Surgical Endoscopy

, Volume 29, Issue 6, pp 1384–1393 | Cite as

Surgical site infection after laparoscopic and open appendectomy: a multicenter large consecutive cohort study

  • Yan Xiao
  • Gang Shi
  • Jin Zhang
  • Jian-Guo Cao
  • Li-Jun Liu
  • Ting-Hao Chen
  • Zhi-Zhou Li
  • Hong Wang
  • Han Zhang
  • Zhao-Fen LinEmail author
  • Jun-Hua Lu
  • Tian YangEmail author



Laparoscopic appendectomy (LA) has been rapidly applied worldwide recently. The issue of surgical site infection (SSI) after appendectomy needs to be re-investigated and analyzed along with this trend. This study aimed to identify risk factors of SSI after appendectomy in recent years.


This retrospective study was conducted among patients with acute appendicitis who underwent either laparoscopic or open appendectomy (OA) at 7 general hospitals in China from 2010 to 2013. The incidence of SSI, classified as incisional SSI and organ/space SSI, was investigated. A multivariate logistic regression model was used to assess independent risk factors associated with overall, incisional, and organ/space SSI, respectively.


Among 16,263 consecutive patients, 3,422 (21.0 %) and 12,841 (79.0 %) patients underwent LA and OA, respectively. The incidences of overall, incisional, and organ/space SSI were 6.2, 3.7, and 3.0 %, respectively. The proportion of LAs among both procedures increased yearly from 5.3 to 46.5 %, while the incidences of overall and incisional SSI after appendectomy simultaneously decreased yearly from 9.6 to 4.5 % and from 6.7 to 2.2 %, respectively. In comparison with OA, LA was associated with lower incidences of overall and incisional SSI (4.5 vs 6.7 %, P < 0.001; and 1.9 vs 4.2 %, P < 0.001), but a similar incidence of organ/space SSI (3.0 vs 3.0 %, P = 0.995). After multivariate logistic regression analyses were performed, LA was found to be independently associated with a decrease in development of overall SSI [odds ratio (95 % confidence interval) OR (95 % CI), 1.24 (1.03–1.70); P = 0.04] or incisional SSI [OR (95 % CI), 1.32 (1.10–1.68); P = 0.01].


With the increasing application trends of laparoscopic procedure, the incidence of SSI after appendectomy declined accordingly. Compared with OA, LA was independently associated with a significantly lower incidence of incisional SSI, but a similar incidence of organ/space SSI.


Appendix Appendectomy Laparoscopy Surgical site infection Postoperative complication Morbidity 



This study was supported by the National Natural Science Foundation of China (No. 81000166, 81101578, 81172020 and 81372262 for T. Y. and J. Z.), Shanghai ‘Phosphor’ Science Foundation (No. 12QA1404800 for T. Y. and 12QA1404900 for J. Z.), Program for Excellent Young Scholars of SMMU (for T. Y.) and Charitable Project on Scientific Research of Shanghai (for T. Y.).


Drs. Yan Xiao, Gang Shi, Jin Zhang, Jian-Guo Cao, Li-Jun Liu, Ting-Hao Chen, Zhi-Zhou Li, Hong Wang, Han Zhang, Zhao-Fen Lin, and Tian Yang have no conflicts of interest or financial ties to disclose.


  1. 1.
    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213CrossRefPubMedCentralPubMedGoogle Scholar
  2. 2.
    National Nosocomial Infections Surveillance (NNIS) System (2004) National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control 32:470–485CrossRefGoogle Scholar
  3. 3.
    Alexander JW, Solomkin JS, Edwards MJ (2011) Updated recommendations for control of surgical site infections. Ann Surg 253:1082–1093CrossRefPubMedGoogle Scholar
  4. 4.
    Hawn MT, Vick CC, Richman J, Holman W, Deierhoi RJ, Graham LA, Henderson WG, Itani KM (2011) Surgical site infection prevention: time to move beyond the surgical care improvement program. Ann Surg 254:494–499 discussion 499–501CrossRefPubMedGoogle Scholar
  5. 5.
    Thompson KM, Oldenburg WA, Deschamps C, Rupp WC, Smith CD (2011) Chasing zero: the drive to eliminate surgical site infections. Ann Surg 254(3):430–436CrossRefPubMedGoogle Scholar
  6. 6.
    Paterson HM, Qadan M, de Luca SM, Nixon SJ, Paterson-Brown S (2008) Changing trends in surgery for acute appendicitis. Br J Surg 95:363–368CrossRefPubMedGoogle Scholar
  7. 7.
    Livingston EH, Woodward WA, Sarosi GA, Haley RW (2007) Disconnect between incidence of nonperforated and perforated appendicitis: implications for pathophysiology and management. Ann Surg 245:886–892CrossRefPubMedCentralPubMedGoogle Scholar
  8. 8.
    Kehagias I, Karamanakos SN, Panagiotopoulos S, Panagopoulos K, Kalfarentzos F (2008) Laparoscopic versus open appendectomy: which way to go. World J Gastroenterol 14:4909–4914CrossRefPubMedCentralPubMedGoogle Scholar
  9. 9.
    Wei B, Qi CL, Chen TF, Zheng ZH, Huang JL, Hu BG, Wei HB (2011) Laparoscopic versus open appendectomy for acute appendicitis: a metaanalysis. Surg Endosc 25:1199–1208CrossRefPubMedGoogle Scholar
  10. 10.
    Olmi S, Magnone S, Bertolini A, Croce E (2005) Laparoscopic versus open appendectomy in acute appendicitis: a randomized prospective study. Surg Endosc 19:1193–1195CrossRefPubMedGoogle Scholar
  11. 11.
    Romy S, Eisenring MC, Bettschart V, Petignat C, Francioli P, Troillet N (2008) Laparoscope use and surgical site infections in digestive surgery. Ann Surg 247:627–632CrossRefPubMedGoogle Scholar
  12. 12.
    Sauerland S, Jaschinski T, Neugebauer EA (2010) Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev 10:CD001546PubMedGoogle Scholar
  13. 13.
    Markides G, Subar D, Riyad K (2010) Laparoscopic versus open appendectomy in adults with complicated appendicitis: systematic review and meta-analysis. World J Surg 34:2026–2040CrossRefPubMedGoogle Scholar
  14. 14.
    Li X, Zhang J, Sang L, Zhang W, Chu Z, Li X, Liu Y (2010) Laparoscopic versus conventional appendectomy: a meta-analysis of randomized controlled trials. BMC Gastroenterol 10:129CrossRefPubMedCentralPubMedGoogle Scholar
  15. 15.
    Ohtani H, Tamamori Y, Arimoto Y, Nishiguchi Y, Maeda K, Hirakawa K (2012) Meta-analysis of the results of randomized controlled trials that compared laparoscopic and open surgery for acute appendicitis. J Gastrointest Surg 16:1929–1939CrossRefPubMedGoogle Scholar
  16. 16.
    Chung RS, Rowland DY, Li P, Diaz J (1999) A meta-analysis of randomized controlled trials of laparoscopic versus conventional appendectomy. Am J Surg 177:250–256CrossRefPubMedGoogle Scholar
  17. 17.
    Aziz O, Athanasiou T, Tekkis PP, Purkayastha S, Haddow J, Malinovski V, Paraskeva P, Darzi A (2006) Laparoscopic versus open appendectomy in children: a meta-analysis. Ann Surg 243:17–27CrossRefPubMedCentralPubMedGoogle Scholar
  18. 18.
    Varela JE, Wilson SE, Nguyen NT (2010) Laparoscopic surgery significantly reduces surgical-site infections compared with open surgery. Surg Endosc 24:270–276CrossRefPubMedGoogle Scholar
  19. 19.
    Swank HA, Eshuis EJ, van Berge Henegouwen MI, Bemelman WA (2011) Short- and long-term results of open versus laparoscopic appendectomy. World J Surg 35:1221–1226 discussion 1227–1228CrossRefPubMedCentralPubMedGoogle Scholar
  20. 20.
    Khiria LS, Ardhnari R, Mohan N, Kumar P, Nambiar R (2011) Laparoscopic appendicectomy for complicated appendicitis: is it safe and justified?: A retrospective analysis. Surg Laparosc Endosc Percutan Tech 21:142–145CrossRefPubMedGoogle Scholar
  21. 21.
    Fleming FJ, Kim MJ, Messing S, Gunzler D, Salloum R, Monson JR (2010) Balancing the risk of postoperative surgical infections: a multivariate analysis of factors associated with laparoscopic appendectomy from the NSQIP database. Ann Surg 252:895–900CrossRefPubMedGoogle Scholar
  22. 22.
    Katsuno G, Nagakari K, Yoshikawa S, Sugiyama K, Fukunaga M (2009) Laparoscopic appendectomy for complicated appendicitis: a comparison with open appendectomy. World J Surg 33:208–214CrossRefPubMedGoogle Scholar
  23. 23.
    Pokala N, Sadhasivam S, Kiran RP, Parithivel V (2007) Complicated appendicitis: is the laparoscopic approach appropriate? A comparative study with the open approach: outcome in a community hospital setting. Am Surg 73:737–741 discussion 741–742PubMedGoogle Scholar
  24. 24.
    Krisher SL, Browne A, Dibbins A, Tkacz N, Curci M (2001) Intra-abdominal abscess after laparoscopic appendectomy for perforated appendicitis. Arch Surg (Chicago, IL: 1960) 136:438–441Google Scholar
  25. 25.
    Li X, Zhang J, Sang L, Zhang W, Chu Z, Li X, Liu Y (2010) Laparoscopic versus conventional appendectomy: a meta-analysis of randomized controlled trials. BMC Gastroenterol 10:129CrossRefPubMedCentralPubMedGoogle Scholar
  26. 26.
    Robertson CM, Coopersmith CM (2006) The systemic inflammatory response syndrome. Microbes Infect 8:1382–1389CrossRefPubMedGoogle Scholar
  27. 27.
    Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR (1999) Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control 27:97–132 quiz 133–134; discussion 96CrossRefPubMedGoogle Scholar
  28. 28.
    Tiwari MM, Reynoso JF, Tsang AW, Oleynikov D (2011) Comparison of outcomes of laparoscopic and open appendectomy in management of uncomplicated and complicated appendicitis. Ann Surg 254:927–932CrossRefPubMedGoogle Scholar
  29. 29.
    Nguyen NT, Zainabadi K, Mavandadi S, Paya M, Stevens CM, Root J, Wilson SE (2004) Trends in utilization and outcomes of laparoscopic versus open appendectomy. Am J Surg 188:813–820CrossRefPubMedGoogle Scholar
  30. 30.
    Saia M, Buja A, Baldovin T, Callegaro G, Sandona P, Mantoan D, Baldo V (2012) Trend, variability, and outcome of open vs. laparoscopic appendectomy based on a large administrative database. Surg Endosc 26:2353–2359CrossRefPubMedGoogle Scholar
  31. 31.
    Brill A, Ghosh K, Gunnarsson C, Rizzo J, Fullum T, Maxey C, Brossette S (2008) The effects of laparoscopic cholecystectomy, hysterectomy, and appendectomy on nosocomial infection risks. Surg Endosc 22:1112–1118CrossRefPubMedCentralPubMedGoogle Scholar
  32. 32.
    Kasatpibal N, Norgaard M, Sorensen HT, Schonheyder HC, Jamulitrat S, Chongsuvivatwong V (2006) Risk of surgical site infection and efficacy of antibiotic prophylaxis: a cohort study of appendectomy patients in Thailand. BMC Infect Dis 6:111CrossRefPubMedCentralPubMedGoogle Scholar
  33. 33.
    Rotermann M (2004) Infection after cholecystectomy, hysterectomy or appendectomy. Health Rep 15:11–23PubMedGoogle Scholar
  34. 34.
    Guller U, Hervey S, Purves H, Muhlbaier LH, Peterson ED, Eubanks S, Pietrobon R (2004) Laparoscopic versus open appendectomy: outcomes comparison based on a large administrative database. Ann Surg 239:43–52CrossRefPubMedCentralPubMedGoogle Scholar
  35. 35.
    Katkhouda N, Mason RJ, Towfigh S, Gevorgyan A, Essani R (2005) Laparoscopic versus open appendectomy: a prospective randomized double-blind study. Ann Surg 242:439–448 discussion 448–450PubMedCentralPubMedGoogle Scholar
  36. 36.
    Moazzez A, Mason RJ, Katkhouda N (2013) Thirty-day outcomes of laparoscopic versus open appendectomy in elderly using ACS/NSQIP database. Surg Endosc 27:1061–1071CrossRefPubMedGoogle Scholar
  37. 37.
    Wei HB, Huang JL, Zheng ZH, Wei B, Zheng F, Qiu WS, Guo WP, Chen TF, Wang TB (2010) Laparoscopic versus open appendectomy: a prospective randomized comparison. Surg Endosc 24:266–269CrossRefPubMedGoogle Scholar
  38. 38.
    Marzouk M, Khater M, Elsadek M, Abdelmoghny A (2003) Laparoscopic versus open appendectomy: a prospective comparative study of 227 patients. Surg Endosc 17:721–724CrossRefPubMedGoogle Scholar
  39. 39.
    Pedersen AG, Petersen OB, Wara P, Ronning H, Qvist N, Laurberg S (2001) Randomized clinical trial of laparoscopic versus open appendicectomy. Br J Surg 88:200–205CrossRefPubMedGoogle Scholar
  40. 40.
    Kirshtein B, Bayme M, Domchik S, Mizrahi S, Lantsberg L (2007) Complicated appendicitis: laparoscopic or conventional surgery. World J Surg 31:744–749CrossRefPubMedGoogle Scholar
  41. 41.
    Tate JJ, Chung SC, Dawson J, Leong HT, Chan A, Lau WY, Li AK (1993) Conventional versus laparoscopic surgery for acute appendicitis. Br J Surg 80:761–764CrossRefPubMedGoogle Scholar
  42. 42.
    Woodham BL, Cox MR, Eslick GD (2012) Evidence to support the use of laparoscopic over open appendicectomy for obese individuals: a meta-analysis. Surg Endosc 26:2566–2570CrossRefPubMedGoogle Scholar
  43. 43.
    Varela JE, Hinojosa MW, Nguyen NT (2008) Laparoscopy should be the approach of choice for acute appendicitis in the morbidly obese. Am J Surg 196:218–222CrossRefPubMedGoogle Scholar
  44. 44.
    Tuggle KR, Ortega G, Bolorunduro OB, Oyetunji TA, Alexander R, Turner PL, Chang DC, Cornwell EE 3rd, Fullum TM (2010) Laparoscopic versus open appendectomy in complicated appendicitis: a review of the NSQIP database. J Surg Res 163:225–228CrossRefPubMedGoogle Scholar
  45. 45.
    Ingraham AM, Cohen ME, Bilimoria KY, Pritts TA, Ko CY, Esposito TJ (2010) Comparison of outcomes after laparoscopic versus open appendectomy for acute appendicitis at 222 ACS NSQIP hospitals. Surgery 148:625–635 discussion 635–637CrossRefPubMedGoogle Scholar
  46. 46.
    Paik PS, Towson JA, Anthone GJ, Ortega AE, Simons AJ, Beart RW Jr (1997) Intra-abdominal abscesses following laparoscopic and open appendectomies. J Gastrointest Surg 1:188–192 discussion 192–193CrossRefPubMedGoogle Scholar
  47. 47.
    Tang E, Ortega AE, Anthone GJ, Beart RW Jr (1996) Intraabdominal abscesses following laparoscopic and open appendectomies. Surg Endosc 10:327–328CrossRefPubMedGoogle Scholar
  48. 48.
    Yagmurlu A, Vernon A, Barnhart DC, Georgeson KE, Harmon CM (2006) Laparoscopic appendectomy for perforated appendicitis: a comparison with open appendectomy. Surg Endosc 20:1051–1054CrossRefPubMedGoogle Scholar
  49. 49.
    Kouwenhoven EA, van Driel OJ, van Erp WF (2005) Fear for the intraabdominal abscess after laparoscopic appendectomy: not realistic. Surg Endosc 19:923–926CrossRefPubMedGoogle Scholar
  50. 50.
    Costa-Navarro D, Jimenez-Fuertes M, Illan-Riquelme A (2013) Laparoscopic appendectomy: quality care and cost-effectiveness for today’s economy. World J Emerg Surg 8:45CrossRefPubMedCentralPubMedGoogle Scholar
  51. 51.
    Fullum TM, Ladapo JA, Borah BJ, Gunnarsson CL (2010) Comparison of the clinical and economic outcomes between open and minimally invasive appendectomy and colectomy: evidence from a large commercial payer database. Surg Endosc 24:845–853CrossRefPubMedCentralPubMedGoogle Scholar
  52. 52.
    Moore DE, Speroff T, Grogan E, Poulose B, Holzman MD (2005) Cost perspectives of laparoscopic and open appendectomy. Surg Endosc 19:374–378CrossRefPubMedGoogle Scholar
  53. 53.
    Martin LC, Puente I, Sosa JL, Bassin A, Breslaw R, McKenney MG, Ginzburg E, Sleeman D (1995) Open versus laparoscopic appendectomy. A prospective randomized comparison. Ann Surg 222:256–261 discussion 261–262CrossRefPubMedCentralPubMedGoogle Scholar
  54. 54.
    Wang CC, Tu CC, Wang PC, Lin HC, Wei PL (2013) Outcome comparison between laparoscopic and open appendectomy: evidence from a nationwide population-based study. PLoS One 8:e68662CrossRefPubMedCentralPubMedGoogle Scholar
  55. 55.
    Bennett J, Boddy A, Rhodes M (2007) Choice of approach for appendicectomy: a meta-analysis of open versus laparoscopic appendicectomy. Surg Laparosc Endosc Percutan Tech 17:245–255CrossRefPubMedGoogle Scholar
  56. 56.
    Liu Z, Zhang P, Ma Y, Chen H, Zhou Y, Zhang M, Chu Z, Qin H (2010) Laparoscopy or not: a meta-analysis of the surgical effects of laparoscopic versus open appendicectomy. Surg Laparosc Endosc Percutan Tech 20:362–370CrossRefPubMedGoogle Scholar
  57. 57.
    Krukowski ZH, Irwin ST, Denholm S, Matheson NA (1988) Preventing wound infection after appendicectomy: a review. Br J Surg 75:1023–1033CrossRefPubMedGoogle Scholar
  58. 58.
    Andersen BR, Kallehave FL, Andersen HK (2005) Antibiotics versus placebo for prevention of postoperative infection after appendicectomy. Cochrane Database Syst Rev 3:CD001439PubMedGoogle Scholar
  59. 59.
    van Rossem CC, Schreinemacher MH, Treskes K, van Hogezand RM, van Geloven AA (2014) Duration of antibiotic treatment after appendicectomy for acute complicated appendicitis. Br J Surg 101:715–719CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Yan Xiao
    • 1
    • 2
  • Gang Shi
    • 3
  • Jin Zhang
    • 4
  • Jian-Guo Cao
    • 5
  • Li-Jun Liu
    • 2
  • Ting-Hao Chen
    • 6
  • Zhi-Zhou Li
    • 7
  • Hong Wang
    • 8
  • Han Zhang
    • 4
  • Zhao-Fen Lin
    • 1
    Email author
  • Jun-Hua Lu
    • 4
  • Tian Yang
    • 4
    Email author
  1. 1.Department of Emergency, Changzheng HospitalSecond Military Medical UniversityShanghaiChina
  2. 2.Department of EmergencySecond Affiliated Hospital of Soochow UniversitySoochowChina
  3. 3.The 3rd Department of General SurgeryAffiliated Hospital of North Sichuan Medical CollegeNanchongChina
  4. 4.Department of Hepatic Surgery, Eastern Hepatobiliary Surgery HospitalSecond Military Medical UniversityShanghaiChina
  5. 5.Department of General SurgeryZhangjiagang First People’s HospitalSoochowChina
  6. 6.Department of General SurgeryZiyang First People’s HospitalZiyangChina
  7. 7.Department of General SurgeryXuancheng People’s HospitalXuanchengChina
  8. 8.Department of General SurgeryLiuyang People’s HospitalLiuyangChina

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