Back to basics – cutting the cord on umbilical infections

Abstract

INTRODUCTION Surgical site infections (SSIs) are a significant cause of postoperative morbidity with laparoscopic surgery associated with lower SSI rates. However, a departmental change in our unit to increased laparoscopic colorectal surgery resulted in increased wound infection rates at umbilical specimen extraction sites, the cause of which we attempted to elucidate. SUBJECTS AND METHODS Prospectively collected data over an 18-month period (April 2008 to September 2009) for laparoscopic colorectal operations in a busy teaching hospital were retrospectively analysed, focusing on operation performed, whether pre-operative skin cleansing was employed, nature of specimen extraction excision, and rate of umbilical wound infection. Comparison was made with open colorectal procedures performed in the preceding year. RESULTS In total, 275 laparoscopic colorectal operations were performed. Over the first 8 months there was a significant increase in infection rates when compared with open procedures over a similar time period (23.5% vs 8.0%; P = 0.0001). Changing practice to use pre-operative skin cleansing and an incision that skirted around, as opposed to traversing, the umbilicus reduced umbilical infection rates significantly from 23.5% to 11.6% (P = 0.01). Patients undergoing right hemicolectomy benefitted more (reduction of 30.0% to 6.9%; P = 0.04) than those undergoing anterior resection (26.8% vs 15.6%, P = 0.13). CONCLUSIONS Umbilical incisions, when extended for specimen extraction, are particularly prone to infection following colorectal surgery but rates can be reduced by simple measures such as pre-operative umbilical cleansing and avoidance of the umbilicus in the incision, without the need for drastic and costly changes in technique or antibiotic prophylaxis.

Modified Intraumbilical Versus Infraumbilical Entry Method at Laparoscopy: A Cohort Study

“…A suggested criticism to transumbilical incisions is the increased rate of surgical-site infection due to the propensity of the umbilicus to microbacterial colonization. 33 Avoiding umbilical incision was considered beneficial in reducing surgicalsite infection. 9 However, Hamzaoglu et al 34 concluded that umbilical flora is not responsible for trocar site infections.…”

Transumbilical laparoscopy for pneumoperitoneum establishment: a comprehensive multicentre evaluation affirming safety, feasibility, and a range of clinical benefits

“…According to several authors, the initiation of pneumoperitoneum is frequently considered the most challenging phase of laparoscopy. This step carries numerous potential complications, irrespective of whether the closed or open technique is employed, which may include vascular and visceral injuries ( 4 ).…”

“…However, transumbilical incisions pose a risk of increased surgical site infections due to the umbilicus's susceptibility to bacterial colonization ( 4 , 11 ).…”

A pilot randomised controlled trial of patient education to improve umbilical cleanliness prior to laparoscopic surgery

“…2,3 The literature on preoperative umbilical cleanliness focuses on reducing the microbial load of the umbilicus in view of preventing surgical site infections (SSIs), which occur more frequently at the umbilicus than other laparoscopic port sites. 3,4 Preoperative antibiotics and 'care bundles' containing items such as antiseptic body wash, bowel preparation and information leaflets have shown varying effectiveness in preventing SSIs in general, [5][6][7][8][9] and it has been suggested that such interventions may be more clinically and cost-effective if they were concentrated in intrinsically dirty areas of the body. 4,10,11 To date, interventions that target gross contaminants of the umbilicus have not been studied, despite having clear practical implications for surgeons and the potential to reduce SSIs by optimising the activity of intraoperative skin antisepsis.…”

“…3,4 Preoperative antibiotics and 'care bundles' containing items such as antiseptic body wash, bowel preparation and information leaflets have shown varying effectiveness in preventing SSIs in general, [5][6][7][8][9] and it has been suggested that such interventions may be more clinically and cost-effective if they were concentrated in intrinsically dirty areas of the body. 4,10,11 To date, interventions that target gross contaminants of the umbilicus have not been studied, despite having clear practical implications for surgeons and the potential to reduce SSIs by optimising the activity of intraoperative skin antisepsis. Surgeons' strategies to prevent SSIs vary greatly, 12 and more research is required to standardise preoperative management.…”