Prospective randomized trial of two wound management strategies for dirty abdominal wounds

Objective To determine the optimal method of wound closure for dirty abdomi nal wounds. Summary Background Data The rate of wound infection for dirty abdominal wou nds is approximately 40%, but the optimal method of wound closure remains c ontroversial. Three randomized studies comparing delayed primary closure (D PC) with primary closure (PC) have not conclusively shown any advantage of one method over the other in terms of wound infection. Methods Fifty-one patients with dirty abdominal wounds related to perforate d appendicitis, other perforated viscus, traumatic injuries more than 4 hou rs old, or intraabdominal abscesses were enrolled. Patients were stratified by cause (appendicitis vs. all other causes) and prospectively randomized to one of two wound management strategies: E/DPC (wound packed with saline- soaked gauze, evaluated 3 days after surgery for closure the next day if ap propriate) or PC. In the E/DPC group, wounds that were not pristine when ex amined on postoperative day 3 were not closed and daily dressing changes we re instituted. Wounds were considered infected if purulence dis charged fro m the wound, or possibly infected if signs of inflammation or a serous disc harge developed. Results Two patients were withdrawn because they died less than 72 hours af ter surgery. The wound infection rate was greater in the PC group than in t he E/DPC group. lengths of hospital stay and hospital charges were similar between the two groups. Conclusion A strategy of DPC for appropriate dirty abdominal wounds 4 days after surgery produced a decreased wound infection rate compared with PC wi thout increasing the length of stay or cost.