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Early Versus Delayed Dressing Removal After Primary Closure Of Clean And Clean-contaminated Surgical Wounds.

Clare D Toon, Charnelle Lusuku, Rajarajan Ramamoorthy, Brian R. Davidson, Kurinchi Selvan Gurusamy
Published 2015 · Medicine
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BACKGROUND Most surgical procedures involve a cut in the skin that allows the surgeon to gain access to the deeper tissues or organs. Most surgical wounds are closed fully at the end of the procedure (primary closure). The surgeon covers the closed surgical wound with either a dressing or adhesive tape. The dressing can act as a physical barrier to protect the wound until the continuity of the skin is restored (within about 48 hours) and to absorb exudate from the wound, keeping it dry and clean, and preventing bacterial contamination from the external environment. Some studies have found that the moist environment created by some dressings accelerates wound healing, although others believe that the moist environment can be a disadvantage, as excessive exudate can cause maceration (softening and deterioration) of the wound and the surrounding healthy tissue. The utility of dressing surgical wounds beyond 48 hours of surgery is, therefore, controversial. OBJECTIVES To evaluate the benefits and risks of removing a dressing covering a closed surgical incision site within 48 hours permanently (early dressing removal) or beyond 48 hours of surgery permanently with interim dressing changes allowed (delayed dressing removal), on surgical site infection. SEARCH METHODS In March 2015 we searched the following electronic databases: The Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. We also searched the references of included trials to identify further potentially-relevant trials. SELECTION CRITERIA Two review authors independently identified studies for inclusion. We included all randomised clinical trials (RCTs) conducted with people of any age and sex, undergoing a surgical procedure, who had their wound closed and a dressing applied. We included only trials that compared early versus delayed dressing removal. We excluded trials that included people with contaminated or dirty wounds. We also excluded quasi-randomised studies, and other study designs. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data on the characteristics of the trial participants, risk of bias in the trials and outcomes for each trial. We calculated risk ratios (RR) with 95% confidence intervals (CI) for binary outcomes and mean difference (MD) with 95% CI for continuous outcomes. We used RevMan 5 software to perform these calculations. MAIN RESULTS Four trials were identified for inclusion in this review. All the trials were at high risk of bias. Three trials provided information for this review. Overall, this review included 280 people undergoing planned surgery. Participants were randomised to early dressing removal (removal of the wound dressing within the 48 hours following surgery) (n = 140) or delayed dressing removal (continued dressing of the wound beyond 48 hours) (n = 140) in the three trials. There were no statistically significant differences between the early dressing removal group and delayed dressing removal group in the proportion of people who developed superficial surgical site infection within 30 days (RR 0.64; 95% CI 0.32 to 1.28), superficial wound dehiscence within 30 days (RR 2.00; 95% CI 0.19 to 21.16) or serious adverse events within 30 days (RR 0.83; 95% CI 0.28 to 2.51). No deep wound infection or deep wound dehiscence occurred in any of the participants in the trials that reported this outcome. None of the trials reported quality of life. The hospital stay was significantly shorter (MD -2.00 days; 95% CI -2.82 to -1.18) and the total cost of treatment significantly less (MD EUR -36.00; 95% CI -59.81 to -12.19) in the early dressing removal group than in the delayed dressing removal group in the only trial that reported these outcomes. AUTHORS' CONCLUSIONS The early removal of dressings from clean or clean contaminated surgical wounds appears to have no detrimental effect on outcomes. However, it should be noted that the point estimate supporting this statement is based on very low quality evidence from three small randomised controlled trials, and the confidence intervals around this estimate were wide. Early dressing removal may result in a significantly shorter hospital stay, and significantly reduced costs, than covering the surgical wound with wound dressings beyond the first 48 hours after surgery, according to very low quality evidence from one small randomised controlled trial. Further randomised controlled trials of low risk of bias are necessary to investigate whether dressings are necessary after 48 hours in different types of surgery and levels of contamination and investigate whether antibiotic therapy influences the outcome.
This paper references
Surgical wound infection.
Parijat Nandi (1999)
NIHR -UK Government organisation for health research), UK. NIHR provides financial support for K Gurusamy for completing the review •
10.1002/bjs.6558
Assessment of risk of bias in randomized clinical trials in surgery.
Kurinchi Selvan Gurusamy (2009)
10.1093/ije/21.5.837
Intention-to-treat analysis: implications for quantitative and qualitative research.
David J. Newell (1992)
Kurinchi Selvan Gurusamy: none known
10.1001/jama.1967.03130020083026
Vulvar condylomata acuminata in prepubertal females.
David Grace (1967)
10.12968/jowc.2002.11.7.26414
Maceration of the skin and wound bed. 1: Its nature and causes.
Keith F. Cutting (2002)
10.1017/S0195941700015241
CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections.
Teresa C. Horan (1992)
[A historical review on International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH) and internationalization of Japan's new drugs development and regulation].
Tatsuo Kurokawa (2014)
10.1136/pgmj.63.735.27
Exposure of the wound--a safe economy in the NHS.
N W Law (1987)
10.1016/S0021-7697(08)73724-4
Pansement versus absencede pansement au delà de 48 heures en milieu tropical : essai randomisé
D. Dosseh Ékoué (2008)
Surgical wound infection: a comparison between dressed and undressed wounds.
Ajao Og (1977)
10.1002/14651858.CD008057.pub2
Staples versus sutures for closing leg wounds after vein graft harvesting for coronary artery bypass surgery.
Fausto Biancari (2010)
10.1016/0195-6701(91)90172-5
Wound infection under occlusive dressings.
J J Hutchinson (1991)
10.1017/S0195941700064080
CDC guidelines for prevention of surgical wound infections, 1985.
Julia S. Garner (1986)
10.1016/j.jhin.2009.03.020
Surgical site infections: how high are the costs?
E. C. J. Broex (2009)
Crossover Procedure/ (31187) 19 (random$ or factorial$ or crossover$ or cross over$ or cross-over$ or placebo$ or assign$ or allocat$ or volunteer$).ti,ab. (918967)
10.1002/sim.1186
Quantifying heterogeneity in a meta-analysis.
Julian P. T. Higgins (2002)
Single-Blind Method/ (15215)
10.1016/S0003-3944(01)00531-4
Pansement ou absence de pansement sur les plaies opératoires. Étude prospective comparative
G. Meylan (2001)
Effect of dressings on saphenous vein harvest incision pain, distress and cosmetic result.
Deidre D. Wipke-Tevis (1998)
Advised on methodology, interpretation and content. Edited the protocol,review and updated review. Ruth Foxlee: designed the search strategy and edited the search methods section
Sally Bell-Syer
10.1097/00004630-199307000-00009
Evaporative water losses through a temporary wound dressing under simulated wound conditions.
A. R. Gwosdow (1993)
10.1002/JPS.21210
Wound healing dressings and drug delivery systems: a review.
Joshua S Boateng (2008)
10.1111/1523-1747.ep12476467
Comparison of the effects of moist and dry conditions on dermal repair.
Mary E. Dyson (1988)
10.1002/sim.698
A comparison of methods to detect publication bias in meta-analysis.
Petra Macaskill (2001)
10.1007/s00383-009-2485-9
Sutureless skin closure with isoamyl 2-cyanoacrylate in pediatric day-care surgery
Zaheer Hasan (2009)
10.1001/jama.273.5.408
Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials.
Kenneth F. Schulz (1995)
10.1136/bmj.39465.451748.AD
Empirical evidence of bias in treatment effect estimates in controlled trials with different interventions and outcomes: meta-epidemiological study
Lesley J. Wood (2008)
10.3341/kjo.2011.25.2.121
A Comparison of 2-Octyl Cyanoacrylate Adhesives versus Conventional Suture Materials for Eyelid Wound Closure in Rabbits
Hee-Bae Ahn (2011)
10.1136/bmj.315.7109.629
Bias in meta-analysis detected by a simple, graphical test
Matthias Egger (1997)
10.1016/S0140-6736(98)01085-X
Does quality of reports of randomised trials affect estimates of intervention efficacy reported in meta-analyses?
David Moher (1998)
edited the protocol; advised on methodology, interpretation and protocol content
Nicky Cullum
10.1001/jama.1967.03130010085022
Comparison of two methods of management of clean surgical wounds. "Open" vs "closed" postoperative wound care.
Reginald Edwards (1967)
10.1016/j.bjps.2006.01.011
Twenty-four hours or 10 days? A prospective randomised controlled trial in children comparing head bandages following pinnaplasty.
Sanjai Ramkumar (2006)
10.1016/j.emc.2010.06.009
Essential concepts of wound management.
Carlos García-Gubern (2010)
10.12968/BJON.2010.19.SUP10.79693
Barrier dressings in surgical site infection prevention strategies.
Fiona Downie (2010)
10.1002/bjs.1800760232
Need for surgical wound dressing.
H Chrintz (1989)
[Discontinuing postoperative wound dressings].
H Chrintz (1989)
10.1097/01.NAJ.0000453038.93499.69
Early vs. delayed removal of dressings covering surgical wounds.
Karolina Lisy (2014)
10.1001/archsurg.143.10.950
Occlusive vs gauze dressings for local wound care in surgical patients: a randomized clinical trial.
Dirk T. Ubbink (2008)
Surgical Wound") S5 (MH "Surgical Wound Dehiscence
S6 mh
editors) on behalf of the Cochrane Information Retrieval Methods Group. Chapter 6: Searching for studies
C Lefebvre 2011 Lefebvre (2011)
10.1001/archsurg.1973.01350160185032
Abdominal wound dehiscence.
R H Keill (1973)
10.1016/S0001-2092(07)62560-5
CDC guideline for prevention of surgical wound infections
Bryan P. Simmons (1983)
10.7326/0003-4819-135-11-200112040-00010
Reported Methodologic Quality and Discrepancies between Large and Small Randomized Trials in Meta-Analyses
Lise Lotte Kjaergard (2001)
Editor: approved the final review prior to submission
Kurinchi Gurusamy screened the search results, assessed full text articles, edited and approved the final updated review version prior to submission, and is guarantor of the review
10.1016/S0190-9622(85)70091-6
Occlusive wound dressings to prevent bacterial invasion and wound infection.
Patricia M. Mertz (1985)
Charnelle Lusuku screened the search results, retrieved articles for assessment and edited the updated review
Physiology of the acute wound
Lawrence Wt (1998)
10.1016/j.jpedsurg.2004.08.017
Pediatric clean surgical wounds: is dressing necessary?
Jamal M. Merei (2004)
10.1002/sim.4780060325
Methods for combining randomized clinical trials: strengths and limitations.
David L. Demets (1987)
10.1016/0197-2456(86)90046-2
Meta-analysis in clinical trials.
Rebecca Dersimonian (1986)



This paper is referenced by
10.1016/j.jvn.2017.03.002
Infrainguinal wound infections in vascular surgery: An antiquated challenge without a modern solution.
B O Aicher (2017)
10.1016/j.ciresp.2017.09.004
Prevention of Surgical Site Infection: Analysis and Narrative Review of Clinical Practice Guidelines.
Francisco Javier Gómez-Romero (2017)
10.1016/J.CIRESP.2017.09.004
Prevención de la infección de sitio quirúrgico: análisis y revisión narrativa de las guías de práctica clínica
Francisco Javier Gómez-Romero (2017)
10.1016/J.CIRENG.2017.11.003
Prevention of Surgical Site Infection: Analysis and Narrative Review of Clinical Practice Guidelines.
Francisco Javier Gómez-Romero (2017)
incidence of subsequent surgical site infection / periprosthetic joint infection ( SSI / PJI ) ?
Ran M Schwarzkopf (2018)
10.1016/j.ajog.2017.02.014
Surgical‐site infection in gynecologic surgery: pathophysiology and prevention
Holly L. Steiner (2017)
10.1016/j.ajog.2016.03.035
Early wound dressing removal after scheduled cesarean delivery: a randomized controlled trial.
David Peleg (2016)
10.1002/9781118999219.CH6
Update on Wound Dressings
Stine Jacobsen (2016)
10.1016/j.wneu.2016.10.002
Fundamental Basis of Scalp Layering Techniques to Protect Against Wound Infection: A Comparative Study Between Conventional and In-to-Out Dissection of the Superficial Temporal Artery.
Yeongu Chung (2017)
10.4172/2157-7099.1000395
Comparative Effectiveness of Cyanoacrylate Bioadhesives and MonofilamentSuture in Wound Healing: A Histopathological and Physicochemical Study inNew Zealand White Rabbit
Alejandro Hevia Angulo (2015)
Prophylaxis, diagnosis and treatment of prosthetic joint infections
Ricardo Sousa (2017)
10.7748/ns.28.46.61.e8402
Wound care considerations in neonates.
Yvonne Cousins (2014)
10.1002/ijgo.12757
Timing of staples and dressing removal after cesarean delivery (the SCARR study)†
Netanella Heinemann (2019)
10.1016/j.ijnurstu.2019.103486
Preoperative and postoperative recommendations to surgical wound care interventions: A systematic meta-review of Cochrane reviews.
Brigid M. Gillespie (2019)
10.1016/j.jvn.2020.01.004
Society for Vascular Nursing endovascular repair of abdominal aortic aneurysm updated nursing clinical practice guideline.
Debra Kohlman-Trigoboff (2020)
10.1002/14651858.CD010075.pub2
Early versus delayed post-operative bathing or showering to prevent wound complications.
Clare D Toon (2013)
10.1007/s00264-017-3607-y
Prevention of fracture-related infection: a multidisciplinary care package
Willem-Jan Metsemakers (2017)
10.1016/J.REFRAC.2019.04.007
Place des pansements dans les plaies aiguës
Véra Boïko-Alaux (2019)
10.1007/978-3-030-28872-3_3
Chronic Wounds and Infections
Eran Shavit (2020)
10.1007/978-3-662-46287-4_11
Prevention of Deep Infection in Total Hip Arthroplasty
Ricardo Sousa (2015)
10.18203/2349-2902.isj20183722
Early versus late dressing removal in clean and contaminated midline laparotomy wounds: a non-randomized pilot study
Chellappa Vijayakumar (2018)
10.1111/wrr.12519
Outcomes in Cochrane systematic reviews related to wound care: An investigation into prespecification
Z. Liu (2017)
10.1016/j.ogc.2014.08.008
Prevention and management of cesarean wound infection.
Joseph L. Fitzwater (2014)
Finns evidens för förbandstyper vid såromläggningar inom primärvården? : En litteraturöversikt
Pelle Back-Träff (2014)
10.1002/bjs.10426
Alternatives to antibiotics for prevention of surgical infection
I B M Ploegmakers (2017)
10.30944/20117582.86
Infección de sitio operatorio en herida abdominal sucia
Ana Lucía Castaño-Cardona (2018)
Dispelling some myths and misconceptions in wound care
Annemarie C. Brown (2018)
10.1007/s40719-019-0157-3
Update on Prevention of Surgical Site Infections
John T. Schulz (2019)
10.1002/CCA.1088
How does early dressing removal compare with late removal after primary closure of clean and clean‐contaminated surgical wounds?
Nicholas G. Rabey (2017)
10.1016/j.jvn.2017.03.004
Society for Vascular Nursing-Carotid endarterectomy (CEA) updated nursing clinical practice guideline.
Kathleen Rich (2017)
Recommendations for the prevention of surgical site infections during postoperative nursing care in surgery departments
M. Szewczyk (2015)
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