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Comparison of surgical-site infection between open and laparoscopic appendectomy

Purpose An inflamed appendix can be removed either openly (open appendectomy [OA]) or laparoscopically (laparoscopic appendectomy [LA]). Surgical-site infection (SSI) is a representative healthcare-associated infection and can impose serious economic burdens on patients as well as affect morbidity and mortality rates. The aim of this study was to compare LA with OA in terms of SSI. Methods The medical records of 749 patients (420 males; mean age, 33 years) who underwent appendectomy (OA, 431; LA, 318) between September 1, 2008 and April 29, 2010 were retrospectively reviewed for demographic and pathologic characteristics, recovery of bowel movement, length of hospital stay, and postoperative complications. Results The frequency of purulent/gangrenous or perforated appendicitis was not significantly different between LA and OA groups (83% [263/318 cases] vs. 83% [359/431 cases], P = 0.183). The time to first flatus after surgery was not significantly different between the two groups (1.38 ± 1.07 days for LA, 1.33 ± 0.90 days for OA, P = 0.444), but the length of hospital stay was significantly shorter in LA group than in OA group (3.37 ± 0.12 days vs. 3.83 ± 0.12 days, P = 0.006). The frequency of overall SSI was not significantly different between the two groups (2.8% for LA, 4.6% for OA, P = 0.204), but that of superficial incisional SSI was significantly lower in LA group (0.6% vs. 3.9%, P = 0.016). Conclusion The results of this study suggest that LA may lead to a shorter length of hospital stay and may have a lower risk of superficial incisional SSI than OA.


INTRODUCTION
Open appendectomy (OA), which was described first by McBurney [1] in 1894, has been accepted as the gold standard of appendectomy for around 100 years. However, since its introduction by Semm [2] in 1983, laparoscopic appendectomy (LA) has been conducted more frequently than OA due to its advantages of being minimally invasive [2][3][4]. In particular, more attention has been paid to recent remarkable innovative development and improvement in laparoscopic equipments, instruments and techniques.
Laparoscopic surgery, as mentioned in many studies, allows for safe and aesthetic operations [3][4][5] and can shorten the length of hospital stay, accelerate postoperative rethesurgery.or.kr covery and produce less pain [6,7]. However, LA may necessitate higher medical costs due to the use of specialized equipments and instruments and may show a higher possibility of intra-abdominal abscess, especially in severe appendicitis, such as perforated appendicitis [8][9][10][11][12]. Surgicalsite infection (SSI) is known to be a representative healthcare-associated infection and may impose serious economic burdens on patients as well as increase morbidity and mortality rates [13][14][15]. The present study compared and analyzed LA and OA especially in terms of SSI. OA was performed through right lower quadrant transverse muscle-splitting incision. The thread ties were placed on the base of the appendix. The tied-off appendiceal stump was dunk in again with purse-string suture.

METHODS
For LA, three ports were used. One 10-mm port for laparoscope entered at the inferior margin of umbilicus with either a vertical or semicircular transverse incision. Two additional 5-mm ports entered at the left lower quadrant and at the suprapubic area. Mesoappendiceal tissue was dis-sected and divided with monopolar electrocautery or ultrasonic scissor. Before transection of appendix, stump was doubly ligated with endoloops as an easy, safe and cost-effective procedure [16]. Transected appendix was retrieved via umbilical port. And the surgeons decided cautiously whether or not to insert a Jackson-Pratt drain bag in severe forms of appendicitis, such as suppurative, gangrenous, or perforated appendicitis.

RESULTS
Appendectomies were performed openly in 431 patients (OA group) and laparoscopically in 318 patients (LA group). The mean age was younger and body mass index (BMI) was higher significantly in the LA group than in the OA group, but the other demographic and pathologic parameters were not significantly different between the two groups (  2 due to ileus, 7 due to surgical-site infection (SSI). b) All due to SSI. Gangrenous/perforated 17, suppurative 3. b) Gangrenous/perforated 6, hyperemic 3.  Table 3). In addition, the difference in the superficial SSI rate was more significant in severe forms of appendicitis, such as suppurative, gangrenous or perforated appendicitis ( Table 4).
The patients were re-classified by the symptoms or signs of the patients, radiologic and operative findings into 1) minimal or localized peritonitis group (n = 682) and 2) diffuse peritonitis group (n = 67 Readmission within 30 days of surgery was observed in 2 cases (0.6%) in the LA group and 9 cases (2.1%) in the OA group, but the difference was not statistically significant.
Of the 9 patients in the OA group, 2 were hospitalized due to ileus and 7 due to SSI, while the 2 patients in the LA group were hospitalized due to SSI.

DISCUSSION
Laparoscopic surgery allows for safe and aesthetic operation [3][4][5] and it is also known to accelerate post-operative recovery and to produce less pain [6]. In the current study, the time to the first flatus after surgery was not significantly different between the two groups. The reason for this may be that the appendectomy is such a minor operative procedure that the recovery of gastrointestinal motility is not significantly affected. However, the length of hospital stay was significantly shorter in the LA group.
The mean age of the patients was significantly younger in the LA group than in the OA group in this study. This may be explained by the fact that young people are usually more concerned about aesthetic outcomes. The frequency of LA was significantly higher in females aged ＜25 years than in those aged ≥25 years (19% [60/318 cases] vs. 12% [51/431 cases], P = 0.007), which suggests that young patients favored the minimally invasive operation.
Operation time was significantly longer in the LA group than in the OA group. Khan et al. [18] reported that the me- BMI was significantly higher in the LA group than in the OA group. Obesity is known to be a risk factor for surgical-site infection and BMI is used to define obesity. Higher BMI tends to correlate with higher SSI rate [19]. However, in the present study, the overall SSI rate was not significantly different between the two groups, and the su- Markides et al. [22] also emphasized the surgeon's discretion and laparoscopic experience in complicated appendicitis, while concluding no difference with regard to intra-abdominal abscess complication rates (level 3a evidence) in their systematic review and meta-analysis.
Therefore, when LA is conducted, the surrounding area of the pelvis should be carefully explored. Abscess should be sufficiently aspirated or the insertion of drains should be considered.
The current study has some limitations in that the enrolled patients were not randomized to the OA and LA groups. Our patients underwent operation by several surgeons with varying degrees of surgical skills. To remove these limitations, well-designed randomized controlled trials with a larger number of patients should be carried out. However, such trials would be practically infeasible due to the continued growth of the popularity of LA as mentioned previously [18].
In conclusion, LA demonstrated a reduced risk of superficial incisional SSI compared to OA. With some advantages of minimal invasiveness, LA would be a preferred surgical option for appendicitis [6,7,[23][24][25].

CONFLICTS OF INTEREST
No potential conflict of interest relevant to this article was reported.