Research Article
Research Article
Research Article
Research Article
Efficacy of Prophylactic Negative-Pressure Wound Therapy with
Delayed Primary Closure for Contaminated Abdominal Wounds
Yo Sato ,1,2 Eiji Sunami,1 Kenichiro Hirano,1 Motoko Takahashi,1 and Shin-ichi Kosugi1,2
1
Department of Digestive and General Surgery, Uonuma Kikan Hospital, 4132 Urasa, Minami-Uonuma, Niigata 9497302, Japan
2
Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, 4132 Urasa, Minami-Uonuma,
Niigata 9497302, Japan
Received 24 August 2022; Revised 13 October 2022; Accepted 4 November 2022; Published 14 November 2022
Copyright © 2022 Yo Sato et al. Tis is an open access article distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background. Prophylactic negative-pressure wound therapy (NPWT) to prevent surgical site infection (SSI) may be efective for
severely contaminated wounds. We investigated the safety and efcacy of NPWT with delayed primary closure (DPC) for
preventing SSI. Methods. For patients with contaminated and dirty/infected surgical wounds after an emergency laparotomy, the
abdominal fascia was closed with antibacterial absorbent threads and the skin was left open. Negative pressure (−80 mmHg) was
applied through the polyurethane foam, which was replaced on postoperative days 3 and 7. DPC was performed when sufcient
granulation was observed. Te duration and adverse events of NPWT, the development of SSI, and the postoperative hospital stay
were retrospectively reviewed. Results. We analyzed the cases of patients with contaminated (n � 15) and dirty/infected wounds
(n � 7). Te median duration of NPWT was 7 days (range 5–11 days). NPWT was discontinued in one (4.5%) patient due to wound
traction pain. SSI developed in seven patients (31.8%), with incisional SSI in one (4.5%) and organ/space SSI in six (27.3%). Te
median postoperative hospital stay was 17 days (range 7–91 days). Tere was no signifcant relationship between postoperative
hospital stay and wound classifcation (P � 0.17) or type of SSI (P � 0.07). Conclusion. Prophylactic NPWT with DPC was feasible
and may be particularly suitable for severely contaminated wounds, with a low incidence of incisional SSI.
1. Introduction chronic wounds and tissue defects [8, 9], but it is now used to
prevent SSI even in abdominal surgical wounds.
Surgical site infection (SSI) frequently occurs in contami- Two NPWT methods have been widely used as pro-
nated wounds after abdominal surgery, resulting in frequent phylaxis for SSI after abdominal surgery: closed NPWT and
dressing changes and poor appearance after healing. SSI is open NPWT. In closed NPWT, the wound is primarily
a risk factor for incisional hernia, which may impair the closed, and a commercially available, simple, and portable
patient’s quality of life [1]. A prolonged hospital stay due to device is applied on the wound surface to indirectly suck
SSI also increases medical costs [2]. All of these are medical the closed wound. In open NPWT, only the fascia is closed,
and socioeconomic problems that should be avoided. and the skin and subcutaneous tissue are left open; a porous
Various approaches to suppress SSI have been taken, fller is adjusted to the wound size by hand and applied
including the use of a subcutaneous drain [3], delayed directly to suck the open wound. Open NPWT is con-
primary closure (DPC) [4], and SSI bundle [5]; however, sidered to have an advantage in that granulation growth
these methods have not sufciently decreased the rate of SSI. may be accelerated by using the fller directly [7]. However,
Negative-pressure wound therapy (NPWT) has attracted a disadvantage of open NPWT is that the time to wound
attention recently; its use promotes wound healing by in- closure is extended [10]. In this condition, DPC is used
ducing angiogenesis, proliferating fbroblasts, and increasing after open NPWT to shorten the time to wound closure
granulation tissue [6, 7]. NPWT was initially used to treat [11–13].
2 Surgery Research and Practice
Table 2: Causes of intraabdominal contamination and CDC Table 3: Surgical site infection and CDC wound classifcation.
wound classifcation.
Surgical site infection
Causes Number (%) Class III/IV n P
Incisional Organ/space
Upper gastrointestinal diseases CDC wound classifcation
Perforated peptic ulcer 2 (9.1) 2/0 Class III 15 1 5
Perforated gastric cancer 1 (4.5) 0/1 0.17
Class IV 7 0 1
Post-ESD perforation 1 (4.5) 0/1 Total 22 1 (4.5%) 6 (27.3%)
Others 1 (4.5) 1/0
CDC: Centers for Disease Control and Prevention.
Lower gastrointestinal diseases
Small bowel injury 7 (41.1) 6/1
Table 4: Te length of postoperative hospital stay according to the
Perforated diverticulitis 2 (9.0) 1/1
wound status.
Malignancy 3 (13.6) 1/2
Perforated appendicitis 2 (9.0) 2/0 Length of hospital
n P
Others 3 (17.7) 2/1 stay (days)∗
Total 22 (100) 15/7 CDC wound classifcation
CDC: Centers for Disease Control and Prevention; ESD: endoscopic Class III 15 16 (7–91) 0.80
submucosal dissection. Class IV 7 18 (9–38)
Wound closure method
delayed suture and wound taping, respectively. Te Delayed primary closure 11 16 (7–91)
0.74
Wound taping 8 20 (9–25)
remaining three patients required no adaptation procedure
None 3 12 (9–23)
because their wounds were likely to close spontaneously.
Surgical site infection
Surgical site infection (SSI) developed in seven (31.8%)
Incisional 1 13
patients, including one (4.5%) superfcial/deep incisional SSI Organ/space 6 23.5 (18–91)
0.07
and six (27.3%) organ/space SSIs (Table 3). Tere was no None 15 13 (7–38)
signifcant relationship between the CDC wound classif- ∗
Data are depicted as median (range). CDC: Centers for Disease Control
cation and incisional SSI (P � 1.00) or organ/space SSI and Prevention.
(P � 0.61). Te median postoperative hospital stay was
17 days (range 7–91 days), and it had no signifcant re-
lationship with the CDC wound classifcation (P � 0.80) or in the present cases with a class IV wound, which is regarded
the delayed wound closure method (P � 0.74) (Table 4). as the highest degree of contamination.
Although not signifcant, the patients with organ/space SSI It is well known that the development of an SSI prolongs
tended to have longer postoperative hospital stays than those the length of hospital stay and increases medical costs [24].
with a superfcial/deep incisional SSI or no SSI (P � 0.07). Our present fndings indicate that the use of open NPWT
with DPC for contaminated wounds may lead to shorter
4. Discussion hospital stays and lower medical costs.
Te NPWT was completed within the median of 7 days,
Our present fndings demonstrated that the prophylactic use and the median length of hospital stay was 17 days in the
of open NPWT with DPC for contaminated wounds after present series. Te length of hospital stay might vary widely
open abdominal surgery was safe and feasible, as NPWT- among patients due to the diferences in the primary disease,
associated adverse events and incisional SSI occurred in only the patients’ general condition at the time of surgery, and the
one patient each (4.5%) in this study. All patients completed occurrence of organ/space SSI or other complications; for
our fxed protocol within 11 days, and the median post- example, the present patients with organ/space SSI were
operative hospital stay was 15 days. Several studies have likely to have longer postoperative hospital stays compared
examined closed NPWT for noncontaminated wounds to those without this type of SSI (P � 0.07). In the previous
[14–18], but open NPWT with DPC for only contaminated investigations of open NPWT with DPC, mainly the in-
wounds has scarcely been investigated. cidence of incisional SSI was reported, not the length of
Te incidence of incisional SSI when only primary hospital stay. A meta-analysis focusing on closed NPWT
closure was performed on contaminated wounds was ≥50% used in elective surgery showed that the length of hospital
[13], and even DPC provided no signifcant reduction of stay was 0.47 days shorter than that following conventional
incisional SSI (against expectations) [14]. On the other hand, wound dressing (95% confdence interval, −0.71 to −0.23;
Glass et al. reported that open NPWT using a fller promotes P < 0.0001) [25]. A subgroup analysis of that study showed
granulation growth and exerts a bacteriostatic efect on the a greater shortening efect of −5.1 days in colorectal surgery,
wound surface, suppressing nonfermentative Gram- which is regarded as posing a higher degree of wound
negative bacilli including Pseudomonas species in particu- contamination than other surgeries [25]. NPWT might have
lar [23]. It was reported that the use of NPWT with DPC a greater efect for shortening the length of hospital stay in
reduced the incidence of incisional SSI from 63.2% to 10.7% proportion to the degree of wound contamination.
[13] and from 37% to 0% [12]. Te incidence of incisional SSI Few studies have compared open and closed NPWT for
in the present study was 4.5%, which was comparable to contaminated wounds. Frazee et al. reported that the in-
these earlier reports. Notable, no incisional SSI was observed cidence of incisional SSI was 4.2% (1/24) in open NPWT and
4 Surgery Research and Practice
8% (2/25) in closed NPWT (P � 1.0) [10]. Because of that POD: Postoperative day
study’s limited sample size, these data should be assessed by SSI: Surgical site infection.
further investigations with larger sample sizes. In the Frazee
et al. report, DPC was not performed after open NPWT Data Availability
(with the median time to wound healing of 48 days), whereas
the corresponding time in closed NPWT was 7 days Te data that support the fndings of this study are available
(P < 0.0001) [10]. In our present study, DPC was added for from the corresponding author upon reasonable request.
all patients, and the median time to closure was 7 days, with
a comparable incisional SSI rate. Based on these results, it Conflicts of Interest
seems desirable to add DPC to open NPWT.
Open NPWT has the advantage of enabling sequential Te authors declare that they have no conficts of interest.
evaluations of the condition of granulation tissue and the
presence of necrotic tissue in the wound bed, where addi- Authors’ Contributions
tional debridement can also be performed appro-
priately, especially in wounds in poorer condition such as Study conception and design were conducted by YS and SK.
contaminated wounds. Moreover, adding DPC to open Acquisition of data was carried out by YS, ES, KH, MT, and
NPWT might shorten the time to wound closure, as is ES. Analysis and interpretation of data were performed by
observed for closed NPWT. YS and SK. Drafting of the manuscript was carried out by YS
Te limitations of this study are as follows: (1) a small and SK.
number of patients were analyzed because this was a single-
institution study conducted only for patients with con- References
taminated wounds after open abdominal surgery. (2) Our
[1] R. Veljkovic, M. Protic, A. Gluhovic, Z. Potic, Z. Milosevic,
hospital was newly established in June 2015, so we did not and A. Stojadinovic, “Prospective clinical trial of factors
have enough historical data to compare. (3) Te cost- predicting the early development of incisional hernia after
efectiveness of NPWT was not analyzed because of the midline laparotomy,” Journal of the American College of
study’s single-arm, noncomparative design. (4) It was un- Surgeons, vol. 210, no. 2, pp. 210–219, 2010.
certain whether our 7-day protocol was optimal, although [2] J. M. Badia, A. L. Casey, N. Petrosillo, P. M. Hudson,
angiogenesis and the growth of granulation tissue during S. A. Mitchell, and C. Crosby, “Impact of surgical site in-
NPWT are reported to progress within 3–10 days [6]. Ma fection on healthcare costs and patient outcomes: a systematic
et al. also reported that NPWT signifcantly improved an- review in six European countries,” Journal of Hospital In-
giogenesis that preceded granulation in dermal regeneration fection, vol. 96, pp. 1–15, 2017.
from days 3 to 7 compared to gauze dressing [6]. Tese [3] B. Manzoor, N. Heywood, and A. Sharma, “Review of sub-
cutaneous wound drainage in reducing surgical site infections
fndings were consistent with our clinical observations; it
after laparotomy,” Surgery Research and Practice, vol. 2015,
thus seemed rational to continue NPWT for at least 7 days. Article ID 715803, 6 pages, 2015.
(5) It was also uncertain whether the negative pressure at [4] B. Siribumrungwong, P. Noorit, C. Wilasrusmee, and
−80 mmHg was optimal, although we selected the recom- A. Takkinstian, “A systematic review and meta-analysis of
mended negative pressure according to the NPWT system randomised controlled trials of delayed primary wound
manufacturer’s instructions. In their review, Birke et al. closure in contaminated abdominal wounds,” World Journal
recommended the negative pressure values within −50 to of Emergency Surgery, vol. 9, no. 1, p. 49, 2014.
−150 mmHg considering the tissue blood fow, granulation [5] T. Yamamoto, T. Morimoto, R. Kita et al., “Te preventive
growth, wound contraction, and microdeformation, and surgical site infection bundle in patients with colorectal
they also recommended setting a lower negative pressure perforation,” BMC Surgery, vol. 15, no. 1, p. 128, 2015.
[6] Z. Ma, Z. Li, K. Shou et al., “Negative pressure wound therapy:
value to improve pain [26]. It seems acceptable that only one
regulating blood fow perfusion and microvessel maturation
patient had traction pain in the present study. through microvascular pericytes,” International Journal of
In conclusion, we performed open NPWT with DPC for Molecular Medicine, vol. 40, no. 5, pp. 1415–1425, 2017.
contaminated and dirty/infected surgical wounds and were [7] A. K. McNulty, M. Schmidt, T. Feeley, and K. Kieswetter,
able to safely treat these wounds. Tis method can be applied “Efects of negative pressure wound therapy on fbroblast
fexibly for wounds of difering status, and it can lower the viability, chemotactic signaling, and proliferation in a pro-
incidence of incisional SSI. Te method is particularly visional wound (fbrin) matrix,” Wound Repair and Re-
suitable for severely contaminated wounds. Further in- generation, vol. 15, no. 6, pp. 838–846, 2007.
vestigation comparing this method with closed NPWT in [8] N. Robert, “Negative pressure wound therapy in orthopaedic
terms of cost-efectiveness and optimal treatment in- surgery,” Orthopaedics and Traumatology: Surgery & Re-
dications is warranted. search, vol. 103, no. 1, pp. S99–S103, 2017.
[9] S. Borys, J. Hohendorf, T. Koblik et al., “Negative-pressure
wound therapy for management of chronic neuropathic non-
Abbreviations infected diabetic foot ulcerations-short-term efcacy and
long-term outcomes,” Endocrine, vol. 62, no. 3, pp. 611–616,
CDC: Centers for disease control and prevention 2018.
DPC: Delayed primary closure [10] R. Frazee, A. Manning, S. Abernathy et al., “Open vs. closed
NPWT: Negative-pressure wound therapy negative pressure wound therapy for contaminated and dirty
Surgery Research and Practice 5
surgical wounds: a prospective randomized comparison,” Reconstructive & Aesthetic Surgery, vol. 70, no. 8, pp. 1028–
Journal of the American College of Surgeons, vol. 226, no. 4, 1037, 2017.
pp. 507–512, 2018. [24] N. Kashimura, S. Kusachi, T. Konishi et al., “Impact of
[11] H. Ota, K. Danno, K. Ohta et al., “Efcacy of negative pressure surgical site infection after colorectal surgery on hospital stay
wound therapy followed by delayed primary closure for ab- and medical expenditure in Japan,” Surgery Today, vol. 42,
dominal wounds in patients with lower gastrointestinal no. 7, pp. 639–645, 2012.
perforations: multicenter prospective study,” Journal of the [25] V. Strugala and R. Martin, “Meta-analysis of comparative
Anus, Rectum and Colon, vol. 4, no. 3, pp. 114–121, 2020. trials evaluating a prophylactic single-use negative pressure
[12] G. Lozano-Balderas, A. Ruiz-Velasco-Santacruz, J. A. Dı́az- wound therapy system for the prevention of surgical site
Elizondo, J. A. Gómez-Navarro, and E. Flores-Villalba, complications,” Surgical Infections, vol. 18, no. 7, pp. 810–819,
“Surgical site infection rate drops to 0% using a vacuum- 2017.
assisted closure in contaminated/dirty infected laparotomy [26] H. Birke-Sorensen, M. Malmsjo, P. Rome et al., “Evidence-
wounds,” Te American Surgeon, vol. 83, no. 5, pp. 512–514, based recommendations for negative pressure wound therapy:
2017. treatment variables (pressure levels, wound fller and contact
[13] K. Danno, C. Matsuda, S. Miyazaki et al., “Efcacy of negative- layer)-steps towards an international consensus,” Journal of
pressure wound therapy for preventing surgical site infections Plastic, Reconstructive & Aesthetic Surgery, vol. 64, pp. S1–S16,
after surgery for peritonitis attributable to lower- 2011.
gastrointestinal perforation: a single-institution experience,”
Surgical Infections, vol. 19, no. 7, pp. 711–716, 2018.
[14] J. Shiroky, E. Lillie, H. Muaddi, M. Sevigny, W. J. Choi, and
P. J. Karanicolas, “Te impact of negative pressure wound
therapy for closed surgical incisions on surgical site infection:
a systematic review and meta-analysis,” Surgery, vol. 167,
no. 6, pp. 1001–1009, 2020.
[15] T. M. Kuper, P. B. Murphy, B. Kaur, and M. C. Ott, “Pro-
phylactic negative pressure wound therapy for closed lapa-
rotomy incisions: a meta-analysis of randomized controlled
trials,” Annals of Surgery, vol. 271, no. 1, pp. 67–74, 2020.
[16] J. Flynn, A. Choy, K. Leavy et al., “Negative pressure dressings
(PICOTM) on laparotomy wounds do not reduce risk of
surgical site infection,” Surgical Infections, vol. 21, no. 3,
pp. 231–238, 2020.
[17] D. P. O’Leary, C. Peirce, B. Anglim et al., “Prophylactic
negative pressure dressing use in closed laparotomy wounds
following abdominal operations: a randomized, controlled,
open-label trial: the P. I. C. O. trial,” Annals of Surgery,
vol. 265, pp. 1082–1086, 2017.
[18] P. Shen, A. U. Blackham, S. Lewis et al., “Phase II randomized
trial of negative-pressure wound therapy to decrease surgical
site infection in patients undergoing laparotomy for gastro-
intestinal, pancreatic, and peritoneal surface malignancies,”
Journal of the American College of Surgeons, vol. 224, no. 4,
pp. 726–737, 2017.
[19] C. Hall, J. Regner, S. Abernathy et al., “Surgical site infection
after primary closure of high-risk surgical wounds in emer-
gency general surgery laparotomy and closed negative-
pressure wound therapy,” Journal of the American College
of Surgeons, vol. 228, no. 4, pp. 393–397, 2019.
[20] D. S. Liu, C. Cheng, R. Islam et al., “Prophylactic negative-
pressure dressings reduce wound complications and resource
burden after emergency laparotomies,” Journal of Surgical
Research, vol. 257, pp. 22–31, 2021.
[21] N. W. Kugler, T. W. Carver, and J. S. Paul, “Negative pressure
therapy is efective in abdominal incision closure,” Journal of
Surgical Research, vol. 203, no. 2, pp. 491–494, 2016.
[22] A. J. Mangram, T. C. Horan, M. L. Pearson, L. C. Silver, and
W. R. Jarvis, “Guideline for prevention of surgical site in-
fection, 1999 Centers for disease control and prevention
(CDC) hospital infection control practices advisory com-
mittee,” American Journal of Infection Control, vol. 27, no. 2,
pp. 97–134, 1999.
[23] G. E. Glass, G. R. F. Murphy, and J. Nanchahal, “Does
negative-pressure wound therapy infuence subjacent bacte-
rial growth? A systematic review,” Journal of Plastic,
Copyright of Surgery Research & Practice is the property of Hindawi Limited and its content
may not be copied or emailed to multiple sites or posted to a listserv without the copyright
holder's express written permission. However, users may print, download, or email articles for
individual use.