Prevention of surgical wound complications
Common postoperative complications are surgical site infections of the skin and subcutaneous tissue and wound dehiscence. There are many factors that increase the risk of postoperative wound complications. For patients undergoing elective surgery, these risk factors must be identified and addressed preoperatively.
The majority of surgical site infections are preventable. Most surgical site infections are caused by contamination of the wound with colonising organisms.
Patient-related risk factors for surgical site infection include:
- advanced age
- malnutrition
- cigarette smoking
- high body mass index
- diabetes (particularly postoperative hyperglycaemia)
- concurrent infection at another body site
- an impaired immune response.
Encourage the patient to stop smoking 4 weeks before surgery. Screen patients for risk of malnutrition using a malnutrition screening tool1. Refer patients to a dietitian for assessment and management if necessary.
Surgical risk factors for surgical site infection include:
- inadequate sterilisation of surgical instruments
- foreign material in the surgical site
- microbial contamination of the surgical site
- surgical drains (particularly those with open drainage)
- inadequate duration of surgical scrub
- inadequate skin antisepsis (see Practice points for preventing surgical site infection)
- preoperative shaving (see Practice points for preventing surgical site infection)
- inadequate or incorrect preoperative skin preparation (see Practice points for preventing surgical site infection)
- prolonged duration of operation
- inappropriate selection of antimicrobial prophylaxis
- poor operating room ventilation
- poor surgical technique (failure to achieve haemostasis, failure to obliterate dead space, tissue trauma, wound tension).
Detailed guidance on prevention of surgical site infections is provided by the World Health Organization. For appropriate antibiotic treatment of surgical site infections, see Surgical site infection.
Wound dehiscence occurs when the edges of a closed surgical wound separate and open, exposing the wound cavity. Dehiscence can be superficial or deep, exposing underlying structures and organs.
Risk factors for surgical wound dehiscence include:
- contaminated, dirty or previously infected surgical wounds2
- surgical site infection
- haematoma (or failure to achieve haemostasis)
- malnutrition
- excessive exudate (with or without seroma)
- reduced vascular supply to the operative site
- mechanical stress on the wound (patient movement, obesity, oedema, local pressure).
Preoperative phase
- encourage the patient to stop smoking
- screen patients for malnutrition
- advise patients to wash (shower or bath) at least the day before surgery
- do not routinely remove hair at the surgical site; if hair has to be removed to perform surgery, use electric clippers with a single-use head on the day of surgery. Do not use razors for hair removal because these increase the risk of infection
- see Surgical antibiotic prophylaxis for prophylaxis regimens
Intraoperative phase
- immediately before incision, prepare the skin at the surgical site using an antiseptic (aqueous or alcohol-based) preparation; povidone-iodine or chlorhexidine are most suitable
- cover surgical incisions with an appropriate dressing at the end of the operation
Postoperative phase
- use an aseptic technique for changing or removing dressings
- aim to keep the postoperative dressing intact, uncontaminated and dry for up to 48 hours after surgery; if necessary, use sterile saline (sodium chloride 0.9%) for wound cleansing during this period
- advise patients that they can shower 48 hours after surgery
- use an appropriate dressing for surgical wounds that are healing by secondary intention (see Ulcer and wound dressings)
- avoid:
- topical antimicrobial products on wounds healing by primary intention
- Edinburgh University Solution of Lime (EUSOL) and gauze, moist cotton gauze, and mercuric antiseptic solutions on wounds healing by secondary intention
For antibiotic treatment of surgical site infections, see Surgical site infection.
All stages
Provide patients and carers with clear information and advice for each stage of care. This should include the risk factors for surgical site infection, the approaches taken to reduce the risk, how to recognise a surgical site infection, and how they are managed.