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Toronto Notes 2019 Surgical Complications General Surgery and Thoracic Surgery GS9
• patientcharacteristics
■ age, DM, steroids, immunosuppression, obesity, burn, malnutrition, patient with other infections,
traumatic wound, radiation, and chemotherapy • otherfactors
■ prolonged pre-operative hospitalization, reduced blood flow, break in sterile technique, multiple antibiotics, hematoma, seroma, foreign bodies (drains, sutures, grafts), skin preparation, hypoxemia, and hypothermia
Prophylaxis
• pre-operativeantibioticsformostsurgeries(cefazolin±metronidazoleorifβ-lactamallergy, clindamycin ± gentamycin)
■ within 1 h pre-incision; can redose at 1-2 half-lives (~q4-8h) in the OR
■ not required for low risk elective cholecystectomy, hemorrhoidectomy, fistulotomy, and
sphincterotomy for fissure
■ some evidence suggests role in breast surgery
• reserve post-operative antibiotics for treatment of suspected or documented intra-abdominal infection
• normothermia(maintainpatienttemperature36-38°CduringOR)
• hyperoxygenation (consider FiO2 of 80% in OR) • chlorhexidine-alcohol wash of surgical site
• hair removal should not be performed unless necessary; if so, clipping superior to shaving • considerdelayedprimaryclosureofincisionforcontaminatedwounds
Clinical Presentation
• typicallyfeverPOD#5-8(StreptococcusandClostridiumcanpresentin24h)
• localizedpain,blanchableerythema,induration,purulentdischarge,andwarmth
• complications:fistula,sinustracts,sepsis,abscess,suppressedwoundhealing,superinfection,spreading
infection to myonecrosis or fascial necrosis (necrotizing fasciitis), wound dehiscence, evisceration, and hernia
Treatment
• examinationofthewound:inspect,compressadjacentareas,swabdrainageforC&SandGramstain • re-openaffectedpartofincision,drain,pack,healbysecondaryintentioninmostcases
• fordeeperinfections,debridenecroticandnon-viabletissue
• antibioticsanddemarcationoferythemaonlyifcellulitisorimmunodeficiency
WOUND HEMORRHAGE/HEMATOMA
• secondarytoinadequatesurgicalcontrolofhemostasis
Risk Factors
• anticoagulanttherapy,coagulopathies,thrombocytopenia,DIC,severeliverdisease,myeloproliferative disorders, severe arterial HTN, and severe cough
• morecommonwithtransverseincisionsthroughmuscle,duetocuttingofmuscle
Clinical Features
• pain,swelling,discolourationofwoundedges,andleakage
• rapidlyexpandingneckhematomacancompromiseairwayandisasurgicalemergency:consider
having a suture kit at bedside in all neck surgery in the event of having to open the wound emergently
Treatment
• pressuredressing
• opendrainage±woundpacking(largehematomaonly)
• ifsignificantbleeding,mayneedtore-operatetofindsource(oftendonotfindadiscretesource)
SEROMA
• fluidcollectionotherthanpusorblood
• secondarytotransectionoflymphvessels • delayshealing
• increasedinfectionrisk
Treatment
• considerpressuredressing±needledrainage • ifsignificantmayneedtore-operate
WOUND DEHISCENCE
• disruptionoffasciallayer,abdominalcontentscontainedbyskinonly • 95%causedbyintactsuturetearingthroughfascia
Risk Factors
• local:technicalfailureofclosure,increasedintra-abdominalpressure(e.g.COPD,ileus,bowel obstruction), hematoma, infection, poor blood supply, radiation, patient not fully paralyzed while closing, and transverse incision
Pre-Operative Skin Antiseptics for Preventing Surgical Wound Infections After Clean Surgery Cochrane DB Syst Rev 2015;4:CD003949
Purpose: To determine if pre-operative skin antisepsis prior to clean surgery prevents surgical- site infection (SSI) and compare the effectiveness of other antiseptics.
Methods: Systematic review of randomized- controlled trials (RCTs) part of the Cochrane Wounds Group Specialised Register and the Cochrane Central Register of Controlled Trials (CENTRAL). Main outcome was SSI. Secondary outcomes included quality of life, mortality, and resource use.
Results: 13 RCTs (n=2,623 patients) were included that made 11 total comparisons between skin antiseptics. A single study found that 0.5% chlorhexidine solution in methylated spirits was significantly superior in preventing SSIs after clean surgery compared to alcohol based povidone iodine solution. No other statistically significant differences were found.
Conclusions: Further research is warranted to determine the effectiveness of one antiseptic over the others at preventing SSI post clean surgery.
Systemic Review and Meta-Analysis of Randomized Clinical Trials Comparing Primary vs. Delayed Primary Skin Closure in Contaminated and Dirty Abdominal Incisions JAMA Surg 2013;148:779-786
Purpose: To compare rates of surgical site infection (SSI) with delayed primary closure (DPC) vs. primary skin closure (PC).
Results/Conclusions: 8 RCTs with 623 patients. Most common diagnosis was appendicitis (77.4%). Although there was significant heterogeneity between studies, DPC (2-5 d time to first review) was found to significantly reduce the chance of
SSI (OR 0.65, 95% CI 0.40-0.93). Although current trials are poorly designed, DPC may be a simple and cost-effective way of reducing the rates of SSIs following abdominal surgery with contaminated or dirty wounds.