|Year : 2021 | Volume
| Issue : 2 | Page : 173-178
Risk factors of port-site infections in laparoscopic surgeries
VK Sheeba Mariyam1, J Muhammed Salim2, Rakesh Praveen Raj2, Riyaz Sheriff3
1 Department of Surgery, Malabar Medical College, Calicut, Kerala, India
2 Department of Surgery, Azeezia Institute of Medical Science and Research, Kollam, Kerala, India
3 Department of Microbiology, Azeezia Institute of Medical Science and Research, Kollam, Kerala, India
|Date of Submission||28-Jul-2021|
|Date of Decision||05-Sep-2021|
|Date of Acceptance||06-Sep-2021|
|Date of Web Publication||15-Nov-2021|
Dr. V K Sheeba Mariyam
Department of Surgery, Malabar Medical College Hospital, Calicut - 673 315, Kerala
Source of Support: None, Conflict of Interest: None
Introduction: Laparoscopic surgery has brought in a paradigm shift in surgery. The ever-expanding applications of laparoscopic surgery have made the study of its complications crucial. Objectives: Our aim was to study the incidence of port-site infection (PSI) in laparoscopic procedures and the associated risk factors. Materials and Methods: A longitudinal observational study was conducted on 96 patients who underwent laparoscopic surgeries for various ailments and were observed for the development of PSIs and the association with the studied risk factors using the Chi-square test. Results: Prolonged duration of surgery (>120 min) was found to have a statistically significant association with increased risk of development of PSI. Obesity, presence of comorbidities and increase in the number of ports also were risk factors that had a statistically significant association with the incidence of PSI. The most common procedure associated with PSI was laparoscopic cholecystectomy and the most common organisms found to be Staphylococcus aureus and Escherichia coli. Conclusion: Proper sterilisation techniques and operation theatre aseptic protocol have brought down the incidence of PSI a great deal. Identification of the other hidden risk factors is vital for the elimination of PSI in laparoscopic surgery.
Keywords: Laparoscopic surgery, port-site infection, surgical-site infections
|How to cite this article:|
Sheeba Mariyam V K, Salim J M, Raj RP, Sheriff R. Risk factors of port-site infections in laparoscopic surgeries. Kerala Surg J 2021;27:173-8
| Introduction|| |
Laparoscopic surgery has become more popular in recent times for various ailments for which previously open surgery was done. Despite the reputation of association with a much less rate of post-operative complications, studies have shown that laparoscopic surgery is associated with problems such as post-operative infections, port-site bleeding, incisional hernia and scar-related complications and rarely port-site metastasis. Major complications are usually associated with the initial access, during port insertion such as major vascular injury or intra-abdominal organ injury/intestinal perforation., This paper presents one of the most troublesome complications of laparoscopic surgery, which is port-site infection (PSI).
| Materials and Methods|| |
The aim of this study was to determine the incidence and risk factors of PSI in laparoscopic surgeries done for various ailments at a tertiary health care hospital and to determine whether the prolonged duration of surgery has any effect on the development of PSIs, to study whether the use of Endo bag for specimen retrieval has any association with PSIs and to find the most common organisms associated with laparoscopic PSIs. A longitudinal observational study was done on patients aged 10–80 years, who underwent laparoscopic surgeries for various ailments during 2018–2019. Patients with human immunodeficiency virus infection, chronic liver and renal diseases, patients on long-term steroid therapy, major skin infections with extensive involvement of abdominal skin, previous major abdominal open surgeries and pregnant women were excluded. The sample size was calculated as 96. Convenience sampling was utilised. After ethical clearance, the involved patients were followed up for 30 days (up to the day of discharge, 1 week post-discharge and 30 days post-operative). In the event of development of signs of infection in between, the patients were educated to visit us in the OPD despite the date of review already given. All diabetic patients were given proper glycaemic control before surgery and continued postoperatively. All patients were given antibiotics preoperatively and postoperatively according to standard antibiotic protocol. Pre-operative workup including blood, radiological, biochemical, pathological and microbiological investigations as required was done. Diagnosis of PSI was done according to National Nosocomial Infection Surveillance Criteria. All the patients diagnosed with PSI were treated with appropriate antibiotics and local wound care regimen. Data collected as per pro forma were analysed using R software (EZR 1.32 version). Percentages were calculated, Chi-square test was applied to find the association between the risk factors and PSIs and significance was assessed at a 5% level.
| Results|| |
Ninety-six patients satisfied the inclusion and exclusion criteria. Majority of patients belonged to the age groups of 30–50 years [Table 1]. Forty-seven patients (49%) were male and 49 (51%) were female.
Most of the patients (65.6%) had body mass index (BMI) ranging from 18 to 29.9. While 30.2% were overweight (BMI 25–29.9), 63 (65.6%) had normal BMI (18.5–24.9) and 4 (4.2%) were underweight (BMI <18.5). Fifty-five (57.3%) had no comorbidities, 37 had diabetes with 15 (15.6%) having diabetes alone, 23 were hypertensive with 3 (3.1%) having hypertension alone and 4 were anaemic with 1 (1%) having anaemia alone. The most common diagnosis was acute appendicitis – 36 patients (37.5%), followed by cholelithiasis with 21 (21.9%), as detailed in [Table 2].
The most common procedure was laparoscopic appendectomy (41.7%) for acute and sub-acute appendicitis. Two patients underwent appendectomy along with ovarian cystectomy. This was followed by laparoscopic cholecystectomy (29.2%), laparoscopic hernia repair (19.8%), laparoscopic ovarian cystectomy (4.2%), laparoscopic adhesiolysis (2.1%) and laparoscopic rectopexy (1%), as shown in [Table 3].
Forty patients (41.7%) underwent emergency procedures, while the rest 56 (58.3%) underwent planned procedures. Standard antibiotic protocol was followed for all patients. Those patients with class 1 and 2 wounds were given prophylactic antibiotics only (54.2%), while those patients whose intraoperative findings suggested infective aetiology/spillage of infectious material (44%–45.8%) or whose systemic conditions warranted antimicrobials were treated with continued antibiotic coverage as required. Intraoperatively, there was no infection in 51 (56.3%). Forty-two (43.7%) patients had intraoperative findings suggestive of infectious aetiology and 3 (3.1%) amongst these patients had spillage of infectious materials during surgery, such as bile leak during laparoscopic cholecystectomy.
Half of the study subjects (48) had duration of surgery of more than 120 min and the other half <120 min. The rate of PSIs in each group was compared. Endo bag was not routinely used at our institution for retrieval of the specimen, hence the lower values. It was used in 8 cases (8.3%) when spillage of infectious material had to be strictly avoided. Fifty-two (54.2%) cases required placement of three ports for completion of surgery, while 39 (40.6%) required four ports. Four patients (4.2%) had five ports and one needed six ports for laparoscopic rectopexy. 0 port vicryl (polyglactin) was used for closure of ports of size 10 mm or more in majority of cases – 75 (78.1%), while in 21 (21.9%) cases, prolene (polypropylene) was used. About 77% of the cases studied required specimen retrieval during surgery and amongst them, 51% (49 cases) used umbilical port for this purpose, while the rest used other ports (26%).
Of the study subjects, 5 patients (5.2%) developed PSI. Three had undergone laparoscopic cholecystectomy, one had laparoscopic adhesiolysis and one had laparoscopic rectopexy. The most commonly affected port was the one that was used for specimen retrieval (40%). Multiple ports were affected in 2 cases (40%). The umbilical port was affected in 20%. About 60% of the PSIs were diagnosed in the surgical post-operative wards before the patients were discharged. Nearly 40% of PSIs were observed on the first review after surgery on day 7. No case was diagnosed beyond 7 days in this study. Staphylococcus aureus and Escherichia More Details coli were observed in equal frequencies amongst PSI at our institute. One case of enterococcal infection was also observed.
The Chi-square value calculated for the association between the BMI and PSI was 6.2 with P value of 0.045 (<0.05). It is inferred that those having a BMI of more than 25 have a statistically significant incidence of PSI than those with BMI <18.5 [Table 4].
On the assessment of association between medical comorbidities, specifically diabetes mellitus, hypertension and anaemia, the Chi-square value was 21.0 with P = 0.002 which is statistically significant [Table 5].
|Table 5: Effect of medical comorbidities on incidence of port-site infections|
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Association between diabetes mellitus and PSI was not statistically significant. Association between the pathological diagnosis and PSI showed Chi-square value of 55.5 with P = 0.000, which is statistically significant [Table 6].
|Table 6: Effect of pathological diagnosis on the incidence of port-site infection|
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The most common diagnosis which developed PSI was acute calculous cholecystitis (60% of the total cases of PSI), followed by rectal prolapse and post-operative intestinal adhesions, with each being 20% of the total cases of PSI [Table 7].
Association between the procedure and incidence of PSI showed a Chi-square value of 55.5 with P = 0.000, which is statistically significant. The most common procedure which developed PSI was found to be laparoscopic cholecystectomy (60% of the total cases of PSI and 10.7% of the total number of laparoscopic cholecystectomies). Association between the antibiotic regime and PSI was not statistically significant. No statistically significant association was observed between intraoperative findings of infective pathology and PSI. Association between the duration of surgery and PSIs showed a Chi-square value of 5.3 with P = 0.022, which is statistically significant. The duration of more than 120 min was found to have a significant effect on the incidence of PSI. Association of PSI with the number of ports revealed a Chi-square value of 24.7 with P = 0.00, which is statistically significant. The incidence of PSI was higher with an increase in the number of ports [Table 8].
There was no statistically significant association between the type of suture material used for port closure and PSI, but there was a statistically significant association between PSI and the site of specimen retrieval with Chi-square value of 6.7 and P = 0.048 [Table 9].
|Table 9: Effect of site of specimen retrieval on the incidence of port-site infection|
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The association between the use of Endo bag for specimen retrieval and PSI showed no statistically significant association.
| Discussion|| |
PSI can be attributed to many factors such as improper sterilisation techniques of laparoscopic instruments and increased number of ports, with the umbilical port being the most common involved. The incidence of PSIs was found to be 3% to 6.7%., AltThough the incidence of port-site complications is believed to be around 21 per 100000 cases, it has escalated with the increase in size of the port-site incision and the trocar;, Staphylococcal sp. was found to be the most common micro-organism in many studies, with Klebsiella being the most common isolate in deep infections. Bacterioids sp. was found to be the predominant flora (60%) in a study by Wolcott et al. Atypical mycobacteria have been found to be a cause of iatrogenic surgical-site infection in some studies, often causing localised skin infections 3–4 weeks postoperatively.
In the present study, the incidence of PSI was 5.2%, which is comparable to reports of others, who reported an incidence ranging from 3 to 6.7%. The most common procedure associated with PSI was laparoscopic cholecystectomy with 60% of total reported cases. The incidence of PSI was 10.7%. This is higher than the reported incidence in other studies., The incidence of PSI after laparoscopic appendectomy was found to be zero in this study which is less compared to studies conducted by Hamsaoglu et al. Emergency procedures were observed to be associated with a higher risk of PSI by various studies,, but in the present study, no statistically significant association could be made out.
The presence of comorbidities such as diabetes, hypertension and anaemia was found to have an increased risk for PSI, similar to the reports by Owens et al. and Boni et al. Almost 80% of the patients who developed PSI in the present study had diabetes mellitus but was statistically insignificant.
Most of the cases of PSI were diagnosed by the 3rd post-operative day/before discharge from the hospital (60%) and the rest on the first review. No PSIs were reported beyond 7 days till the follow-up period in this study. Since the reported cases of atypical mycobacterial PSI developed 3–4 weeks after the surgery, the study of incidence and risk factors of such cases is beyond the scope of this study.
The most common affected port in PSI was found to be ports other than umbilical ports, which is in contrast to the studies Sujith et al., Augustine et al. and Karthik et al. About 60% of the cases of PSI had infection at the site of specimen retrieval which happened to be the epigastric 10 mm port in laparoscopic cholecystectomy used for retrieval of the diseased gallbladder. There was no statistically significant association between the use of Endo bag and incidence of PSI, but since Endo bag is not routinely used at our institute, the significance of this finding may prove controversial.
The increase in the number of ports was associated with increased incidence of PSI in this study which is in concurrence with the findings reported by Augustine et al. and Fuller et al. The factors that affect the placement of more number of ports than routine such as difficult access, intra-abdominal adhesions and inflammatory changes could have an effect on the increased incidence of PSI, which is beyond the scope of this study to comment upon.
Intraoperative findings such as those suggestive of infectious aetiology with spillage of infectious material were found to have no statistically significant association with the incidence of PSI. The suture materials used for port closure in ports of more than 10 mm size were also studied for their association with PSI and no significant association was found in this study.
The most common organisms found in the culture study of PSIs at our institute were found to be S. aureus and E. coli with 40% incidence each. This is in concurrence with the findings of the studies conducted by Prakash et al. The choice of antibiotic regime had no significant association with the incidence of PSI in this study.
Obesity was associated with an increased incidence of PSI by Prakash et al., and similar observations were made in this study where increasing BMI was associated with an increase in the incidence of PSI. This could be attributed to the difficulty in access in obese patients, increased subcutaneous fat, increased incidence of coexisting disease, etc.
The incidence of PSI was more in the group with a duration of more than 120 min. Hence, it is inferred that prolonged duration of surgery is associated with increased risk of PSI. This observation is in concurrence with the findings of Keping et al. and Lilani et al. who also observed that a duration <30 min was associated with a zero incidence of PSI. The impact of prolonged duration of surgery can be attributed to the difficulty in access, intraoperative finding suggestive of spillage of infective material into the peritoneal cavity warranting thorough inspection and clearing of the offending materials, multiple procedures in the same sitting, etc., Further research into these causes and their impact on incidence of PSI is needed. Limitations included a small sample size limited to a single hospital. The study does not throw light on the management of PSI, which warrants further evaluation and research.
| Conclusions|| |
This study identified the statistically significant factors associated with increased risk of PSIs as prolonged duration of surgery (>120 min), increase in the number of ports, presence of comorbidities, obesity (increased BMI) and presence of multiple comorbidities such as diabetes mellitus, hypertension and anaemia. There was also an increased incidence of PSIs with laparoscopic cholecystectomy as compared to other procedures. The most common affected port was the specimen retrieval port. The most common organisms were S. aureus and E. coli.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Anmad G, Duffy JM, Philips K, Watson A. Laparoscopic entry techniques. Cochrane Database Syst Rev 2008;2;CD006583.
Jansen FW, Kolkman W, Bakkum EA, Dekroon CD, Trimbos-Kemper TC, Trimbos JB. Complication of laparoscopy. An inquiry about closed versus open – Entry techniques. Am J Obstet Gynaecol 2004;190:634-8.
Kumar SS, Babu KD, Grace RD, Anpian NB, Bhaskar M. A study of PSIs in laparoscopic surgeries. IOSR J Dent Med Sci 2015;14:20-5.
Karthik S, Augustine AJ, Shibumon MM, Pai MV. Analysis of laparoscopic port site complications: A descriptive study. J Minim Access Surg 2013;9:59-64.
Fuller J, Ashar BS, Carey-Corrado J. Trocar-associated injuries and fatalities: An analysis of 1399 reports to the FDA. J Minim Invasive Gynecol 2005;12:302-7.
Adisa A, Alatise O, Agbakwuru E. Wound complications following laparoscopic surgeries in a Nigerian hospital. Niger J Surg 2014;20:92-5.
] [Full text]
Mir MA, Malik UY, Wani H, Bali BS. Prevalence, pattern, sensitivity and resistance to antibiotics of different bacteria isolated from port site infection in low risk patients after elective laparoscopic cholecystectomy for symptomatic cholelithiasis at tertiary care hospital of Kashmir. Int Wound J 2013;10:110-3.
Aziz R. Practical Manual of Operative Laparoscopy. New York: Springer-Verlag; 1992. p. 1-8.
Kadar N, Reich H, Liu CY, Manko GF, Gimpelson R. Incisional hernias after major laparoscopic gynaecologic procedures. Am J Obstet Gynaecol 1993;168:1493-5.
Chiu CC, Lee WJ, Wang W, Wei PL, Huang MT. Prevention of trocar-wound hernia in laparoscopic bariatric operations. Obes Surg 2006;16:913-8.
Kownhar H, Shankar EM, Vignesh R, Sekar R, Velu V, Rao UA. High isolate of staphylococcus aureus
from surgical site infections in an Indian hospital. J Antimicrob Chemother 2008;61:758-60.
Wolcott RD, Gontcharova V, Sun Y, Zischakau A, Dowd SE. Bacterial diversity in surgical site infections: not just aerobic cocci any more. J Wound Care 2009;18:317-23.
Verghese S, Agrawal P, Benjamin S. Mycobacterium chelonae causing chronic wound infection and abdominal incisional hernia. Indian J Pathol Microbiol 2014;57:335-7.
] [Full text]
Hamzaoglu I, Baca B, Böler DE, Polat E, Ozer Y. Is umbilical flora responsible for wound infection after laparoscopic surgery? Surg Laparosc Endosc Percutan Tech 2004;14:263-7.
Chuang SC, Lee KT, Chang WT, Wang SN, Kuo KK, Chen JS, et al
. Risk factors for wound infection after cholecystectomy. J Formos Med Assoc 2004;103:607-12.
den Hoed PT, Boelhouwer RU, Veen HF, Hop WC, Bruining HA. Infections and bacteriological data after laparoscopic and open gallbladder surgery. J Hosp Infect 1998;39:27-37.
Owens CD, Stoessel K. Surgical site infections: Epidemiology, microbiology and prevention. J Hosp Infect 2008;70 Suppl 2:3-10.
Boni L, Benevento A, Rovera F, Dionigi G, Di Giuseppe M, Bertoglio C, et al
. Infective complications in laparoscopic surgery. Surg Infect (Larchmt) 2006;7 Suppl 2:S109-11.
Sasmal PK, Mishra TS, Rath S, Meher S, Mohapatra D. Port site infections in laparoscopy: A review of its management. World J Clin Cases 2015;3:864-71.
Cheng K, Li J, Kong Q, Wang C, Ye N, Xia G. Risk factors for surgical site infection in a teaching hospital: A prospective study of 1,138 patients. Patient Prefer Adherence 2015;9:1171-7.
Lilani SP, Jangale N, Chowdhary A, Daver GB. Surgical site infection in clean and clean-contaminated cases. Indian J Med Microbiol 2005;23:249-52.
] [Full text]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]