SYSTEMATIC REVIEW AND META ANALYSIS
Laparoscopic Surgery Compared With Open Surgery Decreases
Surgical Site Infection in Obese Patients
A Systematic Review and Meta-Analysis
Daniel M. Shabanzadeh, MD and Lars T. Sørensen, MD
Objective: To compare surgical site infections rate in obese patients after
laparoscopic surgery with open general abdominal surgery.
Background: In mixed surgical populations, surgical site infections are fewer
in laparoscopic surgery than in open surgery. It is not clear if this is also the
case for obese patients, who have a higher risk of surgical site infections than
nonobese patients.
Methods: MEDLINE, Embase, and The Cochrane library (CENTRAL) were
searched systematically for studies on laparoscopic surgery compared with
open abdominal surgery. Randomized controlled trials (RCTs) and observa-
tional studies reporting surgical site infection in groups of obese patients
(body mass index ≥ 30) were included. Separate meta-analyses with a fixed
effects model for RCTs and a random effects model for observational studies
were performed. Methodological quality of the included studies was assessed
according to the Cochrane method and the Newcastle-Ottawa Scale.
Results: Eight RCTs and 36 observational studies on bariatric and non-
bariatric surgery were identified. Meta-analyses of RCTs and observational
studies showed a significantly lower surgical site infection rate after laparo-
scopic surgery (OR = 0.19; 95% CI [0.08-0.45]; P = 0.0002 and OR = 0.33;
95% CI [0.26-0.42]; P = 0.00001). Sensitivity analyses to assess the impact
of selection and detection bias confirmed the significant estimates with ac-
ceptable heterogeneity. No publication bias was present for the observational
studies.
Conclusions: Laparoscopic surgery in obese patients reduces surgical site
infection rate by 70%–80% compared with open surgery across general ab-
dominal surgical procedures. Future efforts should be focused on further
development of laparoscopic surgery for the growing obese population.
Keywords: BMI, laparoscopic surgery, obesity, surgical site infection,
systematic review
(Ann Surg 2012;256: 934–945)
I n general surgery, most studies have found obesity to be an indepen-
dent risk factor for surgical site infection.1–5 Surgical site infection
is the third most prevalent hospital acquired infection accounting for
approximately 30%.6 Considering that obesity is a growing world-
wide epidemic with a prevalence over 30% in populations in Europe
and the United States,7,8 the relative significance of surgical site infec-
tion for postoperative mortality and morbidity seems only to increase
in the future.9–14
Today, laparoscopic surgery has become the primary choice of
most general surgical procedures. In nonobese patients, laparoscopic
From the Department of Surgery K, Bispebjerg Hospital, Copenhagen, Denmark.
Disclosure: No funding contributed to the production of this review.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of
this article on the journal’s Web site (www.annalsofsurgery.com).
Reprints: Daniel M. Shabanzadeh, MD, Department of Surgery K, Bispebjerg
Bakke 23, 2400 Copenhagen, Denmark. E-mail: dmshaban@gmail.com.
Copyright C 2012 by Lippincott Williams & Wilkins
ISSN: 0003-4932/12/25606-0934
DOI: 10.1097/SLA.0b013e318269a46b
934 | www.annalsofsurgery.com
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
surgery has proven to have fewer postoperative complications and
a shorter length of in-hospital stay and postoperative convalescence
compared with open procedures.15–22
Although laparoscopic surgery does not seem to change the
fact that the incidence of surgical site infection in obese patients re-
mains higher than in nonobese patients,23,24 several authors have sug-
gested that obese patients may benefit from laparoscopic surgery in a
similar way as nonobese patients.18,25–29 The objective of this system-
atic review is to assess the impact of laparoscopic versus open general
surgical procedures on surgical site infections in obese patients.
METHODS
The process of the systematic review and meta-analysis
was performed according to the Cochrane Collaboration
recommendations.30 A detailed protocol was produced in advance of
data collection describing the process of the systematic review. This
embraced a number of prespecified criteria for inclusion of studies
and reporting of results according to the MOOSE (Meta-analysis
Of Observational Studies in Epidemiology) and PRISMA (Pre-
ferred Reporting Items for Systematic Reviews and Meta-Analyses)
recommendations.31,32
Search Strategy
We systematically searched MEDLINE, Embase, and The
Cochrane Library (including CENTRAL). The search strategy was
produced by the authors under the supervision of a specialized trial
search coordinator from the Cochrane Colorectal Cancer Group.
The following index terms were included: laparoscopy, laparotomy,
body mass index (BMI), obesity, morbid obesity, bariatric, postoper-
ative complications, wound/surgical/postoperative infection, surgical
wound infection, wound complication, fistula, and abscess. All index
terms were exploded. Free text words were searched using index terms
and additional relevant words in combination with asterisks: open,
conventional, complications, SSI, postoperative/wound morbidity,
wound sepsis, and superficial/deep/organ/space/visceral/skin/soft tis-
sue/subcutis/site/tissue/mesh infection. No limitations or restrictions
such as publication year or filters for study design were used in the
search strategy. The date of the most recent search was May 4, 2011.
Ovid was used for searches, and the computer program ProCite5 was
used for managing references. Additional searches were performed
by hand-searching reference lists of included studies. The full search
strategies are outlined in the Supplemental Digital Content Figure 1
(available at http://links.lww.com/SLA/A281).
Study Selection and Data Extraction
For the selection of studies, first titles and abstracts were eval-
uated. Subsequently, full-text articles were obtained to assess study
eligibility. Conference proceedings and abstracts were included if rel-
evant data could be retrieved. Both authors conducted the searches
and identification of studies independently. Inconsistencies were re-
solved by discussion. Articles written in English, German, Dutch,
and Scandinavian languages were retrieved.
Annals of Surgery r Volume 256, Number 6, December 2012
Annals of Surgery r Volume 256, Number 6, December 2012
FIGURE 1. Study flow diagram.
Data were extracted from each study to preformatted tables by
the primary author of this systematic review. Inadequate data were
resolved by contacting the authors of studies. According to the pro-
tocol, the extracted data were the following: first author, year of pub-
lication, study design [randomized controlled trial (RCT), retrospec-
tive/prospective data collection], BMI in each group/ICD (Interna-
tional Classification of Disease) diagnosis of obesity/other measures
of obesity, definition of surgical site infection, number of patients in
each group, number of patients with surgical site infection in each
group, and postoperative follow-up for surgical site infection or post-
operative complications.
Inclusion Criteria
Observational studies and RCTs complying with all the fol-
lowing criteria were included:
1. Inclusion of obese patients defined as having a BMI ≥ 30 or an
ICD diagnosis of obesity or morbid obesity.33 Other measures of
obesity were accepted if a body weight was included.

C 2012 Lippincott Williams & Wilkins
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Laparoscopic Versus Open Surgery in Obese Patients
2. A specified general surgical laparoscopic operation and an open
comparator operation.
3. Surgical site infection or wound infection defined as the presence
of pus11 or as a superficial, deep, or organ/space infection during
the first 30 postoperative days according to the criteria of the Center
for Disease Control (CDC),34 reported in such a way that data on
obese patients in each treatment group could be extracted.
Quality Scoring and Risk of Bias Assessment
Risk of bias assessment in RCTs was performed according
to Cochrane methodology under consideration of random sequence
generation, allocation concealment, blinding of participants and per-
sonnel, blinding of outcome assessment, incomplete outcome data,
and selective reporting.35 Each category was scored as low, unclear
or high risk of bias and expressed in a summary table with a plus,
question mark and minus, respectively.
The Newcastle-Ottawa Quality Assessment Scale (NOS) for
cohort studies36 was used for quality assessment of observational
studies. This score assesses studies according to selection of patients
www.annalsofsurgery.com | 935
 Shabanzadeh and Sørensen

TABLE 1. Characteristics of RCTs

Study (Author Obesity Patients Lap./ Surgical Criteria Follow-Up

936 | www.annalsofsurgery.com
and Year) Category n Open n Procedure Outcome for SSI for SSI Attrition ITT/AT Conversion Results
Bariatric surgery
Azagra et al, 1999 BMI = 43 (37–66) 68 30/38 VBG WI N.R. Once a month 0% AT 4 L 1/30; O 4/38;
(Belgium)40 P = 0.04
De Wit et al, 1999 BMI = 51.3 50 25/25 AGB Wound abscess N.R. N.R. 0% ITT 2 L 0/25, O 1/25
(The (10.4)/49.7 (5.6);
Netherlands)41 NS
Luján et al, 2004 BMI = 48.5 104 53/51 RYGBP WI, subphrenic N.R. 15 days and after 0% N.R. 4 WI: L 0/53,
(Spain)42 (36–78)/52.2 abscess 3 months O 4/51; SA:
(37–80); NS L 0/53, O 4/51
Nguyen et al, 2001 BMI = 47.6 155 79/76 RYGBP WI Erythema/purulent 1 month 0% ITT 2 L 1/79, O 8/76
(US)4 (4.7)/48.4 (5.4); NS discharge
Sundbom and BMI = 44 (36–54)/45 50 25/25 RYGBP WI Purulent discharge 1 month 0% AT 0 HALS 1/25,
Gustavsson, 2004 (34–54) O 1/25
(Sweden)44
van Dielen et al, BMI = 46.7 100 50/50 LAGB vs. open WI N.R. No postdischarge 0% ITT 3 LAGB 0/50, VBG
2005 (The (6.1)/46.6 (6.4); NS VBG follow-up 1/50
Netherlands)45 before 3 months
Westling and BMI = 41 (4)/44 (4); 51 30/21 RYGBP Minor WI N.R. After 4–6 weeks ITT 7 L 0/30, O 3/21
Gustavsson, 2001 P < 0.05
(Sweden)46
Appendectomy
Clarke et al, 2011 BMI > 30 37 23/14 Appendectomy WI, wound Redness and drainage After 2 weeks N.R. ITT N.R. WI: L 2/23, O
(US)47 drainage from the wound 1/14; Drainage:
requiring opening L 0/23, O 1/14
of the skin incision


AGB indicates adjustable gastric banding; AT, as treated analysis; HALS, hand-assisted laparoscopic surgery; ITT, intention to treat; LAGB, laparoscopic adjustable gastric banding; Lap. or L., laparoscopic; N.R., not reported;
NS, not significant; O, open; RYGBP, Roux-en-Y gastric bypass; SSI, surgical site infections; VBG, vertical banded gastroplasty; WI, wound infection.

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
C 2012 Lippincott Williams & Wilkins
Annals of Surgery r Volume 256, Number 6, December 2012
 
TABLE 2. Characteristics of Observational Studies
Study (Author Lap./Open Surgical Criteria Follow-Up
and Year) Design NOS Obesity Category Patients n n Procedure Outcome for SSI for SSI Attrition ITT/AT Conversion Results

Bariatric surgery
Agaba et al, 2008 Retrospective ∗∗∗∗∗∗ BMI = 46.2 1367 806/561 RYGBP WI N.R. 1 week 0% N.R. 18 L 2/806; O 5/561
(US)48 (4.7)/47.6
(5.7)
Campos et al, 2007 Prospective ∗∗∗∗∗∗ BMI = 46.4 404 332/72 RYGBP WI N.R. 2 weeks N.R. AT 11 L 1/332; O 3/72
(US)49 (42.4–
52.4)/57.4
(49.6–67);
P < 0.001
Coskun et al, 2003 Retrospective ∗∗∗ BMI = 45.2 70 35/35 AGB WI N.R. N.R. N.R. N.R. N.R. L 0/35; O 10/35

C 2012 Lippincott Williams & Wilkins

(Turkey)50
Courcoulas et al, Retrospective ∗∗∗∗ BMI = 35–67 160 80/80 RYGBP Wound/port N.R. N.R. N.R. AT 0 L 3/80; O 9/80
2003 (US)51 infection
Dolan et al, 2004 Retrospective ∗∗∗∗∗ BMI = 56.9 23 35/11 Biliopancreatic WI N.R. N.R. N.R. AT 0 L 2/35; O 3/11
(Australia)52 case- (50.8–83.7)/ diversion and
matched 55.9 LAGB
(50.7–90.6);
P = 0.89
Ezri et al, 2004 Retrospective ∗∗∗∗∗ BMI = 42.3 234 167/67 Restrictive WI N.R. 30 days N.R. ITT 3 L 0/167; O 3/167
(Israel)53 (5.3)/42.2 bariatric
(5.7); surgery (no
Annals of Surgery r Volume 256, Number 6, December 2012

P = 0.86 gastric
bypass)
Gartner et al, 2008 Retrospective ∗∗∗∗ BMI = 47.8 662 231/431 VBG, RYGBP, WI N.R. N.R. N.R. N.R. N.R. L 9/231; O 42/431
(Germany)54 (7.9)/46.5 gastric
(7.6); P < banding
0.005
Gonzalez et al, Prospective ∗∗∗∗∗ BMI = 38– 300 164/136 RYGBP WI N.R. N.R. N.R. N.R. 3 L 5/164; O 17/136
2006 (US)55 database 64/39–94
Gorman et al, 2006 Prospective ∗∗∗∗∗ BMI > 35 22 3/19 RYGBP WI N.R. N.R. N.R. AT N.R. L 0/3; O 2/19
(US)56
Hutter et al, 2006 Prospective ∗∗∗∗∗∗∗ BMI = 47.5 1356 401/955 RYGBP Deep WI NSQIP 30 days 0% N.R. N.R. L 1/401; O 8/955
(US)57 database (43–51)/ (CDC)
(NSQIP) 50.5
(44–55);
P < 0.0001
Lancaster and Prospective ∗∗∗∗∗∗∗ BMI = 47.9 5777 4631 + RYGBP, VGB, Sup. WI, deep NSQIP 30 days 0% N.R. N.R. Sup.: L 2.3%; O
Hutter, 2008 database (8.3)/50.5 3580/ and other Lap. WI, organ (CDC) 5.2%; Deep: L
(US)58 (NSQIP) (10.1); P < 1146 WI 0.2%; O: 1.1%;
0.001 Org.: L 0.6%; O
1.6%; Numbers
for 2006
LRYGB: Sup.:
2.3% of 3580;
Deep: 0.2%;
Org.: 0.5%;

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LAGB: Sup.:
1.4%; Deep:
0.1%; Org.:
0.1%
(Continued)

www.annalsofsurgery.com | 937
Laparoscopic Versus Open Surgery in Obese Patients
 TABLE 2. (Continued)
Study (Author Lap./Open Surgical Criteria Follow-Up
and Year) Design NOS Obesity Category Patients n n Procedure Outcome for SSI for SSI Attrition ITT/AT Conversion Results

Lindsey et al, 2009 Prospective ∗∗∗∗∗ BMI > 35 5921 6404/ RYGBP, LAGB Abscess N.R. N.R. N.R. N.R. N.R. L 6/3912, O
(US,)59 database 2009 5/2009; LAGB:
3/2492
Livingston Prospective ∗∗∗∗∗∗∗ BMI = 47.4 575 73/502 Bariatric Sup. WI, deep NSQIP 30 days 0% N.R. N.R. Sup.: L 0/73, O
et al, 2006 (US)60 database (7)/49.9 procedures WI (CDC) 11/502; Deep:
Shabanzadeh and Sørensen

(NSQIP) (8.4); L 0/73, O 1/502

P = 0.013
Marema et al, 2005 Retrospective ∗∗∗∗∗ BMI = 47.9 2275 1077/ RYGBP WI N.R. 1 year N.R. N.R. 28 L 6.1%; O 12.2%
(US)61 (0.53)/52 1198

938 | www.annalsofsurgery.com
(0.40);
P < 0.01
Miller et al, 2002 Prospective ∗∗∗∗∗ BMI = 46.9 1011 448/563 Lap. AGB and WI N.R. N.R. N.R. N.R. 3 L 0/448; O 19/563
(Germany)62 (7.8)/46.9 open VBG
(9.9); P =
0.57
Nguyen et al, 2000 Retrospective ∗∗∗∗∗ BMI = 51 70 35/35 RYGBP WI (severe and N.R. No N.R. AT 0 Sev. WI: L 0/35, O
(US)63 case- (40–60)/48 minor) follow– 2/35; Min. WI:
matched (41–60); NS up L 1/35, O 1/35
Nguyen, 2007 Prospective ∗∗∗∗∗ ICD-9 codes 22,422 16,357/ RYGBP WI N.R. No N.R. N.R. N.R. L 0.5%; O 2.3%
(US)64 database for obe- 6065 follow-
sity/morbid up
obesity
O’Brien et al, 1999 Prospective ∗∗∗∗∗∗∗ BMI = 44.5 302 277/25 AGB Infected N.R. 4 weeks 0% AT 5 L 1/277; O 4/25
(Australia)65 database (6) reservoir site
See et al, 2002 Prospective ∗∗∗∗∗ BMI = 41.8 72 20/52 RYGBP Intraabdominal N.R. N.R. N.R. N.R. N.R. L 4/20; O 0/52
(US)66 (35–49)/ abscess
46.7
(37–66);
P < 0.001
Sekhar et al, 2007 Prospective ∗∗∗∗∗ BMI = 58.9 967 568/399 RYGBP WI N.R. N.R. N.R. N.R. 10 L 1.7%; O 9.2%
(US)67 database (10.6)/49.1
(7.6); P =
0.001
Smith et al, 2004 Retrospective ∗∗∗∗∗∗ BMI = 46.7 656 328/328 RYGBP WI, subphrenic N.R. 2nd + 0% N.R. N.R. WI: L 4/328, O
(US)68 (35–62)/ abscess 6th 28/328; SA: L
49.5 week 1/328, O 1/328


(35–83)
Suter et al, 1999 Retrospective ∗∗∗∗∗ BMI = 273 76/197 Lap. AGB and WI N.R. 30 days N.R. N.R. 8 L 0/76; O 15/197
(Switzerland)69 45.5/42.7 open VBG
(37–64); P
< 0.01
Tevis et al, 2011 Prospective ∗∗∗∗∗∗ BMI = 25 4/21 RYGBP WI, intraab- N.R. N.R. N.R. AT 0 WI: L 0/4, O 4/21;
(US)70 database 43.9/42.9; P dominal IA: L 0/4, O
= 0.6 abscess, 1/21; FD: L 0/4,
fascia O 1/21

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
dehiscence
van Doesburg et al, Retrospective ∗∗∗∗∗∗ BMI = 49.5 290 57/233 RYGBP WI, intraab- N.R. 30 days 0% N.R. N.R. WI and IA: L
2010 (The (33.2–84.9) dominal 0/57; O 16/233
Netherlands)71 abscess
(Continued)

C 2012 Lippincott Williams & Wilkins

Annals of Surgery r Volume 256, Number 6, December 2012
 
TABLE 2. (Continued)
Study (Author Lap./Open Surgical Criteria Follow-Up
and Year) Design NOS Obesity Category Patients n n Procedure Outcome for SSI for SSI Attrition ITT/AT Conversion Results

Weingarten et al, 2011 Retrospective ∗∗∗∗ BMI = 49.5 797 355/442 Bariatric WI N.R. N.R. N.R. N.R. N.R. L 14/355; O
(US)72 (9.4) procedures 52/442
Westling et al, 1998 Retrospective ∗∗∗∗∗∗ BMI = 43 90 47/43 AGB WI N.R. 4 weeks 0% AT 16 L 0/47; O 4/43
(Sweden)73 (34–57)
Hernia
Ballem et al, 2008 Retrospective ∗∗∗∗∗∗ BMI = 31.9 331 199/192 Ventral hernia WI Based on Initial N.R. ITT 20 L 7.5%; O 9%
(US)74 (1.2); NS repair CDC follow-
up by

C 2012 Lippincott Williams & Wilkins

surgeon
Cholecystectomy
Koperna et al, 1999 Retrospective ∗∗∗∗ BMI > 30 30 15/15 Cholecystec WI N.R. N.R. N.R. AT N.R. L 0/15; O 5/15
(Austria)75 case- (subgroup) tomy
matched
Miles et al, 1992 Retrospective ∗∗∗∗∗ Morbidly 32 21/11 Cholecystec WI N.R. N.R. N.R. AT 0 L 0/21; O 1/11
(US)76 case- obese = tomy
matched 100 pounds
over ideal
body weight
Nicholson Prospective ∗∗∗∗∗∗∗ BMI > 30 63 33/30 Cholecystec WI N.R. N.R. N.R. AT 8 L 1/33; O 2/30
et al, 1995 (UK)77 (subgroup) tomy
Annals of Surgery r Volume 256, Number 6, December 2012

Paajanen et al, 2011 Retrospective ∗∗∗∗ BMI > 30 82 42/40 Cholecystec SSI N.R. N.R. N.R. ITT 16 L 2/42; O 3/40
(Finland)38 diabetic tomy
patients
Appendectomy
Corneille Retrospective ∗∗∗∗ BMI > 30 116 73/43 Appendectomy WI (require in- N.R. N.R. N.R. AT 12 WI: L 0/73, O
et al, 2007 (US)78 tervention), 3/43; IA: L
intraabdom- 5/73, O 5/43
inal
abscess
Varela et al, 2008 Prospective ∗∗∗∗∗ ICD-9 code 1943 906/1037 Appendectomy WI N.R. No follow- N.R. N.R. N.R. L 1/906; O 3/1037
(US)79 database for morbid for acute/ up
obesity perforated
appendicitis
Colorectal resection
Delaney et al, 2005 Prospective ∗∗∗∗∗∗ BMI = 33.3 188 94/94 Colorectal WI, Intraab- N.R. N.R. N.R. ITT 28 WI: L 8/94, O
(US)80 database, (3.7)/33.8 resections dominal 8/94; IA: L
case- (4.5); P = abscess 2/94, O 2/94
matched 0.38
Wick et al, 2011 Retrospective ∗∗∗∗ BMI > 35 or 1243 204/1039 Colorectal ICD-9 codes Based on N.R. N.R. N.R. N.R. L 15/204;
(US)39 ICD-9 code resections for SSI CDC O 116/1039
obesity (sup., deep,
organ)
General surgery
Dindo et al, 2003 Prospective ∗∗∗∗∗ BMI = 34.9 808 377/431 Elective general SSI N.R. N.R. N.R. N.R. N.R. L 8/377; O 17/431

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
(Switzerland)81 (6) surgery
AGB indicates adjustable gastric banding; AT, as treated analysis; ITT, intention to treat; LAGB, laparoscopic adjustable gastric banding; Lap. or L., laparoscopic; N.R., not reported; NS, not significant; NSQIP, National
Surgical Quality Improvement Program; O, open; RYGBP, Roux-en-Y gastric bypass; SSI, surgical site infections; Sup., superficial; VBG, vertical banded gastroplasty; WI, wound infection.

www.annalsofsurgery.com | 939
Laparoscopic Versus Open Surgery in Obese Patients
Shabanzadeh and Sørensen
in the exposed and in the nonexposed group, comparability of the
2 groups, and outcome of the single studies. A study can obtain 0–
9 stars based on these criteria. A threshold of 6 stars or above has
been considered as indicative for high quality in other meta-analyses
and was chosen as well for this review.35 Inspection of funnel plots
based on meta-analyses, including more than 10 studies, was used for
assessment of publication bias.30
Statistical Analysis
Meta-analyses of RCTs and observational studies were per-
formed separately in all analyses by the use of Review Manager
5.1. Separate meta-analysis was performed for bariatric surgery and
nonbariatric surgery and across both subgroups. In all analyses, the
outcomes of surgical site infection were calculated as odds ratios
(ORs) with 95% confidence intervals (CIs). For pooled estimates, the
Mantel-Haenszel χ 2 method was used. Statistical heterogeneity for
the pooled OR was calculated as I2 with a Z-statistic test for overall
effect. The fixed effects model was applied for the meta-analyses of
the RCTs in the case of I2 < 40%. The random effects model was
used for the meta-analyses of observational studies irrespective of
I2 value because of a considerable clinical heterogeneity in different
surgical procedures and study designs.37
Sensitivity analysis was performed to test the validity of the
meta-analyses under consideration of the identified bias. In addition, 2
sensitivity analyses were performed for the observational studies. The
first one only included studies with a NOS score of 6 stars or above,
whereas the second one assumed converted laparoscopy operations
as open operations in the analysis. In all analyses, a threshold of P <
0.05 for overall effect was considered statistically significant.
RESULTS
The electronic searches yielded 2974 records. Additional 6
records were found through hand-search (Fig. 1). The authors of
1 article and 1 conference abstract provided unpublished data that
were included in the analysis.38,39 Two observational studies had zero
events of surgical site infection and were, therefore, excluded during
analysis.30
Characteristics of RCTs
Eight RCTs published between 1999 and 2011 were included.
They originate from the United States, Sweden, The Netherlands,
Belgium, and Spain.40–47 A total of 615 obese patients with BMI
≥ 30 randomized to laparoscopic and open surgery were included.
Seven of the RCTs studied bariatric surgery,40–46 and 1 RCT com-
prised a subgroup analysis of the obese patients included in a RCT of
appendectomy.47 Four of the RCTs reported a nonsignificant dif-
ference in BMI between the intervention and the control group
(Table 1).
Characteristics of Observational Studies
Thirty-six prospective and retrospective observational stud-
ies were included in the meta-analysis. The studies were published
between 1992 and 2011 and originated from the United States, Aus-
tria, England, Finland, Germany, The Netherlands, Sweden, Switzer-
land, Turkey, Australia, and Israel. The total number of obese pa-
tients with BMI ≥ 30 included was 58,755. The studies included
patients who had undergone bariatric surgery,48–73 hernia surgery,74
cholecystectomy,38,75–77 appendectomy,78,79 colorectal resection,39,80
and pooled general surgery.81 Studies on colorectal and general
surgery included patients with cancer, adenomas, inflammatory bowel
disease, and diverticulitis. Seven observational studies reported a non-
significant difference in BMI between the intervention and the control
group (Table 2).
940 | www.annalsofsurgery.com
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 256, Number 6, December 2012
Quality Assessment
The most apparent methodological flaw in the RCTs was the
missing description of blinded outcome assessment and criteria for
diagnosis of surgical site infection. Accordingly, all RCTs had an
unclear risk of detection bias. Six RCTs had no adequate descrip-
tion of allocation concealment and 4 RCTs had comparable BMIs in
the intervention and control groups, introducing an unclear risk of
selection bias. Risk of attrition bias was not present across studies.
The overall risk of all types of bias in the RCTs was generally low to
unclear (Fig. 2).
In the observational studies, the clinical heterogeneity was
considerable. The most typical methodological flaw was a risk of se-
lection bias. None of the studies had confounder control for surgical
site infection outcome and many studies (30/36) had significant dif-
ferences in BMI between groups. Attrition bias was present because
of inadequate reporting on postdischarge follow-up (29/36). Detec-
tion bias was present because of inadequate reporting on surgical site
infection definition (33/36) and inadequate reporting on time point
for postdischarge follow-up (24/36). About half of the studies had ret-
rospective data collection (19/36). Reporting bias was considerable
and was aimed to be eliminated through sensitivity analyses. Risk
of language bias was present as 10 bariatric observational studies
were excluded because of language restriction. The latter, however,
is unlikely to have changed the pooled estimates of the observational
studies because the findings were reproducible across bariatric and
nonbariatric surgery for both RCTs and observational studies. Thir-
teen observational studies across surgical procedures had a NOS score
of 6 stars or above (Table 2).
There were not adequate numbers of RCTs to assess publi-
cation bias. A funnel plot of observational studies was symmetrical
and thereby no publication bias was present (Supplemental Digital
Content Figure 2, available at http://links.lww.com/SLA/A281).
Surgical Site Infection in Obese Patients
Across surgical procedures, the meta-analysis of RCTs dis-
closed significantly fewer surgical site infections after laparoscopic
FIGURE 2. Risk of bias in RCTs.

C 2012 Lippincott Williams & Wilkins
Annals of Surgery r Volume 256, Number 6, December 2012 Laparoscopic Versus Open Surgery in Obese Patients

FIGURE 3. Meta-analysis of RCTs.

TABLE 3. Laparoscopy Versus Open Surgery: Development of Surgical Site Infection in RCTs
Number of Number of
Analysis Studies OR Fixed Effect 95% CI P Patients Heterogeneity I2
All procedures (Fig. 3) 8 0.19 0.08–0.45 0.0002 615 0%
Sensitivity analysis: RCTs with 3 0.28 0.08–0.93 0.04 242 0%
surgical site infection criteria and
postdischarge follow-up
(Supplemental Digital Content
Figure 3, available at http://links.
lww.com/SLA/A281)
Sensitivity analysis: RCTs with 4 0.11 0.03–0.43 0.001 409 0%
comparable BMI between groups
(Supplemental Digital Content
Figure 4, available at http://links.
lww.com/SLA/A281)

surgery than after open procedures (OR = 0.19; 95% CI [0.08–0.45];
P = 0.0002; Fig. 3 and Table 3). In the meta-analysis of the observa-
tional studies, the similar estimated result was an OR = 0.33 (95%
CI [0.26–0.42]; P < 0.00001), thus favoring laparoscopic procedures
compared with open procedures (Fig. 4 and Table 4).
Sensitivity Analysis
The RCTs showed an acceptable statistical heterogeneity (I2 =
0%). Both analyses showed significantly fewer surgical site infections
in laparoscopic surgery compared with open surgery (OR = 0.28;
95% CI [0.08–0.93]; P = 0.04 and OR = 0.11; 95% CI [0.03–0.43];
P = 0.001; Table 3). When combined, a 70%–80% risk reduction was
found.
A considerable statistical heterogeneity was present in the
meta-analysis of observational studies (I2 = 48%; Fig. 4 and Table 4).
When only studies with a NOS score of 6 stars were included in
sensitivity analysis, similar estimates as in the meta-analysis and a
reduced heterogeneity were found. In the “as treated” analysis, sim-
ilar estimates were found, but the heterogeneity was minimal (I2 =
0%). Sensitivity analyses to assess the impact of detection and selec-
tion bias on bariatric and nonbariatric surgery were based on small
numbers of studies when compared with the total pool of included
observational studies included in the meta-analysis. However, they
disclosed similar estimates with similar and acceptable heterogene-
ity as in the meta-analysis and the sensitivity analyses of the RCTs
(Table 4). For forest plots of the sensitivity analyses of observational
studies, see Supplemental Digital Content Figures 5–8 (available at
http://links.lww.com/SLA/A281).
DISCUSSION
This systematic review and meta-analysis shows that in the
obese surgical patients, the incidence of surgical site infection is
significantly less after laparoscopic surgery than after open surgery.
Across general abdominal surgical procedures, the obese patients
have a 70%–80% lower risk of surgical site infection after laparo-
scopic surgery than after open surgery.
Obesity is associated with deficient collagen formation82 and
impaired immunity in responsiveness of lymphocytes,83 in addition
to avascularity of subcutaneous layer of fat tissue.84 Previous clini-
cal and experimental studies have shown that laparoscopic surgery
induces a less pronounced proinflammatory response than open
surgery and a better preservation of the systemic immune function


C 2012 Lippincott Williams & Wilkins www.annalsofsurgery.com | 941

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Shabanzadeh and Sørensen Annals of Surgery r Volume 256, Number 6, December 2012

FIGURE 4. Meta-analysis of observational studies.

942 | www.annalsofsurgery.com 
C 2012 Lippincott Williams & Wilkins

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 256, Number 6, December 2012
TABLE 4. Laparoscopy Versus Open Surgery: Development of Surgical Site Infection in Observational Studies (For Forest Plots
See Supplemental Digital Content Figures 5–8, available at http://links.lww.com/SLA/A281)
Number of
Analysis Studies OR Random Effect
All procedures (Fig. 4) 37 0.33
Studies with NOS score of 6 stars or 13 0.30
above
Sensitivity analysis: Studies with 4 0.50
surgical site infection criteria and
postdischarge follow-up
Sensitivity analysis: Studies with 7 0.36
comparable BMI between groups
Sensitivity analysis: Studies with 12 0.20
converted surgery in the open
group in analysis (“as treated”
analysis)
postoperatively.85,86 The lesser surgical trauma and the fact that la-
paroscopy produces smaller incisions than conventional open surgery
may explain the reduced incidence of surgical site infection. Conver-
sion from laparoscopic to open surgery has been reported to worsen
postoperative outcome.87,88 In our sensitivity analysis, including “as
treated” operations, similar estimates were found compared with the
meta-analysis.
Some studies have reported obesity to be better defined by dis-
tribution of fat tissue instead of the BMI. Accordingly, the thickness
of subcutaneous fat89 and waist circumference90 have proven to be
predictive factors for surgical site infection. In this systematic review,
we defined obesity as a BMI ≥ 3033 or as defined by other quantitative
measures involving body weight being the most accepted measures
for obesity in surgical trials. Some authors have suggested that fewer
complications and other benefits of laparoscopic surgery in obese
patients are the result of incomparable BMI in the intervention and
control groups,91 but this could not be confirmed by this review.
This is the first systematic review and meta-analysis to assess
the impact of obesity on surgical site infections in laparoscopic ver-
sus open general abdominal surgery. The methodological approach in
this systematic review has its strengths and limitations. The strengths
are the inclusion of RCTs and the isolation of only obese partici-
pants. The methodological assessment was performed for both RCTs
and observational studies and the impact of the identified bias was
explored on the pooled estimates. The analyses were performed for
bariatric and nonbariatric surgery combined and separately to assess
if the wide range of general surgical disease, comorbidities, emer-
gency conditions, and cancer affected the final estimates. In addition,
a series of sensitivity analyses eliminated the impact of detection and
selection bias. A general limitation of this review is that surgical site
infection was inconsistently defined between studies, making it prob-
lematic to perform meta-analysis.6 The homogenous pool of included
RCTs had its limitations in mostly studying bariatric surgery and only
including 1 RCT on nonbariatric surgery. Although all RCTs were
well-designed studies of high methodological quality, none of the
studies were designed to assess differences in surgical site infection
rate between laparoscopic and open surgery in the obese patients.
The studies might, therefore, have been underpowered. In the ob-
servational studies, a number of methodological flaws were present:
difference in study designs, clinical confounders not adjusted for, con-
versions to open surgery inconsistently reported, analyses not reported
“as treated” or intention to treat, and lack of addressing attrition.
To conclude, obese patients have fewer surgical site
infections—as nonobese patients—after laparoscopic surgery com-
pared with open surgery. Future clinical practice should, therefore,

C 2012 Lippincott Williams & Wilkins
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Laparoscopic Versus Open Surgery in Obese Patients
Number of
95% CI P Patients Heterogeneity I2
0.26–0.42 <0.00001 58,328 48%
0.18–0.52 <0.0001 16,180 42%
0.40–0.63 <0.00001 12,795 0%
0.14–0.90 0.03 409 32%
0.11–0.37 <0.00001 1360 0%
continue the development and implementation of the laparoscopic
and other minimally invasive operative procedures to reduce adverse
surgical outcome in the rising population of obese patients.
ACKNOWLEDGMENTS
The authors are indebted to Peer Wille-Jørgensen for devel-
oping the idea to this review and for contributing to the editing of
the protocol. We thank Marija Barbateskovic, trial search coordina-
tor at the Cochrane Colorectal Cancer Group, for her assistance in
conducting the electronic searches. Finally, we want to thank Karin
Mønsted Shabanzadeh for the linguistic corrections and Bispebjerg
Hospital for providing office facilities.
REFERENCES
1. Arabshahi KS, Koohpayezade J. Investigation of risk factors for surgical wound
infection among teaching hospitals in Tehran. Int Wound J. 2006;3:59–62.
2. Benoist S, Panis Y, Alves A, et al. Impact of obesity on surgical outcomes after
colorectal resection. Am J Surg. 2000;179:275–281.
3. Postlethwait RW, Johnson WD. Complications following surgery for duodenal
ulcer in obese patients. Arch Surg. 1972;105:438–440.
4. Smith RL, Bohl JK, McElearney ST, et al. Wound infection after elective
colorectal resection. Ann Surg. 2004;239:599–605.
5. Waisbren E, Rosen H, Bader AM, et al. Percent body fat and prediction of
surgical site infection. J Am Coll Surg. 2010;210:381–389.
6. Leaper DJ, van Goor H, Reilly J, et al. Surgical site infection—a European
perspective of incidence and economic burden. Int Wound J. 2004;1:247–273.
7. Berghöfer A, Pischon T, Reinhold T, et al. Obesity prevalence from a European
perspective: a systematic review. BMC Public Health. 2008;8:200.
8. Flegal KM, Carroll MD, Ogden CL, et al. Prevalence and trends in obesity
among US adults, 1999–2008. JAMA. 2010;303:235–241.
9. Astagneau P, Rioux C, Golliot F, et al. Morbidity and mortality associated
with surgical site infections: results from the 1997–1999 INCISO surveillance.
J Hosp Infect. 2001;48:267–274.
10. Coello R, Charlett A, Wilson J, et al. Adverse impact of surgical site infections
in English hospitals. J Hosp Infect. 2005;60:93–103.
11. Cruse PJ, Foord R. The epidemiology of wound infection. A 10-year prospec-
tive study of 62,939 wounds. Surg Clin North Am. 1980;60:27–40.
12. Haley RW, Schaberg DR, Crossley KB, et al. Extra charges and prolonga-
tion of stay attributable to nosocomial infections: a prospective interhospital
comparison. Am J Med. 1981;70:51–58.
13. Kirkland KB, Briggs JP, Trivette SL, et al. The impact of surgical-site infections
in the 1990s: attributable mortality, excess length of hospitalization, and extra
costs. Infect Control Hosp Epidemiol. 1999;20:725–730.
14. Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable
to medical injuries during hospitalization. JAMA. 2003;290:1868–1874.
15. Abraham NS, Young JM, Solomon MJ. Meta-analysis of short-term outcomes
after laparoscopic resection for colorectal cancer. Br J Surg. 2004;91:1111–
1124.
www.annalsofsurgery.com | 943
Shabanzadeh and Sørensen
16. Karthikesalingam A, Markar SR, Holt PJ, et al. Meta-analysis of randomized
controlled trials comparing laparoscopic with open mesh repair of recurrent
inguinal hernia. Br J Surg. 2010;97:4–11.
17. Li X, Zhang J, Sang L, et al. Laparoscopic versus conventional
appendectomy—a meta-analysis of randomized controlled trials. BMC Gas-
troenterol. 2010;10:129.
18. Sauerland S, Jaschinski T, Neugebauer EA. Laparoscopic versus open surgery
for suspected appendicitis. Cochrane Database Syst Rev. 2010;10:CD001546.
19. Sauerland S, Walgenbach M, Habermalz B, et al. Laparoscopic versus open
surgical techniques for ventral or incisional hernia repair. Cochrane Database
Syst Rev. 2011;3:CD007781.
20. Schwenk W, Haase O, Neudecker J, et al. Short term benefits for laparoscopic
colorectal resection. Cochrane Database Syst Rev. 2005;3:CD003145.
21. Siddiqui MR, Sajid MS, Khatri K, et al. Elective open versus laparoscopic
sigmoid colectomy for diverticular disease: a meta-analysis with the Sigma
trial. World J Surg. 2010;34:2883–2901.
22. Wu XJ, He XS, Zhou XY, et al. The role of laparoscopic surgery for ul-
cerative colitis: systematic review with meta-analysis. Int J Colorectal Dis.
2010;25:949–957.
23. Pikarsky AJ, Saida Y, Yamaguchi T, et al. Is obesity a high-risk factor for
laparoscopic colorectal surgery? Surg Endosc. 2002;16:855–858.
24. Da Luz Moreira A, Rottoli M, Geisler DP, et al. Laparoscopic colectomy:
does the location of the specimen extraction site matter? Gastroenterology.
2009;136(suppl 1):891–892.
25. Vadala G, Mangiameli A, Altamore S, et al. L’appendicectomia per via laparo-
scopica [Laparoscopic appendicectomy]. Minerva Med. 1995;86:93–96.
26. Uhl W, Strobel O, Buchler MW. Laparoskopische versus offene appendek-
tomie: Was ist gesichert? [Laparoscopic versus open appendectomy—what is
confirmed?] Chir Gastroenterol Interdiszip. 2000;16:132–139.
27. Näf R, Buchmann P. Ist die offene appendektomie noch zeitgemas? [Is open
appendectomy still up-to-date?]. Ther Umsch. 2005;62:111–117.
28. Pirro N, Berdah SV. Appendicites: coelioscopie ou non? [Appendicitis: yes or
no to laparoscopic approach?]. J Chir (Paris). 2006;143:155–159.
29. Caravaggio C, Hauters P, Malvaux P, et al. Is laparoscopic appendectomy an
effective procedure? Acta Chir Belg. 2007;107:368–372.
30. Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of
Interventions Version 5.1.0. Oxford, UK: The Cochrane Collaboration; 2011.
31. Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies
in epidemiology. JAMA. 2000;283:2008–2012.
32. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic
reviews and meta-analyses: the PRISMA statement. Int J Surg. 2010;8:336–
341.
33. World Health Organization. Obesity and overweight [WHO Web site]. http://
www.who.int/mediacentre/factsheets/fs311/en/index.html. Accessed June 22,
2011.
34. Horan TC, Gaynes RP, Martone WJ, et al. CDC definitions of nosocomial
surgical site infections, 1992: a modification of CDC definitions of surgical
wound infections. Infect Control Hosp Epidemiol. 1992;13:606–608.
36. Lanitis S, Tekkis PP, Sgourakis G, et al. Comparison of skin-sparing mas-
tectomy versus non-skin-sparing mastectomy for breast cancer. Ann Surg.
2010;256:632–639.
35. Wells GA, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS)
for assessing the quality of nonrandomised studies in meta-analyses [OHRI
Web site]. http://www.ohri.ca/programs/clinical epidemiology/oxford.asp. Ac-
cessed April 12, 2011.
37. Borenstein M, Hedges LV, Higgins JPT, et al. Part 3: fixed-effect ver-
sus random-effect models. In: Borenstein M, Hedges LV, Higgins JPT,
et al., eds. Introduction to Meta-analysis. Hoboken, NJ: Wiley; 2009:
61–102.
38. Paajanen H, Suuronen S, Nordstrom P, et al. Laparoscopic versus open chole-
cystectomy in diabetic patients and postoperative outcome. Surg Endosc.
2011;25:764–770. Published and unpublished data were used.
39. Wick EC, Hirose K, Shore AD, et al. Surgical site infections and cost in
obese patients undergoing colorectal surgery. Arch Surg. 2011;146:1068–1072.
Published and unpublished data were used.
40. Azagra JS, Goergen M, Ansay J, et al. Laparoscopic gastric reduction surgery:
preliminary results of a randomized, prospective trial of laparoscopic vs open
vertical banded gastroplasty. Surg Endosc. 1999;13:555–558.
41. De Wit LT, Mathus-Vliegen L, Hey C, et al. Open versus laparoscopic ad-
justable silicone gastric banding: a prospective randomized trial for treatment
of morbid obesity. Ann Surg. 1999;230:800–807.
944 | www.annalsofsurgery.com
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 256, Number 6, December 2012
42. Luján JA, Frutos MD, Hernandez Q, et al. Laparoscopic versus open gastric
bypass in the treatment of morbid obesity: a randomized prospective study.
Ann Surg. 2004;239:433–437.
43. Nguyen NT, Goldman C, Rosenquist CJ, et al. Laparoscopic versus open
gastric bypass: a randomized study of outcomes, quality of life, and costs. Ann
Surg. 2001;234:279–291.
44. Sundbom M, Gustavsson S. Randomized clinical trial of hand-assisted la-
paroscopic versus open Roux-en-Y gastric bypass for the treatment of morbid
obesity. Br J Surg. 2004;91:418–423.
45. van Dielen FM, Soeters PB, de Brauw LM, et al. Laparoscopic adjustable
gastric banding versus open vertical banded gastroplasty: a prospective ran-
domized trial. Obes Surg. 2005;15:1292–1298.
46. Westling A, Gustavsson S. Laparoscopic vs open Roux-en-Y gastric bypass: a
prospective, randomized trial. Obes Surg. 2001;11:284–292.
47. Clarke T, Katkhouda N, Mason RJ, et al. Laparoscopic versus open appendec-
tomy for the obese patient: a subset analysis from a prospective, randomized,
double-blind study. Surg Endosc. 2010;25:1276–1280.
48. Agaba EA, Shamseddeen H, Gentles CV, et al. Laparoscopic vs open gastric
bypass in the management of morbid obesity: a 7-year retrospective study of
1,364 patients from a single center. Obes Surg. 2008;18:1359–1363.
49. Campos GM, Ciovica R, Rogers SJ, et al. Spectrum and risk factors of com-
plications after gastric bypass. Arch Surg. 2007;142:969–975.
50. Coskun H, Bozbora A, Ogunc G, et al. Adjustable gastric banding in a multi-
center study in Turkey. Obes Surg. 2003;13:294–296.
51. Courcoulas A, Perry Y, Buenaventura P, et al. Comparing the outcomes after
laparoscopic versus open gastric bypass: a matched paired analysis. Obes Surg.
2003;13:341–346.
52. Dolan K, Hatzifotis M, Newbury L, et al. A comparison of laparoscopic ad-
justable gastric banding and biliopancreatic diversion in superobesity. Obes
Surg. 2004;14:165–169.
53. Ezri T, Muzikant G, Medalion B, et al. Anesthesia for restrictive bariatric
surgery (gastric bypass not included): laparoscopic vs open procedures. Int J
Obes Relat Metab Disord. 2004;28:1157–1162.
54. Gärtner D, Guhl M, Münz K, et al. Entwicklung der Adipositaschirurgie am
Krankenhaus der Maximalversorgung: Uber 20 Jahre Behandlungserfahrung
[Twenty years of experience with bariatric surgery in a general hospital].
Chirurg. 2008;79:866–873.
55. Gonzalez R, Nelson LG, Murr MM. Does establishing a bariatric surgery
fellowship training program influence operative outcomes? Surg Endosc.
2007;21:109–114.
56. Gorman RS, Stern DL, Inclan DV, et al. Outcomes, health status, and medical
resource utilization after bariatric surgery. Compr Ther. 2006;32:34–38.
57. Hutter MM, Randall S, Khuri SF, et al. Laparoscopic versus open gastric bypass
for morbid obesity: a multicenter, prospective, risk-adjusted analysis from the
National Surgical Quality Improvement Program. Ann Surg. 2006;243:657–
662.
58. Lancaster RT, Hutter MM. Bands and bypasses: 30-day morbidity and mortality
of bariatric surgical procedures as assessed by prospective, multi-center, risk-
adjusted ACS-NSQIP data. Surg Endosc. 2008;22:2554–2563.
59. Lindsey ML, Patterson WL, Gesten FC, et al. Bariatric surgery for obesity:
surgical approach and variation in in-hospital complications in New York State.
Obes Surg. 2009;19:688–700.
60. Livingston EH, Arterburn D, Schifftner TL, et al. National Surgical Qual-
ity Improvement Program analysis of bariatric operations: modifiable risk
factors contribute to bariatric surgical adverse outcomes. J Am Coll Surg.
2006;203:625–633.
61. Marema RT, Perez M, Buffington CK. Comparison of the benefits and com-
plications between laparoscopic and open Roux-en-Y gastric bypass surgeries.
Surg Endosc. 2005;19:525–530.
62. Miller K, Höller E, Hell E. Gastrorestriktive operationstechniken zur behand-
lung der morbiden adipositas-Vertikale bandverstarkte gastroplastik vs. band-
verstellbare Gastroplastik [Restrictive procedures in the treatment of morbid
obesity—vertical banded gastroplasty vs. adjustable gastric banding]. Zentralbl
Chir. 2002;127:1038–1043.
63. Nguyen NT, Ho HS, Palmer LS, et al. A comparison study of laparoscopic
versus open gastric bypass for morbid obesity. J Am Coll Surg. 2000;191:149–
155.
64. Nguyen NT, Hinojosa M, Fayad C, et al. Use and outcomes of laparoscopic
versus open gastric bypass at academic medical centers. J Am Coll Surg.
2007;205:248–255.
65. O’Brien PE, Brown WA, Smith A, et al. Prospective study of a laparoscopically
placed, adjustable gastric band in the treatment of morbid obesity. Br J Surg.
1999;86:113–118.

C 2012 Lippincott Williams & Wilkins
Annals of Surgery r Volume 256, Number 6, December 2012
66. See C, Carter PL, Elliott D, et al. An institutional experience with laparoscopic
gastric bypass complications seen in the first year compared with open gastric
bypass complications during the same period. Am J Surg. 2002;183:533–538.
67. Sekhar N, Torquati A, Youssef Y, et al. A comparison of 399 open and 568
laparoscopic gastric bypasses performed during a 4-year period. Surg Endosc.
2007;21:665–668.
68. Smith SC, Edwards CB, Goodman GN, et al. Open vs laparoscopic Roux-en-Y
gastric bypass: comparison of operative morbidity and mortality. Obes Surg.
2004;14:73–76.
69. Suter M, Giusti V, Heraief E, et al. Early results of laparoscopic gastric banding
compared with open vertical banded gastroplasty. Obes Surg. 1999;9:374–380.
70. Tevis S, Garren MJ, Gould JC. Revisional surgery for failed vertical-banded
gastroplasty. Obes Surg. 2011;21:1220–1224.
71. van Doesburg IA, te Riele WW, Boerma D, et al. Maagbypassoperatie effectief
bij morbide obesitas [Gastric bypass surgery effective for morbid obesity]. Ned
Tijdschr Geneeskd. 2010;154:A1138.
72. Weingarten TN, Flores AS, McKenzie JA, et al. Obstructive sleep apnoea and
perioperative complications in bariatric patients. Br J Anaesth. 2011;106:131–
139.
73. Westling A, Bjurling K, Ohrvall M, et al. Silicone-adjustable gastric banding:
disappointing results. Obes Surg. 1998;8:467–474.
74. Ballem N, Parikh R, Berber E, et al. Laparoscopic versus open ventral hernia
repairs: 5 year recurrence rates. Surg Endosc. 2008;22:1935–1940.
75. Koperna T, Kisser M, Schulz F. Laparoscopic versus open treatment of patients
with acute cholecystitis. Hepatogastroenterology. 1999;46:753–757.
76. Miles RH, Carballo RE, Prinz RA, et al. Laparoscopy: the preferred method
of cholecystectomy in the morbidly obese. Surgery. 1992;112:818–822.
77. Nicholson ML, Dennis MJS, Marshall K, et al. The influence of obesity on
post-operative complications and operative difficulty in open and laparoscopic
cholecystectomy. Minimal Invasiv Ther. 1995;4:19–23.
78. Corneille MG, Steigelman MB, Myers JG, et al. Laparoscopic appendectomy
is superior to open appendectomy in obese patients. Am J Surg. 2007;194:877–
880.

C 2012 Lippincott Williams & Wilkins
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Laparoscopic Versus Open Surgery in Obese Patients
79. Varela JE, Hinojosa MW, Nguyen NT. Laparoscopy should be the approach of
choice for acute appendicitis in the morbidly obese. Am J Surg. 2008;196:218–
222.
80. Delaney CP, Pokala N, Senagore AJ, et al. Is laparoscopic colectomy applicable
to patients with body mass index >30? A case-matched comparative study with
open colectomy. Dis Colon Rectum. 2005;48:975–981.
81. Dindo D, Muller MK, Weber M, et al. Obesity in general elective surgery.
Lancet. 2003;361:2032–2035.
82. Goodson WH, Hunt TK. Deficient collagen formation by obese mice in a
standard wound model. Am J Surg. 1979;138:692–694.
83. Tanaka S, Inoue S, Isoda F, et al. Impaired immunity in obesity: suppressed
but reversible lymphocyte responsiveness. Int J Obes Relat Metab Disord.
1993;17:631–636.
84. Flancbaum L, Choban PS. Surgical implications of obesity. Annu Rev Med.
1998;49:215–234.
85. Gupta A, Watson DI. Effect of laparoscopy on immune function. Br J Surg.
2001;88:1296–1306.
86. Wichman MW, Hüttl TP, Winter H, et al. Immunological effects of laparo-
scopic vs open colorectal surgery. Arch Surg. 2005;140:692–697.
87. Marusch F, Gastinger I, Schneider C, et al. Importance of conversion for
results obtained with laparoscopic colorectal surgery. Dis Colon Rectum.
2001;44:207–214.
88. Belizon A, Sardinha CT, Sher ME. Converted laparoscopic colectomy: what
are the consequences? Surg Endosc. 2006;20:947–951.
89. Fujii T, Tsutsumi S, Matsumoto A, et al. Thickness of subcutaneous fat as a
strong risk factor for wound infections in elective colorectal surgery: impact
of prediction using preoperative CT. Dig Surg. 2010;27:331–335.
90. Balentine CJ, Robinson CN, Marshall CR, et al. Waist circumference predicts
increased complications in rectal surgery. J Gastrointest Surg. 2010;14:1669–
1679.
91. Kennedy GD, Rajamanickam V, Oconnor ES, et al. Optimizing surgical
care of colon cancer in the older adult population. Ann Surg. 2011;253:
508–514.
www.annalsofsurgery.com | 945