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Original Paper
Received: November 11, 1998
Accepted: March 29, 1999
Dig Surg 1999;16:512–514
Wound Complications after Major
Gastrointestinal Operations
The Surgeon as a Risk Factor
Hjörtur Gislason a Odd Søreide b Asgaut Viste a
a Department
of Surgery, Haukeland University Hospital, Bergen, and b Department of Surgery B, National Hospital,
Oslo, Norway
Abstract
Background: Wound complications occur quite often after abdominal operations. Numerous studies have been
performed in the last decades focusing on closure methods, incisions and suture materials. However, the most
important factor, the individual surgeon, has hardly been
taken into account in these studies. Methods: This study
presents results from a prospective randomised study on
abdominal wall closure focusing on the results of the
individual surgeon. Results/Conclusions: We found no
differences in the complication rate between different
suture materials or between continuous and interrupted
closure techniques. There are marked individual differences in complication rates between surgeons. Regular
audit with feedback to individual surgeons is an important instrument for quality improvement.
Copyright © 1999 S. Karger AG, Basel
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© 1999 S. Karger AG, Basel
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Introduction
Wound complications (wound infection, burst abdomen and incisional hernia) occur quite frequently after
major abdominal operations and lead to excess mortality,
morbidity, and to prolonged hospital stay, thereby increasing treatment cost.
Surgical technique, i.e. the method of closure, suture
material, and type of incision are all factors associated
with such complications and are controllable by the surgeon. Patient-related factors such as age, nutritional state,
and co-existing medical diseases are also of importance
[1, 2].
Several recent studies have been published focusing on
the role of suture material, closure technique and type of
incision [1–15]. However, differences in study design,
focus and inclusion criteria, in addition to a limited number of patients in many trials explain why professional
consensus is difficult to reach and why methods of
abdominal closure too often depend on local traditions
and the view of opinion leaders. In many studies the most
important risk factor, namely the surgeon himself, has
been omitted as an individual risk factor. This is obviously wrong. In order to improve results we must focus on
surgeon’s performance, operation time, technique of closure (size of bites, tightness of sutures) and infection risks
Dr. Hjörtur Gislason
Department of Surgery
Haukeland Hospital
N–5021 Bergen (Norway)
Tel. +47 55 298060, Fax +47 55 972761
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Key Words
Abdominal wall closure W Dehiscence W Wound infection W
Incisional hernia
(haemostasis, contamination when bowel anastomoses
are sutured and in fashioning of stomas).
In this study we will focus on wound complication
rates related to individual surgeons in a recent prospective randomized clinical trial [4].
Patients and Methods
During a 14-month period in 1990–1992 all adults (599 patients)
undergoing major gastrointestinal operations at the Department of
Surgery, Haukeland University Hospital, were included in a prospective, randomised trial. Urological, gynaecological, and minor general
surgical operations were excluded as well as patients who had had a
laparotomy within the last 3 months. The randomisation technique,
definition of wound infection, wound failure and demographics of
patients have been described [4]. This study will focus on previously
unpublished data concentrating on surgeon-related factors (volume
and experience).
Three groups were compared: (1) continuous mass closure with
polyglyconate (Maxon®, double suture with loop); (2) polyglactin 910
(Vicryl® ) with continuous mass suture, and (3) polyglactin 910 (Vicryl® ) with interrupted stitches. Sutures were placed a minimum of
1.5 cm from the wound edge, with a minimum of 1.5 cm between
bites. The peritoneum and subcutaneous tissue were not sutured.
Wound infection and burst abdomen (dehiscence) were recorded
in the postoperative period and incisional hernia during a 1-year follow-up. These complications were related to the operating volume of
each participating surgeon during the study period and to the surgeon’s seniority (in training vs. consultant status).
Statistical analyses were by ¯2 test.
Table 1. Summary of background information
Evaluable patients
Emergency operations
Elective operations
Burst abdomen
Wound infection
Emergency operations
Elective operations
Burst abdomen
Incisional hernia
Incisional hernia (at 1 year)
583
186 (32%)
397 (68%)
14/583 (2%)
84/583 (14%)
42/186 (23%)*
42/401 (10%)*
11/84 (13%)*
13/35 (32%)*
35/494a (7%)
Data published in detail previously [4]. Figures denote number of
patients.
* Statistically significant difference: p ! 0.001.
a
494 patients survived 1 year.
Table 2. Wound complications related to the number of operations
performed by each surgeon
Number of
operations
Dehiscence and
incisional hernia
Wound
infection
^5 (12 surgeons)
6–30 (12 surgeons)
1 30 (7 surgeons)
4/26 (15.4%)*
19/170 (11.1%)**
23/305 (7.5%)***
10/31 (32.2%)*
30/209 (14.4%)**
44/347 (12.7%)**
Figures denote number of patients.
* Differ significantly from: ** p ! 0.05 and *** p ! 0.01.
** Differ significantly from: *** p ! 0.05).
Results
The Surgeon and Wound Complications
(3.9%, dehiscence + incisional hernias), as compared to 3
surgeons with the poorest results who operated on 50
patients resulting in 10 (20%) wound failures. This difference could not be explained by differences in the type of
operation or operation time.
Discussion
Most studies have analysed and compared wound
complication rates after wound closure on an aggregated
level, i.e. a department or institution. As documented
here the individual surgeon constitutes a risk factor. We
found that surgeons performing ‘few’ abdominal operations had signicantly higher wound failure rates (15.4%)
than surgeons with a higher volume (7.5%, p = 0.01). This
difference was not explained by the higher proportion of
Dig Surg 1999;16:512–514
513
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599 patients (median age 60.5, range 18–91 years)
were operated on by 31 different surgeons; 32% were
emergency operations. Of the 599 patients, 16 had early
reoperation or died within a week after the operation. One
hundred and two patients died during the first year (17%)
and 494 patients were followed up at 1 year. The main
results are summarised in table 1.
The wound complication rate (wound infection, burst
abdomen (dehiscence) and incisional hernia) were related
to the operative volume (major laparotomies) of the 31
participating surgeons (table 2). A low volume was associated with higher wound complication rates, which can
only partly be explained by the higher percent of emergency operations. There was no difference between senior
surgeons (consultants) and surgeons in training (16.6 vs.
20.1%; p = 0.07; in favour of the seniors). There were,
however, significant differences in the complication rates
between surgeons. The 3 surgeons with the best results
operated on 155 patients with a total of 6 wound failures
emergency operations performed by those with few operations, but probably by a lack of training. In addition, we
also found differences in complication rates among the
surgeons performing a high number of operations. When
analysing individual results for trained surgeons, we
found that the best surgeons operated with wound complication rates of !4%, as compared to approximately 20%
obtained by those with the poorest results.
The development of incisional hernia is often (40.3%)
preceded by postoperative wound infection. Therefore,
prevention of wound infection is the single most important factor in the prevention of incisional hernias [3, 4,
6].
Medina et al. [16] found that two main causes of
wound infection in patients operated for abdominal hernias were related to surgery: the duration of the operation,
and the surgeon. The qualification of the surgeon was a
strong predictor of infection, not confounded by patient
characteristics.
The data presented here clearly show that there is a
potential for a further reduction in abdominal wound
dehiscence and incisional hernia rates. First of all, these
complications could be significantly reduced by preventing abdominal wound infections. We have shown [4] that
minimizing contamination of the operating field, final
preparation of a stoma after closure, and dressing of the
wound will reduce wound infection. Secondly, an atraumatic surgical technique focusing on haemostasis and closure of the abdominal wall with a suture length/wound
length ratio of 14 [17, 18], without tension is clearly of
importance.
In conclusion, the two most important factors concerning wound complications seem to be the closure technique
(related to surgeon volume) and infection risk related to
the individual surgeons. Regular audit of all postoperative
complications with regular feedback of the individual
results combined with technical instructions are important instruments for further quality improvement.
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Dig Surg 1999;16:512–514
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