Can delayed primary wound closure decrease incidence of wound infection after appendectomy in patients with perforated appendicitis?

Acute appendicitis is a common indication for emergency abdominal surgery. An appendectomy with an open right lower quadrant incision is the “gold standard” of treatment for acute appendicitis. After an appendectomy procedure is completed, wound infection is the most common morbidity, and it may result in increased patient pain, longer hospital stay, poor cosmesis, and overall higher costs of treatment. Two routinely used methods of wound management following an appendectomy are delayed primary closure (DPC), which involves packing an open wound for 4w5 days followed by wound closure, and primary closure (PC). For patients with simple appendicitis, the incision was usually primarily closed, and the wound infection rate is usually below 5%. However, some 20%w30% of appendicitis patients had appendiceal perforation upon admission. Perforated appendicitis without a palpable mass can be treated during emergency surgery either laparoscopically or via an open incision. It is well accepted that, once appendiceal perforation occurs, complication rates increase with wound infection and can rise to 15%e25%. Traditionally, in an effort to decrease the risk of infection at the surgical site, patient wounds associated with perforated appendicitis have been managed with DPC. However, no single large randomized trial proved the benefit of DPC in reducing the wound infection rate in patients following an appendectomy. By contrast, clinical trials in the 1990s reported low rates of infection using PC in patients with perforated appendicitis. Recent studies employing metaanalyses indicated that PC does not increase the risk of wound infection after appendectomy for complicated appendicitis. Primary closure has the potential benefit of rapid wound healing associated with the elimination of painful and time-consuming dressing changes, as well as a reduction in overall hospital costs. Although controversy persisted concerning the optimal methods of wound management, recent studies tend to recommend that perforated appendicitis most often can be primarily closed without an increase in the wound infection rate as compared to DPC. In the recent issue of the Journal, Chiang and colleagues reported the results of a prospective clinical trial addressing the question about the use of DPC to prevent wound infection after appendectomy for perforated appendicitis. In the entire series, no patient received laparoscopic appendectomy. Fifteen