Wound Protectors in Reducing Surgical Site Infections in Lower Gastrointestinal Surgery: An Updated Meta-Analysis of Randomized Controlled Trials

Background: Surgical site infection (SSI) is a common complication in gastrointestinal surgery, affecting up to 25% of patients. SSIs increase length of stay, incur increased costs to the healthcare system, and contribute to postoperative morbidity and mortality. Wound protection devices (or "wound retractors") have been increasingly used in the past few decades in the effort to reduce SSI rates. We performed a meta-analysis to determine if the use of wound protectors reduces the incidence of SSIs in lower gastrointestinal surgery.

Methods: MEDLINE and EMBASE databases were searched between 1946 and 2016. Randomized controlled trials comparing SSI rates in wound protector vs. no wound protector in lower gastrointestinal surgery were included. The Odds Ratio was calculated for the primary outcome. We used random effects modelling to account for clinical heterogeneity. Subgroup analysis was conducted comparing single ring vs. dual ring wound protectors.

Results: Twelve RCTs with 3029 participants were included in the meta-analysis. The wound protector group demonstrated significantly decreased odds of developing SSI (OR 0.64, 95%CI 0.45 – 0.90, P<0.01, I2 = 55%). There was evidence of a subgroup effect (P = 0.01) with dual ring wound protectors associated with significantly lower incidence of SSIs (5 studies, OR 0.31, 95%CI 0.18 – 0.52, P<0.0001, I2 = 12%), which was not appreciated in the single ring wound protectors (7 studies, OR 0.84, 95%CI 0.67 – 1.04, P = 0.11, I2 = 0%). Three studies had high risk of bias. The GRADE quality of evidence was moderate.

Discussion: Wound protector use is associated with decreased odds of developing SSIs in patients undergoing lower gastrointestinal surgery. We found that there was a subgroup effect when comparing dual ring to single ring wound protectors.