The impact of subcutaneous irrigation on wound complications after cesarean sections: A prospective randomised study

Incisional Wound Irrigation for the Prevention of Surgical Site Infection: A Systematic Review and Network Meta-Analysis

Importance

Surgical site infections (SSIs) are common postoperative complications and associated with significant morbidity, mortality, and costs. Prophylactic intraoperative incisional wound irrigation is used to reduce the risk of SSIs, and there is great variation in the type of irrigation solutions and their use.

Objective

To compare the outcomes of different types of incisional prophylactic intraoperative incisional wound irrigation for the prevention of SSIs in all types of surgery.

Data Sources

PubMed, Embase, CENTRAL, and CINAHL databases were searched up to June 12, 2023.

Study Selection

Included in this study were randomized clinical trials (RCTs) comparing incisional prophylactic intraoperative incisional wound irrigation with no irrigation or comparing irrigation using different types of solutions, with SSI as a reported outcome. Studies investigating intracavity lavage were excluded.

Data Extraction and Synthesis

This systematic review and network meta-analysis is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Two reviewers independently extracted the data and assessed the risk of bias within individual RCTs using the Cochrane Risk of Bias 2 tool and the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation framework. A frequentist network meta-analysis was conducted, and relative risks (RRs) with corresponding 95% CIs were reported.

Main Outcome and Measure

The primary study outcome was SSI.

Results

A total of 1587 articles were identified, of which 41 RCTs were included in the systematic review, with 17 188 patients reporting 1328 SSIs, resulting in an overall incidence of 7.7%. Compared with no irrigation, antiseptic solutions (RR, 0.60; 95% CI, 0.44-0.81; high level of certainty) and antibiotic solutions (RR, 0.46; 95% CI, 0.29-0.73; low level of certainty) were associated with a beneficial reduction in SSIs. Saline irrigation showed no statistically significant difference compared with no irrigation (RR, 0.83; 95% CI, 0.63-1.09; moderate level of certainty).

Conclusions and Relevance

This systematic review and network meta-analysis found high-certainty evidence that prophylactic intraoperative incisional wound irrigation with antiseptic solutions was associated with a reduction in SSIs. It is suggested that the use of antibiotic wound irrigation be avoided due to the inferior certainty of evidence for its outcome and global antimicrobial resistance concerns.

Intraoperative incision irrigation with high-volume saline reduces surgical site infection for abdominal infections

Purpose

Surgical site infection (SSI) remains one of the most common postoperative complications for patients with abdominal infections. This study aimed at investigating the effectiveness of high-volume normal saline (NS) irrigation in preventing postoperative SSI for patients with abdominal infections.

Methods

In this retrospective before-after clinical study, patients who underwent emergency laparotomy due to abdominal infections between Jan 2015 and Dec 2021 were included consecutively. A cohort of 207 patients with NS irrigation was compared to historical controls. A propensity score matching (PSM) with a 1:1 ratio was performed to reduce potential bias. The primary outcome was the 30-day SSI rate.

Results

Irrigation (n = 207) and control (n = 207) matched patients were statistically identical on baseline characteristics, perioperative, and intraoperative parameters. Irrigation patients had lower overall SSI rates (10.6% vs. 26.1%, p < 0.001), mainly due to reduction in superficial (4.3% vs. 17.9%) and deep (1.4% vs. 3.9%) SSIs, rather than space/organ SSIs (4.8% vs. 4.3%). Irrigation patients also had lower rates of incision seroma (4.8% vs. 11.6%, p = 0.012), shorter duration of antibiotics use (5.2 ± 1.7 d vs. 7.2 ± 2.0 d, p < 0.001), and unplanned readmission (1.0% vs. 8.7%, p < 0.001). Length of hospital stay showed a declining trend with irrigation intervention, while no significant difference was observed. Moreoever, logistic regression revealed that NS irrigationwas an independent protector against SSI (OR 0.309; 95% CI, 0.207–0.462; p < 0.001).

Conclusion

Intraoperative incision irrigation with high-volume NS is associated with a lower rate of SSI for patients with abdominal infections.

Subcutaneous irrigation with rifampicin vs. povidone-iodine for the prevention of incisional surgical site infections following caesarean section: a prospective, randomised, controlled trial

The aim is to investigate the effect of irrigation of subcutaneous tissue with saline, rifampicin, or povidone-iodine on incisional surgical site infections following caesarean section. Three hundred patients scheduled for caesarean section were randomly assigned into one of three groups of 100 members each, as follows: the subcutaneous tissue was irrigated with saline in group 1 (control); saline + rifampicin in group 2; saline + 10% povidone-iodine in group 3. Patients who developed a superficial incisional surgical site infection within 30 days were recorded. The surgical site infection rate did not differ when using rifampicin or povidone-iodine (p = .202). It was observed that there was a statistically significant increase in the rate of incisional surgical site infections as the existence of comorbidities (p = .001), perioperative blood transfusion (p = .020), and midline incision (p = .004). Irrigation of subcutaneous tissue with rifampicin or 10% povidone-iodine is not effective in preventing surgical site infections after caesarean section.IMPACT STATEMENTWhat is already known on this subject? An increase has recently been observed in the incidence of SSI particularly in caesarean sections due to reasons, such as that elderly mothers are more commonly operated on compared to the past and long and complicated operations (Lachiewicz et al. 2015) and there are no clear decisions on measures to be taken. Also, there are not many studies on this subject (De Nardo et al. 2016; Solomkin et al. 2017).What do the results of this study add? In our study, we investigated the effectiveness of subcutaneous agents that have been used by many surgeons for years and we've revealed that it's not effective. There is no study in the literature comparing 3 different irrigation agents as we did in our study. For this reason, we think that we will make an important contribution to the measures to be taken in this important issue.What are the implications of these findings for clinical practice and/or further research? This study may contribute to reaching a sufficient level of evidence on surgical wound infections after caesarean sections, which are still missing in the literature, and that may be guiding for the studies that will be conducted on this subject in the future.

Cesarean delivery: an evidence-based review of the technique

The cesarean section is utilized to deliver babies since the late 19^th century. Nowadays, the frequency of cesarean section is increased, mainly because of the low rate of complications and for the increasing demand from future mothers, scared by the idea of painful labor. Although the technique to perform cesarean section has been refined over time, infections, hemorrhage, pain and other consequences still represent matter of debate. To try to reduce the incidence of these complications many trials, randomized or not, have been performed, with the aim to analyze different technical aspects of this surgery. The aim of our review was to resume all the evidence-based instructions on how to best approach to cesarean section practice, in a step-to-step fashion, considering pre-operative actions, opening and closing steps, and postoperative prophylaxis.

The role of saline irrigation prior to wound closure in the reduction of surgical site infection: a systematic review and meta-analysis

Background

Surgical site infection (SSI) describes an infectious complication of surgical wounds. Although SSI is thought to be preventable, it still represents a major cause of morbidity and substantial economic burden on the health system. Wound irrigation (WI) might reduce the level of bacterial contamination, but current data on its role in reducing or preventing SSI is conflicting. Our aim was to investigate the effectiveness of WI with normal saline prior to wound closure for the reduction of SSI in patients undergoing abdominal surgery.

Methods

We conducted a systematic literature search in MEDLINE, EMBASE, and CENTRAL from inception to present, and cross-checked the reference lists of all included primary studies and relevant systematic reviews. (Quasi-) randomized controlled trials (RCTs) investigating the rate of SSI when using normal saline vs. no irrigation prior to wound closure following abdominal surgery were included. Primary outcome was the rate of SSI, secondary outcome the mean length of hospital stay (LOS).

Results

Four RCTs including a total of 1194 patients were included for analysis. All studies compared wound irrigation with normal saline with no wound irrigation prior to wound closure. Their risk of bias was moderate. The relative risk of developing a SSI was lower when wound irrigation with normal saline was performed prior to wound closure although the effect was not statistically significant (risk ratio 0.73, 95%-confidence level: 0.37 to 1.43). Similarly, there was no difference in the LOS amongst both intervention arms.

Conclusion

This systematic review could not identify an advantage for routine irrigation of abdominal wounds with normal saline over no irrigation prior to wound closure in preventing or reducing the rate of SSI.

Systematic review registration

PROSPERO registry number CRD42018082287.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13037-020-00274-2.

The Case for Standardizing Cesarean Delivery Technique: Seeing the Forest for the Trees

In this Commentary, we explain the case for a standardized cesarean delivery surgical technique. There are three strong arguments for a standardized approach to cesarean delivery, the most common major abdominal surgery performed in the world. First, standardization within institutions improves safety, efficiency, and effectiveness in health care delivery. Second, surgical training among obstetrics and gynecology residents would become more consistent across hospitals and regions, and proficiency in performing cesarean delivery measurable. Finally, standardization would strengthen future trials of cesarean delivery technique by minimizing the potential for aspects of the surgery which are not being studied to bias results. Before 2013, more than 155 randomized controlled trials, meta-analyses or systematic reviews were published comparing various aspects of cesarean delivery surgical technique. Since 2013, an additional 216 similar studies have strengthened those recommendations and offered evidence to recommend additional cesarean delivery techniques. However, this amount of cesarean delivery technique data creates a forest for the trees problem, making it difficult for a clinician to synthesize this volume of data. In response to this difficulty, we propose a comprehensive, evidence-based and standardized approach to cesarean delivery technique.

Marine fish peptides (collagen peptides) compound intake promotes wound healing in rats after cesarean section

Background

Wound complications are a major source of morbidity after cesarean section (CS) and contribute to increased risks in subsequent pregnancies. In the present study, we aim to investigate the wound healing potential of a kind of oligopeptide compound, mainly derived from the marine fish peptides (MFPs), in rats after CS by biomechanical, biochemical, and histological methods.

Methods

Eighty-four pregnant Sprague–Dawleyrats were randomly assigned to four groups, namely the control group and 1.1, 2.2, and 4.4 mg/kg MFP groups, respectively. The MFPs or normal saline of the equal volume was intragastrically administered every morning on the second day after CS. On days 5, 10, and 15 after the surgery, seven rats from each group were randomly selected. The samples of skin wound and uterus were harvested and then used for the following experiments and analyses.

Results

Using the CS rat model, this study demonstrated that in the MFP groups, the skin tensile strength, uterine bursting pressure, and hydroxyproline (Hyp) were significantly higher than those in the control group at all three time points (P < 0.05). The formation of collagen and smooth muscle fibers and the expression of CD34 and connective tissue growth factor at the incision site were increasingly observed in the MFP groups (P < 0.05).

Conclusions

MFPs have a great potential to accelerate the process and quality of wound healing in rats after CS.

Standardising intraoperative irrigation with 0.05% chlorhexidine gluconate in caesarean delivery to reduce surgical site infections: A single institution experience

Background

Surgical site infection is a significant cause of morbidity and mortality following caesarean delivery.

Objective

To determine whether standardising intraoperative irrigation with 0.05% chlorhexidine gluconate during caesarean delivery could decrease infection rates.

Methods

This was a process improvement project involving 742 women, 343 of whom received low-pressured 0.05% chlorhexidine gluconate irrigation during caesarean delivery over a one-year period. Infection rates were compared with a standard-of-care control group (399 women) undergoing caesarean delivery the preceding year.

Results

The treatment group infection rate met the study goal by achieving a lower infection rate than the control group, though this was not statistically significant. A significant interaction effect between irrigation with 0.05% chlorhexidine gluconate and antibiotic administration time existed, such that infection occurrence in the treatment group was not dependent on antibiotic timing, as opposed to the control group infection occurrence, which was dependent on antibiotic timing.

Conclusion

Intraoperative irrigation with 0.05% chlorhexidine gluconate during caesarean delivery did not statistically significantly reduce the rate of infections. It did render the impact of antibiotic administration timing irrelevant in prevention of surgical site infection. This suggests a role for 0.05% chlorhexidine gluconate irrigation in mitigating infection risk whether antibiotic prophylaxis timing is suboptimal or ideal.