Introduction

Surgical site infections (SSIs) are among the most common post-surgical complications. In clean surgical infections, the SSI rate is as low as 0.3-1.9%. However, in cases with an active infection, this post-surgical complication is very likely to manifest. The risk for SSI is multifactorial; patients with relatively higher body mass indices (BMIs) show a greater predilection.

The preventive measures include surgical site antisepsis and perioperative antibiotic prophylaxis. Povidone-iodine (PVP-I) solution is a commonly used agent for pre-surgical skin decontamination. 

Laparoscopic gynecological procedures are now gaining popularity as they offer certain advantages, such as – rapid recovery, improved fertility rate, indistinct scars, and lower costs. These interventions entail vaginal instrumentation––which exposes the surgical site to an array of pathogens. Hence, preoperative skin preparation is crucial during such procedures and the antiseptic agent must be carefully selected to eliminate the chances of post-surgical infection.^1,2

Case Report

A 32-year-old female presented with dysmenorrhea, pelvic pain, and dyspareunia. She reported having pelvic pain on both sides. She did not have symptoms of a urinary tract infection.

The woman had been married for seven years and did not have any children. She had been diagnosed with cystic ovary previously and reported failure to conceive.

Transvaginal ultrasonography was advised which confirmed cystic endometriomas.

The patient was indicated for an elective operative laparoscopy. The patient did not have any active infection and was negative for drug allergies. A standardized presurgical antibiotic prophylaxis was prescribed.

During the surgical procedure, the abdominal and vaginal, and vulvar surgical sites were prepared with an aqueous povidone-iodine solution (Aqu-PVP-I). Hysterectomy was not an option as the lady was nulligravida. Thus, laparoscopic excision of the endometriomas was carried out for fertility preservation.

The skin incisions were approximated with interrupted 3-0 non-resorbable polypropylene sutures. For post-surgical skin cleansing, Aqu-PVP-I was used. 

On follow-up, the woman’s pelvic pain had subsided. The patient rapidly recovered and her surgical sites healed without significant scars. She did not experience any post-surgical infection or related complications. There was no recurrence of endometriosis on long-term follow-up.

PVP-I effectively prevented surgical site infection, as well as accelerated wound healing of this patient. 

Discussion

PVP-I is known for its antiseptic properties and is widely used for surgical site infection prevention. This broad-spectrum antimicrobial agent is bactericidal against both, Gram-positive, -negative, and multi-drug resistant organisms, for example – Staphylococcus aureus, Pseudomonas, Enterococcus, and Mycobacterium. Its microbicidal action encompasses viruses, fungi, protozoa, and spores. An advantage of topical antimicrobial use is that they reduce the chances for antibiotic resistance development. 

PVP-I aids in acute and chronic wound healing without causing resistant bacterial growth or cross-resistance. Added benefits of PVP-I use include – anti-inflammatory properties, low cytotoxicity, biofilm penetration, and good tolerability. Its most remarkable property lies in its wound-healing effect.^3,4

PVP-I has been used over decades and across countries during almost all surgical procedures – for surgical antisepsis, preoperative surgical site preparation, and for wound healing assistance. PVP-I offers a cost-effective option for surgical antisepsis and wound healing promotion. Some common surgical interventions in which PVP-I is routinely used include – orthopedic, gastrointestinal, urinary tract, and ocular surgeries, as well as during implant placement procedures.^{5,6, 7,8,9,10} 

Adequate evidence is also related to the efficacy of PVP-I antisepsis during contaminated surgical procedures.

Conclusion

Wound irrigation with PVP-I solution is an effective measure for preventing SSI when used for surgical site preparation during gynecological surgeries. PVP-I use benefits by providing added advantages of anti-inflammatory action and enhanced wound healing. This agent actively abolishes a wide range of microbes, including – bacteria, viruses, fungi, protozoa, and spores, as well as multi-resistant pathogens. Furthermore, its topical use allows for the avoidance of developing antibiotic resistance as it minimizes the use of pre-and post-surgical antibiotics. PVP-I also does not confer resistant bacterial growth or cross-resistance. 

Thus, PVP-I use is safe and effective and has been widely used during surgical procedures for preventing and treating SSIs.

References

1. Dior UP, Kathurusinghe S, Cheng C, et al. Effect of Surgical Skin Antisepsis on Surgical Site Infections in Patients Undergoing Gynecological Laparoscopic Surgery: A Double-Blind Randomized Clinical Trial. JAMA Surg. 2020;155(9):807-815. doi:10.1001/jamasurg.2020.1953
2. Schrager SB, Falleroni J, Edgoose J. Evaluation and treatment of endometriosis. Am Fam Phys. 2013;87(2):107-13.
3. Bigliardi PL, Alsagoff SAL, El-Kafrawi HY, Pyon JK, Wa CTC, Villa MA. Povidone iodine in wound healing: A review of current concepts and practices. Int J Surg. 2017;44:260-268. doi:10.1016/j.ijsu.2017.06.073
4. Dang T, Yim N, Tummala S, Parsa AA, Parsa FD. Povidone-Iodine versus antibiotic irrigation in breast implant surgery: Revival of the ideal solution. J Plast Reconstr Aesthet Surg. 2020;73(2):391-407. doi:10.1016/j.bjps.2019.09.007
5. Wood T, Ekhtiari S, Mundi R, et al. The Effect of Irrigation Fluid on Periprosthetic Joint Infection in Total Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis. Cureus. 2020;12(4):e7813. Published 2020 Apr 24. doi:10.7759/cureus.7813
6. Yao R, Tan T, Tee JW, Street J. Prophylaxis of surgical site infection in adult spine surgery: A systematic review. J Clin Neurosci. 2018;52:5-25. doi:10.1016/j.jocn.2018.03.023
7. Dumville JC, McFarlane E, Edwards P, Lipp A, Holmes A, Liu Z. Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database Syst Rev. 2015;2015(4):CD003949. Published 2015 Apr 21. doi:10.1002/14651858.CD003949.pub4
8. Koederitz NM, Neely DE, Plager DA, et al. Postoperative povidone-iodine prophylaxis in strabismus surgery. J AAPOS. 2008;12(4):396-400. doi:10.1016/j.jaapos.2007.10.005
9. Wu PC, Li M, Chang SJ, et al. Risk of endophthalmitis after cataract surgery using different protocols for povidone- iodine preoperative disinfection. J Ocul Pharmacol Ther. 2006;22(1):54-61. doi:10.1089/jop.2006.22.54
10. Dang T, Yim N, Tummala S, Parsa AA, Parsa FD. Povidone-Iodine versus antibiotic irrigation in breast implant surgery: Revival of the ideal solution. J Plast Reconstr Aesthet Surg. 2020;73(2):391-407. doi:10.1016/j.bjps.2019.09.007