Enhancing surgical safety: the promise of plastic wound protectors in reducing surgical site infections in open abdominal surgeries

Dear Editor, Surgical site infections (SSIs) represent a significant challenge in postoperative care, particularly in open gastrointestinal (GI) surgeries1–4. The global incidence of SSI is 2.5% with predominance in Africa (7.2%)5. The implications of SSIs are severe, ranging from prolonged hospital stays and increased healthcare costs to heightened morbidity and mortality1,3,6,7. Various interventions are designed to prevent SSI, including avoiding razors for hair removal, maintaining normal body temperature, skin preparation agents, antistaphylococcal skin antiseptics and intranasal agents, negative pressure wound therapy, and maintaining adequate perioperative glucose level4. Despite these prevention approaches, new innovative modalities are needed to prevent SSI. Though the WHO recommended use of wound protector devices for preventing SSIs, limited evidence was available to support this approach8. A recent multicenter, patient-blinded, parallel-arm, randomized clinical trial examined the efficacy of dual ring, plastic wound protectors versus surgical gauze in open GI surgery9. The study, conducted over 5 years across 13 hospitals, involved 458 patients undergoing open abdominal bowel surgeries, such as for bowel perforation9. These procedures are inherently at high-risk for complications, including SSIs, due to the nature of the surgery, which often involves significant manipulation of the bowel and potential for contamination. The primary outcome measured was the incidence of SSIs within 30 days postoperation. The trial reported a substantial relative risk reduction in SSIs of 46.81% in the wound protector group compared to the gauze group9. Specifically, the incidence of SSIs was 10.9% in the wound protector group versus 20.5% in the surgical gauze group9. The effect was particularly pronounced in clean-contaminated wounds, with a relative risk reduction of 43.75%9. This subgroup often includes patients where the GI tract is entered under controlled conditions, which while less risky than contaminated or dirty conditions, still poses a considerable infection risk. Moreover, the study found that the use of wound protectors significantly reduced the rate of superficial SSIs but did not have a significant impact on deep incisional or organ/space infections9. This finding is crucial as it delineates the scope of effectiveness of wound protectors, emphasizing their role in preventing superficial infections, which are the most common type of SSIs. The clinical implications of these findings are profound. First, the study provides robust evidence supporting the use of wound protectors in reducing SSIs in a high-risk surgical cohort. This aligns with previous smaller studies and meta-analyses but provides a stronger level of evidence due to its large scale and rigorous methodology4,10. In surgical practice, the integration of wound protectors should be considered standard, especially in clean-contaminated GI surgeries. The simplicity of the intervention — applying a plastic protector at the incision site — coupled with its significant impact on reducing SSIs, supports its broader adoption. Additionally, the study’s results should prompt surgical guidelines and policies to revisit and potentially advocate more strongly for the use of such devices in relevant surgeries. While the study’s findings are compelling, they also highlight areas needing further exploration. The trial did not conclusively determine the effectiveness of wound protectors in surgeries with higher levels of contamination — contaminated or dirty wounds. These conditions are inherently more complex and have higher baseline rates of SSIs4. Future research should focus on these types of wounds to ascertain if wound protectors can provide similar benefits. Another consideration is the cost-effectiveness and environmental impact of using plastic wound protectors, especially given the current global push towards sustainable healthcare practices. While the clinical benefits of reducing SSIs are clear, the financial and environmental costs of disposable plastic devices must also be factored into decision-making processes. Innovations in biodegradable or reusable wound protectors could be a direction worth exploring. In conclusion, the use of plastic wound protectors represents a practical and effective measure to enhance surgical safety by reducing the incidence of SSIs in open GI surgeries. This trial’s findings should serve as a catalyst for change in surgical practices, potentially setting a new standard of care that prioritizes patient safety while addressing preventable complications. As healthcare continues to evolve, the emphasis must remain on interventions that combine clinical efficacy with sustainability and cost-effectiveness to truly enhance patient outcomes in the long term. Ethical approval Ethical approval is not applicable for this correspondence article. Consent Informed consent is not applicable for this correspondence article. Sources of funding None. Author contribution A.A.: conceptualization, project administration, supervision, validation, writing – original draft, and writing – review and editing; N.A.W.: project administration, validation, writing –original draft, and writing – review and editing; P.S., R.K.S., D.S., M.A., M.N.K., S.G., Q.S.Z., and S.R.: supervision, validation, and writing – review and editing. Conflicts of interest disclosure The authors declare no conflicts of interest. Research registration unique identifying number (UIN) None. Guarantor Ayush Anand. Data availability statement None. Provenance and peer review Not commissioned, externally peer-reviewed. Assistance with the study None.