Research Article | Open Access | 10.31586/Surgery.0201.05
Measuring Quality: The Impact of Minimally Invasive Surgery and Operative Time on Surgical Site Infections
Received January 9, 2015
Revised February 21, 2015
Accepted March 16, 2015
Published March 30, 2015
AbstractObjective: To evaluate the relationship between operative approach, operative time, and SSI rate. Methods: Inpatient database review identified patients undergoing 5 common procedures from 1/2010-12/2011. Patients were stratified into laparoscopic or open approaches. The main outcome measure was the relationship between operative time and SSI by approach. Results: 226,006 patients were evaluated- 28.2% open and 71.8% laparoscopic. Mean overall operative time was significantly shorter laparoscopically (p<0.001). Laparoscopy was associated with significantly lower costs and shorter length of stay (LOS) overall and for each procedure(p<0.0001). Multivariate analysis found SSI increased directly with operative time: for every 30-minute increase, SSI risk increased by 12%. Operative approach was an independent risk factor for SSI: open surgery increased SSI risk by 78%. A direct relationship between open procedures, operative time, and SSI risk was found. Conclusions: Laparoscopy has overall shorter operative time and improved outcomes in SSI rate, LOS, and total costs for common surgical procedures. As operative time and approach were independent risk factors for SSI, the use of laparoscopy and operative time are valuable quality measures.
Keywords: Surgical site infection; Laparoscopic surgery; Postoperative complications; Patient Outcomes; Operative time; Quality Measures
Anderson, D. J., Prevention of surgical site infection: beyond SCIP, AORN J, 99, 315, 2014.
Awad, S. S., Adherence to surgical care improvement project measures and post-operative surgical site infections, Surg Infect (Larchmt), 13, 234, 2012.
Edmiston, C. E. et al., Reducing the risk of surgical site infections: did we really think SCIP was going to lead us to the promised land?, Surg Infect (Larchmt), 12, 169, 2011.
Hedrick, T. L., Turrentine, F. E., Smith, R. L., McElearney, S. T., Evans, H. L., Pruett, T. L., and Sawyer, R. G., Single-institutional experience with the surgical infection prevention project in intra-abdominal surgery, Surg Infect (Larchmt), 8, 425, 2007.
Larochelle, M., Hyman, N., Gruppi, L., and Osler, T., Diminishing surgical site infections after colorectal surgery with surgical care improvement project: is it time to move on?, Dis Colon Rectum, 54, 394, 2011.
Leaper, D. J., Tanner, J., Kiernan, M., Assadian, O., and Edmiston, C. E. J., Surgical site infection: poor compliance with guidelines and care bundles, Int Wound J, 2014.
Wick, E. C. et al., Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections, J Am Coll Surg, 215, 193, 2012.
Klevens, R. M., Edwards, J. R., Richards, C. L. J., Horan, T. C., Gaynes, R. P., Pollock, D. A., and Cardo, D. M., Estimating health care-associated infections and deaths in U.S. hospitals, 2002, Public Health Rep, 122, 160, 2007.
Kirkland, K. B., Briggs, J. P., Trivette, S. L., Wilkinson, W. E., and Sexton, D. J., The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs, Infect Control Hosp Epidemiol, 20, 725, 1999.
Hawkins, R. B. et al., Beyond surgical care improvement program compliance: antibiotic prophylaxis implementation gaps, Am J Surg, 206, 451, 2013.
Surgical Care Improvement Project, Available online at: http://wwwjointcommissionorg/surgical_care_improvement_project/, Accessed June 2014.
Levy, S. M., Phatak, U. R., Tsao, K., Wray, C. J., Millas, S. G., Lally, K. P., and Kao, L. S., What is the quality of reporting of studies of interventions to increase compliance with antibiotic prophylaxis?, J Am Coll Surg, 217, 770, 2013.
Bonjer, H. J. et al., Laparoscopically assisted vs open colectomy for colon cancer: a meta-analysis, Arch Surg, 142, 298, 2007.
Delaney, C. P., Kiran, R. P., Senagore, A. J., Brady, K., and Fazio, V. W., Case-matched comparison of clinical and financial outcome after laparoscopic or open colorectal surgery, Ann Surg, 238, 67, 2003.
Delaney, C. P., Chang, E., Senagore, A. J., and Broder, M., Clinical outcomes and resource utilization associated with laparoscopic and open colectomy using a large national database, Ann Surg, 247, 819, 2008.
Nguyen, N. T., Goldman, C., Rosenquist, C. J., Arango, A., Cole, C. J., Lee, S. J., and Wolfe, B. M., Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs, Ann Surg, 234, 279, 2001.
Schwenk, W., Haase, O., Neudecker, J., and Muller, J. M., Short term benefits for laparoscopic colorectal resection, Cochrane Database Syst Rev, CD003145, 2005.
Veldkamp, R. et al., Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial, Lancet Oncol, 6, 477, 2005.
Aimaq, R., Akopian, G., and Kaufman, H. S., Surgical site infection rates in laparoscopic versus open colorectal surgery, Am Surg, 77, 1290, 2011.
Poon, J. T., Law, W. L., Wong, I. W., Ching, P. T., Wong, L. M., Fan, J. K., and Lo, O. S., Impact of laparoscopic colorectal resection on surgical site infection, Ann Surg, 249, 77, 2009.
Earle, D., Seymour, N., Fellinger, E., and Perez, A., Laparoscopic versus open incisional hernia repair: a single-institution analysis of hospital resource utilization for 884 consecutive cases, Surg Endosc, 20, 71, 2006.
Bailey, M. B., Davenport, D. L., Vargas, H. D., Evers, B. M., and McKenzie, S. P., Longer operative time: deterioration of clinical outcomes of laparoscopic colectomy versus open colectomy, Dis Colon Rectum, 57, 616, 2014.
Keller, D. S., Khorgami, Z., Swendseid, B., Khan, S., and Delaney, C. P., Identifying causes for high readmission rates after stoma reversal, Surg Endosc, 2013.
Kelly, K. N., Iannuzzi, J. C., Rickles, A. S., Monson, J. R., and Fleming, F. J., Risk Factors Associated with 30-Day Postoperative Readmissions in Major Gastrointestinal Resections, J Gastrointest Surg, 2013.
Bennett, C. L., Stryker, S. J., Ferreira, M. R., Adams, J., and Beart, R. W. J., The learning curve for laparoscopic colorectal surgery. Preliminary results from a prospective analysis of 1194 laparoscopic-assisted colectomies, Arch Surg, 132, 41, 1997.
Miskovic, D., Ni, M., Wyles, S. M., Tekkis, P., and Hanna, G. B., Learning curve and case selection in laparoscopic colorectal surgery: systematic review and international multicenter analysis of 4852 cases, Dis Colon Rectum, 55, 1300, 2012.
Park, J. S., Kang, S. B., Kim, S. W., and Cheon, G. N., Economics and the laparoscopic surgery learning curve: comparison with open surgery for rectosigmoid cancer, World J Surg, 31, 1827, 2007.
Shin, R. B., Evaluation of the learning curve for laparoscopic Roux-en-Y gastric bypass surgery, Surg Obes Relat Dis, 1, 91, 2005.
Garcia, N., Fogel, S., Baker, C., Remine, S., and Jones, J., Should compliance with the Surgical Care Improvement Project (SCIP) process measures determine Medicare and Medicaid reimbursement rates?, Am Surg, 78, 653, 2012.
Kao, L. S., Ghaferi, A. A., Ko, C. Y., and Dimick, J. B., Reliability of superficial surgical site infections as a hospital quality measure, J Am Coll Surg, 213, 231, 2011.
de Lissovoy, G., Fraeman, K., Hutchins, V., Murphy, D., Song, D., and Vaughn, B. B., Surgical site infection: incidence and impact on hospital utilization and treatment costs, Am J Infect Control, 37, 387, 2009.
Dua, A., Aziz, A., Desai, S. S., McMaster, J., and Kuy, S., National Trends in the Adoption of Laparoscopic Cholecystectomy over 7 Years in the United States and Impact of Laparoscopic Approaches Stratified by Age, Minim Invasive Surg, 2014, 635461, 2014.
Minutolo, V., Licciardello, A., Di Stefano, B., Arena, M., Arena, G., and Antonacci, V., Outcomes and cost analysis of laparoscopic versus open appendectomy for treatment of acute appendicitis: 4-years experience in a district hospital, BMC Surg, 14, 14, 2014.
Senagore, A. J., Duepree, H. J., Delaney, C. P., Dissanaike, S., Brady, K. M., and Fazio, V. W., Cost structure of laparoscopic and open sigmoid colectomy for diverticular disease: similarities and differences, Dis Colon Rectum, 45, 485, 2002.
Senagore, A. J., Brannigan, A., Kiran, R. P., Brady, K., and Delaney, C. P., Diagnosis-related group assignment in laparoscopic and open colectomy: financial implications for payer and provider, Dis Colon Rectum, 48, 1016, 2005.
Anaya, D. A. et al., Development and validation of a novel stratification tool for identifying cancer patients at increased risk of surgical site infection, Ann Surg, 255, 134, 2012.
Fahrner, R., Malinka, T., Klasen, J., Candinas, D., and Beldi, G., Additional surgical procedure is a risk factor for surgical site infections after laparoscopic cholecystectomy, Langenbecks Arch Surg, 399, 595, 2014.
Kurmann, A., Vorburger, S. A., Candinas, D., and Beldi, G., Operation time and body mass index are significant risk factors for surgical site infection in laparoscopic sigmoid resection: a multicenter study, Surg Endosc, 25, 3531, 2011.
Schlachta, C. M., Mamazza, J., Seshadri, P. A., Cadeddu, M., Gregoire, R., and Poulin, E. C., Defining a learning curve for laparoscopic colorectal resections, Dis Colon Rectum, 44, 217, 2001.
Simons, A. J., Anthone, G. J., Ortega, A. E., Franklin, M., Fleshman, J., Geis, W. P., and Beart, R. W. J., Laparoscopic-assisted colectomy learning curve, Dis Colon Rectum, 38, 600, 1995.