Chronic Laparoscopic Port-Site Infection: A Systematic Review

By Muhammad Tahir Ghani¹, Ibad Ur Rehman², Nain Sukh³, Burhan Tariq⁴, Arif Khurshid⁵, M. Ali Aadwani⁵

Affiliations

1. Department of Surgery, Aero Hospital, Rawalpindi, Pakistan
2. Department of Surgery, Islamabad Medical and Dental College, Islamabad, Pakistan
3. Department of Surgery, HITEC Institute of Medical Sciences, Taxila, Pakistan
4. Department of Surgery, Pakistan Institute of Medical Sciences, Islamabad, Pakistan
5. Department of Surgery, Alhada Armed Forces Hospital, Al Hada, Saudi Arabia

doi: 10.29271/jcpsp.2025.10.1313

ABSTRACT
Chronic laparoscopic port-site infection (PSI) is caused by non-tuberculous mycobacteria (NTM). This systematic review aimed to gather all existing information about the aetiology and management of chronic PSI. A systematic search of PubMed, Google Scholar, Cochrane, and PakMediNet databases was carried out. Ten studies were selected; eight from India and two from Pakistan. A total of 109 patients were reported to have chronic PSI. In all studies, reusable laparoscopic instruments were used, which were chemically sterilised. Clarithromycin, amikacin, ciprofloxacin, and levofloxacin were reported as the most sensitive medicines when used for a duration of three months. Additionally, 11% of cases were treated with standard first-line anti-tuberculous treatment (ATT). NTM was cultured successfully in 52% of patients. Histological examination of the excised tracts showed chronic granulomatous inflammation. The source of NTM was identified as the water used to rinse reusable instruments. Debridement or excision of infected tracts, followed by antimicrobial agents according to culture, was the most successful treatment. The use of disposable laparoscopic instruments and standard sterilisation measures can help prevent these infections.

Key Words: Port-site infections, Non-tuberculous mycobacteria, Anti-tuberculous treatment.

INTRODUCTION

Port-site infection (PSI) in laparoscopic surgery is a trouble- some complication that lessens the advantages of minimally invasive surgeries.¹ Laparoscopic PSI may be either acute or chronic. Acute PSI presents within a few days after laparoscopic surgeries and is usually easily treatable with routine antibiotics, with or without drainage.^2,3 Chronic PSI, which presents after many weeks of surgery, is very different and difficult to treat.³ Patients with chronic PSI present many weeks after surgery with infected port-sites. The cellulitis soon turns into frank abscesses at port sites. Drainage provides temporary relief, and the abscess trends to recurs. Routine bacterial cultures are negative. Non- tuberculous mycobacteria (NTM), also known as atypical mycobacteria, is known to cause chronic PSI.^2-4 NTM are generally less virulent than Mycobacterium tuberculosis.^3,4 The presence of NTM makes these infections very difficult to treat.

 

Resistance to routinely used antibiotics, longer duration of treatment, atypical presentation, and frequent relapses make these infections troublesome for both treating physicians and patients.^4,5 Many surgeons consider NTM as the cause of chronic PSI only late in the course of illness, and patients are initially treated with routinely used antibiotics such as penicillin, to which NTM are resistant.⁶ The diagnostic facilities for NTM are sub- optimal and limited. The diagnosis depends upon the culture of atypical mycobacteria on special medium, which takes many weeks.⁴ Some studies have also reported the isolation of Mycobacterium tuberculosis from chronic PSI wounds, with successful treatment using standard anti-tuberculous treatment (ATT).^7-9 Literature also reports various other organisms responsible for chronic PSI, such as methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas.³

To the authors’ knowledge, there is no systematic and compre- hensive search of the literature focusing on chronic PSI. This review aimed to gather all the existing information about the presentation, diagnosis, and management of chronic laparoscopic PSI.

METHODOLOGY

This systematic review was conducted as per Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines (Figure 1).¹⁰ PubMed, Google Scholar, Cochrane, and PakMediNet databases were searched between 13^th and 23^rd December 2023. The following keywords: laparoscopic ports, port-site infection, laparoscopic infection, and chronic port-site infection were used for each database. The first two authors separately searched and screened the studies, and no conflict was noted during the search process. All retrospective, prospective studies, case reports, case series, and randomised clinical trials were included. Only studies with full text and English language were selected. All those studies which included patients of PSI presenting after three weeks of laparoscopic surgeries were included. Port-site infections presenting within the first three weeks of surgery were excluded.

RESULTS

Ten studies met the inclusion criteria: six were case reports, two were case series, and two were retrospective studies. Eight studies were from India, while two case reports were from Pakistan (Table I). The minimum period reported for the onset of symptoms was three weeks after initial laparoscopic surgery. A total of 109 patients were reported to have chronic PSI. Various laparoscopic (lap) procedures, including laparoscopic cholecystectomies, lap appendicectomies, lap inguinal hernioplasty and laparoscopic urological surgeries, were reported to have chronic PSI. In all studies, reusable laparoscopic instruments were used that were chemically sterilised. The most common surgery reported was laparoscopic cholecystectomy (38%). Various abdominal ports were involved in different proportions, including umbilical, epigastric, and iliac sites.

None of the patients had signs and symptoms of systemic illness, including fever or malaise, and only localised disease was noted. All patients presented with similar complaints, starting with erythema, induration, and tenderness at the port sites, followed by frank pus discharge spontaneously if not surgically drained. None of the wounds healed after drainage, and patients repea- tedly presented with abscesses at the port sites.

The most successful treatment noted was the early excision of tracts, leaving wounds open for secondary closure and prescribing oral clarithromycin, along with injection amikacin or ciprofloxacin for 3-6 months (Table II). Eleven (10%) of patients were prescribed the first-line ATT. Amoxicillin, amoxicillin-clavulanic acid combination, cephradine, cefixime, linezolid, and other commonly used antibiotics for skin soft tissue infections were found ineffective in all cases.

NTM was cultured successfully in 57 (52%) patients. Five cases of PSI were MRSA positive, three had Pseudomonas, and two had coagulase-negative Staphylococci (CONS). Forty-six (42%) patients were treated surgically by excision of infected tracts and antimicrobial agents, while (58%) 63 patients were treated by antimicrobial agents alone, without any surgical treatment done.

Table I: Summary of included studies with reference to characteristics.
 

Reference	Country	Year of publication	Type of study	No. of patients	Type of surgery	Reporting time after surgery	Presenting complaints
Chaudhary et al.3	India	2023	Retrospective	10	Various lap procedures	2-6 months	Discharging sinuses
Rehman et al.7	Pakistan	2023	Case report	1	Lap chole	4 weeks	Pain and tenderness at the port sites
Jagdish et al.8	India	2005	Case report	1	Lap chole	8 weeks	Discharging sinuses
Ghani et al.9	Pakistan	2023	Case report	1	Lap chole	4 weeks	Tender nodules or abscesses
Vijayaraghavan et al.12	India	2020	Case series	35	Various lap procedures	8 weeks	Discharging sinuses and tender nodules
Ghosh et al.13	India	2017	Retrospective	32	Various lap procedures	28-64 days	Nodules, discharging sinuses
Niyas  et al.17	India	2020	Case report	1	Lap chole	2 months	Discharging umbilical sinus
Ramesh et al.18	India	2003	Case report	8	Lap chole	8 weeks	Discharging sinus
Bhandarkar et al 19	India	2001	Case report	1	Lap appendix	4 weeks	Abscess port site
Chaudhuri et al.20	India	2010	Case series	19	Lap chole	3-4 weeks	Erythematosus tender nodules

Table II: Summary of included studies with reference to the causative organism isolation, histology, and management.

Reference	Growth in culture	Diagnostic tests	Treatment
Chaudhary et al.3	2 AFB positive cases, 1 NTM, 2 MRSA, 2 CONS, 5 negative	Necrotising granulomatous inflammation in 4 cases, chronic inflammation in 6 cases.	Tracts were surgically excised in all; 7 patients were treated with oral clarithromycin and ciprofloxacin for 3 months. Two were treated with oral linezolid and clavulanate, 1 patient received ATT.
Rehman et al.7	Not done	Histopathology of the sinus tracts showed epithelioid granulomatous inflammation with Langhans giant cells	Standard 1st-line ATT leads to resolution of symptoms.
Jagdish et al.8	Routine bacterial cultures were negative. AFB stains, NTM cultures were not done	The tracts were excised surgically. Histopathology showed caseating granulomas with Langhans giant cells	Standard ATT given for 9 months, and the patient recovered.
Ghani et al.9	Routine bacterial cultures were negative. Culture for Mycobacterium tuberculosis not done	Histopathology of the excised tracts showed chronic granulomatous inflammation	Multiple tracts were excised and patients were treated with standard 1st line ATT.
Vijayaraghavan et al.12	All patients were positive for atypical Mycobacterium chelonae	NTM found sensitive to clarithromycin, ciprofloxacin, and amikacin	Tracts were debrided, tissues were sent for histology. Sensitive medicines were continued for 2-18 months
Gosh et al.13	AFB positive in 20 cases, NTM positive 15 cases, Staph. aureus and Pseudomonas in 3 cases	Only sensitivity was checked, no treatment was mentioned	Sensitivity testing showed 93% positivity to clarithromycin and amikacin.
Niyas et al.17	Mycobacterium senegalense	Atypical mycobacterium culture: positive, fluid AFB: positive	Oral levofloxacin, trimethoprim-sulphamethoxazole, clarithromycin for 2 months. No surgical treatment
Ramesh et al.18	Three positive cultures for Mycobacterium tuberculosis. All had biopsy-proven tuberculosis.	The tracts were surgically excised in all cases. Histology showed caseating granulomas with Langhans giant cells.	All patients settled with standard ATT.
Bhandarkar et al.19	Mycobacterium chelonae positive	Not done	The tracts were excised surgically followed by administration of clarithromycin, ciprofloxacin and amikacin for 6 months
Chaudhuri et al.20	Not done	Not done	Oral clarithromycin, ciprofloxacin, and injection amikacin. No surgical excision of sinuses done
AFB: Acid-fast bacilli; ATT: Anti-tubercullosis treatment; NTM: Non-tuberculous mycobacterium.

Figure 1: PRISMA flow diagram of the selection process.

DISCUSSION

Delayed surgical site infections are increasingly known to be caused by atypical or NTM. This is also evident from this review, as NTM was successfully cultured in 52% of total cases of PSI. However, other organisms are also responsible for causing chronic PSI. NTM is known to colonise tap water, natural water, and soil.¹¹ In a study of hospital epidemic involving 35 patients with chronic PSI in India, Vijayaraghavan et al. reported contamination of the hospital water supply by NTM and isolated Mycobacterium chelonae in all cases.¹² They also reported that biofilms formed on disinfecting trays of laparoscopic instruments and under the outer sleeves of laparoscopic ports were contaminated by NTM. Chaudhary et al. in their study of ten cases of chronic PSI, isolated NTM in one case and MRSA in two cases.³ Ghosh et al., in a study of 32 cases of chronic PSI, isolated NTM in 15 cases (Table I).¹³

In poor resource countries, laparoscopic instruments are often reused and disinfected chemically with glutaraldehyde solution.^6-9 Tap water is used in hospitals to rinse and wash the instruments.^14,15 There are more than 150 species of atypical mycobacteria, and many species of NTM, such as Mycobacterium abscessus and chelonae, are resistant to glutaraldehyde.¹⁵ Vijayaraghavan et al. isolated Mycobacterium chelonae in all pus cultures, which is resistant to glutaraldehyde.¹² Robertson et al., in their study in India, reported that the majority of secondary care centers where laparoscopic surgery is performed use glutaraldehyde for sterilisation.¹⁶ They found that the staff involved in sterilisation lacked knowledge and training to properly sterilise the instruments. They also reported that glutaraldehyde concentration testing strips were never used and that the manufacturer’s guidelines were not properly followed. Similar problems are faced during laparoscopic surgery in Pakistan.          

Any patient presenting more than three weeks after laparoscopic surgery with infected laparoscopic port sites, negative routine bacterial cultures, and no response to standard antibiotics should be suspected of having infection with NTM. The minimum time for presentation of chronic PSI in this review was three weeks from the initial surgery. All patients presented with tender nodules at the entry port sites. Infection was not limited to any specific site, and various abdominal ports were involved in equal frequency. The following stages of chronic PSI have been described by many clinicians and are noted in this review as well:^1,3,4,9 The appearance of a tender nodule at the port site, usually three weeks after surgery; increase in size and tenderness, eventually leading to discharge of frank pus either surgically or spontaneous rupture of nodule; partial resolution of symptoms, however, some serous fluid discharges daily; progression to a chronic course with persistent pus or serous discharge along with tenderness at the port site; and development of tender nodules in the vicinity of the initial entry port site.

Initially, it was assumed that NTM infection only occurs in immunocompromised individuals; however, in this review, it was found that more than 92% chronic PSI infections occurred in otherwise healthy individuals with no comorbid symptoms. A study conducted by Vijayaragha et al. in India on 35 cases of chronic PSI demonstrated that 29 patients were otherwise healthy adults, and only six patients had chronic illness.¹² Ghosh et al. reported noted no co-morbidities in their study on 32 cases of chronic PSI, and all patients were otherwise healthy.¹³

The diagnosis of NTM is difficult, and consultation with an infectiologist is advisable.^3,5 Diagnosis depends upon typical clinical presentation, culture isolation of the organism, and histopathological findings of chronic granulomatous inflammation in excised tracts. It is not possible to distinguish tuberculosis from NTM based on acid-fast bacilli (AFB) stain alone.⁵ Ghosh et al. isolated NTM in 15 cases. These NTM-positive cases were also positive for AFB staining by Ziehl-Neelsen (ZN) stain.¹³ The isolation of atypical mycobacteria needs culture on specialised media and prolonged incubation for organisms to grow. Specimens should be inoculated in liquid (Mycobacteria growth indicator tube [MGIT]) and/or solid media (Middlebrook 7H10 or 7H11 agar, or Lowenstein-Jensen [L-J] agar) and incubated for a variable period to allow isolation of these organisms.⁵ Niyas et al. isolated Mycobacterium senegalense in a patient with chronic PSI by matrix‑assisted laser desorption–ionisation time‑of‑flight (MALDI‑TOF) technique.¹⁷ Successful isolation of NTM is reported in 52% of cases of chronic PSI.^17-19 The facilities of Mycobacterial cultures are not widely available. Chaudhari et al. could not isolate the organism because of a lack of culture facilities and treated patients empirically.²⁰ In a case report by Ghani et al. from Pakistan, the treating physicians were not able to culture the organism.⁹ The histology of sinuses revealed chronic granulomatous inflammation, with or without necrosis and Langhans giant cells in this review.^3,7,8,10,15 However, it is not possible to differentiate tuberculous from NTM on the basis of histopathology alone, and isolation of the microorganism is necessary.^5,21,22

The antimicrobial agents found to be the most sensitive and effective treatment against NTM, in this review, were the combination of clarithromycin, amikacin, ciprofloxacin, levo-floxacin, trimethoprim, and sulfamethoxazole.^{3,17,18,19,20} A study conducted by Ghosh et al. showed 93% sensitivity of clarithromycin and amikacin against various species of NTM.¹³ These medicines, when used for 3 months after surgical excision or tracts debridement, were found to be most effective. Patients with chronic PSI commonly present with port site abscesses, which often require surgical treatment. Pus should be drained and sent for routine bacterial and NTM cultures. The tracts should be debrided, and tissue should be sent for both histopathology (Table II). Vijayaraghavan et al. treated such patients with tracts debridement combined with culture-guided antimicrobial agents for two to three months.¹² Tracts may need to be surgically excised, with wounds left open to heal by secondary intention, if debridement fails, and the patient has a prolonged history of port-site discharge. Although, tract excision and leaving the wound open carry significant morbidity for the patient. Chaudhary et al., in their study of 10 cases of chronic PSI, excised all the tracts and left the wounds open to heal by secondary intention.³ They treated seven patients with the combination of clarithromycin and ciprofloxacin for three months, and linezolid was prescribed against MRSA and pseudomonas. Tracts excision, followed by antimicrobial therapy, was also successful in individual case reports.^6-9,19

Chaudhari et al. treated 19 cases of chronic PSI with oral clarithromycin, ciprofloxacin, and amikacin injections. No surgical treatment of tracts was carried out.²⁰ Niyas also treated the patient with only antimicrobial agents, and no surgical treatment was carried out.¹⁷ If the patient presents early in the course of illness, drainage of the abscess and antimicrobial therapy for 2-3 months may lead to complete healing, and surgical treatment may be avoided. First-line ATT is also prescribed to patients with chronic PSI. Ramesh et al. in their study treated eight cases of chronic PSI with standard first line ATT.¹⁸ The diagnosis was based on histology of tissue retrieved from the infected tracts, which showed chronic granulomatous inflammation with caseation and Langhans giant cells. In this review, 12 (11%) cases were given standard first line ATT for nine months after histopathological confirmation of tuberculosis.^3,7,8,9,18 However, in the authors’ opinion, further research and evaluation is warranted, as it is not possible to differentiate tuberculous from NTM on the basis of histology alone.^2-24

Disposable laparoscopic instruments are associated with fewer port site infections compared to reusable instru-ments.²⁵Although reusable laparoscopic instruments are cost-effective,^26,27 the authors recommended the use of disposable laparoscopic instruments, if possible, to avoid and minimise the chances of chronic PSI. If reusable laparoscopic instruments are used, the disinfecting agent should be applied in accordance with the manufacturer’s guidelines.^16,28,29 Sterilised water or saline solution should be used to wash instruments, and tap water should be avoided. The laparoscopic instruments and trays should be thoroughly washed. Frequent cultures should be taken from various sites of the operation theatre, and water samples should also be sent for antimicrobial testing.

CONCLUSION

Chronic PSI is a debilitating, difficult-to-treat morbid condition that develops due to poor sterility of reusable laparoscopic instruments. The cause of infection is usually contaminated tap water used to wash the instruments. NTM is the most common organism. The most sensitive medicines are clarithromycin, amikacin, ciprofloxacin, and the trimethoprim-sulfamethoxazole combination. The most effective management strategies are early suspicion of NTM, debridement or excision of tracts, and administration of sensitive antimicrobial agents for 3-6 months.

COMPETING INTEREST:
The authors declared no conflict of interest.

AUTHORS’ CONTRIBUTION:
MTG: Conceptualisation, study design, literature search, and manuscript writing.
IR: Literature search and data analysis.
NS: Critical review and final approval.
BT: Interpretation of the results, editing, and visualisation.
AK: Formal review, editing, writing, and software.
MAA: Assess the quality of included studies, final approval, and resources.
All authors approved the final version of the manuscript to be published.

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