Variations in Incision Management Based on Surgical Scenarios

Author(s):
Jeffrey Santos; Patrick Delaplain; Justin Dvorak; Tina Mele; Rondi Gelbard; Christopher Guidry; Philip Barie; Sebastian Schubl

Background:

Wound classification (WC) can guide management of incisions to decrease rates of surgical site infection and post-op complications. There is variability in assigning WC by surgeons and a lack of consensus regarding incision management at the conclusion of surgery (CoS).

Hypothesis:

Management of incisions at CoS lacks consensus and varies among individual surgeons.

Methods:

Surgical Infection Society member survey on the management of incisions at CoS. Several general surgery (GS) and trauma laparotomy (TL) case scenarios tested influence of operation type, intra-operative contamination (spillage), and hemodynamic (HD) stability on incision management (e.g., close fascia or skin, use of incision or wound vacuum-assisted closure [VAC]). 66% of respondents was considered consensus. Chi-square test, a=0.05. Response heterogeneity was quantified by Shannon index (SI).

Results:

Among 78 respondents, the only consensus GS scenario was elective splenectomy (91% close skin/dry dressing). Open appendectomy and left colectomy/end-colostomy had the greatest heterogeneity (SI 1.68 and 1.63, respectively) with a split (20%-30%) among close skin/dry dressing, incisional VAC, skin open/wet->dry dressing, or another tactic. In TL scenarios, the majority used damage control for HD instability (53%-67%) but not for HD stable patients (pts) (0-1.3%, p<0.001). Two TL scenarios reached consensus: close skin/dry dressing for HD stable splenectomy pts (87%) and fascia open/wound VAC for HD unstable colon resection/anastomosis (67%). Fecal diversion for rectal injury and colon resection/anastomosis (both HD stable) had high heterogeneity (SI 1.56 and 1.48, respectively). In penetrating T, the trend was for more use of wet->dry dressings and incision/wound VAC with increased spillage in HD stable pts (Figure).

Figure. Comparison of intra-operative wound management tactics for penetrating T in HD stable patients by anatomic location and degree of spillage.

Conclusions:

Damage control was favored in HD unstable TL pts, with use of wet->dry dressings and incision/wound VAC with spillage in penetrating T. However, most scenarios did not achieve consensus. High variability of practices regarding incision management at CoS was confirmed.