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Leaving Incisions Open: Rethinking Common Wisdom on Surgical Site Infection Risk Reduction for Colorectal Surgery Patients

Editor's Comment: Prescient Surgical, Co-Founder and Surgeon, Dr. Insoo Suh, MD, discusses whether the benefits of leaving incisions open after colorectal surgery truly offset the pain and risk caused to patients, citing a recently published article in Diseases of the Colon & Rectum Journal1

A key tenet of surgical teaching is to expect and prepare for the worst, so that surgeons can mitigate the risk of the worst to the best of our ability. This is an inherently cautious approach to thinking about clinical problems and generally tends to serve our patients well. Very often, this philosophy specifically involves accepting a tradeoff between a smaller inconvenience or lesser-risk intervention to offset the risk of something worse.

When it comes to surgical incisions, one commonly taught lesson is to leave the skin incision open when the operation involved a grossly contaminated field, in order to prevent trapping of infected debris and propagation of infection. Nowhere is this more relevant than in complicated open colorectal surgical procedures in which the abdomen had been grossly contaminated by enteric contents or pus.  

When the "Board Answer" may be the Opposite of Reality

The classic “board answer” for how to close the incision in this complicated siutation is to close the fascial layer and leave the skin open, with the thought that this effectively eliminates the risk of superficial SSI while decreasing the risk of deeper fascia-level SSI that could potentially lead to fascial breakdown, evisceration and/or hernia formation. But what if the way we are thinking about the worst case scenario is actually the opposite of reality? In a recently published article in Diseases of the Colon & Rectum journal, Mullen and colleagues set out to examine this question.  

The authors performed a large NSQIP database study of patients undergoing open colorectal surgery, comparing outcomes in those whose skin incisions were left open versus those whose incisions were closed.  As expected, the cases in which the incisions were left open were generally higher-risk, and by definition none of these patients developed a superficial SSI since the skin was left open.  However, on matched cohort comparison there were no differences in mortality or other complications including deep SSI and sepsis. In fact, patients with wounds left open had a longer length of stay in-hospital, and had a higher rate of requiring discharge to an advanced nursing facility.

Rethinking What It Means to Prepare for and Mitigate the Worst Case Scenario

This study suggests that the fears that drive the decision to leave the incision open after contaminated surgery may be overblown. It's also important to note that the outcomes specifically relating to infection control are ultimately unaffected. What definitely is affected, for all open incisions, is the patient experience, which is undoubtedly worse. Care of open wounds is more painful, expensive, and resource-intensive, which probably explains why patients require a longer length of hospital stay and often require skilled nursing facilities upon discharge.

Studies such as this should challenge us to rethink what it means to prepare for and mitigate the “worst case scenario.” In this case, leaving an incision open may not be the lesser-risk strategy that offsets an increased risk of worse outcome, but in fact may actually be the worse outcome that primary incision closure can avoid in the majority of patients.  

References

1 Mullen MG, Hawkins RB, Johnston LE, et al. Open Surgical Incisions After Colorectal Surgery Improve Quality Metrics, But Do Patients Benefit? Dis Colon Rectum. 2018;61(5):622-628.