To prevent surgical site infection after colorectal surgery, see the expert consensus!

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The risk of surgical site infection (SSI) after colorectal surgery (CRS) is higher, mainly due to surgical site contamination due to high bacterial load in the colon and rectum, in addition to patient comorbidities It also further increases the risk of SSI. The increased risk of SSI results in a heavy clinical and economic burden. Recently, the panel reached consensus on 15 evidence-based statements, mainly on the intraoperative technical/surgical aspects of preventing SSI during CRS.

1

Incision Location

Current evidence is insufficient to demonstrate that extra-midline incisions reduce the risk of SSI compared with midline incisions. However, an extra-midline incision (if feasible/appropriate) may reduce the risk of incisional hernia after (laparoscopic) colorectal surgery.

(There is less evidence that incision location affects SSI)

2

Incision Protector/Retractor

Using an incision protector/retractor reduces the risk of SSI compared to not using an incision protector/retractor.

(The incision protector theoretically acts as an impermeable barrier to protect the incision from contamination of the surgical field after enterotomy/resection)

3

Incision/Tape drapes

Evidence is insufficient to support the role of incision/adhesive drapes in reducing the risk of SSI.

(surgical incision drape (plain or impregnated with antibacterial agent) is a sterile, clear adhesive film-like plastic surgical drape that is affixed to the skin during surgery to limit skin microbes, Although it has been used for a long time, few studies have evaluated its effect on SSI after colorectal or abdominal surgery)

4

Incision Flush

Antibiotics should not be used to irrigate the incision to reduce the risk of SSI.

In high-risk, contaminated incisions, incision irrigation with iodine solution reduces the risk of SSI compared to no incision irrigation.

(There are many studies on incision irrigation, but the results are mostly heterogeneous and may be at risk of bias. Some guidelines do not recommend using antibiotic solutions for incision irrigation, which increases the risk of antibiotic resistance.)

5

Sterile Incision Closure Tray

Using a separate, dedicated sterile incision closure tray may help reduce the risk of SSI compared to not using a sterile incision closure tray.

(Dedicated sterile incision closure trays are recommended by the panel despite the lack of clear data on reduced risk of SSI. Using sterile instruments for incision closure after CRS may reduce the risk of infection. Trays may as part of a care package to reduce SSI.)

6

Change gloves before incision closure

Switching gloves before the incision is closed may help reduce the risk of SSI compared to not changing gloves.

(Change of gloves is an important consideration, as micro-perforations may develop over time during surgery. Also, once the bowel is opened, gloves are likely to be damaged by pollution)

7

Myofascial suture technique

There is insufficient evidence to suggest that small-pitch suture techniques reduce the risk of SSI compared with large-pitch suture techniques. However, the small spacing suture technique can reduce the risk of surgical incisional hernia.

(The benefit of small spacing sutures is a reduction in overall complications (eg, incisional hernias), which may affect the incidence of SSI. Further study of suture spacing is warranted)

8

Antibacterial sutures

Triclosan-coated or impregnated antibiotic sutures (TCS) reduce the risk of SSI compared to non-antibiotic sutures.

(TCS can inhibit bacterial colonization, prevent suture-repair biofilm formation, kill SSI-associated bacteria through the antimicrobial properties of triclosan coating)

9

Continuous and interrupted sutures

The evidence is insufficient to recommend the effect of continuous or interrupted sutures on postoperative incisional complications (SSI, incisional hernia, or incision dehiscence).

(Continuous and interrupted suture techniques, each with pros and cons for myofascial closure after abdominal incision)

10

Suture-to-skin staples

The evidence is insufficient to recommend skin closure with sutures or skin staples to reduce SSI.

(It is uncertain whether the use of sutures or skin staples affects the risk of SSI after CRS)

11

Topical skinAdhesive

The evidence is insufficient to recommend the use of topical skin adhesives for skin closure to reduce SSI.

(The potential benefit of topical adhesives in reducing SSI has been raised in orthopaedic and orthopaedic procedures, but further research is needed to understand their potential benefit in CRS)

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12

Wound Negative Pressure Therapy

In open, high-risk, contaminated procedures, closed incision negative pressure therapy (NPWT) may help reduce the risk of SSI compared to no incision negative pressure therapy.

(Considering the cost of current commercial NPWT products, further research is warranted to better understand the cost-effectiveness of NPWT in CRS)

13

Advanced Dressing

Evidence is insufficient to support the use of advanced dressings (eg, silver ion dressings) over traditional dressings (eg, standard gauze) to reduce the risk of SSI.

(There may be a potential benefit of using advanced dressings in reducing the risk of SSI, but the current evidence is limited and heterogeneous)

14

Delayed incision closure

The evidence is insufficient to recommend the use of delayed incision closure after open colorectal surgery.

(For patients at high risk of infection, especially in resource-limited settings, delayed primary skin closure may be a better option after a contaminated/unclean open abdominal procedure)

15

Subcutaneous drainage

Evidence is insufficient to support the role of subcutaneous drainage in reducing the risk of SSI.

(Theoretically, the purpose of placing a subcutaneous drain after CRS is to reduce the risk of incisional subcutaneous space and seroma, but the WSES guidelines state that there is insufficient evidence for the use of subcutaneous drains to prevent SSI in high-risk patients)

Reference source: Ruiz-Tovar J, Boermeester MA, et al. Delphi Consensus on Intraoperative Technical/Surgical Aspects to Prevent Surgical Site Infection after Colorectal Surgery. J Am Coll Surg. 2022 Jan 1; 234(1):1-11.