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Impact of wound edge protection devices on surgical site infection after laparotomy: multicentre randomised controlled trial (ROSSINI Trial)

BMJ 2013; 347 doi: (Published 31 July 2013) Cite this as: BMJ 2013;347:f4305

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Re: Impact of wound edge protection devices on surgical site infection after laparotomy: multicentre randomised controlled trial (ROSSINI Trial)

The authors have done well to overcome the difficulties inherent in conducting a multi-centre randomised surgical trial albeit they do not state how patients were identified and recruited merely “enrolled”. The implication is that all eligible patients were enrolled.

The overall wound infection rate of 25.0% is “comparable” to three contemporary reports of colorectal surgery but does not critically discuss why the rate is higher than many studies conducted over a comparable range of operative contamination and with the necessary post-discharge surveillance. An SSI rate of 28.3% in “clean” and 23.3% in “clean-contaminated “ wounds should be ringing alarm bells. To claim that high rates are simply due to more rigorous assessment is not convincing.

Preventing infection in a laparotomy wound is not a uni-dimensional activity and low infection rates result from the application of a consistent policy or, in contemporary parlance, “bundle” of elements which results from identifying best practice in the context of observational rather than randomised studies, which demonstrate high quality outcomes i.e. low SSI rates. Analysing individual elements in a bundle is predictably unlikely to show a difference as occurred in this trial.

We have reported low wound infections rates after laparotomy in both a randomised controlled trial setting (40/757: 5.3%) and longitudinal ten year observational study (116/3100: 3.7%) with post-discharge review in 97.5% of patients. The operative bundle comprised:
1 Immediate pre-incision depilation
2 Single dose peroperative prophylactic antibiotic or three day therapeutic course
3 Chlorhexidine in alcohol skin preparation
4 Wound towels sutured to peritoneum
5 Plastic ring drape before opening hollow viscus
6 Red danger towel technique
7 Peritoneal lavage with tetracycline solution on completion of resection/anastomosis
8 Change of gloves and instruments before abdominal facial closure
9 Further tetracycline lavage of subcutaneous space prior to skin closure

The passage of time has enforced some changes, non-availability of parenteral tetracycline, replaced with cefotaxime, Turkish wound towels replaced with disposable fabric and the red linen “danger” towel with a disposable drape. In our practice this bundle has been consistently applied, every laparotomy wound reviewed after discharge and the information recorded prospectively in a database. In the last 647 emergency and elective colorectal operations with an abdominal incision there have been 27 (4.2%) confirmed or possible wound infections.

The ritual of a red danger towel and change of contaminated instruments, gloves and drapes , espoused by Lord Moynihan may not be standard practice in the UK but perhaps as this paper demonstrates it is time more attention was paid to the technical conduct of a laparotomy2.

Krukowski ZH, Cusick EL, Engeset J, Matheson NA Polydioxanone or polypropylene for closure of midline abdominal incisions: a prospective comparative clinical trial Brit J Surg 1987; 74 828-30
Krukowski ZH, Matheson NA. Ten year computerised audit of infection after abdominal surgery. Brit J Surg 1988;75: 857-61
Moynihan BGA. The ritual of a surgical operation. Brit J Surg 1920;8:27-35

Competing interests: No competing interests

08 August 2013
Zygmunt H Krukowski
Professor of Clinical Surgery
Aberdeen Royal Infirmary
Ward 501, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN