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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 28  |  Issue : 1  |  Page : 9-12

The effect of suction wound drain on laparotomy wound healing in emergency colorectal surgeries


1 Department of General Surgery, Government Medical College, Kottayam, Kerala, India
2 Department of General Surgery, Government Medical College, Thiruvananthapuram, Kerala, India

Date of Submission13-Apr-2022
Date of Decision27-Apr-2022
Date of Acceptance04-May-2022
Date of Web Publication14-Jul-2022

Correspondence Address:
Dr. S G Githu
Chothi, STRA-94, Vetturoad, Kazhakuttom PO, Thiruvananthapuram - 695 582, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ksj.ksj_10_22

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  Abstract 


Background: This prospective observational study attempts to compare the healing in the laparotomy midline wounds closed primarily with negative suction wound drain to those wounds where only linea alba was closed with skin and subcutaneous tissue left open for secondary suturing, in emergency colorectal surgeries. Materials and Methods: This study was conducted on 160 patients in the general surgery department of a tertiary care teaching hospital for 12 months in those who underwent emergency colorectal surgery through midline laparotomy and randomly allotted for either laparotomy midline wound closure with suction drain or closure with linea alba suturing alone with skin and subcutaneous tissue left open for secondary suturing. These two groups were compared for wound healing. Statistical analysis was performed using the SPSS software. Results: The wound contamination in those with closed wound with negative suction wound drain (Group A) had 40% in Grade II and 37.5% in Grade III, whereas those in which skin and subcutaneous tissue was left open after closing linea alba (Group B) had 53.8% in Grade II and 38.8% in Grade I and this might have contributed to the better healing as was seen in Group B than in Group A. This showed that wound healing was better in those wounds where only linea alba was closed with skin and subcutaneous tissue left open for secondary suturing after 1 week. Conclusion: In emergency colorectal surgeries, wound healing is better with reduced chance of surgical site infection in those wounds where only linea alba was closed with skin and subcutaneous tissue left open and secondary suturing was done after a week.

Keywords: Emergency colorectal surgeries, laparotomy midline wounds, negative suction wound drain, wound healing and surgical site infection


How to cite this article:
Githu S G, John B, Saju JM, Sasikumar M N. The effect of suction wound drain on laparotomy wound healing in emergency colorectal surgeries. Kerala Surg J 2022;28:9-12

How to cite this URL:
Githu S G, John B, Saju JM, Sasikumar M N. The effect of suction wound drain on laparotomy wound healing in emergency colorectal surgeries. Kerala Surg J [serial online] 2022 [cited 2022 Sep 24];28:9-12. Available from: http://www.keralasurgj.com/text.asp?2022/28/1/9/350883




  Introduction Top


Surgical site infection (SSI) is a common post-operative complication. It involves infections occurring at the site of the surgical incision and also the surrounding structures of the wound which comes in contact during surgery. It can be caused either by exogenous or endogenous bacteria. The sources of infection may include contamination from the gut flora of the patient, health-care providers, hospital environment, other patients, improper dressings, and usage of contaminated instruments. The common risk factors for SSIs include improper handwashing and poor skin preparation before surgery, site, duration and also the type of the surgery adds onto it. SSIs not only cause increased morbidity but also cause great discomfort and dissatisfaction to the patient and financial burden to them and the health-care system by increasing the duration of hospitalisation.

Although it may not be possible to reduce the SSI rate to zero, strict measures can be taken to improve the already implanted measures to bring down the infection rate. Better understanding of the pathogenesis of the infection and the biology of the microorganisms will help to reduce the infection rate and also reduce the morbidity and costs associated with SSIs. This study is an attempt to know whether wound healing has any effect on the usage of negative suction wound drain or closure of laparotomy wound with linea alba suturing alone with skin and subcutaneous tissue left open for secondary suturing.


  Materials and Methods Top


This is a prospective observational study conducted for 12 months in the general surgery department of a tertiary care teaching hospital. One hundred and sixty patients who underwent emergency colorectal surgeries with midline laparotomy incisions during the study period were included in the study. The study included patients among the age group of 15–80 years of age. Patients with the accidental premature removal of drain in the post-operative period, all immune comprised patients and patients with comorbidities (type 2 diabetes mellitus, bronchial asthma and tuberculosis) were excluded from the study. Written informed consent was obtained from all the patients in the study. Random allocation to either group was done using lots. Group A had 80 cases including closed laparotomy wound with a negative suction wound drain in the subcutaneous plane (shown in series in [Figure 1], [Figure 2], [Figure 3]) and Group B had 80 cases with open wound, wherein linea alba was closed and skin and subcutaneous tissue were left open (shown in [Figure 4]). The cases in either group received a single shot of prophylactic antibiotic an hour before the skin incision. All of them were followed up during their post-operative period to check for any wound infection using the Southampton wound grading system for healing and infection. On the third post-operative day, the drain fluid from Group A and a wound swab from the open wound of Group B were sent to the microbiology department for culture and sensitivity.
Figure 1: The midline laparotomy wound after closing the linea alba

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Figure 2: Negative suction wound drain in the subcutaneous plane

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Figure 3: Closed laparotomy wound with negative suction wound drain in the subcutaneous plane (Group A)

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Figure 4: Group B midline laparotomy wound on the 8th post-operative day

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In Group A, the drain was removed on the post-operative day 3, if drain fluid was <50 ml. In Group B, the open wound was considered for secondary suturing on the 7th post-operative day [Figure 5]. The patients were reviewed on the 30th post-operative day (if they were discharged from the hospital). The wound was inspected from the immediate post-operative period to the 30th post-operative day for wound healing. All data were analysed using the Statistical Package SPSS version 20.0 (IBM-SPSS, New Delhi, India). Chi-square tests were also used. P ≤ 0.05 was considered statistically significant.
Figure 5: Group A with SSI. SSI: Surgical site infection

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  Results Top


Class of wound

While comparing the laparotomy midline incision wounds, they fell upon to the clean-contaminated (Class II) class of wound as per the surgical wound classification. No statistically significant association was found among the classes of wound (P = 0.339), as shown in [Table 1].
Table 1: Class of wound

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Wound grading of infection and healing

The Southampton wound grading system for healing and infection showed that Group B had 43 cases in Grade 2 wound and only six cases in Grade 3 wound with a significant P = 0.000, as depicted in [Table 2]. The grade of the wound was better in Group B. Moreover, in Group A, those with a closed laparotomy wound with a negative suction wound drain had serous discharges from their wounds and had to remove the clips to let open the wound [Figure 6].
Table 2: Wound grading of infection and healing

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Figure 6: Open midline laparotomy wound (Group B)

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Wound healing

The majority of the study population in Group A belonged to 15–21 days, and in Group B, in 8–14 days with a P = 0.024, which is significant as detailed in [Table 3]. This shows that wounds with only linea alba were closed had a better healing when compared with closed wound with negative wound suction drain.
Table 3: Number of days of wound healing

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In either group, Staphylococcus was the most common organism isolated from the culture [Figure 7].
Figure 7: Cultures of the 3rd post-operative day

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Of all the population who were followed to the 30th post operative day, Group B constituted 80% and Group A constituted 50%. The post clinical findings in the various patient groups are detailed in [Table 4]. This clearly establishes that laparotomy wound with linea alba closed with skin and subcutaneous tissue left open heals early than those with negative wound suction drain
Table 4: 30th post-operative day

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  Discussion Top


SSI is among the most common hospital-acquired infections worldwide and is associated with significant morbidity, mortality and prolonged hospitalisation for patients. There are many measures to prevent SSI but it continued to be one of the major post-operative complications

In a study conducted by Khan and Kodalkar[1] about 'a role of the negative suction drain in laparotomy wound infection', patients were divided into two Groups A and B. In Group A, the patients had abdominal wall closure with a negative suction drain in the subcutaneous space (study group), and in Group B, abdominal wall closure without negative suction drain (control group). In the study group, the incidence of wound dehiscence, wound infection and seroma were remarkably lower. The frequency of wound infection was significantly higher in the control group patients. The result was that the use of negative suction drain in midline laparotomy surgery reduces the incidence of post-operative SSI, seroma formation and wound dehiscence.

Among the 160 cases in the present study, even after the administration of prophylactic antibiotics; the 3rd post-operative day culture showed Staphylococcus aureus Scientific Name Search  in either group, with great numbers in Group A (43.8%) and Group B (28.7%).  Escherichia More Details coli was detected in 21.3% of Group A and in 35.0% of Group B wounds. Klebsiella also contributed to wound infection in 28.7% of Group A and 23.8% of Group B wounds. Acinetobacter and Enterococci were found to be minor contributors in both groups.

With respect wound contamination Group A had 40% in Grade II and 37.5% in Grade III, whereas Group B had 53.8% in Grade II and 38.8% in Grade I and this might have contributed to the better healing seen in Group B than in Group A. Group A population had Grade III of the Southampton wound grading system for healing and infection (serous or bloody discharge), even after having a negative suction wound drain; it had to be let open later. This points out that wound healing was better in those wounds where only the linea alba was closed with skin and subcutaneous tissue left open for secondary suturing after 1 week.

Manzoor et al.[2] in their meta-analysis 'review of subcutaneous wound drainage in reducing SSIs after laparotomy', showed that there was no significant reduction in SSI incidence when all the laparotomies were analysed together. The risk ratio determined was 0.84 (0.66–1.09), which cannot be taken as a reliable indication about the efficacy of using drains.

Arasu and Kamaraj[3] showed that in emergency laparotomies, the incidence of infection, pain, hospital stay and post-operative morbidity was not significantly altered between open and closed drainage systems

In the present study, the numbers of days needed for wound healing were more in Group A than in Group B by 44% in 15–21 days. In the end, the number of days needed for wound healing was more in those wounds that were closed primarily with negative suction wound drain due to SSI.

When the study populations were followed to the 30th post-operative day, it was seen that Group B had a better result in wound healing with 80% in Grade 0 (normal grade) and Group A had 40% in Grade 0 and 34% in Grade 1 surgical wounds.

Despite improvements in the surgical and sterilisation techniques and the use of antibiotic prophylaxis, post-operative SSI continues to be a cause of major health-care issue leading to significant morbidity to the patients and economic burden to the health-care system.


  Conclusion Top


In this study, there is evidence that in emergency colorectal surgeries, wound healing is better with reduced chance of SSI in those wounds where only linea alba was closed with skin and subcutaneous tissue left open and secondary suturing was done after a week.

Acknowledgement

We thank Prof. John S Kurien and Dr. Sansho E U of the department of general surgery for their support and encouragement during the study. We thank Dr. Binu John who suggested this topic. We express our gratitude to the junior residents Dr. Vaisakh S and Dr. Laya Rahul, for the immense amount of support during the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Khan AQ, Kodalkar M. A role of negative suction drain in reducing laparotomy wound infection. Int J Sci Res 2016;5:2319-7064.  Back to cited text no. 1
    
2.
Manzoor B, Heywood N, Sharma A. Review of subcutaneous wound drainage in reducing surgical site infections after laparotomy. Surg Res Pract 2015;2015:715803.  Back to cited text no. 2
    
3.
Arasu VT, Kamaraj R. Comparative study on open and closed drainage in emergency laparotomy. IOSR J Dent Med Sci 2016;15:107-12.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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Abstract
Introduction
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