Does using a laparoscopic approach to cholecystectomy decrease the risk of surgical site infection?

The role of antimicrobial prophylaxis in laparoscopic nephrectomy for renal cell carcinoma

BACKGROUND

To investigate the role of antimicrobial prophylaxis in laparoscopic nephrectomy for renal cell carcinoma.

METHODS

We retrospectively enrolled 1000 patients who underwent laparoscopic nephrectomy from August 2019 to November 2021 in the Peking Union Medical College Hospital. Patients were divided into group without antimicrobial prophylaxis (n = 444) and group with antimicrobial prophylaxis (n = 556). Outcomes including 30-day postoperative infection rate, the increase rate of pre- and post-operative white blood cell counts and hospital stay were analyzed.

RESULTS

The overall infection rate was 5.0% (28/556) in the group with antimicrobial prophylaxis, which was similar to 4.1% (18/444) in the group without antimicrobial prophylaxis (P = 0.461). The increase rate of pre- and post-operative white blood cell counts was significantly lower (85.5% versus 97.0%) in the group with antimicrobial prophylaxis (P = 0.004). The postoperative hospital stay was 5 (4, 6) days in both groups (P = 0.483). Logistic regression analyses identified the use of antimicrobial prophylaxis had no influence on the occurrence of infection events (odds ratio = 0.797; 95% confidence interval, 0.435-1.460; P = 0.462). Hemoglobin (odds ratio = 0.430; 95% confidence interval, 0.257-0.719; P = 0.001) and partial nephrectomy (odds ratio = 2.292; 95% confidence interval, 1.724-3.046; P < 0.001) influenced the use of antimicrobial prophylaxis independently.

CONCLUSIONS

The use of antimicrobial prophylaxis had no impact on postoperative infection in patients receiving laparoscopic nephrectomy for renal cell carcinoma.

Randomized controlled trial of olanexidine gluconate and povidone iodine for surgical site infection after gastrointestinal surgery

Aim

Antiseptics used at surgical sites are vital to preventing surgical site infections (SSI). In this study, a comparative investigation of the novel antiseptics olanexidine gluconate (OG) and povidone-iodine (PI) was conducted to determine whether OG is more effective than PI against SSI after gastrointestinal surgery.

Methods

This prospective, randomized, single-blind, interventional, single-center study was conducted between August 2018 and February 2021. Patients scheduled for large-scale gastrointestinal surgeries were randomized into two groups and administered OG (OG group) or PI (PI group) as preoperative antiseptics. The primary endpoint was the SSI occurrence rate within 30 days after surgery.

Results

In total, 525 patients were enrolled in this study, of whom 256 and 254 were in the OG and PI groups, respectively. The total SSI occurrence rate in the OG group (10.8%; n = 26) and the PI group (13.0%; n = 33) was not significantly different (p = 0.335). The occurrence rate of superficial incisional SSI and organ/space SSI did not significantly differ between the groups; however, that of deep incisional SSI showed a significant difference, with 0.4% (n = 1) in the OG group and 4.3% (n = 11) in the PI group (p = 0.003).

Conclusion

OG, as a preoperative skin antiseptic, did not reduce the occurrence rate of total SSI. However, deep incisional SSI may be reduced using OG.

Topical antibiotics in the prevention of port-site infection after elective day care laparoscopic cholecystectomy

BACKGROUND

Wound-related infections and complications are rare after day care laparoscopic cholecystectomy (LC). They can have a significant adverse impact on the postoperative course after an uneventful elective LC. The use of topical antibiotics over the port site may prevent such complications.

MATERIALS AND METHODS

This trial was conducted from January 2018 to June 2019. Two hundred and fifty patients who met the inclusion and exclusion criteria were included in the study. They were randomized into the topical antibiotic group (Group A, n = 125) and control group (Group B, n = 125). All patients underwent four-port LC. Mupirocin 2% topical antibiotic ointment was applied to all four-port sites in Group A, whereas no topical antibiotic was used in Group B. One dose of prophylactic systemic antibiotics was given to all patients in both groups.

RESULTS

The mean age was 43.22 ± 12.7 years in Group A and 43.44 ± 12.5 years in Group B. The comorbidities and the other variables were comparable between the two groups. The port-site infection (PSI) was observed in one patient in Group A and three patients in Group B, which was statistically nonsignificant (P = 0.622). The mean time of detection of infection was 4.75 ± 1.7 days. All the infections were superficial surgical site infections. Microbiological swabs culture of the infected wounds yielded no growth of bacteria.

CONCLUSION

The PSI after LC is very less. The use of topical antibiotics to prevent PSIs after LC could not be established.

Prevalence and risk factors of post-cholecystectomy surgical site infections

Objectives

The objectives of this study were to measure the prevalence of post-cholecystectomy surgical site infection and identify the associated risk factors and their association with its prevalence.

Method

A cross-sectional analytical study including all patients who underwent cholecystectomy in the period from January 2021 to March 2022. The data sheet was filled with records of the patients, and some questions were asked of the patients directly. Many risk factors were assessed and measured in their association with the development of postoperative SSI.

Results

One hundred seventy-two patients with a mean age of 46.41±13.37 participated in the study. Thirty-five (20.3%) of them were males, and 137 (79.7%) were females. Open cholecystectomy 121 (70.3%) was done more than laparoscopic cholecystectomy 51 (29.7%). The most common indication for cholecystectomy was found to be both cholecystitis and cholelithiasis (53.5%). Out of 172 patients, postoperative wound infection [surgical site infection (SSI)] developed in 29 (16.9%) patients. Of these, 8 (27.6%) were males, while 21 (72.4%) were females, with a mean age of 46.38 (SD=14.12) years. Prophylactic antibiotics intraoperatively and therapeutic antibiotics postoperatively were found to decrease the risk of developing SSI [P=0.005, odds ratio (OR)=0.073] (P=0.012, OR=0.153), respectively. However, hospital stay after surgery (<1 week) was also found to decrease the risk (P=0.001, OR=0.179).

Conclusions

The prevalence of post-cholecystectomy SSI is high despite a small sample size in comparison with other studies. Prophylactic antibiotics and short hospital stays have an important role in decreasing the risk of developing postoperative SSI.

Biocompatibility of Antifogging SiO-doped Diamond-Like Carbon Laparoscope Coatings

Laparoscopes can suffer from fogging and contamination difficulties, resulting in a reduced field of view during surgery. A series of diamond-like carbon films, doped with SiO, were produced by pulsed laser deposition for evaluation as biocompatible, antifogging coatings. DLC films doped with SiO demonstrated hydrophilic properties with water contact angles under 40°. Samples subjected to plasma cleaning had improved contact angle results, with values under 5°. Doping the DLC films with SiO led to an average 40% decrease in modulus and 60% decrease in hardness. Hardness of the doped films, 12.0 - 13.2 GPa, was greater than that of the uncoated fused silica substrate, 9.2 GPa. The biocompatibility was assessed through CellTiter-Glo assays, with the films demonstrating statistically similar levels of cell viability when compared to the control media. The absence of ATP released by blood platelets in contact with the DLC coatings suggests in vivo hemocompatibility. The SiO doped films displayed improved transparency levels in comparison to undoped films, achieving up to an average of 80% transmission over the visible spectrum and an attenuation coefficient of 1.1 × 10⁴ cm^-1 at the 450 nm wavelength. The SiO doped DLC films show promise as a method of fog prevention for laparoscopes.

Perforated appendicitis treated with laparoscopic appendicectomy or open appendicectomy: A meta-analysis

Aim

This analysis compared the impact of laparoscopic appendicectomy (LA) and open appendicectomy (OA) on treating adult perforated appendicitis (PA).

Methods

Articles relating to LA and OA in treating PA were retrieved from databases including PubMed, Cochrane Library and Embase since their founding to January 2022. These articles were independently filtered based on the inclusion and exclusion criteria by two investigators. The quality of these articles was assessed and article data were extracted. Dichotomous data were presented in the form of odd's ratio (OR), whereas continuous data were in the form of weighted mean difference (WMD). The included articles reported at least one of the following outcomes: intra-abdominal abscess (IAA), wound infection, operative time, hospital stay and complications.

Results

Three randomised control trials (198 LA cases vs. 205 OA cases) and 12 case - control trials (914 LA cases vs. 2192 OA cases) were included. This analysis revealed that although the IAA formation rate was similar in the LA and OA groups (OR: 1.28, 95% confidence interval [CI]: 0.87-1.88), the wound infection rate was lower in the LA group (OR: 0.38, 95% CI: 0.28-0.51). Furthermore, LA was associated with shorter hospital stay (WMD: -1.43 days, 95% CI: -2.33--0.52) and fewer complications than OA (OR: 0.40, 95% CI: 0.28-0.57).

Conclusion

LA has significant benefits in treating PA and is associated with better post-operative outcomes such as shorter hospital stay, lower incidence of wound infection and other complications. However, more studies with randomised and large-sample populations are still required to determine the clinical benefit of LA in treating PA.

Safety of laparoscopic cholecystectomy in patients with a cerebrospinal fluid shunt in the peritoneal cavity

INTRODUCTION

The management of patients with a cerebrospinal fluid (CSF) shunt located in the peritoneal cavity undergoing laparoscopic surgery is an issue that has not yet been settled. These patients are at risk of increased intracranial pressure caused by peritoneal insufflation, shunt dysfunction, and shunt infection/retrograde meningitis. This study aimed to determine the need for perioperative shunt intervention in CSF shunt patients undergoing laparoscopic cholecystectomy.

METHODS

We reviewed and analyzed five shunt patients who underwent laparoscopic cholecystectomy in our institution between 2012 and 2022, as well as 17 patients described in previous reports.

RESULTS

Among the 22 patients, shunt type was ventriculoperitoneal in 14 and lumboperitoneal in eight. The most common indication for CSF shunt was hydrocephalus caused by cerebral vascular accident (50.0%). Laparoscopic cholecystectomy was performed for cholecystolithiasis in 13 patients (59.1%), acute cholecystitis in eight (36.4%), and gallbladder polyp in one (4.5%). Shunt clamping or externalization was performed in six patients. Two patients in the group that did not undergo shunt clamping or externalization experienced complications (intra abdominal abscess and subcutaneous emphysema). However, the incidence of short-term complications (both overall and shunt-related) and median length of hospital stay did not significantly differ between the two groups.

CONCLUSION

Routine shunt clamping, externalization, or removal might not be necessarily required in patients with a ventriculoperitoneal or lumboperitoneal shunt undergoing laparoscopic cholecystectomy.

Impact on infectious outcomes during laparoscopic cholecystectomy with the use of home-made vs commercial gallbladder retrieval bag: a retrospective comparative study in a high-volume center

BACKGROUND

Laparoscopic cholecystectomy (LC) is one of the most commonly performed emergency procedures, with approximately 600,000 patients undergoing the procedure every year in the United States. Although LC is associated with fewer complications when compared with open cholecystectomy, the risk for infectious complications, including surgical site infection and intra-abdominal abscess, remains a significant source of postoperative morbidity. The goal of this study is to determine whether the gallbladder retrieval technique during LC affects risk of infectious complications.

METHODS AND PROCEDURES

We conducted a retrospective comparative study in a minimally invasive surgery high-volume center in Bogota, Colombia. Patients who underwent LC in 2018 to 2020 were identified. The patients were divided into three groups. One group of LC performed using home-made gallbladder retrieval bag (HMGRB), and another group of LC performed using commercial gallbladder retrieval bag (CGRB). The primary outcomes were infectious complications of superficial site infection and intra-abdominal abscess.

RESULTS

A total of 68 (7.58%) patients underwent LC using an HMGRB, and 828 (92.41%) using a CGRB. There was no significant difference in preoperative sepsis, or sex distribution between patient groups. Using t test, we found differences on age distribution among groups (p < 0.01), surgical times (p < 0.01), and length of stay (p = 0.01). When using Chi square, we found differences in Tokyo and Parkland Grading Scale severity (p < 0.01), use of postoperative antibiotics (p < 0.01), and drain use (p < 0.01). Nonetheless, there was no difference in the rate of superficial surgical site infection (p = 0.92).

CONCLUSION

HMGRB are not associated with increased risk of postoperative intra-abdominal abscess or superficial surgical site infection in comparison with CGRB but imply longer surgical times and length of stay. The use of HMGRB is safe, feasible, and has lower cost during LC.

Laparoscopic vs. open feeding jejunostomy: a systemic review and meta-analysis

BACKGROUND

Feeding jejunostomy is a solid way for patients to maintain enteral nutrition. However, debate over the superiority of the laparoscopic vs. laparotomic method has raised concerns in recent years. This systemic review and meta-analysis aimed to compare the postoperative outcomes between these two approaches.

METHODS

We searched PubMed, Embase, and Scopus from the date of inception to April 2022 for studies comparing laparoscopic and open feeding jejunostomy. Study characteristics and outcomes were extracted from the included articles. The primary outcome was the relative risk (RR) of postoperative complications in each group. We also analyzed the major/minor complication rates and operations, excluding major concomitant procedures. The risk of bias of included studies were assessed using the ROBINS-I tool. The certainty of evidence was rated by the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

A total of seven retrospective studies with 1195 patients in total were included in this systemic review and meta-analysis. Laparoscopic feeding jejunostomy carried a significantly lower postoperative complication rate (RR: 0.62; 95% CI, 0.42-0.91, p = 0.02, low certainty of evidence) compared with laparotomy, and the heterogeneity was moderate (I² = 34%, p = 0.18). After excluding major concomitant procedures, the RR between the laparoscopic and open group was 0.48 (95% CI, 0.33-0.70, p < 0.001, low certainty of evidence), suggesting that the laparoscopic approach was superior in terms of postoperative complications.

CONCLUSIONS

Our results indicate that laparoscopic feeding jejunostomy might reduce the postoperative overall complication rate compared with open feeding jejunostomy.

Surgical Infection Society Guidelines for Antibiotic Use in Patients Undergoing Cholecystectomy for Gallbladder Disease

Background: Manifestations of gallbladder disease range from intermittent abdominal pain (symptomatic cholelithiasis) to potentially life-threatening illness (gangrenous cholecystitis). Although surgical intervention to treat acute cholecystitis is well defined, the role of antibiotic administration before or after cholecystectomy to decrease morbidity or mortality is less clear. Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee convened to develop guidelines for antibiotic use in patients undergoing cholecystectomy for gallbladder disease to prevent surgical site infection, other infection, hospital length of stay, or mortality. PubMed, Embase, and the Cochrane Database were searched for relevant studies. Evaluation of the published evidence was performed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system. Using a process of iterative consensus, all authors voted to accept or reject each recommendation. Results: We recommend against routine use of peri-operative antibiotic agents in low-risk patients undergoing elective laparoscopic cholecystectomy. We recommend use of peri-operative antibiotic agents for patients undergoing laparoscopic cholecystectomy for acute cholecystitis. We recommend against use of post-operative antibiotic agents after elective laparoscopic cholecystectomy for symptomatic cholelithiasis. We recommend against use of post-operative antibiotic agents in patients undergoing laparoscopic cholecystectomy for mild or moderate acute cholecystitis. We recommend a maximum of four days of antibiotic agents, and perhaps a shorter duration in patients undergoing cholecystectomy for severe (Tokyo Guidelines grade III) cholecystitis. Conclusions: This guideline summarizes the current Surgical Infection Society recommendations for antibiotic use in patients undergoing cholecystectomy for gallbladder disease.

Comparison of intra- and postoperative variables between laparoscopic and open ovariectomy in rabbits (Oryctolagus cuniculus)

OBJECTIVE

To compare intraoperative and short-term postoperative variables pertaining to laparoscopic ovariectomy (LapOVE) and open ovariectomy (OVE) in rabbits (Oryctolagus cuniculus).

ANIMALS

Twelve 4- to 5-month-old female New Zealand White rabbits.

PROCEDURES

Rabbits were randomly assigned to undergo LapOVE (n = 6) or OVE (6), with a vessel-sealing device used to seal and transect the ovarian pedicles. Laparoscopic ovariectomy was performed with a 3-port approach. Variables were measured during surgery (surgery and anesthesia times and incision lengths) and for up to 7 days after surgery (food consumption, feces production, body weight, vital parameters, blood glucose and cortisol concentrations, abdominal palpation findings, facial grimace scale scores, and ethograms).

RESULTS

Mean surgery (43.2 vs 21.7 minutes) and anesthesia (76.2 vs 48.8 minutes) times were longer and mean incision length was shorter (24.0 vs 41.5 mm) for LapOVE versus OVE. No significant differences in postoperative variables were identified between groups. During LapOVE, small intestinal perforation occurred in 1 rabbit, which was then euthanized. Postoperative complications for the remaining rabbits included superficial incisional dehiscence (LapOVE, 1/5; OVE, 2/6), subcutaneous emphysema (LapOVE, 1/5; OVE, 0/6), and seroma formation (LapOVE, 1/5; OVE, 0/6).

CONCLUSIONS AND CLINICAL RELEVANCE

Surgery time for LapOVE was twice that of OVE, and LapOVE resulted in unique complications in rabbits. No evidence of a reduction in pain or faster return to baseline physiologic status was found for LapOVE. Further evaluation of LapOVE in rabbits is warranted, with modification to techniques used in this study or a larger sample size.

A cross sectional study of risk factors for surgical site infections after laparoscopic and open cholecystectomy in a tertiary care hospital in North East India

Background:

Surgical site infection (SSI) after cholecystectomy unduly delays patients' early return to normal activities and also leaves behind relatively disfigured cosmetic scars at the port sites. This prospective study was undertaken to assess the various risk factors leading to SSI in patients undergoing cholecystectomy, both by laparoscopic and open techniques in this part of India for which no data is available at present.

Material and Methods:

A total of 1507 cholecystectomies (1184 by laparoscopy and 323 by open technique) during a 6 year period. The various risk factors studied were gender, age, BMI, DM, chronic anaemia, COPD, timing of surgery (elective or emergent), influence of surgeon (operated by resident surgeon or faculty), intraoperative bile spillage, etc., Odd's ratio was calculated to see the influence of the factors on SSI and statistical significance was tested by Chi-square test.

Results:

The overall rate of infection was 3.12% (1.94% in laparoscopy and 7.43% in the open technique). Intraoperative bile spillage, increasing age, increased duration of surgery, laparoscopic cholecystectomy done by resident surgeons, increased intraoperative blood loss, emergent operations done for acute cholecystitis, etc., were associated with higher rates of SSI.

Conclusion:

Meticulous operative techniques avoiding bile spillage and blood loss during cholecystectomy may reduce the chances of developing SSI.

Cholecystectomy Outcomes in the Veterans Affairs Surgical Quality Improvement Program (2006-2017)

Background: Cholecystectomy trends and outcomes have been reported extensively in the private sector. Despite being one of the most common procedures performed in the United States, there is a paucity of reports on the trends and outcomes of laparoscopic and open cholecystectomy in the veteran population. Materials and Methods: Veterans who underwent laparoscopic or open cholecystectomy from 2006 to 2017 were identified using current procedural terminology codes from the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. Multivariable analyses were used to compare laparoscopic and open outcomes. The primary outcome was mortality, and secondary outcomes were postoperative complications and length of stay (LOS). Results: In the VASQIP database, 53,901 patients underwent laparoscopic cholecystectomy and 8011 patients underwent open cholecystectomy during the study period. The laparoscopic approach increased from 82.0% (2006-2008) to 91.9% (2015-2017). Postoperatively, the open group had a significantly higher morbidity rate (15.4% versus 3.8%, P < .001). The 30-day mortality rate and mean LOS were also significantly higher in the open cholecystectomy group (P < .001). Earlier year of operation, diabetes diagnosis, and open approach significantly increased the likelihood of postoperative morbidity (P < .05). Conclusions: Similar to the private sector, minimally invasive cholecystectomy in the Veterans Health Administration (VHA) has increased over the last two decades. Diabetes was present in a significant percentage of the veteran population and was a predictor of all postoperative complications. Finally, the clinical outcomes in the VHA are comparable with those documented in the private sector.

Efficacy and Safety of 100 Laparoscopy-Assisted Transgastric Endoscopic Retrograde Cholangiopancreatography Procedures in Patients with Roux-en-Y Gastric Bypass

Purpose

Laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography (LAERCP) is an alternative for the anatomically challenging conventional ERCP in patients with a Roux-en-Y gastric bypass (RYGB) as it allows access to the biliary tree via the gastric remnant. We investigated the efficacy and safety of LAERCP.

Material and Methods

We retrospectively reviewed all charts from RYGB patients who underwent a LAERCP between January 2009 and August 2019 in a non-academic referral center for bariatric surgery. Patients who underwent pancreatic therapy were excluded. We collected demographic, clinical, and outcome data. An adverse event was defined as any complaint related to the LAERCP up to 30 days after the procedure and graded according to the ASGE lexicon.

Results

We identified 100 LAERCP in 86 patients with RYGB (70% female, median age 54 years). Same-session cholecystectomy was performed in 35 LAERCP (35%). The papilla of Vater was visualized in 100% of LAERCP with a therapeutic success rate of 94%. Stone extraction succeeded in 88.8% and sphincterotomy was performed in 96.7%. We identified 30 adverse events in 28 procedures, of which eight endoscopy-related, 14 laparoscopy-related, and eight non-specified (f.i. fever, allergic reaction). In total, six severe adverse events were reported concerning post-ERCP pancreatitis (n = 2), laparoscopy-related hemorrhage (n = 1), abscess (n = 1), shock (n = 1), and pneumonia (n = 1). No patient died due to LAERCP.

Conclusion

LAERCP is an effective and relatively safe procedure for biliary diseases in patients with RYGB.

An international comparison of the utilisation of and outcomes from minimal access surgery for the treatment of common abdominal surgical emergencies

BACKGROUND

Minimal access surgery (MAS) has suggested improvements in clinical outcomes compared to open surgery in several abdominal elective and emergency surgeries. The aims of this study were to compare England with the United States in the utilisation of MAS and mortality from four common abdominal surgical emergencies.

METHODS

Between 2006 and 2012, the rate of MAS and in-hospital mortality for appendicitis, incarcerated or strangulated abdominal hernia, small or large bowel and peptic ulcer perforation were compared between England and the United States. Univariate and multivariate analyses were performed to adjust for differences in baseline patient demographics.

RESULTS

132,364 admissions in England were compared to an estimated 1,811,136 admissions in the United States. Minimal access surgery was used less commonly in England for appendicitis (odds ratio (OR) 0.27, 95% CI 0.267-0.278), abdominal hernia (OR 0.16, 95% CI 0.15-0.17), small or large bowel perforation (OR 0.33, 95% CI 0.32-0.35) and peptic ulcer perforation (OR 0.93, 95% CI 0.87-0.99). In-hospital mortality was increased in England compared to the United States for all four conditions: appendicitis (OR 2.11, 95% CI 1.66-2.68), abdominal hernia (OR 3.25, 95% CI 3.10-3.40), small or large bowel perforation (OR 3.88, 95% CI 3.76-3.99) and peptic ulcer perforation (OR 3.09, 95% CI 2.94-3.25). In England, after adjustment for patient demographics, open surgery was associated with increased in-hospital mortality for abdominal hernia (OR 1.80, 95% CI 1.26-2.71), small or large bowel perforation (OR 1.59, 95% CI 1.37-1.87) and peptic ulcer perforation (OR 2.31, 95% CI 1.91-2.82).

CONCLUSIONS

Minimal access surgery was performed less commonly and in-hospital mortality was increased in England compared to the United States for common abdominal surgical conditions. Therefore, strategies to enhance adoption of MAS in emergency conditions in England need to be optimised and include appropriate patient selection and improved surgeon MAS training.

Comparison of laparoscopic and open appendectomy on wound infection and healing in complicated appendicitis

The aim of this study was to investigate the effects of laparoscopic and open surgery on the development of postoperative surgical wound infection and wound healing between complicated appendicitis patients. Patients with complicated appendicitis were divided into those underwent laparoscopic and open surgical procedures according to the surgical method. Patients were followed up with regard to development of any postoperative wound infection, and medical, radiological, and surgical treatment methods and results were recorded. A total of 363 patients who underwent appendectomy were examined, of which 103 (28.4%) had complicated appendicitis. Postoperative wound infection rate in patients who underwent open surgery was 15.9%, while it was 6.8% in the laparoscopic surgery group. There was no statistically significant difference between the two groups in terms of infection development rates (P > .05). The rate of surgical drainage use and rehospitalisation was significantly higher in the group with wound infection than in the group without wound infection. (P < .05). We suggest that in terms of wound infection and wound healing, laparoscopic surgery should be the method of choice for patients with complicated appendicitis. In order to reduce the frequency of wound infection, drains should not be kept for a long time in patients undergoing appendectomy.

Neutrophil priming as a risk factor for surgical site infection in patients with colon cancer treated by laparoscopic surgery

Background

The purpose of this study is to identify perioperative marker predicting postoperative surgical site infection (SSI) including with anastomotic leakage (AL) in curative colon cancer patients, laparoscopically.

Methods

In total, 135 colon cancer patients (stage I–III) undergoing curative laparoscopic surgery between January 2004 and December 2013 were enrolled in this study. We collected data on clinicopathological factors, laboratory data on pre and postoperative day 3 (POD3) and tumor markers levels to assess the relation to surgical site infection (SSI) including with anastomotic leakage (AL).

Results

SSI and AL occurred in 16 cases (5.6%) and 4 cases (3%), respectively. SSI and AL were not association with clinicopathological factors. Within laboratory data and tumor markers preoperatively, high neutrophil counts were significantly associated with SSI (P < 0.05) and AL (P < 0.01), respectively. Area under curves (AUC) of SSI and AL were 0.656 and 0.854, respectively. In addition, high neutrophil counts on POD3 also were significantly associated with SSI (P < 0.01) and AL (P < 0.01), respectively. Area under curves (AUC) of SSI and AL were 0.747 and 0.832, respectively.

Conclusion

Neutrophil count on pre and POD3 are potentially valuable indicators of SSI including with AL in colon cancer patients undergoing curative surgery laparoscopically.

Design Parameters for a Small-Gauge Fragmatome

Purpose

Manufacturers of surgical instrumentation have increasingly sought to decrease the size of ophthalmic surgical instruments. We have used finite element modeling to model the stress and strain present in a fragmatome as a function of driving frequency and fragmatome dimensions.

Methods

Finite element calculations using the COMSOL Multiphysics system v3.5 were used to elucidate the influence of wall thickness, length, and excitation frequency on a titanium fragmatome tube with outer diameters of 20, 23, 25, and 27 gauge.

Results

By coupling structural mechanics, fluid mechanics, and acoustical physics, we were able to determine the eigenfrequencies (resonant frequencies) as well as parameters in which the von Mises stress in a fragmatome tube exceeds the yield strength, leading to destruction of the instrument.

Conclusion

Solid fragmatomes have far fewer possible failure modes than fragmatomes with a standard wall thickness. Eigenfrequency analysis and finite element calculations can be critical in predicting potentially catastrophic designs in modern surgical instruments.

Translational Relevance

Instruments developed for microsurgical applications cannot always simply be scaled down versions of conventional instruments. Such an approach can lead to potentially dangerous intraoperative failures, such as a fragmatome shattering inside the eye. Modern engineering techniques are increasingly necessary to investigate potential instrument failure mechanisms and to optimize device performance in a design in silico before in vivo testing.

Gender-related risk factors for surgical site infections. Results from 10 years of surveillance in Germany

Background

Surgical site infections (SSI) are among the most frequently occurring healthcare-associated infections worldwide. Various analyses to determine risk factors have been conducted in the past, generally attributing a higher SSI-risk to male patients. However, when focusing on specific procedures, this is not always true. Our objective was to identify for which procedures male or female sex represents an independent risk factor for SSI and which parameters may explain these differences.

Methods

We used the database of surgical procedures from the German national nosocomial infection surveillance system. We included procedures conducted between 2008 and 2017. We excluded procedures solely executed for one sex (e.g. mastectomy) and procedures with 20,000 or fewer operations. The observed outcome was the occurrence of SSI. All models were adjusted for confounders, which were eliminated with backward selection. The following factors were included in the analysis: age, ASA score, wound contamination class, duration of surgery, and season. All models contained the investigated factor sex.

Results

Sixteen procedure types with 1,266,782 individual procedures and 18,824 SSI were included. Overall, the incidence rate ratio and the adjusted odds ratio for SSI were significantly higher for male patients. The included individual procedures were grouped into five surgical categories. For orthopedics and traumatology as well as abdominal surgery, SSI-rates were significantly higher for male patients. For heart and vascular surgery, SSI-rates were significantly higher for female patients. Other included surgical categories and individual procedures yielded diverse results. Similar results were found when solely analyzing deep and organ-space SSI. Multivariable analysis for attributable gender-related risk factors revealed differences with regard to underlying risk factors.

Conclusions

SSI-rates differ by sex for certain procedures. When examining underlying risk factors, differences between male and female patients can be demonstrated. Our analysis considered a limited number of parameters, which were not sufficient to fully explain the observed differences. Further studies are required to obtain a more comprehensive understanding of the topic and to include gender-specific aspects into future SSI-prevention strategies.

Laparoscopic appendicectomy is superior to open surgery for complicated appendicitis

BACKGROUND

Over the last three decades, laparoscopic appendicectomy (LA) has become the routine treatment for uncomplicated acute appendicitis. The role of laparoscopic surgery for complicated appendicitis (gangrenous and/or perforated) remains controversial due to concerns of an increased incidence of post-operative intra-abdominal abscesses (IAA) in LA compared to open appendicectomy (OA). The aim of this study was to compare the outcomes of LA versus OA for complicated appendicitis.

METHODS

A systematic literature search following PRISMA guidelines was conducted using MEDLINE, EMBASE, PubMed and Cochrane Database for randomised controlled trials (RCT) and case-control studies (CCS) that compared LA with OA for complicated appendicitis.

RESULTS

Data from three RCT and 30 CCS on 6428 patients (OA 3,254, LA 3,174) were analysed. There was no significant difference in the rate of IAA (LA = 6.1% vs. OA = 4.6%; OR = 1.02, 95% CI = 0.71-1.47, p = 0.91). LA for complicated appendicitis has decreased overall post-operative morbidity (LA = 15.5% vs. OA = 22.7%; OR = 0.43, 95% CI: 0.31-0.59, p < 0.0001), wound infection, (LA = 4.7% vs. OA = 12.8%; OR = 0.26, 95% CI: 0.19-0.36, p < 0.001), respiratory complications (LA = 1.8% vs. OA = 6.4%; OR = 0.25, 95% CI: 0.13-0.49, p < 0.001), post-operative ileus/small bowel obstruction (LA = 3.1% vs. OA = 3.6%; OR = 0.65, 95% CI: 0.42-1.0, p = 0.048) and mortality rate (LA = 0% vs. OA = 0.4%; OR = 0.15, 95% CI: 0.04-0.61, p = 0.008). LA has a significantly shorter hospital stay (6.4 days vs. 8.9 days, p = 0.02) and earlier resumption of solid food (2.7 days vs. 3.7 days, p = 0.03).

CONCLUSION

These results clearly demonstrate that LA for complicated appendicitis has the same incidence of IAA but a significantly reduced morbidity, mortality and length of hospital stay compared with OA. The finding of complicated appendicitis at laparoscopy is not an indication for conversion to open surgery. LA should be the preferred treatment for patients with complicated appendicitis.

Randomized trial of umbilical incisional hernia in high-risk patients: extraction of gallbladder through subxiphoid port vs. umbilical port after laparoscopic cholecystectomy

INTRODUCTION

Trocar site incisional hernia (TSIH) is one of the most common complications of laparoscopic surgery. Using the umbilical port as a common hole for removing the gallbladder in laparoscopic cholecystectomy is more likely to lead to TSIH than other ports. Thus, extracting the gallbladder through other ports may reduce the incidence of TSIH.

AIM

To ascertain whether extraction of the gallbladder through the subxiphoid port is more beneficial for reducing umbilical incisional hernia than the umbilical port.

MATERIAL AND METHODS

From April 2014 to March 2017, a randomized clinical trial was conducted among patients with high risk of incisional hernia and accepted for three-port laparoscopic cholecystectomy (TLC) in our department. 182 patients with indications of cholecystectomy were allocated randomly to group A (subxiphoid port) and group B (umbilical port). Data collection was carried out on operative time, postoperative pain, hospital stay, wound infection and TSIH in the early postoperative course, and at 1, 10, and 24 months after surgery.

RESULTS

The incidence of TSIH in group A was lower than that in group B (4.9% vs. 14.6%; odds ratio = 8.02; 95% CI: 2.15-47.6; p < 0.001). The mean operative time of group A was significantly shorter than that of group B (35 ±15.16 min vs. 42 ±14.58 min, p < 0.01). There was no significant difference in wound infection rate between group A and group B (p = 0.068). The data of hospital stay (p = 0.428) and postoperative pain (p = 0.349) of all analyzed patients were similar in the two groups.

CONCLUSIONS

Extraction of the gallbladder through the subxiphoid port can reduce umbilical incisional hernia in high-risk patients effectively.

Identification of Predictors of Surgical Site Infection in Patients With Gastric Cancer Undergoing Surgery With Curative Intent

Surgical site infection (SSI) is a potentially morbid and costly complication of surgery. The purpose of this study was to determine preoperative and operative predictors of SSIs after gastric resection with lymphadenectomy in patients with gastric cancer (GC). Data on clinicopathologic factors, including operative and preoperative laboratory factors, for 384 patients with GC who had undergone curative surgery were analyzed in this retrospective study to assess their associations with SSIs. Superficial/deep incisional SSIs (iSSIs) and organ/space SSIs (o/sSSIs) occurred in 18 (4.6%), and 27 (7.0%), respectively. The o/sSSIs were significantly associated with surgery-related factors such as duration of operation, blood loss, and extent of tumor. Additionally, high levels of preoperative indicators of systemic inflammation, including neutrophil counts, neutrophil/lymphocyte ratio, and C-reactive protein concentrations, were significantly associated with o/sSSIs. Multivariate analyses demonstrated that preoperative neutrophil counts and duration of surgery were independent predictors for o/sSSIs, whereas only preoperative serum albumin concentration was predicted for iSSIs. In patients with GC undergoing curative surgery, preoperative neutrophil count and operation time are potentially valuable predictors of o/sSSIs, whereas only preoperative serum albumin predicts iSSIs.

Risk Factors for Surgical Site Infection After Cholecystectomy

Background

There are limited data on risk factors for surgical site infection (SSI) after open or laparoscopic cholecystectomy.

Methods

A retrospective cohort of commercially insured persons aged 18–64 years was assembled using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure or Current Procedural Terminology, 4th edition codes for cholecystectomy from December 31, 2004 to December 31, 2010. Complex procedures and patients (eg, cancer, end-stage renal disease) and procedures with pre-existing infection were excluded. Surgical site infections within 90 days after cholecystectomy were identified by ICD-9-CM diagnosis codes. A Cox proportional hazards model was used to identify independent risk factors for SSI.

Results

Surgical site infections were identified after 472 of 66566 (0.71%) cholecystectomies; incidence was higher after open (n = 51, 4.93%) versus laparoscopic procedures (n = 421, 0.64%; P < .001). Independent risk factors for SSI included male gender, preoperative chronic anemia, diabetes, drug abuse, malnutrition/weight loss, obesity, smoking-related diseases, previous Staphylococcus aureus infection, laparoscopic approach with acute cholecystitis/obstruction (hazards ratio [HR], 1.58; 95% confidence interval [CI], 1.27–1.96), open approach with (HR, 4.29; 95% CI, 2.45–7.52) or without acute cholecystitis/obstruction (HR, 4.04; 95% CI, 1.96–8.34), conversion to open approach with (HR, 4.71; 95% CI, 2.74–8.10) or without acute cholecystitis/obstruction (HR, 7.11; 95% CI, 3.87–13.08), bile duct exploration, postoperative chronic anemia, and postoperative pneumonia or urinary tract infection.

Conclusions

Acute cholecystitis or obstruction was associated with significantly increased risk of SSI with laparoscopic but not open cholecystectomy. The risk of SSI was similar for planned open and converted procedures. These findings suggest that stratification by operative factors is important when comparing SSI rates between facilities.

Laparoscopic partial cholecystectomy: A safe and effective alternative surgical technique in "difficult cholecystectomies"

OBJECTIVE

Laparoscopic cholecystectomy has become the "gold standard" for benign gallbladder diseases due to its advantages. In the presence of inflammation or fibrosis, the risk of bleeding and bile duct injury is increased during dissection. Laparoscopic partial cholecystectomy (LPC) is a feasible and safe method to prevent bile duct injuries and decrease the conversion (to open cholecystectomy) rates in difficult cholecystectomies where anatomical structures could not be demonstrated clearly.

MATERIAL AND METHODS

The feasibility, efficiency, and safety of LPC were investigated. The data of 80 patients with cholelithiasis who underwent LPC (n=40) and conversion cholecystectomy (CC) (n=40) were retrospectively examined. Demographic characteristics, ASA scores, operating time, drain usage, requirement for intensive care, postoperative length of hospital stay, surgical site infection, antibiotic requirement and complication rates were compared.

RESULTS

The median ASA value was 1 in the CC group and 2 in the LPC group. Mean operation time was 123 minutes in the CC group, and 87.50 minutes in the LPC group. Surgical drains were used in 16 CC patients and 4 LPC patients. There was no significant difference between groups in postoperative length of intensive care unit stay (p=0.241). When surgical site infections were compared, the difference was at the limit of statistical significance (p=0.055). Early complication rates were not different (p=0.608) but none of the patients in the LPC group suffered from late complications.

CONCLUSION

LPC is an efficient and safe way to decrease the conversion rate. LPC seems to be an alternative procedure to CC with advantages of shorter operating time, lower rates of surgical site infection, shorter postoperative hospitalization and fewer complications in high-risk patients.

Objective ergonomic risk assessment of wrist and spine with motion analysis technique during simulated laparoscopic cholecystectomy in experienced and novice surgeons

INTRODUCTION:

There is a rise in prevalence of work-related musculoskeletal disorders in surgeons performing laparoscopic surgeries due to lack of ergonomic considerations to the minimal access surgical environment. The objective of this study was to assess the physical ergonomics in experienced and novice surgeons during a simulated laparoscopic cholecystectomy.

METHODOLOGY:

Thirty-two surgeons participated in this study and were distributed in two groups (experienced and novices) based on the inclusion criteria. Both groups were screened for the spinal and wrist movements on the orientation sensor-based, motion analysis device while performing a simulated laparoscopic cholecystectomy. Simultaneous video recording was used to estimate the other joint positions. The RULA (Rapid Upper Limb Assessment) ergonomic risk scores were estimated with the acquired data.

RESULTS:

We found that surgeons in both novice and experienced groups scored a high on the RULA. Limited awareness of the influence of monitor position on the postural risk caused surgeons to adopt non-neutral range cervical postures. The thoracolumbar spine is subjected to static postural demand. Awkward wrist postures were adopted during the surgery by both groups. There was no statistically significant difference in the RULA scores between the novice and experienced, but some differences in maximum joint excursions between them as detected on the motion analysis system.

CONCLUSION:

Both experienced and novice surgeons adopted poor spinal and wrist ergonomics during simulated cholecystectomy. We concluded that the physical ergonomic risk is medium as estimated by the RULA scoring method, during this minimally invasive surgical procedure, demanding implementation of change in the ergonomic practices.

On-table urethral catheterisation during laparoscopic appendicectomy: Is it necessary?

INTRODUCTION

Laparoscopic appendicectomy (LA) is the most commonly performed surgical emergency procedure. The aim of this study was to highlight a series of iatrogenic bladder injuries during LA and suggest a simple method of prevention.

METHODS

A retrospective review was carried out of all LA performed in a university teaching hospital over a two year period 2012-2013. Iatrogenic visceral injuries were identified and operative notes examined.

RESULTS

During the study period 1124 appendicectomies were performed. Four iatrogenic bladder injuries occurred related to secondary trocar insertion. No patient was catheterised preoperatively. One of the injuries was identified intra-operatively, another in the early postoperative period where as two re-presented acutely unwell post-discharge from hospital. Three were repaired by laparotomy and one laparoscopically.

CONCLUSION

Iatrogenic secondary trocar induced bladder injuries are a rare but preventable and potentially serious complication of LA. Urethral catheterisation during LA is a safe and simple method which can prevent this complication.

Comparison of the Risk of Surgical Site Infection After Laparoscopic Cholecystectomy and Open Cholecystectomy

We assessed the independent contributions of the surgical approach and other variables of the National Nosocomial Infections Surveillance System (NNIS) surgical patient component to the surgical site infection risk after cholecystectomy. Laparoscopic cholecystectomy was associated with a lower overall risk of surgical site infection and a lower risk of incisional infection but not a reduced risk of organ-space infection, compared with open cholecystectomy. The contribution of most of the variables of the NNIS surgical patient component to the risk of surgical site infection depended on the depth of the infection.

Cholecystectomy and wound complications: smoking worsens risk

BACKGROUND

In the United States, approximately 800,000 cholecystectomies are performed annually. We sought to determine the influence of preoperative smoking on postcholecystectomy wound complication rates.

MATERIALS AND METHODS

Using the National Surgical Quality Improvement Program database (2005-2011), patients aged ≥18 y who underwent elective open or laparoscopic cholecystectomy (LC) for benign gallbladder disease were identified using current procedural terminology codes. Multivariate regression was performed to determine the association between smoking status and wound complications, by surgical approach.

RESULTS

Of 143,753 identified patients, 128,692 (89.5%) underwent LC, 27,788 (19.3%) were active smokers, and 100,710 (70.2%) were females. Active smokers were younger than nonsmokers (mean + standard deviation age: 44.2 (14.9) versus 51.6 (17.9) years); P < 0.001) and had fewer comorbidities. Within 30-d postcholecystectomy, wound complications were reported in 2011 (1.4%) patients. Compared with nonsmokers, active smokers demonstrated increased odds of wound complications after both open cholecystectomy (odds ratio 1.28; P = 0.010) and LC (odds ratio 1.20; P = 0.020) after adjustment for demographic and clinical characteristics. Having wound complications increased the average postoperative length of stay by 2-4 d (P <0.001).

CONCLUSIONS

Active smokers are more likely to develop wound complications after cholecystectomy, regardless of surgical approach. Occurrence of wound complications consequently increases postoperative length of stay. Smoking abstinence before cholecystectomy may reduce the burden associated with wound complications.

Role of antibiotics on surgical site infection in cases of open and laparoscopic cholecystectomy: a comparative observational study

INTRODUCTION

Surgical site infection (SSI) comes as third most common healthcare related infection which produces morbidity and deaths at large. Still many authors believe that it is better not to use prophylactic antibiotics in simple and uncomplicated cases. Laparoscope, now-a-days is a much used instrument for abdominal surgeries. Even after new aseptic techniques SSI remains to be a major problem.

AIMS AND OBJECTIVES

To study the effect of antibiotics on superficial SSI in the cases of open and laparoscopic cholecystectomy.

OBSERVATION AND RESULTS

One hundred patients were enrolled for cholecystectomy. The patients were divided into two groups, A and B. Group A consisted of patients in whom laparoscopic cholecystectomy was done and group B in whom open cholecystectomy was done. The male female ratio was 1: 2.23. The mean age of patients in Group A was 46 years and in Group B was 44; Standard deviation (SD) for age was 14.8% and 13.8% in groups A and B respectively; t-value was 0.654 and P value was 0.515 and they were not significant. The number of males and females was 16 and 26 respectively in Group A and 11 and 31 in Group B. The Chi square X(2) = 1.36 and P value was 0.248 and both were insignificant. The rate of superficial surgical site infection was 2.63% in both the groups.

CONCLUSION

Our study concludes that there is no difference in the outcome of patients in cases of open as well as laparoscopic cholecystectomy. There is no significant difference in the surgical site infection rate in cases of open as well as laparoscopic cholecystectomy.

Additional surgical procedure is a risk factor for surgical site infections after laparoscopic cholecystectomy

PURPOSE

Surgical site infections (SSI) are associated with increased costs and length of hospital stay, readmission rates, and mortality. The aim of this study was to identify risk factors for SSI in patients undergoing laparoscopic cholecystectomy.

METHODS

Analysis of 35,432 laparoscopic cholecystectomies of a prospective multicenter database was performed. Risk factors for SSI were identified among demographic data, preoperative patients' history, and operative data using multivariate analysis.

RESULTS

SSIs after laparoscopic cholecystectomy were seen in 0.8 % (n = 291) of the patients. Multivariate analysis identified the following parameters as risk factors for SSI: additional surgical procedure (odds ratio [OR] 4.0, 95 % confidence interval [CI] 2.2-7.5), age over 55 years (OR 2.4 [1.8-3.2]), conversion to open procedure (OR 2.6 [1.9-3.6]), postoperative hematoma (OR 1.9 [1.2-3.1]), duration of operation >60 min (OR 2.5 [1.7-3.6], cystic stump insufficiency (OR 12.5 [4.2-37.2]), gallbladder perforation (OR 6.2 [2.4-16.1]), gallbladder empyema (OR 1.7 [1.1-2.7]), and surgical revision (OR 15.7 [10.4-23.7]. SSIs were associated with a significantly prolonged hospital stay (p < 0.001), higher postoperative mortality (p < 0.001), and increased rate of surgical revision (p < 0.001).

CONCLUSIONS

Additional surgical procedure was identified as a strong risk factor for SSI after laparoscopic cholecystectomy. Furthermore, operation time >60 min, age >55 years, conversion to open procedure, cystic stump insufficiency, postoperative hematoma, gallbladder perforation, gallbladder empyema, or surgical revision were identified as specific risk factors for SSI after laparoscopic cholecystectomy.

Analysis of laparoscopic port site complications: A descriptive study

CONTEXT:

The rate of port site complications following conventional laparoscopic surgery is about 21 per 100,000 cases. It has shown a proportional rise with increase in the size of the port site incision and trocar. Although rare, complications that occur at the port site include infection, bleeding, and port site hernia.

AIMS:

To determine the morbidity associated with ports at the site of their insertion in laparoscopic surgery and to identify risk factors for complications.

SETTINGS AND DESIGN:

Prospective descriptive study.

MATERIALS AND METHODS:

In the present descriptive study, a total of 570 patients who underwent laparoscopic surgeries for various ailments between August 2009 and July 2011 at our institute were observed for port site complications prospectively and the complications were reviewed.

STATISTICAL ANALYSIS USED:

Descriptive statistical analysis was carried out in the present study. The statistical software, namely, SPSS 15.0 was used for the analysis of the data.

RESULTS:

Of the 570 patients undergoing laparoscopic surgery, 17 (3%) had developed complications specifically related to the port site during a minimum follow-up of three months; port site infection (PSI) was the most frequent (n = 10, 1.8%), followed by port site bleeding (n = 4, 0.7%), omentum-related complications (n = 2; 0.35%), and port site metastasis (n = 1, 0.175%).

CONCLUSIONS:

Laparoscopic surgeries are associated with minimal port site complications. Complications are related to the increased number of ports. Umbilical port involvement is the commonest. Most complications are manageable with minimal morbidity, and can be further minimized with meticulous surgical technique during entry and exit.

Time trend and variability of open versus laparoscopic cholecystectomy in patients with symptomatic gallstone disease

BACKGROUND

The purpose of this study was to compare length of stay, as one of the efficacy indicators, and effectiveness, in terms of operative complications and mortality, between laparoscopic (LC) and open cholecystectomy, and to verify the 10-year temporal trends in the application of the LC technique in a large regional population.

METHODS

This was a retrospective cohort study based on 73,853 hospital discharge records of cholecystectomies for gallstone disease (GD) in residents of the Veneto from 2001 to 2010, at both public and accredited private hospitals. The data are from a regional administrative database. The main epidemiological rates calculated, and expressed per 100,000 residents, were the cholecystectomy rate (CR) for gallstones by surgical technique (laparoscopic or open surgery), and the in-hospital mortality rate (MR), considered as the in-hospital MR regardless of the specific cause of death.

RESULTS

The CR was 139.7 higher in females, with a male-to-female ratio of 1:1.5. LC was performed more frequently in females than in males and in younger than in older patients. From 2001 to 2010, there was a significant linear rising trend in the use of LC, in fact during the period considered, the use of laparoscopic surgery increased significant (χ (2) trend: 316,917; p < 0.05), reaching 93.6% of surgical procedures for gallstones during the year 2010.

CONCLUSIONS

There are still some age- and gender-related disparities in its usage, although LC is an increasingly widely applied, as effective procedure.

Prospective nationwide surveillance of surgical site infections after gastric surgery and risk factor analysis in the Korean Nosocomial Infections Surveillance System (KONIS)

OBJECTIVE

To evaluate the risk factors for surgical site infection (SSI) after gastric surgery in patients in Korea.

DESIGN

A nationwide prospective multicenter study.

SETTING

Twenty university-affiliated hospitals in Korea.

METHODS

The Korean Nosocomial Infections Surveillance System (KONIS), a Web-based system, was developed. Patients in 20 Korean hospitals from 2007 to 2009 were prospectively monitored for SSI for up to 30 days after gastric surgery. Demographic data, hospital characteristics, and potential perioperative risk factors were collected and analyzed, using multivariate logistic regression models.

RESULTS

Of the 4,238 case patients monitored, 64.9% (2,752) were male, and mean age (± SD) was 58.8 (± 12.3) years. The SSI rates were 2.92, 6.45, and 10.87 per 100 operations for the National Nosocomial Infections Surveillance system risk index categories of 0, 1, and 2 or 3, respectively. The majority (69.4%) of the SSIs observed were organ or space SSIs. The most frequently isolated microorganisms were Staphylococcus aureus and Klebsiella pneumoniae. Male sex (odds ratio [OR], 1.67 [95% confidence interval (CI), 1.09-2.58]), increased operation time (1.20 [1.07-1.34] per 1-hour increase), reoperation (7.27 [3.68-14.38]), combined multiple procedures (1.79 [1.13-2.83]), prophylactic administration of the first antibiotic dose after skin incision (3.00 [1.09-8.23]), and prolonged duration (≥7 days) of surgical antibiotic prophylaxis (SAP; 2.70 [1.26-5.64]) were independently associated with increased risk of SSI.

CONCLUSIONS

Male sex, inappropriate SAP, and operation-related variables are independent risk factors for SSI after gastric surgery.

A meta-analysis of randomised controlled trials comparing conventional to minimally invasive approaches for repair of an Achilles tendon rupture

Achilles tendon ruptures are a common injury afflicting predominantly the young male occasional sportsman. Previous studies have shown that outcome is better with surgical repair for the young active patient. There is no consensus as to whether there is a difference in outcome between open and percutaneous minimally invasive surgery (MIS). A meta-analysis was undertaken to compare the clinical outcomes of MIS with conventional open surgical repair. Six randomised controlled trials of 277 Achilles tendon repairs were eligible for review. This included 136 minimally invasive repairs and 141 conventional open repairs. On analysis, there was no significant difference between the two surgical approaches in respect to the incidence of re-rupture, tissue adhesion, sural nerve injury, deep infection and deep vein thrombosis (p>0.05). However, MIS had a significantly reduced risk of superficial wound infection, with three times greater patient satisfaction for good to excellent results compared with conventional open surgical approaches.

Cholecystectomy in patients with prior ventriculoperitoneal shunts

BACKGROUND

There is little published evidence regarding intraoperative and postoperative complications in patients with ventriculoperitoneal shunts who undergo cholecystectomy.

METHODS

Nationwide Department of Veterans Affairs databases were searched to identify patients with International Classification of Diseases, 9th revision, Clinical Modification codes for a VP shunt who later had a cholecystectomy during fiscal years 1994 to 2003. Charts on these patients were obtained and reviewed.

RESULTS

Twenty-three patients were deemed evaluable. Of these, 8 had laparoscopic converted to open cholecystectomies. All conversions were owing to dense adhesions. There were 2 cases of postoperative shunt infection that required shunt removal and replacement.

CONCLUSIONS

The rate of conversion from laparoscopic to open cholecystectomy was 57% in this study, significantly higher than the reported rate of conversion for patients without shunts in Department of Veterans Affairs Medical Centers (5%). Cholecystectomy in adult patients with a preexisting ventriculoperitoneal shunt appears to result in a shunt infection rate similar to that reported after shunt insertion or revision.

Changing approaches to cholecystectomy in elderly patients: a 10-year retrospective study in Taiwan

BACKGROUND

The prevalence of symptomatic gallbladder diseases increases with age. The present study evaluated cholecystectomy risk factors and hospital resource utilization in an elderly (aged 60 years and older) population of patients who had undergone open cholecystectomy (OC) or laparoscopic cholecystectomy (LC).

METHODS

The study analyzed 20,538 OC and 29,318 LC procedures performed in Taiwan from 1996 to 2007. Odds ratio (OR) and 95% confidence interval were calculated to assess the relative change rate. Regression models were employed to predict length of stay (LOS) and total surgical cost.

RESULTS

Patient characteristics associated with increased likelihood of undergoing LC were age 60-69 years, female gender, and lack of current co-morbidities. Length of stay associated with both OC and LC decreased during the study period. Total surgical cost for elderly OC patients increased during the study period, whereas that for elderly LC patients declined. Compared to OC patients, LC patients had significantly larger changes in LOS (-2.27 days) and total surgical cost ($ -368.64 U.S. dollars) (p < 0.001). The following factors were associated with considerable increases in both LOS and total surgical cost: advanced age, female gender, presence of one or more co-morbidities, treatment in a regional or a district hospital, and long LOS.

CONCLUSIONS

Decreases in hospital resource utilization were larger in elderly LC patients than in elderly OC patients. Health care providers and patients should observe that hospital resource utilization may depend on hospital attributes as well as patient attributes. These analytical results should be applicable to similar elderly populations in other countries.

Perioperative antibiotic prophylaxis: improved compliance and impact on infection rates

The aims of this study were to determine adherence to the perioperative antibiotic prophylaxis (PAP) protocol used at a large Italian teaching hospital during a 6-year period, to assess the variables associated with inappropriate administration, and to measure the impact on surgical site infection (SSI) rates. There were 28 621 patients surveyed of which 74·6% received PAP. An improvement in adherence to the PAP protocol was registered for 58·8% of patients. Significant risk factors were an American Society of Anesthesiologists (ASA) score ⩾2 [odds ratios (OR) from 1·28 (95% confidence interval (CI) 1·19–1·37) to 1·87 (95% CI 1·43–2·44)], prolonged duration of surgery (OR 1·68, 95% CI 1·56–1·82) and urgent surgery (OR 2·16, 95% CI 1·96–2·37). During the study period, a significant reduction in SSIs rates was detected. We concluded that the global reduction of inadequate PAP administration signifies the efficacy of a multidisciplinary quality improvement initiative on antimicrobial utilization, and this is supported by the observed reduction of the SSI rate.

The learning curve of laparoendoscopic single-site (LESS) cholecystectomy: definable, short, and safe

BACKGROUND

The applications of laparoendoscopic single-site (LESS) surgery, including cholecystectomy, are occurring quickly, although little is generally known about issues associated with the learning curve of this new technique including operative time, conversion rates, and safety.

STUDY DESIGN

We prospectively followed all patients undergoing LESS cholecystectomy, and compared operations undertaken at our institutions in cohorts of 25 patients with respect to operative times, conversion rates, and complications.

RESULTS

One-hundred fifty patients of mean age 46 years underwent LESS cholecystectomy. No significant differences in operative times were demonstrable between any of the 25-patient cohorts operated on at our institution. A significant reduction in operative times (p < 0.001) after completion of 75 LESS procedures was, however, identified with the experience of a single surgeon. No significant reduction in the number of procedures requiring an additional trocar(s) or conversion to open operations was observed after completion of 25 LESS cholecystectomies. Complication rates were low, and not significantly different between any 25-patient cohorts.

CONCLUSIONS

For surgeons proficient with multi-incision laparoscopic cholecystectomy, the learning curve for LESS cholecystectomy begins near proficiency. Operative complications and conversions were infrequent and unchanged across successive 25-patient cohorts, and were similar to those reported for multi-incision laparoscopic cholecystectomy after the learning curve.

Role of Prophylactic Antibiotics in Laparoscopic Cholecystectomy

BACKGROUND

Antibiotic prophylaxis is routinely administered in laparoscopic cholecystetomy but its role is debatable.

METHODS

From January 2004 to August 2008, 417 patients were randomized into 208 in antibiotic group (AG) and 209 in non antibiotic group (NAG). AG received one dose each of injection ciprofloxacin (200 mg) and metronidazole (500mg) preoperatively. NAG was given only intravenous fluids. Besides routine care, all underwent abdominal sonography and liver function tests at least once during the 30 postoperative days.

RESULT

Age, sex and co-morbidity distribution were similar in both the groups. One patient who was on weekly 5mg methotraxate (NAG) had erythema around umbilical port. Other three having umbilical discharge recovered without antibiotics. Nine patients had subhepatic collection (5 AG and 4 NAG). One from NAG underwent re-laparoscopy and drainage. Ten patients had fever. Two from AG had basal lung collapse and were given antibiotics.

CONCLUSION

Antibiotic prophylaxis is not needed for laparoscopic cholecystectomy.

Effectiveness of prophylactic antibiotics in a population-based cohort of patients undergoing planned cholecystectomy

BACKGROUND

In the absence of randomized controlled trials with sufficient power to assess the effectiveness of prophylactic antibiotics (PA), the best evidence is provided by large population-based register studies.

METHODS

The Swedish Register of Gallstone Surgery and ERCP (GallRiks) started in May 2005 and reached 75% national coverage in 2007. During 2006 and 2007, a total of 16,400 operations were registered in GallRiks. In the present study, all elective procedures performed in 2006-2007 in units performing at least 25 operations annually were included in an analysis of the risk for postoperative infectious complications

RESULTS

Altogether 10,927 procedures were performed 2006-2007. Univariate logistic regression analysis revealed a paradoxical increase in postoperative infectious complications requiring antibiotic treatment and postoperative abscess if PA were given (p < 0.05). This increase disappeared in multivariate analysis with adjustment for age, gender, presence of cholecystitis, accidental gallbladder perforation, and presence of bile duct stones.

CONCLUSION

No benefit from PA was seen in this study on elective cholecystectomy. Although a randomized controlled trial could possibly show a reduction in the risk for postoperative infectious complications not detected in this study, such a reduction must be weighed against the risk of promoting drug resistance by the widespread use of PA.

Meta-analysis: Antibiotic prophylaxis in elective laparoscopic cholecystectomy

BACKGROUND

Current guidelines do not support routine antibiotic prophylaxis during elective laparoscopic cholecystectomy. However, routine antibiotic prophylaxis for elective laparoscopic cholecystectomy is still popular in many clinical settings.

AIM

To evaluate the role of antibiotic prophylaxis in elective laparoscopic cholecystectomy.

METHODS

Electronic databases and manual bibliographical searches (updated to April 2008) were conducted. A meta-analysis of all trials evaluating antibiotic prophylaxis in elective laparoscopic cholecystectomy was performed.

RESULTS

Fifteen trials were included, involving 2961 patients. After pooling all the trials, 48 wound infections occurred (48/2961, 1.62%), 22 in antibiotic prophylaxis group (22/1494, 1.47%) and 26 in control group (26/1467, 1.77%). The pooled odds ratio (OR) was 0.79 (95%CI: 0.44, 1.41). Four major infections occurred (4/2961, 0.14%), 3 in antibiotic prophylaxis group (3/1494, 0.20%), and one in control group (1/1467, 0.07%). The pooled OR was 2.51 (95%CI: 0.35, 17.84). Fifteen distant infections occurred (15/2961, 0.51%), six in antibiotic prophylaxis group (6/1494, 0.40%) and nine in control group (9/1467, 0.61%). The pooled OR was 0.53 (95%CI: 0.19, 1.50). Sensitivity analyses also failed to support antibiotic prophylaxis's preventive effect.

CONCLUSIONS

Considering the absent role of antibiotic prophylaxis in reducing the infectious complications, we suggest that antibiotic prophylaxis is unnecessary and should not be routinely used in low-risk elective laparoscopic cholecystectomy patients.

The effects of laparoscopic surgery and nosocomial infections on the cost of care: evidence from three common surgical procedures

OBJECTIVE

To examine the cost of care for laparoscopic versus open surgery and the added cost of nosocomial infections for three common surgical procedures: cholecystectomy, hysterectomy, and appendectomy.

METHODS

The Cardinal Health database repository was utilized to extract reimbursement data for laparoscopic and open cholecystectomy, hysterectomy, and appendectomy surgical procedures. Utilizing a 22-hospital sample and a Health Insurance Portability and Accountability Act compliant clinical data extraction technique, the Cardinal Health database repository produced a Nosocomial Infection Marker to identify and track nosocomial infection rates for these procedures. ICD-9 codes were utilized to identify 10,731 patients who had undergone these procedures between September 2004 and December 2006. Multivariable linear regression models were estimated to isolate the effects of laparoscopic versus open surgery and nosocomial infections on the cost of care.

RESULTS

Laparoscopic surgery significantly reduces the overall cost of care for cholecystectomies, hysterectomies, and appendectomies. Controlling for the cost of nosocomial infection, incremental cost savings from laparoscopic versus open surgery for all three procedures average $1608. Cholecystectomy has the largest savings ($3299), followed by hysterectomy ($1385) and appendectomy ($1032). These cost savings in part reflect that patients undergoing laparoscopic procedures have shorter lengths of stay. In contrast, nosocomial infection increases costs substantially for each surgery type, raising costs for cholecystectomy by $4794, hysterectomy by $4528, and appendectomy by $6108.

CONCLUSION

The cost of care for laparoscopic surgery is lower than open surgery for cholecystectomy, hysterectomy, and appendectomy. This conclusion is based on actual hospital reimbursement data.

Surgical site infection risk factors identified by multivariate analysis for patient undergoing laparoscopic, open colon, and gastric surgery

BACKGROUND

Surgical site infection (SSI) is an important clinical indicator of quality of patient care and infection control; therefore, we aimed to assess risk factors SSI in colon and gastric surgeries.

METHODS

SSI was assessed according to the National Nosocomial Infection Surveillance (NNIS) system (1999). Risk factors examined included operative approach, operative procedure, duration of operation, diabetes mellitus (DM), body mass index (BMI), age, and sex.

RESULTS

Among 3152 operated patients, 1675 patients were included in the study. The univariate analysis showed that male sex, high BMI, and long duration of operation were significant risk factors for colon surgery and that advanced age, presence of DM and long duration of operation were significant risk factors for gastric surgery. The multivariate analysis indicated that significant risk factors for SSI were BMI of 25 or above, open surgery, and long duration of operation for colon surgery and open surgery for gastric surgery. The SSI rate of laparoscopic colon surgery was 40%, less than that of open colon surgery, and that of laparoscopic gastric surgery was 75%, less than that of open gastric surgery.

CONCLUSION

The risk factors for SSI depend on whether the operation is laparoscopic or open and duration of operation. In addition, BMI (25 or above) and age (70 years or above) are risk factors for colon and gastric surgery, respectively.

Ergonomic assessment of neck posture in the minimally invasive surgery suite during laparoscopic cholecystectomy

BACKGROUND

With the expanding implementation of minimally invasive surgery, the operating team is confronted with challenges in the field of ergonomics. Visual feedback is derived from a monitor placed outside the operating field. This crossover trial was conducted to evaluate and compare neck posture in relation to monitor position in a dedicated minimally invasive surgery (MIS) suite and a conventional operating room.

METHODS

Assessment of the neck was conducted for 16 surgeons, assisting surgeons, and scrub nurses performing a laparoscopic cholecystectomy in both types of operating room. Flexion and rotation of the cervical spine were measured intraoperatively using a video analysis system. A two-question visual analog scale (VAS) questionnaire was used to evaluate posture in relation to the monitor position.

RESULTS

Neck rotation was significantly reduced in the MIS suite for the surgeon (p = 0.018) and the assisting surgeon (p < 0.001). Neck flexion was significantly improved in the MIS suite for the surgeon (p < 0.001) and the scrub nurse (p = 0.018). On the questionnaire, the operating room team scored their posture significantly higher in the MIS suite and also indicated fewer musculoskeletal complaints.

CONCLUSIONS

The ergonomic quality of the neck posture is significantly improved in the MIS suite for the entire operating room team.