Shinshu Med J, 63⑵ :91〜101, 2015

Eﬀect of Application of Subcutaneous Suction Drainage with
Subcuticular Sutures for Wound Closure on the Incidence of Incisional
Surgical Site Infection following Elective General Abdominal Surgery:
A Randomized Controlled Trial
Akira SHIMIZU , Akira KOBAYASHI , Naohiko KOIDE , Akira SUZUKI
Daisuke TAKEUCHI , Takahide YOKOYAMA , Hiroaki M OTOYAMANorihiko FURUSAWA , Teruomi TSUKAHARA and Shin‑ichi MIYAGAWA
1) First Department of Surgery, Shinshu University School of Medicine
2) Department of Preventive Medicine and Public Health, Shinshu University School of Medicine

Objective:The aim of this trial was to verify whether use of subcutaneous suction drainage with subcuticularsutures for wound closure might decrease the incidence of incisional surgical site infection (SSI)after generalabdominal surgery.
Summary Background Data :The ideal method for wound closure following general abdominal surgery has
not been established yet.
Methods:Patients were randomly assigned to receive either subcutaneous drainage with subcuticular sutures(drainage group)or subcutaneous sutures with skin stapling (control group). The primary end point was theincidence of incisional SSI within 30 days after surgery. This trial is registered with UMIN‑CTR, number
UMIN000003073.
Results:A total of 160 patients were randomlyassigned to the drainage group (n＝81)or the control group (n＝79). Incisional SSI was observed in 12 patients (14.8%)in the drainage group, and 15 patients (19.2%)in thecontrol group, with no signiﬁcant diﬀerence between the two groups (P ＝0.459). Subgroup analyses showedthat the drainage method signiﬁcantly reduced the incidence of SSIs in patients with diabetes mellitus (P ＝0.048)and/or a subcutaneous fat pad thickness of

2.3 cm (P ＝0.043).

Conclusion :Application of the subcutaneous drainage with subcuticular suture method for wound closure was
not associated with any signiﬁcant decrease in the incidence of incisional SSIs as compared to that of theconventional method. However, the drainage method might be beneﬁcial for reducing the risk of SSIs inpatients with diabetes mellitus and/or a subcutaneous fat pad thickness of

2.3 cm. Shinshu Med J 63 :91―101, 2015
(Received for publication September 30, 2014;accepted in revised form December 9, 2014)
Key words:subcutaneous drainage with subcuticular sutures, surgical site infection,
general abdominal surgery, randomized open‑label trial

Introduction
Surgical site infection (SSI) is a common andCorresponding author:Akira Kobayashi
First Department of Surgery, Shinshu University Schoolof M edicine, 3‑1‑1 Asahi, Matsumoto, Nagano 390‑8621,

serious complication encountered after surgery ,with reported incidence varying in the range of 5%

Japan

to 30% . Development of SSI is associated with

E‑mail:kbys＠shinshu‑u.ac.jp

prolongation of the length of hospital stay, leading

No. 2, 201591

Shimizu.Kobayashi.Koide et al.

to increased medical costs .Whereas several host‑current study, we tested the hypothesis that use of

related risk factors that cannot be easily modiﬁed

subcutaneous drainage with subcuticular sutures forhave been reported to predispose to the develop-

wound closure can decrease the incidence of in-ment of SSI , some surgical factors may also

cisional SSI as compared to the conventional

inﬂuence the risk

method,i.e.,subcutaneous sutures with skin stapling, allowing room for surgeons to

reﬁne their surgical procedures.

after elective general abdominal surgery.

Surgical textbooks teach that wound closure

M aterials and Methods

after abdominal surgery is performed by subcutaneous interrupted sutures to eliminate any dead space,

Patients

followed by skin suture ,or stapler skin closure forThis was a single‑center, randomized open‑label

accurate approximation . Since the last half of thetrial conducted in Japan.The potential participants

1990s, insertion of a subcutaneous drain, in an

in this trial were patients scheduled to undergo

attempt to decrease the subcutaneous dead space byelective clean‑contaminated surgery, i.e., gastro-drainage of blood and serous ﬂuids before the estab-

intestinal surgery or hepatobiliary‑pancreatic sur-lishment of infection, has been reported to begery with bilioenteric reconstruction for somebeneﬁcial to reduce the incidence of incisional SSI in

benign or malignant diseases at Shinshu University

obstetric/gynecologic surgery, colorectal sur-

Hospital. The inclusion criteria were:age between

gery , and liver surgery . Although randomized

20 and 80 years and American Society of Anesth-

trials to verifyits eﬀect on the risk of SSI have been

esiologists score between 1 and 3. The exclusion

extensively conducted in the ﬁeld of obstetric/

criteria were:cases requiring emergency operation,

gynecologic surgery,few studies conforming tothose scheduled to undergo laparoscopic surgery,the CONSORT statement on its eﬀect have beenthose requiring an identical skin incision to that forreported in relation to general abdominal surgery .

a previous abdominal surgery, those with un-

In general abdominal surgery, Fujii et al.

andcontrolled diabetes mellitus,and those with a previ-

reported the eﬀectiveness of subcu-

ous ileostomyor colostomy.The studyprotocol wastaneous drainage on reducing incisional SSI, but

approved by the institutional review board of thethese studies were retrospective. Kaya et al.

per-

Shinshu University School of Medicine.An English‑

formed a randomized controlled trial, but theylanguage summary of the protocol was submitted

failed to conﬁrm the eﬀectiveness of the subcutane-(registration ID : UMIN000003073) to the Clinicalous drainage method for preventing incisional SSI.

Trials Registrymanaged bythe UniversityHospital

Brieﬂy,the subcutaneous drainage method has been

M edical Information Network (UMIN) in Japan,

considered to useful for preventing wound infection,

which can be accessed commission‑free on the

but no randomized controlled trial demonstrates its

internet (available at :http ://www.umin.ac.jp/ctr/

eﬀectiveness in general abdominal surgery. Afterindex.htm).Written informed consent was obtained

elective general abdominal surgery, we use thefrom all the participants.

Tsujita et al.

conventional wound closure method, that is, subcu-

Randomization and masking

taneous sutures with skin stapling, and our in-

The participants were randomlyassigned (1:1)tocisional SSI rate is around 20%.To further reduce

receive either subcutaneous suction drainage com-this rate with a step‑by‑step approach, we decided

bined with subcuticular sutures (drainage group)or

to investigate the results of a newly introduced

subcutaneous sutures with skin stapling (control

method, namely, subcutaneous drainage with sub-group) for wound closure. The assignment was

cuticular sutures,as compared to that of the conven-generated by an internet‑accessed randomization

tional wound closure technique.This was the reason

system supported by the Internet Data and Informa-

we designed this randomized controlled trial.In thetion Center for Medical Research in the UMIN.The

92

Shinshu Med J Vol.63

The ideal method for wound closure

randomization was performed by the minimization

with a sterile ruler at the point of maximum thick-procedure taking into account the following

ness in the incision. The wounds were protectedstratiﬁcation factors: presence or absence ofwith a sterile dressing for 48 hours.

diabetes mellitus (DM ) requiring medication, bodymass index (BMI ＜25 or

SSI was deﬁned according to the criteria of the

25 kg/m ), and theCenters for Disease Control and Prevention .Infec-

scheduled operative procedure (with or withouttion control personnel monitored the development

colostomy). The surgeons employed the assignedof SSI during the patientʼs hospital stay.The princi-

treatment, which was notiﬁed to them just before

pal surgeons evaluated the presence or absence of

the abdominal closure. The patients and the princi-

SSI during the patientʼs hospital stay and at thepal surgeons,who were the outcome assessors,werefollow‑up visit on the 30th postoperative day in

not masked to the technique used in this trial.

patients discharged within one month after surgery.

Procedure

Statistical analysis

In the control group,the subcutaneous tissue and

The primary end point was the incidence ofskin were closed with interrupted sutures using

superﬁcial or deep incisional SSI within 30 days

absorbable monoﬁlament suture material (PDS‑II

after surgery. The secondary end points were the

USP 2‑0;Ethicon.Inc.,Somerville,NJ,USA),and a

postoperative length of hospital stay and postoper-

skin stapler (HOGY skin stapler;Covidien,Dublin,

ative hospital cost.

Ireland),respectively.The timing of staple removal
was postoperative day 7.

A preliminary study in 33 patients undergoing
conventional wound closure following gastrointesti-

In the drainage group, a subcutaneous suction

nal surgery showed that the incidence of incisional

drainage system (10Fr BLAKE Silicon drain ;Eth-SSI was 21%. Farnell et al. reported a woundicon. Inc., Somerville, NJ, USA) was placed andinfection rate of 4.4% in patients treated by subcu-

brought out through a separate stab wound incision.

taneous catheter drainage with subcuticular sutures

The wounds were then closed with interrupted sub-for wound closure following clean‑contaminatedcuticular sutures using absorbable monoﬁlament

operation . Taking these results into considera-

suture material (PDS‑II USP 4‑0; Ethicon. Inc.,tion,we hypothesized that the application of subcu-

Somerville, NJ, USA). All knots were buried in thetaneous drainage combined with subcuticular

wound. The subcutaneous drains were removed, insutures for wound closure,as compared to subcuta-

principle, on postoperative day 3.

neous sutures and skin stapling, may decrease theCefmetazole was administered intravenously at aincidence of incisional SSI by 15%, that is, fromdose of 1 g 30 min before the initial skin incision,

20% to 5%. The sample size required to detect aand repeated every 8 hours during surgery, andstatistically signiﬁcant diﬀerence by the two‑tailed

additional antibiotics at a dose of 1 g per 12 h weretest with a type I error of 5% and statistical power

administered for 3 days after operation. Forof 80% was 76 patients per group,i.e.,a total of 152

patients undergoing preoperative biliary drainage

patients. Taking into account a potential dropout

and showing positive results of bile culture, therate of 5%, we set the target number of study

antimicrobial agent was selected according to thesubjects at 160. The projected accrual period wasresults of the bile culture.The skin of the abdomen

three years,and no interim analysis was performed.

was prepared with a povidone‑iodine solution.After

We used the χ test for analysis of the primaryclosure of the fascia with interrupted absorbableendpoint and the M ann‑Whitney U test for analysis

sutures of PDS‑II USP 1 (Ethicon.Inc.,Somerville,of secondary endpoints.The background character-

NJ,USA),the surgical incisions were irrigated with

istics and surgical outcomes in the two groups were

500 ml of saline solution. The depth of the subcuta-

compared using theχ test or Fisherʼs exact test forneous fat was measured from the fascia to the skin

categorical data and the t test or M ann‑Whitney U

No. 2, 201593

Shimizu.Kobayashi.Koide et al.
Assessed for eligibility (n＝364)
Excluded (n＝204)
Not meeting inclusion criteria (n＝108)
Declined to participate (n＝96)
Randomized (n＝160)

Allocated to subcutaneous drainage(drainage group)(n＝81)

Allocated to subcutaneous suture(control group)(n＝79)

Received allocated intervention (n＝81)

Received allocated intervention (n＝78)

Did not receive allocated intervention (n＝0)

Did not receive allocated intervention(declined to participate)(n＝1)

Lost to follow‑up (n＝0)
Discontinued intervention (n＝0)

Lost to follow‑up (n＝0)
Discontinued intervention (n＝0)

Analysed (n＝81)
Excluded from analysis (n＝0)

Analysed (n＝78)
Excluded from analysis (n＝0)
Fig. 1 Study ﬂow diagram

test for continuous data.We conducted multivariate

364 patients underwent elective gastrointestinal or

logistic regression analysis to assess risk factors

hepatobiliary‑pancreatic surgery at our Hospital.

associated with the occurrence of SSI.Variables toOf these, 96 patients declined to participate in thisbe entered into the regression analysis were chosen

trial,and 108 patients were excluded because of theon the basis of the results of the univariate analysis

following reasons: scheduled to undergo laparos-(P ＜0.10)and consistency with the results of previ-

copic surgery(n＝65),requiring identical incision toous studies .

that for previous abdominal surgery (n＝34), andSubgroup analyses of the odds ratios were perfor-

presence of previous ileostomy or colostomy(n＝9).

med after stratifying the patients by their gender,

The remaining 160 patients in the intention‑to‑treat

age, BM I, presence/absence of DM , presence/

population were randomized to either the drainage

absence of a history of smoking, presence/absencegroup (n＝81) or the control group (n＝79). Oneof a history of alcohol drinking, serum albumin

patient who was assigned to the control grouplevel, operative time, and thickness of the subcuta-

declined to be in the trial after the randomization.

neous fat pad. The median values were selected as

Finally,159 patients were included for the follow‑up

the cutoﬀvalues for the continuous data,except forassessment and their data were analyzed.The trial

the patientsʼage (＜60, 60‑70, or

protocol is shown in Fig.1.The patient characteris-

70 years).

All analyses were performed on an intention‑to‑treat basis. Statistical signiﬁcance was deﬁned as
P ＜0.05. All analyses were performed using PASW
Statistics 18 (SPSS, Chicago, IL).
Results
From April 2010 until November 2012, a total of94

tics and surgical outcomes (Table 1) were similar
between the 2 groups.
The overall incidence of incisional SSI was 16.9 %in this trial. The incidence of incisional SSI was
14.8% (95% conﬁdence interval (CI) 8.5‑24.3%) in
the drainage group, as compared to 19.2% (11.9 ‑
29.5%) in the control group, with no signiﬁcantShinshu Med J Vol.63

The ideal method for wound closure

Table 1 Patientsʼcharacteristics and surgical outcomes
Drainage (n＝81)

Characteristics
Age (y)Gender (male)Body‑mass index (kg/m )67 (57‑63)
57 (70.4)
21.8 (20.5‑24.0)

Control (n＝78)
68 (62‑72)
50 (64.1)
22.5 (20.2‑24.2)

ASA score
1
2
3
Diabetes mellitus
Smoking history
Alcohol history
Preoperative steroid use
Serum albumin (g/dL)
HbA1c (%)
Indication for operation
M alignant tumor
Benign tumor
Inﬂammatory bowel disease
OthersOperation
Gastrointestinal surgery＋hepatectomy

44 (54.3)
35 (43.2)

37 (47.4)
38 (48.7)

2 (2.5)16 (19.8)
50 (61.7)
41 (50.6)
3 (3.7)3.8 (3.5‑4.2)
5.9 (5.6‑6.2)

3 (3.9)15 (19.2)
48 (61.5)
36 (46.2)
2 (2.6)
3.8 (3.5‑4.1)
5.9 (5.6‑6.5)

75 (92.6)
4 (4.9)74 (94.9)
1 (1.3)

1 (1.2)
1 (1.2)0 (0)3 (3.9)35 (44.9)
1 (1.3)18 (23.1)
8 (10.3)0 (0)9 (11.1)
1 (1.2)7 (8.6)13 (16.7)
3 (3.9)5 (6.4)67 (82.7)

53 (67.9)

10 (12.3)
2 (2.5)2 (2.5)342 (268‑422)
230 (100‑415)

16 (20.5)
7 (9.0)2 (2.6)353 (280‑565)
250 (148‑530)

Perioperative packed red blood cell transfusion
Antimicrobial prophylaxis
Cefmetazole
Sulbactam/cefoperazone
Imipenem/cilastatin

11 (13.6)

16 (20.5)

77 (95.1)
2 (2.5)0 (0)68 (87.2)
1 (1.3)3 (3.9)OthersThickness of subcutaneous fat (cm)

2 (2.5)2.4 (2.0‑3.0)

6 (7.7)2.2 (1.6‑3.0)＋hepatectomy＋gynecological surgery
Hepatectomy＋bilioentelic anastomosis
Pancreatoduodenectomy
Colostomy
Type of incision
M idline
J‑shaped
M idline＋transverse
OthersOperative time (min)Blood loss (ml)

0.347
0.400
0.652
0.657

0.934
0.980
0.573
1.000
0.999
0.836
0.238

0.313
41 (50.6)
1 (1.2)24 (29.6)
4 (4.9)1 (1.2)

Colorectal surgery

P value

0.425
0.125

0.142
0.226
0.245
0.120

0.647

ASA, American Society of Anesthesiologistsʼrisk class.
Data are shown as number of patients (percentage)or median (interquartile range).

No. 2, 201595

Shimizu.Kobayashi.Koide et al.
Table 2 Results of the primary and secondary endpoints and other postoperative outcomes
Outcome

Drainage (n＝81)

Control (n＝78)

P value

12 (14.8)
10 (12.3)

15 (19.2)
14 (18.0)

0.459

2 (2.5)

1 (1.3)

Primary endpoint
Incisional surgical site infection
Superﬁcial
Deep
Secondary endpoints
Postoperative hospital stay, days
Postoperative hospital cost, $Other postoperative outcomes
Organ/space surgical site infection

21 (16‑25)
14852 (12032‑16930)

20 (16‑28)
15326 (12736‑21045)

0.728
0.087

4 (4.9)7 (9.0)0.316

Postoperative morbidity
Clavien‑Dindo classiﬁcation
Grade V
Grade IV

27 (33.3)

28 (35.9)

0.734
0.517

0 (0)
0 (0)

0 (0)
0 (0)

Grade III
Grade II
Grade I
Additional antibiotics use

4 (4.9)4 (4.9)11 (13.6)
14 (17.3)

2 (2.6)7 (9.0)13 (16.7)
13 (16.7)

0.918

Data are shown as number of patients (percentage)or median (interquartile range).
Analysis comparing Grade II and Grade III.

diﬀerence between the groups (P ＝0.459) (Table 2).

to conﬁrm the superiorityof the subcutaneous drain-

The median postoperative length of hospital stay,

age with subcuticular suture method over the subcu-

the median postoperative hospital costs, and othertaneous suture with skin stapling method, a result

operative outcomes were comparable between thethat was in line with previous reports

groups (Table 2).

retrospective studies have reported the eﬀectiveness. A few

The multivariate analysis failed to identify anyof subcutaneous drain placement for preventing

variables signiﬁcantly associated with the develop-

incisional SSI in general abdominal surgery. It isment of postoperative incisional SSI,however,therediﬃcult to clearly deﬁne the reasons for the discrep-

was a tendency toward a higher risk of incisionalancy in the results between our trial and the previ-

SSI in patients with DM than in those without

ous studies, but the following may be considered.

(adjusted odds ratio 2.581, 0.945‑7.051, P ＝0.064)

The participants in our trial diﬀered from those in(Table 3).

previous studies. The potential participants in our

Subgroup analyses showed that the drainage

study included those scheduled to undergo elective

method signiﬁcantly reduced the incidence of SSIs

hepatobiliary‑pancreatic surgery with bilioentericin patients with DM (OR : 0.163, 95% CI : 0.027‑

reconstruction (23.9 % of all cases).Previous studies

0.983, P ＝0.048) and/or a subcutaneous fat pad

included only patients receiving colorectal sur-

2.3 cm (0.321, 0.107‑0.964, P ＝0.043)

gery , or hepatectomy , with a shorter operative

thickness of(Fig. 2).

time than in our study.
Discussion

The aim of this trial was to clarify the eﬀect of

The reported incidence of incisional SSI varies
widely according to the type of operation :around
5% for gastric cancer surgery, 10‑26% for

the application of subcutaneous suction drainage

colorectal surgery, and 14‑16% for generalwith the subcuticular suture method for woundabdominal surgery. The overall incidence ofclosure on reducing the incidence of incisional SSI

incisional SSI of 16.9 % in this trial was comparable

after general abdominal surgery .This trial failed

to previously reported ﬁgures96. Surprisingly, we

Shinshu Med J Vol.63

The ideal method for wound closure
Table 3 M ultivariate analysis of risk factors for incisional surgical site infection
Variables
Wound closure method
DrainageControl
GenderM ale
Female
Age
70
60‑69
＜60
Body‑mass index
25 kg/m＜25 kg/m
Diabetes mellitus
Present
AbsentSmoking history
Present
AbsentAlcohol history
Present
AbsentSerum albumin＞3.5 g/dl
3.5 g/dl
Operative time
6h
＜6 h
Thickness of subcutaneous fat
2.3 cm＜2.3 cmn

Odds ratio (95% CI)

P value Adjusted odds ratio (95% CI) P value

8178

0.703 (0.318‑1.679)
1

0.460

0.657 (0.269 ‑1.603)
1

0.356

107
52

0.966 (0.401‑2.327)
1

0.939

0.685 (0.173‑2.715)
1

0.590

61
55
43

0.660 (0.227‑1.923)
1.094 (0.397‑3.012)
1

0.447
0.862

0.547 (0.168‑1.787)
0.906 (0.302‑2.712)
1

0.248
0.860

26
133

2.082 (0.775‑5.593)
1

0.146

1.720 (0.559 ‑5.289)
1

0.344

31
128

2.500 (0.994‑6.285)
1

0.051

2.581 (0.945‑7.051)
1

0.064

98
61

1.300 (0.543‑3.112)
1

0.556

1.133 (0.296‑4.335)
1

0.856

77
82

1.179 (0.515‑2.701)
1

0.696

1.393 (0.464‑4.181)
1

0.554

109
50

1.380 (0.542‑3.515)
1

0.499

1.224 (0.449 ‑3.342)
1

0.693

77
82

1.411 (0.614‑3.245)
1

0.417

1.219 (0.495‑3.002)
1

0.667

82
77

2.125 (0.890‑5.072)
1

0.089

1.647 (0.616‑4.402)
1

0.320

95%CI, 95% conﬁdence interval.
Adjusted for wound closure method,gender,age,body‑mass index,diabetes mellitus,smoking history,alcohol history,
serum albumin, operative time, or thickness of subcutaneous fat.

observed a higher‑than‑expected rate (14.8%) ofthan ours (14.8%). However, there were several

incisional SSI in the patients in whom the subcuta-

divergent elements between these studies. The

neous drainage with subcuticular suture methodpatientsʼcharacteristics in their study showed a

was used for wound closure,which was comparable

younger (54 vs 67 years old)and lower rate of malewith some previously reported rates, butpatients (51% vs 70%), a shorter operation timereported a(within 4 hours in 96% of all patients vs 19 %),and

lower incidence of incisional SSI in their study.

a shorter duration of preoperative hospital stay(2.9However, their trial design and type of subcutane-vs 7.9 days), compared to our study. All these fac-ous drain were diﬀerent from those in our study,sotors have been recognized as risk factors for in-

it is diﬃcult to compare the results of their study

cisional SSI , and that was considered to be thedirectly to ours.Kaya et al. also reported a lower

reason for the discrepancy in the results between

incidence of incisional SSI of subcutaneous drainage

our trial and the previous study.

higher than others. Farnell et al.

group in their randomized controlled trial (5.7%)
No. 2, 2015

Previous studies have documented the following
97

Shimizu.Kobayashi.Koide et al.

Fig. 2 Subgroup analyses

as risk factors for SSI : obesity, weight loss ,infected bile has been suggested to be associatedpresence of DM , packed red blood cell transfu-

with an increased rate of postoperative infectious

sion ,and operation time .Consistent with these,

complications .

the multivariate analysis in this study identiﬁed a

The strengths of this study include the random-tendency toward a higher risk of incisional SSI inized design, high participant retention rate for 2.5

patients with DM than in those without, although

years and zero loss to follow‑up rate with system-

the diﬀerence did not reach statistical signiﬁcance.

atic assessment of the incidence of SSI. However,

The subgroup analyses showed that the investigated

our study had several limitations.First,the diseasemethod for wound closure (subcutaneous suction

distribution in the participants in the trial was

drainage with subcuticular sutures) was associatedheterogeneous;inclusion of diﬀerent surgical proce-with a marginal reduction in the incidence of SSIs indures might have treated a risk of overlooking thepatients with the aforementioned risk factors,suchbeneﬁcial eﬀect of the trial method. Secondly, un‑

as DM and/or a subcutaneous fat pad thickness ofmasked assessment of the primary endpoint could

2.3 cm, suggesting the potential beneﬁts of adopt-have impaired the internal validity. In the present

ing this method in such patient subgroups.

trial, the diagnosis of SSI was made under the

In the present study, cefmetazole was themonitoring of the infection control personnel, how-predetermined prophylactic antibiotic for all

ever it was diﬃcult to mask the assigned method forenrolled patients, except for those undergoing

the outcome assessors, because the staples used in

preoperative biliary drainage and showing positive

the control group could be easily identiﬁed.Thirdly,

results of bile culture, for whom the antimicrobial

despite our best eﬀorts to obtain relevant data toagent was selected according to the results of thecalculate sample size during the study design phase,bile culture. Routine administration of cefmetazole

our trial might have been underpowered to detectfor such patients would be ethically unacceptablediﬀerences in the primary endpoint.

because contamination of the operative ﬁeld by
98

In our study, subgroup analysis showed that subShinshu Med J Vol.63

The ideal method for wound closure

cutaneous drainage reduced the incidence of incisional SSIs in patients with DM and/or a subcutaneous fat pad thickness ofdrainage for preventing incisional SSI.
In conclusion, application of subcutaneous drain-

2.3 cm. DM is consid-

age with the subcuticular suture method for woundered a risk factor for SSI because of protracted

closure was not associated with any signiﬁcantwound healing and increased susceptibility to infec-

decrease in the incidence of incisional SSIs astion. Obesity also has traditionally been considered

compared to that of conventional subcutaneous. It is a well‑suture with the skin stapling method.However,theknown fact that wounds with large areas of deadresults of subgroup analyses suggested that the

space remain hypoxic and heal poorly,therefore thedrainage method might be beneﬁcial for reducing

greater the subcutaneous fat thickness, the greater

the risk of SSIs in patients with DM and/or a

the ischemic insult. Subcutaneous drainage cansubcutaneous fat pad thickness ofa risk factor for incisional SSI

decrease the subcutaneous dead space by drainage

2.3 cm.

Acknowledgmentsof blood and serous ﬂuids before the establishmentof infection, which leads to a reduced risk of in-

The authors thank Drs. Hiroshi Sakai, Noriyuki

cisional SSI.Fujii et al. reported that the subcuta-

Kitagawa,Tsuyoshi Notake,Kenta Yokoi,Kentaro

neous drain is eﬀective for preventing incisional SSI

Fukushima, Yasushi Sekino, Hiroaki Ogiwara,

in patients with thick subcutaneous fat in colorectal

Shigeo Tokumaru,and M asahiro Okumura for theirsurgery in their retrospective study. So, anotherhelp in this study.

randomized trial including only participants who

Conﬂict of Interest

have risk factors for incisional SSI, such as thosewith DM and/or a thick subcutaneous fat pad,may
demonstrate the eﬀectiveness of subcutaneous

The authors declare that they have no conﬂict ofinterest.

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