Systematic Review and Meta-Analysis of Wound Bundles in Emergency Midline Laparotomy Identifies That It Is Time for Improvement

Abstract

Background: Emergency midline laparotomy is the cornerstone of survival in patients with peritonitis. While bundling of care elements has been shown to optimize outcomes, this has focused on elective rather than emergency abdominal surgery. The aim of this study was to undertake a systematic review and meta-analysis of factors affecting the development of surgical site infection (SSI) in patients undergoing midline emergency laparotomy. Methods: An ethically approved, PROSPERO registered (ID: CRD42020193246) meta-analysis and systematic review, searching PubMed, Scopus, Web of Science and Cochrane Library electronic databases from January 2015 to June 2020 and adhering to PRISMA guidelines was undertaken. Search headings included “emergency surgery”, “laparotomy”, “surgical site infection”, “midline incision” and “wound bundle”. Suitable publications were graded using Methodological Index for Non-Randomised Studies (MINORS); papers scoring ≥16/24 were included for data analysis. The primary outcome in this study was SSI rates following the use of wound bundles. Secondary outcomes consisted of the effect of the individual interventions included in the bundles and the SSI rates for superficial and deep infections. Five studies focusing on closure techniques were grouped to assess their effect on SSI. Results: This study identified 1875 articles. A total of 58 were potentially suitable, and 11 were included after applying MINORS score. The final cohort included 2,856 patients from eight countries. Three papers came from the USA, two papers from Japan and the remainder from Denmark, England, Iran, Netherlands, Spain and Turkey. There was a 32% non-significant SSI reduction after the implementation of wound bundles (RR = 0.68; CI, 0.39–1.17; p = 0.16). In bundles used for technical closure the reduction in SSI of 15% was non-significant (RR = 0.85; CI, 0.57–1.26; p = 0.41). Analysis of an effective wound bundle was limited due to insufficient data. Conclusions: This study identified a significant deficit in the world literature relating to emergency laparotomy and wound outcome optimisation. Given the global burden of emergency general surgery urgent action is needed to assess bundle’s ability to potentially improve outcome after emergency laparotomy.

Prophylactic onlay mesh at emergency laparotomy: promising early outcomes with long‐acting synthetic resorbable mesh

“…5 3 M KCI, San Antonio, TX, USA. 6 Smith and Nephew Healthcare, Hull, United Kingdom. The median operation duration was 195 min (range: 85-305 min), and the median length of hospital stay was 10.5 days (range: 6-220 days).…”

“…For over a decade, various evidence‐based interventions have been shown to reduce IHs, including wound bundles, optimal surgical fascial closure techniques and prophylactic mesh placement (PMP) 5 . Wound bundles, a relatively recent innovation in surgery, are a series of evidence‐based interventions known to improve patient outcomes when combined and have a positive impact on both elective abdominal surgeries and emergency laparotomies 6,7 . Simple techniques, including the documentation of suture‐to‐wound length ratios during fascial closure and the use of small bite sutures, have been shown to reduce IH rates by 30% 8 .…”

“…5 Wound bundles, a relatively recent innovation in surgery, are a series of evidence-based interventions known to improve patient outcomes when combined and have a positive impact on both elective abdominal surgeries and emergency laparotomies. 6,7 Simple techniques, including the documentation of suture-to-wound length ratios during fascial closure and the use of small bite sutures, have been shown to reduce IH rates by 30%. 8 benefits and complication profiles.…”

Effect of Personal Protective Equipment (PPE) on Surgical Site Infection in Emergency Laparotomy: An Observational Study From a Tertiary Care Centre

“…Mc Geehan et al have mentioned a significant deficit in the world literature relating to emergency exploratory laparotomy and SSI in 2021 [ 8 ]. The high load of SSI in low-income countries compared to its counterparts in high and middle-income countries has been published by GlobalSurg Collaborative study in 2018.…”

Closure of Emergency Midline Laparotomy over Subcutaneous Closed Suction Drain to Mitigate Incisional Surgical Site Infection, Dehiscence and Hernia: A Prospective Comparative Study

“…Emergency midline laparotomy (EML) is fundamental to rescue emergency patients who suffer from non-traumatic acute abdomen (1)(2)(3) . Two forms of infections at the surgical site, including incisional surgical site infections (ISSI) and organ/space infections, are encountered in more than one third of patients following EML (4) .…”