The systematic review and network meta-analysis by Groenen and colleagues¹ published in a recent issue of JAMA Surgery on incisional wound irrigation for the prevention of surgical site infection (SSI) is a commendable effort in shedding light on a controversial topic in surgery. The key premise is that network meta-analyses can compare the impact of multiple different irrigation solutions on the development of SSI, even when they were not compared in the original studies. Although the study contributes valuable insights, it is essential to scrutinize the inherent challenges in defining and standardizing SSIs, as well as the design limitations that influence the interpretation of the results.

One of the primary challenges in understanding the impact of incisional wound irrigation lies in the vagueness of SSI definitions, which are subjective and dependent largely on the observer. In this analysis, the definition of SSI was 鈥溾��at the discretion of the original study鈥檚 author.鈥�¹ It is never explicitly stated, but it appears that the outcome of interest in all of these studies is superficial SSI. However, the lack of standardized criteria across the included studies may introduce significant and unquantifiable variability. Furthermore, a diverse array of surgical procedures is included, each with distinct contamination risks, dose levels, and techniques. This heterogeneity presents a formidable obstacle when attempting to generalize findings. The amalgamation of such disparate data may dilute the ability to discern the true impact of irrigation on preventing SSIs in specific surgical contexts. Interestingly, in a recent randomized clinical trial of a newer antiseptic agent, polyhexanide (published after this meta-analysis was completed), SSI rates were not decreased in the wound irrigation intervention arm, but contaminated and emergent procedures were excluded from the study.²

Dentists have long used chlorhexidine solutions, such as Peridex (3M), in procedures like root canals, periodontal work, and oral surgery.³ The efficacy of chlorhexidine in preventing infections is well established in dentistry, yet we lack sufficient data on its application in surgical settings. To address these gaps in our understanding, a coordinated study of chlorhexidine-based irrigation in acute care surgery is imperative. High priority topics include intra-abdominal infection, gross contamination during emergent laparotomy, and necrotizing soft tissue infection. This targeted research approach will provide much-needed clarity on the efficacy of incisional wound irrigation in scenarios where the risk of infection is particularly high.

The study by Groenen and colleagues¹ contributes significantly to the discourse on SSIs and confirms the general approach of using antiseptic irrigation to prevent SSI. Acknowledging and addressing the aforementioned limitations will pave the way for more nuanced and context-specific insights into the role of incisional wound irrigation in preventing SSIs. The solution to pollution in surgical settings is not simply dilution, but rather a tailored and meticulous understanding of the infection risk in specific surgical procedures and circumstances.

Corresponding Author: Heather L. Evans, MD, MS, Ralph H. Johnson VA Medical Center, 109 Bee St, Charleston, SC 29401 (heather.evans5@va.gov).

Published Online: April 24, 2024. doi:10.1001/jamasurg.2024.0784

Conflict of Interest Disclosures: Dr Evans reported receiving a restricted stock award from Crely. No other disclosures were reported.