Surgical site infections (SSI) following emergency laparotomies is one of the most common complications. The incidence ranges from 30-60 % in various studies.[1,2] The risk of SSI in emergency laparotomies increases due to various factors like increased contamination, inadequate pre-operative optimization, increased duration of surgery and compromised nutritional status. Co morbid conditions like diabetes mellitus and obesity also contribute to increased incidence of SSI.[2,3] SSI can be minimised by adequate pre operative preparations, infection control, and use of appropriate antibiotic prophylaxis. Proper wound care needs to be done in SSI with targeted antibiotic therapy.[2,3] Tolat A et al has shown that delayed wound closure with absorbable suture in emergency laparotomies has shown better outcomes with respect to wound related complications.[4] Similar results were observed by Mehta et al.[5] The current study compares the role of primary closure versus delayed closure of wound in emergency laparotomies.

A prospective randomised study was carried out in 50 patients who underwent emergency laparotomies at tertiary care centre from October 2022 to October 2023. The permission to conduct the study was taken from institutional ethics committee. Informed consent was taken from the patients for inclusion into the study. Inclusion criteria: All patients undergoing emergency exploratory laparotomy with intestinal perforations within study period and giving consent for the study Exclusion criteria: Elective laparotomies, patients with 2 or more comorbid conditions, immunocompromised patients, patients not giving consent. Patient were randomised into two groups of 25 patients in each group based on inclusion and exclusion criteria. Computerized randomisation was done and envelopes given to patients to allocate group. Group A (n=25) underwent delayed primary closure (DPC) of wound that is 4 days or later while Group B (n=25) underwent primary closure (PC) that is at time of surgery. Same suture material was used in both groups for closure (Nylon 1-0 cutting needle). Patients were followed for 4 weeks and observed for wound infection and wound dehiscence. The primary outcome is the rate of surgical site infection (SSI) and the second outcome is length of hospital stay (LOS). Statistical analysis was done on SPSS software (version 21) and Microsoft excel sheet 2021. Means and standard deviations were calculated using Mann Whittney test. P value calculated with student t test and Chi square test. P value of less than .05 was considered significant.

The mean age of patients was 43.02 years. Group A (DPC) had a mean age of 42.96 years and Group B had a mean age of 43.08 years. The ratio of male: female in Group A was 20:5 while it was 19:6 in Group B (Table 1). Both groups were comparable with respect to age and sex distribution. In both groups common indication was illeal perforation while prepyloric perforation was second commonest in group A and duodenal perforation in group B. (Table 2) There is statistically significant number of patients had discharge from the wound in Group B than group A on follow up week 1,2 and 3 (p<.05). However, no difference was observed after week 4. (Table 3) Majority of patients in Group A had low grade SSI (0 in 32%, n=8) while it was IIIa in majority patients in group B (n=6, 24%). (Figure 1) Incidence of SSI was significantly higher in Group B as compared to group A (p=.007). (Table 4) The mean length of stay in hospital was 11.48 days in Group A while it was 17.2 days in group B. The difference was statistically significant with p=.002. (Figure 2) Tables: Table 1 – Age distribution of patients Group t-value p-value Group A Group B Total Age N 25 25 50 .027 .979 Mean 42.96 43.08 43.02 Standard Deviation 15.37 16.21 15.63 Minimum 19.00 18.00 18.00 Maximum 75.00 75.00 75.00 Table 2– Indication of emergency laparotomy Indications of laparotomy Group A Group B Total Colonic perforation 1 4.0% 0 0.0% 1 2.0% Concealed ileal perforation 0 0.0% 1 4.0% 1 2.0% D-J Perforation 0 0.0% 1 4.0% 1 2.0% Duodenal perforation 3 12.0% 6 24.0% 9 18.0% Enteric fever with ileal perforation 0 0.0% 1 4.0% 1 2.0% Gastric perforation 3 12.0% 0 0.0% 3 6.0% Ileal perforation 6 24.0% 9 36.0% 15 30.0% Ileocecal perforation 1 4.0% 0 0.0% 1 2.0% Jejunal perforation 2 8.0% 1 4.0% 3 6.0% Multiple colonic perforation 1 4.0% 0 0.0% 1 2.0% Multiple Ileal perforations 0 0.0% 1 4.0% 1 2.0% Multiple Intestinal perforations with Gall bladder perforation 0 0.0% 1 4.0% 1 2.0% Prepyloric perforation 5 20.0% 0 0.0% 5 10.0% Pyloric perforation 2 8.0% 2 8.0% 4 8.0% Rectal perforation 0 0.0% 1 4.0% 1 2.0% Rectosigmoid perforation 1 4.0% 0 0.0% 1 2.0% Transverse colon perforation 0 0.0% 1 4.0% 1 2.0% Total 25 100.0% 25 100.0% 50 100.0% Table: 3 Discharge from surgical site Group Chi-Square p-value Group A Group B Total Week 1 Yes 13 52.0% 22 88.0% 35 70.0% 7.714 .005** No 12 48.0% 3 12.0% 15 30.0% Week 2 Yes 4 16.0% 15 60.0% 19 38.0% 10.272 .001** No 21 84.0% 10 40.0% 31 62.0% Week 3 Yes 0 0.0% 4 16.0% 4 8.0% 4.348 .037* No 25 100.0% 21 84.0% 46 92.0% Week 4 Yes 0 0.0% 2 8.0% 2 4.0% 2.083 0.149 No 25 100.0% 23 92.0% 48 96.0% Total 25 100.0% 25 100.0% 50 100.0% Table 4 – Incidence of SSI Group Chi-Square p-value Group A (DPC) Group B (PC) Total SSI Yes 12 48.0% 21 84.0% 33 66.0% 7.219 .007** No 13 52.0% 4 16.0% 17 34.0% Total 25 100.0% 25 100.0% 50 100.0%

The study was conducted for one year on cases of emergency laparotomy with perforation peritonitis. The comparison of wound closure is done and outcomes were observed. The mean age of patients presented to us was comparable in both groups. Most of the patients were in 4th and 5th decade of life. The study was comparable to Eswar et al which showed the mean age of patients were 44.12 years.[2] Similar findings were observed by Mehta et al where most common age group involved was 36-45 years.[5] However, study conducted by Tolat et al showed mean age of emergency laparotomies were 34 years which was slightly lower as compared to current study.[4] The difference could be due to regional incidences. Although the current study was comparable with respect to sex distribution however, male to female ratio was higher in both the groups. The overall male: female ratio was 3.5:1. Similar findings were observed by Tolat et al that show the ratio of 4.8:1.[4] Eswar et al[2] reported slightly slightly less difference with ratio of 2.2:1 while Mehta et al[5] reported almost equal ratio that is 1.94:1. Majority of patients in the current study had duodenal (18%) and illeal (30%) perforation followed by pyloric (8%) and prepyloric (10%) perforations. Study was similar to Tolat et al that observed the majority patients had illeal perforations (24.3%) followed by pyloric perforations (12.1%).[4] As per the study conducted by Lohith et al the commonest site of perforation in India is ileum (32%) followed by appendix and stomach (18% each). The reason was attributed to higher incidence of tuberculosis and enteric fever.[6] Deolakar et al also observed similar results with ileum as commonest site of perforation which was in 30% cases.[7] Surgical site infections (SSI) were higher in group B as compared to group A with significant results observed at 1st, 2nd and 3rd week. It has been observed in many studies that majority of emergency laparotomies had contaminated wounds and often presented with discharge from wound with various organism cultured, hence higher incidence of SSI.[2,6,7] Delayed primary closure had been observed to reduce incidence of post operative SSI. The study conducted by Sasikumar et al observed comparatively less chances of SSI if wound closure was delayed in perforation peritonitis cases.[8] Nayak et al observed that significantly lower incidence of SSI in delayed primary closure (p=.01).[9] Venkateswaran et al also observed significantly lower incidence of SSI in delayed primary closure (p=.00045).[10] The current study also showed similar results with 84% (n=21)patients in group B showing SSI while only 48% (n=12) in group A had SSI which was statically significant (p=.007). The mean hospital stay was longer in group B as compared to group A. The results were significant with p=.002. Similar findings were observed by Nayak et al where mean hospital stay was 12.8 days vs 15.6 days in delayed primary closure group and primary closure group respectively with p value of .002.[9] Significant findings were observed by Sasikumar et al where there is reduced hospital stay in patients having delayed primary closure (p=.001).[8] Venkateswaran et al although showed least hospital stay in primary closure group with uncomplicated cases however there is significantly higher complications rates in primary closure group with longer duration of stay.[10] Hence the morbidity is reduced with delayed primary closure. Although the study was conducted thoroughly but there are certain limitations of the study. The sample size is small. The results can be more accurately observed with large sample sizes and meta-analysis.

The current study concludes that delayed primary closure is good option to reduce SSI and reduce the hospital stay. There is significantly less chances of infection in delayed primary closure and hence reduce morbidity and better patient outcomes.

1. Bansal AR, Mallick MR, Jena S. A study of post-operative complications of all emergency laparotomy in a tertiary care hospital within 90 days. Arch Clin Gastroenterol [Internet]. 2019;5(2):015–8. Available from: http://dx.doi.org/10.17352/2455-2283.000062 2. Eswar PS, Bhimani Z, Shah N, Singh S, Malik M. Incidence of surgical site infection following elective vs emergency laparotomy surgeries, the microorganisms isolated and their sensitivity pattern: A prospective, comparative, observational, single center study. International Journal of Advanced Research in Medicine. 2025;7(2):30-33. 3. Prakash P, Jaiswal S, Srivastava VK, Srivastava N. Evaluation of Surgical Site Infection Rates in Emergency vs Elective Laparotomy: A Cross-Sectional Analysis in a Tertiary Care Center. Journal of Contemporary Clinical Practice. 2025 May;11(5):546-550. DOI : 10.61336/jccp/25-05-76 4. Tolat A, S V A, Chejara R, et al. Evaluation of Wound Closure Outcomes Using Barbed Delayed Absorbable Polydioxanone Sutures After Emergency Laparotomy: An Observational Study. Cureus 2025 Jan;17(1): e77257. doi:10.7759/cureus.77257 5. Mehta N, Meman A, Chauhan H. Comparative study between delayed absorbable and nonabsorbable sutures in cases of abdominal fascia closure for laparotomy. IOSR Journal of Dental and Medical Sciences (IOSR-JDMS) 2020 Oct;19(10):53-55. DOI: 10.9790/0853-1910015355 6. Lohith P, Jindal RK, Ghuliani D, PR. The anatomical site of perforation peritonitis and their microbiological profile: a cross-sectional study. International Surgery Journal 2020;7(4):1251–1257. https://doi.org/10.18203/2349-2902.isj20201407 7. Deolekar S, Patil R, Sawant M, PS. Microbiological Profiles of the Anatomical Sites of Perforation Peritonitis: A Cross-Sectional Study. Cureus 2024 July;16(7): e64415. doi:10.7759/cureus.64415 8. Sasikumar MN, Mammen SC. Primary versus delayed wound closure technique in laparotomy wound of perforation peritonitis. Int Surg J. 2019 Oct;6(10):3708-3714. DOI: http://dx.doi.org/10.18203/2349-2902.isj20194429 9. Nayak KK, Patel KS, Bhagat V, Chaudhary P. Study of Outcome of Primary Skin Closure and Delayed Skin Closure in Class III and Class IV Abdominal Surgical Wounds. CME Journal Geriatric Medicine. 2025 Feb;17(2):1-6. 10. Venkateswaran R, Bhagvat S, Dutt A, Padekar HD, Mirkhushal N, Chetan AA. Primary Closure Versus Delayed Primary Closure of Class III and IV Surgical Wounds Following Emergency Laparotomy: A Prospective Comparative Study. Cureus. 2023 Nov 17;15(11):e48965. doi: 10.7759/cureus.48965. PMID: 38024020; PMCID: PMC10656080.