Surgical Site Infection Rate Drops to 0% Using

a Vacuum-Assisted Closure in Contaminated/

Dirty Infected Laparotomy Wounds
GERARDO LOZANO-BALDERAS, M.D., ALEJANDRO RUIZ-VELASCO-SANTACRUZ, M.D.,
JOSÉ ANTONIO DÍAZ-ELIZONDO, M.D., JUAN ANTONIO GÓMEZ-NAVARRO, M.D.,
EDUARDO FLORES-VILLALBA, M.D.

Escuela de Medicina, Tecnologico de Monterrey, San Pedro Garza Garcı́a, Mexico

Wound site infections increase costs, hospital stay, morbidity, and mortality. Techniques used for
wounds management after laparotomy are primary, delayed primary, and vacuum-assisted closures. The
objective of this study is to compare infection rates between those techniques in contaminated and dirty/
infected wounds. Eighty-one laparotomized patients with Class III or IV surgical wounds were enrolled
in a three-arm randomized prospective study. Patients were allocated to each group with the software
Research RandomizerÒ (Urbaniak, G. C., & Plous, S., Version 4.0). Presence of infection was determined
by a certified board physician according to Centers for Disease Control’s Criteria for Defining a Surgical
Site Infection. Twenty-seven patients received primary closure, 29 delayed primary closure, and 25
vacuum-assisted closure, with no exclusions for analysis. Surgical site infection was present in 10 (37%)
patients treated with primary closure, 5 (17%) with primary delayed closure, and 0 (0%) patients re-
ceiving vacuum-assisted closure. Statistical significance was found between infection rates of the
vacuum-assisted group and the other two groups. No significant difference was found between
the primary and primary delayed closure groups. The infection rate in contaminated/dirty-infected
laparotomy wounds decreases from 37 and 17 per cent with a primary and delayed primary closures,
respectively, to 0 per cent with vacuum-assisted systems.

N OSOCOMIAL INFECTIONS ARE prevalent both in indus-

trialized and emergent countries. The World Health
Organization reports an average nosocomial infection rate
of infection of 10 to 20 per cent for contaminated and
20 to 40 per cent for infected wounds.9 Depending on
the scenario, the techniques used for wounds man-
of 8.7 per cent.1 Wound site, urinary tract, and upper re- agement after laparotomy are primary or delayed pri-
spiratory airways infections being the most common. In mary closure and the use of vacuum-assisted devices,
Mexico, nosocomial infection rate is 7.7 per cent of all which improve blood circulation and enhance cellular
hospital discharges, from which 26 per cent are attributed division rate in the wound.10–12
to surgical site infections.2 The objective of this study is to compare infection
Wound site infections increase both costs and hospital rates between primary, delayed primary, and vacuum-
stay for the patient,2–4 and carry a higher morbidity and assisted closures in contaminated and dirty/infected
mortality.5 In abdominal surgical procedures, it is also the laparotomy wounds.
most relevant prognostic factor for developing postinci-
sional hernias.6–8 Methods
Surgical wounds can be classified as clean, clean
contaminated, contaminated, and infected, with a rate Eighty-one patients were enrolled in a three-arm ran-
domized prospective study, approved by the hospital’s
ethics committee. Inclusion criteria were a minimum age
Protocol Registration
The protocol can be found in [Link], under the title of 18 years and a laparotomy wound Class III or IV,
Comparison of Surgical Site Infection Rate between Primary, according to the Centers for Disease Control’s Surgical
Delayed Primary, and Vacuum-Assisted Closures. Wound Classification.9 Patient allocation to the different
[Link] Identifier: NCT02649543. closure methods was made with the software Research
Address correspondence and reprint requests to Eduardo RandomizerÒ just before fascia closure.
Flores Villalba, M.D., Escuela de Medicina, Tecnologico de
Monterrey, Batallón de San Patricio 112 Piso 1 Ote. Col. Real San A double antibiotic scheme with a cephalosporin and
Agustı́n, San Pedro Garza Garcı́a, NL 66278, México. E-mail: metronidazole was used in all patients. In the three groups,
eduardofloresvillalba@[Link]. the fascia was closed with polyglycolic acid 0 running

512
No. 5 VACUUM-ASSISTED CLOSURE IN LAPAROTOMY WOUNDS ? Lozano-Balderas et al. 513

TABLE 1. Variable Analysis and Comparison between the Three Groups Based on Anthropometric, Personal History and Relevant
Laboratory Data
Closed Vacuum System Delayed Primary Closure Primary Closure
Number Median Number Median Number Median P
Variable (%) (IQR) (%) (IQR) (%) (IQR) value
Female gender 6 (24) 13 (44.8) 7 (25.9) 0.185
Age 32 (22–46) 39 (22.5–53) 30 (20–43) 0.592
BMI 25.9 (24.3–27.3) 27.8 (25.2–28.8) 26.7 (24.5–29.3) 0.112
DM II 4(16) 5 (17.2) 6 (22.2) 0.826
Tobacco use 5 (20) 4 (13.8) 3 (11.1) 0.654
Preoperative transfusion 0 (0) 3 (10.3) 1 (3.7) 0.203
Trichotomy 20 (80) 18 (62.1) 22 (81.5) 0.182
Surgical time 120 (100–190) 120 (90–180) 120 (90–180) 0.428
Class III wound 12 (48) 9 (31) 9 (33.3) 0.388
Albumin 3.6 (3.4–3.95) 3.4 (3.0–3.7) 3.4 (3.0–3.7) 0.061
Total protein 6.6 (6.5–6.9) 6.5 (6.35–6.9) 6.5 (6.2–6.9) 0.305
IQR, interquartile range.

suture. In those patients with primary closure, subcutane- TABLE 2. Acute Abdomen Diagnoses
ous tissue was approximated with polyglycolic acid 3-0, Diagnosis Number (%)
and polypropylene 2–0 was used for the skin. For those Perforated acute apendicitis 35 (43.21)
with a delayed primary closure, the wound was left open Stab wound 14 (17.28)
for at least seven days, after which closure with a poly- Acute diverticulitis 9 (11.11)
propylene 2-0 suture took place if no clinical signs of in- Strangulated hernia 7 (8.64)
Others 16 (19.75)
fection were observed by a certified board surgeon. For the
rest of the patients, the VACÒ (Vacuum Assisted Closure,
KCI, San Antonio, Texas) system was used with routine
changes of dressings every 48 hours, and until healthy Demographic and baseline data are included in Ta-
granulation tissue was found a surgeon decided to close it. ble 1. Main diagnoses leading to surgery are shown in
Discharge of the patients took place only after the Table 2. Class IV wounds were more common, with 51
wound healed with no complications. Revision of the (63%) cases. Surgical site infection was present in 10
wounds took place on a daily basis while the patient (37%) patients treated with primary closure, 5 (17%)
remained hospitalized, as well as in scheduled follow- patients with primary delayed closure, and none of the
up appointments and open consultations as required patients receiving vacuum-assisted delayed closure.
by the patient in a 30-day period after the surgery. The There were no readmission cases during the follow-up
presence of surgical site infection was determined by period. No organ/space infections were identified in
a certified board physician. Centers for Disease Control’s the study. All groups were compared to determine any
Criteria for Defining a Surgical Site Infection, as stated in significant infection rate difference (Table 3).
the Guideline for Prevention of Surgical Site Infection9
were used as definite criteria for all three wound closures.
Discussion
Social, demographic, medical, and surgical (both pre-
operative and postoperative) data were registered. A de- There are several published clinical trials comparing
scriptive analysis expressed as total and percentages, the benefits of vacuum-assisted closure systems over
medians, and interquartile ranges was made. Comparison the primary and delayed primary closures for surgical
between groups was assessed using the Kruskal-Wallis, wounds; however, there is no standard of care.
Mann-Whitney U, or x2 as appropriate. A P value of Traditionally, closure by second intention, is rec-
less than 0.05 was considered significant. ommended for both Classes III and IV laparotomy
wounds.9 However, the infection rate of Class III
wounds using such technique is reported at 10 to 20 per
Results
cent, whereas the rate for Class IV wounds ascends
Eighty-one patients were enrolled and analyzed, 27 up to 20 to 40 per cent.9 Similar infection rates were
patients (33%) received primary closure, 29 (36%) found in our study with such technique. Although
delayed primary closure, and 25 (31%) vacuum- a minor rate of infection was seen in the delayed
assisted closure. There were no patient losses or ex- primary closure compared with the primary closure,
clusions. All the patients analyzed were intervened in no significant difference was found, as stated by other
a 6-month period, from January to July 2014. authors.8, 13
514 THE AMERICAN SURGEON May 2017 Vol. 83

TABLE 3. Surgical Site Infection Rate Comparison between 3. Kusachi S, Kashimura N, Konishi T, et al. Length of stay and
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ported worldwide.14–17 Our study replicated these prevention of surgical site infection, 1999. Hospital Infection
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Limitations of this study are the small sample size meta-analysis of randomized clinical trials comparing primary vs
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Conclusions
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therapy with off-the-shelf components. Am J Surg 2006;192:
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