Get a glimpse of this remarkable text in the excerpt on Surgical-Site Infection Prevention at the end of this post.
Now in it's 3rd edition with over 70 chapters (15 more than the previous edition), Prevention and Management of Laparoendoscopic Surgical Complications comprehensively covers the techniques of minimally invasive surgery for general, endourological, and gyncecological surgeons. From port placement and anatomical landmarks to pediatrics and simulation, this book covers the basics and beyond. Not only will readers learn how to best prepare patients for surgery but also how to warm up and prepare themselves.
PLUS, in keeping with SLS' endeavors to improve patient outcome around the world, this book will be accessible via the SLS website! Keep an eye out for the official launch of the 3rd edition in coming weeks!
"PATIENT PREPARATION FOR LAPAROSCOPIC SURGERY"
by Bradford W. Fenton, MD, PhD, FACOG, Shruti Malik, MD
SURGICAL-SITE INFECTION PREVENTION
In a manner similar to the creation of the Universal Protocol by JCAHO, several healthcare-related organizations have come together to create the Surgical Care Improvement Project (SCIP).64 This program originally was started by the Centers for Disease Control in an effort to decrease postoperative surgical-site infections.65 Since then, the Center for Medicaid Services, ACS, and ASA have joined in along with the IHI to create a series of perioperative care guidelines designed to decrease postoperative complications from several causes. Just as with the Universal Protocol, the federal government and accreditation bodies have become involved, and all guidelines now have specific performance measures. These are checklist driven review notes that allow a chart abstractor or reviewer to evaluate whether certain protocols were followed. In this manner, the SCIP program is really designed to develop a process of care across the country, rather than direct the management of individual patients.
The SCIP program covers the prevention of perioperative infection, thromboembolism prevention, cardiac complication prevention, and respiratory complication prevention.66 The most in-depth guidelines are for infection prevention and cover preoperative antibiotic dose and (dis)continuation, proper skin preparation, proper hair removal, and the maintenance of normothermia. A review of hospitals where these processes have been implemented has demonstrated an improvement in surgical outcomes.67
For many procedures, hair removal is required for a clear operative field; however, there are many different methods to accomplish this task: removal the day of or the day before surgery, and the use of a razor, clippers, or depilatory cream. Since all methods will cause some degree of skin irritation, it is possible that hair removal could lead to an increase in surgical-site infections. Implementation of a preoperative patient management pathway including the SCIP protocol measures has been shown to decrease surgical-site infections.68
As part of a team effort to reduce perioperative surgical-site infections, topical reduction in skin flora using some method of site preparation is a mainstay of modern surgical practice. However, a wide range of traditional methods are available, as are more innovative approaches, such as skin sealants that immobilize bacterial migration into the wound.69
The occurrence of surgical-site infections is due to breaks in the protective dermis of the skin that occurs due to the inherently invasive nature of surgical procedures. The risk factors for the development of surgical-site infection (SSI) are well known and include the contamination of the wound site, advanced age, poor nutritional status, smoking, chronic steroid use, immune deficiency, external catheters or prostheses, prolonged hospitalization, coexistent infection, body mass index, operative approach, length of procedure, significant blood loss, and medical comorbidities.70,71 Using the laparoscopic approach generally decreases SSI by at least half in digestive tract surgery72 and gynecologic surgery.73
Administering prophylactic antibiotics to all patients undergoing any type of surgery has several drawbacks, which are the impetus for the development of the various guidelines. The widespread use of any particular antibiotic will rapidly induce resistance among bacteria, thus limiting the effectiveness of preoperative administration. Antibiotic administration has individual risks as well, typically based on an individual patient’s allergic reaction, which is rarely severe, but a risk that can be avoided by limiting administration to select individuals. Cost effectiveness is often difficult to measure, and for many procedures antibiotics are both inexpensive and effective; however, limiting their use to indicated cases can provide savings when applied across the entire healthcare system.
Prophylactic antibiotic administration for nondental surgeries solely for the purpose of preventing infective endocarditis is no longer recommended.74
Currently, a variety of specialty society guidelines are available that provide recommendations on the use of prophylactic antibiotics to prevent surgical infection. In gynecology, according to the American College of Gynecology guidelines,75. laparoscopy, either diagnostic or operative, does not require the use of prophylactic antibiotics. One reason is that these preocedures are classified as clean, rather than clean/contaminated, which would include all urogynecology procedures and hysterectomy. Laparoscopic supracervical hysterectomy could be considered a more extensive operative laparoscopic procedure and thus not necessarily require the use of preoperative antibiotics; however, current guidelines do not provide such a fine distinction, and it is included with all other hysterectomies.
Guidelines for the use of prophylactic antibiotic use in general surgery have been summarized in the SCIP reccomendations.66 These guidelines do recommend the use of prophylactic antibiotics in cardiovascular, orthopedic, and colorectal surgeries. One of the drawbacks of these consensus statements is that the use of antibiotics in many particular types of surgery, especially laparoscopy, is not addressed. This provides flexibility for the surgeon; however, one of the impetuses for the development of guidelines is to decrease inappropriate antibiotic administration, with the goal of reducing anitbiotic resistance among common pathogens.
Preoperative antibiotic prophlyaxis for urologic procedures has been promulgated by the American Urological Association.76 The administration guidelines agree with those of other specialty societies: antibiotics should begin within 60 minutes of the incision (120 minutes if quinolone or vancomycin is used), active prophylaxis should be provided during the course of the surgery, and should be discontinued within 24 hours. Procedure-specific recommendations are abstracted based on the surgical site: antibiotic prophlyaxis is recommended if entry into the genitourinary tract or intestines is anticipated. For cases where the skin only is incised, antibiotics are indicated only if risk factors for infection are present.
A systematic Cochrane database review77 found no evidence for or against hair removal on the day of surgery compared with the day before. Similarly, there was no difference between clipping or the use of a depilatory cream for hair removal. The only positive finding was that using a razor resulted in more surgical-site infections.78
Randomized clinical trials have compared the 3 common skin preparation techniques: ChloraPrep (2% chlorhexidine gluconate and 70% isopropyl alcohol), DuraPrep (0.7% iodophor and 74% isopropyl alcohol), and povidone-iodine scrub and paint (0.75% iodine scrub and 1.0% iodine paint). However, even the most recent studies have failed to consistently demonstrate the superiority of one approach over another.79,80 For this reason, the current SCIP guidelines do not endorse any one method as superior to another, and simply state that some method of skin preparation must be accomplished prior to incision.
Human body temperature is tightly regulated under physiologic conditions, to within a tenth of a degree. However, during surgery, the combination of sedation, paralysis, and breaks in the insulating layer (surgical incisions) all combine to disrupt normal homeostatic thermoregulation and lead to hypothermia if not treated. Although many regulatory systems are disrupted by hypothermia, the SCIP guidelines target maintenance of temperature as part of the surgical-site infection prevention program. Although including all of the protocol items may appear burdensome, in actual practice they can be implemented and this does decrease infection and complications.81,82 The molecular mechanisms underlying the pathological changes encountered in hypothermia are under investigation and lend further support to this approach.83
Complications of surgical-site infection fall into 2 categories: the development of infection in the patient, and failure to follow SCIP guidelines for the surgeon. Generally, most hospitals will have mandatory protocols in place that limit the opportunity for the surgeon to skip any of the required elements, because removing razors from the surgical suites and the determination of skin preparation typically is not specified by the individual surgeon. Improving compliance with antibiotic reccomendations, including termination of prophylactic antibiotics, can be more challenging from an institutional perspective. Failure to abide by hospital guidelines will generally result in an opportunity to discuss the matter with the surgical quality assurance committee. The consequences of violating hospital policies vary depending on medical staff bylaws.
Surgical-site infection occurs at a variable rate that depends heavily on all of the listed risk factors.84 Aggressive infections with nosocomial bacteria are among the most serious, and their management has been reviewed.85 In general, use of the laparoscopic approach leads to a 50% decrease or more in surgical-site infections compared with open procedures.86,87 Obviously, the best method for management of surgical-site infections is to prevent them by using the techniques described.88
Management of surgical-site infection follows an algorithm ranging from conservative (antibiotics, debridement, packing) to aggresseive (hyperbaric oxygen, vacuum-assisted wound healing). Use of any particular approach will depend on the location of the wound, likely organisms (although wound infections are frequently polymicrobial), response to previous treatments, and medical comorbidities. Management protocols for complex wound infections are available.89 These guidelines have been recently reviewed and expanded for difficult surgical infections.90,91