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Choice of Approach for Appendicectomy: A Meta-analysis of Open Versus Laparoscopic Appendicectomy
Abstract
Although laparoscopic appendicectomy has been performed since 1983, the optimal approach for appendicectomy is still under debate. A systematic review and meta-analysis of all randomized controlled trials between 1995 and 2006 was undertaken. Studies were analyzed overall and in 2 subgroups (pre-2000 and post-2000) to examine for changes in outcomes with increased laparoscopic experience. Operation time was significantly longer for laparoscopy and hospital stay was shorter. Operating time reduced markedly for laparoscopy on subgroup analysis. The risks of postoperative ileus and wound infection are lower for laparoscopy. Perhaps paradoxically, the risk of intra-abdominal abscess development is significantly raised with laparoscopy with an odds ratio of 2.26 (P=0.0002). Laparoscopic appendicectomy is a safe and effective method of treating acute appendicitis. This meta-analysis shows improvement in the outcomes of laparoscopy with increasing laparoscopic experience but open surgery appears to still confer benefits, especially in terms of intra-abdominal abscess incidence.
... Post-operative ileus was lower in laparoscopic group with 17.3 hr and for open group 30.8 hr. The Similar observation have been observed [12,[16][17][18] . Post-operative wound infection rate was lesser in laparoscopic group with 1(4%) as compared with 5(20%) in open method. ...
... Duration of hospital stay was significant lower for the Laparoscopic group (mean 2.8 days) as compared to the open group (mean 7.7 days) with (P< 0.001). Similar studies has been reported by others [9,12,13,15,16,23,24] . The mean total cost for Laparoscopic appendicectomy is Rs 15308 ± 462.78 when compared to Rs 9840 ± 1187.78 in Open appendicectomy, this shows that LA is the more costlier than Open Appendicectomy. ...
... This difference being Significant (P<0.001). Other Studies has also shown Similar result [8,12,13,15,16,19,24] . ...
... Lack of laparoscopic surgical expertise and relatively high cost have hindered the adoption of laparoscopic approaches especially in developing countries (13). The Aga Khan University Hospital (AKUH) in Karachi, Pakistan introduced laparoscopy in 1990 and the first laparoscopic cholecystectomy was performed in 1992. ...
... Surgical site infection was the most common postoperative complication affecting 4.5% [37] of our patients; this included 19 (2.28%) patients with intra-abdominal abscess. Re-admission rate was 1.6% (13). Only two patients required redo surgery for intra-abdominal collection wash out while rest of patients were managed by drain placement radiologically. ...
... This factor keeps the laparoscopic technique from becoming the standard of care. As the experience of a surgeon increases, the duration of operation decreases (13). Our findings are in synchrony with this argument, since over time the duration of laparoscopic appendectomies performed at our institute has decreased significantly. ...
... 2,5, Most of the studies show that laparoscopic appendicectomy is safe with improved diagnostic accuracy compared to the open method. [26][27][28][29][30][31][32][33][34]35,[36][37] Others however mention the drawbacks of laparoscopy in the background of complicated appendicitis and in presence of intraabdominal adhesions. 23,25,35 Laparoscopic technique, in the hands of experienced laparoscopic surgeons takes no longer than open appendicectomy. ...
... 23,25,35 Laparoscopic technique, in the hands of experienced laparoscopic surgeons takes no longer than open appendicectomy. [6][7][8]10,[25][26][27][28] However, most of the studies have shown that laparoscopic method is more time consuming, though patients enjoy the benefits of a faster postoperative recovery. 5,6,8,9,11,15,18,21,[23][24][25][26][27][28]30,37 Aims and Objectives The present study was undertaken to compare the open and laparoscopic methods of appendicectomy in general surgical practice in terms of operating time and certain postoperative parameters. ...
... [6][7][8]10,[25][26][27][28] However, most of the studies have shown that laparoscopic method is more time consuming, though patients enjoy the benefits of a faster postoperative recovery. 5,6,8,9,11,15,18,21,[23][24][25][26][27][28]30,37 Aims and Objectives The present study was undertaken to compare the open and laparoscopic methods of appendicectomy in general surgical practice in terms of operating time and certain postoperative parameters. These parameters included postoperative pain, wound infection, intraabdominal sepsis, adhesive ileus and intestinal obstruction. ...
... With the introduction of minimally invasive endoscopic surgery, laparoscopic appendicectomy (LA) has become increasingly popular and is claimed to be safe and superior to OA in terms of hospital stay, postoperative pain, wound complications, diagnostic abdominal exploration, return to normal activities and cosmetic result, including demonstrated advantages in obese patients with regards to hospital stay and overall complications. [1][2][3] These findings have been challenged by other authors who observed no significant difference in the outcomes between the two procedures and moreover noted higher costs and longer operative times with LA. 4,5 Although safe, LA is not free of complications or specific adverse events such as intra-abdominal abscesses (IAA). 6 Due to prolonged overall surgery duration, high incidence of postoperative IAA and rate of conversion to OA, there is doubt as to the suitability of laparoscopy in complicated appendicitis, which requires advanced laparoscopic skills. ...
... The findings for overall complications reported in the literature are variable with some studies, like ours, showing no difference in overall postoperative complications, 1,7,8,16,20 and others showing significantly lower complications for LA. 4,5,18,21 With regards to the incidence of wound infections, although variations in definition exist, most of the recent studies concur that the incidence is significantly reduced with LA. 1,2,4,7,14,[17][18][19][20]22 This is in keeping with the results of the present study. The sheathed ports used in laparoscopic surgery and in lesser extend the smaller size of incisions along with the placement of the appendix in a bag, reduces the risk for wound infection. ...
... The sheathed ports used in laparoscopic surgery and in lesser extend the smaller size of incisions along with the placement of the appendix in a bag, reduces the risk for wound infection. A recent Cochrane systematic review, supported by other studies, reported that the incidence of IAA in OA was lower compared to LA. 2,7,8,13,14,22 The lack of laparoscopic experience in treating complicated appendicitis and the inadequacy of abdominal lavage, along possibly with non-inversion of the stump, exposure of the infectious source to the whole intra-abdominal space and dissemination due to pneumoperitoneum are mechanisms that could explain this higher incidence in LA. 2,7 However this was not of concern in the present study as no statistical difference was demonstrated between the two techniques, in agreement with other reports. 4,5,17,19,20 It is likely that meticulous irrigation of the peritoneal cavity laparoscopically, with change of position of the patient and use of copious amount of normal saline, along with the improvement of laparoscopic technique can explain this improvement of outcomes. ...
Background:
Despite multiple studies comparing the two methods, the real advantages of laparoscopic appendicectomy (LA) compared to open appendicectomy (OA) are still unclear. Purpose of the current study was to compare the results between the two techniques in a district general hospital.
Methods:
The electronic records of all patients who underwent OA or LA in a one year period were reviewed retrospectively. The comparative data points assessed included age, gender, overall complications, length of stay and Clavien-Dindo Classification of Surgical Complications, including the rates of the main types of complications.
Results:
300 patients were included in the study. 166 patients underwent OA and 134 patients LA. Postoperative complications were documented in 26 patients (8.7%). LA was employed predominantly in female patients (p = 0.004) and in older patients (p = 0.0015) and was associated with significantly more negative appendicectomies than OA (p = 0.002). No statistically significant difference was noted with regards to the length of hospital stay (p = 0.577), overall postoperative morbidity (p = 0.543) and grading of complications (p = 0.460). Finally, following comparison of the incidence of specific types of complications, only wound infections were significantly different, in favour of LA.
Conclusion:
LA is safe and effective, however, besides the lower incidence of wound sepsis, demonstrates no clear advantage over OA. The selection between OA and LA should thus be tailored to the clinical scenario and the surgeon's preference.
... The operating time was significantly shorter in the laparoscopic group. This is contrary to other studies, [2][3][4] which found significantly higher operating times for laparoscopic appendicectomy. In our study, there was no significant difference in complication rates between open appendicectomy and laparoscopic appendicectomy groups. ...
... Patients in the laparoscopic group were found to have shorter hospital stays by 0.43 days as compared to that of the open surgery group. Other studies [2][3][4] have shown similar shorter stays for the laparoscopic surgery group. Appendicectomy scar by the open technique was found to be perceivably worse as compared to the smaller scars of the laparoscopic group in the POSAS scale. ...
... Laparoscopic appendicectomy is safer than open surgery and allows patients a faster postoperative recovery [18][19][20]. Complications such as wound infection and ileus are increased with open surgery [18,20]. Laparoscopy being more expensive and requiring specialized equipment, uninsured, non-white patients, and those presenting to low-volume facilities are less likely to receive it [2-4, 8, 11]. ...
... Laparoscopic appendicectomy is safer than open surgery and allows patients a faster postoperative recovery [18][19][20]. Complications such as wound infection and ileus are increased with open surgery [18,20]. Laparoscopy being more expensive and requiring specialized equipment, uninsured, non-white patients, and those presenting to low-volume facilities are less likely to receive it [2-4, 8, 11]. ...
... After that there were publications which compared LA and OA in obese patients. The differences between these two approaches were greater in the group of obese patients because there is less trauma to the tissue of a thicker abdominal wall, a smaller possibility of wound infection, faster mobilization of patients, and therefore less danger of postoperative ileus and deep vein thrombosis 9,11,13 . ...
Background: Acute appendicitis (AA) is the most common cause of acute abdominal pain in the general population. In the past 30 years, obesity has become twice as common. Emergency surgery services are more often faced with obese patients with acute abdominal pain whose origin is AA. That is why we wanted to compare our results with data from the literature on laparoscopic surgery of obese patients with AA.Materials and methods: This is a retrospective study, which includes the population of obese patients who underwent surgery at our facility during the period from 1.1.2018. to 31.12.2022. Data were taken from our patients’ electronic records. Patients were included in the study who had body mass index (BMI) 30 and more, without any serious comorbidity. Exclusion criteria were: younger than 20 years, previous laparotomy, periappendicular infiltration, unregulated hypertension and diabetes mellitus, and morbidity obesity (BMI 40 and above). We analyzed demographic data, the length of surgery, PH findings of appendicitis, consumption of analgesics, beginning of peristalsis, length of stay and postoperative complications.Results: In the period in question the laparoscopic approach was used in surgery on 190 patients in the treatment of AA. 20 obese patients (10.52%) were included in our study. There were 11 male and 9 female patients, whose average age was 42 years. The duration of the operation was 55 minutes, the most frequent PH finding was phlegmonous inflammation of the appendix in 12 patients. The appearance of peristalsis was on the first postoperative day, consumption of analgesics was two ampullas of metamizole on the day of the operation. The length of stay was 3 days, and there were two abscesses as postoperative complications.Conclusion: The laparoscopic approach has many advantages that are even greater in the obese population in relation to those of normal weight. The operation takes less time, postoperative pain is reduced, recovery after laparoscopic appendectomy is faster, and there are fewer postoperative complications. This approach should be used more often.
... 9 The laparoscopic approach has become increasingly popular over recent years for advantages of shorter hospital stay and reduced risk of infection and ileus. 16 In this case report, a laparoscopic approach without hernia repair was performed. This was because there was no radiographic or intra-operative evidence of bowel herniation, and the hernial defect was quite small in size. ...
The Amyand hernia is a rare type of inguinal hernia where the appendix is located within the hernial sac. It is present in less than 1% of inguinal hernias and in 0.13% of cases, it is associated with complications including acute appendicitis and perforation. This case details an 81-year-old female with recurrent Amyand hernia with perforated appendicitis and a sessile serrated lesion. A literature review was conducted to identify existing cases of the Amyand hernia and neoplasm or recurrent inguinal hernia. Fifteen cases of neoplastic appendix within an Amyand hernia were identified in the literature. All cases found acute appendicitis, three of which were perforated. Histology varied from adenocarcinoma, goblet cell, carcinoid, fibroma, and mucinous cystadenoma. There were nine identified cases of Amyand hernia within a recurrent inguinal hernia. Seven of these cases had acute appendicitis, three of which were perforated, whilst one was gangrenous. All cases performed an appendicectomy, and various open techniques were used for hernia repair with or without mesh. The most interesting finding of the literature review was that Amyand hernia is rarely diagnosed pre-operatively, and that there was a high incidence of appendicitis when in the presence of a neoplastic appendix or a recurrent inguinal hernia. This paper highlights the first reported case of an Amyand hernia with a simultaneous neoplasm and recurrent inguinal hernia, which was managed using a laparoscopic approach without hernia repair.
... As surgical proficiency improves, the operative duration for both groups tends to converge. 14 According to a meta-analysis conducted by Bennet et al, 16 an increase in laparoscopic surgical experience resulted in a notable decrease in the duration discrepancy between laparoscopic and open appendectomies. ...
The worldwide trend of appendectomy is shifting from conventional open to the laparoscopic technique. The study’s objective was to compare laparoscopic and open appendectomy in terms of various operative and postoperative parameters to find the best operative technique. A prospective comparative study was conducted on 142 patients undergoing laparoscopic (n=43) or open appendectomy (n=99) from 1st February 2022 to 30th January 2023 under the Department of Surgery of Kathmandu Medical College Teaching Hospital (KMCTH). In five patients, laparoscopic appendectomy was later converted to open and excluded from the study. The mean operating time for the open appendectomy group was 44.1±13.1 minutes while for the laparoscopic appendectomy group, it was 48.4±14.0 minutes (p=0.047). Visual analogue score taken on 1st, 7th and 30th post-operative day for open and laparoscopic appendectomy were 4.0±2.2 vs 3.6±1.9 (p=0.160); 1.4±1.3 vs 0.6±0.9 (p<0.001) and 0.2±0.5 vs 0.02±0.15 (p=0.107) respectively. The total days of postoperative hospital stay were 1.57±0.96 for open appendectomy and 1.58±1.07 for laparoscopic appendectomy (p=0.843). However, laparoscopic appendectomy group had an earlier return to normal activity (7.30±1.15 days) when compared to the open appendectomy group (8.05±2.42 days) (p=0.023). The laparoscopic appendectomy group also had fewer postoperative complications than the open appendectomy group (18.6% vs 24.2%) (p=0.411). Thus, laparoscopy is a safe and effective method of removal of appendix for acute appendicitis.
... With the introduction of minimally invasive endoscopic surgery, laparoscopic appendectomy, which was first introduced by Kurt Semm, a German gynaecologist in 1981 (10), has become increasingly popular and is claimed to be more safe and superior to open appendectomy in terms of hospital stay, postoperative pain, wound complications, diagnostic abdominal exploration, return to normal activities and cosmetic result (17,18). ...
... rate, and postoperative mortality rate have been noted in laparoscopy patients compared to those who receive open surgery [1,2]. In a systematic review, Chao et al. (2016) indicated that the benefits of laparoscopic surgery experienced in higher-income countries (HICs) could be extended to low-and middle-income countries (LMICs) as well [3]. ...
Background Laparoscopic surgery is rapidly expanding in low-and middle-income countries (LMICs), yet many surgeons in LMICs have limited formal training in laparoscopy. In 2017, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) implemented Global Laparoscopic Advancement Program (GLAP), an in-person simulation-based lapa-roscopic training curriculum for surgeons in LMICs. In light of COVID-19, SAGES adapted GLAP to a virtual format with telesimulation. This study explores the feasibility and efficacy of virtual laparoscopic simulation training in resource-limited settings. Methods Participants from San Jose, Costa Rica, Leon, México, and Guadalajara, México enrolled in the virtual GLAP curriculum, meeting biweekly for 2-h didactic classes and 2-h hands-on live simulation practice. Surgical residents' lapa-roscopic skills were evaluated using the five Fundamentals of Laparoscopic Surgery (FLS) tasks during the initial and final weeks of the program. Participants also completed pre-and post-program surveys assessing their perception of simulation-based training. Results The study cohort consisted of 16 surgical attendings and 20 general surgery residents. A minimum 70% response rate was recorded across all surveys in the study. By the end of GLAP, residents completed all five tasks of the FLS exam within less time relative to their performance at the beginning of the training program (p < 0.05). Respondents (100%) reported that the program was a good use of their time and that education via telesimulation was easily reproduced. Participants indicated that the practice sessions, guidance, and feedback offered by mentors were their favorite elements of the training. Conclusion A virtual simulation-based curriculum can be an effective strategy for laparoscopic skills training. Participants demonstrated an improvement in laparoscopic skills, and they appreciated the mentorship and opportunity to practice laparoscopic skills. Future programs can expand on using a virtual platform as a low-cost, effective strategy for providing laparoscopic skills training to surgeons in LMICs. Keywords Telementoring · Simulation-based learning · Low-and middle-income countries · Global surgery · Laparoscopic surgery · Teleproctoring Laparoscopic surgery is a favorable alternative to open procedures due to its association with fewer complications and decreased utilization of healthcare resources. Most notably, reduced mean hospital length of stay, low wound infection and Other Interventional Techniques
... Our data show a further increase in laparoscopic appendectomies over the observation period to 95% in 2017. This change from the open to the laparoscopic surgery is also described in the literature [45][46][47][48][49][50][51][52][53][54][55][56][57][58]. On the other hand, the conversion rate for open surgery was statistically constant and ranged only from 2.5 to 4.7%. ...
Background:
Acute appendicitis is one of the most common emergencies in general surgery. The gold standard treatment is surgery. Complications may occur during or after an appendectomy. In addition to age, clinically important factors for the outcome after appendicitis seems to be the comorbidities and the stage of the appendicitis at the time of the operation. Large observational data describing these facts are missing.
Methods:
In this retrospective multicenter observational study, all inpatients over the age of 17 years with a diagnosis of acute appendicitis in 47 hospitals of the Clinotel Hospital Group between 2010 and 2017 were included.
Results:
A total of 19,749 patients with acute appendicitis were operated on. The number of patients with more than five secondary diagnoses has increased from 8.4% (2010) to 14.5% (2017). The number of secondary diagnoses correlates with the ages of the patients and leads to a significantly longer hospital stay. Computer tomography (CT) has gained in importance in recent years in the diagnosis of acute appendicitis. A total of 19.9% of patients received a CT in 2017. Laparoscopic appendectomy increased from 88% in 2010 to 95% in 2017 (p < 0.001). The conversion rate did not change relevant in the study period (i.e., 2.3% in 2017). Appendicitis with perforation, abscess, or generalized peritonitis was observed in 24.8% of patients. Mortality was 0.6% during the observation period and was associated with age and the number of secondary diagnoses. The analysis is based on administrative data collected primarily for billing purposes, subject to the usual limitations of such data. This includes partially incomplete clinical data.
Conclusions:
Multimorbidity is increasingly present in patients with acute appendicitis. Mortality is still in an acceptably low range with no increase. A CT scan is necessary for a precise diagnosis in unclear clinical situations to avoid unnecessary operations and was performed more often at the end of the study than at the beginning.
... rate, and postoperative mortality rate have been noted in laparoscopy patients compared to those who receive open surgery [1,2]. In a systematic review, Chao et al. (2016) indicated that the benefits of laparoscopic surgery experienced in higher-income countries (HICs) could be extended to low-and middle-income countries (LMICs) as well [3]. ...
Background
Laparoscopic surgery is rapidly expanding in low-and middle-income countries (LMICs), yet many surgeons in LMICs have limited formal training in laparoscopy. In 2017, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) implemented Global Laparoscopic Advancement Program (GLAP), an in-person simulation-based laparoscopic training curriculum for surgeons in LMICs. In light of COVID-19, SAGES adapted GLAP to a virtual format with telesimulation. This study explores the feasibility and efficacy of virtual laparoscopic simulation training in resource-limited settings.
Methods
Participants from San Jose, Costa Rica, Leon, México, and Guadalajara, México enrolled in the virtual GLAP curriculum, meeting biweekly for 2-h didactic classes and 2-h hands-on live simulation practice. Surgical residents’ laparoscopic skills were evaluated using the five Fundamentals of Laparoscopic Surgery (FLS) tasks during the initial and final weeks of the program. Participants also completed pre-and post-program surveys assessing their perception of simulation-based training.
Results
The study cohort consisted of 16 surgical attendings and 20 general surgery residents. A minimum 70% response rate was recorded across all surveys in the study. By the end of GLAP, residents completed all five tasks of the FLS exam within less time relative to their performance at the beginning of the training program (p < 0.05). Respondents (100%) reported that the program was a good use of their time and that education via telesimulation was easily reproduced. Participants indicated that the practice sessions, guidance, and feedback offered by mentors were their favorite elements of the training.
Conclusion
A virtual simulation-based curriculum can be an effective strategy for laparoscopic skills training. Participants demonstrated an improvement in laparoscopic skills, and they appreciated the mentorship and opportunity to practice laparoscopic skills. Future programs can expand on using a virtual platform as a low-cost, effective strategy for providing laparoscopic skills training to surgeons in LMICs.
... 13 In our opinion, the appendectomy procedure described in the present study has both the accessibility of open appendectomy and the advantages of conventional laparoscopic appendectomy, with less expenses. The two most important complications after appendectomy for severe appendicitis are intra-abdominal abscess formation and surgical site infection, [20][21][22] and the incidences of these complications have been evaluated in various settings. Taguchi et al. reported a wound infection rate of 19% for conventional multiport laparoscopic appendectomy for complicated appendicitis, 16 while Ohno et al. reported a wound infection rate of 7.5% for transumbilical appendectomy for acute, phlegmonous, and perforated appendicitis. ...
Objectives:
We evaluated the clinical outcomes of transumbilical single-incision laparoscopic appendectomy with extracorporeal hand-sewn stump closure in adults.
Methods:
One-hundred-and-thirty-one consecutive adults with acute appendicitis were treated with the intention of performing transumbilical single-incision laparoscopic appendectomy with extracorporeal hand-sewn stump closure from July 2012 to December 2017. The procedure completion rate and outcomes were examined. To evaluate the risk factors for conversion, the background data were compared between the patients in whom the procedure was completed versus those in whom the procedure was uncompleted.
Results:
The procedure was completed in 113 of 131 patients (86.3%). Single-site surgery was completed in 117 patients (89.3%). The median operation time was 79 (range 30-270) minutes and median intraoperative blood loss was 10 (range 0-394) ml. Postoperative complications occurred in 17 patients (13.0%). Postoperative hospital stay was 6 (range 1-27) days. The 18 patients in whom the procedure could not be completed comprised four patients in whom the stapler was used for intraabdominal stump closure, and 14 patients who were converted to multiport laparoscopic surgery or open surgery. Multivariate analysis showed that the independent risk factors for conversion were age, preoperative abscess, and peri-appendiceal fat density. Receiver operating characteristic curve analysis showed that the cutoff value of peri-appendiceal fat density for conversion was -40.51 Hounsfield units.
Conclusions:
Transumbilical single-incision laparoscopic appendectomy with extracorporeal hand-sewn stump closure was safe in adults with acute appendicitis. The risk factors for conversion were age ≥60 years, preoperative abscess, and peri-appendiceal fat density ≥-40.51 Hounsfield units.
... This observation confers a significant advantage to the laparoscopic approach. [11,12] As a result, the need for postoperative analgesia is less in the laparoscopic approach than in an open approach. Smaller incisions in punctures and minimal dissection with precise instruments significantly reduce the severity of pain. ...
Background: Appendicectomy is one of the common procedures performed by a general surgeon. However,
the advent of laparoscopic appendicectomy has reduced the number of open appendicectomies performed. Therefore
there is a need to study the advantages of the laparoscopic approach over the traditional open approach. Aims: The
study aimed to compare laparoscopic appendicectomy with open appendicectomy based on various intraoperative and
postoperative parameters Materials and methods: 50 patients undergoing interval appendicectomy were randomised
into two groups. Group A comprised 25 patients who underwent laparoscopic appendicectomy and group B comprised
25 patients who underwent open appendicectomy. Results: Confirmation of diagnosis and evaluation of intraoperative
findings was easier in group A patients. In addition, early commencement of feeds with early bowel movements, reduced
need for postoperative analgesia due to less pain, lesser complications and shorter duration of hospital stay was observed
in group A patients. Conclusion: Laparoscopic appendicectomy has better outcomes rendering it a preferable procedure
for appendicectomy.
... 1 Laparoscopy is the current standard of care owing to improved outcomes such as fewer wound infections, less intraoperative or post-operative analgesia, shorter hospital stays, and earlier return to normal bowel function compared to open appendectomy. [2][3][4][5] Laparoscopic appendectomy (LA) offers such advantages even for morbidly obese 6,7 and elderly patients, 8 for whom surgery is typically more challenging. However, LA is still associated with intense pain, especially immediately post-operatively. ...
Background
Laparoscopic appendectomy is standard of care for appendicitis in the US. Pain control that limits opioids is an important area of research given the opioid epidemic. This study examined post-appendectomy inpatient opioid use and pain scores following intraoperative use of liposomal bupivacaine (LB) versus non-liposomal bupivacaine.
Methods
This was a retrospective cohort study of 155 adults who underwent laparoscopic appendectomy for acute appendicitis. Patients were divided into four cohorts based on the analgesia administered: (i) bupivacaine hydrochloride (BH)± epinephrine; (ii) undiluted LB; (iii) LB diluted with normal saline; and (iv) LB diluted with BH.
Results
Baseline demographic/clinical attributes, intra-operative findings, and post-operative pain scores were equivalent across cohorts. Post-operative pre-discharge opioid use was higher in the BH vs. LB cohorts (mean 60.4 vs. 46.0, 35.5, and 30.4 morphine milligram equivalents, respectively; p < 0.001).
Conclusions
Pre-emptive analgesia with LB during laparoscopic appendectomy can reduce inpatient opioid use without significantly increasing post-operative pain scores.
... Optimal techniques to reduce superficial (surgical site infection; SSI) and deep space (intraabdominal abscess; IAA) perioperative infection associated with appendectomy are an ongoing topic of debate. Meta-analyses suggest that although LA decreases the risk of SSI, the approach may lead to increased incidence of IAA (compared to open appendectomy) [44,45], whereas an international, multicenter retrospective review found that IAA rate was lower in patients with complicated appendicitis who were treated with LA [46]. Laparoscopic specimen retrieval bags have been explored as a means to decrease the rate of perioperative infection during LA. ...
Introduction
Appendectomy is a common emergency surgery performed globally. Despite the frequency of laparoscopic appendectomy (LA), consensus does not exist on the best way to perform each procedural step. We identified literature on key intraoperative steps to inform best technical practice during LA.
Methods
Research questions were framed using the population, indication, comparison, outcome (PICO) format for 6 key operative steps of laparoscopic appendectomy: abdominal entry, placement of laparoscopic ports, division of mesoappendix, division of appendix, removal of appendix, and fascial closure. These questions were used to build literature queries in PubMed, EMBASE, and the Cochrane Library databases. Evidence quality and certainty was assessed using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) definitions.
Results
Recommendations were rendered for 6 PICO questions based on 28 full length articles. Low quality evidence favors direct trocar insertion for abdominal entry and establishment of pneumoperitoneum. Single port appendectomy results in improved cosmesis with unclear clinical implications. There was insufficient data to determine the optimal method of appendiceal stump closure, but use of a specimen extraction bag reduces rates of superficial surgical site infection and intra-abdominal abscess. Port sites made with radially dilating trocars are less likely to necessitate closure and are less likely to result in port site hernia. When port sites are closed, a closure device should be used.
Conclusion
Key operative steps of laparoscopic appendectomy have sufficient data to encourage standardized practice.
... 217 Along with pharmacologic measures, it should be emphasized that, in otherwise routine laparotomy or laparoscopy, gentle handling of tissues, meticulous attention to hemostasis, and applications of sound principles of wound management are likely to have the greatest impact on optimizing recovery from ileus and minimizing the incidence of prolonged ileus. Efforts to reduce incision size and time spent handling the intestines through the use of laparoscopic approaches clearly improves recovery from ileus in some if not all patients undergoing standardized intra-abdominal procedures such as appendectomy, 218 and colectomy. 219 Even in open procedures, 220 standardization of management and effective communication help expedite clinical fast-track pathways and facilitate earlier recovery of bowel function and discharge from hospital. ...
Discussion of the various causes of obstruction, pathophysiology, diagnosis and treatment.
... Sin embargo, los extremos de la vida no quedan exentos de esta patología, observándose mayor tasa de complicaciones derivadas del diagnóstico tardío. [1][2][3][4] Incluso con un examen clínico completo, la AA puede ser difícil de diagnosticar. Su mortalidad global es del 0.3-11% y está relacionada directamente con el tiempo de evolución del cuadr o y las comorbilidades presentes durante el evento agudo. ...
Introducción:
La apendicitis aguda representa una de las urgencias quirúrgicas más comunes durante la práctica quirúrgica diaria. La decisión de realizar una cirugía abierta versus laparoscópica sigue dependiendo de los recursos y entrenamiento del cirujano.
Objetivo:
El objetivo general del presente trabajo es comparar el tratamiento quirúrgico, tanto laparoscópico como abierto, de la apendicitis aguda en una serie de casos, analizando las complicaciones más comunes y costos que se generan para el paciente.
Material y métodos:
Realizamos un estudio observacional retrospectivo con todos los casos operados por apendicitis aguda en un periodo de 23 meses. Llevamos a cabo un análisis tomando como variables la demografía, hallazgos transoperatorios, días de estancia intrahospitalaria, complicaciones postquirúrgicas, estancia en la unidad de terapia intensiva y costos totales.
Resultados:
En una población total de 713 pacientes, se realizó apendicectomía laparoscópica a 647 (90.74%) y apendicectomía por abordaje abierto a 66; ocho (1.24%) y cuatro (6.06%) pacientes, respectivamente, presentaron alguna complicación postoperatoria durante su tratamiento, lo que generó un incremento considerable en los costos, así como en el promedio de días de estancia intrahospitalaria.
Conclusiones:
El tratamiento laparoscópico de la apendicitis aguda ofrece beneficios, como menor tiempo de estancia intrahospitalaria y menor porcentaje de complicaciones. A diferencia de la cirugía abierta, los abscesos residuales postoperatorios a la cirugía laparoscópica no requirieron reintervención y no hubo casos con dehiscencia de la herida. A pesar de ser más costosa, en promedio, la cirugía laparoscópica ofrece dentro de sus beneficios menos complicaciones, y sus costos, al ser comparados con los generados por la cirugía abierta, son menores.
... 8 As surgical experience with laparoscopic appendicectomy has increased over time, overall operative time has reduced. 9 For these reasons, it is not entirely surprising that the vast majority of registrars completing our survey would opt to perform an appendicectomy laparoscopically. While there were differences in practice reported, there were also areas of uniformity irrespective of subspecialty or seniority. ...
Introduction:
Appendicectomy remains one of the most commonly performed procedures in general surgery. The aim of this study was to explore variation in operative techniques of an appendicectomy among surgical registrars in England.
Materials and methods:
An anonymised survey was sent out to surgical registrars in the UK via email and social media. Subgroup analyses were performed comparing respondents based on their level of seniority and subspecialty background.
Results:
A total of 168 respondents completed the survey, of whom 77.4% (130/168) were specialty trainees years 3-8 and 44.6% (75/168) were colorectal trainees. The majority (98.8%) preferred a laparoscopic approach to appendicectomy. Overall, 73.2% opted to use diathermy to divide an uninflamed mesoappendix. Half of respondents (50%) preferentially used diathermy to control the appendicular artery, followed by 44% preferring use of metal or polymeric clips. The appendicular stump was most often secured with Endoloops (85.7%) when removing a macroscopically uninflamed appendix but less readily used in the visibly inflamed appendix (75.6%, p = 0.01). Colorectal and upper gastrointestinal registrars were more likely to use diathermy on the mucosa of the appendix stump compared with other subspecialties (p = 0.03). The majority (82.1%) of respondents extracted the appendix via a retrieval bag. Regarding skin closure, most respondents (69%) adopted absorbable subcuticular sutures. Preferential duration of postoperative antibiotic use following appendicectomy for complicated appendicitis varied among the respondents.
Conclusion:
There are similarities and differences across surgical registrars in terms of technical practice in appendicectomy, partially attributed to prior experience and training.
... In another meta-analysis, similarly, LA procedure was reported to result in a higher probability of intra-abdominal abscess while also being superior in terms of wound infections and length of hospital stay. The analysis recommended to avoid LA in perforated and gangrenous appendicitis cases (10). In a double-blind, prospective, randomized study dated 2005 comparing LA and OA, no superiority of one procedure to the other was observed other than a better quality of life at the 2nd week after operation for the LA group (1). ...
Objectives:
The clinical results of obese patients who have undergone open or laparoscopic appendectomy, whether one technique is superior to the other is still not clearly known.In our study, we compared the clinical results of obese patients operated with laparoscopic or open technique for acute appendicitis.
Material and methods:
We performed retrospective analyses of patients operated for acute appendicitis between the dates of July 2016 and July 2019 at Istinye University Faculty of Medicine Bahcesehir Liv Training and Research Hospital and Liv Hospital Ankara. Of the 241 patients whose height and weight information was accessible, 57 had a body mass index of 30 kg/m2 or higher. Eighteen of these patients underwent open surgery while the other 39 underwent laparoscopic surgery. The primary result criterion was complication ratio. Secondary criteria were operation time and length of hospital stay.
Results:
Upon comparison of laparoscopic and open techniques in terms of intraoperative-postoperative complications (p= 0.01), operation time (p= 0.02) statistically significant differences were found between the groups. However the mean length of hospital stay (p= 0.181) was similar in both groups.
Conclusion:
In obese appendicitis patients, the laparoscopic technique proved to be superior to the open technique in criteria such as perioperative-postoperative complications, operation time, and etc. Length of hospital stay was determined to be similar between the groups.
... Laparoscopy seems to have a reduced risk of postoperative small bowel obstruction during the following two postoperative years, but not thereafter [122]. Other studies confirmed that SSI is less common by employing the laparoscopic approach than the open approach [117][118][119][120][121][122][123][124][125][126][127][128][129][130]. ...
Background: Acute appendicitis (AA) is one of the most common causes of abdominal pain requiring surgical intervention. Approximately 20% of AA cases are characterized by complications such as gangrene, abscesses, perforation, or diffuse peritonitis, which increase patients’ morbidity and mortality. Diagnosis of AA can be difficult, and evaluation of clinical signs, laboratory index and imaging should be part of the management of patients with suspicion of AA.
Methods: This consensus statement was written in relation to the most recent evidence for diagnosis and treatment of AA, performing a literature review on the most largely adopted scientific sources. The members of the SPIGC (Italian Polispecialistic Society of Young Surgeons) worked jointly to draft it. The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by the American College of Chest Physicians (CHEST) for the strength of the recommendations.
Results: Fever and migratory pain tend to be present in patients with suspicion of AA. Laboratory and radiological examinations are commonly employed in the clinical practice, but today also scoring systems based on clinical signs and laboratory data have slowly been adopted for diagnostic purpose. The clinical presentation of AA in children, pregnant and elderly patients can be unusual, leading to more difficult and delayed diagnosis. Surgery is the best option in case of complicated AA, whereas it is not mandatory in case of uncomplicated AA. Laparoscopic surgical treatment is feasible and recommended. Postoperative antibiotic treatment is recommended only in patients with complicated AA.
... Because of its higher operative time, increased intra-abdominal abscess risk, and higher costs compared to open, it is not yet considered the "gold standard" in the management of acute appendicitis. [18][19][20][21][22][23] According to literature 2 to 7% of appendicitis tends to present with complex features such as a phlegmon or periappendicular abscess. 23,24 They are treated conservatively followed by interval appendectomy, to reduce the risk of recurrence and risk of missing an underlying malignancy. ...
Background: Traditionally, appendectomy has been the treatment of choice for acute appendicitis but many times diagnosis can be difficult. Clinicians are looking through different ways to come to the correct diagnosis to decrease negative appendectomy. The aim of this study was to determine relation between clinical pattern, laboratory and ultrasonography findings with histopathological report of appendectomy specimen and to evaluate the Alvarado scoring regarding its usefulness in the early diagnosis in our set up. Methods: Prospective cross-sectional study was carried out in Gandaki Medical College Teaching Hospital and Fewa City Hospital from Jan 1, 2016 to Dec 31, 2018 on consecutively admitted patients with clinical diagnosis of acute appendicitis with study variables as demography, Alvarado score, radiological/laboratory investigations, surgical management, histopathology, and clinical outcome. Results: Among 1021 patients (48.8% men, 51.2% women), patients with Alvarado score offive and more (967, 88.8%) had abdominal USG and some (134) with score of 5-6 (13.12%) had CT scan. On the basis which 818patients (151 patients with score 5-6 and 667 with score 7 to 10) underwent emergency appendectomy; 705 (86.19%) by open and 113 (13.81%) by laparoscopic technique. Appendicitis was suggestive per-operatively in 76.2% of patients with Alvarado score of 5-6 and 97.4% of patients with the score of 7-10. Histo-pathologically diagnosis was correct in 752 (91.9%), 91.2% in open appendectomy and 96.5% in laparoscopic appendectomy cases. Only two patients had infective complication and no mortality. Conclusion: Alvarado scoring in patients presenting with acute abdominal pain is reliable predicting tool for acute appendicitis.
... Sin embargo, los extremos de la vida no quedan exentos de esta patología, observándose mayor tasa de complicaciones derivadas del diagnóstico tardío. [1][2][3][4] Incluso con un examen clínico completo, la AA puede ser difícil de diagnosticar. Su mortalidad global es del 0.3-11% y está relacionada directamente con el tiempo de evolución del cuadr o y las comorbilidades presentes durante el evento agudo. ...
RESUMEN Introducción: La apendicitis aguda representa una de las urgencias quirúrgicas más comunes durante la práctica quirúrgica diaria. La decisión de realizar una cirugía abierta versus laparoscópica sigue dependiendo de los recursos y entrenamiento del cirujano. Objetivo: El objetivo general del presente trabajo es comparar el tratamiento quirúrgico, tanto laparoscópico como abierto, de la apendicitis aguda en una serie de casos, analizando las complicaciones más comunes y costos que se generan para el paciente. Material y métodos: Realizamos un estudio observacional retros-pectivo con todos los casos operados por apendicitis aguda en un periodo de 23 meses. Llevamos a cabo un análisis tomando como variables la demografía, hallazgos transope-ratorios, días de estancia intrahospitalaria, complicaciones postquirúrgicas, estancia en la unidad de terapia intensiva y costos totales. Resultados: En una población total de 713 pacientes, se realizó apendicectomía laparoscópica a 647 (90.74%) y apendicectomía por abordaje abierto a 66; ocho (1.24%) y cuatro (6.06%) pacientes, respectivamente, presentaron alguna complicación postoperatoria durante su tratamiento, lo que generó un incremento considerable en los costos, así como en el promedio de días de estancia intrahospitalaria. Conclusiones: El tratamiento laparoscópico de la apendicitis aguda ofrece benefi cios, como menor tiempo de estancia intrahospitalaria y menor porcentaje de complicaciones. A diferencia de la cirugía abierta, los abscesos residuales postoperatorios a la cirugía laparoscópica no requirieron reintervención y no hubo casos con dehiscencia de la herida. A pesar de ser más costosa, en promedio, la cirugía laparoscópica ofrece dentro de sus benefi cios menos complicaciones, y sus costos, al ser comparados con los generados por la cirugía abierta, son menores. ABSTRACT Introduction: Acute appendicitis represents one of the most common surgical emergencies during daily surgical practice. The decision to perform open versus laparoscopic surgery continues to depend on the resources and training of the surgeon. Objective: The general objective of this study is to compare the surgical treatment of acute appendicitis, both laparoscopic and open, in a series of cases, analyzing the most common complications and costs generated for the patient. Material and methods: We conducted an observational, retrospective study with all cases operated for acute appendicitis in a period of 23 months. We performed an analysis taking as variables the demographics, transoperative fi ndings, days of in-hospital stay or any postoperative complications. Results: With a total population of 713 patients, laparoscopic appendectomy was performed on 647 (90.74%) and appendectomy by open approach on 66; eight (1.24%) and four (6.06%) patients, respectively, presented postoperative complications during their treatment, which generated a considerable increase in costs, as well as in the average days of in-hospital stay. Conclusions: Laparoscopic management of acute appendicitis off ers benefi ts such as shorter intrahospital stay and a lower percentage of complications. Unlike open surgery, residual abscesses postoperative to laparoscopic surgery did not require reoperation, and there were no cases with wound dehiscence. Although laparoscopic surgery is more expensive on average, it off ers less serious complications and its costs, when compared to those generated by open surgery, are lower.
... However, it is not yet unanimously considered the "gold standard" in the management of AA because of its higher operative time, increased intra-abdominal abscess risk, and higher costs compared to open appendectomy. Several meta-analyses of prospective randomized trials were performed in an attempt to define the role of laparoscopic appendectomy [20][21][22][23][24][25]. Literature reports that 2 to 7% of appendicitis tend to present with complex features such as a phlegmon or peri-appendicular abscess [26,27]. ...
BACKGROUND:
Acute appendicitis (AA) is the most common surgical disease, and appendectomy is the treatment of choice in the majority of cases. A correct diagnosis is key for decreasing the negative appendectomy rate. The management can become difficult in case of complicated appendicitis. The aim of this study is to describe the worldwide clinical and diagnostic work-up and management of AA in surgical departments.
METHODS:
This prospective multicenter observational study was performed in 116 worldwide surgical departments from 44 countries over a 6-month period (April 1, 2016-September 30, 2016). All consecutive patients admitted to surgical departments with a clinical diagnosis of AA were included in the study.
RESULTS:
A total of 4282 patients were enrolled in the POSAW study, 1928 (45%) women and 2354 (55%) men, with a median age of 29 years. Nine hundred and seven (21.2%) patients underwent an abdominal CT scan, 1856 (43.3%) patients an US, and 285 (6.7%) patients both CT scan and US. A total of 4097 (95.7%) patients underwent surgery; 1809 (42.2%) underwent open appendectomy and 2215 (51.7%) had laparoscopic appendectomy. One hundred eighty-five (4.3%) patients were managed conservatively. Major complications occurred in 199 patients (4.6%). The overall mortality rate was 0.28%.
CONCLUSIONS:
The results of the present study confirm the clinical value of imaging techniques and prognostic scores. Appendectomy remains the most effective treatment of acute appendicitis. Mortality rate is low.
... Previous studies showed increased incidence of intraabdominal abscess formation after LA in perforated appendicitis and this is mainly due to spread of infected intaabdominal fluid with gas insufflations. 2,6,17,18 But in contrast, other studies concluded that LA is safer 20 or equivalent 4,9,19,20,22 to OA regarding the intraabdominal abscess formation. In our study, the incidence of postoperative abscess formation was much more common in the OA; it was 2.5% in LA and 14.6% in OA (p < 0.05). ...
Aim: To evaluate the outcome of laparoscopic (LA) open appendectomy (OA) in children with perforated appendicitis. Materials and methods: Retrospective review was conducted from January 2013 to October 2016 evaluating 81 patients with perforated appendicitis based on surgical approach. We compared demographics, mean operative time, length of stay, infectious complications, and follow-up in patients with OA (n = 37) and LA (n = 44). Results: Compared with OA, LA resulted in a lower rate of wound infection (4.5 8.1.5%; p < 0.05). The occurrence of the intraabdominal abscess was significantly lower in the LA group (0 5.4%; p < 0.05). There was a significant difference in the duration of operation between the two groups; it was 61.6 ± 20.3 minutes in OA, compared with the LA group (51.6 ± 28.6 minutes) (p < 0.05). Conclusion: We conclude that LA provides better postoperative course, less postoperative pain, and less postoperative complications. © 2018, Jaypee Brothers Medical Publishers (P) Ltd. All rights reserved.
... reduced incidence of postoperative ileus, shorter length of hospital stay (LOS), and earlier return to regular activity [7][8][9]. Thus, for patients with simple, uncomplicated AA, several meta-analyses have shown that LA is the procedure of choice [9][10][11][12][13][14]. ...
Background
Acute appendicitis is a common condition in the pediatric population. In patients with uncomplicated appendicitis, laparoscopic appendectomy (LA) is preferred as compared to open appendectomy (OA). However, in patients with complicated appendicitis (CA), as defined as suppurative, gangrenous or perforated appendicitis, or appendicitis with periappendicular abscess formation, the decision to perform OA or LA remains unclear.
Methods
The PRISMA guidelines were adhered to. An electronic database search from 1997 to 2017 was performed using the Cochrane, Medline, PubMed, Scopus, Ovid, Embase, and Web of Knowledge databases. Data analysis, including subgroup analysis of randomized-control trials, was performed using RevMan 5.3. Assessment of methodological and statistical heterogeneity, as well as publication bias of the included studies, was performed.
Results
Six randomized-control trials (296 LA versus 373 OA) and 33 case–control trials (3106 LA versus 4149 OA) were analyzed. Compared to OA, LA has a shorter length of stay (WMD = − 0.96, 95% CI − 1.47 to − 0.45) and a lower rate of surgical site infection (OR 0.37, 95% CI 0.25–0.54), although the rates of intraabdominal abscess formation were similar (OR 1.01, 95% CI 0.71–1.43). LA was also shown to have lower readmission rates, lower incidences of postoperative ileus or intestinal obstruction, lower incidence of reoperation, as well as a shorter time taken to oral intake. Operative time for OA was shorter than LA (WMD = 12.44, 95% CI 2.00–22.87).
Conclusion
While studies in the past have associated LA with higher rates of intraabdominal abscess in patients with CA, our meta-analysis has shown that they were similar. Considering this, together with other improved postoperative outcomes, LA should be the procedure of choice in pediatric patients presenting with CA.
... Previous studies showed increased incidence of intraabdominal abscess formation after LA in perforated appendicitis and this is mainly due to spread of infected intaabdominal fluid with gas insufflations. 2,6,17,18 But in contrast, other studies concluded that LA is safer 20 or equivalent 4,9,19,20,22 to OA regarding the intraabdominal abscess formation. In our study, the incidence of postoperative abscess formation was much more common in the OA; it was 2.5% in LA and 14.6% in OA (p < 0.05). ...
... Appendectomy is considered the most common procedure done regarding GIT surgery [1]. Laparoscopic appendectomy is getting popular as it is more cosmetic and patients recover earlier compared to open technique [2]. One of the limitations of laparoscopy is the relative high cost which is linked to the usage of multiple disposable stuff that adds to the cost and may be not widely available. ...
Introduction: Appendectomy is considered the most common GIT surgery. Laparoscopic appendectomy (LA) is getting popular as it is less invasive with earlier patient recovery compared to open technique. Aim: The aim of this study is to evaluate different modalities used to secure the base of the appendix during laparoscopic appendectomy for obstructed appendicitis. Patient and methods: In this study, ninety patients with obstructed appendicitis and unhealthy appendicular base were included. Patients were randomized into three groups according to the method of appendicular stump ligation; Extracorporeal knotting group (30 patients), Endoloop group (30 patients) and titanium Clips group (30 patients). Results: Although there was no leakage in all groups; the operation time was significantly higher in the first (hand-made loop) group (p value = 0.00). Morbidity rates were comparable in all groups with no significant difference (p value = 0.914. Rates were 16.7, 13.3 and 13.3 in first, second and third groups respectively), further analysis revealed that theses complications were related to comorbid medical conditions. Conclusion: Stump closure with extracorporeal knot, endoloop and clips are equal in safety during laparoscopic appendectomy of obstructed appendicitis and choice of the method of stump closure depends up on the surgeon preference and availability of supplies.
... However, it is not yet unanimously considered the "gold standard" in the management of AA because of its higher operative time, increased intra-abdominal abscess risk, and higher costs compared to open appendectomy. Several meta-analyses of prospective randomized trials were performed in an attempt to define the role of laparoscopic appendectomy [20][21][22][23][24][25]. Literature reports that 2 to 7% of appendicitis tend to present with complex features such as a phlegmon or peri-appendicular abscess [26,27]. ...
[Background] Acute appendicitis (AA) is the most common surgical disease, and appendectomy is the treatmentof choice in the majority of cases. A correct diagnosis is key for decreasing the negative appendectomy rate.The management can become difficult in case of complicated appendicitis. The aim of this study is to describethe worldwide clinical and diagnostic work-up and management of AA in surgical departments. [Methods] This prospective multicenter observational study was performed in 116 worldwide surgical departmentsfrom 44 countries over a 6-month period (April 1, 2016–September 30, 2016). All consecutive patients admitted tosurgical departments with a clinical diagnosis of AA were included in the study. [Results] A total of 4282 patients were enrolled in the POSAW study, 1928 (45%) women and 2354 (55%) men, witha median age of 29 years. Nine hundred and seven (21.2%) patients underwent an abdominal CT scan, 1856 (43.3%)patients an US, and 285 (6.7%) patients both CT scan and US. A total of 4097 (95.7%) patients underwent surgery;1809 (42.2%) underwent open appendectomy and 2215 (51.7%) had laparoscopic appendectomy. One hundred eighty-five (4.3%) patients were managed conservatively. Major complications occurred in 199 patients (4.6%). Theoverall mortality rate was 0.28%. [Conclusions] The results of the present study confirm the clinical value of imaging techniques and prognosticscores. Appendectomy remains the most effective treatment of acute appendicitis. Mortality rate is low.
(9) Prospective Observational Study on acute Appendicitis Worldwide (POSAW). Available from: https://www.researchgate.net/publication/324556765_Prospective_Observational_Study_on_acute_Appendicitis_Worldwide_POSAW [accessed Apr 19 2018].
... [2] Because of faster postoperative recovery and reduced postoperative complications, laparoscopic appendectomy is now being more and more widely used for treating acute appendicitis. [14], [15], [16], [17], [18] The key technical aspect in laparoscopic appendectomy is the treatment of appendix stump closure. Nowadays, stapling and endoloop techniques are the most popular ones in securing the appendix stump. ...
... Although some studies show higher intra-abdominal abscess formation in LA, others report no significant difference between LA and OA. [12][13][14][15][16] During the early period of the present study we were inserting double ligature at the base of the appendix to secure the stump. Later on, we started practicing single loop to secure appendix base as there was no difference in post-operative mortality and morbidity between the use of single loop and double loop in LA. 17 As a result operation time was reduced by few minutes. ...
Background: Open appendectomy is one of the most common surgeries done in an emergency operation theatre even after three decades of introduction of laparoscopic surgeries. The previous studies done on laparoscopic appendectomy produced conflicting recommendations, and the adequacy of sample sizes is generally unknown. We compared primary outcomes after laparoscopic and open appendectomy in a sample of predetermined statistical power.Methods: A pre-study power analysis suggested that 200 randomized patients would yield 80% power to show a mean decrease of 1.3 days hospitalization. One hundred ninety-eight patients with a preoperative diagnosis of acute appendicitis were randomized prospectively to laparoscopic or open appendectomy. The primary outcomes measured were duration of operative time, postoperative pain and analgesia, length of hospital stay and cosmetic advantages.Results: It was found that mean operation time was 33±5.8 minute and 37± 7.5 minute in OA and LA respectively. Duration of post-operative hospital stay was 1.2 days shorter in Laparoscopic group. LA required 1.1 shots of less analgesic than OA. Oral feeding was resumed 21 hours earlier following LA compared to OA. Laparoscpic appendectomy was safely performed in paediatric patient without any adverse effect. We also found that, in female patient, concurrent ovarian cysts, tubal pregnancy and endometriosis can be diagnosed and managed laparoscopically in the same sitting.Conclusions: Present study found that laparoscopic appendectomy is an effective and safe procedure irrespective of age and sex of the patient. LA has added advantage of early return of bowel movement, less post-op hospital stays and less requirement of narcotic analgesic.
Background
Access to minimally invasive surgery (MIS) is limited in Sub‐Saharan African countries. In 2019, the Mount Sinai Department of Surgery in New York collaborated with local Ugandans to construct the Kyabirwa Surgical Center (KSC), an independent, replicable, self‐sustaining ambulatory surgical center in Uganda. We developed a focused MIS training program using a combination of in‐person training and supervised telementoring. We present the results of our initial MIS telementoring experience.
Methods
We worked jointly with Ugandan staff to construct the KSC in the rural province of Jinja. A solar‐powered backup battery system ensured continuous power availability. Underground fiber optic cables were installed to provide stable high‐speed Internet. The local Ugandan general surgeon (JOD) underwent a mini‐fellowship in MIS and then trained extensively using the Fundamentals of Laparoscopic Surgery program. After a weeklong in‐person session to train the Ugandan OR team, JOD performed laparoscopic cases with telementoring, which was conducted remotely by surgeons in New York via audiovisual feeds from the KSC OR.
Results
From October 2021 to February 2024, JOD performed 61 telementored laparoscopic operations at KSC including 37 appendectomies and 24 cholecystectomies. Feedback was provided regarding patient positioning, port placement, surgical technique, instrument use, and critical steps of the operation. There were no intra‐operative complications. Postoperatively, field medical workers visited patients at home to collect follow‐up information. Two superficial wound infections (3.3%) were reported in the short‐term follow‐up.
Conclusion
Telementoring can be safely implemented to assist surgeons in previously underserved areas to provide advanced laparoscopic surgical care to the local patient population.
Methods of Teaching Organic Chemistry
Background
Although laparoscopic appendectomy is the criterion-standard treatment method for acute appendicitis, the decision on laparoscopic or conventional technique is usually made according to individual perspectives. The reasons affecting this individual point of view include whether the disease is complicated, the infrastructure of the hospital, the patient's comorbid factors, and previous intra-abdominal operations. This cross-sectional retrospective study aimed to evaluate the safety of laparoscopic appendectomy in patients with a possible diagnosis of “appendicitis” in patients who had undergone previous abdominal surgery.
Methods
Patients who were operated on with the diagnosis of acute appendicitis in our clinic between March 2021 and March 2022 were retrospectively analyzed. Patients were grouped as those with a history of abdominal surgery (group 1) and without (group 2). In addition, demographic data of the patients (age, sex), body mass index, presence of comorbid disease, history of abdominal surgery, operation time, rate of conversion to open surgery, postoperative hospital stay, complications, and radiological and pathological appendix size were recorded.
Results
A total of 181 patients were included in the study. The mean age was 32.51 ± 15.89 years. Seventy (38.7%) of the patients were female, and 111 (61.3%) were male. Thirty-four patients (18.8%) were in group 1, and 111 patients (81.2%) were in group 2. The mean age, body mass index, and operation time in group 1 were statistically higher than in group 2 ( P < 0.001). However, there was no difference between the groups regarding postoperative hospital stay, radiological and pathological appendix size, conversion to open surgery, and presence and severity of complications ( P > 0.05).
Conclusion
In line with the data the authors have shown in their study, a laparoscopic appendectomy can be performed safely in patients who have undergone abdominal surgery. Therefore, surgeons should not stray from a laparoscopic appendectomy when they see an abdominal incision.
Paraoxonase (PON) enzyme family (paraoxonase 1, 2 and 3) has antiatherosclerotic properties. The decreased PON1EA activity, PON1 levels and PON1-L55M polymorphism (PON1P) are risk factors for atherosclerosis (AS). It is known that the effects of aerobic exercises on PON1 level and PON1EA are modified by PON1P, however the effects of anaerobic training and the role of PON1P are unclear. In present study, the effects of anaerobic training on serum PON1 levels, PON1EA and HDL and its subgroups’s paraoxonase activities (HDLPON1EA, HDL2PON1EA, HDL3PON1EA) as well as the role of PON1P were investigated.
The trained male athletes group (handball, basketball, volleyball) (AG: n=36, age=20.56±2.42 years) and the control group (CG: n=39, age=22.26±3.44 years) participated in this study. The PON1 and HDL’s PON1 enzyme activities (by a kinetic methods), the protein levels of PON1 enzyme and oxLDL levels (by ELISA method) and the PON1P (from genomic DNA samples) were determined.
Serum PON1EA and HDLPON1EA enzyme activities of the athletic homozygous LL and M carrier (Mc) groups were not significantly different than sedentary, however the indicated enzyme activities of the athletic LL homozygous group were significantly higher than Mc group (p< 0.05). When the control genotype groups were compared, the control LL (CLL) genotype group had serum PON1EA (38.7%), HDLPON1EA (37.2%), HDL2PON1EA (41.9%) and HDL3PON1EA (33.1%) values of the control Mc (CMc) genotype.
These findings indicate that the genetically higher PON1EA activity of the LL genotype group may have an important role in the beneficial effects of anaerobic exercise training on serum PON1EA as well as HDL and its subgroups PON1 enzyme activities in the LL homozygous group. However the Mc genotype group was genetically negatively effected from anaerobic training, which is risk for AS.
Keywords: Paraoxonase 1, Paraoxonase PON1-L55M polymorphism, Anaerobic training, Atherosclerosis.
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An analysis of modern literature and our own clinical experience suggests that the use of laparoscopic methods in the surgical treatment of acute appendicitis complicated by peritonitis has proven advantages over open surgery. The key to successful treatment of patients is reliable elimination of the source of peritonitis — performing an adequate appendectomy. Early laparoscopic debridement for postoperative peritonitis can be an alternative to non-surgical treatment and delayed intervention. The success of the laparoscopic approach depends not only on technical aspects, but also on the correct determination of indications and contraindications for surgery.
A 27-year-old previously healthy male presented to the emergency room with a 36-h history of periumbilical pain that migrated to his right lower quadrant. He denied nausea or vomiting but had no appetite. He denied fever or chills. Positive clinical findings included right lower quadrant tenderness and right lower quadrant referred pain when palpating his left lower quadrant. Laboratory values were notable for a leukocytosis of 16,000 cells/L and an elevated C-reactive protein of 12 mg/L. An abdominal ultrasound was non-diagnostic, but the computed tomography (CT) scan showed a dilated appendix with periappendiceal fat stranding.
A apendicectomia é uma das cirurgias mais realizadas no mundo, pois ocorre, principalmente, em função de um quadro de apendicite aguda. Por ser uma emergência cirúrgica bastante prevalente, é necessário analisar os dados epidemiológicos como internações, custos, mortalidade e média de estadia hospitalar das formas de realização da mesma: aberta ou laparoscópica, sendo esse o objetivo do trabalho, que utilizou dados da plataforma DATASUS para essa análise. Foram realizadas 30.347 apendicectomias no Rio de Janeiro de agosto de 2016 a julho de 2021, sendo 28.672 cirurgias abertas (94,4%), dentre essas 5.843 urgentes e 236 eletivas, e 1.675 videolaparoscópicas (5,6%), sendo 262 em urgência e 69 programadas. O custo médio de internação foi de R$ 653,47 e R$640,72 nessa mesma ordem. A permanência hospitalar foi de 2,6 dias por vídeo e 3,8 dias para aberta. Ocorreram, 100 óbitos (0,35%) para cirurgia aberta e 3 (0,18%) via laparoscopia. Nos últimos 10 anos, o novo padrão mundial traz a videolaparoscopia como tratamento de escolha, entretanto o Rio de Janeiro ainda não segue essa realidade pela precariedade de infraestrutura e treinamento de cirurgiões. Além disso, tal modalidade por ser menos invasiva diminui as complicações e permanência hospitalar, apesar de apresentar maiores custos. A pandemia do COVID-19 não alterou drasticamente as cirurgias de urgência, uma vez que essa abordagem é fundamental no tratamento de apendicite aguda, diferentemente das cirurgias eletivas. Sendo assim, devido aos benefícios trazidos, deve-se buscar ampliar a realização da videolaparoscopia para retirada do apêndice visando o melhor aos pacientes.
Appendectomy is most common surgical procedure in emergency surgery. Inamed appendix can be removed laparoscopically (laparoscopic appendectomy) or openly (open appendectomy). Surgical site infection is representative of health care associated infection in which it may effect on patients' morbidity and mortality. The aim of the study is to compare laparoscopic appendectomy and open appendectomy in terms of surgical site infection. The frequency of 60 patients who underwent appendectomy open appendectomy-40;laparoscopic appendectomy-20 between September 2019- march2020 which were retrospectively reviewed for demographic and pathological characteristic, recovery of bowel movements, length of hospital stay and post-operative complications. The frequency of purulent/gangrenous or perforated appendix were Laparoscopic appendectomy-10% and in open appendectomy 20%. The time of rst atus after surgery were 2.9 days and in open appendectomy were 2.97 days in laparoscopic appendectomy. Length of hospital stay were relatively short in laparoscopic appendectomy group and in open appendectomy group The frequency of overall surgical site infection were not that difference between the two groups laparoscopic appendectomy -15% open appendectomy group were22%But that of supercial surgical site infection was signicantly lower in laparoscopic appendectomy group5% open appendectomy group 15%.
Acute appendicitis is one of the most common causes for acute abdomen in pediatric populations and appendectomy is the most common surgical procedure performed in pediatric emergency surgery. Also, although there are almost 40 years since the first laparoscopic appendectomy was performed, there is no general consensus regarding the benefits of this procedure, and open appendectomy is still the conventional technique in some pediatric surgery departments. The aim of this study is to retrospectively compare the laparoscopic appendectomy with the open approach, in terms of length of surgery, length of stay and frequency of complications.
Background:
Laparoscopic appendectomy (LA) has been popular for decades because of shorter hospitalisation and return to routine activity. However, complications (e.g. surgical site infection (SSI) and intra-abdominal abscess (IAA)) relative to open appendectomy (OA) are still debated. We therefore conducted an umbrella review to systematically appraise meta-analyses (MA) comparing SSI and IAA between LA and OA.
Methods:
MAs that included only randomised controlled trials (RCTs) were identified from MEDLINE and SCOPUS databases from inception until July 2018. Their findings were described, the number of overlapping studies was assessed using corrected covered area (CCA), and excess significant tests were also assessed. Finally, effect sizes of SSI and IAA were re-pooled.
Results:
Ten MAs were eligible; SSI was reported in all MAs and IAA in 8 MAs. SSI rate was 48% to 70% lower in LA than OA, but conversely IAA rate was 1.34 to 2.20 higher in LA than OA. Overlapping included studies for SSI and IAA were 61% and 54%, respectively, indicating less information was added across MAs. However, there was no evidence of bias from excess significant tests when pooling SSI or IAA estimates. The RRs (95% CI) comparing LA vs OA were re-pooled in adults and children yielding RRs of 0.56 (0.47, 0.67) and 0.40 (0.25, 0.65) for SSI; and 1.20 (0.88, 1.63) and 1.05 (0.61, 1.80) for IAA.
Conclusions:
Evidence from this umbrella review indicates that LA carries a significantly lower risk of SSI but likely a higher risk of IAA than OA.
Level of evidence:
Systematic Review/Meta-analysis, Level I.
Background:
Appendectomy is the most commonly performed emergency operation in the United States, with approximately 370,000 patients undergoing the procedure every year. Although laparoscopic appendectomy is associated with decreased complications when compared with open appendectomy, the risk for infectious complications, including surgical site infection, intra-abdominal abscess, and sepsis, remains a significant source of postoperative morbidity and health care cost. The goal of this study is to determine whether the appendix retrieval technique during laparoscopic appendectomy affects risk of infectious complications.
Methods:
The American College of Surgeons National Surgical Quality Improvement Program database and the Appendectomy Procedure Targeted database were used to conduct this retrospective study. Patients who underwent laparoscopic appendectomy in 2016 were identified. The primary outcomes were infectious complications of superficial site infection and intra-abdominal abscess.
Results:
A total of 10,578 (92.2%) patients underwent laparoscopic appendectomy using an appendix retrieval bag and 897 (7.8%) patients underwent laparoscopic appendectomy without an appendix retrieval bag. There was no significant difference in preoperative sepsis, smoking status, wound class, complicated appendicitis, or American Society of Anesthesiologists class between patient groups (all P > .05). In the univariate analysis, there was no difference in the rate of superficial site infection (0.9% vs 0.6%, P = .28) or intra-abdominal infection (2.7% vs 3.8%, P = .06) between retrieval bag use and non-use. In the multivariable analysis, appendix retrieval bag use was an independent predictor of intra-abdominal infection and associated with a 40% decrease in intra-abdominal infection rates (odds ratio: 0.6, 95% confidence interval: 0.42-0.95, P = .03).
Conclusion:
Appendix retrieval bags are associated with a decreased risk of postoperative intra-abdominal abscess. The use of appendix retrieval bags should be the standard of care during laparoscopic appendectomy.
Background:
The removal of the acute appendix is one of the most frequently performed surgical procedures. Open surgery associated with therapeutic efficacy has been the treatment of choice for acute appendicitis. However, in consequence of the evolution of endoscopic surgery, the operation can also be performed with minimally invasive surgery. Due to smaller incisions, the laparoscopic approach may be associated with reduced postoperative pain, reduced wound infection rate, and shorter time until return to normal activity.This is an update of the review published in 2010.
Objectives:
To compare the effects of laparoscopic appendectomy (LA) and open appendectomy (OA) with regard to benefits and harms.
Search methods:
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE and Embase (9 February 2018). We identified proposed and ongoing studies from World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov and EU Clinical Trials Register (9 February 2018). We handsearched reference lists of identified studies and the congress proceedings of endoscopic surgical societies.
Selection criteria:
We included randomised controlled trials (RCTs) comparing LA versus OA in adults or children.
Data collection and analysis:
Two review authors independently selected studies, assessed the risk of bias, and extracted data. We performed the meta-analyses using Review Manager 5. We calculated the Peto odds ratio (OR) for very rare outcomes, and the mean difference (MD) for continuous outcomes (or standardised mean differences (SMD) if researchers used different scales such as quality of life) with 95% confidence intervals (CI). We used GRADE to rate the quality of the evidence.
Main results:
We identified 85 studies involving 9765 participants. Seventy-five trials included 8520 adults and 10 trials included 1245 children. Most studies had risk of bias issues, with attrition bias being the largest source across studies due to incomplete outcome data.In adults, pain intensity on day one was reduced by 0.75 cm on a 10 cm VAS after LA (MD -0.75, 95% CI -1.04 to -0.45; 20 RCTs; 2421 participants; low-quality evidence). Wound infections were less likely after LA (Peto OR 0.42, 95% CI 0.35 to 0.51; 63 RCTs; 7612 participants; moderate-quality evidence), but the incidence of intra-abdominal abscesses was increased following LA (Peto OR 1.65, 95% CI 1.12 to 2.43; 53 RCTs; 6677 participants; moderate-quality evidence).The length of hospital stay was shortened by one day after LA (MD -0.96, 95% CI -1.23 to -0.70; 46 RCTs; 5127 participant; low-quality evidence). The time until return to normal activity occurred five days earlier after LA than after OA (MD -4.97, 95% CI -6.77 to -3.16; 17 RCTs; 1653 participants; low-quality evidence). Two studies showed better quality of life scores following LA, but used different scales, and therefore no pooled estimates were presented. One used the SF-36 questionnaire two weeks after surgery and the other used the Gastro-intestinal Quality of Life Index six weeks and six months after surgery (both low-quality evidence).In children, we found no differences in pain intensity on day one (MD -0.80, 95% CI -1.65 to 0.05; 1 RCT; 61 participants; low-quality evidence), intra-abdominal abscesses after LA (Peto OR 0.54, 95% CI 0.24 to 1.22; 9 RCTs; 1185 participants; low-quality evidence) or time until return to normal activity (MD -0.50, 95% CI -1.30 to 0.30; 1 RCT; 383 participants; moderate-quality evidence). However, wound infections were less likely after LA (Peto OR 0.25, 95% CI 0.15 to 0.42; 10 RCTs; 1245 participants; moderate-quality evidence) and the length of hospital stay was shortened by 0.8 days after LA (MD -0.81, 95% CI -1.01 to -0.62; 6 RCTs; 316 participants; low-quality evidence). Quality of life was not reported in any of the included studies.
Authors' conclusions:
Except for a higher rate of intra-abdominal abscesses after LA in adults, LA showed advantages over OA in pain intensity on day one, wound infections, length of hospital stay and time until return to normal activity in adults. In contrast, LA showed advantages over OA in wound infections and length of hospital stay in children. Two studies reported better quality of life scores in adults. No study reported this outcome in children. However, the quality of evidence ranged from very low to moderate and some of the clinical effects of LA were small and of limited clinical relevance. Future studies with low risk of bias should investigate, in particular, the quality of life in children.
Die Therapie der Wahl bei der akuten Appendizitis ist unverändert die operative Entfernung der entzündeten Appendix vermiformis. Bezüglich des optimalen Zuganges, konventionell offen oder minimal-invasiv, besteht noch teilweise Uneinigkeit. Anhand der besten verfügbaren Evidenz wird versucht, die Frage nach der derzeit optimalen Verfahrenswahl zu beantworten. Für die laparoskopische Appendektomie bestehen evidenzbasierte Vorteile in Bezug auf das Zugangstrauma, den postoperativen Schmerzmittelbedarf, die Wundinfektionsrate sowie die Rekonvaleszenz. Für die alternativen minimal-invasiven Verfahren Single-Port-Appendektomie, minilaparoskopische Appendektomie oder NOTES-Appendektomie fehlt insgesamt noch die wissenschaftliche Evidenz, um den breiten klinischen Einsatz dieser Verfahren zu befürworten. Es wird empfohlen, dass überall dort, wo es die Infrastruktur erlaubt, die laparoskopische Appendektomie die Therapie der Wahl darstellen sollte.
El dolor pélvico agudo constituye el motivo de consulta más frecuente en ginecología. Requiere un tratamiento estandarizado para no pasar por alto un diagnóstico urgente, potencialmente letal. Deben utilizarse con buen criterio y de manera ordenada los diferentes medios de investigación, que son la anamnesis, la exploración física, los exámenes biológicos y morfológicos y la laparoscopia, para el control del dolor pélvico agudo. La laparoscopia debe emplearse como herramienta terapéutica cuando se piensa en un tratamiento quirúrgico. Entre las principales causas de dolor pélvico agudo, es importante el diagnóstico de cuatro, debido a su potencial gravedad a corto plazo y a las secuelas a largo plazo que pueden producir sobre la fertilidad: la apendicitis, la torsión de anexo, el embarazo extrauterino y la infección genital alta.
Introduction
Fecal appendicular peritonitis (FAP) is a poorly studied, rare form of acute appendicitis, corresponding to peritoneal inflammation with the presence of feces secondary to ruptured appendix. The purpose of this study was to describe FAP and to compare FAP with purulent appendicular peritonitis (PAP).
Patients and methods
This single-center, retrospective study was conducted in consecutive patients to compare the FAP group and the PAP group. The primary endpoint was the 30-day postoperative morbidity and mortality according to the Clavien-Dindo classification. The secondary endpoints were description and comparison of intraoperative data (laparoscopy rate, conversion rate, type of procedure and the mean operating time), and short-term outcomes (types of complications, length of stay, readmission rate, and reoperation rate), comparison of intraoperative bacteriological samples of FAP and PAP as well as the rate of resistance to amoxicillin and clavulanic acid, used as routine postoperative antibiotic therapy.
Results
Between January 2006 and January 2016, 2.2% of appendectomies were performed for FAP. Patients of the FAP group reported a longer history of pain than patients of the PAP group (mean: 58 h [range: 24–120] vs 24 h [range: 6–504], p = 0.0001) and hyperthermia was more frequent in the FAP group than in the PAP group (72% vs 26%, p = 0.0001). Mean preoperative CRP was also higher in the FAP group than in the PAP group (110 mg/L [range: 67–468] vs 37.5 mg/L [range: 3.1–560], p = 0.007). Significantly less patients were operated by laparoscopy in the FAP group (89.7% vs 96.6%, p < 0.0001). Mean length of stay was significantly longer in the FAP group than in the PAP group (10 days [range: 3–24] vs 5 days [range: 1–32], p = 0.001). The overall 30-day complication rate was significantly higher in the FAP group than in the PAP group (62.1% vs 24.7%, p = 0.0005). The readmission rate was not significantly different between the two groups (14% vs 11.2%, p = 0.2), but the reoperation rate was higher in the FAP group than in the PAP group (31% vs 11%, p = 0.01). No significant difference was observed between the FAP and PAP groups in terms of the positive culture rate (75.9% vs 65.6%, p = 0.3). No significant difference was observed between the two groups in terms of resistance to amoxicillin and clavulanic acid (18.2% vs 20.5%, p = 0.8).
Conclusion
FAP is associated with significantly more severe morbidity compared to PAP. Clinicians must be familiar with this form of appendicitis in order to adequately inform their patients.
Background Appendectomy is one of the most frequently performed surgical procedures in the world. Conventional laparoscopic appendectomy is traumatizing and lacking for cosmetic effects. Single-port laparoscopic surgery appendectomy (SPLA) seeks to minimize the trauma of parietal access of laparoscopic appendectomy. Aim The aim of this study was to evaluate the efficacy of SPLA. Patients and methods This study was conducted between May 2015 and October 2016, in a specialized center. We present 60 cases of acute appendicitis who were randomly operated by SPLA. Results SPLA was completed in all patients, and mean age was 25.5±12 years. Mean operation time was 50.7±2 min in the SPLA group. There was no conversion to open appendectomy. No major complications were encountered. Conclusion SPLA demonstrates its feasibility and supports the promise of minimizing the access of laparoscopic surgery. The clear advantage is its cosmetic benefit. SPLA is a safe technique and shows excellent cosmetic results.
Background
The aim of this study was to study the value of diagnostic laparoscopy prospectively in fertile women scheduled for acute appendectomy.
Methods
For this study, 110 women, with acute abdominal pain ages 15 to 47 years, in whom the surgeon had decided to perform an appendectomy, were randomized to either open appendectomy or diagnostic laparoscopy, then open appendectomy if necessary.
Results
Appendicitis was diagnosed in 66% of the women after open surgery, and in 73% after laparoscopy. During laparoscopy, was appendicitis misdiagnosed in only 7% of the women, from whom the appendix unnecessarily removed, whereas 34% in the open surgery group had a healthy appendix removed. No appendicitis was missed in the laparoscopic group. The relative risk of removing a healthy appendix in open surgery was 6.6 relative risk (range, 2–21 C.I.) as compared with laparoscopy. Among the women with a healthy appendix, a gynecologic diagnosis was found in 73% after laparoscopy, as compared with 17% after open surgery.
Conclusions
Laparoscopy reduces unnecessary appendectomies and improves diagnosis in fertile women.
n
= 31) or laparoscopic (
n
= 33) appendectomy. Of the 64 men, 56 (87.5%) had appendicitis (27 open, 29 laparoscopic procedures). The mean operating times
were 50.6 ± 3.7 minutes (± SEM) for open and 58.9 ± 4.0 minutes for laparoscopic appendectomy (
p
= 0.13). Five (15%) patients randomized to laparoscopic appendectomy had an open operation. The mean postoperative hospital
stay was significantly longer for open appendectomy (3.8 ± 0.4 days) than for laparoscopic appendectomy (2.9 ± 0.3 days) (
t
= 2.05,
df
= 62,
p
= 0.045). The complication rate after open appendectomy (25.8%) was not significantly different from that after laparoscopic
appendectomy (12.1%). There was a single postoperative death due to a pulmonary embolus in the laparoscopic group and a single
death due to cardiac and renal failure in the open group. The mean time to return to normal activities was significantly longer
following open appendectomy (19.7 ± 2.4 days) than after laparoscopic appendectomy (10.4 ± 0.9 days), (
t
= 3.75,
df
= 49,
p
= 0.001). In conclusion, laparoscopic appendectomy in men has significant advantages in terms of a more rapid recovery compared
to open appendectomy. There were no significant disadvantages to laparoscopic appendectomy compared to open appendectomy.
A randomized clinical trial was performed to compare open appendectomy (OA) and laparoscopic appendectomy (LA).
201 patients with similar characteristics of appendicitis were randomized to either OA or LA. Operative time and technique, reintroduction of diet, postoperative pain, use of analgesia, hospital stay, and complications were documented.
104 patients were allocated to the OA group and 97 to the LA group. Postoperative pain was significantly less in the LA group on the 1st (p < 0.001) and 2nd (p < 0.001) postoperative day, resulting in less use of analgesics on both days (p < 0.001). Restoration of diet was similar in both groups. Mean operative time was longer in the LA group: 61 vs 41 min (p < 0.001). Postoperative complications did not differ in either group, except for wound infections (six OA group vs zero LA group, p < 0.05). Mean hospital stay was similar in both groups.
LA results in less postoperative pain and fewer wound infections. The laparoscopic procedure is technically more demanding to perform, resulting in longer operative time.
Laparoscopic appendicectomy (LA), has failed to gain unequivocal acceptance by the general surgical community as an alternative to open appendicectomy (OA). This is because the early postoperative recovery leading to quicker hospital discharge, which led to the worldwide acceptance of laparoscopic cholecystectomy, has not been universally seen with LA. Moreover, in the majority of the published series of LAs, there seems to be a trend towards an increased incidence of intra-abdominal abscesses. However, laparoscopy is superior to the 'watch and wait' policy where the diagnosis of appendicitis is questionable. Furthermore, since a large incision can be avoided by using the LA technique in obese patients, the incidence of postoperative morbidity can be reduced considerably. Nevertheless, before endorsing routine and widespread use of LA, it is essential that this technique is critically evaluated in well-designed, controlled, randomised trials, showing clearly the major benefits to the patient in terms of quicker hospital discharge, reduced postoperative pain, decreased wound infection and early return to full activities. Laparoscopic appendicectomy will never replace all open appendicectomies, but should become an alternative in certain groups of patients.
Although classic open surgery is simple, expeditious, and effective, it has some drawbacks, including wound sepsis, delayed recovery, operative difficulties, and possibility of unnecessary appendectomies for false appendicitis. The aim of this study was to assess the applicability and safety of laparoscopic appendectomy (LA) in a prospectively randomized trial. Seventy nonselective patients with suspected appendicitis were randomized to laparoscopic (n = 35, 17 male) or open appendectomy (n = 35, 15 male) and operated on an emergency basis. Operative findings, operating time, postoperative complications, and length of hospital stay were compared. We found that LA is associated with a shorter hospital stay, fewer postoperative complications, and better diagnostic accuracy, and it is recommended as the procedure of choice for the diagnosis and management of acute appendicitis.
The aim of this study was to study the value of diagnostic laparoscopy prospectively in fertile women scheduled for acute appendectomy.
For this study, 110 women, with acute abdominal pain ages 15 to 47 years, in whom the surgeon had decided to perform an appendectomy, were randomized to either open appendectomy or diagnostic laparoscopy, then open appendectomy if necessary.
Appendicitis was diagnosed in 66% of the women after open surgery, and in 73% after laparoscopy. During laparoscopy, was appendicitis misdiagnosed in only 7% of the women, from whom the appendix unnecessarily removed, whereas 34% in the open surgery group had a healthy appendix removed. No appendicitis was missed in the laparoscopic group. The relative risk of removing a healthy appendix in open surgery was 6.6 relative risk (range, 2-21 C.I.) as compared with laparoscopy. Among the women with a healthy appendix, a gynecologic diagnosis was found in 73% after laparoscopy, as compared with 17% after open surgery.
Laparoscopy reduces unnecessary appendectomies and improves diagnosis in fertile women.
Laparoscopic appendectomy is a safe and effective procedure, as both a diagnostic and therapeutic tool. It seems to be more effective than the corresponding open procedure. Aim of this study is to evaluate a group of patients randomly allocated either to laparoscopic appendectomy (LA) or to open appendectomy (OA).
From January 1998 to December 2002, 252 consecutive and nonselected patients, 155 women and 97 men, were randomized either to LA or OA. Recorded data were operative time, postoperative length, of stay and complications.
Mean operative time was 45 min (range 30-120) for OA and 36 min (25-60) for LA, mean postoperative stay was 5.5 days (4-12) for OA and 3.4 days (2-8) for LA. Complication occurred in 20 patients (14.5%) for OA and in four patients (2.6%) for LA.
We believe that LA is effective in any kind of clinical situation, with low traumatic impact and best comfort for the patient.
Background Data: The value of laparoscopy in appendicitis is not established. Studies suffer from multiple limitations. Our aim is to compare the safety and benefits of laparoscopic versus open appendectomy in a prospective randomized double blind study. Methods: Two hundred forty-seven patients were analyzed following either laparoscopic or open appendectomy. A standardized wound dressing was applied blinding both patients and independent data collectors. Surgical technique was standardized among 4 surgeons. The main outcome measures were postoperative complications. Secondary outcome measures included evaluation of pain and activity scores at base line preoperatively and on every postoperative day, as well as resumption of diet and length of stay. Activity scores and quality of life were assessed on short-term follow-up. Results: There was no mortality. The overall complication rate was similar in both groups (18.5% versus 17% in the laparoscopic and open groups respectively), but some early complications in the laparoscopic group required a reoperation. Operating time was significantly longer in the laparoscopic group (80 minutes versus 60 minutes; P = 0.000) while there was no difference in the pain scores and medications, resumption of diet, length of stay, or activity scores. At 2 weeks, there was no difference in the activity or pain scores, but physical health and general scores on the short-form 36 (SF36) quality of life assessment forms were significantly better in the laparoscopic group. Appendectomy for acute or complicated (perforated and gangrenous) appendicitis had similar complication rates, regardless of the technique (P = 0.181). Conclusions: Unlike other minimally invasive procedures, laparoscopic appendectomy did not offer a significant advantage over open appendectomy in all studied parameters except quality of life scores at 2 weeks. It also took longer to perform. The choice of the procedure should be based on surgeon or patient preference.
Background:
A prospective study including 272 patients with suspected appendicitis was performed. The aims were to evaluate the representativity of the study group and to compare diagnostic and therapeutic laparoscopy with conventional appendicectomy.
Methods:
The study was an open, randomized, single-centre trial with sequential design. One hundred and eight patients were randomized between laparoscopy or conventional appendicectomy, of whom 84 had acute appendicitis. Duration of postoperative convalescence was the major endpoint.
Results:
The study patients were representative of the eligible population regarding age and stage of appendicitis. The risk of unnecessary appendicectomy was significantly (P = 0.03) lower after laparoscopy. The mean difference in duration of postoperative convalescence was 4.7 days in favour of of laparoscopic appendicectomy (P = 0.07), and 26 min in duration of operation in favour of conventional appendicectomy (P < 0.01). No differences were detected in postoperative hospital stay, pain assessment or complications.
Conclusion:
The laparoscopic procedure is at least as good as conventional appendicectomy. Initial laparoscopy reduces the rate of misdiagnosis.
Background
While the advantages of laparoscopic cholecyslectomy are clear, the benefits of laparoscopic appendectomy (LA) are more subtle. We conducted a randomized clinical trial to evaluate whether LA is deserving of more widespread clinical application than it has yet received.
Materials and methods
Two hundred fiftythree patients with a preoperative diagnosis of acute appendicitis were randomized into three groups. LA with an endoscopic linear stapler (LAS) (U.S. Surgical Corp., Norwalk, Connecticut) was performed on 78 patients, LA with catgut ligatures (LAL) on 89, and open appendectomy (OA) on 86. LA was performed with a three-trocar technique. OA was accomplished through a right lower-quadrant transverse incision. Data with normal distributions were analyzed by analysis of variance. Nonparametric data were analyzed with either the Kruskal-Wallis H test or Fisher's exact test.
Results
The mean operative times for the procedures were 66 ± 24 minutes (LAS), 68 ± 25 minutes (LAL), and 58 ± 27 minutes (OA). The relative brevity of OA compared to LAS and LAL was statistically significant (P <0.01). Conversion to open procedures was approximately as frequent in the LAS group (n = 5) and the LAL (n = 6). One OA, 2 LAS, and 11 LAL patients experienced vomiting postoperatively (P <0.05). Two intra-abdominal abscesses occurred in LAS, 4 in LAL, and 0 in OA patients (P = NS). Wound infections were more common following OA (n = 11) than LAL (n = 4) or LAS (n = 0) (P <0.05, <0.001). The mean length of postoperative hospital stay was 2.16 ± 3.2 days (LAS), 2.98 ± 2.7 days (LAL), and 2.83 ± 1.6 (OA) (P <0.05 OA versus LAS). The number of days patients required pain medications overall was not different between groups, but a sub-group analysis of 134 patients who rated their postoperative pain on a visual analogue scale revealed a significantly lower mean level among patients undergoing LA (LAS and LAL) versus OA (P <0.001). Patients undergoing LA resumed regular activities sooner than those undergoing OA (9 ± 9 days versus 14 ± 11 days, P <0.001). Rates of readmission to the hospital were similar for all procedures.
Conclusions
Laparoscopic appendectomy appears to have distinct advantages over open appendectomy. The laparoscopic procedures produced less pain and allowed more rapid return to full activities, and LAS required shorter hospital stays. The only disadvantages to the laparoscopic approach were slightly increased operative time for both procedures, and increased emesis following LAL.
Background: The aim of this randomized study was to assess the postoperative acute-phase response of laparoscopic appendectomy and to compare its results with those of open appendectomy. Methods: 81 patients admitted to our emergency service with acute appendicitis were randomized to laparoscopic and open appendectomy groups. Preoperative and postoperative values for acute-phase reactants of white blood-cell count, erythrocyte sedimentation rate, C-reactive protein, and fibrinogen in blood samples were recorded. We also collected data concerning age and gender, total anesthesia time, operation time, time of oral intake, and hospital stay time of the study groups. Results: Although total anesthesia time was significantly longer in the laparoscopic group than in the open group (p < 0.05), there was no significant difference in operation time between both groups (p > 0.05). We found oral intake and hospital stay time to be significantly lower in the laparoscopic appendectomy group than in the open appendectomy group (p < 0.05). The acute-phase reactant levels were significantly lower in the laparoscopic appendectomy group than in the open appendectomy group (p < 0.05). Conclusion: Laparoscopic appendectomy causes relatively less trauma and less tissue damage than the open procedure and appears to have distinct advantages over open appendectomy.
To analyse the reasons for, and outcome of, conversion from laparoscopic to open appendicectomy and to identify factors that may predict the need for conversion.
Subgroup analysis from a randomised multicentre study.
One university hospital and four county hospitals, Sweden.
A total of 500 patients were randomised to laparoscopic (n = 244) or open (n = 256) appendicectomy. Thirty operations (12%) were converted to open appendicectomy.
Reasons for conversion, outcome, and preoperative predictive variables.
Difficult anatomy or the presence of an abscess were the main reasons for conversion (25/30). The incidence of perforated appendicitis was higher among patients who required conversion compared with both the open and laparoscopic group. Operating time, anaesthetic time, and duration of hospital stay were longer after conversion. Time to full recovery and length of sick leave were also longer, except for patients with perforated appendicitis. There was no difference in the complication rate. No predictive factors were identified.
The main reasons for conversion were difficult anatomy and the presence of an abscess. After conversion patients recovered more slowly than those operated on laparoscopically or by primary open operation.
Recent findings in a small number of studies have suggested a trend toward increased infectious complications following laparoscopic
appendectomy. The purpose of the present review was to evaluate the incidence of postappendectomy intra-abdominal abscess
formation following laparoscopic and open appendectomies. Using the surgical database of the Los Angeles County-University
of Southern California Medical Center, we reviewed the records of all appendectomies performed at the center between March
1993 and September 1995. Incidental appendectomies as well as appendectomies in pediatric patients under the age of 18 years
were excluded. A total of 2497 appendectomies were identified; indications for these procedures included acute appendicitis
in 1422 cases (57%), gangrenous appendicitis in 289 (12%), and perforated appendicitis in 786 (31%). The intraoperative diagnosis
made by the surgeon was used for classification. A two-tailedP value of <0.05 was considered significant. There was no significant difference in the rate of abscess formation between the
groups undergoing open and laparoscopic appendectomies for acute and gangrenous appendicitis. In patients with perforated
appendicitis, a total of 26 postappendectomy intra-abdominal abscesses occurred following 786 appendectomies for an over-all
abscess formation rate of 3.3%. Eighteen abscesses occurred following 683 open appendectomies (2.6%), six abscesses occurred
following 67 laparoscopic appendectomies (9.0%), and the remaining two abscesses occurred following 36 converted cases (5.6%).
For perforated appendicitis, however, there was a statistically significant increase in the rate of abscess formation following
laparoscopic appendectomy compared to conventional open appendectomy (9.0% vs. 2.6%,P=0.015). There was no significant difference in the rate of abscess formation between open vs. converted cases or between
laparoscopic vs. converted cases. A comparison of the length of the postoperative hospital stay showed no significant difference
between open and laparoscopic appendectomy for perforated appendicitis (6.1 days vs. 5.9 days). Laparoscopic appendectomy
for perforated appendicitis is associated with a higher rate of postoperative intra-abdominal abscess formation without the
benefit of a shortened hospital stay. Given these findings, laparoscopic appendectomy is not recommended in patients with
perforated appendicitis.
These newly developed endoscopic methods in gynaecology for haemostasis during surgical pelviscopy (Endocoagulation Roeder-loop ligation, endoligature, endo-suture with intra- and extracorporeal knotting) make it possible to carry out appendectomy by endoscopy for any of the following indications: Postoperative adhesion of the appendix especially in "sterility" patients, elongated appendix extending into the small pelvis, endometriosis of the appendix, subacute and chronic appendicitis. The instrument-set employed in this method permits the performance of all the usual classical operative steps (purse-string suture, and Z-suture acc. to McBurney and Sprengel). The point for resection has to be sterilized over 20-30 sec. at 212 degrees F using the crocodile forceps (endocoagulation procedure) before division and extraction of the appendix is effected.
The authors compare open and laparoscopic appendectomy in a randomized fashion with regard to length of operation, complications, hospital stay, and recovery time.
Adult patients (older than 14 years of age) with the diagnosis of acute appendicitis were randomized to either open or laparoscopic appendectomy over a 9-month period. All patients received preoperative antibiotics. The operative time was calculated as beginning with the incision and ending when the wound was fully closed. Patients that were converted from laparoscopic to open appendectomy were considered a separate group. Return to normal activity and work were determined by questioning during postoperative clinic, telephone, or mailed questionnaire.
There was a total of 169 patients randomized, 88 to the open and 81 to the laparoscopic group. The groups were similar demographically. Of the 81 laparoscopic patients, 13 (16%) were converted to open. In the open group, 70 patients (79.5%) had acute appendicitis and 21 (23.9%) had perforative appendicitis. In the laparoscopic group, 62 patients (76.5%) had acute appendicitis and 10 (12.3%) had perforative appendicitis. There was no statistical difference in the return to activity or work between the laparoscopic and open groups. The operative time was significantly longer in the laparoscopic group (102.2 minutes vs. 81.7 minutes, p < 0.01). The hospital stay of 2.2 days in the laparoscopic group and 4.3 days in the open group was statistically (p = 0.007). There was no difference in the hospital stay for those with acute appendicitis (1.89 days vs. 2.61 days, p = 0.067) compared with those with a normal appendix but with pelvic inflammatory disease (1.1 days vs. 2.3 days, p = 0.11). There was a significant difference in patients with perforative appendicitis (1.5 days vs. 9.5 days, p < 0.01). The hospital cost for patients having laparoscopic appendectomy was $6077 and for an open appendectomy $7227 (p = 0.164). There were no increased complications associated with the laparoscopic technique.
Laparoscopic appendectomy is comparable to open appendectomy with regard to complications, hospital stay, cost, return to activity, and return to work. There was a greater operative time involved with the laparoscopic technique. Laparoscopic appendectomy does not offer any significant benefit over the open approach for the routine patient with appendicitis.
The goal of this study was to prospectively define the impact of laparoscopy on the management of patients with a presumed diagnosis of appendicitis.
While the role of laparoscopy in the management of cholelithiasis is well established, its impact on the management of acute appendicitis needs to be objectively defined and compared to that of conventional management. Several authors have predicted that laparoscopic appendectomy will become the preferred treatment for appendicitis.
Two groups of consecutive patients with similar clinical characteristics of acute appendicitis were compared. Data on the laparoscopic group were compiled prospectively on standardized forms; data on the conventional group were collected retrospectively. Operative time, hospital stay, analgesia, cost, and return to normal activities were noted.
Seventeen consecutive patients who underwent appendectomy were compared to 18 consecutive patients who underwent laparoscopy (16 of these 18 had laparoscopic appendectomy). There was no significant difference between the two groups in terms of clinical characteristics and appendiceal histopathology. The mean operative times were 61 +/- 4.1 minutes and 46 +/- 2.9 minutes for the laparoscopy and conventional groups, respectively (p < 0.01). Hospital stay was significantly shorter in the laparoscopic appendectomy group, with 81% of patients being discharged on their first postoperative day (p < 0.001). The laparoscopic appendectomy patients required significantly less narcotic analgesia (p < 0.02). Return to normal activity was not significantly different between the two groups. The average total cost of laparoscopic appendectomy was 30% greater than that of conventional appendectomy.
Laparoscopy is a useful adjunct to the management of patients with a presumed clinical diagnosis of acute appendicitis.
The benefit of laparoscopy to patients has been clearly established in adults undergoing cholecystectomy. Results are less clear for appendectomy. The current study was undertaken to compare the respective 3-day postoperative periods after laparoscopic and open appendectomy in children.
Sixty-three children (aged 8-15 yr) scheduled for appendectomy were randomly assigned to two groups: open and laparoscopic. Postoperative evaluation included delay of postoperative recovery (walking and feeding), pain assessment by visual analog scale during the 3 subsequent days, amount of nalbuphine administered via a patient-controlled analgesia system during the first 48 h and responses by children, parents, and nurses on the overall quality of analgesia.
There was no difference between groups for demographic data (particularly macroscopic aspect of appendix) analgesia, sedation, delay before eating and walking, incidence of urinary retention, nausea, vomiting. Operative time was long (P < or = to 0.05) in the laparoscopic group (54 +/- 17 min) than in the open group (39 +/- 18 min). Thirty five percent of the children had pain at the shoulder in the LAP group versus ten percent in the open group (P < or = 0.05).
Laparoscopy did not improve analgesia and postoperative recovery after appendectomy in children.
Benefits of laparoscopic appendectomy are controversial, and the results of recent clinical studies have contradictory conclusions. We performed a cost analysis comparing laparoscopic and open appendectomies to assess potential efficacy of the laparoscopic approach.
All patients operated on for suspected acute appendicitis at the University of Washington Medical Center (UWMC) from January 1, 1991 through January 1, 1995 were analyzed. Potential benefits of the laparoscopic approach were examined in five major categories: hospital length of stay, total hospital charges, operative time, operating room charges, and postoperative complications. Patients were stratified according to the presence or absence of perforation for outcome analysis.
There were 163 appendectomies performed in 82 men and 81 women. Twenty-seven (17%) patients had laparoscopic evaluation, of which 21 underwent attempted laparoscopic appendectomy. Among nonperforated patients, laparoscopic appendectomy did not reduce hospital stay compared with open appendectomy, but did lead to greater hospital charges ($7760 vs $5064; P < 0.001). Operating times were longer in the laparoscopic group (104 vs 74 minutes; P < 0.001) compared with open appendectomies. Operating room charges for laparoscopic appendectomies exceeded charges for the open approach ($4740 vs $1870; P < 0.001). Complication rates were similar (laparoscopic, 19% vs open, 16%; NS). The false diagnostic rate for women was four times greater than for men among patients undergoing open appendectomy (31% vs 8%; P < 0.01). Patients with perforation undergoing a midline incision had a longer hospital stay (9.5 vs 5.9; P < 0.02) than patients operated on through a right lower quadrant incision.
In our analysis, laparoscopic appendectomy, while safe, was more expensive and was not associated with better clinical outcome compared with open appendectomy patients.
This prospective clinical study was done because our initial retrospective review suggested that laparoscopic appendectomy (LA) offers no significant advantages over open appendectomy (OA) yet is significantly more expensive. From July 1992 to August 1993, 57 patients were approached preoperatively for randomization to either LA (n = 19) or OA (n = 18). There were no statistically significant differences between the LA and OA groups in operative risk: mean age, 28 +/- 2 vs 26 +/- 2 years; percent female, 26% vs 22%; body mass index, 24 +/- 0.8 vs 26 +/- 1.2 kg/m2. All patients were either ASA class I or class II, 78% in each group being class II. The differences between the LA and OA groups in mean operating time required (93 +/- 12 vs 87 +/- 8 minutes), postoperative intramuscular narcotic analgesic usage (24 +/- 6 vs 26 +/- 6 hours), postoperative hospital stay (57 +/- 12 vs 66 +/- 10 hours), and return to normal activity (20 +/- 6 vs 14 +/- 3 days) were also not significant. However, LA was much more expensive because of higher operating room charges. The mean total hospital bill was $4,600 +/- $160 for the LA group and $1,700 +/- $70 for the OA group. This prospective study corroborated our previous analysis. Laparoscopic appendectomy is safe, effective, and expensive and overall has no greatly significant advantages over open appendectomy.
Laparoscopic appendectomy has now gained wider acceptance in clinical practice, particularly in the treatment of women with right iliac fossa pain. However, the precise role of laparoscopic appendectomy in men is unclear, and this study was therefore undertaken to examine this specific issue in a prospective randomized trial.
One hundred men between the ages of 16 and 65 years who had suspected appendicitis were recruited and randomized to undergo either open or laparoscopic appendectomy. Both groups were compared in terms of their clinical parameters, duration of anesthetic and operation times, postoperative pain, duration of ileus, and length of hospital stay.
The histologic confirmation of appendicitis was present in 94% of the cases for both groups of patients. Laparoscopic appendectomy required significantly longer anesthetic time (72.5 minutes versus 55 minutes) and actual operating time (45 minutes versus 25 minutes) compared with open appendectomy. Postoperative pain as measured by visual analog scale on postoperative days 1 and 2 were not significantly different between the patients who underwent laparoscopic and open surgery with values of 4.7 versus 4.4 and 2.1 versus 2.2, respectively. Also no significant difference was seen between the laparoscopic and open appendectomy groups in the recovery of bowel function (24.7 hours versus 21 hours) and in the length of hospital stay (4.9 days versus 5.3 days).
The results of this prospective randomized trial showed that there were no significant advantages of laparoscopic appendectomy over open appendectomy for the treatment of male patients with suspected appendicitis. We recommend that the use of laparoscopy be limited to men with atypical pain of uncertain diagnosis and in obese patients.
The purpose of this review was to evaluate the incidence of postoperative intraabdominal abscess formation following laparoscopic and open appendectomies.
The current study retrospectively examines appendectomies performed during the period from January 1993 to July 1994. Excluded were cases which were started laparoscopically but converted to open procedures. There were 1,287 cases identified; 597 were perforated (46%), 114 were gangrenous (9%), and 576 were acute (45%). These diagnoses represent intraoperative diagnoses.
Of the 576 appendectomies for acute appendicitis, 64 (11%) were performed laparoscopically. There were four intraabdominal abscesses (0.7%), all occurring after open procedures. Of the 114 appendectomies for gangrenous appendicitis, 16 (14%) were done laparoscopically. There were two postoperative abscesses (1.8%), one following an open and one following a laparoscopic procedure. There was no significant difference in abscess rate between laparoscopic and open appendectomies for either acute or gangrenous appendicitis. Of the 597 appendectomies for perforated appendicitis, 28 (5%) were done laparoscopically. There were 19 postoperative abscesses in the whole group, accounting for a 3.2% abscess rate. Sixteen abscesses occurred after open appendectomies and three occurred after laparoscopic appendectomies (2.9% vs 11%, P = 0.054). The preoperative diagnosis was incorrectly identified as acute appendicitis in 95 cases subsequently found to have perforated appendicitis; there was only 1 postoperative abscess in this group. There was no difference in postoperative stay in the open vs laparoscopic group (6.3 days vs 6.1 days).
We found no significant difference in the rate of postoperative intraabdominal abscess formation between laparoscopic and open appendectomies in cases of acute or gangrenous appendicitis. However, laparoscopic appendectomy for perforated appendicitis was associated with an important trend toward a higher rate of postoperative intraabdominal abscess formation than open appendectomy. This observation calls for closer prospective scrutiny of laparoscopic appendectomy in the setting of perforated appendicitis.
To compare the efficacy of laparoscopic appendectomy (LA) and open appendectomy (OA) in the treatment of acute appendicitis.
A prospective randomized trial.
A university teaching hospital.
Eighty-one patients with a diagnosis of acute appendicitis were prospectively randomized to undergo either LA or OA. The two groups were matched for age and sex.
LA or OA.
Number of days in hospital and time to full recovery.
The mean hospital stay for LA was 3.23 days compared with 3.03 days for OA (p < 0.001). The mean number of narcotic injections required for patients in the LA group was 4.05 compared with 5.58 for patients in the OA group (p < 0.001). The mean time to complete recovery for patients in the LA group was 9.0 days compared with 16.2 days for patients in the OA group (p < 0.001). The mean operative time for LA was 73.8 minutes compared with 45.0 minutes for OA (p < 0.001). Three patients in the LA group had intra-abdominal abscesses (p > 0.25). No significant difference in wound infection rates was demonstrated (p > 0.05). Similarly, pain scores at 7 and 28 days showed no significant difference (p > 0.05).
With LA significantly fewer narcotic injections are required and there is a more rapid return to normal activities. LA takes longer to perform and was associated with three intra-abdominal abscesses. In cases of simple acute appendicitis the hospital stay for LA is significantly shorter.
Clinical diagnosis of acute appendicitis is most difficult in fertile-age women. In this patient group up to 50% of open appendectomies are negative for appendicitis. We conducted a randomized study to compare laparoscopic and open appendectomy in young female patients with suspected acute appendicitis.
Fifty female patients between the ages of 16 and 40 years presenting with acute right lower abdominal pain were randomized, 25 to laparoscopy and 25 to an open appendectomy. Diagnostic accuracy, rate of negative appendectomies, safety, and final outcome were compared in the two groups.
Diagnosis was established in 96% of patients in the laparoscopic group and in 72% in the open group. There were 11 (44%) unnecessary appendectomies in the open group, but only one (4%) in the laparoscopic group (p < 0.0005).
In young women with right lower abdominal pain, laparoscopy can give precise diagnosis and reduce the rate of negative appendectomies.
A prospective study including 272 patients with suspected appendicitis was performed. The aims were to evaluate the representativity of the study group and to compare diagnostic and therapeutic laparoscopy with conventional appendicectomy.
The study was an open, randomized, single-centre trial with sequential design. One hundred and eight patients were randomized between laparoscopy or conventional appendicectomy, of whom 84 had acute appendicitis. Duration of postoperative convalescence was the major endpoint.
The study patients were representative of the eligible population regarding age and stage of appendicitis. The risk of unnecessary appendicectomy was significantly (P = 0.03) lower after laparoscopy. The mean difference in duration of postoperative convalescence was 4.7 days in favour of of laparoscopic appendicectomy (P = 0.07), and 26 min in duration of operation in favour of conventional appendicectomy (P < 0.01). No differences were detected in postoperative hospital stay, pain assessment or complications.
The laparoscopic procedure is at least as good as conventional appendicectomy. Initial laparoscopy reduces the rate of misdiagnosis.
To study comparative results between laparoscopic and open appendectomy, all the patients with suspected acute appendicitis who presented between January 1992 and December 1994 (N = 210) were randomized into two groups: laparoscopic (LA, n = 106) and open appendectomy (OA, n = 104). Patient demographics, pathological findings, operative time, postoperative course, and cost were analyzed. Age, gender, previous laparotomy, intraoperative diagnosis, and perforated appendix rate were comparable between both groups. Mean operative time was longer in the LA group (p < 0.05). Earlier resumption of a regular diet, shorter postoperative stay, and less postoperative analgesia also were observed in the LA group (p < 0.05). Postoperative morbidity and hospital readmissions were similar in both groups (p > 0.05). Higher operative cost was observed in the LA group, but global cost was lower in this group (p < 0.05). Laparoscopic appendectomy shows a more comfortable postoperative course (oral resumption, postoperative stay, and analgesia) over open appendectomy, with similar postoperative morbidity. The LA group showed more operative but less global cost.
The aim of this study was to compare the outcome and cost-effectiveness of laparoscopic (LA) and open appendectomy (OA). Methods: Forty consecutive patients were randomized to either the LA (n = 19) or OA (n = 21) group.
The medians of operative times in the LA and OA groups were 31.5 and 41 min, respectively. The total operation room times were 91 and 82 min, respectively. There was no significant difference in postoperative pain or fatigue, but return to normal life was faster in the LA group (14 versus 26. 5 days). The median hospital costs per patient were 8,538 and 6,788 FIM ($1 US = 4.6 FIM) in the LA and OA groups, respectively; but the total costs among working patients were lower in the LA group (20, 963 versus 27,778 FIM) due to faster return to work.
Laparoscopic appendectomy is as safe as open appendectomy. The hospital costs are higher, but LA offers significant cost savings to the payer for working patients.
A prospective randomized multicentre study was performed to compare the outcome of laparoscopic and open appendicectomy in patients with suspected acute appendicitis.
A total of 523 patients was randomized, but because of 23 withdrawals the outcome in 500 patients is reported, 244 in the laparoscopic group and 256 in the open group.
Patients having laparoscopic appendicectomy recovered more quickly than those having open surgery (13 versus 21 days, P < 0.001). There was no significant difference in duration of sick leave after operation (laparoscopic group 11 days versus open group 14 days). Postoperative pain (at 24 h, 7 days and 14 days) was less after laparoscopic operations and a functional index 1 week after operation was more favourable in these patients (P < 0.001). Operating time was significantly longer in the laparoscopic group (60 versus 35 min, P < 0.01). Hospital stay and complications did not differ between the groups. Thirty laparoscopic procedures (12 per cent) were converted to open appendicectomy.
Laparoscopic appendicectomy is as safe as open appendicectomy and has the advantage of allowing a quicker recovery.
To compare the direct and indirect costs of laparoscopic and open appendicectomy.
Randomised study.
University hospital, Sweden.
Total costs for a defined period of time for each option.
102 patients were randomised and 99 were included in the final analysis. All patients had completely recovered within two months of operation. Disposable extra material used for the laparoscopic operation and longer operating time raised its median cost by SEK 912 and 1785, respectively. The mean duration of hospital stay, period off work (indirect costs), and time to complete recovery did not differ between the groups.
Laparoscopic appendicectomy has higher direct costs than open operation and is not as cost-effective when the longterm outcome is the same in both groups.
Abdominal pain of uncertain aetiology (non-specific abdominal pain; NSAP) is the commonest reason for emergency surgical admission. The aim of this study was to examine the role of early laparoscopy in the management of NSAP.
Some 120 patients, admitted between November 1995 and October 1998 with acute abdominal pain of uncertain aetiology, were randomized into two groups: group 1 had laparoscopy during the first 18 h of admission and group 2 had close observation, conventional investigation and surgical intervention if signs of peritonism developed. Outcome measures were diagnosis, operative procedures, duration of hospital stay, readmission rate, morbidity and death, patient satisfaction and total number of investigations performed.
Median hospital stay was 2 (range 1-13) days in both groups (P = 0.87). A diagnosis was established in 48 (81 per cent) of 59 patients in group 1 compared with 22 (36 per cent) of 61 in group 2 (P < 0.0001). The morbidity rate was 14 (24 per cent) of 59 in group 1 and 19 (31 per cent) of 61 in group 2 (P = 0.3629). The readmission rate at a median follow-up of 21 (range 1-35) months was 17 (29 per cent) of 59 in group 1 compared with 20 (33 per cent) of 61 in group 2 (P = 0. 6375). Well-being scores improved from 134 on admission to 149 of 177 6 weeks later in group 1 (P = 0.007) and from 132 to 143 of 177 in group 2 (P = 0.089).
Early laparoscopy provided a higher diagnostic accuracy and improved quality of life in patients with NSAP.
Laparoscopic appendectomy is increasingly used in treating acute appendicitis. Several controlled series have demonstrated the clinical benefit of the procedure. However, some basal pathophysiologic changes caused by the laparoscopy still need clarification, i.e., whether laparoscopy can give rise to bacteremia. The purpose of this randomized controlled study in 30 patients undergoing surgery due to suspected acute appendicitis, either by an open classic technique or by a laparoscopic technique, was (by collecting samples for blood culturing pre-, peri-, and postoperatively) to evaluate whether laparoscopy during carbon dioxide pneumoperitoneum could induce bacteremia. Six patients of 12 in the group treated by laparoscopy presented positive blood cultures peri- and postoperatively. No positive blood cultures were demonstrated in the open operated group. The difference was significant (P = 0.0183). The clinical significance of these findings should be clarified in further clinical investigations.
Laparoscopy in patients with a clinical suspicion of acute appendicitis has not gained wide acceptance, and its use remains controversial.
In a randomized controlled trial of laparoscopic versus open appendicectomy, 583 of 828 consecutive patients consented to participate. Three hundred and one patients were allocated to open appendicectomy and 282 patients to laparoscopy, 65 of whom required conversion to open appendicectomy. Length of stay in hospital was the primary endpoint, while operating time, postoperative morbidity, duration of convalescence and cosmesis were secondary endpoints.
Intention-to-treat analysis revealed an equally short hospital stay in the two groups (median 2 days). The median time to return to normal activity (7 versus 10 days) and work (10 versus 16 days) was significantly shorter following laparoscopy. Laparoscopy was associated with fewer wound infections (P < 0.03) and improved cosmesis (P < 0.001), but the operating time was longer (60 versus 40 min). Laparoscopy was associated with more intraperitoneal abscesses (5 versus 1 per cent) but, adjusted for a greater number of gangrenous or perforated appendices in this group, the difference failed to reach statistical significance.
Hospital stay was equally short, whereas laparoscopic appendicectomy was associated with fewer wound infections, faster recovery, earlier return to work and improved cosmesis.
Previous randomized studies of laparoscopic appendectomy produced conflicting recommendations, and the adequacy of sample sizes is generally unknown. We compared clinical and economic outcomes after laparoscopic and open appendectomy in a sample of predetermined statistical power.
A pre-study power analysis suggested that 200 randomized patients would yield 80% power to show a mean decrease of 1.3 days' hospitalization. One hundred ninety-eight patients with a preoperative diagnosis of acute appendicitis were randomized prospectively to laparoscopic or open appendectomy. Economic analysis included billed charges, total costs, direct costs, and indirect costs associated with treatment.
Laparoscopic appendectomy took longer to perform than open appendectomy (median, 107 vs 91 minutes; P <.01) and was associated with fewer days to return to a general diet (mean, 1.6 versus 2.3 days; P <.01), a shorter duration of parenteral analgesia (mean, 1.6 versus 2.2 days; P <.01), fewer morphine-equivalent milligrams of parenteral narcotic (median, 14 mg versus 34 mg; P =.001), a shorter postoperative hospital stay (mean, 2.6 versus 3.4 days; P <.01), and earlier return to full activity (median, 14 versus 21 days; P <.02). However, operative morbidity and time to return to work were comparable. Billed charges and direct costs were not significantly different in the 2 groups ($7711 versus $7146 and $5357 versus $4945, respectively), but total costs (including indirect costs) of laparoscopic appendectomy were, on average, nearly $2400 less, given the shorter length of stay and abbreviated recuperative period ($11,577 versus $13,965). Subgroup analyses suggested the benefit of a laparoscopic approach for uncomplicated appendicitis and for patients with active lifestyles.
While laparoscopic appendectomy is associated with statistically significant but clinically questionable advantages over open appendectomy, a laparoscopic approach is relatively less expensive. The estimated difference in total costs of treatment (direct and indirect costs) was at least $2000 in more than 60% of the bootstrapped iterations. The economic significance and implications favoring a laparoscopic approach cannot be ignored.
Background:
Laparoscopic appendectomy (LA) has been associated with a faster recovery and less postoperative pain than the open technique. However, few data are available on the clinical outcome of LA in overweight patients.
Methods:
A group of 106 patients with a body mass index (BMI) > 26.4, representing the upper quintile of 500 prospectively randomized patients, were included in the study. They were randomized to undergo either laparoscopic or open appendectomy (OA). Operating and anesthesia times, postoperative pain, complications, hospital stay, functional index (1 week postoperatively), sick leave, and time to full recovery were documented.
Results:
In OA, the operating time for overweight patients was significantly longer than that for patients in the normal weight range (40 vs 35 min, p < 0.05). In LA, there was no difference in operating time between the normal and overweight patients. Overweight patients who underwent LA had longer operating and anesthesia times than their OA counterparts (55 vs 40 min, p < 0.001; and 125 vs 100 min, p < 0.001, respectively). Postoperative pain was significantly greater in overweight patients who underwent OA than in those treated with the laparoscopic technique. Postoperative pain was also significantly greater in overweight patients subjected to OA than in patients of normal weight after 4 weeks; the clinical significance may, however, be of less importance since the values are low (0.26 vs 0.09, p < 0.05). There were no significant differences between the two operating techniques in terms of complications. Hospital stay was longer for overweight patients than for normal-weight patients undergoing OA (3.0 vs 2.0, p < 0.01). The functional index did not differ between any group of patients. Sick leave was longer for overweight patients who underwent OA than for normal-weight patients treated with the same technique (17 vs 13 days, p < 0.01). In the laparoscopic group, however, there were no differences between the overweight and normal-weight patients. Time to full recovery was greater in overweight patients subjected to OA than in the overweight patients in the LA group (22 vs 15 days, p < 0.001).
Conclusion:
In this study, overweight patients who were submitted to LA had less postoperative pain and a faster postoperative recovery than overweight patients who had OA. LA also abolished some of the negative effects that overweight had on operating time, hospital stay, and sick leave with the open technique. However, anesthesia and operating times were significantly longer in LA for both overweight patients and those with a normal BMI.
One hundred men between the age of 15 and 65 admitted to Ain Shams Specialized Hospital and El Demerdash Hospital, Cairo, and to the Saudi German Hospital, Saudi Arabia between November 1998 and December 2000 were randomized to undergo either open or laparoscopic appendicectomy. Both groups were compared in terms of clinical parameters, duration of anaesthesia, operative time, duration of ileus and length of hospital stay. The histologic confirmation of appendicitis was present in 92% in both groups. Laparoscopic appendectomy required significantly longer anaesthetic time (78 minutes versus 51) and operating time (49 minutes versus 23) compared with open appendectomy. No significant difference was noticed between laparoscopic and open appendectomy groups in the recovery of bowel function (24 hours versus 21) and in the length of hospital stay (4.9 days versus 5.3). The result showed no significant advantages of laparoscopic appendectomy over open appendectomy for the treatment of male patients with suspected appendicitis.
43 Kinder im Alter von 7 bis 15 Jahren mit klinischen Symptomen einer akuten Appendizitis wurden randomisiert und entweder einer offenen oder einer laparoskopischen Appendektomie unterzogen. In der Gruppe der offenen Laparotomien fanden sich 15 akute Appendizitiden und 5 perforierte Apppendices, in der Gruppe der laparoskopisch behandelten Kinder 17 akute und 3 perforierte Appendizitiden sowie 3 andere Diagnosen. In der Laparotomiegruppe war die Operationszeit kürzer als bei der Laparoskopie. Hinsichtlich des Krankenhausaufenthaltes und des postoperativen Verlaufs fanden sich keine Unterschiede. Hingegen wurden bei der laparoskopischen Gruppe zwei kleinere Komplikationen beobachtet.
Vergleicht man die beiden Methoden, so ergibt sich im Hinblick auf die nicht perforierten Appendizitiden kein Unterschied, weder im Hinblick auf die Operationszeit, Krankenhausaufenthalt noch beim postoperativen Verlauf.
Schlussfolgerung: Die laparoskopische Appendektomie zeigt keinen Vorteil gegenüber der Laparotomie. Bei einer typischen akuten Appendizitis, insbesondere bei Perforation, sollte deshalb die Laparotomie vorgezogen werden. Die Laparoskopie hat ihren Platz bei unklarer Diagnose.
The benefits of laparoscopic appendectomy appear to be controversial. Since 1994, several abdominal procedures have been completed by using the needlescopic technique, but there appear to be no prospective studies to demonstrate the perceived benefits of needlescopic appendectomy. The authors compared open, laparoscopic, and needlescopic appendectomy in a randomized fashion with regard to duration of surgery, length of hospitalization, analgesic dosage, and surgery-associated complications. From March to July 1998, 75 patients admitted at the emergency station of the authors' hospital with a final diagnosis of acute appendicitis without tumor formation were randomized to receive one of the three treatment categories: open (OA), laparoscopic (LA), and needlescopic (nLA) appendectomy. Laparoscopic and needlescopic appendectomy were performed by using a three-port technique, although the size of the trocar used varied. There were 26 patients in the OA group, 23 in the LA group, and 26 in the nLA group. The mean operation durations for the OA, LA, and nLA groups were 55.4 +/- 28.0 minutes, 69.1 +/- 48.8 minutes, and 62.3 +/- 26.3 minutes, respectively, and these were not significantly different from one another. The mean number of the analgesic doses (Pethidine 1 mg/kg) required was 1.3 +/- 1.2 mg/kg, 0.5 +/- 0.8 mg/kg, and 0.2 +/- 0.6 mg/kg, respectively. Significant differences were noted when comparing the OA with the LA or nLA groups (OA vs. LA, P = 0.02; OA vs. nLA, P = 0.0002; LA vs. nLA, P = 0.06). The mean oral intake durations were 32.2 +/- 16.9 hours, 21.0 +/- 14.6 hours, and 20.8 +/- 16.4 hours, respectively, after surgery for the OA, LA, and nLA groups, and the between-group differences were statistically significant for the OA versus LA group ( P = 0.004) and for the OA versus nLA group ( P = 0.003). The mean durations of hospitalization for the OA, LA, and nLA groups were 3.6 +/-1.8 days, 2.8 +/- 1.4 days, and 2.4 +/- 0.9 days, and difference was detected between the OA and the nLA groups ( P = 0.02). The OA group rendered a greater wound-complication rate and ileus than did the other two groups, but the differences were not detected between the three categories ( P = 0.065, 0.6935). The result of the current study confirmed that the nLA procedure is a feasible and safe one. The nLA procedure provided substantial advantages over the OA procedure in the contexts of diminished postoperative pain and shorter hospital stay without significant increases in postoperative complication rate or surgical time.
Appendectomy can be performed using either a laparoscopic technique (LT) or an open technique (OT). We compared the following items operative, anesthesia, length of stay, post-operative pain, medicine, wound healing, days to return to normal activity in both groups.
This study was carried out at King Fahad Hospital, Hofuf, Al-Hassa, Kingdom of Saudi Arabia, from January 1999 to April 2000. We randomly assigned 60 female patients to appendectomy by LT or OT. The 2 groups were compared concerning demographic data. The differences were considered statistically significant at a P value < 0.05.
The open group had shorter anesthesia and operative time (68, 50 versus 85, 65 minutes). The laparoscopic group had a significant reduced postoperative narcotic requirement (P<0.05), quicker reintroduction of diet and quicker return to normal activity.
Laparoscopic appendectomy in female patients with clinical diagnosis of appendicitis is the procedure of choice for the diagnosis and the management of acute appendicitis.
Appendectomy in the course of acute appendicitis is one of the most frequently performed surgical procedure in general surgery. The aim of this study was to compare the results of laparoscopic and conventional treatments for acute appendicitis in a prospective, randomized, unicenter study.
The study involved 200 patients treated for acute appendicitis in the Department of General and Vascular Surgery at Ceynowa Hospital in Wejherowo, Poland.
The mean operative time for open surgery was 36.99 min. For laparoscopic method the operation was longer, requiring 47.75 min. Suction drainage was applied in 23 patients treated conventionally and 50 patients treated laparoscopically ( p < 0.05). The requirement for analgesia, measured by the number of metamizole ampules, was significantly higher in the conventional group. Pain on postoperative days 2 and 7 measured using a visual analog scale, was significantly more severe for the patients treated conventionally. The hospital stay in both groups did not differ significantly: 5.03 days for the conventional group and 4.71 days for the laparoscopic group. The time until return to work and social activities in the laparoscopic group (15.85 days) and was significantly shorter than in the conventional group (19.65 days). Seven complications occurred in the conventional group (6.7%) and nine (9.4%) in the laparoscopic group. The difference was not statistically significant. No deaths occurred.
On the basis of the conducted study, it may be assumed that laparoscopic appendectomy is a safe procedure, and that postoperative morbidity is comparable with that for a conventional operation. There was less postoperative pain and shorter recovery time after laparoscopic surgery than after the open procedure.
To see whether laparoscopy improves the accuracy of a clinical diagnosis of acute appendicitis in women of reproductive age, and to determine what the long-term sequelae are of not removing an appendix deemed at laparoscopy to be normal.
The initial part of the study was undertaken during 1991-1992. Female patients between 16 and 45 years were eligible for inclusion once a clinical decision had been made to perform an appendicectomy for suspected acute appendicitis. Following consent, patients were randomized into two groups. One group had open appendicectomy, as planned. The other group had laparoscopy, followed by open appendicectomy only if the appendix was seen to be inflamed or was not visualized. The end points for the study were the clinical outcomes of all patients, and the results of histology, where appropriate. An attempt was made to contact all patients at 10 years to determine whether they had had a subsequent appendicectomy, or had been diagnosed with another abdominal condition that might be relevant to the initial presentation in 1991-1992.
Laparoscopic assessment was correct in all cases in which the appendix was visualized. Diagnostic accuracy was improved from 75% to 97%. Laparoscopy was associated with no added complications, no increase in hospital stay in patients who went on to appendicectomy, and a reduction in hospital stay for those who underwent laparoscopy alone. No patients developed a problem over the 10-year follow-up period from having a normal-looking appendix not removed at laparoscopy.
Laparoscopic assessment of the appendix is reliable, and to leave a normal-looking appendix at laparoscopy does not appear to cause any long-term problems.
The aim of this study was to evaluate prospectively whether laparoscopic (LA) and open appendectomy (OA) are equally safe and feasible in the treatment of pediatric appendicitis.
A total of 517 children with acute appendicitis were randomly assigned to undergo LA or OA appendectomy, based on the schedule of the attending surgeon on call. Patient age, sex, postoperative diagnosis, operating time, level of training of surgical resident, length of postoperative hospitalization, and minor and major postoperative complications were recorded. Chi-square analysis and the Student t-test were used for statistical analysis.
In all, 376 OA and 141 LA were performed. The two groups were comparable in terms of patient demographics and the incidence of perforated appendicitis. The operative time was also similar (47.3 +/- 19.7 vs 49.9 +/- 12.9 min). The overall incidence of minor or major complications was 11.2% in the OA group and 9.9% in the LA group.
Pediatric patients with appendicitis can safely be offered laparoscopic appendectomy without incurring a greater risk for complications. Nevertheless, a higher (but not significantly higher) abscess rate was found in patients with perforated appendicitis who underwent laparoscopy.
The comparison of laparoscopic to open appendectomy has been reviewed in many retrospective and prospective studies. Some report shorter hospital stays, less postoperative pain, and earlier return to work while others fail to demonstrate such differences. We performed a prospective, randomized double-blinded trial to evaluate this ongoing debate.
Fifty-two consecutive men presenting with signs and symptoms suggestive of acute appendicitis were randomized to undergo either laparoscopic appendectomy or open appendectomy. Length of operative times, hospital stay, lost work days, visual analog pain scores, and operative costs were compared.
Length of stay averaged 21.5 h for the laparoscopic group and was not statistically different when compared to the open group. Perceived postoperative pain on postoperative days 1 and 7 were not statistically different between the two groups. Mean time to return to work was 11 days, and there was no statistical difference between groups. Operative costs were >600 dollars greater for the laparoscopic approach.
In this prospective randomized double-blinded trial, laparoscopic appendectomy appears to confer no significant advantage over open appendectomy for postoperative pain or lost work days. It does carry an increase in operating room costs and, contrary to other reports, hospital stay is not shortened. Further studies are needed to determine if specific populations, such as the obese or women, may benefit from a minimally invasive approach to appendicitis.
Laparoscopic procedures are performed commonly in children. In general, the cost containment of laparoscopic surgery in children has not been evaluated.
To compare the costs of laparoscopic appendectomy with those of open appendectomy.
Prospective clinical trial between November 1, 1997, and April 30, 2000. For analysis, cost of supplies, operation room use, and recovery in the hospital and after discharge was evaluated. Costs common to both groups were not determined.
Operations performed in a university hospital.Patients Eighty-seven children aged 4 to 15 years who underwent appendectomy for suspected appendicitis. Patients were randomized to laparoscopic or open appendectomy. Intervention Laparoscopic appendectomies performed with the same standard set of reusable equipment.
Cost surplus of the laparoscopic procedure and recovery after surgery were evaluated, to determine the costs and effects of laparoscopic appendectomy compared with those of open appendectomy in children.
Excess operating and complication costs per procedure were 96 euros (EUR) in laparoscopic appendectomy. The increased operative expenses were offset by a shorter hospital stay, resulting in a marginal difference of 53 EUR in itemized total costs between the 2 procedures (total cost, 1023 EUR in the laparoscopic appendectomy group and 970 EUR in the open appendectomy group). After laparoscopic appendectomy, children returned to school and sports earlier than those who had had an open appendectomy.
Laparoscopic appendectomy was marginally more expensive, but it allowed earlier return to normal daily activities than open appendectomy.
To assess the utility of laparoscopic versus conventional surgical exploration in premenopausal women with suspected acute appendicitis.
Female patients aged 15-45 years in whom an independent decision to undertake surgical exploration had been made, were randomised to laparoscopic or open procedures. Comparison of patient groups was conducted on an intention-to-treat basis.
Eighteen patients underwent laparoscopic exploration, with 1 procedure requiring conversion to lower midline laparotomy. Open surgical exploration was performed primarily in 16 patients. Postoperative complications (3 patients versus 1 patient) and diagnostic errors (5 patients versus 1 patient) were more frequent in patients undergoing open surgical procedures. Laparoscopic procedures tended to be of longer duration than open operations, but were generally associated with slightly more favourable indices of postoperative recovery (analgesic requirement, postoperative hospitalisation, return to normal activity, return to work). In patients found not to have acute appendicitis, the difference in mean postoperative hospitalisation following laparoscopic intervention (2.6 days) and conventional surgery (3.4 days) approached statistical significance (p < 0.1).
Laparoscopy may carry some diagnostic advantage over open surgery in premenopausal women with suspected acute appendicitis. Patients found not to have acute appendicitis have a marginally shorter period of hospitalisation after laparoscopic intervention. The outcome following laparoscopic appendicectomy for confirmed acute appendicitis is at least equivalent to that achieved with conventional appendicectomy. Laparoscopic exploration is an acceptable option in premonopausal women requiring surgery for suspected acute appendicitis.
Laparoscopy is safe for diagnostic and therapeutic purposes in patients with suspected acute appendicitis. This study compared recovery after laparoscopic (LA) and open appendicectomy (OA) for confirmed appendicitis, carried out by experienced surgeons in an educational setting.
One hundred and sixty-three patients with laparoscopically confirmed appendicitis suitable for LA were randomized prospectively to either LA or OA in a blinded fashion. The primary endpoint was time to full recovery. Secondary endpoints were operating time, complications, hospital stay and functional status.
There was no significant difference between LA and OA in time to full recovery (9 and 11 days respectively; P = 0.225). Operating time was 55 min in the LA group and 60 min in the OA group (P = 0.416). The complication rate was 8.6 and 11.0 per cent respectively (P = 0.696), and median hospital stay was 2 days in both groups (P = 0.192). Functional status was significantly better in the LA group 7-10 days after operation (P = 0.045).
There was no difference in time to full recovery after LA and OA in patients with laparoscopically confirmed appendicitis. A trend towards better physical activity was noted after the laparoscopic procedure.
A prospective randomized comparison of laparoscopic appendectomy with open appendectomy: clinical and economic analyses
- Long
A randomised control study on the appendectomy of 103 cases with laparoscopy or mini-incision
- Zhang
Laparoscopic appendicectomy: current status [review]
- Memon
The utility of laparoscopy in the diagnosis of acute appendicitis in women of reproductive age
- van Dalen