Emergency laparotomy remains a critical surgical intervention for managing life-threatening abdominal conditions, including perforated viscera, hemorrhage, and acute peritonitis.[1] Despite advances in surgical technique, anesthesia, and perioperative care, surgical site infections (SSIs) continue to represent a significant source of postoperative morbidity and mortality. While SSIs are rarely fatal, they substantially prolong hospitalization, increase healthcare costs, and impose considerable financial burden on patients and families.[1] Surgical infections collectively account for approximately 20% of all healthcare-associated infections globally, with SSIs being among the most prevalent.[2]

SSIs are defined as infections occurring within 30 days following surgery in the absence of prosthetic implantation, or within one year if an implant is present.[1] Both superficial and deep incisional SSIs, along with organ-space infections, can affect up to 35% of patients undergoing emergency abdominal procedures.[3] The global epidemiology of SSIs demonstrates significant geographical variation, with rates ranging from 0.9% in the United States (NHSN data, 2014) to 2.6% in Italy, 2.8% in Australia, and 2.1% in South Korea.[1] The burden is substantially higher in lower-middle-income countries (LMIC), where WHO data from 1995-2015 documented rates of 6.1%, with pooled analyses from South East Asia revealing incidence rates of 7.8% and developing nations reporting overall rates of 11.8%.[1] In India, a study by Mohseni et al. identified SSI rates of 17% in patients without drains and 18% in those with drains, though more recent evidence suggests differential benefits according to patient risk stratification and wound type.[4]

The pathophysiology of SSI development involves multiple patient-related, surgical, and environmental factors. Patient-related risk factors include advanced age, comorbidities such as diabetes mellitus and hypertension, obesity, malnutrition, immunosuppression, and substance use disorders.[5] Surgical factors contributing to SSI risk include prolonged operative duration, intraoperative hypothermia, elevated American Society of Anaesthesiologists (ASA) scores, level of wound contamination, and breach of aseptic technique.[5] Emergency laparotomies carry inherently higher infection risks compared to elective procedures due to limited preoperative optimization, increased contamination from perforated viscera or traumatic injury, and physiological stress associated with acute presentation.

The management of established SSIs follows a systematic, five-step approach emphasizing early pathogen identification through culture, achievement of source control via incision opening or image-guided drainage, initiation of empirical antibiotic therapy, timely de-escalation based on microbiological data, and meticulous local wound care.[6] However, prevention remains superior to treatment. Current preventive strategies include preoperative skin antisepsis with chlorhexidine-alcohol, which demonstrates superiority over povidone-iodine in reducing bacterial load.[7] Perioperative antibiotic prophylaxis, administered within one hour preoperatively, remains a cornerstone of SSI prevention.[8] Emerging technologies, particularly negative pressure wound therapy (NPWT), have shown promise in reducing SSIs in high-risk patients by promoting angiogenesis, reducing edema, and preventing bacterial colonization.[9]

Negative suction closed drains (NSCD) represent a complementary approach to SSI prevention by effectively removing residual blood, serum, and purulent fluid from the subcutaneous space, thereby eliminating the fluid collections that serve as culture media for bacterial proliferation. The rationale for their use is based on the principle that hematomas, seromas, and dead space within surgical wounds increase infection risk by providing optimal conditions for microbial growth and impaired local immunity.[10] However, the evidence regarding the efficacy of subcutaneous drains in preventing SSIs, particularly in emergency surgical settings, remains inconsistent. While some systematic reviews suggest marginal benefit only in high-risk populations (obese patients, contaminated wounds, patients with coagulopathy), other contemporary studies report significant reductions in SSI rates and wound complications with their use.[11][12]

Given the limited literature specifically addressing SSI prevention in emergency laparotomy settings, and the conflicting evidence regarding drain efficacy, we conducted a prospective comparative study to evaluate whether negative suction closed drains reduce incisional SSI rates and associated wound complications in emergency laparotomy patients. We hypothesized that the use of subcutaneous drains would result in lower SSI incidence by facilitating fluid evacuation and reducing bacterial colonization in the early postoperative period.

Study Design and Setting

This prospective comparative study was conducted at the Department of General and Laparoscopic Surgery, V.S.S. Institute of Medical Sciences and Research (VSSIMSAR), Burla, Sambalpur, Odisha, India, from July 2023 to March 2025. The study was approved by the Institutional Review and Ethics Committee (VIREC No. 213-2022I-S-T163, dated 17.06.2023). All enrolled patients provided written informed consent prior to participation.

Study Population and Sampling

A consecutive sampling technique was employed to enroll all eligible patients undergoing emergency laparotomy during the study period. Inclusion criteria encompassed all patients requiring emergency laparotomy for abdominal pathology, regardless of age, gender, comorbidities, or wound classification. Exclusion criteria included patients with incomplete medical records, those lost to follow-up before 30 days postoperatively, and patients with contraindications to drain placement (such as severe coagulopathy requiring reversal). Eighty patients met eligibility criteria and were enrolled consecutively.

Sample Size Calculation

Sample size was determined using the formula for comparison of two proportions:

n = {(Z_a + Z_b)^2 [P_1(1-P_1) + P_2(1-P_2)]}{(P_1 - P_2)^2}

Where P₁ = proportion with SSI in drain group (14%) and P₂ = proportion with SSI in non-drain group (42%), based on preliminary data from previous studies. With 95% confidence level (Z_a = 1.96) and 80% statistical power (Z_b = 0.84), the calculated sample size was 36 patients per group, rounded to 40 per group for a total of 80 participants.

Study Groups

Patients were allocated sequentially into two groups of 40 participants each. Group A comprised patients who received negative suction closed drains (Jackson-Pratt or similar closed suction system) placed in the subcutaneous space before skin closure. Group B comprised patients managed without subcutaneous drains, serving as the control group. Group allocation was based on sequential enrollment without randomization, reflecting clinical practice during the study period.

Surgical Technique and Drain Placement

All patients underwent emergency laparotomy via midline incision (upper, mid, or lower) determined by the primary pathology. Surgical techniques included standard dissection, hemostasis, and source control appropriate to the specific diagnosis. After completion of the intra-abdominal procedure, the peritoneum and fascia were closed in layers using polydioxanone (PDS) sutures with a continuous mass closure technique employing a 4:1 suture-to-wound length ratio.s

For patients in Group A, a closed suction drain was placed in the subcutaneous space before skin closure, positioned to optimize fluid collection from the dependent portions of the incision. The drain was brought out through a separate stab incision adjacent to the main wound to minimize contamination. Skin closure was performed with interrupted sutures or staples. The drain exit site was dressed separately with sterile gauze, and suction was applied immediately postoperatively. Drains were removed when output remained negligible (<30 mL over 24 hours) and wound apposition appeared satisfactory, typically on postoperative days 2-4.

For patients in Group B, the abdominal wall was closed identically except for omission of the subcutaneous drain. Skin closure and dressing procedures were identical.

Data Collection and Follow-up

Intraoperative findings, including nature of peritoneal contamination (bile, blood, pus, fecal material, toxic fluid, or no visible collection), were systematically recorded. Cultures from intra-abdominal fluid were obtained at the time of surgery and again from wound drainage on postoperative days 2-4 if drainage or signs of infection were present. Antibiotic therapy was initiated empirically on the operating table and adjusted on postoperative day 3 based on culture and sensitivity results.

Daily postoperative assessments included evaluation of the incision for signs of infection, measurement of drain output (volume, character, and consistency in Group A), and systemic signs. Patients were followed for 30 days postoperatively, with outpatient review at 2 and 4 weeks from discharge. Postoperative pain was assessed on the visual analog scale, and wound healing was documented photographically.

Outcome Measures

The primary outcome was surgical site infection (SSI) diagnosed according to CDC definitions within 30 days postoperatively. Superficial incisional SSI was defined as infection involving only skin or subcutaneous tissue with at least one of the following: purulent drainage from the incision with positive culture, microorganisms isolated from incisional fluid, or signs of inflammatory response (pain, tenderness, localized swelling, erythema, or heat). Deep incisional SSI involved deeper soft tissues (fascia and muscle), while organ-space SSI involved intra-abdominal contents.

Secondary outcomes included wound complications (hematoma, seroma, dehiscence), duration of hospital stay, postoperative pain score, requirement for surgical intervention (incision opening, drainage procedures, or debridement), organisms isolated from wound cultures, and timing of SSI onset (postoperative day).

Statistical Analysis

Data were entered into Microsoft Excel and analyzed using SPSS version 27.0 (IBM Corp., Chicago, IL, USA) and GraphPad Prism version 5. Numerical variables were expressed as mean ± standard deviation (SD) with range, while categorical variables were presented as frequencies and percentages.

For comparative analysis between groups, two-sample independent t-tests were used for continuous variables, with paired t-tests employed when appropriate. Categorical variables were compared using Pearson's chi-square test (χ²) with two-tailed analysis. Fisher's exact test was applied when expected cell frequencies were less than five. The chi-square test statistic, degrees of freedom, and p-values were calculated explicitly. Statistical significance was set at p ≤ 0.05. All p-values were two-tailed unless otherwise specified.

Of the 80 patients enrolled, 63 (78.75%) were male and 17 (21.25%) were female, reflecting the male predominance typical in emergency surgical populations. Age distribution showed the majority of patients (26.25%) in the 31-40 years range, followed by 18-30 years (25%), with representation across all decades up to 70 years. Demographic characteristics were comparable between groups, with no significant differences in age or sex distribution.

Figure1. SSI Incidence in the study population

Hollow viscus perforation was the most common diagnosis, affecting 29 patients (36.25%), followed by appendicular abscess (13.75%), blunt abdominal trauma (11.25%), and penetrating abdominal injury (11.25%). Other diagnoses included subacute intestinal obstruction, sigmoid volvulus, gallbladder perforation, ventral hernia, and ruptured liver abscess. Distribution of diagnoses was relatively balanced between groups.

The nature of intraoperative peritoneal contamination varied substantially. Bile was the most frequently encountered finding (25 cases, 31.25%), followed by blood (14 cases, 17.5%), pus (14 cases, 17.5%), and fecal contamination (9 cases, 11.25%). Toxic serous fluid and no visible collection occurred in 6 and 12 cases respectively. Notably, Group B had a higher proportion of more severe contamination (fecal material and toxic fluid), while Group A had higher rates of bile and pus contamination. Bile fluid was associated with the lowest SSI risk (20% infection rate, 5 of 25 cases), whereas pus collection carried the highest risk (64.3% infection rate, 9 of 14 cases). Fecal contamination and toxic fluid demonstrated intermediate to high risk (44.4% and 50% respectively), while blood collection and absence of visible fluid had the lowest infection rates (7.1% and 8.3% respectively).

Upper midline incisions were most frequently employed (46.25%, 37 cases), followed by lower midline (40%, 32 cases), with mid-abdominal midline incisions in 11 cases (13.75%). All midline incisions were closed with continuous PDS suture using mass closure technique. Incision type distribution did not differ significantly between groups.

The primary finding of this study was a statistically significant difference in SSI incidence between groups. In Group A (with negative suction closed drains), 5 of 40 patients (12.5%) developed SSI, compared to 18 of 40 patients (45%) in Group B (without drains). This difference was highly significant (χ² = 10.79, p = 0.0013). The absolute risk reduction was 32.5 percentage points, representing a relative risk reduction of 72.2% with drain use.

Analysis of organisms isolated from SSI cultures revealed important differences between groups (Table 1).

TABLE 1. Microbiological Profile of Surgical Site Infections

Secondary analysis revealed marked differences in wound complication rates between groups (p = 0.005, χ² test). In Group A, no cases of hematoma (0%) or seroma (0%) were observed. Four patients (10%) experienced postoperative pain, while 36 (90%) had no complications.

In contrast, Group B experienced 4 cases of hematoma (10%), 4 cases of seroma (10%), 9 cases of postoperative pain (22.5%), and 23 cases (57.5%) without complications. These findings suggest that subcutaneous drains significantly reduce the formation of wound collections that serve as culture media for bacterial proliferation, and consequently, reduce the overall incidence of infection-related sequelae.

The mean duration of hospitalization differed between groups. Patients in Group A remained hospitalized for a mean of 5.95 ± 1.36 days (median 6 days, range 4-10 days), while those in Group B averaged 6.80 ± 1.69 days (median 7 days, range 5-12 days). Although this difference was not subjected to formal statistical testing in the presentation, the trend suggests that SSI development and associated complications in Group B resulted in prolonged hospitalization.

A striking pattern emerged regarding the timing of SSI onset between groups. In Group A, all five cases of SSI occurred early in the postoperative course: four cases (80% of SSIs) on postoperative day (POD) 2 and one case (20%) on POD 3.

Figure 2. SSI onset early vs delayed in the study population

In contrast, Group B showed predominantly delayed SSI onset with no infections in the early postoperative period. Infections were distributed across later postoperative days: 10 cases (55.6% of SSIs) on POD 4, 6 cases (33.3%) on POD 5, and 2 cases (11.1%) on POD 6. This temporal pattern suggests that subcutaneous drains promote early evacuation of fluid collections in the immediate postoperative period, thereby reducing bacterial colonization potential in later days.

Analysis of organisms isolated from SSI cultures revealed important differences between groups. In Group A, no isolates of Escherichia coli or Klebsiella pneumoniae were obtained. Instead, 35 of 40 cultures (87.5%) were negative, 3 cases (7.5%) yielded Pseudomonas aeruginosa, and 2 cases (5%) yielded Staphylococcus aureus.

In Group B, gram-negative organisms predominated: 8 cases (20%) yielded E. coli, 6 cases (15%) yielded K. pneumoniae, 22 cases (55%) had negative cultures, 1 case (2.5%) yielded Pseudomonas, and 3 cases (7.5%) yielded S. aureus. The prevalence of E. coli and Klebsiella—both enteric gram-negative organisms—was substantially higher in the non-drain group, consistent with the hypothesis that fluid accumulation creates an anaerobic environment favoring gram-negative bacterial proliferation.

The nature of intraoperative peritoneal contamination varied substantially and correlated strongly with SSI risk (Table 2).

TABLE 2. Intraoperative Contamination and SSI Risk Stratification

Surgical intervention was required in 6 patients in Group B (15%), including incision opening for drainage, serial debridement, or secondary suturing in the setting of SSI or dehiscence. None of the 40 patients in Group A (0%) required surgical intervention (p = 0.034, χ² test). This finding underscores the clinical significance of drain use in preventing severe postoperative complications that necessitate operative management.

This prospective comparative study demonstrates a substantial and statistically significant reduction in surgical site infection rates in emergency laparotomy patients managed with negative suction closed drains compared to those without drains. The SSI rate of 12.5% in the drain group contrasts sharply with the 45% rate in the non-drain group, yielding an absolute risk reduction of 32.5 percentage points and a relative risk reduction of 72.2%.

Our findings are consistent with, though more favorable than, those reported in several contemporary studies. Verma et al. (2019) reported SSI rates of 15% in the drain group versus 28.5% in the control group (p < 0.05), while Rathi et al. (2019) documented wound complication rates significantly higher in patients without drains (30%) compared to those with drains (15%).[13][14] These results align with more recent data from 2023, where SSI rates in emergency abdominal surgery patients with drains were significantly reduced in contaminated wounds.[15] However, meta-analytic data from earlier systematic reviews suggested that routine drain use in all laparotomy patients does not provide universal benefit, with statistically non-significant overall effect sizes.[16] The apparent discrepancy may reflect important heterogeneity in surgical populations and wound contamination levels—our cohort included exclusively emergency cases with proportionally higher rates of contaminated (Class III) and dirty (Class IV) wounds compared to mixed elective-emergency populations studied in earlier meta-analyses.

The observed temporal pattern of SSI development provides mechanistic insight into drain efficacy. The concentration of SSIs in Group A on postoperative days 2-3 likely represents early infections seeded during surgery or in the immediate postoperative period, whereas the delayed onset in Group B (POD 4-6) reflects the prolonged period during which fluid collections accumulated, providing an increasingly favorable environment for bacterial proliferation. Studies demonstrating the efficacy of negative pressure wound therapy in contaminated abdominal wounds similarly observed that early fluid evacuation reduces subsequent bacterial colonization and SSI development.[17] The absence of any SSIs in the first 48 hours postoperatively in Group B suggests that early fluid accumulation does not immediately precipitate infection; rather, it creates conditions favoring delayed bacterial overgrowth—a phenomenon consistent with the biofilm formation dynamics and the time-dependent increase in bacterial burden within stagnant wound fluid.

The microbiological profile of SSIs in our study warrants particular attention. The predominance of gram-negative enteric organisms (E. coli and Klebsiella) in the non-drain group supports the hypothesis that fluid stasis creates an anaerobic microenvironment conducive to gram-negative bacterial growth and biofilm formation. Gram-positive organisms such as S. aureus, which are primarily skin flora, were distributed relatively equally between groups, suggesting that their presence relates to inoculation at the time of surgery or from contact with the patient's own skin—factors not substantially influenced by postoperative drain use.[18] The dramatic reduction in gram-negative SSIs with drain use strongly suggests that the mechanism of benefit involves prevention of fluid-mediated bacterial proliferation rather than non-specific reduction in wound contamination.

The complete absence of hematoma and seroma in Group A, compared to their occurrence in Group B (4 cases each), reflects the direct mechanical benefit of closed suction drainage in preventing collection formation. Dead space within surgical wounds—particularly in the subcutaneous tissues and at fascial planes—represents a significant risk factor for fluid accumulation, with both hematomas and seromas serving as excellent culture media for bacterial growth. The elimination of these complications in the drain group provides a second mechanism by which drains reduce SSI: not only through direct fluid evacuation, but also through prevention of the favorable microenvironment that collections provide. This finding is consistent with prior studies demonstrating that seroma formation significantly increases infection risk, with reported odds ratios ranging from 3 to 5.[19]

The clinical significance of reducing operative interventions is demonstrated by the requirement for surgical intervention in 15% of non-drain patients versus 0% of drain patients. These interventions (incision opening, drainage, debridement, or secondary suturing) impose substantial costs, extend hospitalization, increase patient morbidity, and carry inherent risks including further tissue trauma, anesthesia exposure, and secondary infection. From an economic perspective, even if drains increased material costs by 50-100 dollars per patient, the cost-effectiveness would be favorable given the reduction in interventions required, decreased length of stay, and prevention of SSI-related complications. Resource-limited settings, such as much of South Asia, stand to gain particular benefit from drain use in high-risk populations.

Our study has several strengths. First, it was prospective in design with systematic data collection and standardized definitions for SSI diagnosis. Second, the study population was homogeneous—all emergency laparotomy patients—eliminating confounding from elective procedures with inherently lower infection risk. Third, all patients were followed for the full 30-day postoperative period with both hospitalization and outpatient surveillance. Fourth, the cohort size was adequate to detect statistically significant differences, with adequate statistical power. Fifth, we systematically recorded intraoperative contamination types and microbiological data, allowing for mechanistic understanding of drain benefits.

However, the study has limitations that merit acknowledgment. First, it was not randomized, relying instead on sequential allocation to study groups. This design, while pragmatic and reflecting real-world practice, introduces potential for selection bias, though the temporal sequence of enrollment and lack of indication for preferential drain use in particular patient subsets during the study period mitigates this concern. Second, the study was conducted at a single tertiary care institution in Eastern India, potentially limiting generalizability to other healthcare settings, resource levels, or geographic regions.

The study period (July 2023 to March 2025) represents contemporary practice, but trends in surgical technique, antibiotic stewardship, or quality improvement initiatives may have changed. Third, while we systematically recorded major comorbidities and ASA scores, we did not perform multivariable logistic regression analysis to adjust for potential confounding variables, particularly given that some comorbidities (such as diabetes mellitus, hypertension, and obesity) independently increase SSI risk. Fourth, analysis of intraoperative findings revealed that Group B had disproportionately more severe contamination (fecal material and toxic fluid), which itself increases SSI risk independently. This imbalance, if it occurred by chance rather than allocation bias, may have artificially inflated the apparent benefit of drains in Group B. Fifth, we did not distinguish between different types of closed suction drains (Jackson-Pratt versus other systems), and different drain systems may have differential efficacy. Sixth, we did not systematically assess adherence to other SSI prevention measures (antibiotic prophylaxis timing, skin antisepsis choice, perioperative temperature management), which may have differed between groups and influenced infection rates. Finally, our follow-up period was limited to 30 days postoperatively, which may have missed later-onset organ-space infections or deep incisional infections that can present at 45-60 days, particularly in patients with complex intra-abdominal pathology.

The findings of this study have important implications for surgical practice, particularly in emergency settings and resource-limited contexts. The use of negative suction closed drains in emergency laparotomy appears to provide substantial and clinically meaningful reductions in SSI incidence, particularly in contaminated wounds. Given the current evidence base—including our findings and those of several contemporary studies—we recommend the routine use of subcutaneous closed suction drains in emergency laparotomy patients, particularly those with significant intraoperative contamination (Class III or IV wounds) or with recognized risk factors for SSI such as obesity, advanced age, diabetes mellitus, or immunosuppression.

Future research should focus on several areas. Large-scale, multicenter, randomized controlled trials are needed to definitively establish drain efficacy while controlling for potential confounders and balancing patient characteristics between groups. Such trials should examine not only binary outcomes (drain versus no drain) but also variations in drain type, position, duration of placement, and target populations (e.g., stratified analyses by wound contamination class, obesity status, or comorbidity burden). Health economic analyses should quantify the cost-effectiveness of routine drain use in different healthcare systems and resource contexts. Investigation of mechanisms—including fluid dynamics, biofilm formation kinetics, and antimicrobial pharmacodynamics in drain environments—could optimize drain design and management strategies. Finally, implementation science approaches should examine barriers and facilitators to drain use in diverse surgical settings to translate evidence into practice.

This prospective comparative study of 80 emergency laparotomy patients demonstrates that the use of negative suction closed drains substantially reduces surgical site infection rates (12.5% versus 45%, p = 0.0013), wound complications including hematoma and seroma formation, and the need for postoperative surgical interventions compared to no drain use. The temporal pattern of SSI development suggests that drains prevent delayed infection by promoting early evacuation of fluid collections, while the microbiological profile indicates preferential reduction in gram-negative enteric infections in the setting of drained wounds. These findings support the routine use of negative suction closed drains in emergency laparotomy, particularly in high-risk surgical populations and in the setting of significant intraoperative contamination. Implementation of this intervention, coupled with adherence to other established SSI prevention measures, represents a practical, cost-effective strategy for improving surgical outcomes in emergency abdominal surgery.

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