Pilonidal Cyst Excision: Primary Midline Closure with versus without Closed Incision Negative Pressure Therapy

Background

Pilonidal cysts are a painful condition that primarily affect young adult men. In the literature, numerous operative techniques for resolving pilonidal cysts are described, with variable outcomes. The objective of this study was to compare primarily closed midline incisions managed with or without the use of closed incision negative pressure therapy after pilonidal cyst excision.

Methods

Twenty-one patients underwent excision and midline primary closure. Postoperative care composed of closed incisional negative pressure therapy (study group; n = 10) or gauze dressings (control group; n = 11). In both groups, the sutures were partially removed on day 14 and completely removed on day 21. Compared outcomes included the duration of hospitalization, pain on the day of surgical procedure, and on postoperative day 7, and time-to-healing.

Results

The median hospital stay was about 9 hours and 23 hours in the study and control groups, respectively (P < 0.05). The median pain scores on the day of operation were 1.20/10 in the study group and 3.36/10 in the control group (P < 0.05). On day 7, study group showed median pain score 0.9/10 and control group showed 2.63/10 (P < 0.05). The mean healing time was 23.8 and 57.9 days in the ciNPT group and gauze group, respectively (P < 0.05).

Conclusion

These outcomes supported the incorporation of closed incision negative pressure therapy into our surgical treatment protocol for pilonidal cysts.

Closed Incisional Negative Pressure Therapy Significantly Reduces Early Wound Dehiscence after Reduction Mammaplasty

Background:

Closed incisional negative pressure therapy (ciNPT) has been shown to improve surgical outcomes. Functional reduction mammaplasty has a wound dehiscence rate of 25% and higher in most series, requiring extra care and delayed secondary healing. We aimed to determine if shifting from standard care dressings to ciNPT reduced early dehiscence after breast reduction.

Methods:

This multisurgeon retrospective study compared consecutive patients undergoing primary breast reduction dressed with ciNPT to similar patients with standard dressing materials. Perioperative management was otherwise unchanged. Early dehiscence was defined as incisional disruption requiring wound care within the first 30 postoperative days. Statistical analyses were performed using t-test and Fisher exact test.

Results:

We analyzed 79 patients with 158 breasts (114 standard and 44 ciNPT). Both groups were similar. Mean ages were 35 and 34 years; body mass index, 28.5 and 27.4 kg/m²; and reduction volumes, 565 and 610 g, respectively. None were active smokers, and 9.5% were former smokers. Wise pattern skin incisions were used in all, and parenchymal resections mostly utilized superomedial pedicles. Median ciNPT treatment was 6 days. Early dehiscence was significantly lower with ciNPT, occurring in only 1 of 44 (2%) breasts, compared to 16 of 114 in the standard group (14%), P = 0.003, a relative risk reduction of 84%. Two control patients required debridement, whereas none of the ciNPT patients did.

Conclusion:

Application of ciNPT markedly decreased early dehiscence requiring wound care, compared to using standard dressings, in otherwise similarly risk-stratified breast reduction patients.

Use of Closed Incisional Negative Pressure Wound Therapy After Revision Total Hip and Knee Arthroplasty in Patients at High Risk for Infection: A Prospective, Randomized Clinical Trial

BACKGROUND

Continuous wound drainage after arthroplasty can lead to the development of a periprosthetic joint infection. Closed incisional negative pressure wound therapy (ciNPWT) has been reported to help alleviate drainage and other wound complications. The purpose of this prospective randomized controlled trial is to compare the use of ciNPWT with our standard of care dressing in revision arthroplasty patients who were at high risk to develop wound complications.

METHODS

A total of 160 patients undergoing elective revision arthroplasty were prospectively randomized to receive either ciNPWT or a silver-impregnated occlusive dressing after surgery in a single institution. Patients were included if they had at least 1 risk factor for developing wound complication(s): wound complication, readmission, and reoperation rates were collected at 2, 4, and 12 weeks postoperatively.

RESULTS

The postoperative wound complication rate was significantly higher in the control cohort compared to the ciNPWT cohort (19 [23.8%] vs 8 [10.1%], P = .022). There was no significant difference between the control and ciNPWT cohorts in terms of readmissions (19 [23.8%] vs 16 [20.3%], P = .595). Reoperation rate was higher in controls compared to ciNPWT patients (10 [12.5%] vs 2 [2.5%], P = .017). After adjusting for the history of a prior periprosthetic joint infection and inflammatory arthritis, the ciNPWT cohort had a significantly decreased wound complication rate (odds ratio 0.28, 95% confidence interval 0.11-0.68).

CONCLUSION

ciNPWT may decrease the rate of postoperative wound complications in patients who are at an increased risk of such wound issues after revision arthroplasty.

Closed-incision negative pressure therapy to reduce groin wound infections in vascular surgery: a randomised controlled trial

Groin wound infections pose a major problem in vascular surgery. Closed-incision negative pressure therapy (ciNPT) was especially designed for the management of incisions at risk of surgical site infections. The aim of this study was to investigate whether ciNPT is able to reduce the incidence of wound infections after vascular surgery. Data on 132 consecutive patients, scheduled for vascular surgery with a longitudinal femoral cutdown, were collected prospectively. All patients were randomised either to the ciNPT group (n = 64) or the control group (n = 68) with conventional dressing. In the ciNPT group, the foam dressing was applied intraoperatively and removed after 5 days. The control group received an absorbent dressing. All wounds were evaluated after 5 and 42 days. Infections were graded according the Szilagyi classification (I-III°). There were no significant differences between both groups considering patient characteristics. Indications for surgery were peripheral arterial disease in 95% (125/132) and aneurysm in 5% (7/132). The overall infection rates were 14% (9/64) in the ciNPT group and 28% (19/68) in the control group (P = 0·055). Early infections were observed in 6% (4/64) of the ciNPT group and 15% (10/68) of the control group (P = 0·125). ciNPT did not reduce infection rates associated with different risk factors for infection. While the experiences with the ciNPT device were encouraging, the study fails to provide evidence of the efficacy of the device to reduce groin wound infections after vascular surgery. It illustrates far more that larger multicentre studies are required and appear promising to provide further evidence for the use of ciNPT.

Improving wound healing and preventing surgical site complications of closed surgical incisions: a possible role of Incisional Negative Pressure Wound Therapy. A systematic review of the literature

Advances in preoperative care, surgical techniques and technologies have enabled surgeons to achieve primary closure in a high percentage of surgical procedures. However, often, underlying patient comorbidities in addition to surgical-related factors make the management of surgical wounds primary closure challenging because of the higher risk of developing complications. To date, extensive evidence exists, which demonstrate the benefits of negative pressure dressing in the treatment of open wounds; recently, Incisional Negative Pressure Wound Therapy (INPWT) technology as delivered by Prevena™ (KCI USA, Inc., San Antonio, TX) and Pico (Smith & Nephew Inc, Andover, MA) systems has been the focus of a new investigation on possible prophylactic measures to prevent complications via application immediately after surgery in high-risk, clean, closed surgical incisions. A systematic review was performed to evaluate INPWT's effect on surgical sites healing by primary intention. The primary outcomes of interest are an understanding of INPWT functioning and mechanisms of action, extrapolated from animal and biomedical engineering studies and incidence of complications (infection, dehiscence, seroma, hematoma, skin and fat necrosis, skin and fascial dehiscence or blistering) and other variables influenced by applying INPWT (re-operation and re-hospitalization rates, time to dry wound, cost saving) extrapolated from human studies. A search was conducted for published articles in various databases including PubMed, Google Scholar and Scopus Database from 2006 to March 2014. Supplemental searches were performed using reference lists and conference proceedings. Studies selection was based on predetermined inclusion and exclusion criteria and data extraction regarding study quality, model investigated, epidemiological and clinical characteristics and type of surgery, and the outcomes were applied to all the articles included. 1 biomedical engineering study, 2 animal studies, 15 human studies for a total of 6 randomized controlled trials, 5 prospective cohort studies, 7 retrospective analyses, were included. Human studies investigated the outcomes of 1042 incisions on 1003 patients. The literature shows a decrease in the incidence of infection, sero-haematoma formation and on the re-operation rates when using INPWT. Lower level of evidence was found on dehiscence, decreased in some studies, and was inconsistent to make a conclusion. Because of limited studies, it is difficult to make any assertions on the other variables, suggesting a requirement for further studies for proper recommendations on INPWT.

Closed incision negative pressure therapy: international multidisciplinary consensus recommendations

Surgical site occurrences (SSOs) affect up to or over 25% of patients undergoing operative procedures, with the subset of surgical site infections (SSIs) being the most common. Commercially available closed incision negative pressure therapy (ciNPT) may offer surgeons an additional option to manage clean, closed surgical incisions. We conducted an extensive literature search for studies describing ciNPT use and assembled a diverse panel of experts to create consensus recommendations for when using ciNPT may be appropriate. A literature search of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials using key words ‘prevention’, ‘negative pressure wound therapy (NPWT)’, ‘active incisional management’, ‘incisional vacuum therapy’, ‘incisional NPWT’, ‘incisional wound VAC’, ‘closed incisional NPWT’, ‘wound infection’, and ‘SSIs’ identified peer‐reviewed studies published from 2000 to 2015. During a multidisciplinary consensus meeting, the 12 experts reviewed the literature, presented their own ciNPT experiences, identified risk factors for SSOs and developed comprehensive consensus recommendations. A total of 100 publications satisfied the search requirements for ciNPT use. A majority presented data supporting ciNPT use. Numerous publications reported SSI risk factors, with the most common including obesity (body mass index ≥30 kg/m²); diabetes mellitus; tobacco use; or prolonged surgical time. We recommend that the surgeon assess the individual patient's risk factors and surgical risks. Surgeons should consider using ciNPT for patients at high risk for developing SSOs or who are undergoing a high‐risk procedure or a procedure that would have highly morbid consequences if an SSI occurred.

Prevention of Sternal Wound Infections by use of a Surgical Incision Management System: First Reported Australian Case Series

BACKGROUND

Sternal wound infections are considered a costly and potentially devastating consequence of the median sternotomy in cardiothoracic surgery. Surgical incision management employs the technique of applying a closed, negative pressure vacuum dressing to a closed wound. Several studies have demonstrated a reduction in sternal wound infections using this system.

METHODS

A retrospective audit of cases receiving surgical incision management demonstrated a statistically significant reduction in sternal wound infections against a predicted rate.

RESULTS

Of the 62 patients identified, only one was complicated by a sternal wound infection with the greatest reduction seen in the high-risk infection group.

CONCLUSIONS

Although smaller in size, the results compared well to trials conducted in larger European and US centres. Although not advocating surgical incision management for routine use, it should be considered on patients considered high-risk for sternal wound infection, such as diabetics, the elderly and the obese.

Negative pressure wound therapy for managementof the surgical incision in orthopaedic surgery: A review of evidence and mechanisms for an emerging indication

Objectives

The period of post-operative treatment before surgical wounds are completely closed remains a key window, during which one can apply new technologies that can minimise complications. One such technology is the use of negative pressure wound therapy to manage and accelerate healing of the closed incisional wound (incisional NPWT).

Methods

We undertook a literature review of this emerging indication to identify evidence within orthopaedic surgery and other surgical disciplines. Literature that supports our current understanding of the mechanisms of action was also reviewed in detail.

Results

A total of 33 publications were identified, including nine clinical study reports from orthopaedic surgery; four from cardiothoracic surgery and 12 from studies in abdominal, plastic and vascular disciplines. Most papers (26 of 33) had been published within the past three years. Thus far two randomised controlled trials – one in orthopaedic and one in cardiothoracic surgery – show evidence of reduced incidence of wound healing complications after between three and five days of post-operative NPWT of two- and four-fold, respectively. Investigations show that reduction in haematoma and seroma, accelerated wound healing and increased clearance of oedema are significant mechanisms of action.

Conclusions

There is a rapidly emerging literature on the effect of NPWT on the closed incision. Initiated and confirmed first with a randomised controlled trial in orthopaedic trauma surgery, studies in abdominal, plastic and vascular surgery with high rates of complications have been reported recently. The evidence from single-use NPWT devices is accumulating. There are no large randomised studies yet in reconstructive joint replacement.

Cite this article: Bone Joint Res 2013;2:276–84.

Use of negative pressure wound therapy over clean, closed surgical incisions

The literature has reported that surgical site infections account for 17-22% of health care-associated infections, while surgical wound dehiscence rates range from 0.25% to 3.0% (post laparatomies), 1.6% to 42.3% (post-caesarean incisions) and 0.5% to 2.5% (sternal incisions). These types of incisional complications can become a significant cost burden to the health care system because of lengthy hospital stays and readmissions, additional nursing care and added surgical procedures. Therefore, the type of therapy used for surgical incisions plays a critical role in the healing process. The success of negative pressure wound therapy (NPWT; V.A.C.® Therapy; KCI USA, Inc., San Antonio, TX) for open wounds has been well documented and has led to its use over clean, closed surgical incisions. This review will focus on clinician experience and literature review of incisional NPWT and will include clinical cases describing NPWT's successful use over surgical incisions.

Negative pressure wound therapy for at-risk surgical closures in patients with multiple comorbidities: a prospective randomized controlled study

PURPOSE

The purpose of this study is to evaluate the effect of Negative Pressure Wound Therapy (NPWT) on closed surgical incisions. We performed a prospective randomized controlled clinical trial comparing NPWT to standard dry dressings on surgical incisions.

METHODS

Patients presenting to a high-volume wound center were randomized to receive either a V.A.C. (KCI, San Antonio, TX) or a standard dry dressing over their incision at the conclusion of surgery. These were primarily high-risk patients with multiple comorbidities. The 2 groups were compared, and all incisions were evaluated for infection and dehiscence postoperatively.

RESULTS

Eighty-one patients were included for analysis. Thirty-seven received dry dressings, and 44 received NPWT. Seventy-four of these underwent lower extremity wound closure. Average follow-up was 113 days. There were no differences in demographic, preoperative, and operative variables between groups; 6.8% of the NPWT group and 13.5% of the dry dressing group developed wound infection, but this was not statistically significant (P = 0.46). There was no difference in time to develop infection between the groups. There was no statistical difference in dehiscence between NPWT and dry dressing group (36.4% vs 29.7%; P = 0.54) or mean time to dehiscence between the 2 groups (P = 0.45). Overall, 35% of the dry dressing group and 40% of the NPWT group had a wound infection, dehiscence, or both. Of these, 9 in the NPWT group (21%) and 8 in the dry dressing group (22%) required reoperation.

CONCLUSIONS

There is a significant rate of postoperative infection and dehiscence in patients with multiple comorbidities. There was no difference in the incidence of infection or dehiscence between the NPWT and dry dressing group. This study is registered with ClinicalTrials.gov. The unique registration number is NCT01366105.