Use of Prolonged Prophylactic Antibiotics with Closed Suction Drains in Ventral Abdominal Hernia Repair

Abstract

Closed suction drains (CSD) are commonly used in ventral hernia repair (VHR), with or without prolonged postoperative prophylactic antibiotics (PPA) for the duration of their use. We examine the evidence that PPA with CSD reduce surgical site infection (SSI) in patients undergoing VHR. We also examine the evidence assessing the association between SSI and CSD in VHR. A systematic review of PubMed, CIHNL, and Cochrane databases was performed to identify studies analyzing rates of SSI with CSD in patients undergoing abdominal VHR and related procedures with or without the concomitant use of PPA. The primary outcome was the rate of SSI. Five studies totaling 772 patients were identified, 525 patients were confirmed to have CSD, and 434 patients received prolonged antibiotics while drains were in place. PPA had no significant effect on SSI in two studies and were associated with decreased SSI in one study (Odds ratio 0.235, 95% confidence interval 0.090–0.617, P = 0.003). Two studies documented a higher rate of SSI in patients with CSD (79% vs 49% and 19% vs 10%) on univariate analysis. One study demonstrated a very low risk of SSI despite CSD (4.2%) and another demonstrated no increased risk with or without CSD. The use of drains is not clearly associated with an increased risk of SSI in VHR, and there is limited evidence to support antibiotic use while the drains are in place to decrease the potential risk. Prospective randomized studies are needed to more clearly assess these associations.

Risks and Prevention of Surgical Site Infection After Hernia Mesh Repair and the Predictive Utility of ACS-NSQIP

“…There is a lack of highquality evidence that subcutaneous CSD reduce seroma formation, surgical site occurrence requiring procedural intervention (SSOPI) or SSI after VHR repair with mesh. [70][71][72][73] Drains may be a surrogate marker for more complex hernia surgery or high-risk patients, and thus be identified in univariate analyses as a risk factor for SSIs. [70][71][72][73] Colonization of drains by skin organisms or environmental pathogens, including multi-resistant organisms, occurs after 24 h. 74,75 Surgeons place drains in more than 50% of open VHR repairs.…”

“…[70][71][72][73] Drains may be a surrogate marker for more complex hernia surgery or high-risk patients, and thus be identified in univariate analyses as a risk factor for SSIs. [70][71][72][73] Colonization of drains by skin organisms or environmental pathogens, including multi-resistant organisms, occurs after 24 h. 74,75 Surgeons place drains in more than 50% of open VHR repairs. 69 However, the decision to place and subsequently remove CSD in VHR is often related to individual surgeon preference rather than evidence-based practise, due to the paucity of RCTs.…”

“…They concluded PPA use could not be supported, the literature evidence of an association between CSD and SSI was limited and conflicting, and RCTs are required to determine if CSD actually promote or prevent SSI in VHR. 72 The impetus for performing such RCTs may have diminished in clean elective VHR surgery due to the evolution of minimally invasive VHR with fascial closure, and use of posterior component separation/TAR in open VHR. However, from the NSQIP data of 10-year hernia repair trends, in 2017, only 36.6% of VHR were performed by a minimally invasive approach.…”