Use of retrieval bag in the prevention of wound infection in elective laparoscopic cholecystectomy: is it evidence-based? A meta-analysis

Abstract

Background: Surgical site infections complicate elective laparoscopic cholecystectomies in 2,4-3,2% of cases. During the operation the gallbladder is commonly extracted with a retrieval bag. We conducted a meta-analysis to clarify whether its use plays a role in preventing infections.

Methods: Inclusion criteria: elective cholecystectomy, details about the gallbladder extraction and data about local or systemic infection rate.

Exclusion criteria: cholecystitis, jaundice, concurrent antibiotic therapy, immunosuppression, cancer. A comprehensive literature search of PubMed, Cochrane Library and MEDLINE databases was carried out independently by two researchers, according to the PRISMA guidelines and applying the GRADE approach. Terms used were ("gallbladder"AND("speciment"OR"extraction"OR"extract"))OR("gallbladder"OR"cholecystectomy")AND("bag"OR"retrieval|"OR|"endobag"OR"endocatch").

Results: The comprehensive literature revealed 279 articles. The eligible studies were 2 randomized trials and a multicentre prospective study. Wound infections were documented in 14 on 334 (4,2%) patients operated using a retrieval bag versus 16 on 271 (5,9%) patients operated without the use of a retrieval bag. The statistical analysis revealed a risk ratio (RR) of 0.82 (0.41-1.63 95% CI). Concerning sensitivity analysis the estimated pooled RR ranged from 0.72 to 0.96, both not statistically significant. Harbord test did not reveal the occurrence of small-study effect (p = 0.892) and the funnel-plot showed no noteworthy pattern.

Conclusions: The results of this review highlight the paucity of well-designed large studies and despite limitations related to the low level of evidence, our meta-analysis showed no significant benefit of retrieval bags in reducing the infection rate after elective laparoscopic cholecystectomy. In absence of acute cholecystitis, accidental intraoperative gallbladder perforation or suspected carcinoma their use, to date, may not be mandatory, so that, further studies focusing on complex cases are needed.

Keywords: Cholecystectomy; Infection; Retrieval bag.

Fig. 1

Flow chart of the comprehensive literature search according to PRISMA Guidelines

Fig. 2

Risk of bias assessment of included studies

Fig. 3

Forest plot of the statistical analysis described the relative risk (RR), the 95% confidence interval (CI) and the subtotal I-squared for all the studies included. Harling et al. [16], Comajuncosas et al. [17] and Majid et al. [18] studies

Fig. 4

The funnel-plot for publication bias assessment showed no noteworthy pattern. Harling et al. [16], Comajuncosas et al. [17] and Majid et al. [18] studies