What is the percentage of surgical site infection (SSI) after laparotomy with resection anastomosis and gross fecal spillage?

Surgical Site Infection Rate After Laparotomy with Resection Anastomosis and Gross Fecal Spillage

The percentage of surgical site infection in a wound after laparotomy with resection anastomosis and gross fecal spillage is approximately 30-40%. 1

Classification and Infection Risk

Surgical wounds with gross fecal spillage are classified as Class IV/Dirty-Infected wounds according to the Centers for Disease Control and Prevention (CDC) classification system. These wounds have the highest risk of infection among all wound classes due to:

• Presence of large bacterial loads directly introduced into the surgical field
• Contamination of both superficial and deep tissues
• Potential for both incisional and organ/space infections

Evidence Supporting the 30-40% Infection Rate

The 30-40% infection rate for laparotomy with resection anastomosis and gross fecal spillage is well-established in surgical literature:

• The Centers for Disease Control and Prevention classifies these as Class IV/Dirty-Infected wounds with an expected infection rate of 30-40% 1
• Primary closure of contaminated/dirty-infected laparotomy wounds results in a 37% infection rate according to data from the World Journal of Emergency Surgery 1
• Resection anastomosis procedures have higher leak rates which further increases infection risk, with leak rates varying by anatomical location (17% in right colon, 25% in transverse colon, and up to 50% in left colon) 1

Risk Factors Contributing to High Infection Rates

Several factors contribute to the high infection rate in these cases:

• Gross fecal contamination introduces large bacterial loads directly into the surgical field 1
• Anastomotic leaks significantly increase the risk of organ/space infections
• Emergency procedures have higher infection rates than elective surgeries
• Blood transfusion requirements increase SSI risk (OR = 5.3 for 1-3 units; OR = 6.2 for ≥4 units) 2
• Creation of ostomy (OR = 2.1) and use of surgical drains (OR = 1.6) are independent risk factors for SSI 2

Prevention Strategies

To reduce the high infection rate in these cases:

• Wound edge protectors, particularly dual-ring protectors, have shown significant benefit in reducing SSI rates (RR = 0.31) 1
• Consider delayed primary closure rather than primary closure (reduces infection from 37% to 17%) 1
• Vacuum-assisted closure systems have demonstrated promising results in reducing infection rates 1
• Closed-incision negative-pressure therapy with delayed closure has shown significant reduction in SSI rates 1
• Maintain intraoperative normothermia 1

Clinical Implications

The high infection rate (30-40%) in these cases has significant implications:

• Deep incisional SSIs have a mortality rate of 5.7%, while organ/space SSIs have a mortality rate of 13.2% 1
• The case-fatality rate following gastrointestinal procedures with SSI is 7.2% 1
• Most surgical site infections are diagnosed around 10 days after surgery, highlighting the importance of vigilant postoperative monitoring 1

Common Pitfalls and Caveats

• Do not confuse the infection rates of different wound classes - clean wounds have much lower rates (1-3%)
• Laparoscopic approaches significantly reduce SSI rates compared to open procedures (0.5% vs 1.8%), but this data is primarily from elective cases without gross contamination 3
• Surgeon-specific factors can significantly influence SSI rates (OR = 1.3-3.3) 2
• The high infection rate of 30-40% applies specifically to cases with gross fecal spillage, not to all colorectal procedures