Research Original Investigation
Minimally Invasive Surgery and Risk for SSIs
excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol. 1999;20(11):725-730. 20. Poulsen KB, Bremmelgaard A, Sørensen AI, Raahave D, Petersen JV. Estimated costs of postoperative wound infections: a case-control study of marginal hospital and Social Security costs. Epidemiol Infect. 1994;113(2):283-295. 21. Nguyen NT, Lee SL, Goldman C, et al. Comparison of pulmonary function and postoperative pain after laparoscopic versus open gastric bypass: a randomized trial. J Am Coll Surg. 2001;192(4):469-477. 22. Nguyen NT, Goldman CD, Ho HS, Gosselin RC, Singh A, Wolfe BM. Systemic stress response after laparoscopic and open gastric bypass. J Am Coll Surg. 2002;194(5):557-567.
23. Wichmann MW, Hüttl TP, Winter H, et al. Immunological effects of laparoscopic vs open colorectal surgery: a prospective clinical study. Arch Surg. 2005;140(7):692-697. 24. Whelan RL, Franklin M, Holubar SD, et al. Postoperative cell mediated immune response is better preserved after laparoscopic vs open colorectal resection in humans. Surg Endosc. 2003; 17(6):972-978. 25. Mohiuddin K, Swanson SJ. Maximizing the benefit of minimally invasive surgery. J Surg Oncol. 2013;108(5):315-319.
large commercial payer database. Surg Endosc. 2010;24(4):845-853. 27. Miskovic D, Ni M, Wyles SM, Tekkis P, Hanna GB. Learning curve and case selection in laparoscopic colorectal surgery: systematic review and international multicenter analysis of 4852 cases. Dis Colon Rectum. 2012;55(12):1300-1310. 28. Keller DS, Hashemi L, Lu M, Delaney CP. Short-term outcomes for robotic colorectal surgery by provider volume. J Am Coll Surg. 2013;217(6): 1603-1609.e1. doi:10.1016/j.jamcollsurg.2013.07.390.
26. Fullum TM, Ladapo JA, Borah BJ, Gunnarsson CL. Comparison of the clinical and economic outcomes between open and minimally invasive appendectomy and colectomy: evidence from a
Invited Commentary
Is a Minimally Invasive Approach the Solution for Reducing Surgical Site Infections? Simon P. Kim, MD, MPH; Marc C. Smaldone, MD, MSHP
During the past decade, performance of minimally invasive surgery (MIS) has rapidly disseminated into clinical practice for commonly performed procedures in the United States owing to lowering of the risk for complications, shortening of the length of stay, and imRelated article page 1039 proving convalescence compared with open surgery.1,2 Assessing the effect of MIS on the risk for surgical site infections (SSIs) is a salient question, because SSIs occur in at least 2% of all surgical procedures and are increasingly targeted under contemporary health care reform.3 Using data from the National Surgical Quality Improvement Program, Gandaglia et al4 investigate the association between surgical approach (MIS vs open) and SSIs for the following 4 commonly performed procedures: appendectomy, colectomy, hysterectomy, and prostatectomy. In more than 250 000 patients, the authors demonstrate substantial variation in SSI rates (1.7%-12.1%) across procedures, but report that MIS for each procedure type was associated with lower odds of SSIs after propensity matching.4 The authors
Conflict of Interest Disclosures: None reported.
ARTICLE INFORMATION Author Affiliations: Department of Urology, Yale University, New Haven, Connecticut (Kim); Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut (Kim); Department of Surgery, Fox Chase Cancer Center, Temple University Health System, Philadelphia, Pennsylvania (Smaldone).
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present compelling data but, because of limitations in the data, their study cannot address other complications or costs, which is necessary to assess the comparative effectiveness of each individual procedure type robustly. Furthermore, differentiation between laparoscopic and robotic approaches is not possible, which in light of current controversies regarding the increased health care costs of implementing new technologies affects the clinical relevance of the reported findings.2,5 Although SSIs represent a single component in defining surgical quality, contemporary comparative effectiveness research efforts have expanded to include patient-centered outcomes such as patient preferences, satisfaction, and quality of life in addition to the more traditionally measured outcomes such as mortality, complications, readmissions, and costs. Because future randomized studies are unlikely, clearly defining outcomes meaningful to patients, health care professionals, and key stakeholders is essential to determining whether an MIS is superior to open surgery or simply another tool selectively used at the discretion of the surgeon on an individual patient basis.
REFERENCES 1. Anderson JE, Chang DC, Parsons JK, Talamini MA. The first national examination of outcomes and trends in robotic surgery in the United States. J Am Coll Surg. 2012;215(1):107-116.
Corresponding Author: Simon P. Kim, MD, MPH, Department of Urology, Yale University, 200 Cedar St, New Haven, CT 06510 ([email protected]).
2. Wright JD, Ananth CV, Lewin SN, et al. Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease. JAMA. 2013;309(7):689-698.
Published Online: August 20, 2014. doi:10.1001/jamasurg.2014.313.
3. Burke JP. Infection control: a problem for patient safety. N Engl J Med. 2003;348(7):651-656.
4. Gandaglia G, Ghani KR, Sood A, et al. Effect of minimally invasive surgery on the risk for surgical site infections: results from the National Surgical Quality Improvement Progam (NSQIP) Database [published online August 20, 2014]. JAMA Surg. doi:10.1001/jamasurg.2014.292. 5. Kim SP, Shah ND, Karnes RJ, et al. Hospitalization costs for radical prostatectomy attributable to robotic surgery. Eur Urol. 2013;64(1):11-16.
JAMA Surgery October 2014 Volume 149, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Thomas Jefferson University User on 05/13/2015
jamasurgery.com
Minimally Invasive Surgery and Risk for SSIs
excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol. 1999;20(11):725-730. 20. Poulsen KB, Bremmelgaard A, Sørensen AI, Raahave D, Petersen JV. Estimated costs of postoperative wound infections: a case-control study of marginal hospital and Social Security costs. Epidemiol Infect. 1994;113(2):283-295. 21. Nguyen NT, Lee SL, Goldman C, et al. Comparison of pulmonary function and postoperative pain after laparoscopic versus open gastric bypass: a randomized trial. J Am Coll Surg. 2001;192(4):469-477. 22. Nguyen NT, Goldman CD, Ho HS, Gosselin RC, Singh A, Wolfe BM. Systemic stress response after laparoscopic and open gastric bypass. J Am Coll Surg. 2002;194(5):557-567.
23. Wichmann MW, Hüttl TP, Winter H, et al. Immunological effects of laparoscopic vs open colorectal surgery: a prospective clinical study. Arch Surg. 2005;140(7):692-697. 24. Whelan RL, Franklin M, Holubar SD, et al. Postoperative cell mediated immune response is better preserved after laparoscopic vs open colorectal resection in humans. Surg Endosc. 2003; 17(6):972-978. 25. Mohiuddin K, Swanson SJ. Maximizing the benefit of minimally invasive surgery. J Surg Oncol. 2013;108(5):315-319.
large commercial payer database. Surg Endosc. 2010;24(4):845-853. 27. Miskovic D, Ni M, Wyles SM, Tekkis P, Hanna GB. Learning curve and case selection in laparoscopic colorectal surgery: systematic review and international multicenter analysis of 4852 cases. Dis Colon Rectum. 2012;55(12):1300-1310. 28. Keller DS, Hashemi L, Lu M, Delaney CP. Short-term outcomes for robotic colorectal surgery by provider volume. J Am Coll Surg. 2013;217(6): 1603-1609.e1. doi:10.1016/j.jamcollsurg.2013.07.390.
26. Fullum TM, Ladapo JA, Borah BJ, Gunnarsson CL. Comparison of the clinical and economic outcomes between open and minimally invasive appendectomy and colectomy: evidence from a
Invited Commentary
Is a Minimally Invasive Approach the Solution for Reducing Surgical Site Infections? Simon P. Kim, MD, MPH; Marc C. Smaldone, MD, MSHP
During the past decade, performance of minimally invasive surgery (MIS) has rapidly disseminated into clinical practice for commonly performed procedures in the United States owing to lowering of the risk for complications, shortening of the length of stay, and imRelated article page 1039 proving convalescence compared with open surgery.1,2 Assessing the effect of MIS on the risk for surgical site infections (SSIs) is a salient question, because SSIs occur in at least 2% of all surgical procedures and are increasingly targeted under contemporary health care reform.3 Using data from the National Surgical Quality Improvement Program, Gandaglia et al4 investigate the association between surgical approach (MIS vs open) and SSIs for the following 4 commonly performed procedures: appendectomy, colectomy, hysterectomy, and prostatectomy. In more than 250 000 patients, the authors demonstrate substantial variation in SSI rates (1.7%-12.1%) across procedures, but report that MIS for each procedure type was associated with lower odds of SSIs after propensity matching.4 The authors
Conflict of Interest Disclosures: None reported.
ARTICLE INFORMATION Author Affiliations: Department of Urology, Yale University, New Haven, Connecticut (Kim); Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut (Kim); Department of Surgery, Fox Chase Cancer Center, Temple University Health System, Philadelphia, Pennsylvania (Smaldone).
1044
present compelling data but, because of limitations in the data, their study cannot address other complications or costs, which is necessary to assess the comparative effectiveness of each individual procedure type robustly. Furthermore, differentiation between laparoscopic and robotic approaches is not possible, which in light of current controversies regarding the increased health care costs of implementing new technologies affects the clinical relevance of the reported findings.2,5 Although SSIs represent a single component in defining surgical quality, contemporary comparative effectiveness research efforts have expanded to include patient-centered outcomes such as patient preferences, satisfaction, and quality of life in addition to the more traditionally measured outcomes such as mortality, complications, readmissions, and costs. Because future randomized studies are unlikely, clearly defining outcomes meaningful to patients, health care professionals, and key stakeholders is essential to determining whether an MIS is superior to open surgery or simply another tool selectively used at the discretion of the surgeon on an individual patient basis.
REFERENCES 1. Anderson JE, Chang DC, Parsons JK, Talamini MA. The first national examination of outcomes and trends in robotic surgery in the United States. J Am Coll Surg. 2012;215(1):107-116.
Corresponding Author: Simon P. Kim, MD, MPH, Department of Urology, Yale University, 200 Cedar St, New Haven, CT 06510 ([email protected]).
2. Wright JD, Ananth CV, Lewin SN, et al. Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease. JAMA. 2013;309(7):689-698.
Published Online: August 20, 2014. doi:10.1001/jamasurg.2014.313.
3. Burke JP. Infection control: a problem for patient safety. N Engl J Med. 2003;348(7):651-656.
4. Gandaglia G, Ghani KR, Sood A, et al. Effect of minimally invasive surgery on the risk for surgical site infections: results from the National Surgical Quality Improvement Progam (NSQIP) Database [published online August 20, 2014]. JAMA Surg. doi:10.1001/jamasurg.2014.292. 5. Kim SP, Shah ND, Karnes RJ, et al. Hospitalization costs for radical prostatectomy attributable to robotic surgery. Eur Urol. 2013;64(1):11-16.
JAMA Surgery October 2014 Volume 149, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Thomas Jefferson University User on 05/13/2015
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