Comparative study of subcutaneous single closed suction drain versus simple closure in emergency midline laparotomy wounds

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Journal of MedVerse Research & Practice

nurexus.com

Comparative study of subcutaneous single closed suction drain versus

simple closure in emergency midline laparotomy wounds

Dr Sunil,

Department of General Surgery, Meenakshi Medical College Hospital and

Research Institute, Kancheepuram

Email ID: sunildr452@gmail.com

Submission Date: 28.05.2024

Accepted Date: 23.06.2024

Published Date: 30.06.2024

article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits

unrestricted use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

Abstract

Background: Wound healing post-surgery significantly affects patient morbidity and quality of life. The term

"surgical site infections" (SSIs) is predominantly employed to denote infections occurring in the surgical wound

after an invasive operation. Wound infections remain a critical concern due to their potential influence on surgical

outcomes and prolonged hospital stays. Patients undergoing emergency laparotomy procedures are at a heightened

risk for surgical site infections and delayed wound healing.

Materials & Methods: This research was conducted at a private medical college and hospital over 12 months,

from December 2022 to November 2023. It constitutes a prospective comparative analysis. Data were gathered

from patients admitted to the General Surgery department who underwent emergency laparotomy procedures at

the hospital. A total of 100 patients were included in two groups, 50 in each group. In one group, the wound was

closed with a subcutaneous drain, and in the other group, a simple skin closure technique was used.

Results: The mean age of the study participants was 39.5±3.5 years. The majority of the participants belonged to

the age group of 31-40 years, and there exists a male gender preponderance. The occurrence of wound

complications, seromas, surgical site infections, and the need for surgical interventions was significantly less

among those cases with subcutaneous drain than among those patients with simple skin closure. The mean days of

hospital stay were comparatively less with the subcutaneous drain.

Conclusion: Subcutaneous single closed suction drains significantly mitigate surgical site infections compared to

patients without such drains, which reduces the need for surgical intervention, which in turn helps in shorter

hospital stay.

Keywords: Subcutaneous single closed, Suction drain, Simple closure, Emergency midline laparotomy wounds.

Introduction

Surgical site infections (SSIs) are prevalent complications following surgical interventions, especially

major abdominal surgeries such as emergency laparotomies.[1] SSIs have the potential to result in

increased morbidity, longer hospital stays, and rising costs associated with medical care. Methods that are

effective in lowering the risk of surgical site infections (SSIs) are of utmost importance in developing

countries, where healthcare resources are frequently limited.[2] The use of subcutaneous suction drains

and simple skin closure techniques, both of which are frequently employed in postoperative wound

management, are two of the strategies that are utilized to diminish the likelihood of these infections

occurring. To improve patient outcomes, it is essential to have a thorough understanding of the relative

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effectiveness of these methods, particularly in high-risk surgeries such as emergency and laparoscopic

procedures.[3]

Emergency laparotomies, which involve immediate surgical intervention for patients in life-threatening

unstable conditions, are included in the category of procedures that contribute to the increased risk of

infection. [4] As a result, the postoperative care of these patients needs to implement a wound closure

technique that is both effective and minimizes the risk of surgical site infections (SSIs). The decision

between subcutaneous suction drains and simple skin closure in abdominal conditions significantly

influences infection and complication rates. Abdominal conditions generally exhibit a greater risk of

surgical site infections (SSIs) compared to elective surgeries.[5] It is important to note that the urgency

and complexity of these procedures, in conjunction with the frequently unstable condition of patients,

contribute to the greater likelihood of infection. Therefore, it is essential to implement a wound closure

technique that is both effective and minimizes the risk of surgical site infections (SSIs) in the care that

these patients receive after their surgeries. The decision between using subcutaneous suction drains or

simply closing the skin can have a significant impact on the rates of infection and other complications.

[6,7]

By actively removing fluid and debris from the wound site, subcutaneous suction drains can perform their

function. This can potentially help prevent the accumulation of bacteria and reduce the likelihood of

infection. By maintaining a dry environment around the wound and reducing the number of bacteria

present, this technique is believed to hasten the healing process. Simple skin closure, on the other hand,

involves suturing the wound without any additional drainage. [8,9] Although this method is simpler, it

may allow fluid to accumulate, which could potentially increase the risk of infection. Despite this, both

methods are widely utilized, and the extent to which they are successful in lowering the number of SSIs is

still a matter of debate. [10.11] The primary objective of this research was to ascertain the effect of a

subcutaneous closed suction drain on the incidence of surgical site infection post-emergency

laparotomy. An examination was conducted to address this inquiry. The secondary objective is to

evaluate the duration of hospitalization for patients utilizing a closed suction drain compared to a

standard closure.

Materials and Methods

This study was conducted at Meenakshi Medical College Hospital and Research Institute situated in

Kancheepuram, South India. This study was done over 12 months, from January 2023 to December 2023,

as a prospective analysis. Data was gathered from patients admitted to the General Surgery department

who underwent emergency laparotomy procedures. A total of 100 patients were included in the sample

during this timeframe. The defined Inclusion Criteria to select the eligible participants are as follows:1.

Patients undergoing emergency laparotomy through a midline incision, 2. Patients aged 20 to 59 years,

of both genders, 3. Patients with a BMI over 31,

4. Both male and female participants. With the following exclusion criteria, ineligible patients were not

included. 1. Patients aged 60 and above, 2. Patients with a previous surgical history, 3. Patients who

declined participation in the study, 4. Immunocompromised individuals, 5. Patients diagnosed with

diabetes mellitus, 6. Patients showing symptoms of jaundice and 7. Patients with anemia

Ethical approval was obtained from the Institutional Ethical Committee before starting the study, and

informed consent was collected from all participants. This prospective comparative study used systematic

random selection to assign patients into two groups before surgery. In Group A, fifty patients received

subcutaneous closed suction drains, while in Group B, fifty patients did not receive any drainage system.

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Individuals admitted to the emergency department. Clinical diagnosis is corroborated by various

diagnostic methodologies. Critical parameters are analyzed. The initial phase of resuscitation is

conducted with crystalloids and blood products as needed. Written consent was acquired after the

patient and their family members were informed of the study protocol. A study group was selected

randomly. The gathered data was inputted into Microsoft Excel. The variables were coded.

Patients admitted to the emergency department underwent a clinical diagnosis, confirmed through

various diagnostic methods. Key parameters were analyzed, and the initial resuscitation phase involved

crystalloids and blood products as necessary. Written consent was obtained after informing the patient

and their family about the study protocol. A study group was selected at random, and the collected data

was entered into Microsoft Excel. Variables were coded, and analysis was performed using SPSS software

(Version 27, IBM). Descriptive statistics were used, and correlations among categorical variables were

assessed, with a p-value below 0.05 considered statistically significant.

Result

A total of 100 patients operated for midline laparotomy were included in the present study. The

average age of the study participants was 39.5 ± 3.5 years.

Table 1: Distribution of patients in the study as per age (N=100)

Age in years

Frequency

Percent

20 – 30

31 – 40

41 – 50

51 – 60

Total

105

100%

The table above displays the frequency (number of individuals) and percentage of participants in each

age group: 20–30 years (11%), 31–40 years (32%), 41–50 years (28%), and 51–60 years (29%). The

total sample consists of 100 individuals.

Table 2: Distribution of the study subjects as per gender (N=100)

Gender

Frequency

Percent

Male

60%

Female

40 %

Total

100

100%

The above table displays the frequency (number of individuals) and percentage of males (60%) and

females (40%) in the overall sample of 100 individuals.

Table 3: Proportion of wound complication among study subjects (N=100)

Wound Complication

Frequency

Percent

Absent

61%

Present

39%

Total

105

100%

The table above shows the number of cases with wound complications (39 cases) and without wound

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complications (61 cases).

Table 4: Proportion of Seroma among the study subjects (N=100)

Presence of Seroma

Frequency

Percent

Absent

80%

Present

20%

Total

105

100%

The table above shows the number of cases in which seroma was observed (20 cases) and not observed

(80 cases).

Table 5: Proportion of SSI among the study subjects (N=100)

SSI

Frequency

Percent

69%

Yes

31%

Total

105

100%

The table presented illustrates the distribution of cases with and without SSI. Out of the total, 31

instances exhibited SSI, while 69 did not. When examining the relative frequencies, cases lacking SSI

constituted 69% of the overall sample, whereas those with SSI represented 31% of the total cases.

Table 6: Proportion of surgical intervention among study subjects (N=100)

Intervention

Frequency

Percentage

68%

Yes

32%

Total

100

100%

The data presented in the table shows that SSI was observed in 31 instances, while 69 instances were

free from SSI. About the total number of cases, those without SSI represent 69% of the sample, whereas

SSI-positive cases constitute 31%. This breakdown illustrates the distribution of cases across both

categories.

Table 7: Association between SSI and Subcutaneous drain

Variables

Subcutaneous drain

P value

Yes (50)

No (50)

<0.01

Wound

Complication

No (61)

42 (68.8%)

19(31.2%)

Yes (39)

8(20.5%)

31(79.5%)

Seroma

No (80)

45(56.2%)

35(43.8%)

<0.01

Yes (20)

5(25%)

15(75%)

SSI

No (69)

45(65.2%)

24(34.8%)

<0.01

Yes (31)

5 (16.1%)

26(83.9%)

Intervention

No 68

44(64.7%)

24(35.3%)

<0.01

Yes 32

6(16%)

26(84%)

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The data presented in the aforementioned table indicate that patients who received subcutaneous drains

experienced significantly lower rates of wound complications, seroma formation, and surgical site

infections compared to those who underwent simple closure. Furthermore, the need for additional surgical

intervention was substantially reduced in cases where subcutaneous drains were employed, as opposed to

instances where simple closure techniques were utilized.

Table 8: Duration of hospital stay between two study groups(N=100)

S.No

Study group

Mean

Standard

deviation

P value

Simple closure

11.45

3.53

<0.05

Subcutaneous drain

8.94

2.76

With regards to the number of days of hospital stay, the patients in the simple closure group had higher

mean duration than the patients in the subcutaneous drain group and this finding was statistically

significant as shown in the above table.

Discussion

The current study was conducted to compare the effectiveness of the usage of a subcutaneous drain

versus the simple closure among patients with midline laparotomy wounds. The study participants had an

average age of 39.5±3.5 years. The largest proportion of subjects (31%) fell within the 31- 40 year age

range. This finding, which showed middle-aged individuals as the primary contributors, was

corroborated by research conducted by Khan RM et al. Their study similarly identified subjects aged 31-

40 years as comprising the majority of their sample.[12] In the present study, there was a male gender

preponderance with almost 2/3

of the subjects being male. This inference is by a study conducted by

Junaid F et al which also showed that 70% of their study participants as male subjects [13]. Thus,

midline laparotomies are most commonly performed among middle-aged male patients.

In our study, it was found that the proportions of wound complications were significantly less among

the cases with a subcutaneous drain in comparison with those cases with simple skin closure of the

wound after midline laparotomy. This finding is supported by the randomized control conducted by

Shunmugam D et al. [14] The main aim of our study is to the incidence of surgical site infection with

subcutaneous drain. The effectiveness of subcutaneous suction drains is evidenced by the substantially

reduced infection rate in patients who received them (16%) compared to those who underwent simple skin

closure (84%). These results align with other research indicating that drain usage decreases the

likelihood of surgical site infections (SSIs), especially in high-risk procedures like emergency

laparotomies. [15] Furthermore, our observations regarding SSIs corroborate global research findings.

Numerous studies worldwide have shown that subcutaneous suction drains effectively minimize wound

fluid accumulation, thereby reducing bacterial presence and helping to prevent infections. According to

the findings of other studies, the high rate of surgical site infections (SSIs) in the group that underwent

simple skin closure, which affected 84% percent of patients, is a reflection of the difficulties associated

with managing wound closure without drainage in high-risk surgeries. On the other hand, the

subcutaneous suction drain group had a significantly lower infection rate of 16%, which is consistent

with the findings of other prospective studies that highlight the benefits of drains in providing relief from

postoperative complications. [11,16]

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The length of time that patients in the simple closure group remained in the hospital was significantly

higher than those in the subcutaneous drain group. The group that received subcutaneous suction drains

had an average stay that was 8.94 days shorter than the group that received a simple skin group focused

on closure (11.45 days). This study's finding is similar to the findings of other studies, which have

demonstrated that the utilization of suction drains can lessen the likelihood of fluid accumulation and

infection, thereby resulting in a more expedient recovery and a shorter duration of hospitalization. Our

research demonstrates that there is a statistically significant difference (p = 0.004), which provides

additional evidence that subcutaneous suction drains are beneficial in terms of enhancing recovery.[17]

Conclusion

In conclusion, the observed findings of our study provide strong support for the utilization of

subcutaneous suction drains in emergency laparotomies in India. This is done to reduce surgical site

infections (SSIs), shorten hospital stays, and improve results for patients. The findings of this

investigation contribute to the increasing amount of proof that supports the utilization of suction drains

in high-risk situations that operations on the abdominal region and provide valuable insights for the

improvement of surgical practices in countries with limited resources.

Acknowledgment: We express our gratitude to all study participants for their involvement and

complete cooperation. We express our gratitude to the faculty of the Department of General

Surgery for their encouragement and support.

Financial support and sponsorship: Nil

Conflicts of interest: Nil

Reference

1. Arora A, Bharadwaj P, Chaturvedi H, Chowbey P, Gupta S, Leaper D, Mani GK, Marya SK,

Premnath R, Quadros K, Srivastava A. A review of prevention of surgical site infections in Indian

hospitals based on global guidelines for the prevention of surgical site infection, 2016. Journal of

Patient Safety and Infection Control. 2018 Jan 1;6(1):1-2.

2. NHSN Surgical Site Infection Event Accessed September 24 2024

3. at: http://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurr ent.pdf

4. Centers for Disease Control and Prevention. National nosocomial infections surveillance (NNIS)

system report, data summary from January 1992-June 2001, issued August 2001. American Journal of

Infection Control. 2001;29(6):404-21.

5. Barie PS. Surgical site infections: epidemiology and prevention. Surgical infections. 2002 Dec

1;3(S1):s9-21.

6. Shao J, Zhang H, Yin B, Li J, Zhu Y, Zhang Y. Risk factors for surgical site infection following

operative treatment of ankle fractures: a systematic review and meta-analysis. International Journal of

Surgery. 2018 Aug 1;56:124-32.

7. Divino CM, Kuerer HM, Tartter PI. Drains prevent seromas following lumpectomy with axillary

dissection. The Breast Journal. 2000 Jan;6(1):31-3.

8. Rosenberger LH, Politano AD, Sawyer RG. The surgical care improvement project and prevention of

post-operative infection, including surgical site infection. Surgical infections. 2011 Jun 1;12(3):163-

9. Gilkar A, Dogra V, Mushtaq U, Peer J, Hassan Y, Hafiz S. Evaluation of subcutaneous negative

pressure drain placement following emergency laparotomy. Int J Curr Res. 2019;11(09):7426-9.

10. Gabriel A, Gupta S, Orgill DP. Challenges and management of surgical site occurrences. Plastic and

reconstructive surgery. 2019 Jan 1;143(1S):7S-10S.

Page 33

11. Farnell MB, Worthington-Self S, Mucha P, Ilstrup DM, McIlrath DC. Closure of abdominal incisions

with subcutaneous catheters: a prospective randomized trial. Archives of Surgery. 1986 Jun

1;121(6):641-8.

12. Arer IM, Yabanoglu H, Aytac HO, Ezer A. The effect of subcutaneous suction drains on surgical site

infection in open abdominal surgery. A prospective randomized study. Annali Italiani di Chirurgia.

2016 Jan 1;87(1):49-55.

13. Khan RM, Sultana F, Islam MO, Uddin MA, Bhuiyan MK, Rana MS, Nasurullah SS, Alam AT,

Chowdhury MA. Role of Drain in the Wound for Prevention of Superficial Surgical Site Infection

Following Open Choledocholithotomy. SAS J Surg. 2022 Mar;3:143-51.

14. Junaid F, Usama M, Anwar F, Khan S, ur Rahman F, Asad S. Sociodemographic and operative factors

associated with abdominal wound dehiscence in midline laparotomies. The Professional Medical

Journal. 2022 Sep 30;29(10):1448-53.

15. Shunmugam D, Shanmugasundaram S, Muralikannan MJ, Gandhi A. Role of subcutaneous closed

suction drainage in cancer patients undergoing surgery through midline laparotomy incisions–a

prospective randomized study. Int J Acad Med Pharm. 2023;5(4):935-8.

16. Manzoor B, Heywood N, Sharma A. Review of subcutaneous wound drainage in reducing surgical

site infections after laparotomy. Surgery research and practice. 2015;2015(1):715803.

17. Gupta P, Kumar R. Role of subcutaneous suction drain in reducing surgical site infections after

emergency laparotomy. International Surgery Journal. 2017 Jul 24;4(8):2717-20.

18. Harish R, Kazi FN, Sharma JP. Efficacy of subcutaneous closed suction drain in reduction of

postoperative surgical site infection. The Surgery Journal. 2021 Oct;7(04):e275-80.