Review
Intraoperative technique as a factor in the prevention of surgical site infection

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Summary

Approximately five percent of patients who undergo surgery develop surgical site infections (SSIs) which are associated with an extra seven days as an inpatient and with increased postoperative mortality. The competence and technique of the surgeon is considered important in preventing SSI. We have reviewed the evidence on different aspects of surgical technique and its role in preventing SSI. The most recent guidelines from the National Institute for Health and Clinical Excellence in the UK recommend avoiding diathermy for skin incision even though this reduces incision time and blood loss, both associated with lower infection rates. Studies comparing different closure techniques, i.e. continuous versus interrupted sutures, have not found a statistically significant difference in the SSI rate, but using continuous sutures is quicker. For contaminated wounds, the surgical site should be left open for four days to allow for treatment of local infection before subsequent healing by primary intention. Surgical drains should be placed through separate incisions, closed suction drains are preferable to open drains, and all drains should be removed as soon as possible. There are relatively few large studies on the impact of surgical techniques on SSI rates. Larger multicentre prospective studies are required to define what aspects of surgical technique impact on SSI, to better inform surgical practice and support education programmes for surgical trainees.

Introduction

Surgical site infections (SSIs) account for 20% of healthcare-associated infections.1 Approximately 5% of patients who undergo surgery develop SSI.2 Patients with SSI are more likely to be admitted to the intensive care unit (ICU), remain in hospital approximately seven days longer, and have a significantly higher postoperative mortality.3 Thus SSI imposes severe demands on healthcare systems at a time when resources are particularly constrained.4

A number of procedure-related risk factors have been associated with SSI. These include long duration of procedure, wound classification, and absence of antibiotic prophylaxis. Length of stay before or after surgery is also a risk factor; inpatient stay for >48 h before or for five days after the procedure increases the chances of SSI.5, 6

Aside from intraoperative technique, there are several standard approaches to prevent SSI. These include patient preparation, hand antisepsis, appropriate antimicrobial prophylaxis before surgery, and postoperative surgical site care.7 Surgical attire is strictly regulated, as is the environment in the operating theatre.7 The bacterial counts in operating room air are directly proportional to the number of people moving about in the room.8 Early studies demonstrated a correlation between airborne bacteria and postoperative SSI in joint arthroplasty.9, 10 However, a recent study queried the use of laminar air flow in operating theatres, reporting no reduction in SSI through its use.11

Most surgical teams have a strict view on surgical attire, changing into scrubs as well as wearing appropriate caps and masks. The number of people moving about in the operating room, although important, can be difficult to restrict given that many hospitals are also major referral centres with significant teaching commitments involving the presence of medical students in the operating theatre. Procedures and protocols in the operating theatre to minimise infection have recently been reviewed, but current practice is based on tradition and ritual, rather than on well-conducted trials.12

The literature suggests that the most important factor in determining postoperative infection rate is competence of the surgeon.13, 14 Guidelines for SSI prevention also acknowledge the importance of surgical technique as a risk factor.7, 15 Issues such as gentle tissue handling to minimise trauma, the use of diathermy, maintenance of haemostasis, and adequate debridement, are regarded as influential and should be stressed in surgical training. Many publications on the epidemiology and prevention of SSI comment on the effect of surgical technique without giving any specifics. Here we review the literature on surgical technique and its role or potential role in preventing SSI.

Section snippets

Methods

A detailed literature assessment was performed of peer-reviewed papers published in English between 1980 and February 2010 recorded in PubMed. Terms used in the search included ‘surgical technique’, ‘operative technique’, ‘surgical site infection’, ‘healthcare associated infection’, ‘surgery’, ‘infection prevention’ and ‘best practice guidelines for surgery’.

Implications for surgical practice

We have assessed guidelines and the literature to see if there is an evidence base to support specific aspects of surgical technique in preventing SSI despite the strong view that the operative technique of the individual surgeon is an important risk factor.13, 14 Establishing which features of intraoperative technique affect SSI rates is vital as this must be incorporated into surgical training. Studies to date have not shown statistically significant differences in SSI rates between different

Conclusion

There are relatively few large or rigorously well-conducted studies on surgical techniques and their impact on SSI rates. Larger multicentred prospective studies are required to define better what aspects of surgical technique impact on SSI. In addition to improving the outcomes from surgery, this evidence base could inform education programmes for surgical trainees with regard to optimising surgical technique.45

Conflict of interest statement/funding sources

H.H. has received research funding or support from Pfizer, Steris Corporation, 3M, Inov8 Science and Cepheid in the last three years. He has also received lecture or consultancy fees from 3M, Novartis and Astellas.

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