You’d never forget to administer timely and appropriate prophylactic antibiotics. After all, that step is an absolutely invaluable way to prevent surgical site infections. For whatever reason, however, wound irrigation is rarely thought of with the same importance (see “Our Bundled Closing Protocol for Colon Resections” on page 48). But it certainly should. You should view the often-overlooked step of irrigation as the final piece of the patient care puzzle. To help make it part of your protocol, here are 4 simple steps you can use to effectively irrigate wounds in 5 minutes or less. You can use this simple but effective irrigation technique for everything from breast mastectomies to hernia repairs to open abdominal procedures to colon resections:

1. Begin the irrigation after closing the fascia. The goal is to focus on the subcutaneous layer and remove any loose fat or possibly contaminated peritoneal fluid that comes through.

2. Elevate and irrigate downstream. During the procedure, you want to make sure the head of the operating table is elevated, and that you have a basin by the wound. This step ensures there is little to no runoff during the irrigation process. If you just irrigate without the head of the bed elevated, it’s going to run over both sides of the bed and create a mess — as well as a slip hazard. But by raising the head up and irrigating downstream, you’ll collect almost all of the saline in that basin.

3. Combine irrigation with massage. You’ll want to use voluminous amounts of saline when you irrigate. Normally about 2 to 5 liters, but that’s just a general guide. You could wind up using a little more, you could wind up using a little less. During the irrigation process, you’ll want to vigorously massage all the wound margins, too.

4. Don’t stop until the fat is all gone. The final step in the process is critical. The irrigation process isn’t complete until you’ve removed all devitalized and loose fatty tissue. To ensure you get everything, keep irrigating until there is no loose fat tissue flooding over the inferior aspect of the incision(s).

Proven to work

That’s all there is to it. The simple irrigation technique is a cheap, quick and proven way to reduce your chances of a patient getting an SSI. When you think of all that could go wrong by not adding this 5-minute step, it’s easy to see why irrigation should always be a part of your closing process.

Plus, it’s proven. While there isn’t as much research as there should be on the subject, the studies that are available all show that wound irrigation does indeed reduce the risk of infection. I dedicated a significant amount of time to testing and proving this theory — and I did it by performing colon resections. Why this procedure? Because it’s considered a “dirty surgery” by physicians everywhere. You can’t do the surgery without some type of contamination. The current infection rate for this procedure is around 10% — sometimes even higher. My thinking was that if I could lower the SSI rate on this procedure, I knew I’d be on to something.

After 154 colon resections in which I conducted all the necessary follow-up to make the research viable, our SSI rate was just 0.5%. Now that wasn’t just due to irrigation. This was just the final part of a very thorough process that included:

• timely and appropriate prophylactic antibiotic administration,
• clipping rather than shaving of hair,
• core temperature control,
• timeliness of the procedure,
• correct non-tension anastomosis,
• glucose control, and
• oxygenation.

But the irrigation certainly played a role in getting that percentage so far below the national average. Normal saline is the most common fluid used in wound irrigation. It doesn’t have many side effects, nor does it alter the normal healing of the wound. Besides being effective, irrigation is also economical. A 250-ml bottle of saline costs around $4. Granted, with all the surgeries you perform, those 4 dollars can certainly add up fast. Of course, the cost of taking this precautionary step if far cheaper than the $75,000 or so it would cost to treat an infection.

Irrigation is also quick. Generally speaking, all it takes is 5 minutes at the end of surgery to do a proper wound irrigation. And sometimes it takes as little as 2 minutes. One exception being when you’re doing an abdominal surgery on a morbidly obese patient. Here, you could be dealing with a subcutaneous layer that’s anywhere from 5 to 10 inches thick. After closing up the fascia, and gently massaging the subcutaneous layer with your fingers while you irrigate, you need to work until all the fat globules come out of the wound. And you wouldn’t believe how much devitalized fat comes out in these cases.

As intensive as this can be, it’s well worthwhile to irrigate. Of the 600 open vertical banded gastroplasties my partner and I performed using vigorous irrigation of the subcutaneous tissue to remove fat globules, we haven’t had a single major wound infection. You can’t argue with those results. OSM