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112 Part II Abdominal Wall
It has been suggested that a continuous, running closure
will result in a more durable wound than an interrupted
closure. e former may allow the more even distribution
of tension across the suture line with less resultant tissue
strangulation and wound disruption. e obvious disadvantage of a continuous closure is its dependence on a single
suture. e majority of studies comparing interrupted and
continuous closure, however, demonstrate similar incidences
of wound dehiscence, incisional hernia, wound infection,
25,27–30
wound pain, and suture sinus formation.
One recent
randomized trial compared interrupted and continuous closure with resorbable suture. No signicant dierence in the
rates of incisional hernia, dehiscence, or wound infection
was observed.
31
In summary, an evidence-based approach to laparotomy
closure narrowly favors the use of nonresorbable or slowly
resorbable suture in order to minimize the risk of hernia formation. e latter is preferred because of the lower-associated
risk of suture sinus formation and decreased postoperative
pain. A running closure is associated with either an equivalent or lower risk of hernia formation and, given the ease
and speed with which it can be performed, is to be preferred.
Importantly, undue tension should not be placed on the
running closure to avoid strangulation of the fascia.
Technique of Mass Closure
of the Abdomen
When closing a midline laparotomy incision, two size #0
looped or size #1 nonlooped slowly resorbable monolament sutures are generally used. One suture is anchored at
the upper extent and one at the lower extent of the wound.
A malleable retractor can be used to protect the underlying
viscera while the fascia is closed. e suture is run in a continuous manner, taking full-thickness bites of the linea alba
fascia incorporating both the anterior and posterior rectus
aponeuroses (Fig. 6-14). Sutures are passed through the fascia
a minimum of 1 cm from the wound edge at 1 cm intervals.
An assistant holds steady tensions on the suture while the
closure progresses. Repetitive relaxation and application of
tension of the suture is avoided to limit injury to the fascia.
Likewise, it is unnecessary and probably counterproductive
to overly tighten the suture as closure progresses, as this may
lead to fascial necrosis. is point has been illustrated in a
study associating evisceration and hernia formation with a
lower suture length to wound length ratio.
are run toward one another and then tied together in the
center of the wound.
33
e two sutures
A B
C D
FIGURE 6-14 Mass closure of the midline abdominal incision.
Chapter 6 Incisions, Closures, and Management of the Abdominal Wound 113
Skin Closure
A number of skin closure techniques can be used following clean (class I) or clean-contaminated (class II) operations; these include interrupted suture, subcuticular suture,
stapled, and adhesive glue. ree randomized-controlled
studies have compared stapled to subcuticular suture closures. Both techniques are associated with equivalent rates
34–36
of wound infection.
Two of the studies suggested that
subcuticular suture closure is associated with less postop-
34,36
erative pain than is stapled closure.
Two studies also
demonstrated a superior cosmetic result early following
suture closure; however, this dierence was insignicant by
6 months after operation.
35,36
Glues are used with increasing frequency for skin closure.
Advantages of glues include ease and rapidity of application
and simplication of wound care; generally, no additional
dressing is required. Closure with glues has been compared
to traditional skin closure methods in several clinical trials.
37,38
Wound durability appears to be comparable,
although
there are conicting data on cosmesis, and postoperative
38,39
pain.
If the surgical site is contaminated (class III or class
IV wound), the skin should be left open to heal by secondary
intention or by delayed primary skin closure.
40
Retention Sutures
e incidence of fascial dehiscence after major abdominal
operations is 1–3% and is associated with a mortality rate of
15–20%.
an increased risk of fascial dehiscence, including advanced
age, male gender, malnutrition, anemia, and steroids use;
however, local mechanical factors and closure technique
appear to have a greater inuence on the rate of dehiscence.
Placement of drains or ostomies through the main incision
compromises fascial integrity and should be avoided. Wound
sepsis and increased intra-abdominal pressure, whether from
ileus, bowel obstruction, atelectasis, or after hernia repair, also
compromise the integrity of a fascial closure. Indications for
prophylactic placement of retention sutures at initial operation
remain controversial. e purpose of retention sutures inthis
setting is to relieve tension along the suture line in order to
prevent signicant wound disruption and evisceration in the
patient at high risk.
closure with and without retention suture placement. Hubbard and associates could not identify a benet of retention
suture closure over standard mass closure of the abdominal
wall.
ever, are well known and include entrapment of underlying
viscera, increased postoperative pain, poor cosmesis, and
leakage of intraperitoneal uid through the wound.
surgeons advocate primary closure with retention sutures in
selected circumstances. In a retrospective study of midline
abdominal wound dehiscence, Makela and colleagues identied preoperative variables that are signicantly associated
41
Several patient-related factors are associated with
41
ere has been only one randomized trial comparing
42
e potential disadvantages of retention sutures, how-
43
Some
with fascial disruption, including hypoalbuminemia, anemia,
malnutrition, chronic pulmonary disease, and emergent operation. For patients with three or more of these preoperative
risk factors, this group recommended internal retention suture
44
closure.
When employed, retention sutures are placed across the
wound prior to formal fascial closure. Interrupted permanent monolament sutures are passed through skin and fascia
approximately 2 cm from the wound margin at intervals of
several centimeters. Placement is facilitated by the use of a long
cutting needle. It may be advantageous to omit the peritoneum
from the retention closure in order to protect underlying viscera from injury or entrapment. After conventional closure
of the fascia, the sutures are threaded through rubber tubing
bolsters or commercially available plastic bolster devices and
tied at the skin level.
Mesh and Biologic Implant Placement
Placement of a mesh underlay represents an alternative
approach to the prophylactic placement of retention sutures
45,46
for the at risk abdominal closure.
Additionally, the
occasional operation that requires resection of a signicant
portion of the abdominal wall, as well as transection of
bowel, sometimes necessitates the placement of a prosthesis
in a potentially contaminated eld. Interposition placement
of resorbable mesh accepts a hernia that will require complex
abdominal wall reconstruction to repair. Moreover, high rates
of stula formation and mesh infection have been described
with resorbable as well as nonresorbable mesh in this setting.
Biologic implants, such as human and porcine acellular dermal
allograft, are an attractive alternative to meshes when faced
with a dicult-to-close abdominal wall, particularly in the
setting of contamination. As with resorbable meshes, underlay rather than interposition placement likely yields a much
more durable result. While the use of these products in acute
47
clinical settings has been described,
there is little denitive
data to guide selective application of such techniques. More
complex abdominal reconstructions utilizing component
separation techniques, releasing incisions or rectus mobilization in conjunction with mesh or biologic implants, may be
undertaken in appropriately selected patients when primary
closure is not possible. More often, such approaches are utilized in a delayed fashion after development of an abdominal
wall hernia.
48
Closure of Laparoscopic Incisions
e closure of laparoscopic incisions poses particular
challenges. Reapproximation of the fascia is made more
challenging in the presence of small skin incisions, which limit
visualization. While small fascial defects may be left open,
any fascial defect 10 mm or greater in the midline or below
the arcuate line should generally be closed to reduce the risk
of port-site hernia formation.
49
e use of radially expanding
46
114 Part II Abdominal Wall
trocars obviates the need for formal closure in many cases,
although larger midline defects still generally require suture
reapproximation.
50–52
While sometimes challenging, particularly in obese
patients, secure reapproximation of the fascia, usually with
several interrupted sutures, can be achieved under direct
visualization. Alternatively, a variety of instrumentation may
be used to facilitate closure, usually in combination with
laparoscopic visualization and maintenance of pneumoperitoneum. e Endoclose device (Tyco Healthcare, Manseld,
Massachusetts) has a sharp tip, which also functions as a
grasper. e tip of a suture is grasped with the device and
driven through the fascia adjacent to the cannula (and fascial defect) under laparoscopic visualization. e end of the
suture is left free inside the abdomen. e grasper is then
placed through the fascia a second time on the opposite side
of the defect, and the free end of the suture is grasped inside
the abdominal cavity and pulled out through the fascia. e
suture is then tied to close the defect. e Carter-omason
System (Inlet Medical, Eden Prairie, Minnesota) additionally
includes a needle director, which is inserted through the fascia instead of the cannula, which ensures that adequate fascia
is obtained by directing the needle at an appropriate angle,
and may expedite closure.
53
Temporary Closure of the Abdomen
Despite the frequent misconception that temporary abdominal closure techniques are a recent innovation, such approaches
have long been utilized. Pringle reported his experience with
temporary packing of hepatic injuries in 1908.
Halsted recommended interposition of a nonadherent layer
55
between the injured liver and packs.
Such an approach did
fall out of favor in the period following the World War II
owing to the very highly observed incidences of late hemorrhage and sepsis. However, beginning in 1973 with a report by
Lucas and Ledgerwood, a number of investigators suggested
the feasibility of utility and temporary abdominal closure,
particularly in the setting of massive traumatic injury.
1993, Rotondo and Schwab introduced the term “damage
control” and outlined a three-phase approach to the management of major abdominal injuries. e rst phase consists
of rapid control of hemorrhage and contamination followed
by temporary abdominal closure; the second phase focuses
on the restoration of normal body temperature, correction of
coagulopathy, and optimization of ventilation; and the third
phase involves removal of abdominal packs, denitive operation, and abdominal closure. In their initial series, Rotondo
and Schwab demonstrated a marked survival advantage in
patients with major vascular injury and two or more visceral
injuries treated using the damage control approach (10 of 13,
77%) compared to those denitively closed at the time of
initial operation (1 of 9, 11%) (p < 0.02).
of this approach have broadened with greater experience.
Patients who may benet from this damage control approach
include those at risk of developing abdominal hypertension
54
In 1913,
56–58
59
e applications
In
(eg, hypothermia, coagulopathy, acidosis, large transfusion
requirement) and those who require a second-look laparotomy
(eg, intestinal ischemia).
is approach has necessitated the evolution of temporary
closure techniques. ese range from the very simple and inexpensive (eg, towel clip closure, running nylon suture close) to
more sophisticated vacuum-assisted closure (VAC) systems.
No single approach is clearly superior and multiple techniques
may have advantages in specic clinical settings. e Bogota
bag utilizes a large IV bag, secured to the skin or fascia. Impermeable plastic drapes may be used alternatively in a similar
fashion. is approach is fast, inexpensive, minimizes uid
losses, and is easily removed. It may be less durable than other
closures; tearing of sutures through the periphery of the bag
can result in evisceration. Absorbable meshes such as polyglactin 910 (Vicryl; Ethicon, Somerville, NJ) and polyglycolic acid
(Dexon; Davis & Geck, Danbury, CT) can be sutured to the
skin or fascia. is approach allows for a degree of exibility
as denitive closure can subsequently be undertaken without
removal of the mesh. Alternatively, the mesh can serve as a bed
for the elaboration of granulation tissue. If reapproximation of
the fascia is not feasible or needs to be substantially delayed, a
skin graft can be placed over the granulation bed. A variation
on mesh closure utilizes the Wittman patch, a device made
of two adherent sheets of biocompatible polymeric material.
e edges of the patch are sewn to the surrounding abdominal fascia. As edema resolves, the fascial edges are gradually
reapproximated by drawing the two sheets closer together and
cutting away excess material.
An increasingly popular alternative to these temporary
closures has been termed the “open abdomen technique.”
60
Generally, a nonadherent barrier (eg, a towel covered with an
adhesive plastic drape) is placed on top of the intra-abdominal
contents, below the fascia. Jackson-Pratt drains are placed above
this barrier to control drainage and maintain the integrity of
an adhesive dressing placed over the entire wound and skin
(Fig. 6-15). is dressing is readily applied, inexpensive, and
facilitates multiple re-explorations. Loss of abdominal domain
can be limited with the additional placement of lacing across
the wound; generally, vessel loops laced through skin staples
are placed along the edges of the wound, which can be progressively tightened as intra-abdominal hypertension resolves.
Maintenance of the open abdomen may be facilitated with the
use of the commercially available abdominal VAC. e abdominal VAC comprises a barrier enveloped in nonadherent plastic,
which is placed over the intra-abdominal contents below the
fascial edges. A polyurethane sponge is cut to the size of the
wound and placed over the barrier. e sponge is then covered
with an adherent dressing. A small defect is created in the dressing and suction tubing with an adherent appliance is applied
over this defect and attached to a vacuum device. Drainage is
drawn out through the sponge through the vacuum tubing
and into a vacuum canister. is system is particularly useful
when multiple re-explorations are anticipated. Additionally,
loss of abdominal domain is minimized by the negative pressure exerted on the dressing. While the use of the abdominal
VAC may facilitate a more delayed denitive closure, the risk of
Chapter 6 Incisions, Closures, and Management of the Abdominal Wound 115
be washed o with sterile saline. In general, the dressing
should be secured without the use of excessive tape, which
may be irritating to the skin. In most cases, the dressing can be
removed within 48 hours of application. is practice is supported by studies from the 1960s documenting that exposure
of clean, closed wounds to the atmosphere on postoperative
day two, is not associated with an increased incidence of infec-
62
In many cases, after closure of a clean wound, no dress-
tion.
ing is necessary. Indeed, in a randomized study of patients
undergoing either inguinal hernia repair or high saphenous
ligation, there was no signicant dierence in the rate of
wound infection whether wounds were immediately exposed,
covered with a dry gauze dressing, or covered with an occlusive
A
lm dressing.
63
A variety of dressing types are used in the management of
surgical wounds and may have advantages in some specic clinical settings. A simple dry dressing composed of gauze secured
with sparing use of tape is generally sucient. Wet- to-dry
dressings are commonly used to dress open and contaminated
wounds; mechanical debridement of the wound results from
removal of dried packing material with adherent devitalized
tissue. Enzymatic agents (eg, papain/urea [Accuzyme]) may be
used in conjunction with wet-to-dry dressings to gently debride
brinous exudate. In addition, application of broad-spectrum
antibacterials (eg, silver sulfadiazine) may limit bacterial colonization and promote wound healing.
Recently, VAC dressings have gained great popularity for
the management of open wounds. e VAC dressing has
three components: (1) the VAC sponge, which is applied
directly to the wound bed; (2) an occlusive dressing, which is
applied over the sponge to seal it to the surrounding skin; and
B
FIGURE 6-15 Open abdominal dressing. Top . A towel wrapped in
adhesive plastic is placed between the abdominal contents and the fascia. Bottom. Jackson Pratt drains and an impermeable dressing are applied over the barrier.
(Images used with permission from Benjamin Braslow, MD.)
(3) a suction pump, which provides regulated negative pressure through the sponge. e VAC dressing has been used
extensively in a variety of clinical settings and appears to promote granulation tissue formation and wound contraction.
A major advantage of the VAC is the need for fewer dressing
changes compared with conventional wet-to-dry dressings.
As discussed above, the VAC has become a prominent part of
the armamentarium for treating abdominal wounds that can-
injury to underlying viscera and stula formation does increase
61
with additional dressing changes.
In the patient who cannot
not be denitively closed at the time of initial operation.
undergo denitive closure after approximately 1 week, transition to a Vicryl mesh closure may be advantageous.
Surgical Site Infections
MANAGEMENT OF THE
POSTOPERATIVE WOUND
Dressing the Wound
At the conclusion of a procedure, a sterile dressing is typically
applied to the wound before removal of the sterile drapes.
eoretically, this dressing prevents bacterial colonization of
the wound during the initial 24–48 hours of healing, allowing
for epithelialization and the formation of coagulum. Before
application of the dressing, excess antiseptic solution should
Surgical site infections (SSIs) are the most common nosocomial infections in surgical patients. It has been estimated that
each SSI results in 7.3 additional inpatient days and adds over
40
$3000 to the hospital charges.
e bacterial colony count
at the surgical site makes a dominant contribution to the
risk of wound infection; colony counts per gram of tissue of
5
or greater are associated with a marked-increased risk. In
10
the presence of a foreign body, however, a much lower count
may lead to infection. Other risk factors for the development
of wound infections include advanced age, obesity, diabetes
mellitus, smoking, malnutrition, altered immune response,
preoperative hospitalization, presence of infection at a remote
body site, length of operation, and use of surgical drains.
40
116 Part II Abdominal Wall
TABLE 6-2: CRITERIA FOR DEFINING SURGICAL SITE INFECTIONS
Incisional SSI
Super cial Incisional Deep Incisional Organ/Space SSI
Infection occurring within 30 days of surgery,
and
Infection involves only skin and subcutaneous
tissue;
and
At least one of the following:
1. Purulent discharge
2. Organisms isolated from aseptically cultured
uid or tissue
3. At least one sign of infection: pain or
tenderness, localized swelling, redness, or heat
and
the incision is deliberately opened by the
surgeon unless the incision is culture negative
4. Diagnosis of SSI by the surgeon or attending
physician
Infection occurring within 30 days of surgery;
or within 1 year of operation if implants are
in place;
and
Infection involves deep soft tissue;
and
At least one of the following:
1. Purulent discharge
2. Deep incision spontaneously dehiscences
or is deliberately opened by a surgeon
when the patient has at least one of the
following symptoms: fever (>38°C),
localized pain or tenderness unless the site
is culture negative
3. Evidence of deep infection on direct
examination, during reoperation, or on
radiological examinations
4. Diagnosis of SSI by the surgeon or
attending physician
Infection occurs within 30 days of surgery,
or within 1 year of operation if implants are
in place;
and
Infection involves any part of anatomy that
was manipulated during an operation, other
than the incision;
and
At least one of the following
1. Purulent drainage that is placed through
a stab wound into the organ space
2. Organism isolated from and aseptically
cultured uid or tissue
3. Evidence of deep infection on the direct
examination, during reoperation, or on
radiological examinations
4. Diagnosis of SSI by the surgeon or
attending physician
SSIs are subdivided into two categories: incisional and
organ/space ( Table 6-2 ). Incisional SSIs are limited to the
surgical site. ey are further divided into super cial SSIs,
which involve the skin and subcutaneous tissue and deep SSIs,
which involve the fascial and muscle layers. Organ/space SSIs
can involve any part of the anatomy that was manipulated
during the surgery excepting the incision.
Wounds can be classi ed by degree of contamination
( Table 6-3 ). e risk of a postoperative SSI re ects, in
part, the wound classi cation; however, infection rates vary
64,
widely within each classi cation group.
65 Other riskscoring systems have, therefore, been developed to better
anticipate the risk of wound infections. Examples of such
scoring systems are the SENIC (Study of the E cacy of
Nosocomial Infection Control) and NNIS (National Nosocomial Infection Surveillance) risk indexes. e SENIC
system predicts risk associated with abdominal surgery,
operations lasting longer than 2 hours, contaminated or
dirty wound classi cations, and operation on patients with
64
three or more discharge diagnoses.
e NNIS system
predicts risk associated with American Society of Anesthesiologists preoperative assessment scores of greater than
2, wound classi cations of contaminated or dirty, and
65
increased duration of the operation.
e organisms most commonly responsible for SSIs are
Staphylococcus aureus and coagulase-negative staphylococci.
After abdominal surgery, infection with enteric organisms
( Escherichia coli and Enterobacter species) is also prevalent.
e Centers for Disease Control and Prevention recommendations for the prevention of SSIs are summarized
in Table 6-4 .
40
e use of preoperative prophylactic antibiotics in all clean-contaminated and clean cases with associated risk factors is recommended. e antibiotic of choice
for most upper gastrointestinal procedures is cefazolin or
a comparable rst-generation cephalosporin. For colorectal surgery, metronidazole is added to this regimen. e
administration of a mechanical and oral antibiotic bowel
preparation has been recommended prior to colorectal surgery, although this practice has been challenged by recent
66,
meta-analyses suggesting no bene t.
67 Preoperative intravenous antibiotics should be administered 30–60 minutes
before the incision is made to allow the agent to reach maximal tissue concentration. In obese patients, the antibiotic
should be adjusted appropriately. For long procedures, the
antibiotic should be readministered after every two halflives to maintain an e ective serum concentration.
e treatment for incisional SSIs includes removal of
skin stitches or staples to allow drainage of any underlying
collection. Antibiotics are indicated in the presence of cellulitis.
e e ective use of antibiotics depends on (1) appropriate
coverage of the o ending organisms and (2) maintenance of
an adequate tissue concentration of the drug. Cefazolin or an
equivalent rst- or second-generation cephalosporin is appropriate for uncomplicated incisional SSI. Wound cultures are
obtained in the presence of purulence and are used to guide
antibiotic selection. Following abscess drainage, wounds are
left open and allowed to close by secondary intention.
Deep space SSIs also require drainage. Increasingly, this
is achieved by percutaneous placement of a drain under CT
or ultrasound guidance. Deep space infections that are not
Chapter 6 Incisions, Closures, and Management of the Abdominal Wound 117
TABLE 6-3: CLASSIFICATION OF SURGICAL WOUNDS
Type of Wound De nition Risk of SSI
Class I: Clean An uninfected operative wound in which no
in ammation is encountered and respiratory,
alimentary, genital, or uninfected urinary is not entered.
ey are primarily closed, and if necessary, drained with
close drainage.
Class II: Clean-contaminated An operative wound in which the respiratory,
alimentary, genital, or urinary tracts are entered
under controlled conditions and without unusual
contamination. In particular, surgeries involving the
biliary tract, appendix, vagina, and oropharynx are
included in this category provided no evidence of
infection or a major break in technique is encountered.
Class III: Contaminated Open fresh accidental wounds. In addition, surgeries
with major breaks in sterile technique (eg, open cardiac
massage) or gross spillage from the gastrointestinal
tract, and incisions in which acute, nonpurulent
in ammation is encountered are included in this
category.
Class IV: Dirty-infected Old traumatic wounds with retained devitalized tissue
and those that involve existing clinical infection or
perforated viscera.
amenable to percutaneous drainage require operative drainage. Broad-spectrum antibiotics are indicated until culture
data is obtained at which point the spectrum should be narrowed to target the o ending organism.
NECROTIZING WOUND INFECTIONS
Necrotizing soft tissue infections are a heterogeneous group
68
of clinical entities
; however, several fundamental concepts
govern the treatment of all. Paramount is early identi cation
followed by operative debridement and initiation of antibiotic therapy. Patients often present early in the postoperative
period (ie, within 48 hours) with incisional pain followed by
the rapid onset of signs and symptoms of sepsis. While the
incision may initially appear benign, more often serous drainage is noted. Patients may also present with bulla or blebs,
crepitus, cutaneous anesthesia, and cellulitis that are refrac-
69
tory to antibiotic therapy.
Tenderness that extends beyond
the borders of the apparent cellulitis suggests progression of
the infection to the deeper cutaneous layers and should raise
suspicion for an early necrotizing process. Importantly, fewer
than 40% of patients exhibit the classic symptoms and signs
described and a high degree of suspicion should be maintained
70,
in the postoperative patient with early signs of sepsis.
71
In the absence of characteristic clinical features, diagnosis
can be challenging. An elevated white blood cell (WBC) count
3
(≤15,400/mm
) and hyponatremia (serum sodium level lower
than 135 mmol/L) are sensitive markers for the presence of
a necrotizing soft tissue infection; however, they are fairly
72
nonspeci c.
Imaging studies, including plain x-ray and CT,
1–5%
2–9%
3–13%
3–13%
may reveal the presence of soft tissue gas, though this nding
is present in a minority of cases.
69,
73 e reported sensitivity of
MRI for diagnosis of necrotizing soft tissue infection ranges
from 89% to 100%, and its speci city ranges from 46% to
74,
75 However, the frequent presence of subcutaneous
86%.
air in an early postoperative wound precludes reliable imaging in most cases and, more importantly, imaging may delay
appropriate treatment.
In suspected cases, immediate surgical exploration and
debridement is recommended and constitutes the most
important single therapy. Clostridium perfringens or group
A beta-hemolytic streptococci are the most frequently
implicated organisms, but necrotizing infections are often
polymicrobial. A sample of debrided tissue should be sent
for gram stain and culture, and initial therapy should have
a broad spectrum of coverage (eg, penicillin, clindamycin,
and an aminoglycoside). Following initial debridement, the
wound should be reexamined frequently. Any evidence of
extension of the necrotizing process should prompt further
debridement. Although the initial management of all
necrotizing infections is essentially the same, there are several
speci c clinical entities that deserve special mention, as they
may require unique therapies.
Gas Gangrene. Gas gangrene infection following abdomi-
nal surgery results from contamination with clostridia,
typically from the alimentary tract or biliary system. Patients
usually present with severe wound pain often associated with
fever and tachycardia. Such wounds often appear edematous
and erythematous; they later become dusky and necrotic.
118 Part II Abdominal Wall
TABLE 6-4: CDC RECOMMENDATIONS TO PREVENT SURGICAL SITE INFECTIONS
Preoperative Factors
Preparation of the patient:
1. Identify and treat all infections remote from the surgical site and
postpone elective surgery until infection has resolved.
2. Do not remove hair unless it interferes with surgery.
3. If hair is to be removed, remove immediately preoperatively
using clippers.
4. Ensure good blood glucose control in diabetic patients and
avoid hyperglycemia.
5. Encourage cessation of tobacco use (at least for 30 days before
surgery, if possible).
6. Do not withhold blood products, as transfusion does not a ect
rates of SSI.
7. Require the patient to shower or bathe with an antiseptic
solution the night before surgery.
8. Remove gross contamination from the surgical site before
performing antiseptic skin preparation.
9. Use an appropriate antiseptic solution for skin preparation.
10. Apply preoperative antiseptic solution for skin preparation in
concentric circles moving outward toward the periphery.
11. Keep the preoperative hospital stay as short as possible.
Hand/forearm antisepsis for surgical team:
1. Keep nails short and do not wear arti cial nails.
2. Perform a preoperative scrub for at least 2–5 minutes up to the
elbows.
3. After performing the surgical scrub, keep the hands up and away
from the body (elbows exed) so that the water runs from the tips
of ngers toward the elbows. Dry hands with a sterile towel and
don a sterile gown and gloves.
4. Clean underneath each ngernail.
5. Do not wear hand or arm jewelry.
Management of infected or colonized surgical personnel:
1. Educate and encourage surgical personnel who have signs
and symptoms of a transmissible infectious illness to report
promptly to their supervisor and occupational health
personnel.
2. Develop well-de ned policies concerning patient care
responsibilities when personnel have potentially transmissible
infectious conditions. ese policies should govern:
(1) responsibility of personnel in using health services and
reporting illness, (2) work restrictions, and (3) clearance to
resume work after an illness that required work restriction. e
policies should also identify sta members that have the authority
to remove personnel from duty.
3. Obtain appropriate cultures and exclude from duty surgical
personnel who have draining skin lesions until infection has been
ruled out, or until these personnel have received adequate therapy
and infection has been resolved.
4. Do not routinely exclude surgical personnel who are colonized
with organisms such as Staphylococcus aureus or group A
streptococci, unless they have been linked epidemiologically to
dissemination of the organism.
Antibiotic prophylaxis:
1. Administer a prophylactic antimicrobial agent only when
indicated, and select it based on its e cacy against the most
common pathogens causing SSIs for a speci c operation, and in
accordance with published recommendations.
2. Administer by the IV route the initial dose of prophylactic
antimicrobial agent, timed such that bactericidal concentration
of the drug is established in serum and tissue when the incision
is made. Maintain therapeutic levels of the agent in serum and
tissues throughout the operation, and for a few hours after the
incision has been closed.
3. Before elective colorectal operations, in addition to the above
measures, mechanically prepare the bowel by using enemas and
cathartic agents. Give nonabsorbable oral antimicrobial agents in
divided doses on the day before the operation.
4. For high-risk cesarean sections, administer the prophylactic
antimicrobial agent immediately after the umbilical cord is clamped.
5. Do not routinely use vancomycin for prophylaxis.
Intraoperative
Ventilation:
1. Maintain positive pressure ventilation in the operating room with
respect to the corridors and adjacent area.
2. Maintain a minimum of 15 air changes per hour, of which at
least 3 should be fresh air.
3. Filter all air, recirculated and fresh, through the appropriate lters
per the American Institute of Architects’ recommendations.
4. Introduce all air at the ceiling, and exhaust air near the oor.
5. Do not use ultraviolet radiation in the operating room.
6. Keep operating suite doors closed except as need for passage of
equipment, personnel, or patients.
7. Consider performing orthopedic implant operations in an
operating suite supplied with ultraclean air.
8. Limit the number of personnel entering the operating room.
Cleaning and disinfection of environmental surfaces:
1. When visible soiling or contamination of surfaces or equipment
with blood or other body uids occurs during an operation, use
an Environmental Protection Agency (EPA)-approved hospital
disinfectant to clean the a ected areas before the next operation.
2. Do not perform special cleaning (in addition to cleaning with
routine EPA-approved hospital disinfectant) or closing of
operating rooms after contaminated or dirty operations.
3. Do not use tacky mats at the entrance to the operating room suite
or individual operating rooms for infection control.
4. Wet vacuum the operating oor with an EPA-approved
disinfectant after the last operation of the day or night.
Microbiological sampling:
1. Do not perform routine environmental sampling of the operating
room.
Sterilization of surgical instruments:
1. Sterilize all surgical instruments according to published guidelines.
2. Perform ash sterilization only for patient care items that
will be used immediately. Do not ash sterilize for reasons of
convenience or to save time.
Surgical attire and drapes:
1. Wear a surgical mask that fully covers the mouth and nose when
entering the operating room if an operation is about to begin or is
underway, or if sterilized instruments are exposed. Wear the mask
throughout the operation.
(continued)
Chapter 6 Incisions, Closures, and Management of the Abdominal Wound 119
TABLE 6-4: CDC RECOMMENDATIONS TO PREVENT SURGICAL SITE INFECTIONS (Continued)
2. Wear a cap or hood to fully cover hair on the head and face.
3. Do not wear shoe covers for prevention of SSIs.
4. Wear sterile gloves if scrubbed as a surgical team member. Put on
gloves after donning the sterile gown.
5. Use surgical gowns and drapes that are e ective barriers when wet.
6. Change scrub suits that are visibly soiled, contaminated, and/or
penetrated by blood or other potentially infectious material.
Asepsis and surgical technique:
1. Adhere to principles of asepsis when placing intravascular devices,
spinal or epidural anesthesia catheters, or when dispensing or
administering IV drugs.
2. Assemble sterile equipment and solutions immediately prior to use.
3. Handle tissue gently, maintain e ective hemostasis, minimize
devitalized tissue and foreign bodies, and eradicate dead space at
the surgical site.
4. Use delayed primary skin closure or leave an incision open
if the surgeon considers the surgical site to be heavily
contaminated.
5. If drain is necessary, use closed suction drain, and place it through
a separate incision distant from the operating incision. Remove
the drain as soon as possible.
Postoperative Incision Care
1. Protect an incision that has been closed primarily with a sterile
dressing for 24–48 hours postoperatively.
2. Wash hands before and after dressing changes and before and
after any contact with surgical site.
3. When an incision dressing must be changed, use a sterile technique.
4. Educate the patient and family regarding proper incision care,
symptoms of SSI, and the need to report such symptoms.
Surveillance
1. Use CDC de nitions of SSI without modi cation for identifying
SSIs among surgical inpatients and outpatients.
2. For inpatient cases, use direct prospective observation, indirect
prospective detection, or a combination of both for the duration
of the patient’s hospitalization.
3. When postdischarge surveillance is performed for detecting SSIs
following certain operations, use a method that accommodates
available resources and data needs.
4. For outpatient cases, use a method that accommodates available
resources and data needs.
5. Assign a surgical wound classi cation upon completion of an
operation. A surgical team member should make the assignment.
6. For a patient undergoing an operation chosen for surveillance,
record those variables shown to be associated with increased risk
of SSI.
7. Periodically calculate operation-speci c SSI rates strati ed by
variables shown to be associated with increased risk of SSI.
8. Report appropriately strati ed operation-speci c SSI rates to
surgical team members. e optimum frequency and format of
such rate computations will be determined by strati ed case-load
sizes and the objectives of local, continuous quality improvement
initiatives.
Wound crepitus and foul smelling watery discharge, so-called
“dishwater drainage,” are characteristics. Early surgical
intervention with debridement of all infected and nonviable tissue is recommended in suspected cases. Although
there have been no controlled clinical trials, there is some
evidence that hyperbaric oxygen is of considerable value in
treating clostridial infection, and reduces the mortality rate
76
by some reports from 66% to 23%.
e potential bene ts
of hyperbaric oxygen include improved leukocyte function
and increased tissue oxygen levels; it is bactericidal for C.
77
perfringens and bacteriostatic for other anaerobic bacteria.
Necrotizing Fascitis. is syndrome has been divided into
two subcategories depending on the implicated organisms.
Type I necrotizing fasciitis is a polymicrobial process; Type
68,
II necrotizing fasciitis is caused by group A streptococci.
78
Polymicrobial necrotizing infections are generally slowly progressive and a ect the total thickness of the skin, but do not
involve the deep fascia. Purulence may or may not be present.
Most often, such infections are heralded by a nonspeci c
cellulitis around the wound that slowly extends over days.
Later, the central area of the cellulitis becomes purple and
then develops typical features of gangrene. ese infections
are referred to as Fournier’s gangrene when they a ect the
perineum. e causative organisms are usually a mixture of
anaerobes, gram-negative rods, and enterococcus species.
Broad-spectrum antibiotics should be initiated early and then
tailored pending the result of microbial cultures.
Necrotizing infections caused by group A streptococci
are more rapidly progressive and can involve the subcutaneous fat, the super cial fascia, and the deep fascia. Early
in the process, the overlying skin is often intact, but later
may become compromised following interruption of the
deep blood supply. e condition is clinically distinguished
from gas gangrene by the absence of crepitus and muscle
involvement. Early operative exploration is recommended in
suspected cases. Group A streptococcus is highly sensitive to
penicillin; however, the addition of clindamycin appears to
78
have clinical bene t.
Treatment must include early surgical
exploration with debridement of involved tissues.
Seroma and Hematoma
Super cial seroma formation is exceedingly common but
rarely has signi cant clinical consequence. Most seromas
can be observed; the rare large seroma that causes troubling
symptoms (eg, discomfort) or is cosmetically unacceptable to
the patient can usually be managed with a single aspiration,
or serial aspirations in the o ce. Refractory large seromas can
120 Part II Abdominal Wall
be treated with percutaneous placement of a drain, which is
maintained until the output is low (usually less than 30 cc per
day) or, rarely, excision (ie, capsulectomy).
e more liberal use of aspirin, plavix, and heparins in
the perioperative period has likely resulted in an increased
incidence of wound hematoma following abdominal surgery;
79,80
now in the range of 4–8%.
Small wound hematomas are
of little consequence and usually resolve without intervention. If larger, hematomas may lead to compromise of the
overlying skin or predispose to infection. Such hematomas
can be aspirated with a large-bore needle, or evacuated by
opening the wound. If the overlying skin is under tension or
ongoing extravasation of blood is noted, hematomas are often
better managed in the operating room where active bleeding
can be controlled, if encountered.
Stitch Abscess
Stitch abscesses or suture sinuses are most often seen at
approximately the 10th postoperative day, but may occur
earlier or weeks after operation. Stitch abscesses may be
supercial or deep. When supercial, they typically present as brown or mauve-colored circumscribed blisters in
the line of the incision. e associated pain can be resolved
by incising the overlying skin, evacuating the contents,
and, if possible, excising residual suture material. Antibiotic treatment is rarely necessary. Deeper stitch abscesses
typically present with an indurated mass. As noted above,
the use of nonabsorbable suture, such as polypropylene, has
been associated with an increased incidence of deep stitch
abscesses when compared to closure with a slowly absorbing
32,81
When permanent suture
has been used, treatment requires removal of the residual
suture material.
Wound Dehiscence and Evisceration
Separation of abdominal wounds (ie, dehiscence) with orwithout protrusion of intraabdominal contents (ie, evisceration)
causes considerable morbidity and mortality. Historically,
wound dehiscence rates of up to 10% were reported; contemporary series estimate an incidence between 1% and 3%.
Mortality associated with dehiscence has been estimated at
84
e mean time to wound dehiscence is 8–10 days
16%.
after operation.
32,84
Classically, dehiscence is heralded by
a sudden rush of pink serosanguinous discharge from the
wound. Sometimes, the acute evolution of a large subcutaneous hematoma or tympanitic swelling that distends the
wound reecting herniation of bowel through the abdominal fascia is also noted.
As mentioned above, the literature on abdominal closure
appears to favor a running mass closure with slowly resorbable
or nonresorbable suture. Notwithstanding such technical
considerations, a variety of patient-associated risk factors for
82,83
dehiscence must be recognized and include advanced age
(>65 years), hypoalbuminemia, wound infection, ascites,
obesity, steroid use, chronic obstructive pulmonary disease,
pneumonia, cerebrovascular accident with residual decit,
anemia (ie, hematocrit <30), prolonged ileus, coughing,
emergency operation, and operative time greater than 2.5
44,83,85
hours.
Although some surgeons advocate prophylactic
placement of retention sutures in those at high risk for
dehiscence, there is little data to support this practice.
Fundamentally, the treatment for a disrupted wound
is reclosure of the wound; this is particularly true when
dehiscence occurs early in the postoperative period. If
evisceration is present, the wound and protruding viscera
should be bathed with warm normal saline solution and
covered with a large sterile dressing prior to prompt transport to the operating room. In the operating room, the
prolapsed bowel is replaced below the level of the fascial
edges. Residual suture material is extracted, and necrotic
wound edges are debrided. Reclosure of the fascia is then
performed, typically using a monolament nonabsorbable
suture such as polypropylene. Although some surgeons
advocate interrupted closure of the fascia following dehiscence, two retrospective analyses have failed to demonstrate
a reduction in the incidence of late ventral hernia formation with this technique compared to a running closure.
e advantage of retention suture placement in this setting is similarly unproven. Retrospective analyses fail to
demonstrate any benet, although a reduction in recurrent evisceration is frequently invoked. Retention sutures
are associated with increased discomfort for the patient.
Placement of resorbable mesh as an underlay may serve to
reinforce the abdominal closure.
On occasion, if the dehiscence is small, the patient is
critically ill, or there is no evisceration, nonoperative management is appropriate. In such cases, the wound is packed
with a moist sterile dressing. An abdominal binder can be
used for further support. e dressing should be changed
at regular intervals until the wound lls in with granulation
tissue. In some cases, delayed reclosure of the skin can be carried out at this stage. Alternatively, the use of a VAC dressing
has been described in this setting.
86
Incisional Hernia
Incisional hernia formation is the most common long-term
complication of abdominal surgery and is discussed extensively in Chapter 7.
Acknowledgements
We would like to thank Bryan M. Burt, Ali Tavakkolizadeh,
and Stephen J. Ferzoco for their contribution to the previous edition of this text, which served as the foundation for
this revised chapter. We would also like to thank Benjamin
Braslow and Bilal Sha for their valuable suggestions.
32,84
43
Chapter 6 Incisions, Closures, and Management of the Abdominal Wound 121
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