Negative-Pressure Wound Therapy for Surgical Site Infection Prevention After Elective Open Abdominal Surgery: A Risk-Stratified Systematic Review and Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Surgical-site infection (SSI) is a major source of morbidity after elective open abdominal surgery. Prophylactic negative-pressure wound therapy (NPWT) may reduce SSI, but evidence specific to elective surgery remains limited. METHODS: PubMed, Embase, CENTRAL, Scopus, and Web of Science were searched through June 2026 for RCTs comparing prophylactic NPWT with standard wound dressing (SWD) in adults undergoing elective open abdominal surgery. The prespecified primary outcome was overall SSI within 30 days. Random-effects (REML) meta-analysis generated risk ratios or mean differences with 95% confidence and prediction intervals; certainty was assessed using GRADE. RESULTS: Sixteen RCTs (2 639 patients) were included; 13 were at low risk of bias. NPWT reduced overall SSI (15 RCTs, 2 134 patients; RR 0.60, 95% CI 0.43-0.84; low certainty; absolute risk 12.6% vs 19.5%, approximately 7% reduction; NNT≈15), superficial SSI (RR 0.58, 95% CI 0.35-0.98), and seroma (RR 0.57, 95% CI 0.38-0.86; both high certainty). No significant differences were observed in deep SSI, hematoma, dehiscence, readmission, length of stay, blood loss, operative time, or mortality. Benefit was concentrated in lower-income-country trials and high-risk patients, whereas high-income multicenter trials showed no benefit. Prediction intervals crossed the null, and funnel asymmetry suggested possible publication bias. CONCLUSIONS: NPWT may reduce overall SSI, superficial SSI, and seroma after elective open abdominal surgery, but effects appear context-dependent and were absent in the highest-quality multicenter trials. Routine use in unselected elective patients is not supported; selective use in high-risk patients may be appropriate, pending confirmatory trials such as PROPEL-2.