Surgical Irrigation

Why is this measure widely used but cautiously recommended

“Intact skin is the best defense mechanism for preventing
microbial invasion.”¹

Almost impossible with surgical interventions.

Thereforeintraoperative wound irrigation is a widely adopted practice in surgical procedures, aiming to promote wound moisturization and prevent Surgical Site Infections (SSIs).²An overwhelming majority of surgeons, approximately 97%, incorporate this technique into their interventions.³However, despite its prevalent use, the approach remains controversial and subject to guarded recommendations and guidelines due to the complexity of the existing evidence.

Both the World Health Organization (WHO) and theCenter ofDisease Control and Prevention (CDC) acknowledge the uncertain trade-offs between the benefits and risks associated with intraoperative antimicrobial irrigation.^2,4

Guidelines

Guideline	Recommendation	Category (if mentioned)
CDC⁴	“Consider intraoperative irrigation of deep or subcutaneous tissues with aqueous iodophor solution for the prevention of SSI.” “Intraperitoneal lavage with aqueous iodophor solution in contaminated or dirty abdominal procedures is not necessary."	Category ll Weak recommendation Moderate-quality evidence
WHO²	“The panel considers that there is insufficient evidence to recommend for or against saline irrigation of incisional wounds before closure for the purpose of preventing SSI.” “The panel suggests considering the use of irrigation of the incisional wound with an aqueous PVP-I solution before closure for the purpose of preventing SSI, particularly in clean and clean-contaminated wounds.” “The panel suggests that antibiotic incisional wound irrigation before closure should not be used for the purpose of preventing SSI.”	Conditional recommendations. Low quality of evidence
NICE⁵	“Do not use wound irrigation to reduce the risk of surgical site infection.” “Do not use intracavity lavage to reduce the risk of surgical site infection.”
KRINKO⁵	Due to the risk of resistance development, antiseptic irrigation prior to wound closure should under no circumstances be performed with antibiotics, but with antiseptics. Surface-active agents should be avoided for this purpose. Solutions containing octenidine should be considered unsuitable for this indication due to retention in the tissue or contraindicated in the absence of drainage.

We see the importance of surgical irrigation in its facets and always try to break new ground.

Denise Leistenschneider, Senior Clinical Consultant

Rationale for surgical irrigation

The lack of evidence stipulates that there are no consistent recommendations for or against the usage, or the way of application for surgical irrigation.

Nevertheless surgical irrigation has it’s reason to be.

Surgical irrigation solutions are known to act as a mechanical cleanser due to their ability to:²

thoroughly remove cellular debris, surface bacteria, and bodily fluids.
dilute and reduce the presence of potential contaminants.
exhibit local antimicrobial properties when appropriate agents are used.

What to avoid

Do not use antibiotics for surgical irrigation.^2,6

Using pulse lavage system for surgical irrigation can contribute to reduction of revision rate in hip/knee arthroplasty⁷ and support the reduction of infection risk⁸

Denise Leistenschneider, Senior Clinical Consultant

Existing discrepancy between theory and practice⁹

“Despite the dissemination of guidelines for surgical site infection (SSI) prevention, gap between the theoretical measures and their compliance persists.”⁹

There is a lack of evaluation and evidence in wound irrigation but this measure is universally accepted by the surgical community resulting from common sense and clinical practice.⁹

Further relevance for surgical irrigation – biofilms¹

Biofilms play a major role in in surgical site infections and need to be removed and managed as they are responsible for:¹

delayed wound healing
limited penetration of antimicrobial agents
anchorage of microorganism on the wound surface
reduced efficacy of antibiotics

While antimicrobial solutions can be beneficial in preventing Surgical Site Infections (SSI), some variations exist in their effectiveness and properties.

Desired properties are to combat biofilms and tackle multi-drug resistant pathogens without promoting resistance.
Furthermore, in terms of tissue toxicity and required exposure time, an antimicrobial rinse fluid should be able to exert its full effect without significant disadvantages.
Antimicrobial fluids have become essential in countering the escalating challenges of antibiotic-resistant and pan-resistant pathogens. They offer crucial effectiveness in addressing these infections.

HARTMANN: food of thoughts

Skin microbiota is the most common source of microbes detected in prosthetic joint infections.

“Irrigation and debridement in the treatment of periprosthetic joint infection serve an integral role in the eradication of bacterial burden and subsequent re-infection rates.¹⁰

Denise Leistenschneider, Senior Clinical Consultant

References:

^{1.Percival SL, Emanuel C, Cutting KF, Williams DW. Microbiology of the skin and the role of biofilms in infection. Int Wound J 2012; 9:14–32}

^{2.WHO (2016) Global guidelines for the prevention of surgical site infection. World Health Organization 2016.}

^{3.Whiteside OJH, et al. (2005) Intra-operative peritoneal lavage – who does it and why? Ann R Coll SurgEngl 87: 255–258.}

^{4.CDC (1999) Guideline for Prevention of Surgical Site Infection. Infect Control Hosp Epidemiol. 20(4): 247–278.}

^{5.NICE (2019) Surgical site infections: prevention and treatment. NICE guidelines. Published 11 April 2019. www.nice.org.uk/guidance/ng125.}

^{6.KRINKO (2018) PräventionpostoperativerWundinfektionen. Empfehlungen der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut. Bundesgesundheitsbl 61: 448–473.}

^{7.Helwig T, et al. (2013) Tibial cleaning method for cemented total knee arthroplasty: An experimental study. IJOO 47: 18–22.}

^{8.Bath MF, et al. (2021) Does pulsed lavage reduce the risk of surgical site infection? A systematic review and meta-analysis. J Hosp Infect 118: 32–39.}

^{9.Badia JM, et al. (2020) The persistent breach between evidence and practice in the prevention of surgical site infection. Qualitative study. Int J Surg 82: 231–239.}

^{10.Siddiqi A, et al. (2021) Pursuit of the ideal antiseptic irrigation solution in the management of periprosthetic joint infections. J Bone Joint Infect 6: 189–198.}

In focus

Expert Advice

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Publications

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Here you will find a selection of recent studies and publications...