Original article

doi:10.1111/j.1463-1318.2010.02302.x

Minimally invasive surgical wound infections: laparoscopic surgery decreases morbidity of surgical site infections and decreases the cost of wound care
M. W. Dobson, D. Geisler, V. Fazio, F. Remzi, T. Hull and J. Vogel
The Department of Colon and Rectal Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA Received 30 December 2009; accepted 19 March 2010; Accepted Article online 29 April 2010

Abstract
Aim The morbidity of surgical site infections (SSIs) were compared in patients who underwent open (OS) vs laparoscopic (LS) colorectal surgery. Method Data from 603 consecutive LS patients and 2246 consecutive OS patients were prospectively recorded. Morbidity of SSIs was assessed by the need for emergency department (ED) evaluation, subsequent hospital re-admission and re-operation. The cost of wound care was measured by the need for home healthcare, wound vacuum assisted closure (VAC) or independent patient wound care. Results SSIs were identied in 5.8% (n = 25) of LS patients and 4.8% (n = 65) of OS patients. ED evaluation for the infection was needed in 24% of the LS group and 42% of the OS group. Hospital re-admission was needed in one LS patient and in 52% OS patients. No LS patient needed re-operation compared with 12% of OS patients. HHC ($162 dressing change) was required in 63% of the OS group compared with 8% of LS group. A home wound VAC system ($107 day) was utilized in 12% of the OS patients but in none of the LS patients. Dressing changes were managed independently by the patient in 92% of the LS compared with 37% of the OS patients. Conclusion Laparoscopic colorectal surgery patients experience less morbidity when they develop SSIs incurring less cost compared with open colorectal surgery patients. Keywords Minimally invasive surgery, surgical site infections surgery, colorectal

Introduction
Postoperative surgical site infections (SSIs) are one of the most common complications in surgical patients. According to The Centers for Disease Control (CDC) and the Prevention National Nosocomial Infections Surveillance (NNIS) system, SSIs are the second leading cause of all nosocomial infection [1] and are the most commonly acquired infection amongst all surgical patients [2,3]. It is estimated that 25% of all patients undergoing an operation will develop a surgical site infection [4]. The incidence is even higher (513%) for patients undergoing gastrointestinal surgery [5]. SSI causes physical discomfort of the wound, impairment of cosmesis and the prolonged recovery time.

Correspondence to: Dr Michael W. Dobson, 2001 Vail Ave. suite 320, Charlotte, North Carolina, USA, 28207. E-mail: [email protected]

Patients who develop SSI are 60% more likely to spend time in an ICU, ve times more likely to be readmitted to the hospital, and have twice the incidence of mortality [6]. Furthermore, patients with SSI have longer hospitalizations and a substantial increase in the cost of care. Kirkland et al. [6] showed that SSI after laparotomy results in double the cost per patient. The average length of hospitalization is extended 710 days and the associated increase in cost is estimated to be around $2000$5000 per case [7,8]. With an estimated 500 000 SSIs per year in the USA, this accounts for over 3.5 million excess hospital days and over 1.6 billion dollars in hospital charges. The current literature contains numerous reports indicating the benets of laparoscopic compared with traditional open surgery. One of these is a smaller incision with less tissue trauma. The aim of this study was to compare SSIs that developed following open and laparoscopic colorectal surgery. We hypothesized that patients who underwent the latter and developed a subsequent

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surgical site infection would experience less morbidity from the wound and incur fewer costs.

Method
This study was conducted following Internal Review Board approval. All patients from 2003 to 2006 who underwent open or laparoscopic intestinal tract surgery in the Department of Colon and Rectal Surgery were identied from a prospectively maintained database and appropriate CPT codes. Both the laparoscopic and the open surgical databases are maintained by our institutions research department. Patients were selected from 2003 onward, as this coincided with new management of the laparoscopic database. The ICD-9 diagnosis codes for wound infection were then cross-referenced with the CPT codes, providing a list of colorectal surgical patients who had developed postoperative surgical site infection. The denition of surgical site infection used for this study was that devised by Horan and colleagues in 1992 [9] and subsequently adopted by the CDC (Table 1). Supercial and deep SSIs were analysed for this study, while organ space SSIs (such as postoperative intraabdominal abscess) were excluded. The medical records of all patients identied as having a postoperative wound infection were retrospectively evaluated by one reviewer

to verify the presence of an SSI. In addition, any information not contained within the prospectively maintained databases was obtained from the patients medical record by the same reviewer. Age, gender and length of hospitalization following surgery were recorded as was the presence of preoperative comorbid risk factors for wound complications. Comorbidities identied included obesity (BMI > 29), diabetes mellitus and the use of steroids or other immunomodulators within six months of surgery. Each patients preoperative diagnosis and the specic operative procedure were determined from the database. Exclusions included individuals who developed SSI but were lost to follow up or those with incomplete medical records. Patients with organ space surgical site infection, a chronic wound, a perineal wound, enterocutaneous stula and anastomotic leakage were also excluded. The clinical outcome included the associated morbidity from an SSI and the cost of wound care. Several variables were used to calculate the increase in morbidity from an SSI. Infections were diagnosed either during the patients original hospitalization, at the postoperative ofce follow up visit, or at an attendance at the emergency department following hospital discharge. The other two variables used to assess morbidity were the need for hospital re-admission to address the SSI and the need for re-operation for the wound.

Table 1 Summary of the denitions of supercial and deep SSIs. Supercial incisional surgical site infections Supercial incisional surgical site infections must meet the following two criteria: 1. Occur within 30 days of procedure 2. Involve only the skin or subcutaneous tissue around the incision Plus at least one of the following criteria: Purulent drainage from the incision Organisms isolated from an aseptically obtained culture of uid or tissue from the incision At least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness or heat Diagnosis of supercial incisional SSI by a surgeon or attending physician The following are not considered supercial SSIs: Stitch abscess Infected burn wounds CDC denition of surgical site infection (SSIs) [9].
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Deep incisional surgical site infections Deep incisional surgical site infections must meet the following three criteria: 1. Occur within 30 days of a procedure (or 1 year in the case of implants) 2. Are related to the procedure 3. Involve deep soft tissue, such as the fascia and muscle Plus at least one of the following criteria: Purulent drainage from the incision but not from the organ space of the surgical site An abscess or other evidence of infection involving the incision is found on direct examination or by histopathologic or radiologic examination A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the signs or symptoms of infection Diagnosis of a deep incisional SSI by a surgeon or attending physician

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In addition to the morbidity of a wound, we also evaluated the charges for outpatient wound care of the SSIs. The cost of common methods of wound care were compared. These included home care by a healthcare nurse who visits for saline gauze dressing changes, at an average cost of $162 per dressing change [10]. Another option was VAC treatment costing approximately $107 per day [11]. In addition to the cost of the equipment and supplies, this also required changes of the VAC three times per week by a home healthcare nurse. The cost of the these two methods of wound care was contrasted with patients who cared for their wound independently with scheduled saline gauze dressing changes by themselves or a family member, at a cost of approximately $10 per day [11]. Data for the number of days of the different types of wound care were not included in the prospectively maintained database. This information was obtained through retrospective review of the patients electronic medical record. The length of time for wound care was determined by communication with the patients and home healthcare agencies that were noted in the records and by follow-up ofce visits.

Results
Utilizing the institutional databases and the CPT codes for open and laparoscopic colorectal surgery, we identied 603 laparoscopic and 2246 open procedures performed by our department from 2003 to 2006. Crossreferencing the CPT codes with the ICD-9 codes for postoperative wound infections was identied in 35 (5.8%) of the 603 laparoscopic and in 108 (4.8%) of the 2246 open surgical patients (P = 0.32). Applying the exclusion criteria stated above, 10 of the 35 patients in the laparoscopic and 43 of the 108 in the open group were excluded from the study. The remaining 25 and 65 in each group were used as the study population (Table 2). The four laparoscopic patients that required conversion to open surgery were included in the open surgical
Table 2 Demographic data. Laparoscopic Group n = 25 Mean age Gender Male Female Median length of hospital stay after surgery Median incision length 50 years (STD 14.3) 14 (56%) 11 2 days (Range 26 days) 5.5 cm (Range 1.58.5 cm)

group. The number of SSIs in the two groups is shown in Table 3. Preoperative risk factors for wound infection were identied in 18 (72%) of the laparoscopic and in 38 (58%) of the open group. Several patients had more than one risk factor. In the laparoscopic group, these included obesity (n = 12), diabetes mellitus (n = 4) and immunomodulation (n = 7). Five of the seven patients were on preoperative steroids. In the open group these were obesity (n = 18), diabetes mellitus (n = 5) and immunomodulation (n = 26). Of the 26 patients, 19 were on preoperative steroids. The major preoperative diagnosis for each patient from the two study groups is given in Table 4. The operative procedure in each group is shown in Table 5. Increased morbidity, dened by the need for emergency department evaluation of a surgical site infection, was present in 24% (n = 6) of the laparoscopic patients and in 42% (n = 27) of the open patients. One of the 65 patients in the open group did not specically state how the wound was identied and therefore was excluded from the analysis. Re-admission specically for a surgical site infection occurred in only 4% (n = 1) in the laparoscopic group and in 52.3% (n = 34) in the open group. None of the 25 laparoscopic patients required any reoperation for the wound infection compared with 12.3% (n = 8) of the open patients. The use of outpatient wound care methods was signicantly higher amongst the open surgical patients. Home healthcare at an average cost of $162 per dressing change [10] was needed in 63% (n = 41) of the open surgical patients. Of these, three required dressing changes thrice daily, 25 twice daily and ve once daily. The remaining eight patients underwent dressing changes three times per week as part of V.A.C. system management (Table 6). Home healthcare dressing changes were required in only two laparoscopic patients, both requiring twice daily changes. The charge for V.A.C. system wound management is $107.46 per day [11], which is in addition to the

Open Group n = 65 49.1 years (STD 14.6) 27 (41.5%) 38 7 days (Range 318 days) Not recorded

P value 0.79 T 0.57 C < 0.001 W

T, t-test C, chi-square test W, Wilcoxon rank sum test.

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Table 3 Surgical site infections. Laparoscopic Group Total number of surgical patients (2003-2006) Total number of SSIs Overall infection rate Number of patients excluded: Final number of patients analysed for study C, chi-square test. 603 35 5.80% 10 25 Open Group 2246 108 4.80% 43 65

Table 6 Adjusted daily charges for Home healthcare dressing Changes: ($162 dressing change) [10]. P value Frequency of dressing changes Thrice daily Twice daily Once daily Three times per week with V.A.C.

Average daily charges $486 per day $324 per day $162 per day $69.42 per day

Open Group n = 41 3 25 5 8

Lap Group n=2 0 2 0 0

0.32 C 0.12 C

Table 4 Preoperative diagnosis. Laparoscopic Group n = 25 Diverticular disease Crohns disease Ulcerative Colitis Colorectal neoplasm Colonic inertia Colonic stricture Rectal prolapse Radiation enteritis Small bowel obstruction 8 5 2 8 1 0 0 0 1 Open Group n = 65 10 15 19 14 2 3 1 1 0

performed by the patient or family member, costing approximately $10 per day [11], was possible in 23 (92%) of the 25 laparoscopic patients managed in this manner compared with 37% (n = 24) of the open surgical patients who were able to manage their wounds independently at home.

Discussion
SSIs are a serious and costly postoperative complication. They are the second most common type of all nosocomial infections and are a major source of morbidity [1]. In this study, SSIs were diagnosed either during the original postoperative hospital admission, during a postoperative ofce visit or as the result of an emergency department visit. An emergency department diagnosis, hospital re-admission and re-operation were taken as indicators of severity. Using these criteria, the open surgical group showed greater severity, supporting our hypothesis that laparoscopic colorectal surgical patients who develop postoperative surgical site infection experience less wound morbidity. In addition, surgical site infection also results in prolonged hospital stay [12] and is a source of excess medical cost [13]. In a study by Zoutman and colleagues [14] of surgical wound infections in a tertiary-care centre, wound infections resulted in an increased inpatient cost of $4228 per SSI and a mean inpatient length of stay of 10 extra days. This increase in healthcare dollars did not even take into account the cost of care once the patient left the hospital. It is difcult to obtain an accurate assessment of cost, as there are many variables involved in the calculation. There are the obvious costs of dressing supplies and excess days in the hospital and the cost of additional nursing care. There are also the costs of laboratory and radiologic testing, medicines and ancillary staff charges. Furthermore, there is the number of working days missed by the patient with the resultant lost income. Our study focused on a single element of the increased cost of care

Table 5 Operative procedure. Open Operations n (65) 11 6 1 4 9 1 2 14 6 9 2 0 Laparoscopic Operations n (25) 5 5 0 2 8 0 1 3 0 0 0 1

Operative Procedure Ileocectomy Right Hemicolectomy Transverse Colectomy Left Hemicolectomy Sigmoidectomy Colostomy Takedown Proctosigmoidectomy Total Abdominal Colectomy Total Proctocolectomy Proctectomy Small Bowel Resection Lysis of Adhesions

charges for the thrice weekly home healthcare dressing changes. None of the 25 laparoscopic patients required a home wound V.A.C. system compared with 12% (n = 8) of the open patients. Outpatient independent wound management with saline gauze dressing changes

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associated with a surgical site infection. We evaluated and compared the charges for several options of outpatient wound care. When the charges for home healthcare ($162 per dressing change) and the home V.A.C. wound management ($107.46 per day) were compared with saline gauze dressings applied by the patient at $10 per day, there was a signicantly greater number of open surgical patients in the more expensive wound care group and almost all the laparoscopic patients were able to manage their wounds independently at minimal cost. These data support the second hypothesis that laparoscopic colorectal surgical patients who develop SSIs require fewer healthcare dollars for wound care. Numerous studies have demonstrated the benets of laparoscopic surgery, such as decreased postoperative pain, faster return of bowel function and shorter hospitalizations [15]. Our study adds another factor to these. Some studies have indicated that laparoscopic surgery decreases the incidence of postoperative surgical site infection [16]. Our data show that when a postoperative surgical site infection does occur following laparoscopic surgery, the infection is less severe, more easily managed and requires less cost compared with similar infections in open surgical patients. Although we were able to show a decrease in the cost for outpatient wound care for laparoscopic patients, our results do not include - other factors contributing to the cost of surgical site infection such as the cost of operating room time and the length of time to wound healing in the two groups. In conclusion, patients undergoing laparoscopic colorectal surgery who subsequently develop a surgical site infection experience less morbidity from the wound compared with patients having open surgery. SSIs that occur following laparoscopic colorectal surgery are more easily managed and require signicantly less cost compared with SSIs that occur following open colorectal surgery.

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