Superficial Surgical Site Infection in Delayed Primary Vs Primary Wound Closure in Complicated Appendicitis

Superficial Surgical Site Infection in Delayed Primary Vs Primary Wound Closure in Complicated Appendicitis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Superficial Surgical Site Infection in Delayed Primary Vs Primary Wound Closure in Complicated Appendicitis Akash Akash, Neeraj Saxena This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2162413/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract 1.1 Background Wound infection is the most common post-op complication encountered after open appendectomy. Various studies comparing risk of superficial surgical site infection (SSI) in primary closure (PC) and delayed primary closure (DPC) of wound has been conducted in the past. But there is no uniform consensus regarding the method of wound closure. So aim of this study was comparison of the two wound closure techniques. 1.2 Material and Methods This was prospective study which enrolled 50 patients who underwent open appendectomy. Patients’ demographics, characteristics and operative findings were recorded. Those who were elder than 18 years and had appendectomy with a right lower quadrant incision were included. Patients with any comorbidity, morbid obesity and pregnancy were excluded. Patients were randomized to undergo two techniques of wound closure namely PC and DPC. On follow-up at one week and one month, SSI, post-op pain and LOS were compared among two groups. Clinical assessment included a visual analog scale (1-10) for pain. 1.3 Results In our study incidence of SSI in DPC group was significantly lower when compared to PC group (p value=0.0002) while post-op pain and LOS were not significantly different on comparison between the two groups. 1.4 Conclusion We concluded that DPC was superior to PC of wound in terms of reduction of incidence of superficial SSI but with respect to post-op pain and LOS the two techniques of wound closure were not different. Superficial Surgical Site Infection Primary Closure Delayed Primary Closure Complicated Appendicitis Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Acute appendicitis is the most common cause of acute abdomen in adults and appendectomy is one of the most common emergency surgical procedure performed in the world [1]. It is rare in infants and elderly but common in early adult life with male to female ratio of 3:2 [1] . Appendicitis is much less common in underdeveloped countries, suggesting that elements of the Western diet, specifically a low-fiber, high-fat intake, may play a role in the development of the disease process. The gold standard and least controversial treatment of acute uncomplicated as well as complicated appendicitis remains prompt appendectomy [ 2 ] , both the open and laparoscopic approaches are acceptable. The patient may require aggressive resuscitation and intravenous antibiotic (to cover gram-negative bacilli and anaerobic cocci) administration pre-operatively. Post-operatively broad spectrum antibiotics can be continued 7-10 days in accordance to Infectious Disease society of America (IDSA) guidelines [ 2 ] . Superficial surgical site infection (SSI) is the most common complication after appendectomy [1] , with reported infection rate of 15-20% in complicated appendicitis (i.e., gangrenous or perforated appendix). Superficial SSI leads to readmission, increases the length of hospital stay, nursing care, and prolonged antibiotic treatment. Consequently, this results in an increase of both direct and indirect medical costs to both health care providers and patients. SSI can be minimized by reducing risk factors (e.g., smoking, or glucose control), or use of established preventive procedures (e.g., prophylactic antibiotics, avoid surgical drain, and unnecessary hair removal). Closure of the wound with delayed primary closure (DPC) or primary closure (PC) for a contaminated wound also affects rate of SSI [2] . In PC, wound is closed immediately after appendectomy, whereas in DPC, instead of closing a wound immediately, the wound is left open followed by standard wound care and then is closed on the 3rd to 5th post-operative day. Latter procedure is claimed to increase local wound resistance, and decrease bacterial contamination, which results in a decreased incidence of superficial SSIs. However, in DPC patient suffers from discomfort, pain from regular dressing, increased length of hospital stay and treatment cost. In a randomized controlled study conducted by Duttaroy DD et al.(2009) [ 3 ] , in 77 patients (DPC = 37, PC = 40) they found that Delayed primary closure is a sound incision management technique that should be utilised for dirty abdominal incisions whereas in systematic review and meta-analysis done by Siribumrungwong B et al [4] in 2014, Superficial SSI rates for the PC group were slightly lower than DPC group in case of complicated appendicitis but this outcome didn’t reach statistical significance. Various studies comparing risk of SSI in PC and DPC of wound after open appendectomy in complicated appendicitis have been conducted in the past. Some favored PC whereas others preferred DPC over PC for method of wound closure, but there is no uniform consensus regarding the method of closure after appendectomy in case of complicated appendicitis. We, therefore, conducted a prospective randomized control trial with the aim of comparing superficial SSIs between DPC and PC of wound in patients with complicated appendicitis. Material And Methods After obtaining approval from the Institutional Ethical Committee and prior written informed consent from all patients or their relatives bilingually (English and Hindi), the study was conducted in the Department of General Surgery at A.B.V.I.M.S. & Dr. Ram Manohar Lohia Hospital on patients operated for appendicitis. Study Venue- Department of Surgery at A.B.V.I.M.S. & Dr. Ram Manohar Lohia Hospital, New Delhi. Study Design- Randomized Comparative Study. Study Duration - 1 st January 2021 to 31 st May 2022 . (Patients were recruited till 30 th April 2022) Sample Size - 50 patients (25 in each group). For randomization, computerzied randomization technique was adopted. Inclusion Criteria Age > 18 years Appendectomy with a right lower-quadrant abdominal incision Exclusion Criteria Patients with Diabetes Mellitus, auto immune diseases, HIV, malignancy, previous radiotherapy, cardiovascular disease, end stage liver and renal diseases. Obesity [Body mass index (BMI) > 40kg/m 2 ] Pregnancy Criteria for complicated appendicitis intra-operatively (Figure 1) w as : Erythematous or swollen appendix with a necrotic wall(dark, greyish in color) Rupture during the procedure Rupture Presence of frank pus. Standard workup of patients included noting of details in history, examination and intervention which could contribute to SSI such as age, sex, BMI, ASA grade, symptom onset, operative time and use of drains. Follow Up- All study patients were kept under surveillance and assessed for the presence of Superficial SSI as per the CDC criteria. Patients were followed up at 1 week, 4 week and the following clinical outcomes were assessed. Outcomes- Primary outcome was presence of Superficial SSI Secondary outcome were as follows: ➣ Post-operative pain ➣ Length of hospital stay Pain was assessed by Visual Analogue Scale. Statistical Analysis- The presentation of the Categorical variables was done in the form of number and percentage (%). On the other hand, the quantitative data were presented as the means±SD and as median with 25th and 75th percentiles (interquartile range). The following statistical tests were applied for the results: 1. The comparison of the variables which were quantitative in nature were analysed using Independent t test. 2. The comparison of the variables which were qualitative in nature were analysed using Chi-Square test. If any cell had an expected value of less than 5 then Fisher’s exact test was used. The data entry was done in the Microsoft EXCEL spreadsheet and the final analysis was done with the use of Statistical Package for Social Sciences (SPSS) software, IBM manufacturer, Chicago, USA, ver 25.0. For statistical significance, p value of less than 0.05 was considered statistically significant. Result And Observations 4.1 Demographic and clinical characteristics of participants The eldest patient was 43 years old and the youngest patient was 18 year old with mean of 26.18 for total population included. There were 74% (n=37) patients in the range of 18 to 30 years of age. In our study, there was a female predominance with a 1.94:1 ratio i.e. 66% females (n=33) and 34% males (n=17). Most of patient’s BMI were between 18.5 to 29.9 i.e. 98% patients (n=48); among which highest was 28.4 and lowest was 16.8. Most patients were under ASA grade 1 (a normal healthy patient) and 2 (a patient with mild systemic disease) i.e. 98% (n=48). In our study, 4 patients (15.38%) in PC group and 4 patients (16.67%) in DPC group were smokers and rest of 42 patients (84%) were non-smokers. In our study, comparison of ALVORADO score between two groups had statistically significant difference. The score of 9-10 was seen in 56% patients (n=28). Majority of patients had TLC between 10000-20000 cells/mm 3 i.e. 86% (n=43). 4.2 Intra-operative and post-operative findings Duration of operation was 60-90 minutes in most patients i.e. 50% (n=25). Of the 50 patients (n=19) had gangrenous appendix whereas 40% patients (n=20) had perforated appendix. Drains were used in 36% (n=18) patients, 09 each in PC and DPC. E.Coli was most cultured organism i.e in 40% patients (n=20). 36% patients (n=18) had no growth in their culture after 48 hours of incubation. In our study, no patient was admitted in ICU in post-op period. 4.3 Clinical Outcomes Superficial Surgical Site Infection Incidence of superficial SSI in PC and DPC group was 69.23% (n=18) and 16.67% (n=4) respectively. The difference between two groups was statistically significant ( p value=0.0002 ). Post-Op Pain In our study, post-op pain in PC group ranged from 1-8 on scale with mean = 4.73±2.01 whereas in DPC group it ranged from 3-8 with mean = 4.88±1.51. However, the difference between PC and DPC on comparison of post-op pain was not significant (p value=0.777). Length of Hospital Stay LOS in PC group ranged from 2-11 days with mean = 6±2.97 whereas in DPC group it ranged from 4-9 days with mean = 5.42±1.53. The difference between PC and DPC on comparison of post-op pain was not significant (p value=0.383). Discussion Wound management techniques in contaminated wounds has greatly evolved over period of last 2 centuries. In early 20th century during world war era, open wound management strategies were popularized and widely used as deaths accounting from wound infections scaled up exponentially. Delayed wound closure, wound debridement and use of anti-microbial agent was adopted in wounds from advanced weapons and contamination from the trench. In complicated appendicitis, the risk of incidence of SSI substantially increases due to contamination of wound during surgery. The cultured organisms are predominantly from the colonic flora. In recent years several group of surgeons suggest primary closure of all complicated appendectomy wounds could be done if we administer intravenous antibiotics peri-operatively. This practice of PC of all wounds is supported by the fact that this technique of wound closure eliminated intense post-op pain, longer hospital stay and reducing financial burden on hospital as well as patients. In last 50 years multiple studies were conducted comparing two techniques of wound closure viz. PC and DPC in case of contaminated wounds but most of them showed no difference between two techniques. So, these techniques were compared against the outcomes to identify the most appropriate technique for wound closure in cases of complicated appendicitis. 5.1 Demographic and clinical data The mean Age of patients included in our study was 26.18 years and female predominance with a Male:Female ratio of 1.94:1. 74% of patients (n=37) were in the age group of 18 to 30 years. So it is clearly evident from above data that majority of population developing complicated appendicitis falls under age group of 18-40 years. But male to female ratio in our study (Indian population) has female predominance whereas other studies has either equal ratio or male predominance. Other demographic parameters namely BMI, ASA Grade and Smoking were analyzed and compared between both group of patients of which difference came out to be not significant statistically. In the systematic review [4] , these parameters were found to be non significant on comparison between two groups. In patients included in RCT done in 2012 [7] , mean Duration of Symptoms was similar to our study and difference was not statistically significant between two groups. Another RCT conducted in 2020 [6] , had statistically significant difference on comparison of duration of symptoms between PC and DPC group (p value=0.04) with mean(±SD) of 1.88±0.78 days and 2.36±0.86 days in PC and DPC group respectively. Chiang RA et al [7] observed mean(±SD) TLC 16.5±1.0 in DPC group and 14.8±0.8 in PC group in their study but their result had statistically significant difference between two groups. In a systematic review done in 2014 [4] mean TLC was comparable among two groups but difference was not significant. Operative Time was similar to the study [6] where operative time in 27 patients was more than 60 minutes. Comparison of operative time also didn’t reach statistically significant difference between both groups in either of study. Pus Cultures obtained were similar to colonic flora with E.Coli being the most common in our study which is similar with two different RCT done in 2012 [7] and 2020 [6] respectively. Another systematic review [4] had Pseudomonas aeruginosa the most common organism cultured followed by E.Coli. None of previous study compared Operative findings, ALVORADO score and use of drains for outcomes. 5.2 Clinical Outcomes Out of 50 patients who underwent appendectomy in view of complicated appendicitis, Superficial SSI was present in 22 patients out of which 81.9% (n=18) patients belonged to the PC group whereas 18.1% (n=4) patients belonged to the DPC group. A Total of 28 patients (30.77% in PC group; 60.33% in DPC group) didn’t develop SSI. This clearly demonstrates that DPC group had statistically significant lower (p value=0.0002) SSI. SSI incidence was more in PC group inspite of peri-op antibiotics administration which contradicts the National Nosocomial Infection Surveillance (NNIS) report by CDC which considers that peri-operative antibiotic administration allows PC of all appendectomy wounds. Findings of this study was in line with results demonstrated by some studies conducted in past [3,6-8] in which comparison of SSI reached statistical significance in favour of DPC group. On the contrary, RCT conducted in 2018 [5] demonstrated that the superficial SSI rate was 2.7% less in PC as compared to DPC, although this result was not statistically significant (p value=0.12). In our study, there was no statistically significant difference in Post-op Pain on comparison between the groups. As regard to Post-op Pain, p-value was 0.777 which was in contrast to other study [6] which showed statistically significant difference in favour of DPC (p value=0.001). In our study, there was no statistically significant difference in Length of Stay on comparison between the groups. LOS in DPC and PC group ranges 4-9 days and 2-11 days respectively. In systematic review done in 2014 [4] , they found longer LOS in DPC than PC although the difference between both the groups was not statistically significant. Since majority of studies comparing the two methods of wound closure did not reach statistical significance, PC is favoured by majority of surgeons now a days and DPC is not much prevalent inspite of its advantages as in our study. Limitations- Small sample size. Lack of inclusion of patients with co-morbidities in sample size. Study subjects were residents of limited demographic area i.e. North Indian population. Study did not consider pediatric, pregnant and geriatric population. Conclusion And Recommendations Superficial SSI in post-op period of complicated appendicitis is a pre-dominant component of morbidity which includes increased post-op pain and increased length of hospital stay. These complications could be easily overcome by adopting correct technique of wound closure. In our study, we concluded that DPC was superior to PC of wound in terms of reduction of incidence of superficial SSI in cases of complicated appendicitis. Although with respect to LOS and post-op pain the two techniques of wound closure were not different . So, DPC should be established as standard protocol for wound closure. However, more such research studies on variable sample size and different demographic settings are required. Abbreviations IDSA - Infectious Disease society of America SSI - Surgical Site Infection DPC - Delayed Primary Closure PC - Primary Closure CDC - Center of Disease Control LOS - Length of hospital Stay RCT - Randomized controlled trial VAS - Visual Analog Scale Declarations Sources of Funding None Financial disclosure statement None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. Declaration of competing interest None of the authors has a financial interest in any of the products, devices, or the drugs mentioned in this manuscript. All authors have nothing to declare. Ethical Approval Ethical approval was given by Institutional Ethics Committee, ABVIMS and Dr. RML Hospital, New Delhi under the chair of Dr. Arun Kumar Agarwal on 22nd December 2020 (Approval Number:IEC/ABVIMS/RMLH/422). Consent Written informed consent was obtained from the patients for publication of this randomized controlled trial and accompanying images. A copy of the written consent is available for the review by the Editor-in-Chief of this journal on request. Credit authorship contribution statement Author AA wrote the first draft of the manuscript, collected data and managed the literature searches. Authors AA and NS were operating surgeons. Author NS was scientific advisor. All authors read and approved the final manuscript. Guarantor Akash Akash Data Statement Data sharing not applicable to this article as no datasets were generated or analyzed during the current study. Provenance and peer review Not commissioned, externally peer-reviewed. Acknowledgements First and foremost, I am grateful to my parents for encouraging and supporting me along this interminable road of my academic career. You should know that your support and encouragement was worth more than that can be expressed in words. My sincerest thanks are extended to my supervisor, Dr. Neeraj Saxena. He has given me invaluable guidance, motivation, advice, and encouragement throughout the course of this thesis. He gave me all the freedom to pursue this study while ensuring that I stay on the right track and do not digress from the aim of the study. I thank him with all sincerity for his observations and expert remarks on the matter of this project. His contribution to ensure the effortless advancement of this project has been invaluable. Last but not least I am grateful to the patients and their family members who cooperated with patience and made this study possible. References Muslow J.,The vermiform appendix. Bailey and love’s short practice of surgery. 2018; 27: 1320–1338. Maa J., Kirkwood KS, The appendix, Sabiston textbook of surgery, 2012;19:1279–1293. Duttaroy DD, Jitendra J, Duttaroy B, Management strategy for dirty abdominal incisions: primary or delayed primary closure? A randomized trial. Surg Infect (Larchmt). 2009;10:129–136. Siribumrungwong B, Noorit P, Wilasrusmee C, Chantip A.et al. A systematic review and meta-analysis of randomised controlled trials of delayed primary wound closure in contaminated abdominal wounds. World J Emerg Surg. 2014;9:49. Siribumrungwong B, Chantip A, Noorit P, et al. Comparison of Superficial Surgical Site Infection Between Delayed Primary Versus Primary Wound Closure in Complicated Appendicitis: A Randomized Controlled Trial. Ann Surg. 2018;267(4):631–637. Mostafa ASA, Borai MIH et al. Comparison of Superficial Surgical Site infection between delayed primary versus primary wound closure in complicated appendicitis. Med. J. Caro Univ. 2020;80(3):1257–1264. Chiang RA, Chen SL et al. Delayed primary closure versus primary closure for wound management in perforated appendicitis: A prospective randomized controlled trial, Journal of the Chinese Medical Association. 2012;75(4):156–159. Cohn SM, Giannotti G, Ong AW, et al. Prospective randomized trial of two wound management strategies for dirty abdominal wounds. Ann Surg. 2001;233:409–413. Tables Table 1- Depicting comparison of study variables and between PC and DPC group. PC DPC p-value Age 0.809 Gender 0.197 Male 11 09 Female 15 18 BMI 0.783 18-25 28 30 25-30 24 18 Smoking(%) 8 8 1 ASA 0.211 Grade 1+2 52 44 Grade 3 Nil 4 Duration of symptoms 2.15+1.12 2.67+1.31 0.142 TLC 0.037 5k-15k 18 34 >15k 34 14 ALVORADO score 0.05 8 36 20 OT time 0.46 60 minutes 38 32 OT findings 0.493 Gangrenous Appendix 22 16 Perforated Appendix 22 18 Purulent discharge 8 14 Drain use 0.832 Yes 18 18 No 34 30 Pus Culture 0.37 No growth 24 12 Pseudomonas 4 8 Bacteriodes fragilis Nil 4 E.Coli 20 20 Mixture of organisms 4 4 ICU stay Nil Nil Nil SSI 0.0002 Present 36 8 Absent 16 40 Pain 4.73+2.01 4.88+1.51 0.777 Length Of stay 6+2.97 5.42+1.53 0.383 Table 2-Comparison of outcome between primary closure and delayed primary closure . Outcome Primary closure(n=26) Delayed primary(n=24) Total P value Surgical site infection Present 18 (69.23%) 4 (16.67%) 22 (44%) 0.0002 * Absent 8 (30.77%) 20 (83.33%) 28 (56%) Post-operative pain Mean ± SD 4.73 ± 2.01 4.88 ± 1.51 4.8 ± 1.77 0.777 ‡ Median(25th-75th percentile) 5 (2.25-6) 4.5 (4-6) 5 (4-6) Range 1-8 3-8 1-8 Length of stay(days) Mean ± SD 6 ± 2.97 5.42 ± 1.53 5.72 ± 2.38 0.383 ‡ Median(25th-75th percentile) 7 (2-8) 5 (4-6) 5 (4-7) Range 2-11 4-9 2-11 * Fisher's exact test, ‡ Independent t test. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2162413","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":145865921,"identity":"a947de65-6335-4950-a138-b1049bbb6fe1","order_by":0,"name":"Akash Akash","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIiWNgGAWjYDACHgYGZoYfEjz27c0HgFwJGeK0MPbYyBnwHEsAaeEh0ha2NGMDCR8DKJ8A4O85/PhzAc/hxO0SPJ9f3aix4GFgP3x0Az4tEmfbzKRnWBxO3Dm7d5t1zjGgw3jS0m7gteY8gxkzD9CWhjtntxnnsAG1SPCY4dUif57982ceNqCWGznPjHP+EaHF4GyPgTQPyPs3cpgf57YRocXwzJkyaV5gIEv2HDNjzu2T4GEj5Be5M+mbP/MAo5Kfvfnx55xvdXL87IeP4fc+EmCTAJPEKgcB5g+kqB4Fo2AUjIKRAwCCWEgcT/ixfAAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0003-1753-7739","institution":"Dr. Ram Manohar Lohia Hospital PGIMER: Atal Bihari Vajpayee Institute of Medical Sciences \u0026 Dr Ram Manohar Lohia Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Akash","middleName":"","lastName":"Akash","suffix":""},{"id":145865922,"identity":"ee20523f-94e1-439b-8169-6423269e23a8","order_by":1,"name":"Neeraj Saxena","email":"","orcid":"","institution":"Atal Bihari Vajpayee Institute of Medical Sciences \u0026 Dr Ram Manohar Lohia Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Neeraj","middleName":"","lastName":"Saxena","suffix":""}],"badges":[],"createdAt":"2022-10-13 12:19:45","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2162413/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2162413/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":28192940,"identity":"8c54362d-9e69-464b-b6c1-56f56d522c88","added_by":"auto","created_at":"2022-10-24 18:02:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1338025,"visible":true,"origin":"","legend":"\u003cp\u003eIntra-Op images demonstrating friable appendix(left) and gangrenous appendix(right).\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-2162413/v1/722b89a89a05b7462accdde7.png"},{"id":28192942,"identity":"314aff1a-405b-427b-8b0c-7856095b65f5","added_by":"auto","created_at":"2022-10-24 18:02:54","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1342050,"visible":true,"origin":"","legend":"\u003cp\u003ePost-Operative image demonstrating Primary Wound closure with abdominal drain placement in case of open appendectomy of gangrenous appendix.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-2162413/v1/a2fbe90dbbc0278a8122071e.png"},{"id":28193773,"identity":"cda98d54-5baa-4ed1-b555-a8cd27fe7d1d","added_by":"auto","created_at":"2022-10-24 18:07:54","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":892477,"visible":true,"origin":"","legend":"\u003cp\u003eDemonstrating wound on POD-3(left) when it was left open in post-op period for Delayed Primary wounds closure. Wound after closure(with non-absorbable interrupted sutures) and drain removal on POD-5(right).\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-2162413/v1/6cad286c85f1299ffb207a9e.png"},{"id":28192941,"identity":"b1a83d9f-f52c-4a8a-bd84-075c68eb2347","added_by":"auto","created_at":"2022-10-24 18:02:54","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":843740,"visible":true,"origin":"","legend":"\u003cp\u003eAfter primary closure of wound in complicated appendix, erythematous skin on local site on POD-2(left); another wound of case with complicated appendix which was primarily closed had sero-purulent discharge on POD-4(right)-skin staplers removed.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-2162413/v1/d76ea22741b4d5cc425ff47a.png"},{"id":28194195,"identity":"1b5c022c-6c26-4a9d-be74-bb76f8af2f0b","added_by":"auto","created_at":"2022-10-24 18:12:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4554845,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2162413/v1/f200bad9-82d0-447b-b7ff-993eb569aac6.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eSuperficial Surgical Site Infection in Delayed Primary Vs Primary Wound Closure in Complicated Appendicitis\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAcute appendicitis is the most common cause of acute abdomen in adults and appendectomy is one of the most common emergency surgical procedure performed in the world\u0026nbsp;\u003csup\u003e[1].\u003c/sup\u003e\u003csup\u003e\u0026nbsp;\u0026nbsp;\u003c/sup\u003eIt is rare in infants and elderly but common in early adult life with male to female ratio of 3:2\u0026nbsp;\u003csup\u003e[1]\u003c/sup\u003e.\u0026nbsp;Appendicitis is much less common in underdeveloped countries, suggesting that elements of the Western diet, specifically a low-fiber, high-fat intake, may play a role in the development of the disease process.\u003c/p\u003e\n\u003cp\u003eThe gold standard and least controversial treatment of acute uncomplicated as well as complicated appendicitis remains\u0026nbsp;prompt appendectomy\u0026nbsp;\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e2\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e, both the open and laparoscopic approaches are acceptable. The patient may require aggressive resuscitation and intravenous antibiotic (to cover gram-negative bacilli and anaerobic cocci) administration pre-operatively. Post-operatively broad spectrum antibiotics can be continued 7-10 days in accordance to Infectious Disease society of America (IDSA) guidelines\u0026nbsp;\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e2\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eSuperficial surgical site infection (SSI) is the most common complication after appendectomy \u003csup\u003e[1]\u003c/sup\u003e, with reported infection rate of 15-20% in complicated appendicitis (i.e., gangrenous or perforated appendix). Superficial SSI leads to readmission, increases the length of hospital stay, nursing care, and prolonged antibiotic treatment. Consequently, this results in an increase of both direct and indirect medical costs to both health care providers and patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSSI can be minimized by reducing risk factors (e.g., smoking, or glucose control), or use of established preventive procedures (e.g., prophylactic antibiotics, avoid surgical drain, and unnecessary hair removal). Closure of the wound with delayed primary closure (DPC) or primary closure (PC) for a contaminated wound also affects rate of SSI \u003csup\u003e[2]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIn PC, wound is closed immediately after appendectomy, whereas in DPC,\u0026nbsp;instead of closing a wound immediately, the wound is left open followed by standard wound care and then is closed on the 3rd to 5th post-operative day. Latter procedure is claimed to increase local wound resistance,\u0026nbsp;and decrease bacterial contamination, which results in a decreased incidence of superficial SSIs.\u0026nbsp;However, in DPC patient suffers from discomfort, pain from regular dressing, increased length of hospital stay and treatment cost.\u003c/p\u003e\n\u003cp\u003eIn a randomized controlled study conducted by Duttaroy DD et al.(2009)\u0026nbsp;\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e3\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e,\u0026nbsp;in 77 patients (DPC = 37, PC = 40) they found that Delayed primary closure is a sound incision management technique that should be utilised for dirty abdominal incisions\u0026nbsp;whereas in\u0026nbsp;systematic review and meta-analysis done by Siribumrungwong B et al \u003csup\u003e[4]\u0026nbsp;\u003c/sup\u003ein\u0026nbsp;2014,\u0026nbsp;Superficial SSI rates for the PC group were slightly lower than DPC group in case of complicated appendicitis but this outcome didn\u0026rsquo;t reach statistical significance.\u003c/p\u003e\n\u003cp\u003eVarious studies comparing risk of SSI in PC and DPC of wound after open appendectomy in complicated appendicitis have been conducted in the past. Some favored PC whereas others preferred DPC over PC for method of wound closure, but there is no uniform consensus regarding the method of closure after appendectomy in case of complicated appendicitis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe, therefore, conducted a prospective randomized control trial with the aim of comparing superficial SSIs between DPC and PC of wound in patients with complicated appendicitis.\u003c/p\u003e"},{"header":"Material And Methods","content":"\u003cp\u003eAfter obtaining approval from the Institutional Ethical Committee and prior written informed consent from all patients or their relatives bilingually (English and Hindi), the study was conducted in the Department of General Surgery at A.B.V.I.M.S. \u0026amp; Dr. Ram Manohar Lohia Hospital on patients operated for appendicitis.\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003eStudy Venue-\u003c/strong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Department of Surgery at A.B.V.I.M.S. \u0026amp; Dr. Ram Manohar Lohia Hospital, New Delhi.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eStudy Design-\u003c/strong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Randomized Comparative Study.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eStudy Duration\u003c/strong\u003e\u003cstrong\u003e- \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e1\u003csup\u003est\u003c/sup\u003e January 2021 to 31\u003csup\u003est\u003c/sup\u003e May 2022\u003cstrong\u003e.\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;(Patients were recruited till 30\u003csup\u003eth\u003c/sup\u003e April 2022)\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003eSample\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eSize\u003c/strong\u003e\u003cstrong\u003e-\u003c/strong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 50 patients (25 in each group).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eFor randomization, computerzied randomization technique was adopted.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003eAge \u0026gt;\u0026nbsp;18 years\u003c/li\u003e\n\u003cli\u003eAppendectomy with a right lower-quadrant abdominal incision\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003ePatients with Diabetes Mellitus, auto immune diseases, HIV, malignancy, previous radiotherapy, cardiovascular disease, end stage liver and renal diseases.\u003c/li\u003e\n\u003cli\u003eObesity [Body mass index (BMI) \u0026gt; 40kg/m\u003csup\u003e2\u003c/sup\u003e]\u003c/li\u003e\n\u003cli\u003ePregnancy\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eCriteria for\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ecomplicated appendicitis\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eintra-operatively\u003c/strong\u003e\u003cstrong\u003e(Figure 1)\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;w\u003c/strong\u003e\u003cstrong\u003eas\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eErythematous or swollen appendix with a necrotic wall(dark, greyish in color)\u003c/li\u003e\n\u003cli\u003eRupture during the procedure\u003c/li\u003e\n\u003cli\u003eRupture\u003c/li\u003e\n\u003cli\u003ePresence of frank pus.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eStandard workup of patients included noting of details in history, examination and intervention which could contribute to SSI such as age, sex, BMI, ASA grade, symptom onset, operative time and use of drains.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFollow Up-\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll study patients were kept under surveillance and assessed for the presence of Superficial \u0026nbsp;SSI as per the CDC criteria.\u003c/p\u003e\n\u003cp\u003ePatients were followed up at 1 week, 4 week and the\u0026nbsp;following clinical outcomes were assessed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcomes-\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003ePrimary outcome was presence of Superficial SSI\u0026nbsp;\u003c/li\u003e\n\u003cli\u003eSecondary outcome were as follows:\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e➣ Post-operative pain\u003c/p\u003e\n\u003cp\u003e➣ Length of hospital stay\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Pain was assessed by Visual Analogue Scale.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis-\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe presentation of the Categorical variables was done in the form of number and percentage (%). On the other hand,\u0026nbsp;the quantitative data were presented as the means\u0026plusmn;SD and as median with 25th and 75th percentiles (interquartile range).\u0026nbsp;The following statistical tests were applied for the results:\u003c/p\u003e\n\u003cp\u003e1. The\u0026nbsp;comparison of the variables which were quantitative in nature\u0026nbsp;were\u0026nbsp;analysed\u0026nbsp;using\u0026nbsp;Independent t test.\u003c/p\u003e\n\u003cp\u003e2. The comparison of the variables which were qualitative in nature were analysed using Chi-Square test. If any cell had an expected value of less than 5 then Fisher\u0026rsquo;s exact test was used.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe data\u0026nbsp;entry was done in the\u0026nbsp;Microsoft\u0026nbsp;EXCEL spreadsheet and\u0026nbsp;the final\u0026nbsp;analysis was done\u0026nbsp;with the use of\u0026nbsp;Statistical Package for Social Sciences (SPSS) software, IBM manufacturer, Chicago, USA,\u0026nbsp;ver\u0026nbsp;25.0.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;For statistical significance, p value of less than 0.05 was considered statistically significant.\u0026nbsp;\u003c/p\u003e"},{"header":"Result And Observations","content":"\u003cp\u003e\u003cstrong\u003e4.1 \u003cu\u003eDemographic and clinical characteristics of participants\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe eldest patient was 43 years old and the youngest patient was 18 year old with mean of 26.18 for total population included. There were 74% (n=37) patients in the range of 18 to 30 years of age.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn our study, there was a female predominance with a 1.94:1 ratio i.e. 66% females (n=33) and 34% males (n=17).\u003c/p\u003e\n\u003cp\u003eMost of patient\u0026rsquo;s BMI were between 18.5 to 29.9 i.e. 98% patients (n=48); among which highest was 28.4 and lowest was 16.8. Most patients were under ASA grade 1 (a normal healthy patient) and 2 (a patient with mild systemic disease) i.e. 98% (n=48). In our study, 4 patients (15.38%) in PC group and 4 patients (16.67%) in DPC group were smokers and rest of 42 patients (84%) were non-smokers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn our study, comparison of ALVORADO score between two groups had statistically significant difference. The score of 9-10 was seen in 56% patients (n=28).\u003c/p\u003e\n\u003cp\u003eMajority of patients had TLC between 10000-20000 cells/mm\u003csup\u003e3\u0026nbsp;\u003c/sup\u003ei.e. 86% (n=43).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.2 \u003cu\u003eIntra-operative and post-operative findings\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuration of operation was 60-90 minutes in most patients i.e. 50% (n=25).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOf the 50 patients (n=19) had gangrenous appendix whereas 40% patients (n=20) had perforated appendix. Drains were used in 36% (n=18) patients, 09 each in PC and DPC.\u003c/p\u003e\n\u003cp\u003eE.Coli was most cultured organism i.e in 40% patients (n=20). 36% patients (n=18) had no growth in their culture after 48 hours of incubation.\u003c/p\u003e\n\u003cp\u003eIn our study, no patient was admitted in ICU in post-op period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.3 \u003cu\u003eClinical Outcomes\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSuperficial Surgical Site Infection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIncidence of superficial SSI in PC and DPC group was 69.23% (n=18) and 16.67% (n=4) respectively. The difference between two groups was \u003cstrong\u003estatistically significant\u003c/strong\u003e (\u003cstrong\u003ep value=0.0002\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePost-Op Pain\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn our study, post-op pain in PC group ranged from 1-8 on scale with mean = 4.73\u0026plusmn;2.01 whereas in DPC group it ranged from 3-8 with mean = 4.88\u0026plusmn;1.51. However, the difference between PC and DPC on comparison of post-op pain was \u003cstrong\u003enot significant\u003c/strong\u003e (p value=0.777).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLength of Hospital Stay\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLOS in PC group ranged from 2-11 days with mean = 6\u0026plusmn;2.97 whereas in DPC group it ranged from 4-9 days with mean = 5.42\u0026plusmn;1.53. The difference between PC and DPC on comparison of post-op pain was \u003cstrong\u003enot significant\u003c/strong\u003e (p value=0.383).\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWound management techniques in contaminated wounds has greatly evolved over period of last 2 centuries. In early 20th century during world war era, open wound management strategies were popularized and widely used as deaths accounting from wound infections scaled up exponentially. Delayed wound closure, wound debridement and use of anti-microbial agent was adopted in wounds from advanced weapons and contamination from the trench.\u003c/p\u003e\n\u003cp\u003eIn complicated appendicitis, the risk of incidence of SSI substantially increases due to contamination of wound during surgery. The cultured organisms are predominantly from the colonic flora. In recent years several group of surgeons suggest primary closure of all complicated appendectomy wounds could be done if we administer intravenous antibiotics peri-operatively. This practice of PC of all wounds is supported by the fact that this technique of wound closure eliminated intense post-op pain, longer hospital stay and reducing financial burden on hospital as well as patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn last 50 years multiple studies were conducted comparing two techniques of wound closure viz. PC and DPC in case of contaminated wounds but most of them showed no difference between two techniques. So, these techniques were compared against the outcomes to identify the most appropriate technique for wound closure in cases of complicated appendicitis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5.1 Demographic and clinical data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean \u003cstrong\u003eAge of patients\u003c/strong\u003e included in our study was 26.18 years and female predominance with a \u003cstrong\u003eMale:Female\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;ratio\u003c/strong\u003e of 1.94:1. 74% of patients (n=37) were in the age group of 18 to 30 years. So it is clearly evident from above data that majority of population developing complicated appendicitis falls under age group of 18-40 years. But male to female ratio in our study (Indian population) has female predominance whereas other studies has either equal ratio or male predominance.\u003c/p\u003e\n\u003cp\u003eOther demographic parameters namely \u003cstrong\u003eBMI, ASA Grade and Smoking\u003c/strong\u003e were analyzed and compared between both group of patients of which difference came out to be not significant statistically. In the systematic review\u003csup\u003e[4]\u003c/sup\u003e, these parameters were found to be non significant on comparison between two groups. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn patients included in RCT done in 2012\u003csup\u003e[7]\u003c/sup\u003e, mean \u003cstrong\u003eDuration of Symptoms\u003c/strong\u003e was similar to our study and difference was not statistically significant between two groups. Another RCT conducted in 2020\u003csup\u003e[6]\u003c/sup\u003e, had statistically significant difference on comparison of duration of symptoms between PC and DPC group (p value=0.04) with mean(\u0026plusmn;SD) of 1.88\u0026plusmn;0.78 days and 2.36\u0026plusmn;0.86 days in PC and DPC group respectively.\u003c/p\u003e\n\u003cp\u003eChiang RA et al\u003csup\u003e[7]\u003c/sup\u003e observed mean(\u0026plusmn;SD) \u003cstrong\u003eTLC\u0026nbsp;\u003c/strong\u003e16.5\u0026plusmn;1.0 in DPC group and 14.8\u0026plusmn;0.8 in PC group in their study but their result had statistically significant difference between two groups. In a systematic\u0026nbsp;review done in 2014\u003csup\u003e[4]\u0026nbsp;\u003c/sup\u003emean TLC was comparable among two groups but difference was not significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOperative Time\u003c/strong\u003e was similar to the study\u003csup\u003e[6]\u003c/sup\u003e where operative time in 27 patients was more than 60 minutes. Comparison of operative time also didn\u0026rsquo;t reach statistically significant difference between both groups in either of study.\u003c/p\u003e\n\u003cp\u003ePus Cultures obtained were similar to colonic flora with E.Coli being the most common in our study which is similar with two different RCT done in 2012\u003csup\u003e[7]\u003c/sup\u003e and 2020\u003csup\u003e[6]\u0026nbsp;\u003c/sup\u003erespectively. Another systematic review\u003csup\u003e[4]\u003c/sup\u003e had Pseudomonas aeruginosa the most common organism cultured followed by E.Coli.\u003c/p\u003e\n\u003cp\u003eNone of previous study compared \u003cstrong\u003eOperative findings, ALVORADO score and use of drains\u003c/strong\u003e for outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5.2 \u0026nbsp;Clinical Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOut of 50 patients who underwent appendectomy in view of complicated appendicitis, \u003cstrong\u003eSuperficial SSI\u0026nbsp;\u003c/strong\u003ewas present in 22 patients out of which 81.9% (n=18) patients belonged to the PC group whereas 18.1% (n=4) patients belonged to the DPC group. A Total of 28 patients (30.77% in PC group; 60.33% in DPC group) didn\u0026rsquo;t develop SSI. This clearly demonstrates that DPC group had statistically significant lower \u003cstrong\u003e(p value=0.0002)\u003c/strong\u003e SSI. SSI incidence was more in PC group inspite of peri-op antibiotics administration which contradicts the National Nosocomial Infection Surveillance (NNIS) report by CDC which considers that peri-operative antibiotic administration allows PC of all appendectomy wounds. Findings of this study was in line with results demonstrated by some studies conducted in past\u003csup\u003e[3,6-8]\u0026nbsp;\u003c/sup\u003ein which comparison of SSI reached statistical significance in favour of DPC group. On the contrary, RCT conducted in 2018\u003csup\u003e[5]\u0026nbsp;\u003c/sup\u003edemonstrated that the superficial SSI rate was 2.7% less in PC as compared to DPC, although this result was not\u0026nbsp;statistically significant\u0026nbsp;(p value=0.12).\u003c/p\u003e\n\u003cp\u003eIn our study, there was no statistically significant difference in \u003cstrong\u003ePost-op Pain\u0026nbsp;\u003c/strong\u003eon comparison between the groups. As regard to Post-op Pain, p-value was 0.777 which was in contrast to other study\u003csup\u003e[6]\u003c/sup\u003e which showed statistically significant difference in favour of DPC (p value=0.001).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn our study, there was no statistically significant difference in \u003cstrong\u003eLength of Stay\u0026nbsp;\u003c/strong\u003eon comparison between the groups. LOS in DPC and PC group ranges 4-9 days and 2-11 days respectively. In systematic review done in 2014\u003csup\u003e[4]\u0026nbsp;\u003c/sup\u003e, they found longer LOS in DPC than PC although the difference between both the groups was not statistically significant.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSince majority of studies comparing the two methods of wound closure did not reach statistical significance, PC is favoured by majority of surgeons now a days and DPC is not much prevalent inspite of its advantages as in our study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations-\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eSmall sample size.\u003c/li\u003e\n\u003cli\u003eLack of inclusion of patients with co-morbidities in sample size.\u003c/li\u003e\n\u003cli\u003eStudy subjects were residents of limited demographic area i.e. North Indian population.\u003c/li\u003e\n\u003cli\u003eStudy did not consider pediatric, pregnant and geriatric population.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Conclusion And Recommendations","content":"\u003cp\u003eSuperficial SSI in post-op period of complicated appendicitis is a pre-dominant component of morbidity which includes increased post-op pain and increased length of hospital stay. These complications could be easily overcome by adopting correct technique of wound closure. \u003cstrong\u003e\u003cem\u003eIn our study, we concluded that DPC was superior to PC of wound in terms of reduction of incidence of superficial SSI in cases of complicated appendicitis. Although with respect to LOS and post-op pain the two techniques of wound closure were not different\u003c/em\u003e.\u0026nbsp;\u003c/strong\u003eSo, DPC should be established as standard protocol for wound closure. However, more such research studies on variable sample size and different demographic settings are required.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cul\u003e\n\u003cli\u003eIDSA - Infectious Disease society of America \u003c/li\u003e\n\u003cli\u003eSSI - Surgical Site Infection\u003c/li\u003e\n\u003cli\u003eDPC - Delayed Primary Closure\u003c/li\u003e\n\u003cli\u003ePC - Primary Closure\u003c/li\u003e\n\u003cli\u003eCDC - Center of Disease Control\u003c/li\u003e\n\u003cli\u003eLOS - Length of hospital Stay\u003c/li\u003e\n\u003cli\u003eRCT - Randomized controlled trial\u003c/li\u003e\n\u003cli\u003eVAS - Visual Analog Scale\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eSources of Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial disclosure statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of competing interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone of the authors has a financial interest in any of the products, devices, or the drugs mentioned in this manuscript. All authors have nothing to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was given by Institutional Ethics Committee, ABVIMS and Dr. RML Hospital, New Delhi under the chair of Dr. Arun Kumar Agarwal on 22nd December 2020 (Approval Number:IEC/ABVIMS/RMLH/422).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patients for publication of this randomized controlled trial and accompanying images. A copy of the written consent is available for the review by the Editor-in-Chief of this journal on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCredit authorship contribution statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthor AA wrote the first draft of the manuscript, collected data and managed the literature searches.\u003c/p\u003e\n\u003cp\u003eAuthors AA and NS were operating surgeons.\u003c/p\u003e\n\u003cp\u003eAuthor NS was scientific advisor.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGuarantor\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAkash Akash\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData sharing not applicable to this article as no datasets were generated or analyzed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProvenance and peer review\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Not commissioned, externally peer-reviewed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFirst and foremost, I am grateful to my parents for encouraging and supporting me along this interminable road of my academic career. You should know that your support and encouragement was worth more than that can be expressed in words.\u003c/p\u003e\n\u003cp\u003eMy sincerest thanks are extended to my supervisor, Dr. Neeraj Saxena. He has given me invaluable guidance, motivation, advice, and encouragement throughout the course of this thesis. He gave me all the freedom to pursue this study while ensuring that I stay on the right track and do not digress from the aim of the study. I thank him with all sincerity for his observations and expert remarks on the matter of this project. His contribution to ensure the effortless advancement of this project has been invaluable.\u003c/p\u003e\n\u003cp\u003eLast but not least I am grateful to the patients and their family members who cooperated with patience and made this study possible.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eMuslow J.,The vermiform appendix. Bailey and love\u0026rsquo;s short practice of surgery. 2018; 27: 1320\u0026ndash;1338.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMaa J., Kirkwood KS, The appendix, Sabiston textbook of surgery, 2012;19:1279\u0026ndash;1293.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDuttaroy DD, Jitendra J, Duttaroy B, Management strategy for dirty abdominal incisions: primary or delayed primary closure? A randomized trial. Surg Infect (Larchmt). 2009;10:129\u0026ndash;136.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSiribumrungwong B, Noorit P, Wilasrusmee C, Chantip A.et al. A systematic review and meta-analysis of randomised controlled trials of delayed primary wound closure in contaminated abdominal wounds. World J Emerg Surg. 2014;9:49.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSiribumrungwong B, Chantip A, Noorit P, et al. Comparison of Superficial Surgical Site Infection Between Delayed Primary Versus Primary Wound Closure in Complicated Appendicitis: A Randomized Controlled Trial. Ann Surg. 2018;267(4):631\u0026ndash;637.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMostafa ASA, Borai MIH et al. Comparison of Superficial Surgical Site infection between delayed primary versus primary wound closure in complicated appendicitis. Med. J. Caro Univ. 2020;80(3):1257\u0026ndash;1264.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eChiang RA, Chen SL et al. Delayed primary closure versus primary closure for wound management in perforated appendicitis: A prospective randomized controlled trial, Journal of the Chinese Medical Association. 2012;75(4):156\u0026ndash;159.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eCohn SM, Giannotti G, Ong AW, et al. Prospective randomized trial of two wound management strategies for dirty abdominal wounds. Ann Surg. 2001;233:409\u0026ndash;413.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1- Depicting comparison of study variables and between PC and DPC group.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"567\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003ePC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003eDPC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.4634%;\" valign=\"top\" width=\"24.867724867724867%\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.4634%;\" valign=\"top\" width=\"24.867724867724867%\"\u003e\n \u003cp\u003e0.809\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 17.4634%;\" valign=\"top\" width=\"24.867724867724867%\"\u003e\n \u003cp\u003e0.197\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 17.4634%;\" valign=\"top\" width=\"24.867724867724867%\"\u003e\n \u003cp\u003e0.783\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e18-25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e25-30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003eSmoking(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.4634%;\" valign=\"top\" width=\"24.867724867724867%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003eASA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 17.4634%;\" valign=\"top\" width=\"24.867724867724867%\"\u003e\n \u003cp\u003e0.211\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eGrade 1+2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eGrade 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eNil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003eDuration of symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e2.15+1.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e2.67+1.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.4634%;\" valign=\"top\" width=\"24.867724867724867%\"\u003e\n \u003cp\u003e0.142\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003eTLC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 17.4634%;\" valign=\"top\" width=\"24.867724867724867%\"\u003e\n \u003cp\u003e0.037\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e5k-15k\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u0026gt;15k\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003eALVORADO score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 17.4634%;\" valign=\"top\" width=\"24.867724867724867%\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u0026lt;8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u0026gt;8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003eOT time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 17.4634%;\" valign=\"top\" width=\"24.867724867724867%\"\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u0026lt;60 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u0026gt;60 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003eOT findings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 17.4634%;\" valign=\"top\" width=\"24.867724867724867%\"\u003e\n \u003cp\u003e0.493\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eGangrenous Appendix\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003ePerforated Appendix\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003ePurulent discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003eDrain use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.4634%;\" valign=\"top\" width=\"24.867724867724867%\"\u003e\n \u003cp\u003e0.832\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.4634%;\" valign=\"top\" width=\"24.867724867724867%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.4634%;\" valign=\"top\" width=\"24.867724867724867%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003ePus Culture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"6\" style=\"width: 17.4634%;\" valign=\"top\" width=\"24.867724867724867%\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eNo growth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003ePseudomonas\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eBacteriodes fragilis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eNil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eE.Coli\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eMixture of organisms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003eICU stay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003eNil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003eNil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.4634%;\" valign=\"top\" width=\"24.867724867724867%\"\u003e\n \u003cp\u003eNil\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003eSSI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 17.4634%;\" valign=\"top\" width=\"24.867724867724867%\"\u003e\n \u003cp\u003e0.0002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003ePain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e4.73+2.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e4.88+1.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.4634%;\" valign=\"top\" width=\"24.867724867724867%\"\u003e\n \u003cp\u003e0.777\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003eLength Of stay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e6+2.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.8082%;\" valign=\"top\" width=\"25.044091710758376%\"\u003e\n \u003cp\u003e5.42+1.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.4634%;\" valign=\"top\" width=\"24.867724867724867%\"\u003e\n \u003cp\u003e0.383\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2-Comparison of outcome between primary closure and delayed primary\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eclosure\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"639\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary closure(n=26)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDelayed primary(n=24)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" width=\"100%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical site infection\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e18\u0026nbsp;\u003cbr\u003e\u0026nbsp;(69.23%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e4\u0026nbsp;\u003cbr\u003e\u0026nbsp;(16.67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e22\u0026nbsp;\u003cbr\u003e\u0026nbsp;(44%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e0.0002\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e8\u0026nbsp;\u003cbr\u003e\u0026nbsp;(30.77%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e20\u0026nbsp;\u003cbr\u003e\u0026nbsp;(83.33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e28\u0026nbsp;\u003cbr\u003e\u0026nbsp;(56%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" width=\"100%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-operative pain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e4.73 \u0026plusmn; 2.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e4.88 \u0026plusmn; 1.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e4.8 \u0026plusmn; 1.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e0.777\u003csup\u003e\u0026Dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003eMedian(25th-75th percentile)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e5\u003cbr\u003e\u0026nbsp;(2.25-6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e4.5\u003cbr\u003e\u0026nbsp;(4-6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e5\u003cbr\u003e\u0026nbsp;(4-6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e1-8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e3-8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e1-8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" width=\"100%\"\u003e\n \u003cp\u003e\u003cstrong\u003eLength of stay(days)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e6 \u0026plusmn; 2.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e5.42 \u0026plusmn; 1.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e5.72\u0026nbsp;\u0026plusmn; 2.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e0.383\u003csup\u003e\u0026Dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003eMedian(25th-75th percentile)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e7\u003cbr\u003e\u0026nbsp;(2-8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e5\u003cbr\u003e\u0026nbsp;(4-6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e5\u003cbr\u003e\u0026nbsp;(4-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e2-11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e4-9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e2-11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003e*\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Fisher\u0026apos;s exact test, \u003csup\u003e\u0026Dagger;\u003c/sup\u003e Independent t test.\u003c/strong\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Superficial Surgical Site Infection, Primary Closure, Delayed Primary Closure, Complicated Appendicitis","lastPublishedDoi":"10.21203/rs.3.rs-2162413/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2162413/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003e1.1 Background\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWound infection is the most common post-op complication encountered after open appendectomy. Various studies comparing risk of superficial surgical site infection (SSI) in primary closure (PC) and delayed primary closure (DPC) of wound has been conducted in the past. But there is no uniform consensus regarding the method of wound closure. So aim of this study was comparison of the two wound closure techniques.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.2 Material and Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was prospective study which enrolled 50 patients who underwent open appendectomy. Patients’ demographics, characteristics and operative findings were recorded. Those who were elder than 18 years and had appendectomy with a right lower quadrant incision were included. Patients with any comorbidity, morbid obesity and pregnancy were excluded. Patients were randomized to undergo two techniques of wound closure namely PC and DPC. On follow-up at one week and one month, SSI, post-op pain and LOS were compared among two groups. Clinical assessment included a visual analog scale (1-10) for pain.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.3 Results\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn our study incidence of SSI in DPC group was significantly lower when compared to PC group (p value=0.0002) while post-op pain and LOS were not significantly different on comparison between the two groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.4 Conclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe concluded that DPC was superior to PC of wound in terms of reduction of incidence of superficial SSI but with respect to post-op pain and LOS the two techniques of wound closure were not different.\u003c/p\u003e","manuscriptTitle":"Superficial Surgical Site Infection in Delayed Primary Vs Primary Wound Closure in Complicated Appendicitis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-10-24 18:02:51","doi":"10.21203/rs.3.rs-2162413/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d2ee4526-7845-4cef-91ed-9dbcba9694d5","owner":[],"postedDate":"October 24th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-10-24T18:02:52+00:00","versionOfRecord":[],"versionCreatedAt":"2022-10-24 18:02:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2162413","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2162413","identity":"rs-2162413","version":["v1"]},"buildId":"GqpaHPwrfC8PjnIFayRh5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}