Surgical Wound​

Diverse approaches with numerous, sometimes divergent strategies

How do guidelines consider this measure

An illustration of a covered wound on a shoulder
Definition of the term “surgical wound” by the WHO:

“A wound created when an incision is made with a scalpel of other sharp cutting device and then closed in the operating room by suture, staple, adhesive tape, or glue and resulting in close approximation to the skin edges.”1

Management of a surgical wound is complex. It begins with the incision and ends with its continued care until wound closure. In order not to make this contents too confusing, we will limit ourselves to presenting the points of wound disinfection, wound closure, wound dressings and some other points that are mentioned in the guidelines. The measures surgical irrigation and wound drain are presented separately.

Guidelines​

GuidelineRecommendationCategory (if mentioned)
CDC2“Do not apply antimicrobial agents (ie, ointments, solutions, or powders) to the surgical incision for the prevention of SSI.”
“Randomized controlled trial evidence was insufficient to evaluate the trade-offs between the benefits and harms of repeat application of antiseptic agents to the patient’s skin immediately before closing the surgical incision for the prevention of SSI.“
Category IB,

Unresolved issue

WHO1

“The panel suggests considering the use of wound protector (WP) devices in clean-contaminated, contaminated and dirty abdominal surgical procedures for the purpose of reducing the rate of SSI.”

“The panel suggests the use of prophylactic negative pressure wound therapy (pNPWT) in adult patients on primarily closed surgical incisions in high-risk wounds, for the purpose of the prevention of SSI, while taking resources into account.”

“The panel suggests that antimicrobial sealants should not be used after surgical site skin preparation for the purpose of reducing SSI.”

Conditional recommendation, very low quality of evidence

“The panel suggests that antibiotic incisional wound irrigation before closure should not be used for the purpose of preventing SSI.”Conditional recommendation, low quality of evidence
NICE3“Only apply an antiseptic or antibiotic to the wound before closure as part of a clinical research trial.”
“Use sterile saline for wound cleansing up to 48 hours after surgery.”
“Use tap water for wound cleansing after 48 hours if the surgical wound has separated or has been surgically opened to drain pus.”
“Do not use topical antimicrobial agents for surgical wounds that are healing by primary intention to reduce the risk of surgical site infection.”
“Do not use Eusol and gauze, or moist cotton gauze or mercuric antiseptic solutions to manage surgical wounds that are healing by secondary intention.”		-
KRINKO4--

GuidelineRecommendationCategory (if mentioned)
CDC2,5”Use delayed primary skin closure of leave an incision open to heal by second intention if the surgeonconsiders the surgical site to be heavily contaminated (e.g., Class III and Class IV). (IB)”5

”Consider the use of triclosan-coated sutures for the prevention of SSI.”2

Category IB
Category II
WHO1“The panel suggests the use of triclosan-coated sutures for the purpose of reducing the risk of SSI,independent of the type of surgery.”Conditional recommendation,moderate quality of evidence
NICE4“When using sutures, consider using antimicrobial triclosan-coated sutures, especially for paediatricsurgery, to reduce the risk of surgical site infection.”

“Consider using sutures rather than staples to close the skin after caesarean section to reduce the risk ofsuperficial wound dehiscence.”

-
KRINKO5Antiseptic-coated sutures have a reducing effect on the risk of infection only in very high baseline SSIrates, in contamination class III and IV surgeries, and in multimorbid patients.Category II

GuidelineRecommendationCategory (if mentioned)
CDC2,5

“Randomized controlled trial evidence suggested uncertain trade-offs between the benefits and harms regarding antimicrobial dressings applied to surgical incisions after primary closure in the operating room for the prevention of SSI.”2

Unresolved issue

“Protect with a sterile dressing for 24 to 48 hours postoperatively an incision that has been closed primarily.”5
“Wash hands before and after dressing changes and any contact with the surgical site.”5
Category IB
“When an incision dressing must be changed, use sterile technique.”5Category II
“No recommendation to cover an incision closed primarily beyond 48 hours, nor on the appropriate time to shower or bathe with an uncovered incision.”5
Unresolved issue
WHO1“The panel suggests not using any type of advanced dressing over a standard dressing on primarily closed surgical wounds for the purpose of preventing SSI.”
Conditional recommendation, low quality of evidence
NICE4“Cover surgical incisions with an appropriate interactive dressing at the end of the operation.”
“Use an aseptic non-touch technique for changing or removing surgical wound dressings.”
“Use an appropriate interactive dressing to manage surgical wounds that are healing by secondary intention.”
“Ask a tissue viability nurse (or another healthcare professional with tissue viability expertise) for advice on appropriate dressings for the management of surgical wounds that are healing by secondary intention.”
–
KRINKO5Cover the surgical wound with a sterile dressing at the end of the operation. Perform the first dressing change after about 48 hours, unless there are indications of a complication that would necessitate an earlier dressing change.
Category IB
If the wound is then dry and closed, it is not necessary to cover the wound again with a sterile dressing for hygienic reasons.
The dressing change or removal of sutures or drains should be carried out using a dressing trolley or tray system. It is not necessary to use different dressing trolleys for aseptic and infected wounds - it is essential to protect the trolley from contamination. In all other respects, the rules of basic hygiene must be observed during these manipulations.Category II

GuidelineRecommendationCategory (if mentioned)
CDC2,5“Educate the patient and family regarding proper incision care, symptoms of SSI, and the need to report such symptoms.”5
Category II
WHO1--
NICE4“Offer patients and carers information and advice on how to care for their wound after discharge.”
“Use a structured approach to care to improve overall management of surgical wounds. This should include preoperative assessments to identify people with potential wound healing problems. Enhanced education of healthcare workers, patients and carers, and sharing of clinical expertise is needed to support this.”		-
KRINKO5Infection prevention considerations have no influence on the choice between electrocautery and scalpel.

Regular medical inspection of the wound is part of complete and proper aftercare.

Category II

HARTMANN:​

Portrait of Denise Leistenschneider, Senior Clinical Consultant
Denise Leistenschneider, Senior Clinical Consultant
"The surgical wound is the critical entry point for SSI and therefore deserves special attention."

Extract of recommendations​

icon of a drop

Wound disinfection:

  • Do not use antimicrobial sealants after skin preparation.1

  • Do not use antibiotic incisional wound irrigation for the purpose of preventing SSI.1

icon of arrow in circle

Wound closure:
Consider the use of Triclosan-coated sutures for wound closure.1,3,4

icon of layers

Wound dressings:

  • Use a sterile dressing to cover surgical incision.1,2,5

  • Use sterile, non-touch technique for changing or removing wound dressings.2,4

  • Leaving dressings in place beyond a 48-hour period is not routinely recommended.2

icon of arrows right

Others:

  • Consider the use of wound protector (WP) devices or prophylactic negative pressure wound therapy (NPWT) in risk wounds to prevent SSI.1

  • Inspect wounds on a regular basis as part of a complete and proper aftercare.5

  • Inform and educate patients and carer on appropriate wound care.2,4

  • Use a structured care approach to improve surgical wound management.4

Surgical wound classification4​

  • “Clean: an incision in which no inflammation is encountered in a surgical procedure, without a break in sterile technique, and during which the respiratory, alimentary or genitourinary tracts are not entered.”

  • “Clean-contaminated: an incision through which the respiratory, alimentary, or genitourinary tract is entered under controlled conditions but with no contamination encountered.”

  • “Contaminated: an incision undertaken during an operation in which there is a major break in sterile technique or gross spillage from the gastrointestinal tract, or an incision in which acute, non-purulent inflammation is encountered. Open traumatic wounds that are more than 12 to 24 hours old also fall into this category.”

  • “Dirty or infected: an incision undertaken during an operation in which the viscera are perforated or when acute inflammation with pus is encountered (for example, emergency surgery for faecal peritonitis), and for traumatic wounds if treatment is delayed, there is faecal contamination, or devitalised tissue is present.”

HARTMANN advice:

Treat what you see & T.I.M.E. (Tissue, Inflammation, Moisture, Edges) Carefully measure and document the characteristic of the wound and surrounding tissue. Select your dressing based on the wound assessment.

  1. WHO (2018) Global guidelines for the prevention of surgical site infection. World Health Organization 2018.
  2. Berrios-Torres SI, et al. (2017) Centers of Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg 152(8): 784–791.
  3. NICE (2020) Surgical site infections: prevention and treatment. NICE guidelines. Published: 11 April 2019. Last updated:19 August 2020. www.nice.org.uk/guidance/ng125.
  4. KRINKO (2018) Prävention postoperativer Wundinfektionen. Empfehlungen der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut. Bundesgesundheitsbl 61: 448–473.
  5. CDC (1999) Guideline for Prevention of Surgical Site Infection. Infect Control Hosp Epidemiol. 20(4): 247–278.
  6. https://www.who.int/infection-prevention/publications/ipc-cc-mis.pdf

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