The Effects of Post-Operative Interventions on Surgical Site Occurrences in AWR

Study Overview
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Brief Summary
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Randomized controlled trial to compare SSO's in abdominal wall reconstruction patients using Prevena, Prineo, and traditional incisional dressings.

Detailed Description
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Surgical site occurrences (SSOs) are a common complication of complex abdominal wall reconstruction (AWR), with rates ranging from 29-63.6%. Contributors to the high rates include: 1) comorbidities in this patient population such as; obesity, diabetes, smoking, and poor nutrition; 2) the need for complex surgical techniques including component separation, the use of mesh, skin resection, and the creation of adjacent skin flaps; 3) the possibility of contamination as a result of enterotomies or infected mesh from a previous procedure. Any measures that can be taken to reduce the rates of surgical site occurrences are worthy of investigation, as they would help to decrease the morbidity and mortality of these procedures, while also potentially decreasing the overall cost associated with them. One measure of particular interest is what post-operative intervention, or wound dressing, is used. Many options exist. Those widely used include Prevena™, a vacuum assisted therapy that goes directly over the closed incision to assist with closure. This system works by placing a small piece of foam over the closed incision and then applying a vacuum over the foam. This allows the vacuum to apply uniformed pressure over the incision. It is thought that this vacuum creates negative pressure that helps to prevent contamination, hold the incision together, and remove fluid and infectious materials from the incision site. Another commonly used product is Prineo™, a self-adhering mesh that utilizes Dermabond™ glue technology that goes directly over the closed incision to assist with closure. The glue dries quickly over the incision and mesh, creating a barrier that is flexible but also resistant to contamination. While blocking potential contaminants such as water and bacteria from getting in, it allows water vapor to escape, while promoting a moist wound healing environment. There is also the traditional wound dressing which consists of Bacitracin antibiotics on a xeroform gauze, covered with a standard abdominal pad and tape. Prevena™ has been widely studied in plastic surgery, specifically in AWR for large ventral hernias and for other complex abdominal reconstructions and is associated with reductions in SSOs from 22-51%. While there is strong evidence to support the use of Prevena in this patient population, there remains skepticism due to the lack of randomized, prospective studies to support its use. Prineo™ has not been studied as in depth, but multiple studies have shown it to be as efficacious as standard wound dressings in regard to wound healing, if not better. There are currently no published reports comparing the rates of SSOs between these three therapies. This information is important to collect due to their potential abilities to reduce the rates of SSOs. Finding which decreases this rate the most can help guide decision making in our practice and potentially across the world. When a patient with a ventral hernia or an abdominal wall tumor presents to the senior author for evaluation for abdominal wall reconstruction, a full history and physical examination will be performed. Patients who satisfy the study inclusion and exclusion criteria will be offered the opportunity to participate in the study. If they agree to participate, informed consent and HIPAA forms will be filled out and signed. Patients will then be randomized to group A (Prevena™) or group B (Prineo™) or group C (Standard wound dressing) using a random number generator made in Microsoft Excel. They will not be told which group they are in, and only the principal investigator, co-investigators and operating room staff will be aware of which post-operative intervention is being used until after the surgery. The patients will be asked to fill out 1 survey preoperatively: PROMIS Pain Intensity survey They will then undergo surgery and will be followed within one week for wound dressing removal if needed, then at 6 weeks, 3 months, and 1 year and as needed. They will be evaluated for ventral hernia recurrence, bulge, or other SSOs throughout the follow-up period. They will be asked to fill out the PROMIS Pain Intensity survey and POSAS 2.0 survey at 6 weeks, 3 months, and 1 year.

Official Title
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The Effects of Post-Operative Interventions on Surgical Site Occurrences in Abdominal Wall Reconstructions: A Randomized Controlled Trial

Conditions
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Abdomen Hernia

Intervention / Treatment
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* Device: Prevena
* Device: Prineo
* Drug: Traditional


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age > 18 Patients presenting for elective ventral hernia repair Patients deemed to be good surgical candidates, with no active life-threatening cardiac disease, pulmonary disease, renal disease, hematologic disease -Patients who will have a closed incision following the surgery Exclusion Criteria: Known allergy to any material used in any wound treatment (Prevena- Acrylic adhesive or silver, Prineo- Dermabond glue, Standard- Bacitracin, Xeroform, surgical tape) -Active smokers (within the past 4 weeks) presenting for elective hernia repair Patients with active life-threatening cardiac disease, pulmonary disease, renal disease, hematologic disease presenting for elective ventral hernia repair Patients presenting for emergent ventral hernia repair (in the setting of bowel strangulation, necrosis, penetrating trauma) as it will be difficult to consent those patients for the study preoperatively Patients with severe systemic sepsis Patients with frank purulence in the wound -Patients with an open wound following surgery -Patients undergoing a panniculectomy

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Single Group Assignment
Interventional Model Description: Partially blinded prospective, randomized-controlled trial
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Prevena<br>Patients will then be randomized to group A (Prevena™) or group B (Prineo™) or group C (Standard wound dressing) using a random number generator made in Microsoft Excel. They will be made aware of which group they are in after the consent and randomization process, in order for proper post-operative teaching during the pre-operative clinic visit. The principal investigator, co-investigators and operating room staff will be aware of which post-operative intervention is being used on the day of surgery. | Device: Prevena<br>* Incisions will be dressed with closed incisional negative pressure wound therapy<br>|
| Experimental: Prineo<br>Patients will then be randomized to group A (Prevena™) or group B (Prineo™) or group C (Standard wound dressing) using a random number generator made in Microsoft Excel. They will be made aware of which group they are in after the consent and randomization process, in order for proper post-operative teaching during the pre-operative clinic visit. The principal investigator, co-investigators and operating room staff will be aware of which post-operative intervention is being used on the day of surgery. | Device: Prineo<br>* Incisions will be dressed with Prineo<br>|
| Active Comparator: Standard Dressing<br>Patients will then be randomized to group A (Prevena™) or group B (Prineo™) or group C (Standard wound dressing) using a random number generator made in Microsoft Excel. They will be made aware of which group they are in after the consent and randomization process, in order for proper post-operative teaching during the pre-operative clinic visit. The principal investigator, co-investigators and operating room staff will be aware of which post-operative intervention is being used on the day of surgery. | Drug: Traditional<br>* Incisions will be dressed with bacitracin/xeroform<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rate of Infection |  | At 6 weeks postoperatively | 
| Rate of Seroma |  | At 6 weeks postoperatively | 
| Rate of Hematoma |  | At 6 weeks postoperatively | 
| Rate of Dehiscence |  | At 6 weeks postoperatively | 
| Rate of Skin necrosis |  | At 6 weeks postoperatively | 
| Rate of Enterocutaneous fistula |  | At 6 weeks postoperatively | 
| Rate of Mesh infection |  | At 6 weeks postoperatively | 
| Rate of Hernia recurrence |  | At 6 weeks postoperatively | 
| Rate of Bulge |  | At 6 weeks postoperatively | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Average Cost | In USD of postoperative wound care and complications | At 6 weeks postoperatively | 
| Average Cost | In USD of postoperative wound care and complications | At 3 months postoperatively | 
| Average Cost | In USD of postoperative wound care and complications | At 1 year postoperatively | 
| Average pain assessment score: PROMIS Pain Intensity survey | Minimum 3, Maximum 15, higher scores are worse pain/outcomes | At 6 weeks postoperatively | 
| Average pain assessment score: PROMIS Pain Intensity survey | Minimum 3, Maximum 15, higher scores are worse pain/outcomes | At 3 months postoperatively | 
| Average pain assessment score: PROMIS Pain Intensity survey | Minimum 3, Maximum 15, higher scores are worse pain/outcomes | At 1 year postoperatively | 
| Average scar assessment score: POSAS (Patient and Observer Scar) Assessment Scale) 2.0 survey | Provider score: Minimum 7, Maximum 70, higher scores are worse appearance/outcome. Patient score: Minimum 7, Maximum 70, higher scores are worse appearance/outcome. | At 1 year postoperatively | 
| Average scar assessment score: POSAS (Patient and Observer Scar) Assessment Scale) 2.0 survey | Provider score: Minimum 7, Maximum 70, higher scores are worse appearance/outcome. Patient score: Minimum 7, Maximum 70, higher scores are worse appearance/outcome. | At 6 weeks postoperatively | 
| Average scar assessment score: POSAS (Patient and Observer Scar) Assessment Scale) 2.0 survey | Provider score: Minimum 7, Maximum 70, higher scores are worse appearance/outcome. Patient score: Minimum 7, Maximum 70, higher scores are worse appearance/outcome. | At 3 months postoperatively | 
| Rate of infection |  | At 3 months postoperatively | 
| Rate of infection |  | At 1 year postoperatively | 
| Rate of Seroma |  | At 3 months postoperatively | 
| Rate of Seroma |  | At 1 year postoperatively | 
| Rate of Hematoma |  | At 1 year postoperatively | 
| Rate of Hematoma |  | At 3 months postoperatively | 
| Rate of Dehiscence |  | At 3 months postoperatively | 
| Rate of Dehiscence |  | At 1 year postoperatively | 
| Rate of Skin Necrosis |  | At 3 months postoperatively | 
| Rate of Skin Necrosis |  | At 1 year postoperatively | 
| Rate of Enterocutaneous fistula |  | At 3 months postoperatively | 
| Rate of Enterocutaneous fistula |  | At 1 year postoperatively | 
| Rate of Mesh infection |  | At 3 months postoperatively | 
| Rate of Mesh infection |  | At 1 year postoperatively | 
| Rate of Hernia Recurrence |  | At 3 months postoperatively | 
| Rate of Hernia Recurrence |  | At 1 year postoperatively | 
| Rate of Bulge |  | At 3 months postoperatively | 
| Rate of Bulge |  | At 1 year postoperatively | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Infection, seroma, hematoma, skin necrosis, EC fistula, Mesh infection, Hernia recurrence, Bulge, Prevena, Prineo, Abdominal wall reconstruction, SSO, dressings