BEFORE CLOSING Use 2 to 5 liters of saline and vigorously massage the wound margins.

There are myriad important steps when it comes to preventing surgical site infections, but as a general surgeon, I've identified a critical step that wasn't part of my training. With abdominal surgery, it's absolutely vital to irrigate the abdominal cavity, including and even more importantly the subcutaneous layer, to remove loose fat and possibly contaminated peritoneal fluid.

It's a step we need to add to all the other well-known important steps, such as 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.

I've used this technique in all wound closures of the abdomen for the past 40 years, essentially handling all wounds in a similar manner, including mastectomies, open appendectomies and even minor excision wounds.

Here's how to do it:

• Begin irrigation after closure of the fascia.
• Make sure the head of the operating table is elevated and that you have a basin at the lower end of the wound.
• Use voluminous amounts of saline (typically 2 to 5 liters) and vigorously finger massage the wound margins.
• To ensure that all devitalized and loose fatty tissue is removed, continue irrigating until no loose fat tissue floods over the inferior aspect of the incision.

The technique adds little time to the procedure, it's inexpensive, and it works. My partner and I have used vigorous irrigation of the subcutaneous tissue to remove devitalized fat in 600 open vertical banded gastroplasties and haven't had a single major wound infection. I have no doubt that the time we've invested has decreased the cost of care by preventing potentially costly complications.