SSIs from Lap Surgery

Pathogenesis of a Deep-Organ Surgical Site Infection (SSI) from a Contaminated Laparoscopic Instrument

According to the Centers for Disease Control and Prevention (CDC), over 30,000 patients die every year in the U.S. from a surgical infection. Among hospital acquired infections (HAIs), surgical site infections (SSIs) are associated with greater increases in hospital stays and costs as compared to all other HAIs. Deep organ SSIs involving organs or spaces, as opposed to SSIs confined to the incision, have an even greater impact on patient morbidity and mortality.

Advances in infection control practices in operating rooms over the past decade include improved operating room ventilation, better surgical drapes and gowns, advanced surgical techniques, and a four hundred percent (400%) increase in antimicrobial prophylaxis over this period.1 Despite all of these activities and increased expenditures, the rate of deep organ SSIs has remained at 2% for laparoscopic procedures nationwide. 2

So what steps can you and your staff take to help reduce your patients’ risk of contracting a deep organ SSI associated with a laparoscopic procedure? The first step is to understand the cause of the problem.

The primary cause of deep organ SSIs in laparoscopic surgery has been and continues to be reusable laparoscopic instruments, including modular instruments. The CDC notes that "Microbial contamination of the surgical site is a necessary precursor of a surgical infection".3 Laparoscopic instruments contaminated with dead, sterile bioburden after reprocessing and sterilization are the number one source of contamination of the deep organ space.

The pathogenesis of a deep organ infection is quite simple. When dead, sterile bioburden gets deposited into the body during a laparoscopic procedure from a contaminated laparoscopic instrument, the foreign, organic material begins to decompose and is attacked by the body’s phagocytes. This process is seen most frequently in a surgical patient who presents with a fever of unknown origin and an elevated white blood cell count within 24 - 48 hours of a laparoscopic surgery.

Phagocytes are the white blood cells that protect the body from harm by ingesting (phagocytosing) harmful foreign particles, including dead, sterile cells. Part of this process involves the production of lysozymes that break down the cell walls of the organic material. Frequently those dead, sterile cell walls contain endotoxins that are then released into the blood stream. 4

Microorganisms may contain or produce toxins and other substances that increase their ability to invade a host, produce damage within the host, or survive on or in host tissue. 5 For example, many gram-negative bacteria produce endotoxin, which stimulates cytokine production. In turn, cytokines can trigger the systemic inflammatory response syndrome that sometimes leads to multiple system organ failure. One of the most common causes of multiple system organ failure following a laparoscopic procedure is an intra-abdominal infection. 6

According to the CDC "The release of endotoxins in the body stimulates cytokine production. In turn, cytokines can trigger the systemic inflammatory response syndrome that sometimes leads to multiple system organ failure." 7

Even more troubling is the fact that when patients died from a surgical infection, “77% of the deaths were reported to be related to the infection, and the majority (93%) were serious infections involving organs or spaces accessed during the operation." 8

Having identified the role that contaminated laparoscopic instruments play in causing deep organ SSIs, the next step for you and your staff is to implement a solution to the problem. The most effective step you can take is to only use laparoscopic instruments whose cleaning and sterilization Instructions for Use (IFUs) have been ‘validated.’

If your facility is using laparoscopic instruments whose IFUs have not been validated, there is no way for you and your staff to ensure clean, sterile, moisture-free laparoscopic instruments on every reprocessing cycle, regardless of how hard you try. You need to know that for a set of IFUs to be validated, the instruments have to have been tested by an independent laboratory using AAMI and FDA validation testing protocols.

If an instrument manufacturer can’t, or won’t, provide you with IFUs that have been independently validated using AAMI/FDA testing protocols, then you need to look for another manufacturer who can and will provide you with a copy of their validated IFUs.

Laparoscopic instruments whose IFUs have been validated are the only way for you and your staff to ensure clean, sterile, moisture-free instruments for every patient, every time!

  1. CDC Publication “Guideline For The Prevention Of Surgical Site Infection
  2. https://www.cdc.gov/
  3. CDC Publication “Guideline For The Prevention Of Surgical Site Infection
  4. Op. Cite.
  5. Henderson B, Poole S, Wilson M. “Microbial/host interactions in health and disease: who controls the cytokine network?” Immunopharmacology 1996; 35:1-21.
  6. Morrison DC, Ryan JL. “Endotoxins and disease mechanisms.”  Ann Rev Med 1987; 38:417-32.
  7. Demling R, LaLonde C, Saldinger P, Knox J. “Multiple-organ dysfunction in the surgical patient: pathophysiology, prevention, and treatment.” Current Problems in Surgery 1993; 30:345-414.
  8. CDC Publication “Guideline For The Prevention Of Surgical Site Infection