing aesthetic or body contouring procedures, comparison of ciNPT with conventional dressings, and documentation of wound complications and/or incision quality.

RESULTS

One animal and multiple small, retrospective comparison articles are discussed. Scientific mechanism of action and economic analysis are also discussed. There are no level 1 randomized prospective controlled trials that directly evaluate the effects of ciNPT dressings in cosmetic patients.

CONCLUSION

For patients undergoing certain cosmetic procedures, preliminary data support the idea that ciNPT dressings provide aesthetic benefit, but more research is clearly needed.

Complex Open Abdominal Wall Reconstruction: Management of the Skin and Subcutaneous Tissue

Optimal skin and soft tissue management in complex open abdominal wall reconstruction is an integral element of the operation to achieve optimal outcomes. Failure to provide stable, well-vascularized soft tissue coverage over the hernia repair can jeopardize the reconstruction through association with nonhealing wounds, mesh exposure, and even possible hernia recurrence. The literature has shown that careful attention to the skin and soft tissue, especially when part of a multidisciplinary approach to complex abdominal wall reconstruction, improves patient outcomes significantly.

Chinese Trauma Surgeon Association for management guidelines of vacuum sealing drainage application in abdominal surgeries-Update and systematic review

Vacuum sealing drainage (VSD) is frequently used in abdominal surgeries. However, relevant guidelines are rare. Chinese Trauma Surgeon Association organized a committee composed of 28 experts across China in July 2017, aiming to provide an evidence-based recommendation for the application of VSD in abdominal surgeries. Eleven questions regarding the use of VSD in abdominal surgeries were addressed: (1) which type of materials should be respectively chosen for the intraperitoneal cavity, retroperitoneal cavity and superficial incisions? (2) Can VSD be preventively used for a high-risk abdominal incision with primary suture? (3) Can VSD be used in severely contaminated/infected abdominal surgical sites? (4) Can VSD be used for temporary abdominal cavity closure under some special conditions such as severe abdominal trauma, infection, liver transplantation and intra-abdominal volume increment in abdominal compartment syndrome? (5) Can VSD be used in abdominal organ inflammation, injury, or postoperative drainage? (6) Can VSD be used in the treatment of intestinal fistula and pancreatic fistula? (7) Can VSD be used in the treatment of intra-abdominal and extra-peritoneal abscess? (8) Can VSD be used in the treatment of abdominal wall wounds, wound cavity, and defects? (9) Does VSD increase the risk of bleeding? (10) Does VSD increase the risk of intestinal wall injury? (11) Does VSD increase the risk of peritoneal adhesion? Focusing on these questions, evidence-based recommendations were given accordingly. VSD was strongly recommended regarding the questions 2-4. Weak recommendations were made regarding questions 1 and 5-11. Proper use of VSD in abdominal surgeries can lower the risk of infection in abdominal incisions with primary suture, treat severely contaminated/infected surgical sites and facilitate temporary abdominal cavity closure.

Closed-incision negative-pressure therapy decreases complications in ventral hernia repair with concurrent panniculectomy

PURPOSE

Ventral hernia repair with concurrent panniculectomy (VHR-PAN) is associated with high wound complication rates despite reported increased patient satisfaction. Some surgeons believe negative-pressure therapy after primary closure of the surgical incision (ciNPT) may lower wound complications in high-risk abdominal wounds. This study aims to evaluate if ciNPT improves outcomes in patients undergoing VHR-PAN.

METHODS

An 8-year retrospective cohort study was performed on patients who underwent VHR-PAN. Patients were divided into two groups: those who received closed-incision negative-pressure therapy ("ciNPT") and those who received standard sterile dressings ("SSD"). The primary outcome of interest was the rate of postoperative complications between these groups. Complications were subdivided into surgical site occurrences (which included surgical site occurrences that required an intervention), return to the operating room, and hernia recurrence.

RESULTS

A total of 104 patients were analyzed: 62 in the ciNPT group and 42 in the SSD group. Median follow-up duration was similar between both groups (182 days vs 195 days, p = 0.624). Patients in the ciNPT group had fewer total complications (57% vs. 83%, p = 0.004) and fewer SSO (47% vs. 69%, p = 0.025). However, no differences were noted when comparing individual complications (SSI, wound dehiscence, skin necrosis, chronic wound, seroma, and hematoma). There was no difference in return to the operating room (27% vs. 26%, p = 0.890) or hernia recurrence (21% vs 19%, p = 0.811). Multivariate analysis showed that ciNPT decreased the risk of SSOPI nearly fourfold (odds ratio 0.28, 95% CI = 0.09-0.87, p = 0.027).

CONCLUSIONS

This study showed that closed-incision negative-pressure therapy in ventral hernia repair with concurrent panniculectomy may decrease the rate of wound complications in this high-risk population.

Vacuum Sealing Drainage Therapy for Refractory Infectious Wound on 16 Renal Transplant Recipients

BACKGROUND

Refractory infectious wounds on renal transplantation (RT) recipients significantly prolong hospital stay, increase medical costs, and threaten allograft survival. Vacuum sealing drainage (VSD) therapy is a new technique for managing wounds based on the principle of application of controlled negative pressure. The aim of this study was to summarize the efficacy and safety of VSD therapy in the management of refractory infectious wounds following RT.

MATERIALS AND METHODS

This is a retrospective study of a cohort of 661 consecutive patients who received renal transplants over a period of 3 years in which the data were collected and analyzed retrospectively.

RESULTS

Out of the 661 patients, 16 (2.4%) developed refractory wound infection following RT. Nineteen organisms were identified by culture from all patients, including 10 patients infected with 1 or more bacteria, 2 patients with fungal infection, and 4 patients with both. Specifically, mucormycosis was demonstrated in 4 patients, pan-resistant Klebsiella pneumoniae in 2 patients, and Acinetobacter baumannii in 2 patients. All 16 patients were treated with VSD therapy for a median of 37 days (range, 6-111 days). The number of VSD sets used ranged from 4 to 28 sets (mean, 11.1 sets). A combination of antibiotics, debridement, and VSD therapy lead to 100% (16 of 16) wound healing. No VSD-relevant adverse events were observed.

CONCLUSIONS

VSD therapy is an effective and safe adjunct to conventional treatment modalities for the management of refractory wound infection following RT.

Successful wound treatment using negative pressure wound therapy without primary closure in a patient undergoing highly contaminated abdominal surgery

BACKGROUND

The indications for negative pressure wound therapy (NPWT) continue to expand, and NPWT has become a powerful tool for the treatment of interactive wounds. Recently, the use of NPWT over closed incisions has been shown to prevent surgical site infection (SSI) in patients undergoing contaminated or acute care surgery as prophylactic NPWT. In this article, we present our successful experience using NPWT without primary skin closure for wound treatment after a highly contaminated enterological surgery. The procedure we present in this case report is considerably different from the conventional prophylactic NPWT and a novel method in the field of gastrointestinal surgery.

CASE PRESENTATION

A 33-year-old man with Crohn's disease underwent a dirty, infected enterological surgical procedure for the treatment of abdominal wall abscess and multiple fistulas around his colonic stoma. The stoma reconstruction and wound debridement resulted in a broad skin defect, and the incision was strategically left open. In addition to the infected wound condition (class IV), Crohn's disease itself is a risk factor for SSI; consequently, we induced NPWT immediately after the surgery and closed the incision from both ends in a stepwise manner using sutures each time we changed the dressing. This procedure was effective, enabling complete healing and closure at the surgical site on postoperative day 14 without infection or a skin defect.

CONCLUSION

For highly contaminated enterological surgery, purposely leaving the incision open and starting NPWT immediately after the procedure is an effective strategy for early wound closure and the prevention of SSI.

The application of incisional negative pressure wound therapy for perineal wounds: A systematic review

Impaired perineal wound healing is a major source of morbidity after abdominoperineal resection. Incisional negative pressure wound therapy can improve healing, prevent infections, and decrease the frequency of dehiscence. Our objective was to summarise existing evidence on the use of incisional negative pressure wound therapy on perineal wounds after abdominoperineal resection and to determine the effect on perineal wound complications. Electronic databases were searched in January 2017. Studies describing the use of incisional negative pressure wound therapy on primarily closed perineal wounds after abdominoperineal resection were included. Of the 278 identified articles, 5 were retrieved for inclusion in the systematic review (n = 169 patients). A significant decrease in perineal wound complications when using incisional negative pressure wound therapy was demonstrated, with surgical site infection rates as low as 9% (vs 41% in control groups). The major limitation of this systematic review was a small number of retrieved studies with small patient populations, high heterogeneity, and methodological issues. This review suggests that incisional negative pressure wound therapy decreases perineal wound complications after abdominoperineal resection. Further prospective trials with larger patient populations would be needed to confirm this association and delineate which patients might benefit most from the intervention.

Closed-incision negative pressure therapy to reduce groin wound infections in vascular surgery: a randomised controlled trial

Groin wound infections pose a major problem in vascular surgery. Closed-incision negative pressure therapy (ciNPT) was especially designed for the management of incisions at risk of surgical site infections. The aim of this study was to investigate whether ciNPT is able to reduce the incidence of wound infections after vascular surgery. Data on 132 consecutive patients, scheduled for vascular surgery with a longitudinal femoral cutdown, were collected prospectively. All patients were randomised either to the ciNPT group (n = 64) or the control group (n = 68) with conventional dressing. In the ciNPT group, the foam dressing was applied intraoperatively and removed after 5 days. The control group received an absorbent dressing. All wounds were evaluated after 5 and 42 days. Infections were graded according the Szilagyi classification (I-III°). There were no significant differences between both groups considering patient characteristics. Indications for surgery were peripheral arterial disease in 95% (125/132) and aneurysm in 5% (7/132). The overall infection rates were 14% (9/64) in the ciNPT group and 28% (19/68) in the control group (P = 0·055). Early infections were observed in 6% (4/64) of the ciNPT group and 15% (10/68) of the control group (P = 0·125). ciNPT did not reduce infection rates associated with different risk factors for infection. While the experiences with the ciNPT device were encouraging, the study fails to provide evidence of the efficacy of the device to reduce groin wound infections after vascular surgery. It illustrates far more that larger multicentre studies are required and appear promising to provide further evidence for the use of ciNPT.

Closed incision negative pressure therapy decreases complications after periprosthetic fracture surgery around the hip and knee

INTRODUCTION

Periprosthetic fractures (PPFXs) are becoming increasingly common following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patients sustaining PPFXs face considerable perioperative morbidity, with relatively increased rates of surgical site infection. We sought to evaluate the efficacy of closed-incision negative-pressure wound therapy (ciNPT) in decreasing perioperative wound complications following lower extremity periprosthetic fracture surgery.

METHODS

We performed a retrospective review of 69 consecutive patients who underwent surgery to address lower extremity periprosthetic fractures around hip or knee implants performed over a 6.5-year period. The population was divided into two groups based on the surgical dressing used at the conclusion of the procedure: (1) a sterile, antimicrobial hydrofiber dressing, or (2) ciNPT. There were no baseline demographic differences between the two groups. Rates of wound complications, surgical site infection, and reoperation related to the surgical site were compared between groups. Continuous variables were analyzed using a student's t-test, and categorical variables using either chi-square or fisher's exact test.

RESULTS

Patients treated with ciNPT developed fewer wound complications (4% vs. 35%; p=0.002), fewer deep infections (0% vs. 25%; p=0.004), and underwent fewer reoperations related to the surgical site (4% vs. 25%; p=0.021) compared to patients treated with standard of care.

CONCLUSIONS

Our findings suggest that ciNPT may reduce wound complications, SSIs, and reoperations in patients undergoing lower extremity periprosthetic fracture surgery. This is the first study to investigate ciNPT as a treatment for periprosthetic fracture surgery, and has the potential to change the postoperative management of these patients.

Effectiveness of negative pressure wound therapy/closed incision management in the prevention of post-surgical wound complications: a systematic review and meta-analysis

BACKGROUND

The treatment of post-surgical wound complications, such as surgical site infections and surgical wound dehiscence, generates a significant burden for patients and healthcare systems. The effectiveness of negative pressure wound therapy has been under investigation but to date no systematic review has been published in relation to its effectiveness in the prevention of surgical wound complications.

OBJECTIVES

To identify the effectiveness of negative pressure wound therapy in the prevention of post-surgical wound complications in adults with a closed surgical incision compared to standard surgical dressings.

INCLUSION CRITERIA

Male and female adults who have had negative pressure wound therapy applied to their surgical incision following a procedure in one of the following areas: trauma, cardiothoracic, orthopedic, abdominal, or vascular surgery.The intervention of interest was the use of negative pressure wound therapy directly over an incision following a surgical procedure; the comparator was standard surgical dressings.Both experimental and epidemiological study designs, including randomized controlled trials, pseudo-randomized trials, quasi-experimental studies, before and after studies, prospective and retrospective cohort studies, case control studies, and analytical cross sectional studies were sought.The primary outcome was the occurrence of post-surgical wound infection or dehiscence as measured by the following: surgical site infections - superficial and deep; surgical wound dehiscence; wound pain; wound seroma; wound hematoma.

SEARCH STRATEGY

Published and unpublished studies in English from 1990 to 2013 were identified by searching a variety of electronic databases. Reference lists of all papers selected for retrieval were then searched for additional studies.

METHODOLOGICAL QUALITY

Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument.

DATA COLLECTION

Data were extracted from the included papers using a standardized data extraction tool from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument. In addition to study results, the data extracted included details of the study population, setting, intervention and author's conclusion.

DATA SYNTHESIS

Where appropriate, data were pooled using Comprehensive Meta-Analysis software. Meta-analyses were performed for three outcomes. In cases of heterogeneity between studies a narrative summary of results was undertaken.

RESULTS

Eight studies were included in the review. Meta-analyses revealed a statistically significant difference in favor of the use of negative pressure wound therapy as compared to standard surgical dressings was found for surgical site infections. Conflicting results were found for wound dehiscence and seroma.

CONCLUSIONS

Given the small number of studies, mostly retrospective comparative cohort in design, no definitive conclusions can be reached as to the effectiveness of the use of negative pressure wound therapy in the prevention of surgical wound complications. However, there was a demonstrated association between the use of negative pressure wound therapy and reduction in surgical site infection.

IMPLICATIONS FOR PRACTICE

Negative pressure wound therapy in preference to standard postoperative dressings, for example dry gauze, may be considered for closed surgical incisions in adults assessed as high-risk for surgical site infections.

IMPLICATIONS FOR RESEARCH

The focus of further research on this topic should be level one studies (randomized controlled trials) on patients identified as 'at risk' in the preoperative period.

Comparison of a standardized negative pressure wound therapy protocol after midline celiotomy to primary skin closure and traditional open wound vacuum-assisted closure management

A negative pressure wound therapy (NPWT) protocol using Hydrofera Blue® bacteriostatic foam wicks and silver-impregnated foam overlay to close midline skin incisions after emergency celiotomy was compared to primary skin closure only and traditional open wound vacuum-assisted closure management as part of a quality improvement initiative. This single-institution retrospective cohort study assessed all consecutive emergency celiotomies from July 2013 to June 2014 excluding clean wounds. Included variables were demographics, wound classification, NPWT days, and surgical site occurrences (SSOs). Primary outcome was days of NPWT. Secondary outcomes included SSOs (surgical site infections, fascial dehiscence, return to operating room). Analysis used exact chi-square between categorical variables, Kruskal-Wallis for analysis of variance for ordinal and categorical variables, and Wilcoxon rank sum for total days of NPWT. One hundred fifty-eight patients underwent emergency celiotomy with primary skin closure (n = 51), open NPWT (n = 63), or the NPWT protocol (n = 44). There was no difference in American Society of Anesthesiologists Physical Status score, body mass index, wound classification, or SSO between the three groups. Total NPWT days were reduced in protocol versus open NPWT (median 3 vs 20.5 days, range 3-51 vs 3-405 days, P = 0.001). Primary skin closure and NPWT protocol had fewer patients discharged with NPWT than open NWPT (0% and 14% vs 63.5%, P < 0.0001, odds ratio = 10.7, 95% confidence interval 3.7-35.1). Primary skin closure and NPWT protocol decrease NPWT usage days and maintain low SSOs in emergency midline celiotomy incisions.

Incisional Negative Pressure Wound Therapy for Prevention of Wound Healing Complications Following Reduction Mammaplasty

BACKGROUND

It has been proposed that negative pressure wound therapy (NPWT) applied prophylactically to a closed incision may decrease the incidence of wound complications. Patients undergoing reduction mammaplasty are at risk of wound complications such as delayed healing, infection, and dehiscence, and the bilateral nature of the surgery allows for a within-patient randomized study to evaluate incisional NPWT's effect in reducing healing complications.

METHODS

In this multicenter trial, 200 patients undergoing bilateral reduction mammaplasty were treated with PICO Single-Use NPWT System or standard wound-care dressings randomized to right or left breast for up to 14 days to enable within-patient comparison. Follow-up assessments were conducted to evaluate the difference in incision healing complications up to 21 days postsurgery. Healing complications (for the primary endpoint) were defined as delayed healing (incision not 100% closed by 7 days) and occurrence of dehiscence or infection within 21 days. Individual healing complications were assessed separately as secondary endpoints.

RESULTS

Significantly fewer healing complications (primary endpoint) were noted in NPWT-treated breasts [113 (56.8%)] versus standard care [123 (61.8%)]. The difference of 10 (5.0%) patients with fewer healing complications using NPWT was statistically significant (P = 0.004). NPWT also resulted in a significantly lower incidence of dehiscence (secondary endpoint) compared with standard care [32 patients (16.2%) versus 52 patients (26.4%)] by day 21, a relative reduction of 38% (P < 0.001).

CONCLUSIONS

This is the first major prospective, within-patient, randomized, controlled, multicenter study to provide evidence for an incisional NPWT strategy to reduce healing complications.

The use of adjuncts to reduce seroma in open incisional hernia repair: a systematic review

BACKGROUND

Seroma formation remains a common complication after an incisional hernia repair. The use of surgical drains is widespread, but evidence for their use and other adjuncts is limited. Our aim was to perform a systematic review of the literature on techniques used to reduce the incidence of post-operative seroma formation.

METHODS

A systematic search of PubMed and Embase databases was conducted using terms including "incisional hernia" and "seroma". All studies on adults undergoing open incisional hernia repair with at least one intervention designed to reduce seroma formation were included.

RESULTS

Of the 1093 studies identified, 9 met the inclusion criteria. Medical talc: one cohort study of 74 patients undergoing talc application following pre-peritoneal mesh placement found a significantly decreased rate of seroma formation of 20.8 versus 2.7% (p < 0.001), but a retrospective study including 21 patients with onlay mesh found an increased rate of 76% seroma formation from 9.5% (p = 0.001). Fibrin glue: one comparative study including 60 patients found a reduction in seroma formation from 53 to 10% (p = 0.003), whereas a retrospective study of 250 patients found no difference (11 vs. 4.9% p = 0.07). Negative pressure wound therapy: four retrospective studies including a total of 358 patients found no difference in seroma outcome. Others: one randomised study of 42 patients undergoing either suction drainage or "quilting" sutures found no difference in seroma formation.

CONCLUSIONS

There is currently insufficient quality evidence to recommend any of the investigated methods, some of which incur significant additional cost.

Reduction of groin wound complications in vascular surgery patients using closed incision negative pressure therapy (ciNPT): a prospective, randomised, single-institution study

Groin wound infections in patients undergoing vascular procedures often cause a lengthy process of wound healing. Several clinical studies and case reports show a reduction of surgical site infections (SSIs) in various wound types after using closed incision negative pressure therapy (ciNPT). The aim of this prospective, randomised, single-institution study was to investigate the effectiveness of ciNPT (PREVENA™ Therapy) compared to conventional therapy on groin incisions after vascular surgery. From 1 February to 30 October 2015, 100 patients with 129 groin incisions were analysed. Patients were randomised and treated with either ciNPT (n = 58 groins) or the control dressing (n = 71 groins). ciNPT was applied intraoperatively and removed on days 5-7 postoperatively. The control group received a conventional adhesive plaster. Wound evaluation based on the Szilagyi classification took place postoperatively on days 5-7 and 30. Compared to the control group, the ciNPT group showed a significant reduction in wound complications (P < 0·0005) after both wound evaluation periods and in revision surgeries (P = 0·022) until 30 days postoperatively. Subgroup analysis revealed that ciNPT had a significant effect on almost all examined risk factors for wound healing. ciNPT significantly reduced the incidence of incision complications and revision procedures after vascular surgery.

Placental Membranes for Management of Refractory Cutaneous Sinus Tracts of Surgical Origin: A Pilot Study

Despite advances in surgical technique, postoperative complications may lead to refractory cutaneous sinus tracts or tunnels. Negative pressure wound therapy is difficult to apply in longer tracts with a narrow diameter opening and conservative treatment failures ultimately necessitate surgical revisions. The aim of this pilot study was a clinical utility assessment of two different commercial placental membrane products for refractory cutaneous sinus tracts of surgical origin. Patients were treated with viable cryopreserved placental membrane (vCPM, n = 6) or devitalized dehydrated amnion/chorion membrane (dHACM, n = 6). The primary outcome measurement was the proportion of complete sinus tract depth resolution without exudate. Secondary endpoints included 4-week percent reduction in sinus tract probing depth and peri-tract wound surface area, days and number of grafts to resolution, number of wound-related infections, and 1-year recurrence rate for closed sinus tracts. All vCPM patients demonstrated complete sinus tract resolution compared to zero closures in the dHACM group (p = 0.00216). The vCPM group achieved greater percent reduction in probing depth (73.3 ± 21.9 versus −4.4 ± 91.3) and surrounding wound surface area (34.8 ± 86.8 versus −279.3 ± 454.9) at 4 weeks than dHACM. The use of viable intact cryopreserved placental membrane has demonstrated positive clinical outcomes for the treatment for refractory exudative sinus tracts and may be an alternative to repeat surgical intervention.

Management of skin and subcutaneous tissue in complex open abdominal wall reconstruction

PURPOSE

Open abdominal wall reconstruction is often a complex endeavor, usually performed on patients with multiple risk factors and co-morbidities.

METHODS

In this article, we review soft tissue management techniques that can optimize the skin and subcutaneous tissue, with the goal of reducing surgical-site occurrences.

RESULTS

Regardless of the hernia repair technique used, outcomes can be highly dependent on the appropriate management of the skin and subcutaneous tissue. Indeed, dehiscence and surgical-site infection can jeopardize the entire reconstruction, especially in cases where synthetic mesh might become exposed and/or infected, setting up a "vicious cycle" (Holihan et al. in J Am Coll Surg 221:478-485, 2015).

CONCLUSION

Multidisciplinary cooperation between the general and plastic surgeon is useful in cases of tenuous blood supply to the abdominal skin, in cases of redundant, marginal or excessive skin, and in cases of deficient skin.

Negative Pressure Wound Therapy for Closed Surgical Wounds in Musculoskeletal Oncology Patients - A Case-Control Trial

Following excision of musculoskeletal tumours, patients are at high risk of wound issues such as infection, dehiscence and delayed healing. This is due to a multitude of factors including the invasive nature of the disease, extensive soft tissue dissection, disruption to blood and lymphatic drainage, residual cavity and adjuvant therapies. The use of negative pressure wound therapy (NPWT) has a growing body of evidence on its beneficial effect of wound healing such as promoting cell differentiation, minimising oedema and thermoregulation. Traditionally, these dressings have been used for open or dehisced wounds; however recent research has investigated its role in closed wounds.

Aim:

To evaluate the effect of NPWT in patients with closed wounds, either primarily or with flap coverage, in our high risk group. Consecutive patients who had a NPWT dressing applied were selected, and a control group was established by a blinded researcher with matching for tissue diagnosis, surgical site, gender and age. The primary outcome measured was documented for wound complications, with secondary data collected on radiotherapy and wound drainage.

Results:

Patients were well matched between the intervention (n=9) and control (n=9) groups for gender, age and tissue diagnosis. Both groups had 1 patient who underwent preoperative radiotherapy. A total of 3 wound infections occurred in the control group and none in the NPWT group. Overall there was a trend towards lower drain output and statistically significantly reduced infection rate in the NPWT group.

Conclusion:

In this short series, despite the NPWT patients having more additional risk factors for wound issues, they resulted in fewer infections. The sample size is not sufficient to have statistically significant reduction. Further evaluation on the value of NPWT in this patient group should be prospectively evaluated.

Closed incision prophylactic negative pressure wound therapy in patients undergoing major complex abdominal wall repair

Purpose

To evaluate if incisional prophylactic negative pressure wound therapy (pNPWT) reduces wound infections and other wound complications in high-risk patients undergoing major complex ventral abdominal wall repair.

Methods

Retrospective before–after comparison nested in a consecutive series of patients undergoing elective major complex abdominal wall repair. Starting January 2014, pNPWT was applied on the closed incisional wound for a minimum of 5 days. To minimize selection bias, we compared two periods of 14 months before and after January 2014. Wound infections according to the Centre for Disease Control Surgical Site Infection classification as well as other wound complications were recorded.

Results

Thirty-two patients were included in the pNPWT group and 34 in the control group. The study group involved clean-contaminated and contaminated operations due to enterocutaneous fistula, enterostomies or infected mesh. Median duration of pNPWT was 5 days (IQR 5–7). Overall wound infection rate was 35%. pNPWT was associated with a significant decrease in postoperative wound infection rate (24 versus 51%; p = 0.029, OR 0.30 (95% CI 0.10–0.90)). Incisional wound infection rates dropped from 48 to 7% (p < 0.01, OR 0.08 (95% CI 0.16–0.39), whereas the number of subcutaneous abscesses was comparable in both groups. Moreover, less interventions were needed in the pNPWT group (p < 0.001).

Conclusions

Closed incision pNPWT seems a promising solution to reduce the incidence of wound infections in complex abdominal wall surgery. Randomized controlled trials are needed to estimate more precisely the value and cost-effectiveness of pNPWT in this high-risk setting.

Evidence-Based Strategies to Reduce Postoperative Complications in Plastic Surgery

Reconstructive plastic surgery is vital in assisting patients with reintegration into society after events such as tumor extirpation, trauma, or infection have left them with a deficit of normal tissue. Apart from performing a technically sound operation, the plastic surgeon must stack the odds in the favor of the patient by optimizing them before and after surgery. The surgeon must look beyond the wound, at the entire patient, and apply fundamental principles of patient optimization. This article reviews the evidence behind the principles of patient optimization that are commonly used in reconstructive surgery patients.

Closed-incision negative-pressure therapy in high-risk general surgery patients following laparotomy: a retrospective study

AIM

Surgical site infection (SSI) and wound dehiscence are dreaded complications following laparotomy in general surgical patients, and can potentially occur more often in various comorbid states. Negative-pressure wound therapy (NPWT) has a positive effect of on open and complicated wounds and so has been used for at-risk surgical incisions with the aim of redistributing lateral tension and holding incision edges together. The aim of the present study was to compare the rate of wound complications following laparotomy in high-risk general surgical patients with a clean incision treated with closed-incision negative-pressure therapy (ciNPT) with those receiving conventional care.

METHOD

A retrospective review was performed of the hospital medical records of patients who underwent laparotomy between 1 October 2010 and 31 March 2012. Records of 69 patients who received ciNPT and 112 who were managed by adherent gauze dressings were included in the final analysis.

RESULTS

Two (2.9%) patients in the ciNPT group and 23 (20.5%) in the non-NPWT group developed a wound complication following laparotomy (P < 0.0009). The relative risk (RR) was 0.14 (0.03-0.58), suggesting that infection is less likely to occur in ciNPT-treated incisions, compared with gauze dressings.

CONCLUSION

ciNPT was associated with a positive clinical outcome and was a safe and effective method of postsurgical management in our general surgery patients considered to have risk of developing wound complications following laparotomy.

Evidence based review of negative pressure wound therapy

Vacuum-assisted closure, sometimes referred to as microdeformational wound therapy or most commonly negative pressure wound therapy (NPWT), has significantly improved wound care over the past two decades. NPWT is known to affect wound healing through four primary mechanisms (macrodeformation, microdeformation, fluid removal, and alteration of the wound environment) and various secondary mechanisms (including neurogenesis, angiogenesis, modulation of inflammation, and alterations in bioburden) which are described in this review. In addition, the technique has many established uses, for example in wound healing of diabetic and pressure ulcers, as well as burn and blast wounds. This therapy also has many uses whose efficacy has yet to be confirmed, for example the use in digestive surgery. Modifications of the traditional NPWT have also been established and are described in detail. This therapy has various considerations and contraindications which are summarized in this review. Finally, future perspectives, such as the optimal cycling of the treatment and the most appropriate interface material, are touched upon in the final segment. Overall, despite the fact that questions remain to be answered about NPWT, this technology is a major breakthrough in wound healing with significant potential use both in the hospital but also in the community.

Improving wound healing and preventing surgical site complications of closed surgical incisions: a possible role of Incisional Negative Pressure Wound Therapy. A systematic review of the literature

Advances in preoperative care, surgical techniques and technologies have enabled surgeons to achieve primary closure in a high percentage of surgical procedures. However, often, underlying patient comorbidities in addition to surgical-related factors make the management of surgical wounds primary closure challenging because of the higher risk of developing complications. To date, extensive evidence exists, which demonstrate the benefits of negative pressure dressing in the treatment of open wounds; recently, Incisional Negative Pressure Wound Therapy (INPWT) technology as delivered by Prevena™ (KCI USA, Inc., San Antonio, TX) and Pico (Smith & Nephew Inc, Andover, MA) systems has been the focus of a new investigation on possible prophylactic measures to prevent complications via application immediately after surgery in high-risk, clean, closed surgical incisions. A systematic review was performed to evaluate INPWT's effect on surgical sites healing by primary intention. The primary outcomes of interest are an understanding of INPWT functioning and mechanisms of action, extrapolated from animal and biomedical engineering studies and incidence of complications (infection, dehiscence, seroma, hematoma, skin and fat necrosis, skin and fascial dehiscence or blistering) and other variables influenced by applying INPWT (re-operation and re-hospitalization rates, time to dry wound, cost saving) extrapolated from human studies. A search was conducted for published articles in various databases including PubMed, Google Scholar and Scopus Database from 2006 to March 2014. Supplemental searches were performed using reference lists and conference proceedings. Studies selection was based on predetermined inclusion and exclusion criteria and data extraction regarding study quality, model investigated, epidemiological and clinical characteristics and type of surgery, and the outcomes were applied to all the articles included. 1 biomedical engineering study, 2 animal studies, 15 human studies for a total of 6 randomized controlled trials, 5 prospective cohort studies, 7 retrospective analyses, were included. Human studies investigated the outcomes of 1042 incisions on 1003 patients. The literature shows a decrease in the incidence of infection, sero-haematoma formation and on the re-operation rates when using INPWT. Lower level of evidence was found on dehiscence, decreased in some studies, and was inconsistent to make a conclusion. Because of limited studies, it is difficult to make any assertions on the other variables, suggesting a requirement for further studies for proper recommendations on INPWT.

New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective

Surgical site infections (SSIs) are the most common health-care-associated infections in developing countries, but they also represent a substantial epidemiological burden in high-income countries. The prevention of these infections is complex and requires the integration of a range of preventive measures before, during, and after surgery. No international guidelines are available and inconsistencies in the interpretation of evidence and recommendations in national guidelines have been identified. Considering the prevention of SSIs as a priority for patient safety, WHO has developed evidence-based and expert consensus-based recommendations on the basis of an extensive list of preventive measures. We present in this Review 16 recommendations specific to the intraoperative and postoperative periods. The WHO recommendations were developed with a global perspective and they take into account the balance between benefits and harms, the evidence quality level, cost and resource use implications, and patient values and preferences.

Deconstructing negative pressure wound therapy

Since its introduction 20 years ago for the treatment of chronic wounds, negative pressure wound therapy use has expanded to a variety of other wound types. Various mechanisms of action for its efficacy in wound healing have been postulated, but no unifying theory exists. Proposed mechanisms include induction of perfusion changes, microdeformation, macrodeformation, exudate control and decreasing the bacterial load in the wound. We surmise that these different mechanisms have varying levels of dominance in each wound type. Specifically, negative pressure wound therapy is beneficial to acute open wounds because it induces perfusion changes and formation of granulation tissue. Post-surgical incisional wounds are positively affected by perfusion changes and exudate control. In the context of chronic wounds, negative pressure wound therapy removes harmful and corrosive substances within the wounds to affect healing. When skin grafts and dermal substitutes are used to close a wound, negative pressure wound therapy is effective in promoting granulation tissue formation, controlling exudate and decreasing the bacterial load in the wound. In this review, we elucidate some of the mechanisms behind the positive wound healing effects of negative pressure wound therapy, providing possible explanations for these effects in different wound types.

A systematic review and meta-analysis including GRADE qualification of the risk of surgical site infections after prophylactic negative pressure wound therapy compared with conventional dressings in clean and contaminated surgery

OBJECTIVE

Systematically review and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) studies on prophylactic negative pressure wound therapy (pNPWT) to prevent surgical site infections (SSIs).

INTRODUCTION

pNPWT has been suggested as a new method to prevent wound complications, specifically SSIs, by its application on closed incisional wounds.

METHODS

This review was conducted as part of the development of the Global Guidelines for prevention of SSIs commissioned by World Health Organization in Geneva. PubMed, Embase, CENTRAL, CINAHL, and the World Health Organization database between January 1, 1990 and October 7, 2015 were searched. Inclusion criteria were randomized controlled trials and observational studies comparing pNPWT with conventional wound dressings and reporting on the incidence of SSI. Meta-analyses were performed with a random effect model. GRADE Pro software was used to qualify the evidence.

RESULTS

Nineteen articles describing 21 studies (6 randomized controlled trials and 15 observational) were included in the review. Summary estimate showed a significant benefit of pNPWT over conventional wound dressings in reducing SSIs in both randomized controlled trials and observational studies, odds ratio of 0.56 (95% confidence interval, 0.32-0.96; P = 0.04) and odds ratio of 0.30 (95% confidence interval, 0.22-0.42; P < 0.00001), respectively. This translates into lowering the SSI rate from 140 to 83 (49-135) per 1000 patients and from 106 to 34 (25-47) per 1000 patients, respectively. In stratified analyses, these results were consistent in both clean and clean-contaminated procedures and in different types of surgery, however results were no longer significant for orthopaedic/trauma surgery. The level of evidence as qualified with GRADE was however low.

CONCLUSIONS

Low-quality evidence indicates that prophylactic NPWT significantly reduces the risk of SSIs.

The use of a negative pressure wound management system in perineal wound closure after extralevator abdominoperineal excision (ELAPE) for low rectal cancer

BACKGROUND

Perineal wound healing is a significant challenge after extralevator abdominoperineal excision (ELAPE) due to a high rate of wound breakdown. Negative pressure therapy has proven benefits in open wounds, and recently a negative pressure system has been developed for use on closed wounds at high risk of breakdown, such as apronectomy and hysterectomy. The aim of the present study was to determine whether negative pressure therapy applied to closed perineal wounds after ELAPE improved wound healing and compare outcomes to the published literature and outcomes from a historical cohort of patients who had undergone 'standard' abdominoperineal resection (APR) and primary closure of the perineal wounds.

METHODS

Prospective data on consecutive patients having ELAPE in the period from November 2012 to April 2015 were collected. The pelvic floor defect was reconstructed with biologic mesh. The adipose tissue layer was closed with vicryl sutures, a suction drain was left in the deep layer, the subcuticular layer and skin were closed, and the negative pressure system was applied. Any wound breakdown within the first 30 days postoperatively was recorded.

RESULTS

Of the 32 consecutive ELAPE patients whose perineal wounds were closed within 30 days with the use of the negative pressure system, there was 1 patient with major perineal wound breakdown and 2 patients with a 1 cm superficial wound defect, which needed no further treatment. In the remaining 29 (90 %) patients, the perineal wounds healed fully without complications. Twenty-five patients underwent standard APR in 2010-2011 with primary closure of their perineal wounds. Ten out of 25(40 %) of patients who had undergone standard APR and primary closure of perineal wounds had major wound complications (p = 0.01).

CONCLUSIONS

Our results suggest that after ELAPE the application of a negative pressure system to the perineal wound closed with biologic mesh may reduce perineal wound complications and may reduce the need for major perineal reconstruction.

Does negative pressure wound therapy applied to closed incisions following ventral hernia repair prevent wound complications and hernia recurrence? A systematic review and meta-analysis

Background

Despite advances in surgical technique, ventral hernia repair (VHR) remains associated with significant postoperative wound complications.

Objective

A systematic review and meta-analysis was performed to identify whether the application of negative pressure wound therapy to closed incisions (iNPWT) following VHR reduces the risk of postoperative wound complications and hernia recurrence.

Methods

The PubMed/MEDLINE, EMBASE and SCOPUS databases were searched for studies published through October 2015. Publications that met the following criteria were included: adult patients undergoing VHR; comparison of iNPWT with conventional dressings; and documentation of wound complications and/or hernia recurrence. The methodological quality of included studies was independently assessed using the Methodological Index for Non-Randomized Studies guidelines. Outcomes assessed included surgical site infection (SSI), wound dehiscence, seroma, and hernia recurrence. Meta-analysis was performed to obtain pooled ORs.

Results

Five retrospective cohort studies including 477 patients undergoing VHR were included in the final analysis. The use of iNPWT decreased SSI (OR 0.33 [95% CI 0.20 to 0.55]; P<0.0001), wound dehiscence (OR 0.21 [95% CI 0.08 to 0.55]; P=0.001) and ventral hernia recurrence (OR 0.24 [95% CI 0.08 to 0.75]; P=0.01). There was no statistically significant difference in the incidence of seroma formation (OR 0.59 [95% CI 0.27 to 1.27]; P=0.18).

Conclusion

For patients undergoing VHR, current evidence suggests a decreased incidence in wound complications using incisional NPWT compared with conventional dressings.

Closed incision negative pressure therapy: international multidisciplinary consensus recommendations

Surgical site occurrences (SSOs) affect up to or over 25% of patients undergoing operative procedures, with the subset of surgical site infections (SSIs) being the most common. Commercially available closed incision negative pressure therapy (ciNPT) may offer surgeons an additional option to manage clean, closed surgical incisions. We conducted an extensive literature search for studies describing ciNPT use and assembled a diverse panel of experts to create consensus recommendations for when using ciNPT may be appropriate. A literature search of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials using key words ‘prevention’, ‘negative pressure wound therapy (NPWT)’, ‘active incisional management’, ‘incisional vacuum therapy’, ‘incisional NPWT’, ‘incisional wound VAC’, ‘closed incisional NPWT’, ‘wound infection’, and ‘SSIs’ identified peer‐reviewed studies published from 2000 to 2015. During a multidisciplinary consensus meeting, the 12 experts reviewed the literature, presented their own ciNPT experiences, identified risk factors for SSOs and developed comprehensive consensus recommendations. A total of 100 publications satisfied the search requirements for ciNPT use. A majority presented data supporting ciNPT use. Numerous publications reported SSI risk factors, with the most common including obesity (body mass index ≥30 kg/m²); diabetes mellitus; tobacco use; or prolonged surgical time. We recommend that the surgeon assess the individual patient's risk factors and surgical risks. Surgeons should consider using ciNPT for patients at high risk for developing SSOs or who are undergoing a high‐risk procedure or a procedure that would have highly morbid consequences if an SSI occurred.

Closed-Incision Negative-Pressure Therapy Versus Antimicrobial Dressings After Revision Hip and Knee Surgery: A Comparative Study

BACKGROUND

This study evaluates the efficacy of closed-incision negative-pressure therapy (ciNPT) in decreasing wound complications and surgical site infections (SSIs) after revision hip and knee surgery.

METHODS

A retrospective quality improvement analysis of 138 consecutive revision hip and knee operations performed by a single surgeon over a 34-month period was performed. ciNPT was used selectively in higher-risk patients with multiple risk factors for SSIs over the last 15 months of the study period. Rates of wound complications, SSIs, and reoperation were compared with patients treated with a sterile antimicrobial dressing.

RESULTS

Antimicrobial dressings were used in 108 patients, whereas ciNPT was used in 30 patients. Patients treated with ciNPT developed fewer overall wound complications (6.7% vs 26.9%, P = .024) and fewer total SSIs (3.3% vs 18.5%, P = .045) than patients treated with antimicrobial dressings. In addition, there were trends toward a lower rate of superficial wound dehiscence (6.7% vs 19.4%, P = .163), fewer deep periprosthetic joint infections (0.0% vs 9.3%, P = .118), and fewer reoperations (3.3% vs 13.0%, P = .191) among patients treated with ciNPT.

CONCLUSION

Our findings suggest that ciNPT may decrease wound complications and SSIs in patients undergoing revision hip and knee surgery.

Incisional negative pressure wound therapy in reconstructive surgery of poststernotomy mediastinitis

The efficacy of negative pressure wound therapy in the treatment of poststernotomy mediastinitis has been revealed in many reports. The present retrospective observational study examined the efficacy of incisional negative pressure wound therapy in the reconstructive surgery of poststernotomy mediastinitis. We retrospectively examined 1034 consecutive patients, who underwent median sternotomy in the period between October 2013 and September 2015. Mediastinitis developed in 21 patients (2%), who subsequently underwent surgical reconstruction. We applied incisional negative pressure wound therapy (iNPWT) after primary closure of the wound over redon drains in ten patients (iNPWT + redon group). In 11 patients, only redons were used (redons only group). We observed the time between the introduction and removal of redon drains, hospital stay until final wound closure and the rate of failure of treatment. Failure of treatment is defined as the need for further surgical reconstruction. In the iNPWT + redon group, the duration of redon drainage therapy was 6·9 ± 5·2 days versus 13·36 ± 11·58 in the redons only group. Hospital stay was 11·4 ± 8·6 versus 101·64 ± 89·2, and failure of treatment was 10% versus 45·5%, respectively. The primary results of this study appear to support the beneficial effect of iNPWT after radical wound reconstruction.

Closed Incision Negative-Pressure Therapy Is Associated with Decreased Surgical-Site Infections: A Meta-Analysis

BACKGROUND

Negative-pressure therapy has recently been used over closed incisions to decrease surgical-site occurrences, including infection and dehiscence. A meta-analysis was performed to evaluate the effectiveness of closed incision negative-pressure therapy in lowering the incidence of surgical-site infections compared with standard dressings.

METHODS

A literature search was conducted to find publications comparing closed incision negative-pressure therapy to standard incisional care. A fixed-effects model was used to assess between-study and between-incision location subgroup heterogeneity and effect size. Funnel plots were used to assess publication bias.

RESULTS

The overall weighted average rates of surgical-site infection in the closed incision negative-pressure therapy and control groups were 6.61 percent and 9.36 percent, respectively. This reflects a relative reduction in surgical site infection rate of 29.4 percent. A decreased likelihood of surgical-site infection was evident in the closed incision negative-pressure therapy group compared with the control group across all studies, and across all four incision location subgroups. Across all studies, odds of surgical-site infections decreased 0.564 (p < 0.00001). After excluding groin incision studies because of heterogeneity following sensitivity analysis, the odds of surgical-site infection decrease was still 0.496 (p < 0.00001). In addition, overall rates of dehiscence in closed incision negative-pressure therapy and control groups were 5.32 percent and 10.68 percent, respectively.

CONCLUSIONS

The results of this meta-analysis suggest that closed incision negative-pressure therapy is a potentially effective method for reducing surgical-site infections. It also appears that closed incision negative-pressure therapy may be associated with a decreased incidence of dehiscence, but the published data available were too heterogeneous to perform meta-analysis.