ALEXIS O-Ring wound retractor vs conventional wound protection for the prevention of surgical site infections in colorectal resections(1)

Role of wound protectors in preventing surgical site infection in patients undergoing abdominal surgery: a meta-analysis of randomized controlled trials

OBJECTIVE

To investigate the role of wound protectors (WPs) in surgical site infection (SSI) prevention in patients undergoing abdominal surgery.

BACKGROUND

Despite practitioners having pursued the ultimate aim of "getting to zero" for centuries, SSI is still a global healthcare burden. WPs are thought to be able to prevent the incision from bacterial contamination, however, contradictory results have been reported.

METHOD

A meta-analysis was performed to compare the SSI rate in patients with and without WPs after abdominal surgery. It includes subgroup analysis of the SSI rate in different surgical sites and different degrees of wound contamination. A systematic literature search was conducted in the PubMed, Embase, Cochrane Library databases, and Web of Science from their respective inceptions until July 6, 2024. All randomized controlled trials with consistent definitions of SSI were included. The bias of each included RCT was assessed by using the Cochrane Risk of Bias 2. To evaluate the risks of random errors resulting from repeated significant testing, a trial sequential analysis was performed. The quality of evidence was assessed by using GRADEpro Guideline Development Tool.

RESULTS

A total of 4779 participants were involved in the 19 RCTs. The results showed that the application of WPs during abdominal surgery could significantly reduce the SSI rate (RR = 0.63, 95% CI: 0.50-0.80, P = 0.0001, very low certainty evidence). Subgroup analysis showed that the implementation of WPs significantly reduced the SSI rate after colorectal and gastrointestinal surgery (RR = 0.58, 95% CI: 0.38-0.91, P = 0.02, very low certainty evidence; RR = 0.49, 95% CI: 0.36-0.67, P < 0.00001, moderate certainty evidence, respectively), while had no clear protect role in other types of abdominal surgery. The WPs significantly reduced the SSI rate in patients with a clean-contaminated wound (RR = 0.64, 95% CI: 0.46-0.89, P = 0.008, very low certainty evidence) and contaminated or dirty wound (RR = 0.61, 95% CI: 0.41-0.92, P = 0.02, moderate certainty evidence), respectively.

CONCLUSIONS

The results indicated that the WPs should not be used indiscriminately in all abdominal but gastrointestinal surgery. For patients with contaminated or dirty incisions, WPs should be considered. More studies are needed to determine the effect of WPs in laparoscopic surgery.

CLINICAL TRIAL NUMBER

Not applicable.

Prophylactic PICO◊ dressing shortens wound dressing requirements post emergency laparotomy (EL-PICO◊ trial)

BACKGROUND

Surgical site infection (SSI) is a very common complication of emergency laparotomy and causes significant morbidity. The PICO◊ device delivers negative pressure wound therapy (NPWT) to closed incisions, with some studies suggesting a role for prevention of SSI in heterogenous surgical populations. We aimed to compare SSI rates between patients receiving PICO◊ versus conventional dressing post-emergency laparotomy. Secondary objectives were to observe seroma and dehiscence rates, length of stay, days on dressing and patients' wound experience.

METHODS

This double blinded randomized controlled trial was conducted in University Malaya Medical Centre between October 2019 and March 2022. Patients undergoing emergency laparotomy requiring incisions less than 35 cm were included. Statistical analysis was performed using χ2 test for categorical variables, independent T-test or Mann-Whitney U were used for parametric or non-parametric data respectively besides logistic regression. P values of < 0.05 were considered to be significant.

RESULTS

Ninety-six patients were analyzed (47 interventions, 49 controls). The duration on dressing was more consistent in the intervention arm (PICO◊) versus control arm [9.78 ± 10.20 vs 17.78 ± 16.46 days, P < 0.001]. There was a trend towards lower SSI [14.3 vs 4.3%, P = 0.09], dehiscence [27.1 vs 10.6%, P = 0.07] and seroma [40.8 vs 23.4%, P = 0.08] rates in the intervention arm but this did not reach statistical significance. Length of stay [9 (IQR: 6-14) vs 11 (IQR: 6-22.5) days, P = 0.18] was fairly similar between the two arms, but more patients were very satisfied with PICO◊ compared to the conventional dressing [80% vs 57.1%, P = 0.03].

CONCLUSION

The use of NPWT in emergency laparotomy improves patients wound care experience, and was associated with trends towards fewer wound related complications. Cost effectiveness needs to be explored in order to further validate its use in the emergency setting, especially for patients with additional risk for SSI. Trial registration National Medical Research Registry (NMRR): NMRR-20-1975-55222.

Surgical Site Infections in Colorectal Cancer Surgeries: A Systematic Review and Meta-Analysis of the Impact of Surgical Approach and Associated Risk Factors

BACKGROUND

Surgical site infections (SSIs) represent a noteworthy contributor to both morbidity and mortality in the context of patients who undergo colorectal surgery. Several risk factors have been identified; however, their relative significance remains uncertain.

METHODS

We conducted a meta-analysis of observational studies from their inception up until 2023 that investigated risk factors for SSIs in colorectal surgery. A random-effects model was used to pool the data and calculate the odds ratio (OR) and 95% confidence interval (CI) for each risk factor.

RESULTS

Our analysis included 26 studies with a total of 61,426 patients. The pooled results showed that male sex (OR = 1.45), body mass index (BMI) ≥ 25 kg/m2 (OR = 1.09), American Society of Anesthesiologists (ASA) score ≥ 3 (OR = 1.69), were all independent risk factors for SSIs in colorectal surgery. Conversely, laparoscopic surgery (OR = 0.70) was found to be a protective factor.

CONCLUSIONS

The meta-analysis conducted revealed various risk factors, both modifiable and non-modifiable, associated with surgical site infections (SSIs) in colorectal surgery. These findings emphasize the significance of targeted interventions, including optimizing glycemic control, minimizing blood loss, and using laparoscopic techniques whenever feasible in order to decrease the occurrence of surgical site infections in this particular group of patients.

Alexis® Orthopedic Protector Provides Wound Protection and Aids in Hypertrophic Scar Prevention in Total Hip Arthroplasty

PURPOSE

Total hip arthroplasty (THA) is one of the most widely performed orthopedic surgeries. Techniques for small skin incisions and preservation of muscles and tendons have been developed. However, avoiding skin complications and muscle damage due to forced deployment and surgical manipulation is challenging. This study aimed to investigate whether the use of Alexis® Orthopedic Protector (Applied Medical Resources Corp., Rancho Santa Margarita, CA, USA) affects postoperative outcomes.

METHODS

This was a retrospective cohort study including 118 patients who underwent primary THA by the same surgeon at our single institution between March 2021 and March 2023. Protectors were used alternately for each operation. Fifty-nine patients were in the protector-using group (P group), and 59 were in the nonprotector-using group (N group), with comparisons made between groups. Protectors were placed under the fascia in all patients.

RESULTS

Preoperative blood tests showed no difference in renal and hepatic function between the two groups. No differences in postoperative C-reactive protein (CRP) and creatine kinase (CK) values or in the Japanese Orthopedic Association Hip Disease Evaluation Questionnaire (JHEQ) and Numerical Rating Scale (NRS) scores were observed. Postoperative redness was significantly higher in the N group than in the P group (49.2% vs. 7%). The percentage of hypertrophic scars at three months postoperatively was 18.6% in the N group and 7% in the P group. Furthermore, the Japan Scar Workshop Scar Scale (JSS) indicated that hypertrophic scars were significantly worse in the N group than in the P group (p = 0.0012).

CONCLUSION

Alexis® Orthopedic Protectors can not only provide short-term wound protection but also reduce the rate and degree of hypertrophic scarring.

Alexis retractor efficacy in transthoracic thoracoscopically assisted discectomy for thoracic disc herniations

PURPOSE

A transthoracic anterior or lateral approach for giant thoracic disc herniations is a complex operation which requires optimal exposure and maximal visualisation. Traditional metal rigid retractors may inflict significant skin trauma especially with prolonged operative use and limit the working angles of endoscopic instrumentation at depth. We pioneer the use of the Alexis retractor in transthoracic thoracoscopically assisted discectomy for the first time.

METHODS

The authors describe and demonstrate the technical use of the Alexis retractor during operative cases. Patient positioning, clinical rationale and operative nuances are elucidated for readers to gain an appreciation of the transthoracic approach to thoracic disc herniations.

RESULTS

The advantages of the Alexis retractor include minimally invasive circumferential flexible retraction, facilitation of bimanual instrument use, diminished risk of surgical site infections and reduced rib retraction leading to less postoperative pain.

CONCLUSION

Use of the flexible and intuitive Alexis retractor maximises operative exposure and is an effective adjunct when performing complex transthoracic approaches for thoracic disc herniations.

Comparison of the Ventral Approach to the Canine Hip Joint Using Gelpi Retractors and an Elastic O-Ring Wound Retractor

This study included 10 fresh adult cadavers of large breed dogs (6 males and 4 females). Their weight ranged from 25 to 45 kg (mean ± SD: 33.9 ± 6.2 kg). The breeds represented were crossbreed dogs (n = 5), German shepherds (n = 2), Bernese mountain dogs (n = 1), American Staffordshire terriers (n = 1), and Gordon setters (n = 1). Access to the target area and identification of the femoral head and neck was achieved with two Gelpi retractors inserted orthogonally and with the O-WR in all procedures. In each dog, the approach to the hip joint was made on the left and right sides. There was no significant difference in the area of the surgical wound bed between the two sides using either the Gelpi retractors (-0.52 ± 1.87 cm2; CI 95%: -1.86, 0.81 cm2; p = 0.398) or the O-WR (-0.27 ± 2.34 cm2; CI 95%: -1.94, 1.41 cm2; p = 0.729). The area of the surgical wound bed was 6.28 ± 1.72 cm2 (2.72-9.70 cm2) for the Gelpi retractors and 6.34 ± 1.81 cm2 (4.13-10.77 cm2) for the O-WR, and the difference between the Gelpi retractors and the O-WR was not significant (-0.06 ± 1.72 cm2; CI 95%: -0.86, 0.74 cm2; p = 0.879).

Effect of wound protectors in reducing the incidence of surgical site wound infection in lower gastrointestinal surgery: A meta-analysis

We performed a meta-analysis to evaluate the effect of wound protectors in reducing the incidence of surgical site wound infection in lower gastrointestinal surgery. A systematic literature search up to June 2022 was performed and 6026 subjects with lower gastrointestinal surgery at the baseline of the studies; 3090 of them were using the wound protector, and 2936 were using no wound protector. Odds ratio (OR) with 95% confidence intervals (CIs) were calculated to assess the effect of wound protectors in reducing the incidence of surgical site wound infection in lower gastrointestinal surgery using the dichotomous methods with a random or fixed-effect model. The surgical site wound infection was significantly lower with single-ring wound protectors (OR, 0.53; 95% CI, 0.39-0.83, P = .004), and dual-ring wound protectors (OR, 0.44; 95% CI, 0.35-0.56, P < .001) in subjects with lower gastrointestinal surgery compared with no wound protector. The surgical site wound infection was significantly lower with single-ring wound protectors, and dual-ring wound protectors in subjects with lower gastrointestinal surgery compared with no wound protector. The analysis of outcomes should be with caution because of the low sample size of 5 out of 28 studies in the meta-analysis and a low number of studies in certain comparisons.

Alexis O-ring wound retractor versus traditional metal retractors for the prevention of postcaesarean surgical site infections

BACKGROUND

Postcaesarean surgical site infections (SSI) remain a burden globally. The Alexis® O C-Section Retractor, a plastic sheath retractor known to have decreased incidence of SSIs in gastrointestinal surgery, is yet to have its efficacy established during caesarean section (CS). This study aimed to compare the differences in the rate of postcaesarean surgical wound site infections between the Alexis® retractor and traditional metal retractors during CS at a large tertiary hospital in Pretoria.

METHODS

Pregnant women scheduled for elective CS were prospectively randomised to either the Alexis® retractor group or the traditional metal retractor group at a tertiary hospital in Pretoria between August 2015 and July 2016. The defined primary outcome was development of SSI, and secondary outcomes comprised patients' peri-operative parameters. All participants' wound sites were observed in the hospital for 3 days before discharge and again at 30 days postpartum. Data were analysed using SPSS version 25 with p  0.05 considered significant.

RESULTS

A total of 207 participants were involved, Alexis® (n = 102) and metal retractors (n = 105). None of the participants developed postsurgical site wound infection after 30 days, and there were no differences in time to delivery, total operative time, estimated blood loss or postoperative pain between the two arms of study.

CONCLUSION

The study found no difference in participants' outcomes using the Alexis® retractor in comparison with the traditional metal wound retractors. We suggest that the use of Alexis® retractor be at the surgeon's discretion and its routine use not advised for now.Contribution: This research being the first of its kind in South Africa in which patients' clinical outcomes were compared post caesarean section from Alexis's plastic sheath group and metal retractors group in an attempt to proffer solution to the high burden of SSI. Although no difference was seen at this point, the research was pragmatic, as it was carried out in a setting with high burden of SSI. The study is going to serve as a baseline against which studies carried out in future can be compared.

Role of single or double ringed circumferential wound protectors in reducing surgical site infections following colorectal resections. A systematic review

Objective

The objective of this article is to explore whether the use of single or double ringed wound protectors (WP) in patients undergoing colorectal resection (CRR) are associated with reduced risk of surgical site infections (SSI).

Materials and methods

Analysis was conducted according to PRISMA guidelines. With the help of expert local librarians, systematic search of medical databases like MEBASE, MEDLINE and PubMed was conducted to find appropriate randomized controlled trials (RCT) according to predefined inclusion criteria. The analysis of the pooled data was done using the principles of meta-analysis on statistical software RevMan version 5.

Result

Twelve RCT on 2425 patients fulfilled the inclusion criteria. There were 1216 patients in the WP group and 1209 patients in the no-WP group. In the random effects model analysis, the use of WP during CRR was associated with the reduced risk of SSI [odds ratio 0.60, 95% CI (0.41–0.90), z = 2.49, P = 0.01]. However, there was significant heterogeneity (Tau² = 0.22; Chi² = 25.87, df = 11; (p = 0.007; I² = 57%) among included studies.

Conclusion

Use of WP seems to reduce the risk of SSI and therefore, may routinely be used during both open and laparoscopic CRR.

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Surgical site infections (SSIs) are a frequent complication following major abdominal surgery.

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The aim is to assess the effectiveness of using wound protectors in decreasing post operative SSIs in colorectal resection.

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Twelve RCTs were used to obtain the submitted data.

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Using wound protectors was associated with reduced post operative SSIs in colorectal resections.

Surgical site infections: a scoping review on current intraoperative prevention measures

INTRODUCTION

Surgical site infections (SSIs) remain a significant cause of morbidity for surgical patients worldwide and with growing rates of antibiotic resistance, the development of new nonantimicrobial techniques to target SSI reduction is crucial. This review aimed to explore available nonantibiotic intraoperative interventions to reduce the risk of SSI.

METHODS

A literature search was undertaken using Medline, Web of Science, Embase, and Cochrane Library databases. Any study published from 1 January 1980 to 1 September 2021 that described any nonantibiotic intraoperative physical technique aiming to reduce SSI rates, with a primary or secondary outcome of SSI rates, was included.

FINDINGS

A total of 45 articles were included in the final scoping review. The current nonantibiotic intraoperative interventions advised for use include chlorhexidine skin preparation with alcohol, pressurised wound irrigation, Triclosan-coated sutures for skin closure, and negative pressure wound therapy. Many other widely used surgical practices do not have the supporting evidence to validate their routine use in clinical practice to reduce SSI rates.

CONCLUSIONS

We identified several techniques that can be used in the operating theatre to provide additional opportunities to reduce SSI rates. However, strict adherence to current established SSI prevention guidelines remains the mainstay of ensuring SSI rates remain low.

Colorectal Surgery in Critically Unwell Patients: A Multidisciplinary Approach

A proportion of patients require critical care support following elective or urgent colorectal procedures. Similarly, critically ill patients in intensive care units may also need colorectal surgery on occasions. This patient population is increasing in some jurisdictions given an aging population and increasing societal expectations. As such, this population often includes elderly, frail patients or patients with significant comorbidities. Careful stratification of operative risks including the need for prolonged intensive care support should be part of the consenting process. In high-risk patients, especially in setting of unplanned surgery, treatment goals should be clearly defined, and appropriate ceiling of care should be established to minimize care that is not in the best interest of the patient. In this article we describe approaches to critically unwell patients requiring colorectal surgery and how a multidisciplinary approach with proactive intensive care involvement can help achieve the best outcomes for these patients.

Technique for transvaginal removal of large specimen using an Alexis Contained Extraction System during laparoscopic hysterectomy

Objective

Transvaginal removal of large specimens during laparoscopic hysterectomy can be a complex surgical procedure that poses a risk of organ injury and tissue spillage into the abdominal cavity and is associated with extraction of the specimen and manual morcellation. Our objective was to demonstrate a technique for transvaginal removal of large specimens using the Alexis Contained Extraction System (CES) in laparoscopic hysterectomy.

Methods

The technique used for transvaginal removal of large specimens using the Alexis CES was presented in this video. Surgery was performed at a tertiary hospital.

Results

Following resection of the specimen during laparoscopic hysterectomy, the Alexis CES was inserted into the abdominal cavity through the umbilical trocar wound. The specimen was placed in a bag to prevent tissue spillage. The ring retractor was guided to the vagina and pulled out transvaginally. By repeatedly turning the ring retractor, tension was applied to the specimen bag, and the vaginal wall was unfolded all around to enable a secure surgical field. During manual morcellation of the specimen in the bag, the retractor was pulled and additionally turned to roll and re-tension the specimen bag when the bag was loosened. The specimen was pushed out of the vagina and safely and effectively extracted without concerns about tissue spillage in the abdominal cavity or related organ injuries.

Conclusion

The technique for transvaginal removal of large specimens using the Alexis CES enables simple, effective, and safe tissue extraction with contained manual morcellation during laparoscopic hysterectomy.

OUP accepted manuscript

Background

Surgical site infection (SSI) is a common complication after abdominal surgery. The effectiveness of wound edge protectors in reducing infection of the surgical sites is still unclear. The purpose of this study was to determine the clinical effectiveness of a wound edge protector (WEP) in reducing SSI rates after abdominal surgery.

Methods

PubMed, Embase, Web of Science, and the Cochrane Library were systematically searched to obtain relevant articles published up to September 2021. Publications were retrieved if they contain primary data on the use of WEPs in reducing SSI compared with standard care in patients undergoing abdominal surgery. Subgroup analyses were performed for different WEP types, surgical sites, and levels of contamination. The outcome of interest was a clinically defined SSI. Qualitative variables were pooled using risk ratios (RRs).

Results

Twenty-two eligible randomized clinical trials involving 4492 patients were included in this meta-analysis. WEP was associated with the reduced incidence of overall SSI (RR = 0.66; 95 per cent c.i. 0.53 to 0.83; P = 0.0003), and superficial SSI (RR = 0.59; 95 per cent c.i. 0.38 to 0.91; P = 0.02). In addition, WEP also successfully reduced the risk of SSI in clean-contaminated wounds (RR = 0.61; 95 per cent c.i. 0.40 to 0.93; P = 0.02) as well as in contaminated wounds (RR = 0.47; 95 per cent c.i. 0.33 to 0.67; P < 0.0001); however, WEP did not reduce SSI incidence in colorectal surgery (RR = 0.68; 95 per cent c.i. 0.46 to 1.01; P = 0.05).

Conclusion

This study suggests that WEP was efficient in reducing superficial SSI. Both double-ringed and single-ringed devices were efficient in reducing SSI. WEP was effective in reducing SSI incidence in clean-contaminated and contaminated surgery; however, its use does not reduce the SSI rate in colorectal surgery.

Cost analysis of utilising wound edge protector in open appendicectomy to prevent surgical site infection

Background

The rate of surgical site infection (SSI) differ with variable nature with appendicitis with a global incidence of up to 11%. Several randomised trials describe a significant reduction in incisional SSI using wound edge protectors (WEP), mainly in elective procedures. This study was designed to analyse WEP use in emergency open appendicectomy.

Method

This randomised controlled trial enrolled 200 patients who underwent emergency open appendicectomy. Permuted block randomisation was used to assign subjects to either mechanical retraction or double ring WEP. The primary endpoints were SSI rates and cost analysis between the methods.

Results

The incidence of SSI was similar, n = 7 (7.4%) in the control group and n = 8 (8.4%) in the WEP group, and demonstrates no statistically significant difference (p > 0.05). Cost analysis showed a statistically significant (p < 0.001) higher total cost in the WEP group, MYR 456.00 (414.75, 520.00) as compared to the control group, MYR 296.00 (296.00, 300.00). However, the median cost of managing patients complicated with SSI was significantly lower at MYR 750.50 (558.75, 946.50) in the WEP group when compared to the control group MYR 1453.00 (1119.00, 2592.00) (p = 0.008).

Conclusion

The use of WEP does not reduce the incisional SSI rate, and it is not cost-effective for application in all open appendicectomies. However, when faced with incisional SSI, the use of WEP had a significantly lower cost in incisional SSI management. Selective WEP use is economical in clinically suspected perforated appendicitis when laparoscopic appendicectomy approach is unsuitable.

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Wound edge protector use does not reduce the SSI rate in emergency open appendicectomy.

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It is economical for management of incisional SSI with use of wound edge protector used for open appendicectomy.

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Selective use of wound edge protector in clinically suspected perforated appendicitis would be more cost-effective.

Initial Outcomes of a Novel Irrigating Wound Protector for Reducing the Risk of Surgical Site Infection in Elective Colectomies

BACKGROUND

Surgical site infection (SSI) rates in elective colorectal surgery remain high due to intraoperative exposure of colonic bacteria at the surgical site. We aimed to evaluate 30-day SSI outcomes of a novel wound retractor that combines barrier protection with continuous wound irrigation in elective colorectal resection.

MATERIALS AND METHODS

A retrospective single-center cohort-matched analysis included all patients undergoing elective colorectal resection utilizing the novel irrigating wound protector (IWP) from April 2015 to July 2019. A control cohort of patients who underwent the same procedures with a standard wound protector over the same time period were also identified. Patients from both groups were matched for procedure type, procedure approach, pathology requiring operation, age, sex, race, body mass index, diabetes, smoker status, hypertension, presence of disseminated cancer, current steroid or immunosuppressant use, wound classification, and American Society of Anesthesiologist classification. SSI frequency, SSI subtype (superficial, deep, or organ space), hospital length of stay (LOS) and associated procedure were tabulated through 30 postoperative days. Fisher's exact test and number needed to treat (NNT) were used to compare SSI rates and estimate cost between both groups.

RESULTS

The IWP group had 41 patients. The control group had 82 patients. Control-matched variables were similar for both groups. 30-day SSI rates were significantly lower in the IWP group (P=0.0298). length of stay was significantly shorter in the IWP group (P=0.0150). The NNT for the IWP to prevent one episode of SSI was 8.2 patients.

CONCLUSIONS

The novel IWP device shows promise to reducing the risk of SSI in elective colorectal surgery.

The Japan Society for Surgical Infection: guidelines for the prevention, detection, and management of gastroenterological surgical site infection, 2018

BACKGROUND

The guidelines for the prevention, detection, and management of gastroenterological surgical site infections (SSIs) were published in Japanese by the Japan Society for Surgical Infection in 2018. This is a summary of these guidelines for medical professionals worldwide.

METHODS

We conducted a systematic review and comprehensive evaluation of the evidence for diagnosis and treatment of gastroenterological SSIs, based on the concepts of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The strength of recommendations was graded and voted using the Delphi method and the nominal group technique. Modifications were made to the guidelines in response to feedback from the general public and relevant medical societies.

RESULTS

There were 44 questions prepared in seven subject areas, for which 51 recommendations were made. The seven subject areas were: definition and etiology, diagnosis, preoperative management, prophylactic antibiotics, intraoperative management, perioperative management, and wound management. According to the GRADE system, we evaluated the body of evidence for each clinical question. Based on the results of the meta-analysis, recommendations were graded using the Delphi method to generate useful information. The final version of the recommendations was published in 2018, in Japanese.

CONCLUSIONS

The Japanese Guidelines for the prevention, detection, and management of gastroenterological SSI were published in 2018 to provide useful information for clinicians and improve the clinical outcome of patients.

Post-operative Glycaemic Control Using an Insulin Infusion is Associated with Reduced Surgical Site Infections in Colorectal Surgery

BACKGROUND

The incidence of surgical site infection (SSI) in colorectal surgery (CRS) is higher than other forms of general surgery. Post-operative hyperglycaemia causes increased SSI in CRS. Post-operative hyperglycaemia control in cardiac surgery reduces SSI. The aim was to evaluate using a cohort comparison the effect of post-operative glycaemic control using an insulin infusion on SSI in CRS.

METHODS

Collection of data for the ACS-NSQIP was commenced in 2015. The CRS unit added post-operative glycaemic control to the SSI bundle in late 2016. The intervention was an insulin infusion to titrate blood glucose between 135 and 180 mg/Dl (7.5 and 10 mmol/l). The effect of glycaemic control on SSI was assessed comparing ACS-NSQIP raw data prior and after the intervention was commenced.

RESULTS

The NSQIP data from July 2015 to June 2016 revealed the incidence of SSI were 25%. From January 2017 to December 2017, there was a significant reduction in SSI to 6.1% (OR = 517 Cl = 1.92-16.08, p < 0.001). The incidence of organ/space SSI fell significantly from 13% to 1.0% (OR = 11.35, Cl = 1.62-488.7, p < 0.001). There was non-significant reduction in superficial SSI from 11 to 4.0% (OR = 2.93, Cl = 0.68-13.03, p = 0.06). There was no significant difference in other factors associated with SSI in CRS.

CONCLUSION

Post-operative glycaemic control in CRS reduces the rate of SSI. Post-operative glycaemic control should be included in SSI bundles for CRS and may be of benefit in other surgical specialties.

Usefulness of a circumferential wound retractor in emergency colorectal surgery as a preventive measure for surgical site infection. Alexis O-Ring® and emergency surgery

INTRODUCTION AND AIMS

More than 20% of healthcare-associated infections correspond to those at surgical sites, and there is a higher incidence of infections in colorectal surgery due to the associated bacterial load. Surgical wound protectors are designed to prevent contamination and mechanical trauma. Our aim was to demonstrate the usefulness of a circumferential wound retractor/protector for the prevention of surgical site infections (SSIs) in emergency colorectal surgery.

METHODS

Forty-one patients that underwent emergency open surgery at a tertiary care hospital were randomized into 2 groups: 20 cases without the retractor (group A) and 21 cases with the retractor (group B). Subjects were assigned to a group in a 1:1 randomization allocation ratio. The chi-square and Fisher's exact tests were employed for the quantitative variables, and the statistical analysis was performed using the IBM Statistical Package for the Social Sciences software for Mac, version 16.0 (IBM SPSS Inc., Chicago, IL, USA).

RESULTS

The SSI rate was 17%. Six group A patients developed SSI versus one group B patient. The use of a circumferential wound retractor/protector was statistically significant for the prevention of surgical wound infections, with a P=.031 and an OR of 8.5. In addition, preoperative blood glucose levels below 200mg/dl provided a 3.2-times higher protective effect, compared with glucose levels above 200mg/dl.

CONCLUSIONS

In the present prospective randomized pilot study, the use of the circumferential wound retractor/protector significantly decreased the likelihood of SSI in emergency colorectal surgery.

A novel prevention bundle to reduce incisional infections after radical cystectomy

PURPOSE

Our institution implemented a novel intervention bundle to reduce incisional surgical site infections (SSIs) for patients undergoing radical cystectomy. The primary objective of this study was to evaluate the efficacy of the bundle in reducing incisional SSIs post-cystectomy.

MATERIAL AND METHODS

A before-after cohort study was performed on all patients who underwent radical cystectomy by urologic oncologists at The Ottawa Hospital from January 2016 to March 2019. Thirty-day postoperative incisional SSIs were identified from the medical record and were compared to institutionally collected National Surgical Quality Improvement Program data. The SSI reduction strategy was implemented as of March 1st, 2018. Adjusted associations between the SSI intervention with the risk of incisional SSI were determined. Cystectomy incisional SSI rates were compared to all other National Surgical Quality Improvement Program-collected surgeries at The Ottawa Hospital during the same time period.

RESULTS

One hundred and thirty-two patients were included; 41 following implementation of the SSI reduction bundle. Mean age was 69 years, 104 (79%) were male, and 59 (45%) received neobladders. The risk of incisional SSI decreased from 16.5% preintervention to 2.4% post intervention (risk ratio 0.17; P = 0.004). Intraoperative transfusion and diabetes were independently associated with an increased risk of incisional SSI (P < 0.05). The SSI rate for all other surgical procedures at our institution remained stable during the same time period.

CONCLUSIONS

The risk of SSI after radical cystectomy is high. Use of an SSI reduction bundle was associated with a large reduction in incisional SSIs. Further evaluation of this intervention in other centers is warranted.

O-Ring Protector in Prevention of SSIs in Laparoscopic Colorectal Surgery

Background:

Surgical-site infections (SSIs) remain a serious complication of colorectal surgery, causing a significant financial burden to the health care system. The aim of this study is to investigate whether the use of an O-ring retractor can be effective in preventing the incidence of wound infections after elective laparoscopic colorectal surgery.

Methods:

A retrospective case-control study from January 2014 to June 2018 was performed. Data were analyzed from a retrospective colorectal database. SSI was defined according to criteria published by the European Centre for Disease Prevention and Control and analyzed as a primary outcome.

Results:

Three hundred twelve consecutive patients (n = 312) were enrolled in our study. Among them, 158 patients (Group A) in which an O-ring retractor device was used during surgery was compared with a control group of 154 patients (Group B) in which an O-ring retractor device was not used. Primary outcome was to determine SSIs rates among the 2 groups. No statistically differences were observed with regard to baseline characteristics between both groups. A total of 9 patients (5.69%) and 24 (15.58%) with SSIs were identified in Group A and B, respectively, and the difference was statistically significant (OR, 0.32; 95% CI, 0.14–0.72; P = .0045). The median postoperative hospital stay length was 6.7 days in group A and 7.6 days in group B (P ≤ .05).

Conclusions:

SSIs infections rates were significantly higher in patients in which an O-ring retractor device was not used. This study suggests that the use of a wound protector device can be considered for routine use in elective colorectal surgery.

Alexis Retractor: Institutional Experience of Its Applications in Head and Neck Surgery and Review of the Literature

BACKGROUND

The Alexis retractor is a device that provides simultaneous radial retraction and wound protection during surgical procedures. Although typically used in abdominal and pelvic surgeries, there has been increased development of novel operative techniques utilizing the Alexis retractors in head and neck surgeries.

METHODS

We describe 2 cases of utilizing the Alexis retractor to attain transoral exposure in the setting of free flap reconstruction of intraoral defects.

RESULTS

In both cases, the Alexis retractor provided improved retraction, decreasing the number of instruments required for adequate exposure. Additionally, the polyurethane sheath component acted as a protective membrane over the lips and mucosa.

CONCLUSIONS

The Alexis retractor can be a powerful retraction tool for certain surgical procedures involving the head and neck regions.

Circular pOlyethylene drape in preVEntion of suRgical site infection (COVER trial): study protocol for a randomised controlled trial

INTRODUCTION

Surgical site infection (SSI) after abdominal surgery remains a significant cause of morbidity and is associated with an increased socioeconomic burden and a reduced quality of life. Circular wound protectors have been expected to reduce the risk of SSI, but previous studies reported conflicting results on their protective effects. The purpose of this study was to evaluate the efficacy of circular wound protectors in reducing SSI in open abdominal surgery.

METHODS AND ANALYSIS

The circular pOlyethylen drape in preVEntion of suRgical site infection (COVER) trial investigates whether the application of a dual-ring circular plastic wound protector reduces the rate of SSI in patients undergoing elective or emergent open abdominal surgery related to the gastrointestinal tract, regardless of the type of wound classified by the Centers for Disease Control. The COVER trial is a multicentre, randomised controlled clinical trial with two parallel arms-one using a dual-ring wound protector with circular polyethylene drape and the other using conventional surgical dressing gauze. The primary outcome will measure the rate of SSI within 30 days after surgery in two groups. Statistical analysis of the primary end point will be based on the intention-to-treat population. The sample size was determined to achieve a study power of 80% with 95% two-sided confidence limits. Considering a dropout rate of up to 5%, a total of 458 patients, 229 patients in each group, will be enrolled in this study.

ETHICS AND DISSEMINATION

The trial protocol and informed consent document have been reviewed and approved by the institutional review board at each participating centre. Written informed consent will be obtained from each study participant. The clinical outcomes of this trial will be submitted to an international peer-reviewed journal and presented at international conferences.

TRIAL REGISTRATION NUMBER

NCT03170843.

Impact of a Dual-Ring Wound Protector on Outcome After Elective Surgery for Colorectal Cancer

BACKGROUND

The impact of dual-ring wound protectors (DRWPs) on the long-term outcomes of patients with colorectal cancer (CRC) undergoing elective surgery remains unclear. The aim of this cohort study was to compare short- and long-term outcomes after CRC resection with or without use of a DRWP.

METHODS

This study enrolled 625 patients with stage I-III CRC undergoing curative resection and divided them into DRWP (n = 348) and control (n = 277) groups. Primary endpoints were postoperative short- and long-term complications. Secondary endpoints were oncological outcomes including wound recurrence, disease-free survival, and overall survival.

RESULTS

Rates of postoperative complications (P = 0.004) and laparotomy wound infection (LWI) (P < 0.001) were markedly lower in the DRWP group. Operation quality, as per the number of lymph nodes harvested and rate of R0 resection, did not differ between the groups (all P > 0.05). The DRWP group exhibited significantly lower rates of incisional hernia occurrence (5.3% versus 9.5%, P = 0.045) compared with the control group. Multivariable analyses demonstrated an increased risk of LWI with no wound protector in colorectal surgery (odds ratio, 3.778; P = 0.001), and patients who developed LWI after surgery were more than 4 times more likely to develop an incisional hernia during outpatient follow-up (odds ratio, 4.333; P = 0.001). One patient in the control group (0.36%) had isolated wound recurrence at 12 mo postoperatively.

CONCLUSIONS

Fewer postoperative and late complications, comparable oncological safety, and similar long-term clinical outcomes confirmed the benefits of DRWP use for patients with CRC undergoing elective surgery. Therefore, the use of DRWP may be considered in curative CRC resection.

Mini-invasive approach for removal of iliopsoas migrating grass awns with an atraumatic wound retractor

This case series describes a novel mini coeliotomy approach using a radial, atraumatic self-retaining retractor for the retrieval of migrant plant foreign bodies from the iliopsoas muscles of six male dogs under intra-operative ultrasonographic guidance. Four dogs had a history of pulmonary disease potentially compatible with inhalation of a foreign body approximately 2-4 months before presentation. Under ultrasonographic guidance, the grass awns were identified in the iliopsoas muscle and were completely removed. In this case series, the annular ring device provided an excellent view of the surgical field for intra-abdominal manipulations. Patient follow-up at 15 days and 6 to 12 months after surgery indicated a full recovery, and no grass awn fragment residues were identified.

Introduction of a self-holding retractor for optimized abdominal visualization in ventriculoperitoneal shunt surgery: first experiences at a single center

OBJECTIVE

Ventriculoperitoneal shunt implantation is a common procedure in general neurosurgery. The patient population is often fragile, ranging from elderly to pediatric patients, and avoidance of perioperative complication is of utmost importance. Abdominal catheter dislocation has been found to be a common cause for early shunt dysfunction and needs to be avoided by optimal visualization of the abdominal catheter insertion zone. Here, we introduce a self-holding wound retractor system Alexis® and demonstrate its use for abdominal shunt surgery in a series of patients.

METHODS

We explain the use of the Alexis® self-holding wound retractor during open ventriculoperitoneal shunt surgery in a series of 16 patients operated at our institution.

RESULTS

The self-holding retractor consists of two polymer rings connected by a polymer membrane. The deep ring is easily placed on the internal fascia of the straight muscle and circular retraction is achieved by twisting the upper ring. Free hand working can then be performed by a single surgeon with good abdominal exposure. No case of abdominal dislocation or infection occurred in our series, although no properly powered statistical analysis can be performed regarding the sample size.

CONCLUSION

We demonstrate the Alexis® Wound Retractor, which is an easy tool for optimal visualization of the abdominal catheter insertion zone. We believe it can facilitate surgical practice of shunt surgery, especially in obese patients.

Wound protectors for improved exposure in open hernia repair

INTRODUCTION

Achieving adequate surgical exposure is fundamental to good surgical practice. Traditionally, in the repair of ventral and open inguinal hernias, this has been accomplished with the aid of self-retaining retractors or by extending the incision length. We propose that using disposable wound protectors, surgical exposure will be improved for a given incision length in the repair of ventral and open inguinal hernias, compared to traditional methods.

METHOD

Through the use of an animal tissue model, we compared incisions of varying lengths and measured the dimensions of the exposure achieved with disposable wound protectors (Alexis™) and a Mollison self-retainer. We calculated the surface area and, therefore, exposure gained using the specified wound retraction devices and compared the results.

RESULTS

The average superficial surface area of wound with a self-retainer compared to the small and extra-small disposable wound protector was 2.65 cm² vs 2.27 cm² (small) and 2.2 cm² (extra-small) for 2 cm incision length, 3.6 cm² vs 4.93 cm² and 4.2 cm² for 3 cm incision length, 5.19 cm² vs 8.25 cm² and 6.27 cm² for 4 cm incision length, 6.17 cm² vs 12.25 cm² and 9.07 cm² for 5 cm incision length, and 8.75 cm² vs 16.73 cm² and 10.78 cm² for 6 cm incision length [p = 0.038 (small) and p = 0.049 (extra-small)]. Our results show a statistically significant increase in surface area of a wound for each incision length when a disposable wound protector was used for exposure, compared to a self-retainer.

CONCLUSION

Our results demonstrate that the use of disposable wound protectors provides superior surgical exposure for a given incision length compared to traditional techniques in the repair of ventral and open inguinal hernia repairs.

Interventions and Innovation to Prevent Surgical Site Infection in Colorectal Surgery: A Cost-Effectiveness Analysis

BACKGROUND

Surgical site infection (SSI), particularly in colorectal surgery, continues to cause substantial morbidity and cost. Both process- and product-based interventions have been proposed and implemented. No cost-effectiveness analysis of such interventions has been published.

MATERIALS AND METHODS

This study used a decision-analytic model to evaluate the cost-effectiveness of strategies for the prevention of SSI. Costs, utilities, and transition probabilities were obtained from literature review. We used a lifetime time horizon, captured with explicit event modeling for a year plus quantification of enduring health outcomes. We represented costs in 2017 US dollars and health effects in Quality-Adjusted Life Years (QALYs). Deterministic and probabilistic sensitivity analyses were performed.

RESULTS

Both process- and device-based strategies were dominant-clinically superior and also less expensive-compared with no intervention. Two types of double-ring wound protection barrier devices with greater anticontamination functionality were found to be both clinically superior and cost-saving compared with bundled process measures and simpler single-ring devices. Gains in QALYs were 230 per 1000 patients, and cost savings were 2.2 million dollars per 1000 patients, driven primarily by the high cost of SSI.

CONCLUSIONS

We found process-based interventions and wound protection devices to be superior to no intervention in the prevention of SSI. Double ring devices offered a distinct advantage over simpler devices, with small reductions in SSI risk leading to substantial cost savings. Further innovation in device-based wound protection devices may offer increased prevention of SSI at acceptable cost-effectiveness levels.

Alexis Wound Retractor for Radical Cystectomy: A Safe and Effective Method for Retraction

Surgical site infection rates remain a common postoperative problem that continues to affect patients undergoing urologic surgery. Our study seeks to evaluate the difference in surgical site infection rates in patients undergoing open radical cystectomy when comparing the Bookwalter vs. the Alexis wound retractors. After institutional review board approval, we performed a retrospective chart review from February 2010 through August 2017 of patients undergoing open radical cystectomy with urinary diversion for bladder cancer. We then stratified the groups according to whether or not the surgery was performed with the Alexis or standard Bookwalter retractor. Baseline characteristics and operative outcomes were then compared between the two groups, with the main measure being incidence of surgical site infection as defined by the CDC. We evaluated those presenting with surgical site infections within or greater than 30 postoperatively. Of 237 patients who underwent radical cystectomy with either the Alexis or Bookwalter retractor, 168 patients were eligible to be included in our analysis. There was no statistical difference noted regarding surgical site infections (SSIs) between the two groups; however, the trend was in favor of the Alexis (3%) vs. the Bookwalter (11%) at less than 30 days surgery. The Alexis wound retractor likely poses an advantage in reducing the incidence in surgical site infections in patients undergoing radical cystectomy; however, multicenter studies with larger sample sizes are suggested for further elucidation.

Use of Alexis retractor in thyroid and parathyroid surgery

In thyroid and parathyroid surgical procedures, good visibility of the thyroid gland is essential. This is traditionally achieved by means of traction sutures of the dermo-plastysmal flaps to the drapes of the operative field, producing tension and even damage to the skin. The Alexis^® retractor ring improves exposure and facilitates stable access to the thyroid, protecting the skin from injury during the intervention.

Dual Ring Wound Protector Reduces Circular Stapler Related Surgical Site Infections in Patients Undergoing Laparoscopic Roux-En-Y Gastric Bypass

BACKGROUND

While there are various techniques to create the gastrojejunostomy during a laparoscopic Roux-en-Y gastric bypass (LRYGB), many surgeons prefer using a circular stapler. One drawback of this method, however, is the higher incidence of surgical site infections (SSIs). To investigate the effect of a dual ring wound protector on SSIs during LRYGB.

METHODS

In April 2016, our bariatric surgical group implemented an intervention whereby a dual ring wound protector in conjunction with a conical EEA stapler introducer was used when creating the gastrojejunostomy. SSIs from pre- and post-intervention were compared using Fisher's exact test. Only LRYGBs performed with a circular stapler were included in our analysis. Student's t test and χ2 were used to compare pre- and post-intervention groups with respect to demographics and co-morbidities.

RESULTS

Between April 2015 and January 31st, 2017, our surgeons performed 158 LRYGBs using a circular stapler for the gastrojejunostomy. There were 84 patients (53%) in the pre-intervention group and 74 (47%) in the post-intervention group. The pre- and post-intervention groups were not statistically different. The SSI rate for the pre-intervention group was 9.5% while the SSI rate was 1.35% in the post-intervention group (p = 0.0371). The use of a dual ring wound protector for LRYGBs with circular stapled gastrojejunostomy was associated with an 86% relative risk reduction in SSIs.

CONCLUSION

Using a dual ring wound protector in conjunction with a conical EEA introducer for LRYGBs with circular stapled gastrojejunostomy significantly decreased SSIs.

The Benefits of a Wound Protector in Preventing Incisional Surgical Site Infection in Elective Open Digestive Surgery: A Large-Scale Cohort Study

BACKGROUND

The objective of this study was to evaluate the benefits of wound protectors (WPs) in preventing incisional surgical site infection (I-SSI) in open elective digestive surgery using data from a large-scale, multi-institutional cohort study.

METHODS

Patients who had elective digestive surgery for malignant neoplasms between November 2009 and February 2011 were included. The protective value of WPs against I-SSI was evaluated.

RESULTS

A total of 3201 patients were analyzed. A WP was used in 1022 patients (32%). The incident rate of I-SSI (not including organ/space SSI) was 9%. In the univariate and the multivariate analyses for perioperative risk factors for I-SSI, the use of WP was an independent favorable factor that reduced the incidence of I-SSI (odds ratio 0.73, 95% confidence interval 0.55-0.98. P = 0.038). The subgroup forest plot analyses revealed that WP reduced the risk of I-SSI only in patients aged 74 years or younger, males, non-obese patients (body mass index <25 kg/m²), patients with an American Society of Anesthesiologists score of 1/2, patients with a previous history of laparotomy, non-smokers, and patients who underwent colon and rectum operations. In patients who underwent colorectal surgery, the postoperative hospital stay was significantly shorter in patients with WP than those without WP (median 13 vs. 15 days, P = 0.040). In terms of the depth of SSI, WP only prevented superficial I-SSI and did not reduce the incidence of deep I-SSI.

CONCLUSIONS

WP is a useful device for preventing superficial I-SSI in open elective digestive surgery.

TRIAL REGISTRATION NUMBER

UMIN000004723.

Wound-edge protection devices in gastrointestinal surgery: a meta-analysis

BACKGROUND

The role of wound-edge protection devices (WEPDs) in wound infection prevention is still controversial. The aim of this meta-analysis was to assess the protective efficiency of WEPDs in gastrointestinal surgery in a pooled analysis of randomized controlled trials.

MATERIALS AND METHODS

A variety of sources were searched for randomized controlled trials evaluating the protective efficiency of WEPDs in gastrointestinal surgery. Subgroup analysis and meta-regressions were conducted to investigate the possible influence of the type of WEPD on the size of intervention effect. This review was conducted in accordance with a prespecified protocol based on the guidance of the Cochrane Handbook and Preferred Reporting Items for Systematic Reviews and Meta-analyses statement.

RESULTS

Sixteen studies with 3663 patients were included. The WEPDs usage led to a significant decrease in surgical wound infection (risk ratio [RR] = 0.64; 95% confidence interval [CI]: 0.46-0.87; P = 0.005; I² = 63%), with the dual-ring design usage yielding a more significant reduction in surgical wound infection (RR = 0.24; 95% CI: 0.11-0.50; P = 0.0002; I² = 29%), whereas the single-ring design usage yielding a nonsignificant result (RR = 0.78; 95% CI: 0.58-1.04; P = 0.09; I² = 53%).

CONCLUSIONS

Double-ring WEPD, but not single-ring design, reduces wound infection rate significantly in gastrointestinal surgery. Therefore, the use of single-ring WEPD should be reconsidered.

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.

Impact of a surgical site infection reduction strategy after colorectal resection

AIM

This study was performed to determine the impact of a surgical site infection (SSI) reduction strategy on SSI rates following colorectal resection.

METHOD

American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data from 2006-14 were utilized and supplemented by institutional review board-approved chart review. The primary end-point was superficial and deep incisional SSI. The inclusion criterion was colorectal resection. The SSI reduction strategy consisted of preoperative (blood glucose, bowel preparation, shower, hair removal), intra-operative (prophylactic antibiotics, antimicrobial incisional drape, wound protector, wound closure technique) and postoperative (wound dressing technique) components. The SSI reduction strategy was prospectively implemented and compared with historical controls (pre-SSI strategy arm). Statistical analysis included Pearson's chi-square test, and Student's t-test performed with spss software.

RESULTS

Of 1018 patients, 379 were in the pre-SSI strategy arm, 311 in the SSI strategy arm and 328 were included to test durability. The study arms were comparable for all measured parameters. Preoperative wound class, operation time, resection type and stoma creation did not differ significantly. The SSI strategy arm demonstrated a significant decrease in overall SSI rates (32.19% vs 18.97%) and superficial SSI rates (23.48% vs 8.04%). Deep SSI and organ space rates did not differ. A review of patients testing durability demonstrated continued improvement in overall SSI rates (8.23%).

CONCLUSION

The implementation of an SSI reduction strategy resulted in a 41% decrease in SSI rates following colorectal resection over its initial 3 years, and its durability as demonstrated by continuing improvement was seen over an additional 2 years.

An Alternative Use of Wound Retractor as Camera Trocar in Thoracoscopic Surgery

Trocars used during video-assisted thoracic surgery (VATS) present some technical disadvantages due to their rigid structure. We propose the use of an extra-small wound retractor system, designed for general surgery, as alternative to rigid trocar for camera port during VATS. In our experience the wound retractor presents 5 objective advantages: reduces intercostal nerve compression and skin injuries, improves the camera maneuverability, does not displace during operation, and protects the camera by any small parietal bleeding.

The use of the Alexis(®) device in breast augmentation to improve outcomes: a comparative randomized case-control survey

BACKGROUND

We present our experience in using a disposable wound retractor commonly used in abdominal surgery named Alexis(®) (Applied Medical Resources Corporation, Rancho Santa Margarita, CA, USA), during breast augmentation in order to improve outcomes, particularly final scar length.

METHODS

Between January 2010 and November 2012, 40 patients undergoing breast augmentation with an inframammary approach were enrolled in the present study. Patients were randomly assigned to two groups: group 1 underwent breast augmentation with the standard technique; group 2 underwent breast augmentation by using the Alexis(®) (Applied Medical Resources Corporation) device. Patients were followed-up for a 12-month period. The time of surgery, the days of drain duration and the length of the incisions were recorded for both groups and statistical significance was evaluated with the Wilcoxon rank sum test. Also, final scar appearance was evaluated using a visual analogue scale (VAS).

RESULTS

Patients in group 2 reported a lower incidence of hematomas and had shorter drain duration. The difference in scar length between the two groups was statistically significant (P<0.05). Surgeons and patients were mostly satisfied with the final appearance of the scar.

CONCLUSIONS

The use of the Alexis(®) (Applied Medical Resources Corporation) device has proven useful in reducing the length of the inframammary incision. Interestingly, the increased visibility obtained with the use of the Alexis device allowed a better hemostasis, as suggested by the shorter drain duration and lower incidence of hematomas. However, its use prolongs the operative time, for which we recommend surgeons to allow themselves some time to become familiar with the device.

LEVEL OF EVIDENCE

level I, evidence obtained from at least one properly designed randomized controlled trial.