Читать книгу Complications in Canine Cranial Cruciate Ligament Surgery - Ron Ben-Amotz - Страница 34

Surgical wound closure and protection play a controversial role in SSI development. Surgical staples in comparison to intradermal skin closures have been reported to increase, decrease or not have any effect on surgical site inflammation and/or SSI development [6, 30, 32]. Skin closure using absorbable skin staples has shown no benefit over stainless steel surgical staples in reducing SSI development [20]. With inconclusive evidence to suggest superiority of one closure method over another, considerations such as time for closure, associated tissue trauma, and potential irritation to the patient must play a role in decision making. While staples may reduce the closure time and thus overall surgery time, this is likely to be negligible for an experienced surgeon. Tissue trauma may also be reduced with skin staples due to minimal manipulation required for placement, but increased inflammation has been noted when surgical staples are used compared to intradermal sutures [6]. Finally, the noncompliant nature of skin staples may lead to increased local irritation and thus potential for self‐trauma from licking or chewing at the surgical site, if not adequately protected from access.

Suture has the proven propensity for biofilm formation and as such may act as a nidus for SSI development [76]. Antimicrobial‐coated suture, specifically triclosan‐coated suture, has been assessed in vitro and in vivo for its ability to resist or reduce SSI development. In vitro, triclosan‐coated monofilament suture had the least bacterial adherence compared to other monofilament and braided suture materials and had greater inhibition for S. pseudintermedius, including MRSP, than Escherichia coli [77, 78]. In vivo, the use of triclosan‐coated monofilament suture was not shown to significantly reduce the risk of SSI in one hospital, while its use contributed to a reduction in SSI rates in another hospital [32, 64]. Further investigation of the use of antimicrobial‐coated suture is warranted. While a true benefit to antimicrobial‐coated suture remains unclear, the only limitation to its use is its increased cost, and as such, use of antimicrobial‐coated sutures should be considered.

Postoperative fibrin formation to create a complete seal of a surgical wound takes 3–5 hours and therefore protection of the fresh surgical wound from its environment is recommended [79]. Considering evidence for environmental contamination from the anesthesia transportation gurney and radiology table used for postoperative radiographs, immediate protection with a sterile dressing is recommended [46]. Despite these recommendations, direct comparison of a topical adhesive applied to the incision, an adhesive antimicrobial barrier dressing, and no dressing following TPLO surgery found no significant difference in SSI rates amongst the dressing options [28]. In another study involving significant protocol changes for animals undergoing TPLO surgery, the addition of a soft padded bandage with mupirocin ointment directly on the surgical wound, use of single‐use gloves for all postoperative patient interactions, and placement of an Elizabethan collar for additional barrier protection resulted in an 88% reduction in the odds ratio for developing an SSI [64]. While many factors likely contributed to this SSI reduction, simple incisional protective measures are easy to implement into routine postoperative care. Additionally, while the use of gloves does not replace appropriate hand hygiene, sterile gloves are recommended to be worn during examination of clean surgical wounds to prevent transmission of bacteria to the surgical site [80].