[Skip to Content]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
[Skip to Content Landing]
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Original Investigation
    Infectious Diseases
    October 18, 2019

    Association of Open Approach vs Laparoscopic Approach With Risk of Surgical Site Infection After Colon Surgery

    Author Affiliations
    • 1Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts
    • 2now with Department of Infectious Diseases, Lahey Hospital and Medical Center, Burlington, Massachusetts
    • 3Department of Biostatistics and Epidemiology, University of Massachusetts Amherst School of Public Health and Health Sciences, Amherst
    • 4Section of Infectious Disease & International Health, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
    • 5now with Boston University School of Medicine, Boston, Massachusetts
    • 6Division of General Surgery, University of California, San Francisco
    • 7Division of Infectious Diseases and the Health Policy Research Institute, University of California Irvine School of Medicine, Irvine
    JAMA Netw Open. 2019;2(10):e1913570. doi:10.1001/jamanetworkopen.2019.13570
    Key Points español 中文 (chinese)

    Question  Is laparoscopic colon surgery associated with a lower surgical site infection rate than an open approach, even in patients with high medical complexity?

    Findings  In this cohort study of 229 726 patients undergoing colon operations, compared with an open approach, laparoscopic colon surgery was associated with a lower surgical site infection rate regardless of medical comorbidities. Patients with multiple comorbidities underwent open colon surgery more often than laparoscopy.

    Meaning  Increasing the use of laparoscopy for colon surgery may be associated with reduced risk of surgical site infection.


    Importance  Colon surgery is associated with a high rate of surgical site infection (SSI), and there is an urgent need for strategies to reduce infection rates.

    Objective  To assess whether laparoscopic colon surgery is associated with a lower surgical site infection rate than open-approach laparoscopy, especially in patients with medically complex conditions.

    Design, Setting, and Participants  This cohort study used previously validated diagnosis and procedure codes from Medicare beneficiaries who underwent colon surgery from January 1, 2009, to November 30, 2013. Analyses were performed from August 1 to December 31, 2018.

    Main Outcomes and Measures  Outcome measures were SSI events, medical comorbidities, and laparoscopic or open approach procedures.

    Results  A total of 229 726 patients (mean [SD] age, 74.3 [9.4] years; 128 499 [55.9%] female) underwent colon procedures. There were 105 144 laparoscopic procedures and 124 582 open procedures. The overall mean SSI rate was 6.2%, varying by surgical procedure from 5.8% to 7.6%. Among the full study population, adjusted model results showed a significant association of laparoscopy with lower odds of SSI (odds ratio, 0.43; 95% CI, 0.41-0.46; P < .001). When stratified by surgical approach, the mean SSI rates were 4.1% (procedure-specific range, 3.9%-5.1%) for the laparoscopic approach and 7.9% (procedure-specific range, 7.4%-10.2%) for the open approach. When stratified by Elixhauser score groups, the mean SSI rates were 6.2% (procedure-specific range, 3.2%-8.7%) for group 1 (0-1 comorbidity), 5.5% (procedure-specific range, 3.6%-11.1%) for group 2 (2 comorbidities), and 6.6% (procedure-specific range, 4.6%-10.6%) for group 3 (3-13 comorbidities). An interaction was also observed between laparoscopic approach and Elixhauser groups, with increased odds of SSI among patients who had 3 to 13 comorbidities present at the time of the procedure (odds ratio, 1.21; 95% CI, 1.11-1.32) compared with patient groups with fewer comorbidities. The population attributable fraction of SSIs for use of the open approach was 34.2%. A total of 2317 of 3882 hospitals (59.7%) performed few (0%-10%) or most (>50%) procedures laparoscopically.

    Conclusions and Relevance  Policy changes that promote surgical education and resources for laparoscopy, especially at low-adoption hospitals, may be associated with reduced colon SSI rates. Support of the development of innovative educational policies may help achieve improvement in patient outcomes and decreased health care use in colon surgery.