Leaving the Skin Incision Open May Not Be as Beneficial as We Have Been Taught.
BACKGROUND
Currently, various methods of skin closures are used in contaminated and dirty abdominal wounds without solid, evidence-based guidance. This study investigates whether closure methods affect surgical site infection (SSI) and other incisional complications. We hypothesize that open management of the skin would have the lowest complications, including SSI.


METHODS
Patients age ≥18 who underwent trauma laparotomy (TL) or damage control laparotomy (DCL) from 2008-2013 and had class III/IV wounds were included. Demographic, injury, treatment, and outcome variables were compared based on skin closure methods: Primary closure, intermittently stapled with wicks, or open management. Subgroup analyses for TL, DCL, and high-risk patients with stomach, colon, or rectal injuries were performed. Bivariable and multivariable logistic regression (MLR) analyses were performed to identify risk factors for superficial/deep SSI and surgical incision complications.


RESULTS
A total of 348 patients were included. The median age was 47 years; 14% were female; 21% had blunt injuries. Overall SSI was highest for open incisions (p < 0.05), but there was no difference in superficial/deep SSI. Primary closures healed a median of 20 days, compared with 68 and 71 days for the intermittently stapled and open groups, respectively (p < 0.001). Primary closure in TL and high-risk patients also had the lowest SSI rates (all p < 0.05), but there were no differences in superficial/deep SSI in any subgroup. In TL patients, diabetes mellitus and colon injuries were independently associated with the development of superficial/deep SSI and surgical incision complications; however, skin closure method was not.


CONCLUSIONS
In class III and IV wounds, primary closure was associated with the lowest SSI, shortest length of stay and healing time. Method of skin closure, however, did not have an independent effect on the development of superficial/deep SSI or surgical incision complications. These suggest that primary skin closure in contaminated and dirty abdominal wounds may be performed more safely than commonly perceived.
Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine , Cleveland, Ohio.
Jack C
JC
He
Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine , Cleveland, Ohio.
Brenda M
BM
Zosa
Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine , Cleveland, Ohio.
David
D
Schechtman
Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine , Cleveland, Ohio.
Brian
B
Brajcich
Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine , Cleveland, Ohio.
Jonathan C
JC
Savakus
Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine , Cleveland, Ohio.
Amanda L
AL
Wojahn
Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine , Cleveland, Ohio.
Derek Z
DZ
Wang
Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine , Cleveland, Ohio.
Jeffrey A
JA
Claridge
D000328:Adult; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011182:Postoperative Care / Q000379:methods* / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D000072836:Surgical Wound / Q000628:therapy*; D013530:Surgical Wound Infection / Q000453:epidemiology / Q000517:prevention & control / Q000628:therapy; D055815:Young Adult
incision management; skin; surgical site infection; trauma