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Laparoscopic Versus Open Appendectomy: A Prospective Randomized Double-Blind Study
Abstract
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.
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.
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).
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.
... Although the incidence of intra-abdominal abscess formation was higher after laparoscopic appendectomy, all complications occurred early in our practice. Greater experience and improvements in our technique has made it possible to eradicate this catastrophic complication (12) . ...
... Another study done by Katkhouda et al. (12) showed that the operative time was significantly longer in the laparoscopic group (80 minutes versus 60 minutes with P = 0.000. ...
... On the other hand, the study done by Katkhouda et al. (12) showed that the severity of pain experienced and its influence on activity were similar for both groups. Narcotic medication usage to control postoperative pain was also equivalent between the 2 groups which can be compared to this study. ...
... In our study, mean duration of operation in two groups was comparable and difference was not statistically significant (p>0.05). This finding was supported by few studies [11][12][13] and not supported by other studies [14][15][16][17] . In this study, 4.7% patient in OA group and 00% in LA group develop surgical site infection which was not statistically significant (p>0.05). ...
... In this study, 4.7% patient in OA group and 00% in LA group develop surgical site infection which was not statistically significant (p>0.05). Similar observations were reported from other studies 2,11,15,18 . Significantly higher infection rate was seen in OA group in few studies [7][8][9][10]13,19 . ...
... Less tissue handling and less post operative pain are the probable reasons of such findings. Similar finding was seen in few studies 2,9,19,21 and opposing finding in another study 15 . Early return to light and heavy works was observed in LA group in our study (p<0.001) which was supported by few studies 17,20,21 . ...
Introduction: Open appendectomy and laparoscopic appendectomy are two modalities in the treatment of appendicitis. Superiority of one over another is not clear. Objectives: To compare per-operative and post operative outcomes between open and laparoscopic appendectomy. Material and Methods: Prospective comparative study was conducted on patients with acute appendicitis who underwent open appendectomy (OA) (n=43) or laparoscopic appendectomy (LA) (n=59) from October 2018 to October 2019 in Combined Military Hospital (CMH), Savar. The two groups were compared in respect to patients' characteristics, duration of operation, operative findings, post operative pain, return of peristalsis, resume of oral feeding, post operative complications, return to activities and cosmesis. Statistical analysis was performed using SPSS 25.0. Continuous and categorical variables were analyzed using independent sample t test and chi-square test respectively and p <0.05 was considered statistically significant. Results: There was no statistical difference regarding patient characteristics between the two groups except total leukocyte count (TLC) and neutrophil count, both were higher in OA group (p<0.001). LA group was associated with less post operative pain (p<0.001), early resume of oral feed (OA-34.74±8.34 minutes vs LA-24.51±6.13 minutes; p<0.01), early return to light work (OA-4.26±1.3 days vs LA-2.53±0.7 days; p<0.001), heavy work (OA-66.93+19.38 days vs LA-37.36+10.02 days; p<0.001) and better cosmesis (highly satisfied in LA group 96.6% vs 30.2% in OA group). No significant difference was seen in duration of operation (50±13.72 and 53.31±7.69 minutes in OA and LA groups respectively; p>0.05). There was no significant difference in post operative complications (p>0.05). Conclusion: Laparoscopic appendectomy was found clearly superior to open appendectomy in terms of less post operative pain, early resume of oral feed, early return to light and heavy works and better cosmetic result. Both procedures are comparable in terms of duration of operation and post operative complications. JAFMC Bangladesh. Vol 16, No 2 (December) 2020: 51-54
... appendisectomy has been the gold standard for treating patients with acute appendicitis for more than a century, but the efficiency and superiority of laparoscopic approach compared to the open technique is the subject of much debate nowadays.[3][4][5]There is evidence that minimal surgical trauma through laparoscopic approach resulted in significant shorter hospital stay, less postoperative pain, faster return to daily activities in several settings related with gastrointestinal surgery.[6][7]However, several retrospective studies[3,[8][9][10][11][12][13][14], several randomized trials[15][16][17][18][19][20]and metaanalyses[21,22]comparing laparoscopic with open appendisectomy have provided conflicting results. Some of these studies have demonstrated better clinical outcomes with the laparoscopic approach[15][16][17]20], while other studies have shown marginal or no clinical benefits[18,19]and higher surgical costs.[4,19]Bearing in mind that laparoscopic appendisectomy, unlike other laparoscopic procedures, has not been found superior to open surgery for acute appendicitis, we designed the present study to determine any possible benefits of the laparoscopic approach. ...
... several retrospective studies[3,[8][9][10][11][12][13][14], several randomized trials[15][16][17][18][19][20]and metaanalyses[21,22]comparing laparoscopic with open appendisectomy have provided conflicting results. Some of these studies have demonstrated better clinical outcomes with the laparoscopic approach[15][16][17]20], while other studies have shown marginal or no clinical benefits[18,19]and higher surgical costs.[4,19]Bearing in mind that laparoscopic appendisectomy, unlike other laparoscopic procedures, has not been found superior to open surgery for acute appendicitis, we designed the present study to determine any possible benefits of the laparoscopic approach. ...
... several retrospective studies[3,[8][9][10][11][12][13][14], several randomized trials[15][16][17][18][19][20]and metaanalyses[21,22]comparing laparoscopic with open appendisectomy have provided conflicting results. Some of these studies have demonstrated better clinical outcomes with the laparoscopic approach[15][16][17]20], while other studies have shown marginal or no clinical benefits[18,19]and higher surgical costs.[4,19]Bearing in mind that laparoscopic appendisectomy, unlike other laparoscopic procedures, has not been found superior to open surgery for acute appendicitis, we designed the present study to determine any possible benefits of the laparoscopic approach. ...
... 45 prospective randomized studies, 4 meta analyses, 4 systematic reviews (including 1 cochrane database ) and 4 large non randomized comparative trials were included in the review. 25 In 1993, Tate et al from Hong Kong published data collected on the initial 55 patients 6 months after the introduction of LA in their hospital, that were compared to 100 OA. 26 They found significant benefits in favor of LA. These same authors in a follow up PRS conducted in the same institution concluded that their study could "no longer support the widespread adoption of a laparoscopic alternative to a traditional operation based on initial uncontrolled studies. ...
Background:Appendicectomy has been the treatment of choice for acute appendicitis. Since advent Laparoscopic appendicectomy (LA) has struggled to prove its superiority over the open technique. This is in contrast to laparoscopic cholecystectomy, which has promptly become the gold standard for gallstone disease. Open appendicectomy (OA) has withstood the test of time for more than a century. The procedure is standardized among surgeons and unlike cholecystectomy, OA is typically completed using a small right lower quadrant incision and postoperative recovery is usually uneventful. Hence there a need to compare both in terms of efficacy and other issues. Methodology: The primary objective of this study is to compare the results of LA with that of OA in terms of operating time, post-operative pain, wound infection, duration of hospital stay and time to return to usual activities. The secondary objective is to study the intra-operative factors causing conversion of LA to OA. Observational comparative study between two groups ie Open appendicectomy group and Laparoscopic appendicectomy group during period of Jan 2014 to Dec 2016 in a tertiary care teaching hospital results were analysed and conclusions were made with respect to post operative pain, stay, conversions etc Results and conclusion: A Total of 192 cases included in the study of which 100 manged by open appendicectomy and 85 by laparoscopic appendicectomy 7 were excluded from the study as lap converted to open so primary analysis cannot be interpreted. Most of the cases were males most common cause of conversion is difficulty in identification of appendix due to anatomy or technique of approach. There is no much of differences between outcomes and laparoscopic is little advantageous in view of less post operative pain and early recovery and post op wound infections requiring interventions are relatively low however Cost factor and of-course in cases with peritonitis open appendicectomy is preferred.
... Appendicitis is a common general surgical emergency admission with the mainstay of treatment being appendicectomy, which is performed either by an open technique or laparoscopically 1,2 . Antibiotics are used during the course of the operation, either pre-operatively or at induction of anaesthesia to reduce the incidence of postoperative complications, especially wound infections. ...
... LA has been proven in several trials [23][24][25][26] to be safe and to result in a speedier recuperation to regular work with fewer wound problems. Other studies have contrast results, claiming that there is no substantial variation in outcome between the two surgeries and that LA is more expensive [27][28][29][30] . ...
Background: The most frequent reason of pain abdomen and a common cause of emergency surgery is appendicitis. Males have an 8.6% lifetime risk of suffering appendicitis, while females have a 6.7 percent lifetime risk. Materials and Methods: Between July 2018 and June 2019, we did a retrospective review of patients who had appendectomies at The Oxford Medical College Hospital in Bangalore, Karnataka. We looked at the clinical data of 140 patients who matched the inclusion criteria. The patients were split into two groups: those who had a laparoscopic appendectomy [LA = 70] and those who had an open appendectomy [OA = 70]. A total of 140 patients with acute appendicitis, 70 patients each underwent open and laparoscopic appendectomy.Results: The time taken to return to ordinary daily activities were significantly different between the two groups, with the laparoscopic group taking 11.5±3.1 days on average against 16.1±3.3 days in the open appendectomy group. In the laparoscopic group, seven patients had complications, while in the open appendectomy group fifteen had complications. Laparoscopic appendectomy has fewer complications than open appendectomy.Conclusion: Regardless of age, sex, or return to regular activity, laparoscopic appendectomy is the operation of choice for the majority of patients. It has fewer complications and requires a fewer hospital stays, as well as the ability to treat concurrent disorders.
... In our study, post-operative complications were low occurred in 5 cases(16.7%). Katkhouda et al. (6) in his prospective randomized double-blind study and Sauerland (7) in his Cochrane Review of 45 studies reported a low wound infection, high operating time & high incidence of intra-abdominal abscess (IAA) for laparoscopic appendectomy. ...
Background: The role of laparoscope in management of complicated appendicitis is increasing. Methods: 30 patients with complicated appendicitis underwent laparoscopic appendectomy were studied. Patients undergoing laparoscopic appendectomies were evaluated according to patient safety, postoperative outcome as regard Analgesia use, length of hospital stay, return to normal oral feeding and postoperative complications. Results: laparoscopy is efficient in management of complicated appendicitis, diagnose and treat associated diseases and less post-operative complications. Conclusions: laparoscopic appendectomy is a safe and efficient method in management of complicated appendicitis. It could tried first for every case of complicated appendicitis.
... feasible in patients with SARS-CoV-2, but even more, that it may be a safe alternative as compared to laparoscopic appendectomy with regard to the frequency and grade of complications (25). The high rates of respiratory complications and death which were reported in the largest multi-national study but not present in our experience, may be hypothesized to be due to our frequent (90%) use of regional anesthesia, however anesthetic approach was not associated with pulmonary or other complication in existing reports (8). ...
Background:
We present outcomes of patients with SARS-CoV-2 undergoing appendectomy in order to aid in clarification of current controversies regarding safety of therapeutic options for emergency surgical diseases in patients with SARS-CoV-2. Peru has the greatest number of per capita deaths due to SARS-CoV-2 of any country and is one of few with a COVID-dedicated hospital.
Materials and methods:
This prospective observational study included all adult patients with acute appendicitis admitted to an urban, public, COVID-dedicated hospital over two months. Baseline characteristics and post-operative outcomes at 28 days are reported.
Results:
58 patients, 35 male and 23 female, ages 15-73 years with SARS-CoV-2 as diagnosed by IgM (12%), IgG (19%) or both (69%) and acute appendicitis as diagnosed using the Alvarado Score and confirmed intraoperatively were enrolled. All patients presented with right lower quadrant pain, 86% with leukocytosis, 88% with nausea/emesis and no patients with respiratory complaints. All patients underwent open appendectomy, 90% under regional anesthesia. Average operative time was 54±25 minutes, length of stay 2.5±1.5 days. 14% of patients had a post-operative complication, all were minor, four (7%) incisional surgical site infections, one (2%) organ space, and three (5%) incisional seromas, no deaths or serious complications.
Conclusion:
Open surgical management of acute appendicitis with regional anesthesia in adults with pre-operative diagnosis of SARS-CoV-2 is feasible and not associated with an increased frequency or severity of post-operative complications, longer operative time, or extended hospitalization as compared to reports in similar patients without SARS-CoV-2.
... The findings in our study were comparable with other national and international studies. [7][8][9][10][11][12] Male to female ratio in our study was 1.14:1 and 1:1 in open and laparoscopic group respectively. Similar findings were also noted in Subramaniam and Khatana et al study. ...
... For example, Katkhouda et al. reported that laparoscopic appendectomy, unlike other minimally invasive procedures, did not offer a significant advantage over open appendectomy in their studied parameters, with the exception of the quality of life scores at 2 weeks. The study also noted the longer time needed to perform LA [34]. ...
Purpose
Deemed as a safe and easily performed procedure in children, transumbilical laparoscopic-assisted appendectomy (TULA) also offers several other advantages: reduced costs, a lower wound infection rate, fewer postoperative complications, and better cosmetic outcomes. The present investigation compares the results of three methods of appendectomies: 1-conventional, 2- laparoscopic, and 3- transumbilical laparoscopic-assisted.
Methods
The current study enrolled 210 patients and divided them into three groups of 70 each. Each group underwent one of the three methods of appendectomy. In TULA, the appendix exteriorized from the umbilicus laparoscopically, and then an extra-corporeal appendectomy was performed. The surgical approaches for the other two patient groups were standard techniques normally utilized in laparoscopic (LA) and open appendectomy (OA).
Results
In TULA, the mean operation length was significantly shorter than that in LA. Regarding scar size, the smallest were from the TULA group, with a significant difference in surgical wound size when compared with those of the other two groups. The length of the hospital stay was significantly shorter for TULA and LA patients than for OA patients. In addition, there was a lower wound infection rate associated with TULA than with LA and OA.
Conclusions
TULA is an alternative method of appendectomy in uncomplicated pediatric acute appendicitis. Compared to other approaches, TULA is technically easier, has a shorter operation time, offers better surgical outcomes, involves less surgical site infections, and results in excellent cosmetic results.
Trial registration
The trial is registered in the Iranian Registry of Clinical Trials (IRCT id: IRCT201703088375N12).
... Operating room costs and time were increased and the hospital stay was not shortened. Only quality of life scores at 2 weeks were in favor of the laparoscopic procedure [147][148][149][150]. An umbrella review of meta analyses reported a lower rate of surgical site infections but higher rate of intra-abdominal abscess formation in laparoscopic compared to open appendectomy [151]. ...
As many meta-analyses comparing pediatric minimally invasive to open surgery can be found in the literature, the aim of this review is to summarize the current state of minimally invasive pediatric surgery and specifically focus on the trends and developments which we expect in the upcoming years. Print and electronic databases were systematically searched for specific keywords, and cross-link searches with references found in the literature were added. Full-text articles were obtained, and eligibility criteria were applied independently. Pediatric minimally invasive surgery is a wide field, ranging from minimally invasive fetal surgery over microlaparoscopy in newborns to robotic surgery in adolescents. New techniques and devices, like natural orifice transluminal endoscopic surgery (NOTES), single-incision and endoscopic surgery, as well as the artificial uterus as a backup for surgery in preterm fetuses, all contribute to the development of less invasive procedures for children. In spite of all promising technical developments which will definitely change the way pediatric surgeons will perform minimally invasive procedures in the upcoming years, one must bear in mind that only hard data of prospective randomized controlled and double-blind trials can validate whether these techniques and devices really improve the surgical outcome of our patients.
... But leaving some studies, others have not given any clearcut benefit of preferring laparoscopic technique over open. 4,7,8 ...
Background:-laparoscopic/ minimally invasive surgery since starting has been a prime focus for surgeons for performing various surgeries. First documented laparoscopic appendicectomy being performed 1982 and since then with gaining experience, the laparoscopic appendicectomy is gaining preference. Our study, which has been held at a tertiary care centre in north India is done to prove the same. Methods:-this study was done over 5 years period (june 2014 to june 2019). A total of 120 patients were treated by laparoscopic appendicectomy and were followed up for 3 months post operatively. Restrospective data was collected from outpatient and inpatient clinical records compiled and tabulated. Post operative morbidity record in the form of pain, bleeding, fistula formation, wound infection, etc was noted and documented.
... 11 Th is practice has been aggressively pursued by surgeons on the basis of its association with a "low" incidence of infectious complications, the elimination of painful and time-consuming dressing changes and reduction in cost. 9,14 Primary closure of appendicitis with perforation has also found its way into the management algorithm, without adequate assessment of adverse outcomes. More recently, Yellin and colleauges 15 found a wound infection rate of 4% after delayed primary closure of all their advanced appendicitis wounds. ...
... The findings in our study were comparable with other national and international studies. [7][8][9][10][11][12] Male to female ratio in our study was 1.14:1 and 1:1 in open and laparoscopic group respectively. Similar findings were also noted in Subramaniam and Khatana et al study. ...
Background: Open appendectomy has been the gold standard for the treatment of acute appendicitis since its introduction by Charles Mc Burney in 1889.The introduction of laparoscopic surgery has dramatically changed the field of surgery. Various studies showed conflicting results about the superiority of laparoscopic approach over open for treatment of acute appendicitis. Present study is conducted to determine any possible benefits of the laparoscopic approach over open surgery.Methods: The study was conducted in Dr. V. M. Government Medical College and hospital located in Solapur (Maharashtra) from September 2017 to September 2019. It is a prospective comparative study. Patients were randomly divided into 2 groups alternately where group A and B were operated by conventional and laparoscopic techniques respectively and their outcomes were compared.Results: Mean age of patients in open and laparoscopic appendicectomy group was 29.67 years and 31 years respectively. Post-operative pain, wound infection and hospital stay was significantly more in open group as compared to laparoscopic group (p<0.05).Conclusions: From the results of our study we conclude that laparoscopic appendicectomy has superior results as compared to open appendicectomy.
... Postoperative ileus in our study was twice in OA than in LA, 10 patients (37%) in OA while only 5 patients (18.5%) in LA. This is agreed with a study done by Katkhouda and his collogues in (2005), which reported that laparoscopic surgery reduces postoperative ileus with early switch to oral diet (table 1) (4) . ...
... However, in some studies conducted by Yong JL et al 2005, Katkhouda et al 19 and Heinzelmann et al 20 showed no significant difference between the complication rates of open and laparoscopic appendectomy. In cases of LA, infection is significantly less due to lack of contamination to the abdominal wall. ...
... Numerous studies have compared laparoscopic and open appendicectomy without any conclusive benefit demonstrated. [6][7][8][9] Any differences between the two techniques in terms of outcomes is minimal in paediatric patients. What has been advocated more is the appropriate technique for an individual surgeon and individual patient. ...
The new generation of trainees may be obtaining more experience of laparoscopic appendicectomy, at the expense of exposure to open surgery training.
... [3]. Sauerland et al. also reported the early recovery to normal activity among LA treated patients [8], whereas Guller et al. reported early discharge in case of LA [9]. Similarly, another study carried out in Jeddah also documented an early reintroduction of diet and recovery to normal activity in LA as compared to OA [10]. ...
... The time taken for bowel to return to normal activity is measured by assessing bowel sounds & passage of flatus. Previous studies have also shown similar results for the time taken for bowel sounds to return.17 Laparoscopic appendectomy has a lower incidence of complications compared with open appendectomy. ...
... Although open appendectomy (OA) has been the gold standard for treatment of acute appendicitis for more than a century, the management of appendiceal abscess is controversial. [1][2][3] Open surgery for periappendiceal abscess is technically challenging, and may be fraught with postoperative complications. On the other hand, persistent symptoms, recurrent abscesses, and numerous home healthcare visits may complicate drainage procedures followed by interval appendectomy. ...
Laparoscopic appendectomy (LA) has become well accepted, but the role of LA for appendicitis upon presentation with an abscess remains undefined. This study was to assess the postoperative recovery and complications following LA in pediatric patients with appendiceal abscess in comparison with open appendectomy (OA).
We conducted a retrospective review of patients presented with appendiceal abscess between 2005 and 2016. Propensity score matching (PSM) was conducted to adjust for any potential selection bias for the surgical approaches. In 108 matched patients, operative outcomes and surgical complications were evaluated based on LA or OA.
The patients with LA experienced prompt postoperative gastrointestinal function recovery, like first bowel movement (risk ratio [RR], 0.52; 95% confidence interval [CI], 0.44–0.69; P < .001), so spend the lower mean length of hospitalization (RR, 0.53; 95% CI, 0.41–0.76; P < .001) in comparison with patients with OA. Furthermore, the immunologic and inflammatory variable white blood cell (WBC) (RR, 0.56; 95% CI, 0.46–0.73; P < .001) and C-reactive protein (CRP) (RR, 0.58; 95% CI, 0.43–0.86; P = .011) on postoperative days (POD) 5 was reduced in patients undergone LA compared with that of OA. A lower overall postoperative complication rate, including surgical wound infection (odds ratio [OR], 0.38; 95% CI, 0.18–0.81; P = .008) and incision dehiscence (OR, 0.06; 95% CI, 0.01–0.45; P < .001) was noted in patients with LA compared with OA.
LA was feasible and effective for appendicitis upon presentation with an abscess and associated with beneficial clinical effects, such as postoperative gastrointestinal function recovery and reduced postoperative complications. LA should be seriously considered as the first line procedure of choice.
El dolor abdominal es una causa frecuente de consulta en cualquier servicio de urgencias, y por esto, los médicos de atención primaria deben conocer las patologías que puedan poner en peligro la vida de sus pacientes. Se hace una revisión de las patologías mas frecuentemente asociadas a dolor abdominal en el ámbito de urgencias, y se hace énfasis en los medios por los que se puede llegar al diagnóstico adecuado y los conceptos generales del tratamiento de cada una de estas condiciones.
Introduction:
The findings of previous studies in the management of acute appendicitis with peritonitis complications are debatable. Thus, in this study, we aim to evaluate two surgical procedures in the management of acute appendicitis.
Material and methods:
We piloted an observational prospective study on 50 subjects of both genders with acute appendicitis and peritonitis complication. They were divided equally into two groups who received laparoscopic and conventional open surgery. The data were collected for the various clinical parameters, the complications that followed, and the success rates. The data were analyzed using the t test deliberating P < 0.05 as significant.
Results:
We observed a similar distribution of genders, and the mean was 41 ± 0.5 years. We observed that among the laparoscopic group, the longer the surgical time, the shorter the stay at the hospital. Lower complications though not significant were noted than the open method.
Conclusion:
The laparoscopic approach may be suggested for the management of patients with acute appendicitis and with peritonitis. This method showed early patient discharge and fewer post-surgical complications.
Background:
Laparoscopic appendectomy (LA) is claimed to require less analgesic and allow for a faster return to work. This study examines whether these benefits hold true in Asian patient populations.
Methods:
A retrospective audit of emergency appendectomies over one year was conducted to study outcomes of postoperative pain, length of stay (LOS), duration of analgesia, and hospitalization leave (HL). A telephone questionnaire evaluated post-discharge analgesic intake, residual symptoms at follow-up, adequacy of HL and opinion on teleconsult reviews.
Results:
Of the 201 patients, 187 (93%) underwent LA. Presurgery symptoms were significantly longer in the open appendectomy (OA) group (mean: OA 3.79, LA 1.81 days; p = 0.026) which also had a higher frequency of perforation (71.4%). LA patients reported less pain compared to OA (LA 3.60 vs. OA 4.14; p = 0.068) but were prescribed the same 2 weeks of analgesics as OA. LOS was significantly less for LA (mean LA 3.09, OA 6.93 days; p = 0.006). Mean HL for LA and OA were 17.9 and 21.8 days respectively (p = 0.05). Nearly 83% patients did not complete the prescribed course of analgesics and 47% patients felt that HL was more than adequate. Seventy-five percent of patients were asymptomatic at hospital follow-up and nearly 41% agreed to teleconsult reviews.
Conclusion:
Majority of LA patients do not need 2 weeks of analgesics and their HL can be shortened for faster return to work thereby realizing the true benefits of minimally invasive surgery. Selected cases can be offered postoperative teleconsultation.
Background
COVID-19 infection is a global pandemic that affected routine health services and made patients fear to consult for medical health problems, even acute abdominal pain. Subsequently, the incidence of complicated appendicitis increased during the Covid-19 pandemic. This study aimed to evaluate recurrent appendicitis after successful drainage of appendicular abscess during COVID-19.
Material and methods
A prospective cohort study conducted in the surgical emergency units of our University Hospital between March 15, 2020 to August 15, 2020 including patients who were admitted with the diagnosis of an appendicular abscess and who underwent open or radiological drainage. Main outcomes included incidence, severity, and risk factors of recurrent appendicitis in patients without interval appendectomy.
Results
A total of 316 patients were included for analysis. The mean age of the patients was 37 years (SD ± 13). About two-thirds of patients were males (60.1%). More than one-third (39.6%) had co-morbidities; type 2 diabetes mellitus (T2DM) (22.5%) and hypertension (17.1%) were the most frequent. Approximately one quarter (25.6%) had confirmed COVID 19 infection. About one-third of the patients (30.4%) had recurrent appendicitis. More than half of them (56.3%) showed recurrence after three months, and 43.8% of patients showed recurrence in the first three months. The most frequent grade was grade I (63.5%). Most patients (77.1%) underwent open surgery. Age, T2DM, hypertension, COVID-19 infection and abscess size >3 cm were significantly risking predictors for recurrent appendicitis.
Conclusions
Interval appendectomy is suggested to prevent 56.3% of recurrent appendicitis that occurs after 3 months. We recommend performing interval appendectomy in older age, people with diabetes, COVID-19 infected, and abscesses more than 3 cm in diameter.
Research question
Is interval appendectomy preventing a high incidence of recurrent appendicitis after successful drainage of appendicular abscess during COVID-19 pandemic?
Background
Appendicitis is classified as either complicated (CA) or uncomplicated (UA). Some authors have shown that the epidemiologic trends of CA and UA may differ. The aim of this study was to clarify differences in backgrounds and surgical outcomes between CA and UA patients.
Methods
This study was a cohort study. We extracted case data from the Japanese Diagnosis Procedure Combination (DPC) database from January 2014 to December 2017. Patients were classified into three groups, depending on whether they underwent emergency appendectomy for CA (CA group), emergency appendectomy for UA (UA group), or elective appendectomy (EA group). We evaluated patient characteristics and surgical outcomes for each group.
Results
We included 89,355 adult patients in the study, comprising 29,331 CA, 48,691 UA, and 11,333 EA patients. Old age, larger body mass index, smoking, and medication with antidiabetic drugs, oral corticosteroids, oral antiplatelet drugs, and oral anticoagulant drugs were independent risk factors for CA. The percentage of CA increased with age. In-hospital mortality (0.15%, 0.02%, and 0.00%) and 30-d mortality (0.09%, 0.01%, and 0.00%), respectively, of CA patients were significantly higher than those of the UA and EA groups. The duration of postoperative antibiotic administration, duration of fasting, and time before removal of a prophylactic drain were significantly longer in the CA group than in the UA and EA groups.
Conclusion
Backgrounds and treatment outcomes of CA and UA patients after emergency surgery are entirely different. Thus, the treatment strategy of CA and UA patients should differ accordingly.
Acute appendicitis is the leading cause of abdominal emergency surgery worldwide and appendectomy continues to be the definitive
treatment of choice. This cost-effectiveness analysis evaluates laparoscopic versus open appendectomies performed in public health
services in the state of Bahia (Brazil). We conducted a retrospective observational study using the database from the Department of
Informatics of the Unified Health System (DATASUS). Available data on appendectomies between 2008 and 2019 were included, and
we evaluated the temporal trend of hospital admissions, procedure-related mortality rates, length of stay, and costs. Statistical analysis
was performed using the R-software (R Foundation, v.4.0.3) and the BioEstat software (IMDS, v. 5.3), considering p<0.05 as significant.
During 2008-2019, 53,024 appendectomies were performed in the public health services in Bahia, of which 94.9% were open surgeries.
The open technique was associated with a higher mortality rate (4.9/1,000 procedures; p<0.05) and a higher risk of death (RR=4.5;
p<0.05) compared to laparoscopy (1.1/1,000 procedures). Laparoscopic appendectomy (median of 2.7 days) had a shorter length of
stay compared to laparotomy (median of 4.15 days) (p<0.05). There was no difference in the medians of costs nor hospital services,
per procedure (p=0.08 and p=0.08, respectively). Laparoscopic professional median costs were higher by US$ 1.39 (p<0.05). Minimally
invasive surgery for appendicitis is a safe and efficacious procedure in Brazilian public health care services, as it provides advantages
over the open method (including lower procedure-related mortality rate and earlier discharges), and it did not imply higher expenses for
public service budgets in the state of Bahia.
Introduction
The world has been engulfed with the pandemic of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which have created significant impact in the emergency surgical health delivery including acute appendicitis. The main aim of this study was to compare the demographic and clinical parameters between two cohorts before the onset of lockdown and within the pandemic.
Methods
A retrospective analysis was performed between two groups A and B, who presented with acute appendicitis three months prior to and after initiation of lockdown on March 24 2020 respectively in one of the tertiary centers of Nepal. These two cohorts were compared in demographics, clinicopathological characteristics and surgical aspects of acute appendicitis.
Results
There were 42 patients in group A and 50 patients in group B. Mean age of the patients was 31.32±17.18 years with male preponderance in group B (N = 29). Mean duration of pain increased significantly in group B [57.8±25.9(B) vs 42.3±25.0(A) hours, P = 0.004] along with mean duration of surgery [51.06±9.4(B) vs 45.27±11.8(A) minutes, P = 0.015]. There was significant decrease in post-operative hospital stay among group B patients [3.04±1.1(B) vs 3.86±0.67(A) days, P = 0.0001]. Complicated cases increased in group B including appendicular perforation in 10 cases. Similarly, mean duration of presentation to hospital significantly increased in group B patients with perforation [69.6±21.01 vs 51.57±17.63 hours, P = 0.008].
Conclusion
During the adversity of the current pandemic, increased number of cases of acute appendicitis can be dealt with surgery as the chances of late presentation and complexity of the lesion exists.
Background The evidence regarding the safety and efficacy of nonoperative management is growing. However, the best treatment strategy for acute complicated appendicitis remains controversial. We aimed to evaluate the cost-effectiveness of treatment strategies for complicated appendicitis patients. This study sought to determine the most cost-effective strategy from the health care-payer's perspective
Methods The primary outcome was an incremental cost effectiveness ratio (ICER) using nonoperative management with or without interval laparoscopic appendectomy (ILA) as the intervention compared with operative management with emergency laparoscopic appendectomy (ELA) alone as the control. Model variables were abstracted from a literature review, and from data obtained from the hospital records of Tochigi Medical Center. Cost-effectiveness was evaluated using an ICER. We constructed a Markov model to compare treatment strategies for complicated appendicitis in otherwise-healthy adults, over a time horizon of a single year. Uncertainty surrounding model parameters was assessed via one-way- and probabilistic-sensitivity analyses. Threshold analysis was performed using the willingness-to-pay threshold set at the World Health Organization's criterion of $107,690.
Results Three meta-analysis were included in our analysis. Operative management cost $6,075 per patient. Nonoperative management with interval laparoscopic appendectomy (ILA) cost $984 more than operative management and produced only 0.005 more QALYs, resulting in an ICER of $182,587. Nonoperative management without ILA cost $235 more than operative management, and also yielded only 0.005 additional QALYs resulting in an ICER of $45,123 per QALY. Probabilistic sensitivity analysis with 1,000 draws resulted in average ICER of $172,992 in nonoperative management with ILA and $462,843 in Nonoperative management without ILA. The threshold analysis demonstrated that regardless of willingness-to-pay, nonoperative management without ILA would not be most cost-effective strategy
Conclusions Nonoperative management with ILA and Nonoperative management without ILA were not cost-effective strategies compared with operative management to treat complicated appendicitis. Based on our findings, operative management remains the standard of care and nonoperative management would be reconsidered as a treatment option in complicated appendicitis from economic perspective.
Background The evidence regarding the safety and efficacy of nonoperative management is growing. However, the best treatment strategy for acute complicated appendicitis remains controversial. We aimed to evaluate the cost-effectiveness of treatment strategies for complicated appendicitis patients. This study sought to determine the most cost-effective strategy from the health care-payer's perspective
Methods The primary outcome was an incremental cost effectiveness ratio (ICER) using nonoperative management with or without interval laparoscopic appendectomy (ILA) as the intervention compared with operative management with emergency laparoscopic appendectomy (ELA) alone as the control. Model variables were abstracted from a literature review, and from data obtained from the hospital records of Tochigi Medical Center. Cost-effectiveness was evaluated using an ICER. We constructed a Markov model to compare treatment strategies for complicated appendicitis in otherwise-healthy adults, over a time horizon of a single year. Uncertainty surrounding model parameters was assessed via one-way- and probabilistic-sensitivity analyses. Threshold analysis was performed using the willingness-to-pay threshold set at the World Health Organization's criterion of $107,690.
Results Three meta-analysis were included in our analysis. Operative management cost $6,075 per patient. Nonoperative management with interval laparoscopic appendectomy (ILA) cost $984 more than operative management and produced only 0.005 more QALYs, resulting in an ICER of $182,587. Nonoperative management without ILA cost $235 more than operative management, and also yielded only 0.005 additional QALYs resulting in an ICER of $45,123 per QALY. Probabilistic sensitivity analysis with 1,000 draws resulted in average ICER of $172,992 in nonoperative management with ILA and $462,843 in Nonoperative management without ILA. The threshold analysis demonstrated that regardless of willingness-to-pay, nonoperative management without ILA would not be most cost-effective strategy
Conclusions Nonoperative management with ILA and Nonoperative management without ILA were not cost-effective strategies compared with operative management to treat complicated appendicitis. Based on our findings, operative management remains the standard of care and nonoperative management would be reconsidered as a treatment option in complicated appendicitis from economic perspective.
Background
The evidence regarding the safety and efficacy of nonoperative management is growing. However, the best treatment strategy for acute complicated appendicitis remains controversial. We aimed to evaluate the cost-effectiveness of treatment strategies for complicated appendicitis patients. This study sought to determine the most cost-effective strategy from the health care-payer’s perspective.
Methods
The primary outcome was an incremental cost effectiveness ratio (ICER) using nonoperative management with or without interval laparoscopic appendectomy (ILA) as the intervention compared with operative management with emergency laparoscopic appendectomy (ELA) alone as the control. Model variables were abstracted from a literature review, and from data obtained from the hospital records of Tochigi Medical Center. Cost-effectiveness was evaluated using an ICER. We constructed a Markov model to compare treatment strategies for complicated appendicitis in otherwise-healthy adults, over a time horizon of a single year. Uncertainty surrounding model parameters was assessed via one-way- and probabilistic-sensitivity analyses. Threshold analysis was performed using the willingness-to-pay threshold set at the World Health Organization’s criterion of $107,690.
Results
Three meta-analysis were included in our analysis. Operative management cost $6075 per patient. Nonoperative management with interval laparoscopic appendectomy (ILA) cost $984 more than operative management and produced only 0.005 more QALYs, resulting in an ICER of $182,587. Nonoperative management without ILA cost $235 more than operative management, and also yielded only 0.005 additional QALYs resulting in an ICER of $45,123 per QALY. Probabilistic sensitivity analysis with 1000 draws resulted in average ICER of $172,992 in nonoperative management with ILA and $462,843 in Nonoperative management without ILA. The threshold analysis demonstrated that regardless of willingness-to-pay, nonoperative management without ILA would not be most cost-effective strategy.
Conclusions
Nonoperative management with ILA and Nonoperative management without ILA were not cost-effective strategies compared with operative management to treat complicated appendicitis. Based on our findings, operative management remains the standard of care and nonoperative management would be reconsidered as a treatment option in complicated appendicitis from economic perspective.
Background
Although evidence regarding the safety and efficacy of nonoperative management is growing, the best treatment strategy for acute complicated appendicitis remains controversial. We aimed to evaluate the cost-effectiveness of treatment strategies in complicated appendicitis patients. This study sought to determine the most cost-effectiveness strategy from the health care-payer's perspective
Methods
The primary outcome was an incremental cost effectiveness ratio (ICER) using nonoperative management with or without interval laparoscopic appendectomy (ILA) as the intervention compared with operative management with emergency laparoscopic appendectomy (ELA) alone as the control. Model variables were abstracted from a literature review, and from data from the hospital records of Tochigi Medical Center. Cost-effectiveness was evaluated using an ICER. We constructed a Markov model to compare treatment strategies for complicated appendicitis in otherwise-healthy adults, over a time horizon of a single year. Uncertainty surrounding model parameters was assessed via one-way- and probabilistic-sensitivity analyses. Threshold analysis was performed using the willingness-to-pay threshold set at the World Health Organization's criterion of $107,690.
Results
Three meta-analysis were included in our analysis. Operative management cost $6,075 per patient. Nonoperative management with interval laparoscopic appendectomy (ILA) cost $984 more than operative management and produced only 0.005 more QALYs, resulting in an ICER of $182,587. Nonoperative management without ILA cost $235 more than operative management, and also yielded only 0.005 additional QALYs resulting in an ICER of $45,123 per QALY. Probabilistic sensitivity analysis with 1,000 draws resulted in average ICER of $172,992 in nonoperative management with ILA and $462,843 in Nonoperative management without ILA. The threshold analysis demonstrated that regardless of willingness-to-pay, nonoperative management without ILA would not be most cost-effective strategy
Conclusions
Nonoperative management with ILA and Nonoperative management without ILA were not cost-effective strategies compared with operative management to treat complicated appendicitis. Based on our findings, operative management remains the standard of care and nonoperative management would be reconsidered as a treatment option in complicated appendicitis from economic perspective.
Background: Although evidence regarding the safety and efficacy of nonoperative management is growing, the best treatment strategy for acute complicated appendicitis remains controversial. In this study, we performed a cost-effectiveness analysis of operative management with emergency laparoscopic appendectomy (ELA) alone as the first-line therapy in complicated appendicitis patients in a municipal hospital in Japan.
Methods: We constructed a Markov model to compare treatment strategies for complicated appendicitis with emergency laparoscopic appendectomy in otherwise-healthy adults. Health outcomes were measured in quality-adjusted life years (QALYs) gained, and cost-effectiveness was evaluated using an incremental cost effectiveness ratio (ICER). Model variables were abstracted from a literature review, and from data from the hospital records of Tochigi Medical Center. Uncertainty surrounding model parameters was assessed via one-way- and probabilistic-sensitivity analyses. Threshold analysis was performed using the willingness-to-pay threshold set at the World Health Organization's criterion of ¥12 million.
Results: Operative management cost ¥677,570 per patient. Nonoperative management without interval laparoscopic appendectomy (ILA) cost ¥109,257 more than operative management and produced only 0.005 more QALYs. Nonoperative management without ILA cost ¥26,049 more than operative management, and also yielded only 0.005 additional QALYs. The ICER for both nonoperative managements were > ¥12 million/QALY in the probabilistic sensitivity analysis.
Conclusions : Nonoperative management with ILA and Nonoperative management without ILA were not cost-effective strategies compared with operative management to treat complicated appendicitis. Operative management remains the standard of care, but nonoperative management deserves serious consideration as a treatment option in complicated appendicitis.
Purpose:
To compare the surgical outcomes of peritoneal irrigation versus suction alone during laparoscopic appendectomy and to identify the risk factors of surgical site infection in patients with uncomplicated acute appendicitis.
Methods:
Data from patients with uncomplicated acute appendicitis between January 2014 and March 2016 were reviewed. We compared the irrigation and suction alone groups with regard to the following parameters: postoperative complication incidence rate, length of hospital stay, operation time, time to flatus, time to diet commencement, and duration of postoperative antibiotic.
Results:
A total of 578 patients underwent laparoscopic appendectomy for uncomplicated acute appendicitis. Twenty-five patients were excluded from the analysis because of need for drain insertion, loss to follow-up, simultaneous surgery for another indication, presence of an appendix tumor, or pregnancy. A total of 207 patients (37.4%) had undergone irrigation, and 346 patients (62.6%) received suction alone during laparoscopic appendectomy. The preoperative fever rate was significantly higher in the irrigation group than in the suction alone group. Operative time was also significantly longer in the irrigation group than in the suction alone group (53.8 ± 18.5 minutes vs. 57.8 ± 21.4 minutes, P = 0.027). The postoperative complication rate was higher in the irrigation group than in the suction alone group (4.5% vs. 12.6%, P = 0.001). Multiple logistic regression analysis showed that irrigation and preoperative fever were risk factors for surgical site infection after laparoscopic appendectomy for uncomplicated acute appendicitis.
Conclusion:
There is no advantage to irrigating the peritoneal cavity over suction alone during laparoscopic appendectomy for uncomplicated acute appendicitis. Irrigation may actually prolong the operative time and therefore be detrimental.
Purpose
The aim of this long-term study was the comparison of appendiceal stump closure with polymeric clips or staplers with respect to perioperative costs and surgical outcome under routine conditions in a university centre.
Methods
For this retrospective chart review, a total of 618 patients undergoing laparoscopic appendectomy for suspected acute appendicitis between 2010 and 2017 were reviewed: 410 patients in the stapler group and 208 patients in the clip group. The database contained demographic data, operation time, inflammation parameters, closure method of the stump, surgeon status, length of hospital stay, and complications as well as histology reports. The costs were also compared.
Results
Clip application was more likely among younger patients (mean age 33.6 years vs. 41.7 years). Histopathological evidence for appendiceal pathology was found in 96.6% of patients in the clip group and 99.5% of patients in the stapler group. Laparoscopic appendectomy in the clip group was more frequently performed by resident physicians (69.2%) than in the stapler group (57.8%). The mean postoperative stay was 2.9 days in the clip group and 3.7 days in the stapler group. The use of the polymeric clip resulted in considerable cost savings (19.94€ vs. 348.70€).
Conclusions
The use of polymeric clips for appendiceal stump closure during appendectomy is safe and effective. The base of the appendix is amenable to clipping in 32% of appendectomies in adult patients. This study supports the use of polymeric clips over staplers to decrease cost and environmental impact.
Introducción. La apendicectomía por puerto único, asistida por laparoscopia, ofrece una alternativa terapéutica en el abordaje de la apendicitis aguda. En el presente estudio, se evalúa el beneficio terapéutico de la técnica por único puerto asistida por laparoscopia y se compara esta técnica con la apendicectomía abierta.
Materiales y métodos. Se trata de un estudio observacional analítico retrospectivo de cohorte, llevado a cabo en el Hospital Universitario Clínica San Rafael, de Bogotá. Se incluyeron 106 pacientes mayores de 15 años con apendicitis aguda, que fueron sometidos a apendicectomía por puerto único, asistida por laparoscopia o apendicectomía abierta. La relación entre el grupo con apendicectomía por laparoscopia y el de técnica abierta, fue de 1:1. Se incluyeron variables sociodemográficas, clínicas y quirúrgicas (tiempo quirúrgico, frecuencia de infección del sitio operatorio, estancia hospitalaria, dolor, reingresos y resultado estético).
Resultados. La edad promedio fue de 32 años y la mayoría de los pacientes eran de sexo masculino. El tiempo operatorio fue menor en los casos de apendicectomía por puerto único, asistida por laparoscopia, con un promedio de 34,1 minutos. Según la escala análoga, el dolor posoperatorio fue de 2,2 con la técnica laparoscópica y de 3,2 con la apendicectomía abierta (p
Background
The advantages of laparoscopic appendectomy did not meet the same acceptance in the setting of perforated appendicitis as in uncomplicated appendicitis in the general surgical community. The aim of this study was to compare the clinical outcome of laparoscopic and open appendectomy in perforating appendicitis.
Methods
A randomized controlled study was conducted on 126 patients presenting with perforated appendicitis. Sixty patients were subjected to laparoscopic appendectomy (LA) and 66 patients underwent traditional open appendectomy (OA).
Results
65 (51.6%) patients were female, and 61 (48.4%) patients were male in whom the mean age was 37.6 + 8.5 years. A significant difference was calculated in the domains of postoperative pain, less need for analgesics, hospital stay, and return to daily activities. The mean operative time was shorter in OA 94 ± 10.4 min than LA 120.6 ± 17.7 min. No statistically significant difference between both groups was detected as regard occurrence of intra-abdominal collection.
Conclusion
In view of its clinical outcomes, laparoscopy should be considered in the context of perforated appendicitis. The possibility of intra-abdominal collection should not be a barrier against the widespread practice of this surgical procedure amidst laparoscopic surgeons if adequate precautions are employed.
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.
Introduction
This study aims to compare the clinical effects of an incision skin tissue retractor for mini-incision open appendectomy and laparoscopic surgery for pediatric appendicitis.
Methods
From January 2014 to July 2017, a total of 248 patients were included in the present study. Laparoscopic appendectomy was performed for 108 cases (LA group), and mini-incision open appendectomy with an incision skin tissue retractor was performed for 140 cases (MOA-ISTR group). Then, medical history, age, gender, operative duration, amount of bleeding during the operation, the determination of whether or not the appendix was perforated during the operation, hospitalization days, total cost of hospitalization, and complications after the operation (incision infection or intestinal obstruction) were compared. The SPSS 20.0 software package was used for the statistical analysis.
Results
There were no statistically significant differences in history, age, gender, perioperative perforation of the appendix, postoperative hospital stay and postoperative complications (incisional infection or intestinal obstruction, P > 0.05). However, the values for duration of surgery, intraoperative blood loss and total hospitalization expense were smaller, when compared with the LA group (P < 0.05).
Conclusion
Mini-incision open appendectomy with an incision skin tissue retractor has similar efficacy and incision appearance when compared with laparoscopic appendectomy. Furthermore, this approach leads to shorter operation time, less intraoperative blood loss and less hospitalization time, and is more convenient, especially for perforated appendicitis. Moreover, it can be widely used for pediatric appendicitis, and is more suitable for doctors who are not skilled in basic hospitals and laparoscopy.
Purpose:
According to surgical dogma, patients who are recovering from general anesthesia after abdominal surgery should begin with a clear liquid diet, progress to a full liquid diet and then to a soft diet before taking regular meals. We propose patient-controlled nutrition (PCN), which is a novel concept in postoperative nutrition after abdominal surgery.
Methods:
A retrospective pilot study was conducted to evaluate the feasibility and effects of PCN. This study was carried out with a total of 179 consecutive patients who underwent a laparoscopic appendectomy between August 2014 and July 2016. In the PCN group, diet was advanced depending on the choice of the patients themselves; in the traditional group, diet was progressively advanced to a full liquid or soft diet and then a regular diet as tolerated. The primary endpoints were time to tolerance of regular diet and postoperative hospital stay.
Results:
Time to tolerance of a regular diet (P < 0.001) and postoperative hospital stay (P < 0.001) showed statistically significant differences between the groups. Multivariate analysis using linear regression showed that the traditional nutrition pattern was the only factor associated with postoperative hospital stay (P < 0.001). Multivariate analysis using logistic regression showed that traditional nutrition was the only risk factor associated with prolonged postoperative hospital stay (≥3 days).
Conclusion:
After abdominal surgery, PCN may be a feasible and effective concept in postoperative nutrition. In our Early Recovery after Surgery program, our PCN concept may reduce the time to tolerance of a regular diet and shorten the postoperative hospital stay.
Purpose
We aimed to introduce a new surgical method for open appendectomy including a right groin incision with adipocutaneous flap and to compare its feasibility, safety, and cosmetic outcomes with classic McBurney’s incision.
Methods
Patients with the diagnosis of acute appendicitis who were candidates for appendectomy surgery at General Surgery Department, Besat Hospital, Hamadan University of Medical Sciences, Iran, in 2016 and 2017, were enrolled in a randomized controlled clinical study. Patients were randomly assigned to two groups each containing 50 patients. In the case and control groups, patients underwent appendectomy using right groin incision with adipocutaneous flap and traditional McBurney’s methods, respectively.
Results
One hundred patients with the mean age of 23.6 years (range = 4–44) old including 65 males were enrolled in the study. Patients’ demographics, histopathology, and anatomical location of the appendix were not significantly different in the case and control groups. There was no significant difference in postoperative wound infection, cellulitis, hematoma, and seroma between the two groups. Patients in the case group were significantly more satisfied in terms of cosmesis than in the control group (P < .001); however, the operative time and pain were higher in the case group compared to the control group (P values = 0.016 and 0.033, respectively).
Conclusions
The right groin incision for open appendectomy may be safe and feasible and the most cosmetically appealing method especially in children and patients with cosmetic concerns.
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.
Background:
In adult patients, it is generally accepted that laparoscopic appendicectomy (LA) is the predominant operative pathway in treating acute appendicitis. The case for a similar pathway utilising LA in children is less clear. We investigate usage, trends and complications after LA in children in a single co-located adult/paediatric centre with contemporaneous adults as controls.
Methods:
A retrospective case-control study was conducted over 12 years including patients who underwent appendicectomy, and the paediatric series (<16 years) was divided into age-groups-based quartiles. An anonymous questionnaire-based national survey was circulated among general and paediatric surgeons.
Results:
Of the 5784 appendicectomy patients, 2960 were children. LA rate in paediatric appendicitis was 65%. Yearly trends in LA reached a steady state in both groups after 2010 (Δ 0-1%/year). Rates of LA and LA IAA (respectively) differed significantly between age groups: 60, 3% (0-9 years); 65, 1% (10-13 years); 71, 2% (14-16 years) and 93, 3% (>16 years) (p = 0.001, 0.02). The national survey showed respondents believed LA was not superior to OA in paediatric patients except in terms of cosmesis. There was strong support in the use of LA in older children and children >40 kg.
Conclusion:
The use of LA in paediatric appendicectomies in the study region is similar to international rates, but not increasing over time. Irish surgeons still favour OA in younger children and prefer a case-by-case approach rather LA being the preferred pathway. This is despite the regional and international evidence showing favourable outcomes with LA in children.
Introduction: Laparoscopic appendectomy (LA) is now a treatment of choice in patients with appendicitis. This study compares the treatment outcomes of LA and open appendectomies (OA) in our department.
Patients and Methods: From January 2006 to April 2016 a total of 185 patients underwent appendectomy at our institution. We divided the patients into two groups; LA group (LAG) and OA group (OAG). Following parameters were analyzed: age, gender, preoperative clinicolaboratory characteristics, operative factors, interval appendectomy, length of hospital stay (LHS), and surgical site infections (SSI).
Results: There were 93 patients in LA G and 92 in OAG. According to the Univariate analysis, there were statistically significant differences among age (p = 0.037), LHS (p = 0.0001), duration till resuming oral intake (p = 0.016), blood loss (p = 0.038), SSI ratio (p = 0.044) and CRP level (p = 0.038) between the LAG and the OAG. According to the Multivariate analysis, blood loss (p = 0.038) and LHS (p = 0.023) were significantly different between both groups.
Conclusion: LA was decreasing blood loss and LHS.
The female pelvis contains non-gynecologic structures with associated disorders that gynecologists frequently encounter. Most of these conditions are very common, easily recognized and depending on surgeons’ comfort level, may be treated by the operating gynecologist or referred for care to General Surgeons. The purpose of this chapter will be to discuss the recognition, diagnosis, and treatment of some of the more commonly encountered General Surgery conditions that may be seen during laparoscopic gynecologic surgery and give recommendations and tips on care.
p>Surgical site infection (SSI) is defined as infection at surgical site within 01 month after surgery (or within a year in case of implant). Surgical-site infection requires microbial contamination of the surgical wound to occur. LA provides considerable benefits over OA, including a shorter length of hospital stay, less postoperative pain, earlier postoperative recovery, and a lower complication rate. This was a prospective observational study conducted inpatient department of Chittagong Medical College Hospital and private hospitals and clinics in Chittagong city. The patients were interviewed face to face by the researcher for the purpose of collection of data and were examined by the researcher for certain signs recorded in the fixed protocol. Collected data was classified, edited, coded and entered into the computer for statistical analysis by using SPSS-22. Out of 200 cases mean age was found 33.76 ± 23.35 years in OA group and 32.21 ± 16.51 years in LA group. Male was found 58% in OA group and 53% in LA group. Female was found 42% and 47% in OA and LA group respectively. Mean operative time was found 41.2±8.5 minutes in OA group and 49.3±8.9 minutes in LA group. Alternate pathology were more frequently detected in LA due to wide area of vision. Superficial incisional SSI was found 10% in OA group and 5% in LA group. Deep incisional SSI was found 2% in OA group and 2% in LA group. Organ/space SSI was 2% and 3% in OA group and LA group respectively. Staphylococcus aureus is the commonest organism isolated form the surgical wounds from 41.34% followed by Pseudomonas 21.26%, no growth 11.1%, E.coli 9.6%, others 9.4%, Klebsiella 7.0%. Laparoscopic appendectomy was better than open appendectomy with respect to wound infection rate, postoperative pain, postoperative hospital stay and return to normal activities.
Medicine Today 2017 Vol.29(1): 6-11</p
PurposeAcute appendicitis (AA) is among the most common causes of lower abdominal pain and admissions to the emergency department. Over the past 20 years, there has been a renewed interest in the conservative management of uncomplicated AA, and several studies demonstrated that an antibiotic-first strategy is a viable treatment option for uncomplicated AA. The aim of this prospective non-randomized controlled, multicenter trial is to compare antibiotic therapy and emergency appendectomy as treatment for patients with uncomplicated AA confirmed by US and/or CT or MRI scan. Methods
All adult patients in the age range 18 to 65 years with suspected AA, consecutively admitted to the Surgical Department of the 13 participating Italian Hospitals, will be invited to take part in the study. A multicenter prospective collected registry developed by surgeons, radiologists, and pathologists with expertise in the diagnosis and treatment of uncomplicated acute appendicitis represents the best research method to assess the long-term role of antibiotics in the management of the disease. Comparison will be made between surgical and antibiotic-first approaches to uncomplicated AA through the analysis of the primary outcome measure of complication-free treatment success rate based on 1-year follow-up. Quality of life, length of hospital stay, pain evaluation, and time to return to normal activity will be evaluated as secondary outcome measures. Trial registrationClinicaltrials.gov ID: NCT03080103
Background:
Laparoscopic appendectomy is the predominant method of treatment of acute appendicitis. There is insufficient evidence on the most effective management of the appendix stump. The aim of this study was to investigate the relative effectiveness and provide a treatment ranking of different options for securing the appendix stump.
Methods:
Electronic databases were searched to identify randomized controlled trials comparing ligation methods of the appendix. The primary outcomes were organ/space infection and superficial operative site infection. We performed a network meta-analysis and estimated the pairwise relative treatment effects of the competing interventions using the odds ratio and its 95% confidence interval. We obtained a hierarchy of the competing interventions using rankograms and the surface under the cumulative ranking curve.
Results:
Forty-three randomized controlled trials were eligible and provided data for >5,000 patients. Suture ligation seemed to be the most effective treatment strategy, in terms of both organ/space infection and superficial operative site infection. Statistical significance was reached for the comparisons of clip versus endoloop (odds ratio 0.56, 95% confidence interval, 0.32-0.96) for organ/space infection; and suture versus clip (odds ratio 0.20, 95% confidence interval 0.08-0.55) and clip versus endoloop (odds ratio 2.22, 95% confidence interval 1.56-3.13) for superficial operative site infection. The network was informed primarily by indirect treatment comparisons.
Conclusion:
The use of suture ligation of the appendix in laparoscopic appendectomy seems to be superior to other methods for the composite parameters of organ/space and superficial operative site infection.
Background: Conventional open appendicectomy is a common emergency surgical procedure being used for more than a century. Despite continuously increasing popularity of minimal access surgery, laparoscopic appendicectomy has not gained enough popularity.Methods: A prospective randomized study to compare laparoscopic and open appendicectomy for the treatment of appendicitis was carried out from April 2015 to October 2016. Thirty patients each were randomized to two groups. Decision to operate was taken on clinical grounds.Results: Twenty-five patients in each group were confirmed to be suffering from appendicitis. While alternative diagnosis could be established in 4 out of remaining 5 patients in laparoscopic group, in only 1 out of 5 patients from open appendicectomy definitive diagnosis for pain could be established. There was no significant difference in operative time between two groups. Patients in laparoscopic group had lesser postoperative pain scores and wound complications. They also got discharged and returned to normal activity earlier than those in open appendicectomy group.Conclusions: Laparoscopic appendicectomy has lesser postoperative morbidity and improves diagnosis in nonappendicitis patients.
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.
Laparoscopic appendectomy is feasible, but whether it confers any advantage to patients with acute appendicitis is not known. We performed a randomized controlled trial to compare results of laparoscopic and open appendectomy in patients with signs and symptoms suggesting acute appendicitis who were seen by one surgical team.
Sixty-two consecutive patients were randomized, 30 to laparoscopy and 32 to a classical open appendectomy. Postoperative recovery, complications, and return to normal activities were compared in the two groups.
The laparoscopy group were discharged earlier (2.5 vs 3.8 days, p less than 0.01). Postoperative complications were more frequent after open appendectomy. Follow-up showed less pain, shorter bed stay at home, and faster return to work and sport after laparoscopic appendectomy.
This prospective randomized study shows that laparoscopic appendectomy is superior to open appendectomy in terms of hospital stay, postoperative complications, and return to normal activities and is recommended as the approach of choice in the management of acute appendicitis.
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.
In patients with clinically suspected appendicitis, computed tomography (CT) is diagnostically accurate. However, the effect of routine CT of the appendix on the treatment of such patients and the use of hospital resources is unknown.
We performed appendiceal CT on 100 consecutive patients in the emergency department who, on the basis of history, physical examination, and laboratory results, were to be hospitalized for observation for suspected appendicitis or for urgent appendectomy. Outcomes were determined at surgery and by pathological examination in 59 patients, and by clinical follow-up two months later in 41 patients. Treatment plans made before CT were compared with the patients' actual treatment. We also determined the costs of surgery that revealed no appendicitis (from data on 61 patients), one day of observation in the hospital (from data on 350 patient-days in patients with suspected appendicitis), and appendiceal CT (from data on all pelvic CT examinations in 1996).
Fifty-three patients had appendicitis, and 47 did not. The interpretations of the appendiceal CT scans were 98 percent accurate. The results of CT led to changes in the treatment of 59 patients. These changes resulted in the prevention of unnecessary appendectomy in 13 patients, admission to the hospital for observation in 18 patients, admission to the hospital for observation before necessary appendectomy in 21 patients, and admission to the hospital for observation before the diagnosis of other conditions by CT in 11 patients. The effects of performing appendiceal CT on the use of hospital resources included the prevention of unnecessary appendectomy in 13 patients (for a savings of $47,281) and the prevention of unnecessary hospital admission for 50 patient-days (for a savings of $20,250). After the cost of 100 appendiceal CT studies ($22,800) was subtracted, the overall savings was $447 per patient.
Routine appendiceal CT performed in patients who present with suspected appendicitis improves patient care and reduces the use of hospital resources.
Objective:
To compare open appendectomy (OA) with laparoscopic appendectomy (LA) for length of the operation, complications, postoperative pain control, length of hospitalization, postdischarge recovery time, and hospital charges.Design:Prospective randomized clinical trial of patients with acute appendicitis.Setting:
Tertiary care, urban teaching hospital.Patients:
A population-based sample of patients (aged ≥ 12 years; weight, >49.7 kg) admitted to a surgical teaching service with a clinical diagnosis of acute appendicitis. Patients were prospectively randomized to either OA or LA during a 20-month period (from April 1, 1994, to December 31, 1995). Fifty-seven patients were initially enrolled in the study; 7 did not complete the study because of a protocol violation. All remaining patients completed the study, including postdischarge follow-up.Interventions:
Two (7.4%) of the 27 patients in the LA group required conversion to OA because of technical difficulties. One patient (in the OA group) underwent a second surgical procedure for drainage of a pelvic abscess. Three patients (in the LA group) required second surgical procedures. For analysis, no crossovers were allowed and all patients remained in their originally randomized group.Main Outcome Measures:
Length of the operation, intraoperative and postoperative complications, postoperative pain control, length of hospitalization, postdischarge recovery time, and hospital charges.Results:
Fifty patients (19 women and 31 men) were examined. Twenty-seven patients underwent LA, 2 requiring conversion to an OA. Twenty-three patients underwent an OA. Patient demographics were similar between groups. Statistical differences between the 2 groups were found for (1) length of the operation (median, 81.7 vs 66.8 minutes, LA vs OA group; P<.002), (2) operating room charges (median, $3191 vs $1514, LA vs OA group; P<.001), and (3) total hospital charges (median, $5430 vs $3673, LA vs OA group; P<.001). No statistical differences between the 2 groups were found for (1) length of hospitalization (median, 1.1 vs 1.2 days, LA vs OA group), (2) pain control (mean, 4 vs 3.7 of 10 [0 indicates least pain; 10, most pain], LA vs OA group), (3) recovery time (time necessary before returning to work or school) (median, 14.0 days for both groups), and (4) complications (5 vs 1, LA vs OA group).Conclusions:
Laparoscopic appendectomies and OAs are comparable for complications, postoperative pain control, length of hospitalization, and recovery time. Patients who underwent an OA had a shorter operative time and lower operating room and hospital charges. Laparoscopic appendectomy does not offer any proved benefits compared with the open approach for the routine patient with acute appendicitis.Arch Surg. 1997;132:708-712
Objectives:
To determine the efficacy of laparoscopic appendectomy compared with open appendectomy in patients with acute appendicitis and to compare the morbidity between the two groups.
Design:
Prospective sampling of 102 patients who underwent diagnostic laparoscopy and laparoscopic appendectomy for acute appendicitis and retrospective hospital chart review of 204 patients who underwent open appendectomy for acute appendicitis.
Results:
The mean±SD duration of surgery was 83±29 minutes in the laparoscopic group and 64±30 minutes in the open appendectomy group (P<.001). Hospital stay was shorter in the laparoscopic group (P<.04). There was no difference in the complication rate between the patients who underwent laparoscopic appendectomy (13%) and the patients who underwent open appendectomy (11%). The occurrence of postoperative ileus was correlated with the duration of operation (P<.01) but not with laparoscopic appendectomy.
Conclusions:
The results confirm that laparoscopic appendectomy had a longer time of surgery, a shorter hospital stay, and no difference in complications. Further investigation will likely establish that laparoscopic appendectomy can be considered the "gold standard."(Arch Surg. 1995;130:782-785)
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: There is increasing pressure on surgeons to minimize the time patients stay in hospital, and there is therefore a need to establish guidelines for reasonable lengths of stay for common operations. This study was conducted to test the feasibility and safety of early discharge after open appendicectomy. In addition, this study was performed to provide standards for open appendicectomy against which the results of laparoscopic appendicectomy can be compared.
Methods: A prospective study of all patients having open appendicectomy for suspected acute appendicitis at Liverpool Hospital, Sydney during a 4 month period was undertaken. An early discharge programme was established, with the aim of discharging patients within 48 h of operation in uncomplicated cases. Discharge was allowed when the patient was eating, walking, and had passed flatus. Follow up was with the consultant surgeon at I week postoperatively, and with a community nurse at 2 weeks. Multivariate linear regression, using the number of postoperative hours to discharge as the outcome, was used to analyse the data for the following four factors: age, gender, incision type, and pathology.
Results: One hundred and sixteen consecutive patients were enrolled in the study. The median postoperative stay for all patients was 46 h. Perforation of the appendix, use of a midline laparotomy for appendicectomy, and age significantly prolonged hospital stay, but gender had no effect. The main complication was wound infection, which was seen in 7.5% of patients. No patient had a problem directly related to early discharge. A community nurse saw 81% of patients 2 weeks after discharge. Over three-quarters of the patients seen had returned to full normal activities by 2 weeks, including work or school. Eighty-eight per cent of patients considered the timing of their discharge ‘good’ or ‘excellent’.
Conclusions: Discharge at 2 days after open appendicectomy is both feasible and safe for patients having an unperforated appendix removed through a right iliac fossa incision. Passage of stool is not required prior to discharge. Early discharge is well accepted by patients and may result in financial savings for hospitals where payment is according to Diagnosis-Related Groups. On the basis of the results of the six randomized controlled trials comparing laparoscopic and conventional open appendicectomy published to date, and on the results of this study, the authors conclude that laparoscopic appendicectomy should not yet be considered the ‘procedure of choice’, and surgeons are justified in performing appendicectomy by either method.
Although widely practiced, laparoscopic appendectomy (LA) has not met with universal approval. Several controlled trials
have been conducted, some in favor, others not. The goal of this review was to ascertain (1) if laparoscopy was capable of
improving the diagnostic and therapeutic difficulties encountered during open appendectomy (OA) and (2) if the introduction
of laparoscopy in the overall management of acute appendicitis has changed anything in practice. Analysis and criticism of
17 controlled studies (nearly 1800 patients) on laparoscopic appendectomy and 2 randomized studies dealing with diagnostic
laparoscopy are reported. Because of the questionable quality of randomized controlled trials (number of patients, exclusions,
withdrawals, blinding, intention-to-treat analysis), publication biases, local practice variations (hospital stay, rate of
enrollment), results regarding analgesia requirements, return to activity and work, duration of hospital stay, outcome, follow-up,
and antibiotic prophylaxis the studies must be interpreted with caution. The real world of appendicitis probably differs greatly
from the atmosphere under which controlled trials comparing LA and OA have been performed. Statistical significance is contrary
to the clinical significance of the results. Consistently longer operating times [the difference ranging from 8 minutes (NS)
to 29 minutes (p < 0.0001)], a minimal reduction in hospital stay [0.1 day (NS) to 2.1 days (p < 0.007)], and, somewhat more controversial, an earlier return to normal activity were reported for LA. Data on analgesic
requirements were confusing, but wound complications were more frequent after OA [pooled odds ratio for 10 studies: 2.6 (95%
CI 1.3–5.2)]. Unsolved problems include national behavioral problems, age and experience of operating surgeons (LA or OA),
and emergency conditions (availability of staff, instruments). Results of cost analysis vary according to the standpoint of
disease, the patient, the surgeon, the treatment center, industry, and society. Three questions remain: Because of the competition
of LA versus OA, OA has improved greatly. Can it be improved any more? Is there a place or need for further randomized controlled
trials? Should we not conclude once and for all that LA is out?
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.
A randomized, controlled trial is considered to be the "gold standard" to evaluate a new procedure. Thus, this critical review assessed whether the published randomized trials on laparoscopic appendectomy show that it is superior to the open approach.
Twelve original articles involving a randomized, controlled trial on laparoscopic appendectomy in adults published between January 1990 and December 1996 were selected. We studied first whether each trial was positive (a procedure is superior to the other) or negative (no difference). We reviewed for each trial the methodology used and the following outcomes: operating time, intraoperative and postoperative complications, time until resumption of diet, postoperative pain, hospital stay, cost, and quality of life analyses. Postoperative morbidity was considered as the major primary outcome.
There were six positive and six negative trials. Postoperative complication rates were similar, but the two approaches had specific potential complications, wound infections following open appendectomy, and intra-abdominal abscesses following laparoscopic appendectomy. This review failed to show a superiority of the laparoscopy for the other outcomes, particularly postoperative pain.
Differences in positive trials concerned subjective and controversial outcomes, and the flaw in negative trials was their lack of power. Thus, nothing is definitively well established, even after 12 randomized trials.
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.
To determine the efficacy of laparoscopic appendectomy compared with open appendectomy in patients with acute appendicitis and to compare the morbidity between the two groups.
Prospective sampling of 102 patients who underwent diagnostic laparoscopy and laparoscopic appendectomy for acute appendicitis and retrospective hospital chart review of 204 patients who underwent open appendectomy for acute appendicitis.
The mean +/- SD duration of surgery was 83 +/- 29 minutes in the laparoscopic group and 64 +/- 30 minutes in the open appendectomy group (P < .001). Hospital stay was shorter in the laparoscopic group (P < .04). There was no difference in the complication rate between the patients who underwent laparoscopic appendectomy (13%) and the patients who underwent open appendectomy (11%). The occurrence of postoperative ileus was correlated with the duration of operation (P < .01) but not with laparoscopic appendectomy.
The results confirm that laparoscopic appendectomy had a longer time of surgery, a shorter hospital stay, and no difference in complications. Further investigation will likely establish that laparoscopic appendectomy can be considered the "gold standard."
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.
While the advantages of laparoscopic cholecystectomy 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.
Two hundred fifty-three 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.
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 subgroup 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.
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.
Randomised assessment of new laparoscopic surgical techniques is difficult. Surgeons need time to become experienced with the methods and tend, when they have experience, to favour one or other approach. We have carried out a prospective randomised comparison of laparoscopic and conventional appendicectomy done by surgeons of comparable experience in patients with suspected acute appendicitis. Postoperative management decisions were made by surgeons other than the operating surgeon. 140 patients were randomly assigned to open (OA) or laparoscopic (LA) appendicectomy (70 each). The age, sex ratio, duration of symptoms, and proportion of patients with histologically confirmed appendicitis was similar in the two groups. Operating time was longer for LA than for OA (mean 70.3 [SD 21.9] vs 46.5 [25.9] min; p < 0.001). There were no major intraoperative complications in either group. 14 (20%) patients in the LA group required conversion to an open operation. No significant differences between the groups were found postoperatively for pain score, analgesic requirement, time to reintroduction of diet, or hospital stay. 46 LA patients and 42 OA patients attended follow-up 3 weeks after surgery. Similar proportions had returned to work (36 [79%] vs 31 [74%]). The frequency of wound complications and wound pain after leaving hospital was lower after LA but not significantly so. We conclude that the postoperative course after LA and conventional OA does not differ significantly.
The authors determined whether there was an advantage to laparoscopic appendectomy when compared with open appendectomy. SUMMARY/BACKGROUND DATA: The advantages of laparoscopic appendectomy versus open appendectomy were questioned because the recovery from open appendectomy is brief.
From January 15, 1992 through January 15, 1993, 75 patients older than 9 years were entered into a study randomizing the choice of operation to either the open or the laparoscopic technique. Statistical comparisons were performed using the Wilcoxon test.
Thirty-seven patients were assigned to the open appendectomy group and 38 patients were assigned to the laparoscopic appendectomy group. Two patients were converted intraoperatively from laparoscopic appendectomies to open procedures. Thirty-one patients (81%) in the open group had acute appendicitis, as did 32 patients (84%) in the laparoscopic group. Mean duration of surgery was 65 minutes for open appendectomy and 87 minutes for laparoscopic appendectomy (p < 0.001). There were no statistically significant differences in length of hospitalization, interval until resumption of a regular diet, or morbidity. Duration of both parenteral and oral analgesic use favored laparoscopic appendectomy (2.0 days versus 1.2 days, and 8.0 days versus 5.4 days, p < 0.05). All patients were instructed to return to full activities by 2 weeks postoperatively. This occurred at an average of 25 days for the open appendectomy group versus 14 days for the laparoscopic appendectomy group (p < 0.001).
Patients who underwent laparoscopic appendectomies have a shorter duration of analgesic use and return to full activities sooner postoperatively when compared with patients who underwent open appendectomies. The authors consider laparoscopic appendectomy to be the procedure of choice in patients with acute 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.
A study was carried out of 137 patients with a diagnosis of acute appendicitis who were randomized to either laparoscopic or open appendicectomy. Patients found to have perforated or normal appendices at histological examination were excluded. Fifty-two patients undergoing laparoscopic appendicectomy and those receiving 57 open procedures were analysed. Laparoscopic appendicectomy took no longer than the open procedure (mean 43 versus 40 min). The number of doses of pethidine (1 mg per kg body-weight) required in the immediate postoperative period did not differ between the two groups but the mean number of doses of oral analgesic (naproxen sodium 550 mg twice daily) required was less in patients undergoing laparoscopic appendicectomy (2.8 versus 5.0, P < 0.05). There was no significant difference between time to resumption of fluid and diet intake and length of hospital stay. There were five (9 per cent) wound infections after open appendicectomy compared with none after the laparoscopic operation (P < 0.01). Patients who underwent laparoscopy returned to full home (17 versus 30 days, P < 0.01) and social (19 versus 32 days, P < 0.05) activities earlier than those who underwent open operation. Laparoscopic appendicectomy may allow reduction in the number of wound infections and earlier return to normal activities.
A total of 155 consecutive patients with suspected acute appendicitis were studied to compare laparoscopic and conventional operations. Patients were not randomized: laparoscopy was performed when a suitably trained surgeon and laparoscopic instruments were available. Laparoscopic appendicectomy was attempted in 51 patients and was successful in 46 (90 per cent); all conversions to open operation were because of marked inflammatory adhesions around the appendix. There were no intraoperative complications. Reintroduction of normal diet and discharge from hospital occurred earlier after laparoscopic than open surgery (P < 0.05). The requirement for analgesia after successful laparoscopic surgery was less than that after conventional appendicectomy, but the difference was not significant. The incidence of wound infection was reduced after the laparoscopic procedure (P = 0.06). It is concluded that laparoscopic appendicectomy is practical and may have advantages over conventional operation, although a randomized study is necessary.
n
= 79) or an open appendectomy (
n
= 72) showed no difference in sex, age, American Society of Anesthesiology (ASA) rating, or previous abdominal surgery. The histologic classification of normal, catarrhal, inflamed, suppurative, and gangrenous appendicitis was not different between the two groups. Conversion from laparoscopic to open appendectomy was necessary in seven patients (9%) who had advanced forms of appendiceal inflammation. When compared to open appendectomy the laparoscopic group had a longer median operating time (63 minutes versus 40 minutes), fewer wound infections (2% versus 11%), less requirement for narcotic analgesia, and an earlier return to normal activity (median 7 days versus 14 days). There was no difference in morbidity, and both groups had a median time to discharge of 3 days. Laparoscopic appendectomy is as safe as open appendectomy; and despite the longer operating time, the advantages such as fewer wound infections and earlier return to normal activity make it a worthwhile alternative for patients with a clinical diagnosis of acute appendicitis.
We report a prospective randomised comparison between laparoscopic and small-incision cholecystectomy in 200 patients which was designed to eliminate bias for or against either technique.
Patients were randomised in the operating theatre and anaesthetic technique and pain-control methods were standardised. Four experienced surgeons did both types of procedure. Identical wound dressings were applied in both groups so that carers could be kept blind to the type of operation.
There was no significant difference between the groups for age, sex, body mass index, and American Society of Anaesthesiologists grade. Laparoscopic cholecystectomy took significantly longer than small-incision cholecystectomy (median 65 [range 27-140] min vs 40 [18-142] min, p<0.001). The operating time included operative cholangiography which was attempted in all patients. We found no significant difference between the groups for hospital stay (postoperative nights in hospital, median 3-0 [1-17] nights for laparoscopic vs 3-0 [1-14] nights for small-incision, p=0.74), time back to work for employed persons (median 5-0 weeks vs 4.0 weeks; p=0.39), and time to full activity (median 3-0 weeks vs 3.0 weeks; p=0.15).
Laparoscopic cholecystectomy takes longer to do than small-incision cholecystectomy and does not have any significant advantages in terms of hospital stay or postoperative recovery.
There is increasing pressure on surgeons to minimize the time patients stay in hospital, and there is therefore a need to establish guidelines for reasonable lengths of stay for common operations. This study was conducted to test the feasibility and safety of early discharge after open appendicectomy. In addition, this study was performed to provide standards for open appendicectomy against which the results of laparoscopic appendicectomy can be compared.
A prospective study of all patients having open appendicectomy for suspected acute appendicitis at Liverpool Hospital, Sydney during a 4 month period was undertaken. An early discharge programme was established, with the aim of discharging patients within 48 h of operation in uncomplicated cases. Discharge was allowed when the patient was eating, walking, and had passed flatus. Follow up was with the consultant surgeon at 1 week postoperatively, and with a community nurse at 2 weeks. Multivariate linear regression, using the number of postoperative hours to discharge as the outcome, was used to analyse the data for the following four factors: age, gender, incision type, and pathology.
One hundred and sixteen consecutive patients were enrolled in the study. The median postoperative stay for all patients was 46 h. Perforation of the appendix, use of a midline laparotomy for appendicectomy, and age significantly prolonged hospital stay, but gender had no effect. The main complication was wound infection, which was seen in 7.5% of patients. No patient had a problem directly related to early discharge. A community nurse saw 81% of patients 2 weeks after discharge. Over three-quarters of the patients seen had returned to full normal activities by 2 weeks, including work or school. Eighty-eight per cent of patients considered the timing of their discharge "good' or "excellent'.
Discharge at 2 days after open appendicectomy is both feasible and safe for patients having an unperforated appendix removed through a right iliac fossa incision. Passage of stool is not required prior to discharge. Early discharge is well accepted by patients and may result in financial savings for hospitals where payment is according to Diagnosis-Related Groups. On the basis of the results of the six randomized controlled trials comparing laparoscopic and conventional open appendicectomy published to date, and on the results of this study, the authors conclude that laparoscopic appendicectomy should not yet be considered the "procedure of choice', and surgeons are justified in performing appendicectomy by either method.
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.
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 compare open appendectomy (OA) with laparoscopic appendectomy (LA) for length of the operation, complications, postoperative pain control, length of hospitalization, postdischarge recovery time, and hospital charges.
Prospective randomized clinical trial of patients with acute appendicitis.
Tertiary care, urban teaching hospital.
A population-based sample of patients (aged > or = 12 years; weight, > 49.7 kg) admitted to a surgical teaching service with a clinical diagnosis of acute appendicitis. Patients were prospectively randomized to either OA or LA during a 20-month period (from April 1, 1994, to December 31, 1995). Fifty-seven patients were initially enrolled in the study; 7 did not complete the study because of a protocol violation. All remaining patients completed the study, including postdischarge follow-up.
Two (7.4%) of the 27 patients in the LA group required conversion to OA because of technical difficulties. One patient (in the OA group) underwent a second surgical procedure for drainage of a pelvic abscess. Three patients (in the LA group) required second surgical procedures. For analysis, no crossovers were allowed and all patients remained in their originally randomized group.
Length of the operation, intraoperative and postoperative complications, postoperative pain control, length of hospitalization, postdischarge recovery time, and hospital charges.
Fifty patients (19 women and 31 men) were examined. Twenty-seven patients underwent LA, 2 requiring conversion to an OA. Twenty-three patients underwent an OA. Patient demographics were similar between groups. Statistical differences between the 2 groups were found for (1) length of the operation (median, 81.7 vs 66.8 minutes, LA vs OA groups: P < .002), (2) operating room charges (median, $3191 vs $1514, LA vs OA group; P < .001), and (3) total hospital charges (median, $5430 vs $3673, LA vs OA group; P < .001). No statistical differences between the 2 groups were found for (1) length of hospitalization (median, 1.1 vs 1.2 days, LA vs OA group), (2) pain control (mean, 4 vs 3.7 of 10 [0 indicates least pain; 10, most pain], LA vs OA group), (3) recovery time (time necessary before returning to work or school) (median, 14.0 days for both groups), and (4) complications (5 vs 1, LA vs OA group).
Laparoscopic appendectomies and OAs are comparable for complications, postoperative pain control, length of hospitalization, and recovery time. Patients who underwent an OA had a shorter operative time and lower operating room and hospital charges. Laparoscopic appendectomy does not offer any proved benefits compared with the open approach for the routine patient with acute appendicitis.
Meta-analyses are now widely used to provide evidence to support clinical strategies. However, large randomized, controlled trials are considered the gold standard in evaluating the efficacy of clinical interventions.
We compared the results of large randomized, controlled trials (involving 1000 patients or more) that were published in four journals (the New England Journal of Medicine, the Lancet, the Annals of Internal Medicine, and the Journal of the American Medical Association) with the results of meta-analyses published earlier on the same topics. Regarding the principal and secondary outcomes, we judged whether the findings of the randomized trials agreed with those of the corresponding meta-analyses, and we determined whether the study results were positive (indicating that treatment improved the outcome) or negative (indicating that the outcome with treatment was the same or worse than without it) at the conventional level of statistical significance (P<0.05).
We identified 12 large randomized, controlled trials and 19 meta-analyses addressing the same questions. For a total of 40 primary and secondary outcomes, agreement between the meta-analyses and the large clinical trials was only fair (kappa= 0.35; 95 percent confidence interval, 0.06 to 0.64). The positive predictive value of the meta-analyses was 68 percent, and the negative predictive value 67 percent. However, the difference in point estimates between the randomized trials and the meta-analyses was statistically significant for only 5 of the 40 comparisons (12 percent). Furthermore, in each case of disagreement a statistically significant effect of treatment was found by one method, whereas no statistically significant effect was found by the other.
The outcomes of the 12 large randomized, controlled trials that we studied were not predicted accurately 35 percent of the time by the meta-analyses published previously on the same topics.
The role of laparoscopic surgery in the management of patients with suspected appendicitis is still debated despite a number of recent randomized controlled trials (RCTs).
A systematic review has been undertaken of all published RCTs comparing laparoscopic appendicectomy with open appendicectomy. Studies were identified through Medline and supplemented with a manual search of relevant journals and meeting abstracts. Data were extracted and analysed according to predefined criteria.
Ten studies were identified, seven of which reported results on an intention-to-treat basis. Laparoscopic appendicectomy was associated with a longer operating time (8-29 min), a minimal reduction in hospital stay and, probably, an earlier return to normal activity. It was also associated with a reduced risk of wound infection (odds ratio 2.6) with no increase in other complications. However, bias, particularly resulting from lack of blinding, makes some of these results difficult to interpret.
Laparoscopic appendicectomy was associated with some advantages and no obvious disadvantages, apart from prolonged operating time. Future RCTs should be blinded to minimize bias, document adequate follow-up and analyse results on an intention-to-treat basis.
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.
It is not clear whether the laparoscopic approach does decrease the incidence of postoperative infectious complications after appendectomy.
One hundred sixty-nine patients were randomized, 87 with laparoscopic (LA) and 82 with open appendectomy (OA). Patients in the OA group had a McBurney incision; LA was performed in the lithotomy position.
Acute appendicitis was confirmed in 75% of patients. The appendix was perforated in 5 patients of the LA versus 2 patients of the OA group. No conversion to the open procedure was necessary. The median operating time was 35 minutes in the LA group and 31 minutes in the open group (P = 0.58). The median postoperative hospital stay was shorter after laparoscopic than after open surgery (3 days versus 4 days, P = 0.026), whereas the time required for return to work was not significantly different (14 versus 15 days). There were 5 (6%) patients with superficial wound infection following LA and 6 (7%) after OA (P = 0.67). Intra-abdominal fluid collections were found in 2 (2%) patients following LA and 3 (4%) patients following OA (P = 0.60). In the LA group, 3 patients presented with intra-abdominal hemorrhage and another 3 developed a paralytic ileus that was treated conservatively.
Laparoscopic appendectomy is as safe and as effective as the open procedure; however, it does not decrease the rate of postoperative infectious complications.
There have been numerous retrospective and uncontrolled series of laparoscopic appendectomy (LA), as well as 16 prospective randomized studies published to date. Although most of these have concluded that the laparoscopic technique is as least as good as open appendectomy (OA), there has been considerable controversy as to whether LA is superior. To help clarify this issue, we performed a metaanalysis of the randomized prospective studies.
A metaanalysis of all formally randomized prospective trials of LA versus OA in adults.
A total of 1,682 patients were analyzed. When compared with OA, LA results in significantly less postoperative pain, earlier resumption of solid foods, a shorter hospital stay, and a faster return to normal activities. The wound infection rate in the LA patients is less than one half the rate in patients undergoing OA. LA, however, requires longer operating times and the incidence of intraabdominal abscess is higher, but this failed to reach statistical significance. There were no differences in complications or hospital charges.
LA offers considerable advantages over OA, primarily because of its ability to reduce the incidence of wound infections and shorten recovery times. Its widespread acceptance should be considered. The trend toward increased intraabdominal abscess formation is worrisome, however, and demands further investigation.
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.
To compare the effectiveness and safety of laparoscopic and conventional "open" appendectomy in the treatment of acute appendicitis.
Meta-analysis of randomised controlled trials available by May 1998 that compared both techniques. Within each trial and for each outcome an effect size was calculated; the effect sizes were then pooled by a random-effects model.
We summarised outcome data of 2877 patients included in 28 trials. Operating time was +16 min (95% confidence interval +12-20 min) longer for laparoscopic appendectomy. Overall complication rates were comparable, but wound infections were definitely reduced after laparoscopy [rate difference -4.2%, (-2.3% to -6.1%)]. Intra-abdominal abscesses, however, occurred slightly more frequently [+0.9%, (-0.4% to +2.3%)]. Hospital stay after laparoscopic appendectomy was 15 h (8-23 h) shorter, and patients returned to full fitness or work 7 days (5-9 days) earlier. Pain intensity on day 1 was slightly less. Heterogeneity was present for some outcome measures due to methodological differences among the primary studies.
Laparoscopic appendectomy reduces wound infections and eases postoperative recovery. Nevertheless, the various differences among the primary studies and their partly flawed methodology make it difficult to generalise from these findings.
We performed a meta-analysis to determine whether laparoscopic or open appendectomy gives better outcomes for patients with suspected acute appendicitis. Studies were selected from the MEDLINE database, personal files, and meeting abstracts. Eleven of 21 randomized controlled trials were included in the meta-analysis. Pooled effect size estimates were calculated using a random effects model. Laparoscopic appendectomy reduced time to full functioning by 5.48 days (95% confidence interval [CI] 3.70 to 7.26; p < 0.001), improved postoperative pain at 24 hours measured by a visual analog scale from 0 to 10 by 1.19 points (95% CI -2.14 to -0.24 points; p=0.014), and decreased the absolute risk for wound infection by 3.2% (95% CI -5.6% to -0. 8%; p=0.009). Operating time was increased by 17.12 min (95% CI 14.19 to 20.03; p < 0.0001). There was no difference between the two surgeries for length of hospital stay, readmission rate, and intra-abdominal abscess formation. Laparoscopic appendectomy improves patient outcomes.
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.
Despite many randomized controlled trials, the merits of laparoscopic appendectomy remain unclear. A meta-analysis may provide insights not evident from any individual studies.
Systematic literature search yielded 17 trials (1,962 subjects) of true randomized design with usable statistical data comparing laparoscopic and conventional appendectomy in adults. The effect sizes for operating time, hospitalization, postoperative pain, return to normal activity, wound infection, and intra-abdominal abscess were calculated, using the random effects model to allow for heterogeneity. An estimate of the robustness of all positive findings was also calculated.
Modest but statistically significant effect sizes were found for four of the six outcome measures. Laparoscopic appendectomy takes 31% longer to perform, but results in less postoperative pain, faster recovery (by 35%), and lower wound infection rates (by 60%).
Laparoscopic appendectomy offers significant improvement in postoperative outcomes at the cost of a longer operation.
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.