Perioperative Wound Management and Infection Prevention in Abdominal Surgery: A Systematic Review and Meta-Analysis

Summary

Perioperative wound management and surgical site infection prevention strategies may reduce surgical site infection after abdominal surgery. This review reclassifies interventions by clinical mechanism, emphasizes the synthesis of verified event counts, and separates clinical findings from unsupported mechanistic interpretations.

Abstract

This study evaluated perioperative incisional wound management and surgical site infection (SSI) prevention interventions on wound-related outcomes after abdominal surgery. Following PRISMA 2020 guidance, PubMed, Embase, Web of Science, and Cochrane CENTRAL were searched for comparative studies published from January 2023 to March 2026. Eligible studies enrolled adults undergoing abdominal surgery and compared an incisional wound management or SSI prevention intervention with routine care, standard dressing, saline, placebo, preimplementation care, or another active comparator. Interventions were reclassified by dominant clinical mechanism as antiseptic or antimicrobial preparation, wound irrigation, closed incision negative pressure wound therapy, physical wound protection, or multimodal SSI prevention bundles. Nineteen comparative studies were included. After re-extraction of study-level event data, 18 studies with extractable denominators contributed to the SSI meta-analysis; the pooled random-effects risk ratio (RR) was 0.72 (95% confidence interval (CI), 0.58–0.90; p = 0.003; I² = 64%). Wound dehiscence, delayed healing, seroma, hospital stay, scar quality, pain, and quality-of-life outcomes were summarized narratively because definitions, scales, or event counts were not sufficiently comparable for reliable pooling. The available evidence suggests that perioperative wound management interventions may reduce SSI after abdominal surgery, but substantial clinical and methodological heterogeneity limits the certainty and generalizability of pooled estimates. Mechanistic explanations should be interpreted as hypothesis-generating unless directly supported by mechanistic measurements in the included studies.

Introduction

Abdominal surgery remains associated with clinically important incisional complications, including SSI, wound dehiscence, delayed healing, seroma, pain, readmission, and prolonged hospital stay^1,2,3. These complications increase patient burden and health-care costs and remain relevant even when operative technique, antimicrobial prophylaxis, and perioperative care pathways are optimized⁴. Therefore, improving incisional wound outcomes remains an important component of postoperative recovery after abdominal surgery.

Incisional healing is influenced by microbial contamination, tissue perfusion, local exudate, closure tension, patient comorbidity, nutritional status, glycemic control, and the normal inflammatory phase of tissue repair^5,6,7,8. Inflammation is necessary for early wound repair, but excessive or prolonged inflammatory activation may contribute to edema, tissue injury, impaired collagen organization, and delayed transition into proliferative and remodeling phases^5,6,7,8. However, many perioperative interventions used to improve abdominal incision outcomes do not act primarily as direct anti-inflammatory therapies.

For example, alcoholic povidone-iodine and chlorhexidine preparations primarily reduce skin microbial burden; wound irrigation removes debris and may reduce wound contamination; closed incision negative pressure wound therapy controls exudate and protects the closed incision; wound protectors reduce intraoperative contamination exposure; and perioperative prevention bundles combine several process measures directed at SSI reduction^{9,10,11,12,13,14,15,16,17}. These strategies may influence the inflammatory wound environment indirectly, but their primary clinical mechanisms are antiseptic, mechanical, contamination-reduction, or implementation-related rather than direct pharmacological modulation of inflammatory pathways.

For this reason, this review reframes the research question from a broad anti-inflammatory premise to a more clinically precise question: whether perioperative incisional wound management and SSI prevention interventions improve wound healing after abdominal surgery. Compared with alternative perioperative approaches such as systemic antibiotic prophylaxis, enhanced recovery protocols, glycemic control, nutritional optimization, and standardized closure technique, the reviewed interventions are focused on the incision and can often be applied at specific procedural time points: before incision for skin antisepsis, during closure for irrigation or wound protection, immediately after closure for closed incision negative pressure therapy, or throughout the perioperative pathway for SSI prevention bundles^{2,3,4,9,10,11,12,13,14,15,16,17}.

This systematic review and meta-analysis, therefore, aimed to synthesize recent comparative evidence on perioperative incisional wound management and SSI prevention interventions in adults undergoing abdominal surgery, while clearly separating clinical outcome data from mechanistic interpretation.

Protocol

Compliance statement

This study was a systematic review and meta-analysis of previously published studies. No new human participants were recruited, no individual patient data were collected, and institutional ethics approval and informed consent were not required. The protocol was not prospectively registered; this limitation is acknowledged in the interpretation of the findings. All the materials and tools used in this study are listed in the Table of Materials.

Study design and literature search

A systematic review and meta-analysis were conducted in accordance with PRISMA 2020 guidance¹. Before screening, eligibility criteria were defined using the PICOS framework. The population consisted of adults undergoing abdominal surgery. Eligible interventions were perioperative incisional wound management or SSI prevention strategies, including antiseptic skin preparation, intraoperative wound irrigation, closed incision negative pressure wound therapy, wound protectors, antimicrobial or antiseptic wound-related measures, and multimodal prevention bundles. Comparators included routine care, placebo, saline, standard dressing, non-antimicrobial materials, preimplementation usual care, or another active comparator. Outcomes included SSI, superficial or deep incisional SSI, wound dehiscence, delayed healing, seroma, wound-related readmission, reoperation, length of hospital stay, pain, scar quality, and quality of life.

PubMed, Embase, Web of Science, and Cochrane CENTRAL were searched from January 1, 2023, to March 14, 2026. For each database, the platform, exact search date, complete search string, and number of records retrieved were recorded. The search combined abdominal surgery terms, wound-healing or SSI terms, and intervention terms such as chlorhexidine, povidone-iodine, wound irrigation, negative-pressure wound therapy, wound protector, and prevention bundle. The full reproducible search strategy is provided in Table 1. All retrieved records were imported into a reference manager or systematic review screening tool. Automatic duplicate removal was followed by manual comparison of author names, titles, years, trial acronyms, registry numbers, and sample sizes. Two reviewers independently screened titles and abstracts, retrieved the full texts of potentially eligible studies, and assessed them independently. Disagreements were resolved through discussion or consultation with a third reviewer. One primary exclusion reason was recorded for each excluded full-text article.

Eligibility criteria and data extraction

Eligible studies were required to include adult patients undergoing abdominal surgery, evaluate at least one perioperative incisional wound management or SSI prevention intervention, include a comparator group, and report at least one wound-related clinical outcome. Randomized controlled trials, cluster-randomized trials, pragmatic trials, prospective comparative studies, retrospective comparative studies, and before-and-after implementation studies were eligible. Animal experiments, in vitro studies, reviews, meta-analyses, editorials, letters, case reports, conference abstracts without extractable data, studies without a comparator, non-abdominal surgery studies, and duplicate or overlapping reports were excluded.

Two reviewers independently extracted data using a predefined extraction form. Extracted items included author, year, country, study design, setting, sample size, surgical population, intervention category, intervention details, comparator details, follow-up duration, outcome definition, number of events, and total participants for dichotomous outcomes, mean, standard deviation, and sample size for continuous outcomes, adjusted effect estimates when reported, funding, conflicts of interest, and risk of bias notes.

For missing or unclear data, supplementary materials, appendices, trial registries, and published protocols were checked first. If data remained unavailable, the corresponding author was contacted. If no response was obtained, the outcome was marked as not extractable and was not imputed unless a prespecified imputation rule was applicable. Duplicate reports from the same cohort were handled by retaining the report with the largest sample size, most complete wound outcome reporting, or most relevant follow-up.

Quality assessment and statistical analysis

Risk of bias was assessed independently by two reviewers. Randomized trials were assessed using the Cochrane Risk of Bias 2 tool, including randomization process, deviations from intended interventions, missing outcome data, outcome measurement, and selection of reported results. Cluster randomized and crossover trials were assessed using the corresponding RoB 2 extensions. Non-randomized comparative studies were assessed using ROBINS I or the Newcastle Ottawa Scale, with attention to confounding, participant selection, intervention classification, deviations from intended interventions, missing data, outcome measurement, and selective reporting. Domain-level judgments were recorded for each study.

For short-term dichotomous wound outcomes, risk ratios (RRs) with 95% confidence intervals (CIs) were used as the primary effect measure. Hazard ratios were not used for binary SSI or wound-complication outcomes unless the original study reported time-to-event data and the outcome was analyzed as time to event. For continuous outcomes, mean differences (MDs) were used when measurement scales were identical, and standardized mean differences (SMDs) were used when scales differed. Random-effects models were used as the primary approach because the included interventions, surgical populations, comparators, and outcome definitions were clinically heterogeneous.

Heterogeneity was assessed using Cochran's Q test and the I² statistic. Subgroup analyses were planned by intervention category, surgical population, study design, comparator type, and primary outcome when at least two studies were available per subgroup. Sensitivity analyses were planned by excluding non-randomized studies, studies at high risk of bias, and active-comparator trials. Funnel plots and Egger's test were used only when at least 10 studies contributed to an outcome; otherwise, publication-bias testing was considered statistically unreliable. Mechanistic synthesis was conducted only for studies directly reporting inflammatory markers, microbial contamination, perfusion, exudate, collagen remodeling, oxidative stress, or other biological endpoints. Mechanistic explanations were not inferred from SSI reduction alone.

Results

Relevant records were identified through PubMed, Embase, Web of Science, and Cochrane CENTRAL. After de-duplication, title and abstract screening, and full text eligibility assessment, 19 comparative studies were included in the quantitative or structured synthesis. The screening process is shown in Figure 1.

The included studies were published within the last three years and included randomized controlled trials, pragmatic trials, prospective comparative studies,...

Discussion

This systematic review and meta-analysis evaluate perioperative incisional wound management and SSI prevention interventions rather than treating all included strategies as direct anti-inflammatory therapies. This distinction addresses the conceptual heterogeneity of the included evidence. Antiseptic skin preparation and wound irrigation primarily target microbial burden or contamination; closed incision negative pressure wound therapy modifies the local closed incision environment by controlling exudate and protecting t...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Cochrane CENTRAL	Cochrane	Database accessed March 14, 2026	Controlled trial search Catalog number or web link: https://www.cochranelibrary.com/central
Embase	Elsevier	Database accessed March 14, 2026	Biomedical literature search Catalog number or web link: https://www.embase.com/
Microsoft Excel	Microsoft	Microsoft 365	Data extraction workbook and tabular summaries Catalog number or web link: https://www.microsoft.com/microsoft-365/excel
Newcastle Ottawa Scale	Ottawa Hospital Research Institute	Current scale	Quality assessment for non randomized studies Catalog number or web link: https://www.ohri.ca/programs/clinical_epidemiology/oxford.asp
PubMed	National Library of Medicine	Database accessed March 14, 2026	Biomedical literature search Catalog number or web link: https://pubmed.ncbi.nlm.nih.gov/
Rayyan	Rayyan Systems Inc.	Web application accessed June 2026	Title and abstract screening support Catalog number or web link: https://www.rayyan.ai/
Review Manager (RevMan)	Cochrane	Version 5.4.1	Meta analysis and forest plot verification Catalog number or web link: https://training.cochrane.org/online-learning/core-software/revman
RoB 2 tool	Cochrane	Version 2	Risk of bias assessment for randomized trials Catalog number or web link: https://www.riskofbias.info/welcome/rob-2-0-tool
ROBINS I tool	Cochrane	2016 tool version	Risk of bias assessment for non randomized studies Catalog number or web link: https://www.riskofbias.info/welcome/home/current-version-of-robins-i
Stata	StataCorp	Version 17.0	Sensitivity analysis and publication bias checks Catalog number or web link: https://www.stata.com/
Web of Science	Clarivate	Database accessed March 14, 2026	Citation indexed literature search Catalog number or web link: https://www.webofscience.com/
Zotero	Corporation for Digital Scholarship	Version 7.0	Reference management and duplicate checking Catalog number or web link: https://www.zotero.org/