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Dual Ring Wound Protector Reduces Circular Stapler Related Surgical Site Infections in Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass


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Dual Ring Wound Protector Reduces Circular Stapler Related Surgical Site Infections in Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass

Jennwood Chen, MD, Margaux Miller, MS, Ellen Morrow, MD, Anna R. Ibele, MD, Robert Glasgow, MD, Eric T. Volckmann, MD



•Circular (EEA) stapler use to create the gastrojejunostomy (GJ) during laparoscopic Roux-en-Y gastric bypass (LRYGB) allows for a predetermined, reproducible anastomosis
•One drawback of this method is an increased risk of surgical site infection (SSI). 
•To reduce SSI costs and complications, physical barrier methods have been developed to protect incision sites .
•Plastic adhesive drapes and strict asepsis with repeat scrubbing before laparotomy closure have not been shown to reduce SSI risk .1,2
•Wound edge protectors (WEP) have shown the most promise in SSI reduction for abdominal surgery. While single ring devices have not been proven effective, dual ring WEPs significantly reduce the SSI incidence in contaminated laparotomies.3
•Use of  WEPs during laparoscopic sleeve gastrectomy have been shown to decease time and physical effort in extracting resected gastric segments.4
•Although the effectiveness of decreasing SSI in colorectal resection surgery has been demonstrated5, the outcomes of dual ring WEP in LRYGB have yet to be explored. 


To investigate the effect of a dual ring wound protector on SSIs when used during LRYGB with circular stapled GJ. 


•A retrospective study of SSI incidence in patients undergoing LRYGB before and after University of Utah bariatric surgical group wide implementation of dual ring WEP.
•Wound infection prevention prior to our intervention included use of a plastic protective sleeve over the stapler along with the conical EEA introducer followed by primary closure with or without wound irrigation, packing, or drainage.
•Intervention involved insertion of an XX-small (1-3 cm) dual ring WEP through a 15 mm port.  The EEA stapler (with conical introducer) used for GJ creation was then  introduced and removed through the dual ring WEP.
•Pre and post-intervention groups were compared with respect to SSIs, age, gender, body mass index (BMI), and smoking status as well as diabetes (DM), hypertension (HTN), and hyperlipidemia (HLD).
•Statistical analysis included t-tests, chi-squared or Fisher’s exact tests as appropriate.


•Between April 15th, 2015 and January 31st, 2017, our surgeons performed 158  primary LRYGBs using a circular stapler for the GJ.
•There were 84 patients (53%) in the pre-intervention group and 74 (47%) in the post-intervention group.
•The pre and post-intervention groups did not differ with respect to age, gender, BMI, smoking status or prevalence of DM, HTN or HLD.
•The SSI rate for the pre-intervention group was 9.5% while the SSI rate was 1.35% in the post-intervention group (p = 0.037).
•Thus, the use of a dual ring wound protector for LRYGBs with circular stapled GJ was associated with an 8.15% decrease in SSIs.


In our single center study, using the smallest size dual ring wound edge protector in conjunction with a conical EEA introducer for LRYGBs with circular stapled GJ as part of a system-wide intervention significantly decreased SSIs. Further studies are warranted to confirm these findings, and more experience with the wound protector may further lower wound infection rates.


1. Webster J, Alghamdi A. Use of plastic adhesive drapes during surgery for preventing surgical site infection. Cochrane Database of Systematic Reviews 2015, Issue 4. Art.

2. Ortiz H, Armendariz P, Kreisler E, Garcia-Granero E, Espin-Basany E, Roig JV, Martín A, Parajo A, Valero G, Martínez M, Biondo S. Influence of Rescrubbing Before Laparotomy Closure on Abdominal Wound Infection After Colorectal Cancer SurgeryResults of a Multicenter Randomized Clinical Trial. Arch Surg.

 3. Zhang, M.-X., Sun, Y.-H., Xu, Z., Zhou, P., Wang, H.-X. and Wu, Y.-Y. (2015), Wound edge protector for prevention of surgical site infection in laparotomy: an updated systematic review and meta-analysis. ANZ J Surg

4. Gabrielsen J, Petrick A, Ibele A, Wood GC, Benotti P. A Novel Technique for Wound Protector Deployment and Efficient Specimen Extraction Following Laparoscopic Sleeve Gastrectomy. Journal of Gastrointestinal Surgery2014.

5. Cheng, K. P., Roslani, A. C., Sehha, N., Kueh, J. H., Law, C. W., Chong, H. Y. and Arumugam, K. (2012), ALEXIS O-Ring wound retractor vs conventional wound protection for the prevention of surgical site infections in colorectal resections1. Colorectal Disease, 14.


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