SURGICAL WOUNDS

Local surgical factors such as infection, edema, seroma and hematoma formation, wound tension, wound trauma, wound drainage, the presence of drainage devices, muscle spasticity, and wound dressings all affect postoperative wound healing. Considerations to optimize healing should be given to reduce tension across the surgical site and to improve perfusion, nutrition, and free radical destruction. Surgical reconstructive options should be considered for selected patients whose length of healing would be extraordinarily long and whose health status is appropriate for rapid healing.

A systematic literature search for clinical practice guidelines on surgical wounds was completed using the Medline, CINAHL, and Embase databases and 46 guideline clearinghouses. A librarian was involved in identifying the appropriate keywords and search strategies to ensure that all guidelines on the topic were found.

112 surgical wounds treatment clinical practice guidelines were found in the English literature from 2002 until May 2007. Many of these published articles were excluded due to a variety of reasons. They were: not specifically addressing surgical wounds, articles, review papers, not CPGs, supplemental documents of a guideline and quick reference guides.

Of the identified papers, 14 guidelines were appraised by a minimum of three reviewers using the AGREE instrument (http://www.agreecollaboration.org/instrument/). The AGREE instrument has six domains: scope and purpose, stakeholder involvement, rigour of development, clarity and presentation, applicability, and editorial independence. It is not recommended that the scores obtained for the domains be aggregated. Instead the guidelines that received the highest scores for most of the domains and particularly for rigour of development were ranked highest and their recommendations will be reported throughout this Acute Wounds – Surgery stream.

The most highly ranked guidelines were developed by the Scottish Intercollegiate Guidelines Network (SIGN) on Postoperative Management in Adults: A Practical Guide to Postoperative Care for Clinical Staff (2004); Holmes’ Skeletal Pin Site Care: National Association of Orthopaedic Nurses guidelines for Orthopaedic Nursing (2005); McKibben’s Guidance on Public Reporting of Healthcare-associated Infections: Recommendations of the Healthcare Infection Control Practices Advisory Committee (2005); Johnson’s Consensus Recommendations for the Diagnosis, Treatment and Control of Myobacterium Ulcerans Infection (Bainsdale or Buruli Ulcer) in Victoria, Australia (2007).

The following figure indicates the AGREE domain scores for these surgical wounds treatment guidelines.

The following general recommendations are intended to help busy clinicians provide excellent care. They are based on the high ranking guidelines that are referenced. Only the SIGN guideline provides guidance for general post-surgical care. The other guidelines are directed toward specific topics that are not discussed in our recommendations. Practitioners are advised to review guidelines that address their surgical specialty.

Identify and Treat the Cause		Level of Evidence
1	Monitor patients’ physical status post-operatively to identify and treat potential infections or other complications.	5
2	If an acute confusional state is present, exclude treatable causes by appropriate history, physical examination and investigations.	5
Address Patient-Centered Concerns		Level of Evidence
3	Provide ongoing support and education to patient and family regarding incision care.	5
4	Maintain optimal strategies for caring for patients postoperatively.	5
5	Consult appropriate Professionals, including Dieticians to ensure appropriate nutrition.	5
Provide Local Wound Care		Level of Evidence
6	Review the results from microbiological specimens regularly and change antibiotics as necessary.	5
7	Perform hand washing with soap and water or with alcoholic cleansing agents before and after patient contact. Use gloves for hand-contaminating activities.	5
8	Consider adjunction therapy, including hyperbaric oxygen to assist healing, as appropriate.	4
Provide Organizational Support		Level of Evidence
9	Empower an interprofessional surgery team ensuring involvement of appropriate professionals, e.g., dietician, and provide education and support.	5

High Ranking Guidelines
1	Quality Indicator	Type: CPG (Clinical Practice Guideline)
Scottish Intercollegiate Guidelines Network. (2004). Postoperative Management in Adults: A Practical Guide to Postoperative Care for Clinical Staff.
This guideline emphasizes the importance of pre-emptive management in postoperative care. Regular assessment, selective monitoring and timely documentation are key to postoperative care. The method of recommendations is by consensus statement, developed from structured discussion, informed by any existing evidence and the group’s clinical experience, and validated using a formal scoring system.
2	Quality Indicator	Type: CPG (Clinical Practice Guideline)
Holmes SB and Brown SJ. Pin Site Care Expert Panel, (2005). Skeletal pin site care: National Association of Orthopaedic Nurses guidelines for orthopaedic nursing. Orthop.Nurs. 24 (2), 99-107.
This guideline provided evidence-based recommendations for the care of the skin immediately surrounding the skeletal pin. The recommendations provided are very specific. The levels of evidence are supported by RCTs, case series, and expert opinion.
3	Quality Indicator	Type: CPG (Clinical Practice Guideline)
McKibben L, Horan T, Tokars JI, Fowler G, Cardo DM, Pearson ML, Brennan PJ. Healthcare Infection Control Practices Advisory Committee, (2005). Guidance on public reporting of healthcare-associated infections: recommendations of the healthcare infection control practices advisory committee. Am.J.Infect.Control, 33 (4), 217-226.
This guideline is intended to assist policymakers, program planners, consumer advocacy organizations, and others tasked with designing and implementing public reporting systems for Healthcare Associated Infections. The recommendations are provided by the Healthcare Infection Control Practices Advisory Committee based on expert opinion.
4	Quality Indicator	Type: CPG (Clinical Practice Guideline)
Johnson P, Hayman JA, Quek TY, Fyfe J, Jenkin GA, Buntine JA, Athan E, Birrell M, Graham J, Lavender CJ. (2007). Consensus recommendations for the diagnosis, treatment and control of Mycobacterium ulcerans infection (Bairnsdale or Buruli ulcer) in Victoria, Australia. The Medical Journal of Australia. 186 (2): 64-68.
This guideline presents recommendations for the treatment of Bairnsdale ulcer by using oral antibiotics and intravenous amikacin. The recommendations are very specific and they are based on consensus statements from plastic surgeons, general practitioners, laboratory scientists, pathologists, infectious disease physicians and public health experts. The level of evidence is 4/5 (0bservational case series/expert opinion), except where specific references are cited.
5	Quality Indicator	Type: Concensus Statement
Fleck T, Gustafsson R, Harding K, Ingemansson R, Lirtzman MD, Meites HL, Moidl R, Price P, Ritchie A, Salazar J, Sjogren J, Song DH, Sumpio BE, Toursarkissian B, Waldenberger F, Wetzel-Roth W. (2006). The management of deep sternal wound infections using vacuum assisted closureTM (V.A.C.) therapy. Int.Wound.J. 3 (4), 273-280.
This guideline presents the VAC Therapy to assist wound closure. VAC Therapy is favoured because the standard approach to management of deep sternal wound infections was labour intensive and had implications for health care costs and staffing. The effects of the VAC Therapy include increased wound perfusion, reduction in inhibitory substances and lowering of bacterial load, oedema and increased granulation tissue formation. The recommendations are based on current evidence or the majority consensus of the international group of experts.

Abdominal wound dehiscence is associated with substantial morbidity and mortality, especially in elderly or malnourished patients. Burst abdomen is a complication of abdominal surgery whose incidence has not changed appreciably over the past century. Predisposing, contributing and causative factors have long been recognized. In the majority of cases, lack of compliance with suture protocols, with inadequate knot and suture technique, are causative.

Meta-analyses have revealed that the ideal suture is nonabsorbable and the ideal closure is continuous. However, many exceptions exist. Healthy thin patients undergoing elective laparotomy for benign conditions may safely have a continuous closure with absorbable sutures. Interrupted absorbable sutures provide better results with fewer complications for contaminated wounds and patients with serious or multiple comorbidities. Additional retention sutures may be required, and closure may be immediate or delayed. Delayed primary closure may reduce infection rates in dirty abdominal wounds compared with primary closure. An interrupted X closure may reduce the risk of dehiscence in patients with risk factors, such as anemia, sepsis, cough, malnutrition, or abdominal distention. It is also important to address patient risk factors for dehiscence preoperatively, if possible.

The incidence of abdominal herniation is approximately 4–10%. Transverse incisions have a lower rate of herniation than midline and paramedian incisions. Repair of incisional herniation can often be accomplished in a single stage unless complications develop.

Abdominal wall defects may result from malignancy or trauma. Traumatic abdominal injuries, such as gunshot wounds, are often grossly contaminated and require multiple-stage delayed reconstruction and closure. Abdominal wall infections may result from infections of mesh repairs of abdominal fascia. Mesh infections resist wound care techniques and antibiotic therapy and often present as draining abdominal sinuses. Resolution of the infection usually requires removal of infected mesh and staged abdominal reconstruction.

Standard wound care principles should also be applied to abdominal wounds, including care of the wound bed, appropriate local wound care and use of dressings, and management of systemic factors.

Small skin deficits can usually be repaired with primary closure by approximating the skin edges after undermining the skin extensively. Larger defects may require tissue expansion, myocutaneous or fasciocutaneous flaps, or prosthetic mesh and staged reconstruction. The major advantage of mesh is prevention of large intra-abdominal pressure increases that may sometimes be seen with hernia repairs and that may predispose to recurrence. The presence of prosthetic material and the likelihood of extensive adhesions are associated with a risk of infection. Temporary fascial approximation using absorbable mesh minimizes the fascial defect. After complete granulation, skin grafting and maturation of the graft, final reconstruction is performed.

Vacuum-assisted closure (VAC) promotes wound granulation and can be used to manage exposed fascia or grafts. VAC may accelerate healing of enteric-cutaneous fistulas by removing enteric fluids and promoting ingrowth of granulation tissue.

Identify and Treat the Cause		Level of Evidence
1	Plan the appropriate type of closure for specific patient and clinical situations.	Not Assessed
2	Institute appropriate management of patient risk factors for dehiscence, such as malnutrition, anemia, sepsis and other factors, preoperatively if possible.	Not Assessed
3	Determine and implement the most appropriate closure for large skin defects to prevent dehiscence and herniation, including use of tissue expansion, flaps and prosthetic mesh and staged reconstruction.	Not Assessed
Address Patient-Centered Concerns		Level of Evidence
4	Provide individualized education about post-operative care.	5
Provide Local Wound Care		Level of Evidence
5	Use delayed primary closure on contaminated or dirty abdominal wounds.	Not Assessed
6	Plan staged reconstruction when abdominal wall infection is present, with removal of prosthetic materials, such as mesh, which harbour infection.	Not Assessed
7	Close small skin defects using primary closure and adequate skin mobilization.	Not Assessed
8	Consider the use of vacuum-assisted closure to increase granulation, especially where drainage is delaying healing.	Not Assessed
9	Apply the principles of wound care to management of abdominal wounds.	Not Assessed
Provide Organizational Support		Level of Evidence
10	Establish and empower an interprofessional team to provide post-operative care.	5

Essential Publications
1	Disinfecting agent – Povidone-iodine	Quality Indicator	Type: RCT
Chang FY, Chang MC, Wang ST, Yu WK, Liu CL, Chen TH. Can povidone-iodine solution be used safely in a spinal surgery? European Spine Journal 2006;15(6):1005-1014.
The purpose of this study was to evaluate the effectiveness and safety of the use of povidone-iodine solution in spinal surgeries. There was no significant difference in wound healing, fusion rate, pain and function score, and ambulatory capacity between those treated with povidone-iodine and those treated only with normal saline solution. This indicates that povidone-iodine can be used safely in spinal surgery.
2	Disinfecting agent – Povidone-iodine	Quality Indicator	Type: RCT
Harihara Y, Konishi T, Kobayashi H, Furushima K, Ito K, Noie T, Nara S, Tanimura K. Effects of applying povidone-iodine just before skin closure. Dermatology 2006;212(Suppl 1):53-57.
In this study, povidone-iodine was examined to see if it reduces the incidence of surgical site infection. The difference in infection rates with and without povidone-iodine was not significant.
3	Enteral nutrition	Quality Indicator	Type: Systematic review
Andersen HK, Lewis SJ, Thomas S. Early enteral nutrition within 24h of colorectal surgery versus later commencement of feeding for postoperative complications. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004080. DOI: 10.1002/14651858.CD004080.pub2.
In this paper, the effect of early enteral feeding of gastrointestinal surgery patients is discussed. There was not a significant difference between enteral feeding and the traditional method of keeping patients “nil by mouth” in reducing complications.
4	Prophylactic antibiotics – Appendectomy	Quality Indicator	Type: Systematic review
Andersen BR, Kallehave FL, Andersen HK. Antibiotics versus placebo for prevention of postoperative infection after appendicectomy. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD001439. DOI: 10.1002/14651858.CD001439.pub2.
The effect of prophylactic antibiotics on the prevention of complications in appendectomy patients is examined in this study. 45 studies containing 9576 patients were reviewed, and the general consensus was that the use of antibiotics at any point before, during, or after surgery is effective in preventing complications.
5	Prophylactic antibiotics – Fourth-degree perineal tear	Quality Indicator	Type: Systematic review
Buppasiri P, Lumbiganon P, Thinkhamrop J, Thinkhamrop B. Antibiotic prophylaxis for fourth-degree perineal tear during vaginal birth. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD005125. DOI: 10.1002/14651858.CD005125.pub2.
The researchers hoped to examine the effectiveness of antibiotic prophylaxis in reducing complications in fourth-degree perineal tear from vaginal birth, but no randomised controlled trials could be found. Research is needed on this topic.
6	Prophylactic antibiotics – Hernia	Quality Indicator	Type: Systematic review
Aufenacker TJ, Koelemay MJW, Gouma DJ, Simons MP. Systematic review and meta-analysis of the effectiveness of antibiotic prophylaxis in prevention of wound infection after mesh repair of abdominal wall hernia. British Journal of Surgery 2006;93(1):5-10.
The purpose of this study was to determine whether systematic antibiotic prophylaxis prevented infection after surgery for an abdominal wall hernia repaired with mesh. There is no indication for routine prophylactic antibiotics, especially in low-risk patients. Further studies are needed to verify this finding.
7	Prophylactic antibiotics – Hernia	Quality Indicator	Type: Systematic review
Sanchez-Manuel FJ, Lozano-García J, Seco-Gil JL. Antibiotic prophylaxis for hernia repair. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD003769. DOI: 10.1002/14651858.CD003769.pub3.
Elective hernia repair has a higher than average infection rate for clean surgeries. In this review, the effectiveness of prophylactic antibiotics for preventing infection in this type of surgery is examined. The results were non-significant, with prophylaxis reducing infection rate only marginally, therefore prophylactic antibiotics cannot be universally recommended.
8	Prophylactic antibiotics – Laparoscopic cholecystectomy	Quality Indicator	Type: RCT
Chang WT, Lee KT, Chuang SC, Wang SN, Kuo KK, Chen JS, Sheen PC. The impact of prophylactic antibiotics on postoperative infection complication in elective laparoscopic cholecystectomy: a prospective randomized study. Am J Surg 2006;191(6):721-725.
The purpose of this paper was to investigate the effects of prophylactic antibiotics on postoperative infection complications in elective laparoscopic cholecystectomy. The difference in infection rate was not significant between the antibiotic group and the control group administered isotonic sodium chloride solution. The authors do not recommend the use of prophylactic antibiotics because they do not significantly lower the already low infection rate. The credibility of these findings was compromised by the study’s weak methodology. The allocation was determined by the operative schedule and dropouts were not described, though the study was single-blinded.
9	Prophylactic antibiotics – Postcesarean infection	Quality Indicator	Type: RCT
Rudge MV, Atallah AN, Peracoli JC, Tristao Ada R, Mendonca Neto M. Randomized controlled trial on prevention of postcesarean infection using penicillin and cephalothin in Brazil. Acta Obstet Gynecol Scand 2006;85(8):945-948.
In this study, different antibiotic regimens were evaluated based on their effectiveness at preventing infectious complications in low-income women undergoing cesarean delivery. Cost-effectiveness was also analysed. A postcesarean prophylactic antibiotic regimen such as penicillin or intravenous cephalothin decreases the risk of infection and is cost-effective.
10	Surgical tools – High-frequency electric surgical knives	Quality Indicator	Type: RCT
Ji GW, Wu YZ, Wang X, Pan HX, Li P, Du WY, Qi Z, Huang A, Zhang LW, Zhang L, Chen W, Liu GH, Xu H, Li Q, Yuan AH, He XP, Mei GH. Experimental and clinical study of influence of high-frequency electric surgical knives on healing of abdominal incision. World J Gastroenterol 2006;12(25):4082-4085.
In this study, the use of electric surgical knives was associated with a significantly higher infection rate and delayed wound healing compared to a common lancet. Details on the animal testing that led to the clinical testing in this paper were provided. The authors suggest using a common lancet rather than an electric knife.

Infection of the sternotomy wound is a devastating complication after cardiac surgery, associated with prolonged hospitalization, high cost, and significant mortality. Management of infection by the previously employed strategy of open packing and antibiotic irrigation was associated with mortality approaching 50%. (Jones et al, Ann Surgery 1997) Use of radical sternal debridement, with removal of all wires and compromised tissue and closure with muscle or omental flaps reduced mortality to less than 10%. A small percentage of patients required additional procedures to treat recurrent infection.

Retrosternal complications include mediastinitis, pericardial effusion, hematoma, loculated effusion, and empyema. Early diagnosis and treatment are critical. Flap closure complications included hematoma, partial flap loss, wound dehiscence, wound necrosis and abdominal hernia. Factors associated with flap closure complications, recurrent infection or death include both patient- and technique-related factors. These include obesity, history of smoking, hypertension, diabetes, post sternotomy septicemia, internal mammary artery harvest, use of an intra-aortic balloon pump, and perioperative myocardial infarction. In addition, overt or subclinical malnutrition may play a role, along with immune status.

Today, up to 20% of organisms cultured from infected sternotomy sites are methicillin-resistant Staphylococcus aureus (MRSA) and approximately 20% are gram-negative organisms. Appropriate antibiotic therapy is crucial to successful treatment of mediastinitis. As most patients have already received prophylactic antibiotic therapy, it is important to institute very broad and deep empiric antibiotic coverage including Pseudomonas species. Culture results can then guide antibiotic use. Long-term treatment is often required, usually for several weeks or months.

• Careful evaluation is required of the wound, wound drainage, wire exposure, sternal instability and potential communication with the pleural space to identify all possible problems.
• Early identification of mediastinitis and improvements in perioperative management and critical care of patients with multisystem organ failure can reduce morbidity and mortality rates.
• Successful management requires early recognition based on a high index of suspicion, detailed physical examination, awareness of clinical signs and symptoms, appropriate imaging and prompt surgical therapy.
• Advanced wound therapies, such as the use of Apligraf, a bioengineered skin substitute, or negative-pressure wound therapy, can increase healing of sternotomy wounds.

Consensus on effective prevention techniques has yet to be reached. Careful patient evaluation, meticulous surgical technique, and complete adherence to aseptic protocols within the operating room are required to prevent sternal wound complications.

The following classification of sternal wound infections was developed. Type Depth Description 1a Superficial Skin and subcutaneous tissue dehiscence 1b Superficial Exposure of sutured deep fascia 2a Deep Exposed bone, stable wired sternotomy 2b Deep Exposed bone, unstable wired sternotomy 3a Deep Exposed necrotic or fractured bone, unstable, heart exposed 3b Deep Type 2 or 3 with septicemia

Identify and Treat the Cause		Level of Evidence
1	Take a careful history and conduct an inspection.	Not Assessed
Address Patient-Centered Concerns		Level of Evidence
2	Provide individualized education about post-operative care.	5
Provide Local Wound Care		Level of Evidence
3	Monitor sternotomy wound healing closely to ensure early detection of complications.	Not Assessed
4	Evaluate sternotomy complications carefully and use imaging as necessary to assess infection.	Not Assessed
5	Perform radical debridement of infected sternotomy wounds promptly and close the wound with muscle or omental flaps as necessary.	Not Assessed
6	Administer broad-spectrum empiric antibiotic therapy to treat sternotomy infection and modify treatment based on culture results.	Not Assessed
7	Consider the use of advanced wound healing modalities.	Not Assessed
Provide Organizational Support		Level of Evidence
8	Establish and empower an interprofessional team to provide post-operative care.	5

Essential Publications
1	Dressings – Impermeable vs. absorbent	Quality Indicator	Type: RCT
Segers P, de Jong AP, Spanjaard L, Ubbink DT, de Mol BA. Randomized clinical trial comparing two options for postoperative incisional care to prevent poststernotomy surgical site infections. Wound Repair Regen 2007;15(2):192-196.
Adhesive impermeable drapes and permeable absorbent dressings are compared in this study. The difference in incidence of sternal surgical site infection was not significant between the two types of dressings.
2	Prophylactic antibiotics – Gentamicin	Quality Indicator	Type: RCT
Friberg O, Dahlin LG, Levin LA, Magnusson A, Granfeldt H, Kallman J, Svedjeholm R. Cost effectiveness of local collagen-gentamicin as prophylaxis for sternal wound infections in different risk groups. Scand Cardiovasc J 2006;40(2):117-125.
The researchers found that the use of local collagen-gentamicin in addition to a regular prophylaxis regimen significantly reduced the risk of sternal wound infection. This reduction in infection led to lower costs, making the use of local collagen-gentamicin beneficial both clinically and economically.
3	Prophylactic antibiotics – Gentamicin	Quality Indicator	Type: RCT
Friberg O, Svedjeholm R, Kallman J, Soderquist B. Incidence, microbiological findings, and clinical presentation of sternal wound infections after cardiac surgery with and without local gentamicin prophylaxis. Eur J Clin Microbiol Infect Dis 2007;26(2):91-97.
In this study, the effect of local collagen-gentamicin on sternal wound infections was examined. The incidence of some infectious agents was reduced when gentamicin was administered and some symptoms of sternal wound infection were reduced.
4	Vacuum assisted closure	Quality Indicator	Type: Concensus Statement
Fleck T, Gustafsson R, Harding K, Ingemansson R, Lirtzman MD, Meites HL, Moidl R, Price P, Ritchie A, Salazar J, Sjogren J, Song DH, Sumpio BE, Toursarkissian B, Waldenberger F, Wetzel-Roth W. The management of deep sternal wound infections using vacuum assisted closure (V.A.C.) therapy. Int.Wound.J 2006;3(4):273-280.
This guideline presents the VAC Therapy to assist wound closure. VAC Therapy is favoured because the standard approach to management of deep sternal wound infections was labour intensive and had implications for health care costs and staffing. The effects of the VAC Therapy include increased wound perfusion, reduction in inhibitory substances and lowering of bacterial load, oedema and increased granulation tissue formation. The recommendations are based on current evidence or the majority consensus of the international group of experts.

Epithelialization occurs within a few days of surgery and, after approximately 5 days, fibroplasia and collagen production begin, at which time collagen deposition and remodeling begin strengthening the wound. A healing surgical wound regains 3–5% of its original strength by 2 weeks, 15% by 3 weeks, 35% at 1 month and a final 80% after several months. Lack of healing of post-surgical wounds may be related to dehiscence, necrosis and infection.

• Dehiscence (incisional separation): Failure of a surgical wound to heal in apposition is most often due to surgical error, but local or systemic factors may also cause dehiscence. Inadequate undermining or poor planning may produce excessive tension on the wound, causing sufficient mechanical force to separate the incision. Excessively tight sutures may cause tissue necrosis, decreasing wound strength. Electrocautery causes necrosis, increased inflammation and decreased wound strength. Premature removal of superficial sutures may cause dehiscence, especially if deeper tissue layers have not been sutured adequately. Ineffective hemostasis and dead space also increase the risk of dehiscence. Systemic factors associated with dehiscence include tobacco use, a variety of comorbid conditions, age greater than 65 years, and several medications, especially antiinflammatory and immunosuppressive agents.

Wounds that have dehisced due to premature suture removal or trauma may be resutured if no infection is present. Freshening of healthy wound edges should be avoided, to allow already active fibroblasts to continue the wound-healing process. Wounds dehisced due to hematoma formation may be resutured after complete removal of the hematoma. Dehiscence due to delayed hematoma formation or infection may be best managed with healing by secondary intention (granulation), with scar revision usually delayed until at least 8 weeks later.

• Necrosis: Tissue ischemia is the proximate cause of necrosis. The most common cause is tissue damage during surgery, possibly due to too much undermining, suturing or tension on wound edges. In addition, superficial undermining and some flaps or grafts may leave wound edges with barely adequate circulation for healing. An expanding hematoma may contribute to tissue necrosis by increasing suture line tension and compromising the circulation.

Cigarette smoking causes vasoconstriction and hypoxia and increases blood viscosity and platelet aggregation, which promote microvascular thrombosis. This process can substantially reduce the survival of reconstructive flaps and grafts, but benefits can be seen by having patients stop or decrease smoking for at least 2 days before and 7 days after surgery.

The necrotic area should be fully demarcated before debridement, to prevent loss of viable tissue, unless infection or a hematoma is present. Easy separation of the eschar from the wound bed indicates that careful sharp debridement may be performed. A high risk of infection is present, and systemic antibiotics may be required. The wound can be allowed to heal by secondary intention, and scar revision may be considered at a later date.

• Infection: Most often, infection results from a combination of a break in aseptic technique and impaired host defenses, through interference with blood flow or development of local inflammation. Signs and symptoms of wound infection usually develop and increase from approximately days 4–6 and may include early tenderness, erythema, warmth and swelling, followed by cellulitis, lymphangitis and fever. An early infection may be treated with oral antibiotics and the patient followed closely. Infection that has progressed further, to purulence, fluctuance, inflammatory edema or systemic symptoms, requires the incision to be opened, lavaged with sterile saline and packed with iodoform gauze. Empiric antibiotic therapy should be instituted when wound cultures are taken and adjusted as necessary. The infection should be cleared and the wound allowed to heal by secondary intention.

Negative-pressure wound therapy (NPWT) reduces interstitial fluid and bacterial colonization and increases angiogenesis and perfusion, to assist in healing dehisced wounds. The benefits of this modality may relate to continuous removal of wound effluent, which may contain both bacteria and inhibitory cytokines. NPWT should ideally be continued until the wound is completely granulated and no longer undermined. Adequate nutrition is essential for healing, and advanced technologies, such as NPWT, are ineffective if the patient’s body cannot respond.

When the objective of NPWT is closure of an abdominal wound, the abdominal fascia must be intact to prevent evisceration. Implants and vascular grafts must not be infected to prevent ongoing wound drainage as granulation covers these ‘foreign bodies.’ Appropriate debridement to provide a clean wound bed allows maximal benefit from angiogenic stimulation.

Appropriate management of excessive bacterial burden or infection with systemic antibiotics or topical antimicrobial preparations is critical to prevent abscess formation. Similarly, regular monitoring for developing abscesses simplifies management during healing. Unroofing of tracts is beneficial, as thin skin bridges between two wounds in an incision are often poorly vascular. Beefy red granulation tissue is a sign of healing with NPWT, whereas pale and friable granulation tissue may be an important indicator of infection. Hypergranulation tissue may require control with silver nitrate to prevent problems with epithelialization.

Skin protection is important, as the airtight seal of the NPWT unit to the skin surrounding the wound may compromise skin barrier function. Skin protection can usually be provided with hydrocolloids, and antifungal preparations can manage candidal infections.

Hyperbaric oxygen therapy also increases tissue oxygen levels, angiogenesis and growth factor production, while reducing tissue edema.

Identify and Treat the Cause		Level of Evidence
1	Take a careful history and conduct an inspection of the surgical site.	Not Assessed
Address Patient-Centered Concerns		Level of Evidence
2	Provide individualized patient education.	5
Provide Local Wound Care		Level of Evidence
3	Ensure adequate nutrition to support healing of complicated surgical wounds.	Not Assessed
4	Manage clean non-healing wounds by addressing the causative factors, if possible, and resuturing.	Not Assessed
5	Non-healing surgical wounds that cannot be resutured should be allowed to heal by granulation, after addressing contributing factors, such as hematomas, dead space and infection.	Not Assessed
6	Infection in nonhealing surgical wounds should be treated appropriately and the wound allowed to heal by second intention.	Not Assessed
7	Consider negative-pressure wound therapy or hyperbaric oxygen therapy to speed granulation of nonhealing surgical wounds.	Not Assessed
Provide Organizational Support		Level of Evidence
8	Establish and empower an interprofessional team to provide post-operative care.	5

Essential Publications
1	Antisepsis – Lavasept	Quality Indicator	Type: RCT
Fabry W, Trampenau C, Bettag C, Handschin AE, Lettgen B, Huber FX, Hillmeier J, Kock HJ. Bacterial decontamination of surgical wounds treated with Lavasept. Int J Hyg Environ Health 2006;209(6):567-573.
The purpose of this study was to determine if 0.2% Lavasept solution leads to a reduction in the bacterial count on the surgace of wounds and if it interferes with wound healing. There was no evidence that Lavasept was superior to the Ringer solution.
2	Dressings	Quality Indicator	Type: Systematic review
Vermeulen H, Ubbink D, Goossens A, de Vos R, Legemate D. Dressings and topical agents for surgical wounds healing by secondary intention. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD003554. DOI: 10.1002/14651858.CD003554.pub2.
The purpose of this study was to evaluate different dressings and topical agents used to treat surgical wounds healing by secondary intention. Only small, poor quality randomised controlled trials that provided inadequate evidence were found. Quality research is required on this topic.
3	Dressings – Gauze	Quality Indicator	Type: RCT
Ubbink DT, Vermeulen H, van Hattem J. Comparison of homecare costs of local wound care in surgical patients randomized between occlusive and gauze dressings. Journal of Clinical Nursing 2008;17(5):593-601.
The purpose of this paper was to examine the cost and outcome of gauze compared to occlusive dressings in home-based wound care. The occlusive dressings were changed significantly less often than the gauze dressings, median 0.6/day versus 1.1/day (p = 0.008). The daily cost of the occlusive dressing was €5.31 compared to €0.71 for gauze, yielding a significant mean difference of €4.60 (95% CI €2.68 to €6.83). However, the mean difference between total daily costs, which includes material and nursing costs, was not significant (mean €2.86, 95% CI €-6.50 to €-10.25). Wound healing required a median of 48 days for occlusive compared to 30 days for gauze dressings (NS). Gauze dressings were found to reduce the length of time required for healing acute surgical wounds and were more cost-effective than occlusive dressings. Readers of this article are warned that the authors’ conclusions are very controversial as a result of research methodology issues (e.g., small sample size, number of wound types, and 3 different dressing options per group).
4	Dressings – Hydrofiber with silver	Quality Indicator	Type: RCT
Jurczak F, Dugre T, Johnstone A, Offori T, Vujovic Z, Hollander D. Randomised clinical trial of Hydrofiber dressing with silver versus povidone-iodine gauze in the management of open surgical and traumatic wounds. Int Wound J 2007;4(1):66-76.
In this study, Hydrofiber Ag was found to be more effective than povidone-iodine in open wound treatment. Lack of blinding could have adverse effects on the results of the study as the primary outcome of pain severity is a subjective measurement.
5	Tissue adhesives	Quality Indicator	Type: Systematic review
Coulthard P, Worthington H, Esposito M, van der Elst M, van Waes OJF. Tissue adhesives for closure of surgical incisions. Cochrane Database of Systematic Reviews 2002, Issue 3. Art. No.: CD004287. DOI: 10.1002/14651858.CD004287.pub2.
In this review, various aspects of tissue adhesives for closure of surgical incisions are analyzed. It was unclear whether tissue adhesives were more effective than sutures or tapes. Further research is required.
6	Tissue adhesives	Quality Indicator	Type: Systematic review
Farion KJ, Russell KF, Osmond MH, Hartling L, Klassen TP, Durec T, Vandermeer B. Tissue adhesives for traumatic lacerations in children and adults. CochraneDatabase of Systematic Reviews 2001, Issue 4. Art.No.:CD003326.DOI: 10.1002/14651858.CD003326.
In this review, tissue adhesives are shown to be an acceptable alternative to standard wound closure techniques such as sutures, staples, and adhesive strips for simple traumatic lacerations.
7	Vacuum assisted closure	Quality Indicator	Type: RCT
Armstrong DG, Lavery LA. Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trial. Lancet 2005;366:1704-10.
The purpose of this paper is to determine the efficacy of vacuum assisted closure in wound healing compared with moist wound dressings in complex diabetic acute foot amputation site wounds. The researchers found that vacuum assisted therapy was superior to moist wound dressings in both wound healing and total healing time.
8	Vacuum assisted closure	Quality Indicator	Type: RCT
Armstrong DG, Lavery L A, Boulton AJ. Negative pressure wound therapy via vacuum-assisted closure following partial foot amputation: what is the role of wound chronicity? Int Wound J 2007;4(1):79-86.
In this study, evidence suggesting that negative pressure wound therapy treatment is superior to standard wound treatment is provided. It was found that negative pressure wound therapy had a faster healing time and is a viable option for treating chronic wounds. Further research is required to confirm these findings.
9	Vacuum assisted closure	Quality Indicator	Type: RCT
Braakenburg A, Obdeijn MC, Feitz R, van Rooij IA, van Griethuysen AJ, Klinkenbijl JH. The clinical efficacy and cost effectiveness of the vacuum-assisted closure technique in the management of acute and chronic wounds: a randomized controlled trial. Plast Reconstr Surg 2006;118(2):390-397.
In this study, the use of vacuum assisted closure therapy in the treatment of wounds is examined, and some interesting preliminary evidence that it may be a better treatment for patients with cardiovascular disease and/or diabetes than modern dressings is uncovered. Small study groups prevent the results from being significant. More research is needed to verify these findings.
10	Vacuum assisted closure	Quality Indicator	Type: RCT
Huang WS, Hsieh SC, Hsieh CS, Schoung JY, Huang T. Use of vacuum-assisted wound closure to manage limb wounds in patients suffering from acute necrotizing fasciitis. Asian J Surg 2006;29(3):135-139.
In this paper, it was found that the vacuum assisted closure technique was effective in treating wounds. The population used in the study was very small, so the results are questionable.
11	Vacuum assisted closure	Quality Indicator	Type: RCT
Stannard JP, Robinson JT, Anderson ER, McGwin G Jr, Volgas DA, Alonso JE. Negative pressure wound therapy to treat hematomas and surgical incisions following high-energy trauma. J Trauma 2006;60(6):1301-1306.
Two related studies concerning the positive effect of negative pressure wound therapy through vacuum assisted closure in treating both hematomas and fractures sustained from trauma were described in this study. While the results from this study appear convincing, the population was fairly small and, for the hematoma study, the group sizes were lopsided in favour of the VAC group (31 patients vs 13 in the control group).
12	Vacuum assisted closure	Quality Indicator	Type: RCT
Vuerstaek JDD, Vainas T, Wuite J, Nelemans P, Neumann, MHA, Veraart JCJM. State-of-the-art treatment of chronic leg ulcers: a randomized controlled trial comparing vacuum-assisted closure (V.A.C.) with modern wound dressings. Journal of Vascular Surgery 2006;44(5):1029-37.
The purpose of this study was to determine the efficacy of vacuum assisted closure in wound healing compared with standard wound dressings in hospitalized patients with chronic venous, combined venous and arterial, or micro angiopathic leg ulcers with durations greater than six months. Vacuum assisted closure significantly reduced the healing time compared to standard wound dressings, though recurrence rates, relapse rates, and complications were similar between the two groups.

Surgery to replace the hip and knee joints is an increasingly common orthopedic procedure, which may be required as a result of osteoarthritis, rheumatoid arthritis (RA), aseptic necrosis, fractures and dislocation. In addition, RA and diabetic complications may necessitate orthopedic procedures of the foot and ankle. As the majority of these procedures are performed on elderly patients, a variety of systemic factors may compromise healing. These factor include, in addition to diabetes and RA, anemia, nutritional deficiencies, and immunosuppression due to medications used to treat RA.

The major complications of joint replacement surgery are infection and delayed wound healing. Hematoma formation and wound discharge are risk factors for infection, including infection of the prosthesis. Neither open nor closed vacuum-assisted wound drainage systems affect hematoma formation, infection, or the need for revision surgery. Closed systems, however, increase the need for blood transfusion. Allogeneic transfusion is associated with both infection and delayed wound healing after joint replacement. The use of erythropoietin or autologous transfusion can substantially reduce transfusion risk in high-risk patients, especially in older women with low body weight or decreased hemoglobin.

If infection develops within 4 weeks of surgery, wound debridement and long-term antibiotic therapy (at least 6 weeks), based on culture and sensitivity, may effectively treat the infection and allow retention of the implant. Infections occurring later than 4 weeks after surgery may also require revision of the components, often using a two-stage procedure.

In RA patients, as leflunamide has been found to increase the incidence of early wound healing complications and infection, it is recommended that treatment be interrupted preoperatively to reduce this incidence. In contrast, tumour necrosis factor-α (TNF-α) inhibitors, such as etanercept and infliximab, and immunosuppressive drugs, including methotrexate and corticosteroids, have not been shown to affect healing in these patients.

In diabetic patients, osteomyelitis may develop from typical polymicrobial infection of diabetic foot ulcers. Salvage of the foot usually requires aggressive debridement, including resection of infected bone; revascularization; and antibiotic therapy. These wounds are allowed to heal by granulation. Acute life-threatening infection or chronic infection that is unresponsive to medical treatment may necessitate amputation. Early identification of the need for amputation can reduce overall morbidity. Early reduction and arthrodesis of Charcot arthropathy may preserve function and prevent ulceration.

Identify and Treat the Cause		Level of Evidence
1	Assess and correct systemic factors, such as malnutrition and anemia, prior to elective joint replacement surgery.	Not Assessed
2	Glycemic control and aggressive management of diabetic foot ulcers may reduce the incidence of osteomyelitis and the need for amputation.	Not Assessed
3	Evaluate and modify as necessary immunosuppressive medication regimens in RA patients undergoing joint replacement.	Not Assessed
Address Patient-Centered Concerns		Level of Evidence
4	Provide individualized education about post-operative care.	5
Provide Local Wound Care		Level of Evidence
5	Identify and manage infection aggressively in patients after joint replacement surgery. Consider implant retention if the infection occurs within 4 weeks of surgery.	Not Assessed
6	Optimize wound healing environment.	Not Assessed
Provide Organizational Support		Level of Evidence
7	Establish and empower an interprofessional team to provide post-operative care.	5

Essential Publications
1	Antibiotics – Open limb fractures	Quality Indicator	Type: Systematic review
Gosselin RA, Roberts I, Gillespie WJ. Antibiotics for preventing infection in open limb fractures. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD003764. DOI: 10.1002/14651858.CD003764.pub2.
The purpose of this review was to determine the ability of antibiotics in reducing the risk of infection in open limb fractures. Antibiotics were very effective at decreasing the incidence of early infections, but more research needs to be conducted on bone infection and long-term morbidity.
2	Closed suction surgical wound drainage	Quality Indicator	Type: Systematic review
Parker MJ, Livingstone V, Clifton R, McKee A. Closed suction surgical wound drainage after orthopaedic surgery. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD001825. DOI: 10.1002/14651858.CD001825.pub2.
In this paper, the effectiveness of closed suction drainage systems in orthopedic surgery and its ability to reduce the incidence of hematoma and infection is examined. The difference between draining and not draining orthopedic wounds on incidence of hematoma and infection was found to be non-significant. More research is required to verify these results.
3	Pin site care	Quality Indicator	Type: Systematic review
Temple J, Santy J. Pin site care for preventing infections associated with external bone fixators and pins. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD004551. DOI: 10.1002/14651858.CD004551.
Different cleansing and dressing methods of orthopedic percutaneous pin sites were evaluated to determine their effect on infection rates in this review. Only one randomised controlled trial was found, but it suggested that cleansing was better than no cleansing at reducing infection rate. Further research is required to better understand this topic.
4	Pulse lavage	Quality Indicator	Type: RCT
Hargrove R, Ridgeway S, Russell R, Norris M, Packham I, Levy B. Does pulse lavage reduce hip hemiarthroplasty infection rates? J Hosp Infect 2006;62(4):446-449.
The purpose of this paper was to determine if pulse lavage reduces infection rates during hemiarthroplasty to treat hip fractures. Infection rate was significantly lowered by pulse lavage.

Reconstructive plastic surgery may be used to correct facial and other abnormalities occurring as a result of birth defects, trauma, infection or disease. The goal of reconstructive surgery may be to improve function, appearance or both. Reconstructive surgery is usually carefully planned and often carried out in stages.

Large skin defects often require the use of grafts, tissue expansion or flaps. Local, regional, musculocutaneous, fasciocutaneous, bone/soft tissue or microvascular free flaps may be used to fill defects. For some time now, microsurgery has allowed reattachment of severed limbs.

Complications of reconstructive surgery include delayed healing, bleeding and hematoma formation, dehiscence, graft failure, scar formation and contracture, failure of vessel anastamoses, and infection. Patient factors increasing the risk of complications are smoking, history of radiation, connective tissue diseases, poor perfusion, malnutrition, and immunocompromise. Surgical factors affecting complications include inadequate hemostasis, poor suturing technique, inadequate vascularity of graft sites, and excessive manipulation of graft sites, interfering with graft take.

A study of risk factors for complications after breast reconstructive surgery found obesity, smoking and radiation significantly to influence development of complications, including wound-healing complications, infection and reoperation.

Preoperative analysis of individual surgical needs and risk factors for complication development can help determine candidacy for reconstructive surgery, optimal preoperative management approaches to reduce the risk of complications, the best procedures or techniques to achieve the desired result, and the optimal timing of the procedure. Detailed planning can minimize the development of postoperative complications.

Management of wound complications follows the principles of wound healing: addressing systemic and local factors, bacterial balance and infection, and patient-centred concerns.

Identify and Treat the Cause		Level of Evidence
1	Develop a detailed approach for patient assessment and reconstructive surgery planning to reduce the risk of postoperative complications.	Not Assessed
2	Conduct a inspection.	Not Assessed
Address Patient-Centered Concerns		Level of Evidence
3	Provide individualized patient education.	5
Provide Local Wound Care		Level of Evidence
4	Manage wound complications by addressing systemic and local factors, bacterial balance and infection, and patient-centred concerns.	Not Assessed
5	Optimize wound healing environment.	Not Assessed
Provide Organizational Support		Level of Evidence
6	Establish and empower an interprofessional team to provide post-operative care.	5

Essential Publications
1	Fibrin glue – Face lifts	Quality Indicator	Type: RCT
Marchac D, Greensmith AL. Early postoperative efficacy of fibrin glue in face lifts: A prospective randomized trial. Plast. Reconstr. Surg. 2005;115(3):911-916.
The purpose of this study was to determine the efficacy of the use of fibrin glue in face lifts. The use of glue significantly reduced wound drainage compared to no glue (p = 0.037), but this difference was not deemed surgically significant. There was no significant difference in grades of hematomas, ecchymosis, and edema. On the basis of this study, the authors have reduced their use of fibrin glue for this purpose.
2	Preoperative showering – Antiseptics	Quality Indicator	Type: RCT
Kalantar-Hormozi AJ, Davami B. No need for preoperative antiseptics in elective outpatient plastic surgical operations: A prospective study. Plast. Reconstr. Surg. 2005;116(2):529-531.
The purpose of this study was to determine the efficacy of preoperative showering with antiseptics in preventing wound infections in elective outpatient plastic surgery. 1810 patients were evenly divided into two groups (using a randomization procedure regarded as not appropriate), one showering with normal saline solution and the other showering with the antiseptics Chlorhexidine or Betadine. No surgical site infections occurred in either group. This indicates that preoperative showering with antiseptics does not significantly reduce levels of infection.
3	Preoperative showering – Povidone-iodine	Quality Indicator	Type: RCT
Veiga DF, Damasceno CAV, Filho JV, Silva Jr RV, Cordeiro DL, Vieira AM, Andrade CHV, Ferreira LM. Influence of povidone-iodine preoperative showers on skin colonization in elective plastic surgery procedures. Plast. Reconstr. Surg. 2008;121(1):115-118.
The researchers examined the effect of preoperative showering with povidone-iodine on skin colonization in elective plastic surgery in this study. Showering with povidone-iodine significantly reduced levels of staphylococcal skin colonization compared to showering without povidone-iodine, but the difference for fungi and enterobacteria colonies was non-significant.

Skin scarring is the normal endpoint of tissue repair, and scars generally develop after dermal injury. Individuals vary considerably in their potential for scarring. Scars may be normal fine lines or abnormal scars, which may be categorized as widespread (stretched), atrophic, hypertrophic, and keloid. Scar contracture may also occur. (Bayat, BMJ, 2003;326:88–92) Abnormal scarring can produce functional (even disabling), cosmetic, psychologic and social problems that may carry a high emotional and financial cost. Scar revision considerations include balancing potential benefits against the risk of poor response and iatrogenic complications.

• Stretched: Tension on a scar in one direction produces a stretched scar, usually in the first 3 weeks after surgery. Stretched scars are flat, pale, soft and symptomless, and they are often seen after knee or shoulder surgery.
• Atrophic: These scars are small, flat, depressed below the level of the surrounding skin, and often indented or inverted. Atrophic scars are often seen after chickenpox or acne.
• Scar contractures: Contracture often occurs in scars crossing a joint or skin crease at right angles, especially scars due to burns. Contracture begins before the scar matures and may be disabling or dysfunctional. Contractures are typically hypertrophic.
• Hypertrophic: These scars are raised but remain within the boundary of the original lesion. Tension on a scar from many directions produces a hypertrophic scar. Hypertrophic scars are often red, inflamed, itchy and possibly painful and often occur after burn injury. They tend to regress spontaneously.
• Keloid: These are raised scars that have spread beyond the margins of the original lesion. The pattern of keloid development tends to be site specific. Ear lobe keloids often grow into large lobules, deltoid keloids grow vertically, and central sternal keloids often assume a butterfly shape. This scar type may be inflamed, itchy and painful. Keloids do not regress, but continue to grow over time, and they almost always recur after simple excision.

Accurate assessment is required to diagnose a scar and develop an appropriate management strategy. Discussion of the options with the patient is crucial. Scar severity can be assessed visually or using a scar scale. Assessment considerations include:

• Cause and course (improvement or worsening)
• Anatomic location
• Symptoms
• Scar severity
• Severity of functional impairment
• Stigma or psychological impact.

Management approaches include:

• Leave alone: It is appropriate to monitor scars for at least a year to allow maturation before determining an appropriate course of action. Some scars are best left alone in the long term.
• Non-invasive: Compression therapy, masks and clips, splinting or casting, topical therapy, antihistamines, silicone sheeting, psychologic counselling, and massage therapy are non-invasive options.
• Invasive: Surgical revision, intralesional corticosteroid injection, laser therapy, injection of fluorouracil, bleomycin or interferon gamma, radiotherapy and cryosurgery are invasive options for scar management.

In general,

• Stretched scars are usually managed by revision to reduce the width, possibly with splinting.
• Atrophic scars can be improved with chemical peels, laser resurfacing, dermabrasion, punch excision and fillers.
• Keloid scars: Surgery plus radiotherapy or an intralesional corticosteroid is the most common treatment for keloid scars.
• Scar contracture: Surgical release with splinting, casting and compression may be required. Skin grafts may also be required.

Silicone gel sheeting and intralesional corticosteroids are the only therapies for which sufficient evidence exists to make evidence-based recommendations. These treatments are useful in a wide variety of abnormal scars, such as hypertrophic scars and keloids.

Identify and Treat the Cause		Level of Evidence
1	Take a careful history about previous scarring.	Not Assessed
2	Conduct a skin inspection.	Not Assessed
Address Patient-Centered Concerns		Level of Evidence
3	Discuss treatment options and expectations with the patient to allow informed decision-making.	5
Provide Local Wound Care		Level of Evidence
4	Perform an accurate scar assessment to diagnose the scar and develop a management strategy.	Not Assessed
5	Monitor most scars for at least one year to allow maturation before determining a course of treatment.	Not Assessed
Provide Organizational Support		Level of Evidence
6	Establish and empower an interprofessional team to provide post-operative skin care.	5

Essential Publications
1	Fluid and pharmacological agents	Quality Indicator	Type: Systematic review
Metwally M, Watson A, Lilford R, Vandekerckhove P. Fluid and pharmacological agents for adhesion prevention after gynaecological surgery. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD001298. DOI: 10.1002/14651858.CD001298.pub3.
In this review, the effect of fluid and pharmacological agents on preventing adhesion in pelvic surgery is examined. It demonstrates how the use of some pharmacological agents can cause complications and that many only show limited benefits. More research that takes outcomes such as pregnancy rate into consideration is needed.
2	Sutures – Absorbable vs. nonabsorbable	Quality Indicator	Type: Systematic review
Al-Abdullah T, Plint AC, Fergusson D. Absorbable versus nonabsorbable sutures in the management of traumatic lacerations and surgical wounds: A meta-analysis. Pediatric Emergency Care 2007;23(5):339-44.
This review was well written and of high methodological quality. It compares the cosmetic outcomes that result from the use of absorbable and nonabsorbable sutures. No significant difference was found between the two types of sutures, but very few studies have been done on this topic.

Despite ongoing prevention efforts, surgical site infections (SSIs) account for approximately 40% of hospital-acquired infections among surgical patients. Approximately 3% of surgical patients develop an infection postoperatively. These infections increase length of hospital stay and associated costs, significantly increase risk of ICU admission, and double the risk of mortality compared with surgical patients who do not develop an infection. SSI is a key surgical outcome indicator.

SSI surveillance is an important tool to identify quality of care and areas of improvement for surgical services. As hospital stays have decreased in length, some of this surveillance must be conducted after discharge. Such surveillance may include telephone contact with patients, distribution of questionnaires to patients and surgeons, and follow-up with physicians diagnosing SSIs.

The major source of infection is the patient’s normal flora entering the body through the incision, although contamination from the surgical environment also contributes. Factors increasing the risk of developing an SSI include diabetes, smoking, perioperative blood transfusion, corticosteroid use and preoperative hospitalization and colonization with Staphylococcus aureus.

Standardized criteria from the Centers for Disease Control (CDC) describe SSI categories:

• Superficial incisional infection: Develops within 30 days of the surgical procedure and involves skin or subcutaneous tissue of the incision
• Deep incisional infection: Develops within 30 days of the surgical procedure or within 1 year of implant placement and involves deep soft tissues of the incision
• Infection of organ or space: Develops within 30 days of the surgical procedure or, if implant is in place, within 1 year and involves any part of the anatomy that was manipulated or opened during surgery, except for the incision.

It is estimated that approximately half of SSIs can be prevented. The Institute for Healthcare Improvement (IHI) recommends the following evidence-based approaches to reduce the incidence of SSIs:

Give the correct perioperative antibiotics appropriately at the appropriate time. Prophylactic antibiotic use is determined by the type of surgical wound (CDC classification):

• Class I: Clean, uninfected wounds without inflammation, closed by primary intention, which do not enter the respiratory, alimentary, genital or uninfected urinary tract
• Class II: Clean-contaminated wounds, which involve entry to respiratory, alimentary, genital or urinary tract under controlled conditions without unusual contamination
• Class III: Contaminated wounds, including fresh open accidental wounds, surgery with major breaks of sterile technique or gross spillage from gastrointestinal tract, and incisions with visible acute nonpurulent infection
• Class IV: Dirty-infected wounds, including old traumatic wounds with necrotic tissue, wounds with perforated viscera, and those with existing infection.

Prophylactic antibiotics should generally be given within 1 hour before incision to provide bactericidal blood and tissue levels (vancomycin, within 2 hours). Contaminated or dirty wounds usually require a therapeutic course of antibiotics. Among elderly patients undergoing general surgery, a case-control study found the use of prophylactic antibiotics reduced the risk of 60-day mortality by half.

• Remove hair appropriately. The CDC recommends hair not be removed unless it interferes with the surgery, and then removed with electric clippers, rather than shavers or depilatories. Shaving creates microscopic cuts that increase SSI risk and depilatories may cause hypersensitivity reactions. Development of hair removal protocols and removal of razors from the hospital may be helpful.

• Maintain postoperative blood glucose control in major cardiac surgery patients. Hyperglycemia increases SSI risk, and glucose control decreases mortality in critically ill patients with diabetes. The degree of hyperglycemia can be correlated with the SSI risk for sternal wounds and cardiac surgery. Preoperative screening for diabetes, staff education and a perioperative glucose control or insulin infusion protocol may be useful.

• Maintain normothermia in colorectal surgery patients. Hypothermia (

Other promising interventions include the following:

• Having the patient bathe or shower with an antimicrobial soap preoperatively to reduce epidermal colonization
• Ensuring appropriate operating room standards for ventilation, cleaning and disinfection and monitoring adherence to the standards
• Increasing oxygen tension at the incision site by providing supplemental perioperative oxygen, including for 2 hours postoperatively
• Covering the incision for 24 to 48 hours with a non-adherent sterile dressing: fibrin seals a surgical incision within 24 hours
• Maintaining meticulous hand hygiene before and after dressing changes, contact with the incision and with other parts of the patient’s body
• Using sterile gloves and techniques for dressing changes
• Individualizing patient education before discharge, about caring for the incision, identifying an infection, and knowing when to call the physician.

Identify and Treat the Cause		Level of Evidence
1	Take a careful history and conduct an inspection to identify and modify potential infection sources.	Not Assessed
Address Patient-Centered Concerns		Level of Evidence
2	Provide individualized education to patients about incision care.	5
Provide Local Wound Care		Level of Evidence
3	Assess and document the status of the incision.	Not Assessed
4	Optimize the wound healing environment.	Not Assessed
Provide Organizational Support		Level of Evidence
5	Determine rates of surgical site infection by appropriate category, such as patient and surgery type, floor, etc., and review current preventive approaches.	Not Assessed
6	Identify areas for improvement, develop additional protocols as necessary, and implement ongoing staff education.	Not Assessed
7	Monitor surgical infection rates and adherence to prevention strategies routinely.	Not Assessed

Essential Publications
1	Antisepsis – Preoperative bathing or showering	Quality Indicator	Type: Systematic review
Webster J, Osborne S. Meta-Analysis of Preoperative Antiseptic Bathing in the Prevention of Surgical Site Infection. British Journal of Surgery 2006;93(11):1335-41.
This comprehensive review addresses a specific, focused question and is of high methodological quality. It examines the effectiveness of preoperative bathing with an antiseptic in the prevention of surgical site infections. No evidence was found supporting antiseptic bathing as a means of reducing the incidence of infection.
2	Antisepsis – Preoperative bathing or showering	Quality Indicator	Type: Systematic review
Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD004985. DOI: 10.1002/14651858.CD004985.pub3.
This review addresses preoperative procedures to help prevent surgical infections. In a review of over ten thousand patients, it was found that, while bathing or showering was helpful in reducing risk of infection, the benefit of antiseptics over other wash products was questionable.
3	Antisepsis – Preoperative skin antiseptics	Quality Indicator	Type: Systematic review
Edwards PS, Lipp A, Holmes A. Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database of Systematic Reviews 2004, Issue 3. Art. No.: CD003949. DOI: 10.1002/14651858.CD003949.pub2.
Preoperative skin antisepsis is believed to help prevent postoperative wound infections, but this review was unable to confirm this. The varying results from the studies included in this review prevented a cohesive conclusion from being made. More high quality studies are needed.
4	Antisepsis – Surgical hand antisepsis	Quality Indicator	Type: Systematic review
Tanner J, Swarbrook S, Stuart J. Surgical hand antisepsis to reduce surgical site infection. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD004288. DOI: 10.1002/14651858.CD004288.pub2.
The purpose of this paper was to determine the effect of surgical hand antisepsis on the incidence of surgical site infections and the number of bacterial colony forming units on the surgical team’s hands. Only one randomised controlled trial was found that measured occurrence of surgical site infections, and it showed that there was no difference between alcohol rubs containing additional active ingredients and aqueous scrubs. It was difficult to compare the colony forming unit results from the different randomised controlled trials because each study presented a different comparison, and results were mixed.
5	Post-discharge surveillance	Quality Indicator	Type: Systematic review
Petherick ES, Dalton JE, Moore PJ, Cullum N. Methods for Identifying Surgical Wound Infection After Discharge from Hospital: A Systematic Review. BMC Infectious Diseases 2006: Art No.: 170. ate of Pubaton: 27 NO 2006.
Many surgical site infections develop outside of the hospital setting. This study identified the need for reliable post-discharge surveillance programs to control surgical site infections that do occur. The review found that a valid method has not been developed, and that further research is needed to devise one.
6	Prevention – Disposable surgical face masks	Quality Indicator	Type: Systematic review
Lipp A, Edwards P. Disposable surgical face masks for preventing surgical wound infection in clean surgery. Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD002929. DOI: 10.1002/14651858.CD002929.
This systematic review evaluated the role of surgical face masks in the prevention of surgical site infections. Only two randomized controlled trials were found, and they produced conflicting results. More research needs to be conducted on this topic that could potentially have important implications on surgery.
7	Prevention – Double gloving	Quality Indicator	Type: Systematic review
Tanner J, Parkinson H. Double gloving to reduce surgical cross-infection. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD003087. DOI: 10.1002/14651858.CD003087.pub2.
In this systematic review the effects of different types of gloves, in particular double gloves, as a precautionary measure in the operating room to reduce the risk of surgical site infections were studied. There was no direct evidence supporting the reduction of surgical site infections when the surgical team wore additional glove protection. More research is needed on this topic.
8	Prevention – Incision barrier	Quality Indicator	Type: Systematic review
Ozer MT, Yigit T, Uzar AI, Eryilmaz M, Kozak O, Cetiner S, Arslan I, Tufan T. Can incision barrier decrease the risk of surgical site infection after appendectomy? Saudi Med J, 2006;27(8):1259-1261.
In this study, the use of an incision barrier, a device inserted into a surgical incision that protects the wound from contamination, was examined. Surgical site infection rate was higher when an incision barrier was not used, but the study was poorly randomized and had a limited population that only consisted of men aged 20 to 44.
9	Prevention – Nail polish and finger rings	Quality Indicator	Type: Systematic review
Arrowsmith VA, Maunder JA, Sargent RJ, Taylor R. Removal of nail polish and finger rings to prevent surgical infection. Cochrane Database of Systematic Reviews 2001, Issue 1. Art. No.: CD003325. DOI: 10.1002/14651858.CD003325.
In this systematic review, the effect of nail polish and finger rings worn by the surgical team on the incidence of surgical site infections in the patient was investigated. The premise was that bacteria are harboured in nail polish and under rings, and cause infection in surgical patients. There have been virtually no studies on this topic, with the researchers finding only one small randomized controlled trial that indicated that wearing nail polish, both freshly applied and old, had no significant difference in the number of bacteria on the hands compared to not wearing nail polish. Further research is needed and could potentially alter operating room standards.
10	Prevention – Preoperative hair removal	Quality Indicator	Type: Systematic review
Tanner J,Woodings D,Moncaster K. Preoperative hair removal to reduce surgical site infection. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004122. DOI: 10.1002/14651858.CD004122.pub3.
A longstanding belief is that removing body hair from the surgical site reduces the risk of surgical site infection. This systematic review challenges this traditional belief by examining whether preoperative hair removal is superior to no hair removal in preventing infection. Evidence shows that the difference between the two methods in reducing infection is non-significant.
11	Prevention – Preoperative hair removal	Quality Indicator	Type: RCT
Celik SE, Kara A. Does shaving the incision site increase the infection rate after spinal surgery? Spine 2007;32(15):1575-1577.
This study of 789 spinal surgery patients examines whether presurgical shaving of the incision site has any effect on infection rate. The postsurgical infection rate in the nonshaved group was lower than in the shaved group. This difference was statistically significant, indicating that not shaving may reduce the incidence of infection.
12	Prophylactic antibiotics – Administration – Colorectal Cancer Surgery	Quality Indicator	Type: RCT
Kobayashi M, Mohri Y, Tonouchi H, Miki C, Nakai K, Kusunoki M, Mie Surgical Infection Research Group. Randomized clinical trial comparing intravenous antimicrobial prophylaxis alone with oral and intravenous antimicrobial prophylaxis for the prevention of a surgical site infection in colorectal cancer surgery. Surg Today 2007;37(5):383-388.
This study achieves its objective of showing that intravenous antimicrobial prophylaxis is not inferior to a combination of oral and intravenous treatment.
13	Prophylactic antibiotics – Breast cancer surgery	Quality Indicator	Type: Systematic review
Cunningham M, Bunn F, Handscomb K. Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD005360. DOI: 10.1002/14651858.CD005360.pub2.
Breast cancer surgery has a higher than average risk of infection for clean surgery. In this review, prophylactic antibiotics significantly reduced the risk of infection for these patients. More research is needed to determine which antibiotic is best suited for this particular situation.
14	Prophylactic antibiotics – Breast cancer surgery	Quality Indicator	Type: Systematic review
Tejirian T, DiFronzo LA, Haigh PI. Antibiotic Prophylaxis for Preventing Wound Infection After Breast Surgery: A Systematic Review and Metaanalysis. Journal of the American College of Surgeons 2006;203(5):729-34.
The incidence of infection in breast surgery ranges from 3% to 30%, which is much higher than the accepted rate of 1.5% for clean operations. In this systematic review, prophylactic antibiotics reduced postoperative wound infections in breast surgery with little to no adverse reactions.
15	Prophylactic antibiotics – Ceftriaxone	Quality Indicator	Type: Systematic review
Esposito S, Noviello S, Vanasia A, Venturino P. Ceftriaxone Versus Other Antibiotics for Surgical Prophylaxis : A Meta-Analysis. Clinical drug investigation 2004;24(1):29-39.
The purpose of this well conducted and well written systematic review was to evaluate the effectiveness of the prophylactic antibiotic ceftriaxone in preventing both local and remote postoperative infections. Ceftriaxone was shown to be superior to other antibiotics in preventing infection.
16	Prophylactic antibiotics – Cesarean section	Quality Indicator	Type: Systematic review
Smaill F, Hofmeyr GJ. Antibiotic prophylaxis for cesarean section. Cochrane Database of Systematic Reviews 2002, Issue 3. Art. No.: CD000933. DOI: 10.1002/14651858.CD000933.
Cesarean section poses a high risk for postpartum maternal infection. This study looked at the effect of antibiotic prophylaxis, usually administered intravenously but can be orally administered, on reducing the risk of infection. The review found that the administration of antibiotics, regardless of signs of infection, is very beneficial in preventing infection.
17	Prophylactic antibiotics – Dosage – Gastric Cancer Surgery	Quality Indicator	Type: RCT
Mohri Y, Tonouchi H, Kobayashi M, Nakai K, Kusunoki M, Mie Surgical Infection Research Group. Randomized clinical trial of single- versus multiple-dose antimicrobial prophylaxis in gastric cancer surgery. Br J Surg 2007;94(6):683-688.
The purpose of this study was to compare the effects of a single-dose against a multiple-dose treatment plan of prophylactic antibiotics in preventing surgical site infections in gastric cancer surgery patients. The difference was not significant, indicating that a single-dose regimen of antibiotics is just as effective as a multiple-dose regimen at preventing infection.
18	Prophylactic antibiotics – Ear surgery	Quality Indicator	Type: Systematic review
Verschuur HP, Wever WWH de, Benthem PPG van. Antibiotic prophylaxis in clean and clean-contaminated ear surgery. Cochrane Database of Systematic Reviews 2004, Issue 3. Art. No.: CD003996. DOI: 10.1002/14651858.CD003996.pub2.
The purpose of this well-conducted systematic review was to assess the effectiveness of local and/or systemic antibiotics in preventing post-operative complications in patients undergoing clean or clean-contaminated ear surgery. There is no evidence that they were useful in reducing wound infection, discharge from the outer ear canal, labyrinthitis, graft failure, adverse reaction to antibiotic, length of hospital stay or re-operation due to infection. Clinicians will need to make experience informed decisions about using antibiotics to prevent post-operative complications.
19	Prophylactic antibiotics – Gentamicin-collagen – Anal fistula flap	Quality Indicator	Type: RCT
Gustafsson UM, Graf W. Randomized clinical trial of local gentamicin-collagen treatment in advancement flap repair for anal fistula. Br J Surg 2006;93(10):1202-1207.
Anal fistula has a high recurrence rate, and this may be due to infection. The purpose of this paper was to determine if gentamicin-collagen improves healing of anal fistula after endoanal advancement flap repair is performed. This study establishes that the local antibiotic gentamicin-collagen does not improve healing.
20	Prophylactic antibiotics – Mupirocin – Staph arriers- cardiac surgery	Quality Indicator	Type: RCT
Konvalinka A, Errett L, Fong IW. Impact of treating Staphylococcus aureus nasal carriers on wound infections in cardiac surgery. J Hosp Infect 2006;64(2):162-168.
This well designed study that showed the effect of mupirocin on clearing nasal colonies of S. aureus. The researchers hypothesized that clearing S. aureus would help reduce the incidence of post-surgical infection. Although significantly more mupirocin patients cleared S. aureus compared to the placebo group, there was no significant difference in infection rates.
21	Prophylactic antibiotics – Oncological surgery	Quality Indicator	Type: RCT
Skitareli N, Morovi M, Manestar D. Antibiotic prophylaxis in clean-contaminated head and neck oncological surgery. J Craniomaxillofac Surg 2007;35(1):15-20.
The purpose of this paper was to examine the efficacy of two different prophylactic antibiotics, amoxicillin-clavulanate and cefazolin, in preventing infection in oncological surgery. The difference in occurrence of infection between the two antibiotics was found to be non-significant, but the surgical procedure performed was not standardized. Researchers found that the type of procedure performed influenced the incidence of postoperative infection, so a study using a standardized surgical procedure may provide a better perspective on the effect and potential differences of the two antibiotics.
22	Prophylactic antibiotics – Orthopedic surgery	Quality Indicator	Type: RCT
Kato D, Maezawa K, Yonezawa I, Iwase Y, Ikeda H, Nozawa M, Kurosawa H. Randomized prospective study on prophylactic antibiotics in clean orthopedic surgery in one ward for 1 year. Journal of Orthopaedic Science 2006;11(1):20-27.
The purpose of this study was to examine the ability of antimicrobial agents on controlling the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) and reduce surgical site infections caused by MRSA. The use of sulbactam/ampicillin decreased the isolation rate of MRSA compared to cefazolin, but the rate of infection was not affected by either antibiotic. Unfortunately, the credibility of the findings of this study is compromised by the methodological deficits of the research. The groups were not truly randomized, there was no mention of blinding, and the control group was not standardized.
23	Surgical techniques – Cataract surgery	Quality Indicator	Type: RCT
Parmar P, Salman A, Kaliamurthy J, Prasanth DA, Thomas PA, Jesudasan CA. Anterior chamber contamination during phacoemulsification and manual small-incision cataract surgery. Am J Ophthalmol 2006;141(6):1160-1161.
In this paper, two different surgical techniques, phacoemulsification and manual small-incision cataract surgery, were examined with the goal of reducing infection during cataract surgery. The difference in the incidence of anterior chamber contamination between the two groups was not significant.
24	Wound cleansing – Water	Quality Indicator	Type: Systematic review
Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD003861. DOI: 10.1002/14651858.CD003861.pub2.
In this systematic review, various solutions, water in particular, were examined for cleansing wounds. There was no statistically significant evidence that water reduces the risk of infection in treating both acute and chronic wounds. The evidence was also not strong concerning the idea that cleansing wounds in general increased healing or reduced infection. Better-quality and well-designed studies are needed on this topic.
25	Antisepsis – Preoperative showering	Quality Indicator	Type: RCT
Kalantar-Hormozi AJ, Davami B. No need for preoperative antiseptics in elective outpatient plastic surgical operations: A prospective study. Plast. Reconstr. Surg. 2005;116(2):529-531.
The purpose of this study was to determine the efficacy of preoperative showering with antiseptics in preventing wound infections in elective outpatient plastic surgery. 1810 patients were evenly divided into two groups (using a randomization procedure regarded as not appropriate), one showering with normal saline solution and the other showering with the antiseptics Chlorhexidine or Betadine. No surgical site infections occurred in either group. This indicates that preoperative showering with antiseptics does not significantly reduce levels of infection.

The most frequently used conduit for coronary artery bypass grafting (CABG) procedures is the greater saphenous vein. Problems with healing of the leg incision may be associated with underlying systemic conditions, such as unrecognized peripheral vascular disease (PVD) due to congestive heart failure, diabetes or smoking; the type of surgical procedure used for vein harvesting; surgical technique; female gender; smoking; obesity; preoperative anemia; and other factors, such as preoperative hospitalization, the use of elastic bandages in the operating room, the length of time the incision remained open in the operating room, and intravenous nicardipine administration postoperatively. Complications can cause significant morbidity, increase patient risk and delay recovery and return to normal activity.

Wound-healing problems include increased wound tension, hematoma formation, wound dehiscence, infection, and flap necrosis. Local infection can progress to a potentially fatal septicemia if not identified promptly. Complications often become evident at approximately 7–10 days after surgery.

• Ischemia: Unrecognized PVD, which may be associated with smoking, can result in persistent ischemia and impaired wound healing in the leg. These patients generally require revascularization before healing can occur.
• Type of procedure: A long continuous incision, the traditional method for harvesting this vein, is associated with problems with wound healing in up to 24% of patients, poor cosmetic results and delayed mobilization. Minimally invasive procedures using direct vision can reduce the postoperative occurrence of wound-healing problems in the leg, while providing a substantially better cosmetic outcome.
• Surgical technique: Identifying the path of the saphenous vein is critical. Extensive dissection and creation of large flaps significantly increases the risk of wound healing complications, whereas minimally traumatic surgical technique with meticulous hemostasis and elimination of dead space can reduce the development of postoperative problems.

In some cases, preoperative identification of risk factors for wound complications can prevent the occurrence of complications. In other cases, the surgical procedure can be modified to reduce the risk of complications.

Wound-healing problems are managed using standard wound care techniques. Readmission for intravenous antibiotic therapy, surgical or nonsurgical debridement, and additional surgery may be required. Negative-pressure wound therapy can reduce granulation time of these wounds. The use of Apligraf, a bioengineered skin substitute, may significantly reduce wound healing time among patients who develop complications.

Identify and Treat the Cause		Level of Evidence
1	Perform a preoperative evaluation to identify patients with an increased risk of developing wound healing problems after saphenous vein harvest.	Not Assessed
2	Consider patient risk of complications when planning the saphenous vein harvest.	Not Assessed
Address Patient-Centered Concerns		Level of Evidence
3	Provide individualized education.	5
Provide Local Wound Care		Level of Evidence
4	Manage leg wound-healing problems using standard wound care practices.	Not Assessed
5	Optimize the wound healing environment.	Not Assessed
6	Consider the use of Apligraf and negative-pressure wound therapy to speed healing in patients with surgical wound breakdown.	Not Assessed
Provide Organizational Support		Level of Evidence
7	Establish and empower an interprofessional team to facilitate post-operative care.	5

Essential Publications
1	Coronary artery bypass grafting	Quality Indicator	Type: RCT
Stenvik M, Tjomsland O, Lien S, Gunnes S, Kirkeby-Garstad I, Astudillo R. Effect of subcutaneous suture line and surgical technique on wound infection after saphenectomy in coronary artery bypass grafting: a prospective randomised study. Scand Cardiovasc J 2006;40(4):234-237.
The impact of an additional subcutaneous suture line on the incidence of postoperative infection at the vena saphena magna harvesting site after coronary artery bypass grafting surgery is examined in this study. The difference between intracutaneous closure and additional subcutaneous closure was not statistically significant.
2	Coronary artery bypass surgery – Diabetics	Quality Indicator	Type: RCT
Li JY, Sun S, Wu SJ. Continuous insulin infusion improves postoperative glucose control in patients with diabetes mellitus undergoing coronary artery bypass surgery. Tex Heart Inst J 2006;33(4):445-451.
The purpose of this study was to compare the effect of continuous insulin infusion against glucometer-guided insulin injection on glucose control after coronary artery bypass surgery. The difference in incidence of sternal wound infection was not significant, but significantly more infusion patients achieved satisfactory blood glucose levels than injection patients. The researchers were unable to do any blinding in the study due to the different and obvious insulin administration techniques. This caused dropouts in the injection group because of physician concerns that may have had a negative impact on the study because it appeared that the continuous infusion group was able to control their blood glucose levels better.
3	Minimally invasive vein harvesting	Quality Indicator	Type: Systematic review
Athanasiou T, Aziz O, Skapinakis P, Perunovic B, Hart J, Crossman MC, Gorgoulis V, Glenville B, Casula R. Leg wound infection after coronary artery bypass grafting: A meta-analysis comparing minimally invasive versus conventional vein harvesting. Annals of Thoracic Surgery 2003;76(6):2141-6.
In this review, the minimally invasive vein harvesting technique was compared with the conventional technique to determine whether one is more effective at preventing leg wound infection during coronary artery bypass surgery. The researchers found that the minimally invasive vein harvesting significantly reduced the infection rate. Further research is necessary to fully understand all aspects of this technique.
4	Minimally invasive vein harvesting	Quality Indicator	Type: Systematic review
Athanasiou T, Aziz O, Sharif A, Philippidis P, Jones C, Purkayastha S, Casula R, Glenville B. Are wound healing disturbances and length of hospital stay reduced with minimally invasive vein harvest? A meta-analysis. European Journal of Cardio-Thoracic Surgery 2004;26(5):1015-26.
In this study, the effect of minimally invasive vein harvesting on non-infective wound healing disturbances was examined. Non-infective wound healing disturbances include wound drainage, hematoma, dehiscence, necrosis, need for surgical debridement, and seroma formation. It was found that the minimally invasive vein harvesting technique was effective at reducing the risk of non-infective wound healing disturbances.
5	Prophylactic antibiotics – Coronary artery bypass surgery	Quality Indicator	Type: RCT
Dhadwal K, Al-Ruzzeh S, Athanasiou T, Choudhury M, Tekkis P, Vuddamalay P, Lysler H, Amrani M, George S. Comparison of clinical and economic outcomes of two antibiotic prophylaxis regimens for sternal wound infection in high-risk patients following coronary artery bypass grafting surgery: A prospective randomised double-blind controlled trial. Heart 2007;93(9):1126-1133.
The purpose of this study was to compare clinical and economic outcomes of a longer and broader-spectrum prophylactic antibiotic regimen against cefuroxime in high-risk patients following coronary artery bypass grafting surgery. The longer and broader-spectrum regimen significantly reduced the incidence of sternal wound infection as well as being significantly more cost-effective.
6	Post-surgical leg wound complications	Quality Indicator	Type: Retrospective Analysis
Paletta CE, Huang DB, Fiore AC, Swartz MT, Rilloraza FL, Gardner JE. Major leg wound complications after saphenous vein harvest for coronary revascularization. Ann Thorac Surg. 2000; 70(2):492-7.
The purpose of this study was to analyze leg wound complications following coronary revascularization procedures. The results show that there are a number of risk factors for leg complications, and that it is possible to identify patients with a high likelihood of experiencing problems. Female patients with peripheral vascular disease and postoperative intraaortic balloon pumps were found to be at greatest risk for developing complications. In order to minimize complications, it would be beneficial to perform vascular evaluations prior to saphenous vein harvest. Greater attention to proper surgical technique and careful harvest site selection would also be beneficial.