title: Reducing Surgical Site Infections in Abdominal Surgery: Are Ring Retractors Effective? A Systematic Review and Meta-Analysis.
abstract: BACKGROUND
  Surgical site infection (SSI) is one of the main causes of morbidity and death after surgical intervention. The use of physical barriers, including gloves, drapes, and gowns to reduce SSI after abdominal surgery is long-standing practice. The aim of this systematic review and meta-analysis was to determine the efficacy of ring incision retractors in reducing the risk of SSI in abdominal surgery.
  
  
  METHODS
  PubMed, CINAHL, the Cochrane randomized controlled trials (RCTs) Central Register, and the ISRCTN registry were searched for RCTs in which ring retractors were utilized to reduce SSI in abdominal surgery. The PRISMA guidelines and RevMan 5.3 were used for study selection and analysis. Additional subgroup analyses were performed, including trials using incision class (clean, clean-contaminated contaminated, and dirty) and trials that used the U.S. Centers for Disease Control and Prevention's SSI definition in their protocol.
  
  
  RESULTS
  A total of 19 RCTs inclusive of 4,229 patients were included. The utility of ring retractors in reducing SSI was suggested by an overall risk ratio of 0.62 (95% confidence interval 0.48-0.81). However, study heterogeneity caused by differences in effect size between individual RCTs, the non-standardized utilization of concomitant measures to reduce SSI, and an overall lack of high-quality trials was found.
  
  
  CONCLUSIONS
  A reduction in SSI incidence with the use of ring retractors is suggested by the findings. However, this result must be treated with caution because in addition to some old trials poor quality and the large number of factors affecting SSI, there were substantial differences between trials in effect sizes in statistical heterogeneity. Further RCTs are needed to confirm this provisional finding.
authors.affiliation: 1 Department of Surgery, National University of Ireland , Galway, Ireland .|2 Royal College of Surgeons in Ireland , Dublin, Ireland .
authors.forename: Khalid
authors.initials: K
authors.lastname: Ahmed
authors.affiliation: 3 Department of Vascular Surgery, University Hospital Limerick , Limerick, Ireland .
authors.forename: Khalid
authors.initials: K
authors.lastname: Bashar
authors.affiliation: 1 Department of Surgery, National University of Ireland , Galway, Ireland .
authors.forename: Tara T M
authors.initials: TT
authors.lastname: Connelly
authors.affiliation: 2 Royal College of Surgeons in Ireland , Dublin, Ireland .
authors.forename: Tom
authors.initials: T
authors.lastname: Fahey
authors.affiliation: 1 Department of Surgery, National University of Ireland , Galway, Ireland .
authors.forename: Stewart R
authors.initials: SR
authors.lastname: Walsh
mesh_terms: D000005:Abdomen / Q000601:surgery*; D006801:Humans; D015994:Incidence; D016032:Randomized Controlled Trials as Topic; D013514:Surgical Procedures, Operative / Q000379:methods*; D013530:Surgical Wound Infection / Q000453:epidemiology* / Q000517:prevention & control*