Pediatric Surgery International (2021) 37:973–981

https://doi.org/10.1007/s00383-021-04911-4

REVIEW ARTICLE

Surgical site infection after open and laparoscopic surgery in children:

a systematic review and meta‑analysis
Mashriq Alganabi1 · George Biouss1 · Agostino Pierro1 

Accepted: 15 April 2021 / Published online: 1 May 2021

© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021

Abstract
Surgical site infections (SSIs) are the most common healthcare-associated infections in patients undergoing surgery. Various
randomised control trials (RCTs) indicate that laparoscopic procedures can be associated with better outcomes compared to
open procedures. However, how open versus laparoscopic approaches compare across various paediatric procedures with
respect to SSI rate remains poorly defined. In this review, we examined RCTs that directly compare SSI rates after open versus
laparoscopic operations for appendicitis, gastro-esophageal reflux, inguinal hernia, and pyloric stenosis. MEDLINE, Embase,
and Web of Science were searched for RCTs comparing four types of open versus laparoscopic operations in children. The
operations included appendectomy, fundoplication for gastro-esophageal reflux, inguinal hernia repair, or pyloromyotomy.
364 records were identified and screened, 54 full-text articles were assessed for eligibility, and 17 RCTs were included in
the analysis. SSI rate was the primary outcome. Operative time and length of stay (LOS) were the secondary outcomes. A
meta-analysis was conducted using RevMan 5.4 software. Laparoscopic appendectomy had a lower SSI rate than open appen-
dectomy (odds ratio of 2.22 [1.19, 4.15] p = 0.01). Laparoscopic fundoplication for gastro-esophageal reflux, inguinal hernia
repair, or pyloromyotomy for pyloric stenosis were not associated with lower SSI rate compared to open surgery. Operative
time was shorter in open fundoplication (– 71.22 min [– 89.79,  – 52.65] p < 0.00001) than laparoscopic fundoplication. There
was no significant difference in operative time of any of the other procedures. There was no significant difference in LOS
between open and laparoscopic procedures for all types of operations analysed. Based on the findings of this review, it is
recommended to utilise the laparoscopic approach over the open approach to reduce SSI risk in paediatric appendectomy.

Keywords  Surgical site infections · Open · Laparoscopic · Appendectomy · Fundoplication · Inguinal hernia repair ·
Pyloromyotomy

Introduction common after correction for congenital defects such as gas-

Surgical wound classification is an important measurement
of quality of care and is the foundation for infection risk
assessment often informing perioperative protocols and
surgical decisions [1]. SSIs are associated with significant
morbidity, additional use of antibiotics, antibiotic resistant
pathogen growth, potential for additional surgery, and lead
to longer hospitalisation, all of which increase the burden
on healthcare resources [2, 3]. In addition, SSIs are fairly
* Agostino Pierro
agostino.pierro@sickkids.ca
1
Division of General and Thoracic Surgery, Translational
Medicine Program, University of Toronto, The Hospital
for Sick Children, 555 University Ave, Toronto,
ON M5G 1X8, Canada
troschisis, omphalocele and small intestinal atresia; this is
particularly the case for preterm neonates [4]. Traditionally,
surgical wounds are classified as: (i) clean, (ii) clean/con-
taminated, (iii) contaminated, and (iv) dirty based on bacte-
rial load [5, 6]. Wound classification can be predictive of the
incidence of SSIs for a given surgical procedure [7].
One of the major innovations of the last few decades in
general surgery has been the implementation of laparoscopic
techniques for surgical interventions in both adult and pae-
diatric populations [8]. The use of laparoscopic approaches
in general surgery have been slower in paediatric patient
populations compared to adults, due to the smaller size of
the patients, smaller patient populations, frequently longer
operative time in laparoscopic approaches, and lack of lapa-
roscopic training [9, 10]. In 2016, we reported a national
epidemiological study which provided a benchmark for the

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use of laparoscopy in children and highlighted the need
for adhering to evidence-based surgical practice to achieve
high, steady level of implementation of novel laparoscopic
procedures in children [11]. Despite various RCTs, and sin-
gle centre observational studies comparing outcomes after
laparoscopic versus open procedures in the most common
paediatric surgical procedures, including appendectomy,
pyloromyotomy, fundoplication and inguinal hernia repair
[12], there is still no clear consensus on which procedures
does laparoscopy reduce the risk of developing SSIs.
Herein, we aimed to systematically review and conduct a
meta-analysis on all available RCTs that compare the inci-
dence of SSIs in children undergoing laparoscopic versus
open appendectomy for appendicitis, fundoplication for
gastroesophageal reflux, inguinal hernia repair, and pyloro-
myotomy for pyloric stenosis. We also examined operative/
surgical time and LOS between the open and laparoscopic
approaches to the aforementioned surgical procedures.
Methods
Search strategy
MEDLINE, Embase, and Web of Science databases were
searched for the terms as shown in Table 1 up to April 30,
2020. Articles were searched with no language restrictions.
Search results were acquired using The Hospital for Sick
Children library resources.
Study selection criteria
Predetermined inclusion and exclusion criteria were estab-
lished prior to the review. Inclusion criteria were open
versus laparoscopic approaches being directly compared,
RCTs, human studies, patients ≤ 21 years of age, surgical
outcome provided including SSIs, no language restriction,
and no publication date restriction. There were four opera-
tions evaluated, including appendectomy for appendicitis,
fundoplication for gastroesophageal reflux, inguinal her-
nia repair, and pyloromyotomy for pyloric stenosis. These
procedures were selected because they are among the most
common laparoscopic and open operations performed in
children [11]. Exclusion criteria were non-RCT studies,
patients > 21 years of age, no surgical outcome provided for
either open or laparoscopic approach, no SSI rate provided
for either open or laparoscopic approach and overlapping
patients with another study.
Study selection process
MEDLINE, Embase, and Web of Science search results
were combined, and duplicate articles were removed. Based
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Pediatric Surgery International (2021) 37:973–981
on the inclusion and exclusion criteria, papers were then
screened for eligibility using the titles and abstracts by two
independent authors (MA and GB). Full texts were similarly
reviewed by the same two independent authors and papers
were selected for inclusion in this review. Disagreements
were addressed through discussions and resolved by con-
sensus agreement.
Outcome assessment
The primary outcome assessed was SSIs in a direct compari-
son between open and laparoscopic paediatric procedures.
The secondary outcomes assessed included the operative
time and the LOS at the hospital for the patients. All papers
included in the review contained the primary outcome as
it was a requirement for inclusion, and all papers included
contained both secondary outcomes with the exception of
Simon et al. [13] which did not contain the operative time.
Data extraction
Agreed on articles following full-text review underwent data
extraction. Two independent authors (MA and GB) assessed
each of the papers, and extracted: type of study, surgery type,
location of study and/or patients, age of patients in the study,
primary outcome of SSI data/results, and secondary out-
come of operative time and LOS data/results. A follow-up
meeting between the authors was then used to consolidate
the data.
Quality assessment
The Risk of Bias 2 (RoB2) tool for assessing risk of bias
in randomised control trials was used [14] in this review.
This is the recommended tool to assess the risk of bias in
randomised control trials included in Cochrane Reviews. It
contains a fixed set of domains of bias, focussing on differ-
ent aspects of trial design, conduct and reporting. In each
domain, judgement is made on the level of risk and catego-
rised into “low risk”, “some concern”, or “high risk”.
Statistical analysis
Pooled odds ratios (OD) and their respective 95% confi-
dence intervals (CI) were utilised for dichotomous variables.
Weighted mean difference (WMD) and their 95% CI were
utilised for continuous variables using inverse variance.
Heterogeneity of data was assessed using I2. A fixed effect
model was used if I2 < 50% and a random effect model was
used if I2 ≥ 50%. Statistical analysis was conducted using
Review Manager 5.4 (Cochrane Collaboration). A p value
of ≤ 0.05 was considered significant.
Pediatric Surgery International (2021) 37:973–981 975

Table 1  Search keywords and strategy

MEDLINE
Ovid MEDLINE(R) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R) 1946
to Apr 30, 2020
Embase Classic + Embase
1947 to Apr 30, 2020
Number Searches Results

1 Infan* or newborn* or newly born* or perinat* or neonat* or baby* or babies or toddler* or boy* or 11,296,266
girl* or kid* or pediat* or prematur* or preterm* or pre-term* or child* or pediat* or paediat* or
adolescent*
2 Append* 179,304
3 Pyloromyot* or pyloric stenosis* or pylorus 45,768
4 GERD* or gastroesophageal reflux* or gastroaesophageal reflux* or reflux* or pyloro* or fundo* or 205,463
nissen fundo* or dor fundo* or toupet fundo*
5 Inguinal hernia* or groin hernia* or pelvic hernia* or direct hernia* or indirect hernia* 36,170
6 Open* or laparotom* 1,758,911
7 Laparoscop* or laparasco* or laprasco* 379,363
8 1 and 2 and 6 and 7 2505
9 1 and 3 and 6 and 7 362
10 1 and 4 and 6 and 7 1727
11 1 and 5 and 6 and 7 997
12 7 or 8 or 9 or 10 4430
13 Limit 12 to randomized controlled trial 330
14 Limit 13 to human 330
Web of Science
1900 to Apr 30, 2020
Number Searches Results

1 infan* or newborn* or newly born* or perinat* or neonat* or baby* or babies or toddler* or boy* or 3,656,078
girl* or kid* or pediat* or prematur* or preterm* or pre-term* or child* or pediat* or paediat* or
adolescent*
2 Append* 88,950
3 Pyloromyot* or pyloric stenosis* or pylorus 80,706
4 GERD* or gastroesophageal reflux* or gastroaesophageal reflux* or reflux* or pyloro* or fundo* or 93,034
nissen fundo* or dor fundo* or toupet fundo*
5 Inguinal hernia* or groin hernia* or pelvic hernia* or direct hernia* or indirect hernia* 15,811
6 Open* or laparotom* 1,547,534
7 Laparoscop* or laparasco* or laprasco* 150,723
8 1 and 2 and 6 and 7 715
9 1 and 3 and 6 and 7 129
10 1 and 4 and 6 and 7 535
11 1 and 5 and 6 and 7 346
12 7 or 8 or 9 or 10 1308
13 Limit 12 to randomized controlled trial 162
14 Limit 13 to human 162

Results after duplicates were removed. 310 articles were excluded

Literature search
Study search and selection were conducted in accordance
with PRISMA guidelines [15]. MEDLINE, Embase and
Web of Science databases search yielded 364 records
after title and abstract screening, and an additional 37
were excluded at the full-text stage due to one or more of
the following reasons: (1) no direct comparison between
open and laparoscopic approach (2) inability to identify
or isolate SSI rates for paediatric population in the study
(3) not an RCT or (4) study does not fit any additional

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predesignated inclusion or exclusion criteria. 17 studies
[13, 16–31] were included in the qualitative and quantita-
tive analyses (Fig. 1).
Study and patient characteristics
All studies included were RCTs with a patient population
that was less than 21 years. There was a wide distribution
of patient ages and children from 12 countries (Austria,
Canada, China, England, Finland, France, Germany, Italy,
Norway, Pakistan, Turkey, and USA) were included in the
analysed studies which can be seen in Table 2. All studies
directly compared children undergoing open versus lapa-
roscopic approaches to one of the four (appendectomy,
fundoplication, inguinal hernia repair, or pyloromyotomy)
surgical procedures examined.
SSIs
Children with appendicitis undergoing open appendectomy
had a significantly higher chance of developing SSIs than
those undergoing laparoscopic appendectomy (odds ratio of
2.22 [1.19, 4.15] p = 0.01) (Fig. 2a). There were only two
Fig. 1  PRISMA flowchart of
article selection for the system-
atic review
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Pediatric Surgery International (2021) 37:973–981
studies that examined inguinal hernia repairs one looking at
only boys with no SSI events in either open or laparoscopic
approaches and another with only one SSI event in the open
group, as a result a meta-analysis of SSI risk in paediatric
inguinal hernia repairs was not possible (Fig. 2b). However,
it should be noted that in each of the two inguinal hernia
studies no statistically significant difference in SSI risk was
identified. There was no significant difference in the odds of
developing SSIs in children undergoing open fundoplication
or pyloromyotomy relative to their laparoscopic equivalents
(Fig. 2b–d).
Operative time
There was no significant difference in the operative time
between open and laparoscopic appendectomy (Fig. 3a).
Operative time was significantly shorter in open fundopli-
cation than in laparoscopic fundoplication ( – 71.22 min-
utes [ – 89.79,  – 52.65] p < 0.00001) (Fig. 3b). Open ingui-
nal hernia repairs and pyloromyotomy had no significant
difference in operative time compared to their laparoscopic
counterparts (Fig. 3c, d).
Pediatric Surgery International (2021) 37:973–981 977

Table 2  Study and patient characteristics

Study number Study Study type Surgery type Location of study/patients Age of patients

1 Ali [16] RCT​ Appendectomy Pakistan 7–13 years old

2 Bolla [17] RCT​ Appendectomy Italy 8 months–9 years old
3 Lavonius [22] RCT​ Appendectomy Finland 7–15 years old
4 Lejus [24] RCT​ Appendectomy France 8–15 years old
5 Lintula [25] RCT​ Appendectomy Finland 4–15 years old
6 Lintula [26] RCT​ Appendectomy Finland 4–15 years old
7 Little [27] RCT​ Appendectomy USA 1–16 years old
8 Oka [29] RCT​ Appendectomy USA 2–20 years old
9 Simon [13] RCT​ Appendectomy Germany 7–16 years old
10 Yu [31] RCT​ Appendectomy China 5–12 years old
11 Knatten [21] RCT​ Fundoplication Norway  < 15 years old
12 McHoney [28] RCT​ Fundoplication England  > 1 month–10 years old
13 Celebi [18] RCT​ Inguinal Hernia repair Turkey 6–14 years old
14 Gause [19] RCT​ Inguinal Hernia repair USA  <  = 3 years old
15 Hall [20] RCT​ Pyloromyotomy England, USA, Austria, Fin-  < 1 month
land, and Canada
16 Leclair [23] RCT​ Pyloromyotomy France  < 1 year old
17 St Peter [30] RCT​ Pyloromyotomy USA  < 3 months

Fig. 2  Open versus laparoscopic SSI rates a SSI rates in open versus no events, a meta-analysis was not possible. d SSI rates in open ver-
laparoscopic appendectomy. b SSI rates in open versus laparoscopic sus laparoscopic pyloromyotomy. Data presented as odds ratio and
fundoplication. c SSI rates in open versus laparoscopic inguinal her- 95% confidence interval
nia repair. Since there were only two studies and one study contained

Length of stay (LOS)
There was no significant difference in the LOS between
open appendectomy, fundoplication, inguinal hernia repair
and pyloromyotomy in comparison to their laparoscopic
equivalents (Fig. 4a–d). Average LOS in each of the two
groups (open versus laparoscopic) varied from 0.5 to 1 day
after inguinal hernia repair to 4.5–7.5 days after fundoplica-
tion (Fig. 4).

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Fig. 3  Open versus laparoscopic operative time. a Operative time
(minutes) in open versus laparoscopic appendectomy. b Operative
time (minutes) in open versus laparoscopic fundoplication. c Opera-
Risk of bias assessment (RoB2)
RoB2 was used and identified a high risk of bias with respect
to blinding as only three RCTs [20, 23, 28] were double-
blinded. In this context, double-blinding refers to blinding
the patients or caregivers to the type of procedure performed
by obtaining consent to surgical approaches (for example
open or laparoscopic) as well as blinding nursing and medi-
cal staff by using for instance opaque dressing. Patients were
otherwise appropriately randomised in all the included stud-
ies. It should be noted that Celebi et al. [18] selected for boys
in their inguinal hernia study. Other bias was designated
as some concern in studies where either the surgeries were
not all performed by the same surgeon or where it was not
explicitly stated that the surgeons performing the operations
were equally/highly experienced. Individual scoring per
Fig. 4  Open versus laparoscopic LOS. a LOS measured in days in
open versus laparoscopic appendectomy. b LOS (days) in open ver-
sus laparoscopic fundoplication. c LOS (days) in open versus lapa-
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Pediatric Surgery International (2021) 37:973–981
tive time (minutes) in open versus laparoscopic inguinal hernia repair.
d Operative time (minutes) in open versus laparoscopic pyloromyot-
omy. Data presented as weighted mean and 95% confidence interval
RoB2 criteria for each study can be found in Fig. 5. Overall
RoB2 was designated as low to some concern for all the
studies included.
Discussion
In the current study, 17 RCTs with a total of 1975 paediatric
patients were included for analysis. We identified that there
was a significantly higher risk of developing SSIs in open
appendectomy than in laparoscopic appendectomy (Fig. 2a).
In the cases of fundoplication and pyloromyotomy this did
not hold true as there was no difference in the risk of the
open technique relative to the laparoscopic one (Fig. 2b–d).
A meta-analysis of SSI risk after inguinal hernia repair was
not possible due to the fact that in one of the two studies
roscopic inguinal hernia repair. d LOS (days) in open versus laparo-
scopic pyloromyotomy. Data presented as weighted mean and 95%
confidence interval
Pediatric Surgery International (2021) 37:973–981 979
Fig. 5  Risk of Bias 2 (RoB2) scoring for included studies
(Celebi et al. 2004) there was no SSI in either study group.
In addition, when the two studies are examined individually,
neither of them had a statistically significant difference in
SSI risk between open and laparoscopic approach (Fig. 2c).
These findings align with the higher contamination classi-
fication designated for appendectomy than with the other
procedures.
In general, inguinal hernia repair and pyloromyotomy
are classified as clean procedures, fundoplication as clean-
contaminated when combined with a gastrostomy or as clean
when not combined with a gastrostomy, and appendectomy
as contaminated procedures [32–34]. Consequently, the find-
ing that SSI rate was most impacted by using a laparoscopic
approach in the more contaminated procedure was expected.
In the case of the cleaner procedures, it appears that the
risk of developing SSI was relatively low in both open and
laparoscopic approaches resulting in no clear advantage of
one technique over the other.
Operative time was significantly shorter in open fundopli-
cation than in laparoscopic fundoplication (Fig. 3b). There
was no significant difference in the operative time between
open and laparoscopic appendectomy, inguinal hernia repair
or pyloromyotomy (Fig. 3).
Laparoscopic surgery can extend the operative time [21,
35, 36] particularly in more complex procedures. However,
as laparoscopy has become more widely used and familiarity
with the techniques involved become more ubiquitous this
has become less of a factor in more recent years [37–39].
We can see this reflected in our analysis that showed no
significant difference in operative time between open and
laparoscopic appendectomy, inguinal hernia repair or
pyloromyotomy.
There was no significant difference in the LOS between
open appendectomy, fundoplication, inguinal hernia repair
and pyloromyotomy with their laparoscopic counterparts.
Several studies including some of the ones analysed in
this review have shown that laparoscopic surgery is often
associated with shorter LOS in children than in their open
approach counterparts [13, 16, 20, 25, 29–31, 40]. However,
in the procedures examined in this review, all of them have
generally short post-operative hospital stay ranging from as
little as half a day to the highest average LOS of 7.5 days for
patients undergoing open fundoplication in the Knatten et al.
study [21]. Postoperative length of hospital stay is a heavily
discussed topic as it can often greatly impact cost of care as
well as the quality of the patient experience. With respect to
laparoscopy, smaller incision size, reduced pain, and faster
recovery are often cited for shorter duration of hospital stay
[41–46]. In our review, however, we were unable to iden-
tify a significant difference in LOS between the open and
laparoscopic approaches to appendectomy, fundoplication,
inguinal hernia repair or pyloromyotomy.
The overall quality of evidence in this review is high as
all the included studies were RCTs with appropriate ran-
domisation. However, it should be noted that the majority
of the RCTs were not double-blinded. Furthermore, in the
majority of the studies it was not explicitly stated that all the
surgeons performing operations had comparable levels of
experience which can be an important consideration espe-
cially with respect to laparoscopic operative time. In addi-
tion, there is the potential for some bias with respect to lack
of subgroup analysis, an important one could be subgroup
analysis for simple or complicated appendicitis. However,
this analysis was mostly lacking in the trials included in
this systematic review and meta-analysis. Overall, the risk
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of bias using RoB2 was designated as low to some concern
across all studies.
Conclusion
Based on the findings of this review, it is recommended to
utilise the laparoscopic approach in paediatric appendec-
tomy over the open approach to reduce SSI risk. There
was no clear favour for open or laparoscopic approaches to
fundoplication, inguinal hernia repair, and pyloromyotomy
with respect to SSI risk. The overall risk of bias using RoB2
yielded a low to some concern level.
Acknowledgements  AP is the recipient of a Canadian Institutes of
Health Research (CIHR) Foundation Grant 353857. The funding
had no impact on study design, data collection, analysis, interpreta-
tion, the writing of the report, or the decision to submit the paper for
publication.
Declarations  expectations. Laparoscopy versus laparotomy. La Pediatria
Conflict of interest  The authors declare that they have no conflict of
interest.
Ethical approval  This article does not contain any studies with human
participants or animals performed by any of the authors.
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