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 ABC © 1999 S. Karger AG, Basel 0253–4886/99/0166–0512$17.50/0 Fax + 41 61 306 12 34 E-Mail email@example.com www.karger.com Accessible online at: www.karger.com/journals/dsu 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 Downloaded by: Linköpings Universitetsbibliotek 22.214.171.124 - 10/27/2017 5:02:33 AM 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 . 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 . 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 . 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 Downloaded by: Linköpings Universitetsbibliotek 126.96.36.199 - 10/27/2017 5:02:33 AM 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.  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  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. References 514 Dig Surg 1999;16:512–514 7 Osther PJ, Gjøde P, Mortensen BB, Bartholin J, Gottrup F: Randomized comparison of polyglycolic acid and polyglyconate sutures for abdominal fascial closure after laparotomy in patients with suspected impaired wound healing. Br J Surg 1995;82:1080–1082. 8 Sahlin S, Ahlberg J, Granström L, Ljungström KG: Monofilament versus multifilament absorbable sutures for abdominal closure. Br J Surg 1993;80:322–324. 9 Israelsson LA, Jonsson T: Closure of midline laparotomy incisions with polydioxanone and nylon: The importance of suture technique. Br J Surg 1994;81:1606–1608. 10 Kendall SWH, Brennan TG, Guillou PJ: Suture length to wound length ratio and the integrity of midline and lateral paramedian incisions. Br J Surg 1991;78:705–707. 11 Krukowski ZH, Cusick EL, Engeset J, Matheson NA: Polydioxanone or polypropylene for closure of midline abdominal incisions: A prospective comparative clinical trial. Br J Surg 1987;74:828–830. 12 Cameron AEP, Parker CJ, Field ES, Gray RCF, Wyatt P: A randomised comparison of polydioxanone (PDS) and polypropylene (Prolene) for abdominal wound closure. Ann R Coll Surg Engl 1987;69:113–115. 13 Corman ML, Veidenheimer MC, Coller JA: Controlled clinical trial of three suture materials for abdominal wall closure after bowel operations. Am J Surg 1981;141:510–513. 14 Schoetz DJ, Coller JA, Veidenheimer MC: Closure of abdominal wounds with polydioxanone. Arch Surg 1988;123:72–74. 15 Wadström J, Gerdin B: Closure of the abdominal wall: How and why? Acta Chir Scand 1990; 156:75–82. 16 Medina M, Sillero M, Martinez-Gallego G, Delgado-Rodriguez M: Risk factors of surgical wound infection in patients undergoing herniorrhaphy. Eur J Surg 1997;163:191–198. 17 Jenkins TPN: The burst abdominal wound: A mechanical approach. Br J Surg 1976;63:873– 876. 18 Israelsson LA, Jonsson T: Suture length to wound length ratio and healing of midline laparotomy incisions. Br J Surg 1993;80:1284– 1286. Gislason/Søreide/Viste Downloaded by: Linköpings Universitetsbibliotek 188.8.131.52 - 10/27/2017 5:02:33 AM 1 Bucknall TE, Cox PJ, Ellis H: Burst abdomen and incisional hernia: A prospective study of 1,129 major laparotomies. Br Med J 1982;27: 931–933. 2 Riou JPA, Cohen JR, Johnson H: Factors influencing wound dehiscence. Am J Surg 1992; 163:324–330. 3 Bucknall TE, Ellis H: Abdominal wound closure: A comparison of monofilament nylon and polyglycolic acid. Surgery 1981;89:672–677. 4 Gislason H, Grønbech JE, Søreide O: Burst abdomen and incisional hernia after major gastrointestinal operations: Comparison of three closure techniques. Eur J Surg 1995;161:349– 354. 5 Leaper DJ, Pollock AV, Evans M: Abdominal wound closure: A trial of nylon, polyglycolic acid and steel sutures. Br J Surg 1977;64:603– 606. 6 Wissing J, van Vroonhoven TJ, Schattenkerk ME, Veen HF, Ponsen RJG, Jeekel J: Fascia closure after midline laparotomy: Results of a randomized trial. Br J Surg 1987;74:738–741.