No drain, no antibiotics, and biological glue: Are doctors not afraid of infection?

Of course, in this world, if any surgeon tells you they are not afraid of infection, they are probably … lying. I am not just afraid; I am extremely afraid.

However, being afraid does not mean we should use antibiotics indiscriminately just to … ease our fear, nor does it mean failing to apply new scientific and technical improvements to enhance patient satisfaction and convenience. Every improvement must be meticulously researched and scientifically grounded. I am proud to say that over the last two years, I have not prescribed postoperative antibiotics for most of my orthopedic and sports medicine surgeries, yet the infection rate has been somewhere around just 1 or 2 cases. And in the past 10 months, with an experience of about hundreds of major surgeries as well as minor carpal tunnel procedures using biological glue, (touch wood) no infection has been recorded yet. Along with this is a reduction in the risk of multi-drug resistant bacteria caused by the overuse of antibiotics.

So in this article, I will analyze it so everyone can understand why we can do this.

During surgery, there are 2 groups of solutions that help us combat infection:

1. The first group of solutions reduces or weakens the attacking factors (bacteria), such as: operating room sterilization, instrument sterilization, adherence to aseptic principles in the operating room (proper scrubbing, gowning, gloving, and masking, etc.), scrubbing and disinfecting the surgical site, using prophylactic antibiotics during surgery, postoperative wound care and dressing changes, and shortening the duration of surgery.
2. The second group of solutions enhances the defense and protective factors, such as performing surgery to reduce soft tissue trauma, minimizing intraoperative blood loss, using small minimally invasive incisions or arthroscopic surgery…

I will talk about the second group first because this depends largely on the surgeon. The use of minimally invasive incisions plays a very important role. The concept of "minimally invasive" is not about making the incision as small as possible, but about causing as little muscle and soft tissue damage as possible. For example, the muscle-sparing hip approach. To reach the inside of the bone or joint, bacteria must pass through the layers of skin, subcutaneous tissue, tendons, muscles, and joint capsule. If these layers are preserved intact, they will form a strong barrier preventing bacteria. Even when using large incisions, following the anatomical intermuscular planes correctly, minimizing the use of electrocautery, and preserving the periosteum will always help the wound heal faster, reduce pain, and decrease blood loss. And when there is no bleeding, we can omit drains and apply biological glue.

Limiting blood loss is also extremely important. Just like two armies fighting, the food supply line is always crucial. When surgery involves significant blood loss, it means the nutritional supply to the wound will be poorer, leading to delayed healing and an increased risk of infection.

The first group of solutions sounds easy to do, but in reality, it is harder because it requires the coordination of many steps and dozens of medical staff during the pre-, intra-, and postoperative phases. When interacting with me during a consultation, patients might feel that I am quite a humorous person, but in the operating room, it is the exact opposite—I am very strict. Nobody wants to be strict in the operating room, but if we are not strict, the one who pays the price is sometimes the patient. I always demand that surgical instruments be autoclaved, surgical wounds be carefully scrubbed and disinfected, and everyone present in the operating room must strictly respect aseptic principles, which makes me the "scrutineer" with "killer eyes".

Photos 1-2: The killer eyes specializing in finding faults of Dr. Vu Anh

One typical example that I really hate is wearing a mask with both nostrils exposed. That is so foolish because it means all bacteria from the upper respiratory tract will fly straight into the surgical wound, and by the way, if you want to sneeze, what would you do? And there are many other examples that can harbor infection risks. In short, rules are established for us to follow, not to violate, because obviously, the issue here is the patient's best interest.

So when these two groups of solutions are well executed, we can be completely confident in performing surgeries without drains, using biological glue, and without postoperative antibiotics. Of course, all theories are relative. There are still some infection cases that cannot be explained, and it also depends on each surgical facility to apply them flexibly rather than generalizing everything.

Whether or not to use antibiotics is not meant to show whose surgical skills are better than another's; rather, it reflects the surgeon's careful thought and consideration before prescribing antibiotics to the patient. If a case is assessed as having an infection risk, using antibiotics is extremely necessary, and vice versa.

And finally, the most important thing is probably the companionship, sharing, and empathy from both sides—the doctor and the patient—during the treatment process, whether it is a smooth, successful surgery or an unfortunate infection.