Surgical site infection in cesarean sections with the use of a plastic sheath wound retractor compared to the traditional self-retaining metal retractor

Alexis retractor efficacy in transthoracic thoracoscopically assisted discectomy for thoracic disc herniations

PURPOSE

A transthoracic anterior or lateral approach for giant thoracic disc herniations is a complex operation which requires optimal exposure and maximal visualisation. Traditional metal rigid retractors may inflict significant skin trauma especially with prolonged operative use and limit the working angles of endoscopic instrumentation at depth. We pioneer the use of the Alexis retractor in transthoracic thoracoscopically assisted discectomy for the first time.

METHODS

The authors describe and demonstrate the technical use of the Alexis retractor during operative cases. Patient positioning, clinical rationale and operative nuances are elucidated for readers to gain an appreciation of the transthoracic approach to thoracic disc herniations.

RESULTS

The advantages of the Alexis retractor include minimally invasive circumferential flexible retraction, facilitation of bimanual instrument use, diminished risk of surgical site infections and reduced rib retraction leading to less postoperative pain.

CONCLUSION

Use of the flexible and intuitive Alexis retractor maximises operative exposure and is an effective adjunct when performing complex transthoracic approaches for thoracic disc herniations.

Comparison of the Ventral Approach to the Canine Hip Joint Using Gelpi Retractors and an Elastic O-Ring Wound Retractor

This study included 10 fresh adult cadavers of large breed dogs (6 males and 4 females). Their weight ranged from 25 to 45 kg (mean ± SD: 33.9 ± 6.2 kg). The breeds represented were crossbreed dogs (n = 5), German shepherds (n = 2), Bernese mountain dogs (n = 1), American Staffordshire terriers (n = 1), and Gordon setters (n = 1). Access to the target area and identification of the femoral head and neck was achieved with two Gelpi retractors inserted orthogonally and with the O-WR in all procedures. In each dog, the approach to the hip joint was made on the left and right sides. There was no significant difference in the area of the surgical wound bed between the two sides using either the Gelpi retractors (-0.52 ± 1.87 cm2; CI 95%: -1.86, 0.81 cm2; p = 0.398) or the O-WR (-0.27 ± 2.34 cm2; CI 95%: -1.94, 1.41 cm2; p = 0.729). The area of the surgical wound bed was 6.28 ± 1.72 cm2 (2.72-9.70 cm2) for the Gelpi retractors and 6.34 ± 1.81 cm2 (4.13-10.77 cm2) for the O-WR, and the difference between the Gelpi retractors and the O-WR was not significant (-0.06 ± 1.72 cm2; CI 95%: -0.86, 0.74 cm2; p = 0.879).

Alexis O-ring wound retractor versus traditional metal retractors for the prevention of postcaesarean surgical site infections

BACKGROUND

Postcaesarean surgical site infections (SSI) remain a burden globally. The Alexis® O C-Section Retractor, a plastic sheath retractor known to have decreased incidence of SSIs in gastrointestinal surgery, is yet to have its efficacy established during caesarean section (CS). This study aimed to compare the differences in the rate of postcaesarean surgical wound site infections between the Alexis® retractor and traditional metal retractors during CS at a large tertiary hospital in Pretoria.

METHODS

Pregnant women scheduled for elective CS were prospectively randomised to either the Alexis® retractor group or the traditional metal retractor group at a tertiary hospital in Pretoria between August 2015 and July 2016. The defined primary outcome was development of SSI, and secondary outcomes comprised patients' peri-operative parameters. All participants' wound sites were observed in the hospital for 3 days before discharge and again at 30 days postpartum. Data were analysed using SPSS version 25 with p  0.05 considered significant.

RESULTS

A total of 207 participants were involved, Alexis® (n = 102) and metal retractors (n = 105). None of the participants developed postsurgical site wound infection after 30 days, and there were no differences in time to delivery, total operative time, estimated blood loss or postoperative pain between the two arms of study.

CONCLUSION

The study found no difference in participants' outcomes using the Alexis® retractor in comparison with the traditional metal wound retractors. We suggest that the use of Alexis® retractor be at the surgeon's discretion and its routine use not advised for now.Contribution: This research being the first of its kind in South Africa in which patients' clinical outcomes were compared post caesarean section from Alexis's plastic sheath group and metal retractors group in an attempt to proffer solution to the high burden of SSI. Although no difference was seen at this point, the research was pragmatic, as it was carried out in a setting with high burden of SSI. The study is going to serve as a baseline against which studies carried out in future can be compared.

Implementation of an evidence-based bundle to reduce surgical site infection after caesarean section - Review of the interventions

BACKGROUND

Surgical site infection (SSI) is the most common complication post caesarean section (CS) with a significant impact on women and health services. A bundle approach incorporating previously studied individual interventions has shown increased reductions in SSI.

AIM

To assess compliance with a SSI intervention bundle and to examine readmission rates for SSI.

METHODS

A retrospective audit of women who underwent CS at a regional hospital in Queensland, Australia pre-intervention (February 2015-January 2017) and post-intervention (February 2018-December 2020).

RESULTS

There was good compliance with vaginal cleansing (27.7% vs 84.8%), chlorhexidine skin preparation (90.4% vs 98.4%), BMI-based antibiotic dose adjustment (48.8% vs 74.3%), and Alexis retractor use (9.9% vs 66%), pre and post-implementation periods respectively. There was a reduction in documented hair shaving (2.1% vs 0.5%). There was a trend towards less admission for SSI, a trend that could have been even better had there not been an increasing number of women with high BMI over the years. Fewer cases needed return to theatre post-implementation. Endometritis rates were unchanged.

CONCLUSIONS

Good compliance can be achieved with good collaboration. There was a reduction in admission rates for SSI. Larger prospective studies are needed to further examine these findings.

Laparoscopic guided minilaparotomy: a modified technique for management of benign large ovarian cysts

BACKGROUND

The aim of the study is to evaluate the efficiency and safety of a novel technique to treat large benign ovarian cysts combining benefits of laparoscopic management along with mini-laparotomy without affection of the ovarian reserve.

METHODS

The study included 112 women with large benign ovarian cyst candidate for ovarian cystectomy. The technique started with laparoscopy followed by guided cyst aspiration followed by exteriorization of the ovary through minilaprotomy and completion of cystectomy through microsurgical technique. The primary outcome was ipsilateral recurrence of the cyst. Other outcomes included ovarian reserve assessment and postoperative pain.

RESULTS

The number of women with recurrence in the ipsilateral ovary after 12, 18 and 24 months were 5 (4.5%),16 (14.3%),20 (17.85%) respectively. Assessment of ovarian reserve revealed a significant decrease in the level of serum AMH (2.82 ± 0.44 vs. 2.50 ± 0.42) and a significant increase in AFC (3.5 ± 1.7 vs. 4.9 ± 1.3) after our novel technique in surgical treatment of ovarian cysts (P value < 0.001). The operative time was 50 ± 7 and 62 ± 7 min in unilateral and bilateral cysts respectively.

CONCLUSIONS

Laparoscopic guided minilaparotomy is a safe and effective technique for the management of large benign ovarian cysts with minimal recurrence rate, ovarian reserve affection and adhesions.

TRIAL REGISTRATION

clinical trial registry no. NCT03370952. Registered 13 December 2017, https://clinicaltrials.gov/ct2/show/NCT03370952.

Alexis Retractor: Institutional Experience of Its Applications in Head and Neck Surgery and Review of the Literature

BACKGROUND

The Alexis retractor is a device that provides simultaneous radial retraction and wound protection during surgical procedures. Although typically used in abdominal and pelvic surgeries, there has been increased development of novel operative techniques utilizing the Alexis retractors in head and neck surgeries.

METHODS

We describe 2 cases of utilizing the Alexis retractor to attain transoral exposure in the setting of free flap reconstruction of intraoral defects.

RESULTS

In both cases, the Alexis retractor provided improved retraction, decreasing the number of instruments required for adequate exposure. Additionally, the polyurethane sheath component acted as a protective membrane over the lips and mucosa.

CONCLUSIONS

The Alexis retractor can be a powerful retraction tool for certain surgical procedures involving the head and neck regions.

Mini-invasive approach for removal of iliopsoas migrating grass awns with an atraumatic wound retractor

This case series describes a novel mini coeliotomy approach using a radial, atraumatic self-retaining retractor for the retrieval of migrant plant foreign bodies from the iliopsoas muscles of six male dogs under intra-operative ultrasonographic guidance. Four dogs had a history of pulmonary disease potentially compatible with inhalation of a foreign body approximately 2-4 months before presentation. Under ultrasonographic guidance, the grass awns were identified in the iliopsoas muscle and were completely removed. In this case series, the annular ring device provided an excellent view of the surgical field for intra-abdominal manipulations. Patient follow-up at 15 days and 6 to 12 months after surgery indicated a full recovery, and no grass awn fragment residues were identified.

Infections complicating cesarean delivery

PURPOSE OF REVIEW

Cesarean sections are common surgical procedures performed in a healthy population and are unique because of a relatively high rate of postoperative infection. There have been many important advances in understanding the pathogenesis of infection and evaluation of interventions to prevent post cesarean section infections in the last few years. Our purpose in this review is to analyze these new data, discuss unanswered questions, and propose changes in standard of care.

RECENT FINDINGS

Wound closure techniques including subcuticular sutures and subcutaneous suturing have been shown to be effective at reducing surgical site infections. Wound dressings including negative pressure dressings likely do not decrease infection rates. The type, timing, and duration of preoperative prophylactic antibiotics, including adjunctive azithromycin for laboring women and multidose antibiotics in obese women, have also yielded mixed results. Our understanding of normal uterine microbiome and the impact of intrapartum antibiotics on the newborn is emerging.

SUMMARY

The pathogenesis of surgical site infections after Cesarean section is complex and multifactorial. Many interventions to reduce infections have been studied with varying degrees of effectiveness. Despite advances in the area, important questions remain unanswered.

Wound protectors for improved exposure in open hernia repair

INTRODUCTION

Achieving adequate surgical exposure is fundamental to good surgical practice. Traditionally, in the repair of ventral and open inguinal hernias, this has been accomplished with the aid of self-retaining retractors or by extending the incision length. We propose that using disposable wound protectors, surgical exposure will be improved for a given incision length in the repair of ventral and open inguinal hernias, compared to traditional methods.

METHOD

Through the use of an animal tissue model, we compared incisions of varying lengths and measured the dimensions of the exposure achieved with disposable wound protectors (Alexis™) and a Mollison self-retainer. We calculated the surface area and, therefore, exposure gained using the specified wound retraction devices and compared the results.

RESULTS

The average superficial surface area of wound with a self-retainer compared to the small and extra-small disposable wound protector was 2.65 cm² vs 2.27 cm² (small) and 2.2 cm² (extra-small) for 2 cm incision length, 3.6 cm² vs 4.93 cm² and 4.2 cm² for 3 cm incision length, 5.19 cm² vs 8.25 cm² and 6.27 cm² for 4 cm incision length, 6.17 cm² vs 12.25 cm² and 9.07 cm² for 5 cm incision length, and 8.75 cm² vs 16.73 cm² and 10.78 cm² for 6 cm incision length [p = 0.038 (small) and p = 0.049 (extra-small)]. Our results show a statistically significant increase in surface area of a wound for each incision length when a disposable wound protector was used for exposure, compared to a self-retainer.

CONCLUSION

Our results demonstrate that the use of disposable wound protectors provides superior surgical exposure for a given incision length compared to traditional techniques in the repair of ventral and open inguinal hernia repairs.

Alexis Wound Retractor for Radical Cystectomy: A Safe and Effective Method for Retraction

Surgical site infection rates remain a common postoperative problem that continues to affect patients undergoing urologic surgery. Our study seeks to evaluate the difference in surgical site infection rates in patients undergoing open radical cystectomy when comparing the Bookwalter vs. the Alexis wound retractors. After institutional review board approval, we performed a retrospective chart review from February 2010 through August 2017 of patients undergoing open radical cystectomy with urinary diversion for bladder cancer. We then stratified the groups according to whether or not the surgery was performed with the Alexis or standard Bookwalter retractor. Baseline characteristics and operative outcomes were then compared between the two groups, with the main measure being incidence of surgical site infection as defined by the CDC. We evaluated those presenting with surgical site infections within or greater than 30 postoperatively. Of 237 patients who underwent radical cystectomy with either the Alexis or Bookwalter retractor, 168 patients were eligible to be included in our analysis. There was no statistical difference noted regarding surgical site infections (SSIs) between the two groups; however, the trend was in favor of the Alexis (3%) vs. the Bookwalter (11%) at less than 30 days surgery. The Alexis wound retractor likely poses an advantage in reducing the incidence in surgical site infections in patients undergoing radical cystectomy; however, multicenter studies with larger sample sizes are suggested for further elucidation.

The use of O-ring retractors at Caesarean section : A systematic review and meta analysis

O-ring retractors (Alexis/Mobius) have been shown to reduce the risk of Surgical site infection (SSI) following general abdominal surgery. The benefit at caesarean section (CS) remains to be established given the relatively high cost.

OBJECTIVES

To assess the efficacy of O-ring retractors when used at CS.

STUDY DESIGN

Systematic review and meta-analysis. Electronic databases were searched from inception of each database until January 2018. No language restrictions were applied. All randomised controlled trials (RCTs) which compared the use of an O-ring retractor to routine care at CS were included. Primary outcome was SSI. Secondary outcomes were operating time, estimated blood loss, need for blood transfusion, need to exteriorise the uterus, requirement for additional postoperative analgesia and adequate operative field visualisation. Analysis was performed using Revman 5.3.

RESULTS

6 RCTs were included in the qualitative synthesis and the meta-analysis. This included 1669 women. The use of O-ring retractors did not reduce the risk of SSI when used at CS RR 0.76 (95% CI 0.34-1.70). Nor did the use of O-ring retractors reduce the operating time, estimated blood loss, the need for blood transfusion or the need for additional postoperative analgesia. The use O-ring retractors did reduce the need for exteriorisation of the uterus RR 0.48 (95% CI 0.33-0.69), and did increase the rate of adequate visualisation of the operative field RR 1.05 (95% CI 1.00-1.10). In a planned subgroup analysis there was a reduction in the rate of SSI with the use of O-ring retractors in women with a BMI < 35 RR 0.34(95% CI 0.12-0.98).

CONCLUSION

This review has shown that O-ring retractors do not reduce the incidence of the common measurable complications of CS; SSI, blood loss, need for blood transfusion and need for additional postoperative analgesia. There may be a subgroup where these retractors are useful, but present evidence does not justify their routine use at CS.