Commentary on “Surgical Site Infection Research Opportunities”

To the Editor:

We have read carefully the article by Itani et al [1]. The article presents a detailed analysis of future research areas in relation to surgical site infections, and it has concluded: “This article presents opportunities for SSI research focusing on prevention effectiveness and high-yield questions to prioritize SSI research opportunities over the next few years.” Since the introduction of antibiotic prophylaxis in the 1970s, very little improvement has been achieved in wound infection outcomes, especially after gastrointestinal surgery [2,3]. Most of the preventive efforts have been directed toward the destruction of the bacterial inoculum in the surgical wounds; this method is still being proposed in this article as the direction of future research. On the other hand, it has been proposed to detect patient-associated risk factors as an alternative method for managing wound infections. Nonetheless, the only inarguable fact is that to produce a surgical wound infection, it is necessary that pathogenic germs come into contact with it.

The introduction in abdominal surgical procedures of auto-retractors, which also act as barrier protectors, has resulted in a dramatic decrease in the rates of surgical wound infections in colorectal surgery [3–5]. In a prospective study conducted for us, of 310 patients who had undergone gastrointestinal and abdominal operations with double ring auto-retractors (116 colorectal resections, 100 appendectomies, 69 open cholecystectomies, 11 gastric resections, and 14 laparotomies), only two operative wound infections occurred.

Along the same lines as discussed in the article, we would like to add an idea that is not described in this article. To our understanding, double ring retractors are the most promising line of research for the reduction of surgical wound infections after gastrointestinal surgical procedures. We are referring to the use of the self-retractors–double ring.

Although we agree with the article by Itani et al., we propose addressing measures aimed at physically avoiding bacterial inoculation in the tissues of the operative wound or to use mechanisms that seriously hinder the production of the inoculum for the prevention of surgical wound infections in all abdominal surgical procedures as a future line of research.