J. A. Zebley1, A. Klein1, K. Wanersdorfer1, M. Quintana1, J. Estroff1, B. Sarani1, S. Kartiko1 1George Washington University School Of Medicine And Health Sciences, Surgery, Washington, DC, USA
Introduction:
Patients who undergo exploratory laparotomy (EL) in an emergent setting are at higher risk for surgical site infections (SSI). Previously described methods of reducing infection rates include allowing wounds to heal by secondary intention and placement of wound vacs. Packaged 0.05% chlorhexidine irrigation solution (Irrisept) reduces superficial SSI rates in non-emergency settings. We hypothesize that the use of 0.05% chlorhexidine gluconate irrigation solution prior to closure of EL incisions in the emergency setting will be associated with lower rates of superficial SSI and allow for increased rates of primary skin closure following laparotomy in contaminated cases.
Methods:
We performed a retrospective observational study of all EL done under emergency whose subcutaneous tissue were irrigated with 0.05% chlorhexidine gluconate to achieve primary wound closure from March 2021 to June 2022. Patients with active soft tissue infection of the abdominal wall were excluded. Our primary outcome is rate of primary skin closure following laparotomy. Descriptive statistics, including t-test, chi square test, were used to compare groups as appropriate. A p-value <0.05 was statistically significant.
Results:
66 patients (35 % female) with a median age of 51 years (range 18 to 92 years) underwent emergent EL. Primary skin closure techniques included staples, 87.9% (58/66) or running subcuticular 12.1% (8/66). 98.5% of patients (65/66) achieved primary wound closure; 72.7% (48/66) requiring no additional wound interventions. Bedside removal of a portion of incisional staples was required in 27.3% of patients (18/66) due to erythema and wound discharge on examination. We report no cases of fascial dehiscence. 1 patient required removal of all staples and conversion to open negative pressure wound vac after surgery for perforated viscous. Wounds were classified as dirty (n = 23), contaminated (n = 25), and clean contaminated (n = 18). Median BMI was 26 kg/m2 (IQR: 22.1, 30.9). Median antibiotic therapy was 4 days (1, 8.5). 15 patients had open abdomen management with a median duration of 1 day (1, 2). 2 patients (3%) required reoperation for anastomotic leaks following bowel resection. There were no statistically significant associations between SSI and wound class (p = 0.135). History of diabetes (p = 0.001), coronary artery disease (p = 0.031), chronic kidney disease (p = 0.001), and congestive heart failure (p = 0.004) were associated with a higher risk of needing a portion of incisional staples being removed. In-hospital mortality rate was 4.5% (3/66) which were all related to septic shock following perforated viscous.
Conclusion:
In trauma and emergency general surgery patients undergoing laparotomy, irrigation of the subcutaneous tissue with 0.05% chlorhexidine gluconate is a viable option for intraoperative use to allow for primary skin closure without increasing complication rates. Further studies are needed to prospectively evaluate our findings.