The impact of a closing protocol on wound morbidity in abdominal wall reconstruction with mesh

Wound complications (WC) after abdominal wall reconstruction (AWR) are associated with increased cost, recurrence, and mesh infection. Operative closing protocols (CP) have been studied in other surgical disciplines but not in AWR. Our aim was to study the effect of a CP on WC after AWR.

The CP consists of antibiotic wound irrigation, glove and complete instrument exchange, and re-draping of the sterile field to cover the skin entirely prior to mesh implantation. A prospective institutional database at a tertiary hernia center was queried for patients who underwent open AWR with mesh. Standard descriptive and inferential statistics are reported. A Bayesian structured time-series analysis was performed to evaluate rates of wound infection (WI) and WC before and after implementation of a CP in late 2016.

A total of 2541 AWR patients were examined. Mean age and BMI were 57.9 ± 12.6 years and 32.9 ± 9.8 kg/m², 56.7% were female, and 24.2% were diabetic. Significantly more CP patients had contaminated wounds. Mean defect size was 203.1 ± 205.8 cm². Average follow-up was 31.5 ± 41.4 months. WI rate before CP (preCP) was 14.5% compared to 2.6% after CP (P < 0.001). WC rate was higher before CP (29.3% vs 10.3%, P < 0.001). Specifically, wound cellulitis (9.7% vs 2.7%, P < 0.001), wound infection (13.8 vs 1.8%, P < 0.001), and mesh infection (2.1% vs 0.6%, P < 0.004) rates were reduced after CP implementation. For WI, Bayesian Structured time-series analysis showed that the implementation of CP had an effect of 83% (± 2%, 95% CI - 87%, - 78%; P < 0.001) reduction in WI compared to counterfactual. For WC, the Bayesian analysis revealed a reduction compared to counterfactual for WC of - 67% (± 3%, 95% CI - 60%, - 72%; P < 0.001).

Introduction of a CP for open AWR with mesh has reduced overall WI and WC rates. The use of a CP should be strongly considered in AWR.