Delayed Primary Closure Using Negative Pressure Wound Therapy
Delayed Primary Closure Using Negative Pressure Wound Therapy
Surgical site infection rates for contaminated or dirty laparotomy wounds can be as high as
 45%. Surgical management of dirty and contaminated wounds has been controversial in the
 literature and between surgeons. Primary closure (PC) of these wounds can lead to multiple
 complications including surgical site infection (SSI), necrotizing soft tissue infection,
 wound and fascial dehiscence, evisceration, sepsis and hernia development. However, an
 alternative technique of utilizing secondary intention results in prolonged healing time and
 increased cost and healthcare resource utilization. Delayed primary closure (DPC) was
 developed to address many of these issues. Bhangu completed a systematic review and
 meta-analysis comparing primary versus delayed primary skin closure in contaminated and dirty
 abdominal wounds. They included 8 studies randomizing 623 patients with contaminated or dirty
 abdominal wounds to either DPC or PC. The most common diagnosis was appendicitis (77.4%),
 followed by perforated abdominal viscus (11.5%), ileostomy closure (6.5%), trauma (2.7%), and
 intra-abdominal abscess/other peritonitis (1.9%). The time to first assessment for DPC was
 between 2 and 5 days postoperatively. In all studies, the DPC group had significantly less
 SSIs using a fixed-effect model (odds ratio, 0.65; 95%CI, 0.40-0.93; P = .02). However,
 heterogeneity was high (72%), and using a random-effects model, the effect was no longer
 significant (odds ratio, 0.65; 95% CI, 0.25-1.64; P = .36). Additionally, all of the studies
 were found to be at high risk of bias, with marked deficiencies in study design and outcome
 assessment.

 A recent systematic review showed improved fascial closure rates with negative pressure wound
 therapy (NPWT) Yet, a large national study using NPWT to perform a DPC has been shown to
 actually decrease the rate of closure. Access to NPWT has increased over the years and
 innovative wound management techniques including incisional application of negative pressure
 therapy have allowed clinicians to apply this method to dirty wounds following the principles
 of delayed primary closure. There are currently no studies available to help determine the
 safety and efficacy of advanced NPWT techniques to optimize surgical wound management from
 the open abdomen to skin closure. Within our Division, we have decided to make a practice
 change and develop a standard closure plan for open abdomens using the negative pressure
 devices available within our institution.
Inclusion Criteria:

 -  18 years or older

 -  undergone midline laparotomy and managed with an open abdomen for at least one day

 -  contaminated or dirty wound classification

 Exclusion Criteria:

 -  Less than 18 years of age

 -  Prisoners

 -  Pregnant females

 -  Non-surgical patients