PROLONGED POST – OPERATIVE HOSPITALIZATION PREDICTS HIGH BURDEN OF UMBLICAL PORT SITE INFECTION IN LAPAROSCOPIC CHOLECYSTECTOMY.

; Background; Laparoscopic cholecystectomy is one of the commonly performed surgical procedure these days which is associated with significant reduction of morbidities and mortality. This study was conducted to ascertain port site infection after laparoscopic cholecystectomy without using gloves. Objective; To determine frequency of port site infection (PSI) in patients undergoing laparoscopic cholecystectomy when gallbladder is removed without using gloves. Material and Methods; A total of 254 patients undergoing laparoscpic cholecystectomy were enrolled in our study. The laparoscopic cholecystectomy was performed and after removal of gall bladder without endogloves the laparoscope was moved to the epigastric port, and a large-tooth grasping forceps were inserted through the umbilical port to grasp the gallbladder at the area of the cystic duct and were followed for wound infection. Results; Of these 254 study cases, 98 (36.6 %) were male patients while 156 (61.4 %) were female patients. Mean age of our study cases was 49.58 ± 6.32 years. Of these 254 study cases, 89 (35.0 %) belonged to rural areas and 165 (65.0 %) belonged to urban areas. Diabetes was present in 68 (26.8 %) of our study cases. Hypertension was present in 126 (49.6 %) of our study cases. Mean duration of surgery was 55.28 ± 15.23 minutes and 185 (72.8 %) had duration of procedure up to 1 hour. Mean hospital stay was 5.22 ± days and 204 (80.3%) had hospital stay up to 6 days. Umblical port site infection (PSI) was noted in 20 (7.9%). Conclusion; High frequency of umblical port site infection was noted in our study among patients undergoing laparoscopic cholecystectomy without using gloves, so use of gloves is safe, cost effective and reduces related morbidities. Port site infection was significantly associated with increasing, gender, diabetes, residential status, prolonged duration of surgery and duration of hospitalization.

remarkable advances in the use of surgical techniques and prophylactic antibiotics and environmental/ergonomic improvements in the operating room, surgical site infections (SSIs) remain a significant cause of patient morbidity and mortality and are the third-most common source of hospital-acquired infection. Of concern is that SSIs occur in up to 30% of all surgical procedures, and yet most are preventable 5,6 .
Port site infection (PSI), although infrequent, is one of the bothersome complications which undermine the benefits of minimal invasive surgery. Not only does it add to the morbidity of the patient but also spoils the reputation of the surgeon. Despite the advances in the field of antimicrobial agents, sterilization techniques, surgical techniques, operating room ventilation, PSIs still prevail. The emergence of rapid growing atypical mycobacteria with multidrug resistance, which are the causative organism in most of the cases, has further compounded the problem. PSIs are preventable if appropriate measures are taken preoperatively, intraoperatively and postoperatively. PSIs can often be treated non-surgically, with early identification and appropriate management. Macrolides, quinolones and aminoglycosides antibiotics do show promising activity against the atypical mycobacteria 7 .
There are number of factors contributing to the development of postoperative wound infections. Attempts have been made to control these by variety of methods. However there is misplaced belief that antibiotics are solution to all of these, thus leading to their inappropriate use and resultant emergence of the resistant microorganisms 8 . Taj et al 8 reported 5.28 % PSI without using gloves in patients undergoing laparoscopic cholecystectomy while with gloves PSI was 0.20 % 8 .
The aim of this study was to assess PSI in patients undergoing laparoscopic cholecystectomy without using gloves. It will help to take more preventive measures by surgical team to decrease these infections which are associated with increased morbidity, prolonged hospitalizations, mortality and increased hospital costs.

MATERIAL AND METHODS;
Consecutive 254 patients undergoing laparoscopic cholecystectomy were taken. Patients meeting inclusion criteria was enrolled in this study from department of surgery, Nishtar Hospital Multan. Severely anemic patients, Chronic liver disease, Alcoholic abuse and pregnant ladies were excluded from our study. Informed consent was taken from each patient describing them objectives of this study, ensuring them confidentiality of the information and fact that there is no risk involved to the patient while taking part in this study. All baseline investigations like blood tests (FBS, RBS and Hb levels) and ultrasonography were done at hospital facility free of cost. The laparoscopic cholecystectomy was performed by a senior same surgeon having more than 5 years of experience after fellowship and after removal of gall bladder without endo-gloves the laparoscope was moved to the epigastric port, and a large-tooth grasping forceps was inserted through the umbilical port to grasp the gallbladder at the area of the cystic duct. Under direct vision, the gallbladder was then retrieved and pulled out as far as possible through the umbilical port and was followed till 30 days to document Port Site Infections. All the data was entered and analyzed using SPSS-20. Mean and standard deviation for the post-operative hospital stay and age was calculated. Frequencies and percentage were calculated for the categorical variables like gender, diabetes, hypertension, age groups, PSI (Yes/No), obesity (Yes/No) and residential status.

RESULTS;
Our study comprised of a total of 254 patients meeting inclusion criteria of our study. Of these 254 study cases, 98 (36.6 %) were male patients while 156 (61.4 %) were female patients. Mean age of our study cases was 49.58 ± 6.32 years (with minimum age of our study cases was 39 years while maximum age was 60 years). Mean age of the male patients was noted to be 48.71 ± 5.01 years while that female patients was 50.13 ± 6.98 years (p=0.083). Our study results have indicated that majority of our study cases i.e. 155 (61 %) were aged more than 45 years. Of these 254 study cases, 89 (35.0 %) belonged to rural areas and 165 (65.0 %) belonged to urban areas. Diabetes was present in 68 (26.8 %) of our study cases. Hypertension was present in 126 (49.6 %) of our study cases. Mean body mass index of our study cases was 26.21 ± 1.82 kg/m 2 and obesity was present in 78 (30.7 %) of our study cases. Mean duration of surgery was 55.28 ± 15.23 minutes and 185 (72.8 %) had duration of procedure up to 1 hour. Mean hospital stay was 5.22 ± 2.18 days and 204 (80.3%) had hospital stay up to 6 days. Umblical port site infection (PSI) was noted in 20 (7.9%) of our study cases.   Our study comprised of a total of 254 patients meeting inclusion criteria of our study. Of these 254 study cases, 98 (36.6 %) were male patients while 156 (61.4 %) were female patients. A study conducted by Channa et al 11 from Jamshoro also reported high female gender predominance with male to female ratio was 1:3 which is in compliance with that of our study results. Samad et al 12 from Hyderabad also reported 87 % female gender preponderance which is in compliance with our study results. A Study conducted by Rahman et al 13 from Peshawar also reported male to female ratio was 1:2 which is in compliance with our study results. Sattar et al 14 from Karachi also reported 73 % female gender predominance in patients with cholelithiasis which is in compliance with our study results.
Mean age of our study cases was 49.58 ± 6.32 years (with minimum age of our study cases was 39 years while maximum age was 60 years). Mean age of the male patients was noted to be 48.71 ± 5.01 years while that female patients was 50.13 ± 6.98 years (p=0.083). Our study results have indicated that majority of our study cases i.e. 155 (61 %) were aged more than 45 years. A study conducted by Channa 15 reported mean post -operative hospital stay to be 5.2 ± 1.40 days in patients with laparoscopic cholecystectomy which is close to our study results. Gutt et al 16 reported Mean length of hospital stay 5.4 days in patients with laparoscopic cholecystectomy which is in compliance with our study results. Jamil et al 17 reported mean hospital stay was 3.47±1.40 days which is slightly less than that being reported in our study.
Mean duration of surgery was 55.28 ± 15.23 minutes and 185 (72.8 %) had duration of procedure up to 1 hour. Khan et al 17 from Peshawar also reported 55 minutes mean duration of surgery in laparoscopic cholecystectomy which is close to our study results. Ozkardeş et al 15 reported operative time in laparoscopic cholelcystectomy was 67±28.515 (min) which is close to our study results.