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Laparoscopy versus open surgery for suspected appendicitis
Abstract
Laparoscopic surgery for acute appendicitis has been proposed to have advantages over conventional surgery.
To compare the diagnostic and therapeutic effects of laparoscopic and conventional 'open' surgery.
We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, SciSearch, the congress proceedings of endoscopic surgical societies.
We included randomized clinical trials comparing laparoscopic (LA) versus open appendectomy (OA) in adults or children. Studies comparing immediate OA versus diagnostic laparoscopy (followed by LA or OA if necessary) were separately identified.
Two reviewers independently assessed trial quality. Missing information or data was requested from the authors. We used odds ratios (OR), relative risks (RR), and 95% confidence intervals (CI) for analysis.
We included 54 studies, of which 45 compared LA (with or without diagnostic laparoscopy) vs. OA in adults. Wound infections were less likely after LA than after OA (OR 0.45; CI 0.35 to 0.58), but the incidence of intraabdominal abscesses was increased (OR 2.48; CI 1.45 to 4.21). The duration of surgery was 12 minutes (CI 7 to 16) longer for LA. Pain on day 1 after surgery was reduced after LA by 9 mm (CI 5 to 13 mm) on a 100 mm visual analogue scale. Hospital stay was shortened by 1.1 day (CI 0.6 to 1.5). Return to normal activity, work, and sport occurred earlier after LA than after OA. While the operation costs of LA were significantly higher, the costs outside hospital were reduced. Five studies on children were included, but the result do not seem to be much different when compared to adults. Diagnostic laparoscopy reduced the risk of a negative appendectomy, but this effect was stronger in fertile women (RR 0.20; CI 0.11 to 0.34) as compared to unselected adults (RR 0.37; CI 0.13 to 1.01).
In those clinical settings where surgical expertise and equipment are available and affordable, diagnostic laparoscopy and LA (either in combination or separately) seem to have various advantages over OA. Some of the clinical effects of LA, however, are small and of limited clinical relevance. In spite of the mediocre quality of the available research data, we would generally recommend to use laparoscopy and LA in patients with suspected appendicitis unless laparoscopy itself is contraindicated or not feasible. Especially young female, obese, and employed patients seem to benefit from LA.
... In the developing countries only a few studies have been conducted comparing the two modalities in the treatment of acute appendicitis 6 . At present, although there is no consensus regarding the superiority of the laparoscopic approach over the conventional technique, there is trend towards greater utilization of laparoscopic appendectomy 7,8 . ...
... 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 . Some studies have reported statistically significant postoperative ileus in LA group compared to OA 2,19 . ...
... As far as post operative pain is concern, our study revealed significantly less pain in LA group (p<0.001). Some studies have reported less pain after laparoscopic appendectomy 7,16,20 and other studies found no difference in pain 12,18 . ...
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
... 10 In the Cochrane Central Register of Controlled Trials, the incidence of intraabdominal abscesses was increased after LA than after OA (OR = 2.48, 95% CI=1.45 -4.21). 16 In our study, there was a statistically significant shorter hospital stay in the LA group (1.5 ± 0.5 days) than the OA group (2 ± 1 days) (P<0.001). This result was consistent with other studies. ...
... 10 In another study, the unadjusted length of stay was significantly shorter after LA (2.6 days) than after OA (3.8 days) (P<0.0001). 15 In a 3 rd study, hospital stay was shortened by 1.1 days (95% CI = 0.6 to 1.5) after LA. 16 However, in a study the length of hospitalization was the same for both groups (P = 0.66). 13 In our study, for patients who were operated upon in Ain Shams University Specialized Hospital: The average cost for patients in the LA group was 3300 ± 400 LE, which was significantly higher than the average cost in the OA group (1500 ± 200 LE) (P<0.001). ...
... 10 In the Cochrane Central Register of Controlled Trials, while the operation costs of LA were significantly higher, the costs outside hospital were reduced. 16 In conclusion, our study results demonstrated that laparoscopic appendicectomy is safe as there is no significant incidence of major intraoperative complications than OA. LA is also associated with significantly lower incidence of postoperative complications especially wound infection than OA. ...
... Diese stellt hierzulande momentan in den meisten Fällen den Goldstandard zur Therapie der akuten Appendizitis dar. 14,22 Mittlerweile existieren zahlreiche Studien, Reviews und Meta-Analysen, um die beiden Operationstechniken zu vergleichen und mögliche Vor-und Nachteile zu diskutieren. [14][15][16][17][18][19][96][97][98] Zusätzlich zu den bereits oben genannten Vorteilen, scheinen von der laparoskopischen Appendektomie v.a. ...
... 14,22 Mittlerweile existieren zahlreiche Studien, Reviews und Meta-Analysen, um die beiden Operationstechniken zu vergleichen und mögliche Vor-und Nachteile zu diskutieren. [14][15][16][17][18][19][96][97][98] Zusätzlich zu den bereits oben genannten Vorteilen, scheinen von der laparoskopischen Appendektomie v.a. adipöse Patienten, Patienten >65 Jahre und Frauen <40 Jahre zu profitieren. ...
... 97,98 Als nachteilig werden die längeren Operationszeiten und höheren Kosten beschrieben. 98 Sauerland et al. 14 zeigten, dass die diagnostische Laparoskopie besonders bei Frauen im gebärfähigen Alter die Zahl der negativen Appendektomien reduzierte. 14 Liegt eine gangränöse oder perforierte Appendizitis vor, so gibt es Hinweise, dass sich nach einer laparoskopischen Appendektomie vermehrt intraabdominelle Abszesse bilden. ...
Mit einer Lebenszeitprävalenz von ca. 7% stellt die Appendizitis einer der häufigsten Gründe für Schmerzen im Unterbauch und somit für die Vorstellung in Notaufnahmen dar. Lange Zeit galt jegliche Form der Appendizitis als uneingeschränkte Indikation zur Appendektomie. In den letzten Jahren wird diskutiert, inwieweit die primär antibiotische Therapie als gleichwertige Behandlungsalternative zur Appendektomie bei der akuten unkomplizierten Appendizitis angesehen werden kann. Eine große Studie aus Finnland mit insgesamt 530 Patienten konnte eine Erfolgsrate der antibiotischen Therapie von 72,8% zeigen. 27,2% benötigten während des einjährigen Follow-Ups eine sekundäre Appendektomie. Langzeitergebnisse dieser Studie zeigen eine Erfolgsrate der antibiotischen Therapie von 60,9%. Das primäre Ziel der vorliegenden Studie war, die Sicherheit, Effektivität sowie die Machbarkeit der antibiotischen Behandlung der akuten unkomplizierten Appendizitis im klinischen Alltag zu evaluieren. Hierzu wurden alle Patienten, die sich für eine konservative Therapie eigneten und dieser zustimmten, eine Woche, drei Monate sowie ein Jahr nach stationärem Aufenthalt mittels Telefoninterview re-evaluiert. Weitere Ziele waren neben der Erfassung von Komplikationen, Schmerzstärke und Krankenhausverweildauer in beiden Behandlungsgruppen, die quantifizierte Erfassung und Auswertung der Patienten, bei denen die primäre konservative Therapie versagte und eine sekundäre Appendektomie notwendig war. Die definierten Endpunkte wurden schließlich mit der Kontrollgruppe der Patienten, mit primär chirurgischer Therapie der akuten Appendizitis, verglichen. Insgesamt wurden 124 Patienten in die Studie eingeschlossen, darunter 70 Patienten mit primärer Appendektomie und 54 Patienten mit primärer konservativer Therapie. 92,6% (95%-KI: 82,1–98%) der antibiotisch therapierten Patienten konnten ohne notwendige sekundäre Appendektomie aus dem Krankenhaus entlassen werden. Die Erfolgsrate der konservativen Therapie nach 1 Jahr Follow-Up lag bei 77,1% (95%-KI: 62,8–88%), diejenige der primären Appendektomie bei 100%. Eine sekundäre Appendektomie erfolgte bei insgesamt 22,9% (95%-KI: 12–37,3%). Komplikationen unterschieden sich nach einjährigem Follow-Up nicht signifikant zwischen beiden Gruppen, jedoch konnte im Vergleich zur Appendektomie-Gruppe in der konservativen Behandlungsgruppe eine um 6,3% (95%-KI: -0,1–22%) geringere Gesamtkomplikationsrate gezeigt werden (20,8% vs. 27,1%). Sekundär appendektomierte Patienten hatten eine um 18% (95%-KI: -2–38%) geringere Komplikationsrate als primär appendektomierte Patienten. Die mittlere initiale Krankenhausverweildauer war in der Antibiotika-Gruppe signifikant kürzer (3,6 vs. 4,8 Tage, p=0,03), nach einjährigem Follow-Up unterschied sich die kumulative Krankenhausverweildauer jedoch nur noch um 0,6 Tage. Auch die Schmerzintensitäten unterschieden sich nicht wesentlich zwischen beiden Gruppen. Die Ergebnisse der vorliegenden Studie zeigen, dass die antibiotische Therapie der unkomplizierten Appendizitis bei ausgewählten Patienten als alternative und sichere Behandlungsmethode zur Appendektomie angeboten werden kann und bei Patienten auf hohe Akzeptanz stößt. Gegenüber Patienten mit primärer Appendektomie ist für Patienten mit einer konservativen Therapie sowohl hinsichtlich der Gesamtkomplikationsrate als auch hinsichtlich der Komplikationen bei einer ggf. notwendigen sekundären Appendektomie kein höheres Risiko zu erwarten. Da die Erfolgsrate der primären Appendektomie sowohl in der vorliegenden Studie als auch in der internationalen Literatur höher war als die der antibiotischen Therapie, bleibt die Appendektomie dennoch das effektivere Verfahren. Um noch weitere Erkenntnisse über die Effektivität der antibiotischen Therapie auch über mehrere Jahre hinweg zu gewinnen, wären Untersuchungen mit einem Nachbeobachtungszeiträumen von mindestens 5 Jahren hilfreich.
... Laparoscopic surgery offers many proven advantages over conventional open surgery for many procedures [123]. The benefits include: i) minimal surgical trauma, ii) less postoperative pain, iii) rapid postoperative recovery, iv) exploration of the entire abdominal cavity, v) management of unexpected findings, vi) better cosmetic outcomes, and vii) rapid return to normal activities [123][124][125][126][127][128][129]. These advantages have increased the utilization and acceptability of laparoscopy. ...
... The emerging fact to date is that many private and public hospitals are adopting the technique for different conditions. Still, there exist some worries about the safety and overall outcome of laparoscopy for various circumstances in our developing setting [123][124][125][126]. In many developing countries like Nigeria, the challenges posed by the burden of infectious diseases and other primary healthcare concerns have limited government support for the development of modern tertiary healthcare facilities. ...
... Indeed, laparoscopic surgery is practiced in only a few tertiary hospitals across the country. Especially for those surgeons that share similar enthusiasm and now able to sustain the routine practice of laparoscopy in general surgery [123][124][125][126]. ...
BACKGROUND: Appendicitis is one of the leading causes of general surgical emergency admission worldwide. Available clinical research has produced conflicting reports about best practice, delivery and, a possible variation in outcome in the sub-Saharan Africa. Accordingly, the disease represents an important burden on modern health systems with severe emerging atypical presentations. So far, there has not been any systematic review of the literature on appendicitis research in Nigeria.
AIM: To examine the literature critically for possible changes in the pattern of appendicitis and to determine the impact of emerging atypical presentations in contemporary Nigerian settings.
METHOD: Published articles discussing appendicitis in Nigeria up to November 2019 were obtained for review from Medline search, medical libraries, and Google.
RESULTS: Fourteen articles were included in the quantitative analysis. Some were excluded from the subgroup analyses. The current estimated incidence of appendicitis is 22.1-49.8 new cases per 100,000 per annum from Nigeria. The result reflects a rising incidence of similar studies over the last decades. Negative appendicectomies occurred at a rate of 10.5% (457/4566). The perforation rate for appendicectomy patients was 19% (868/4566), and the overall mortality rate was 0.4% (18/4566). Research efforts focused on disease patterns and management outcome measures within the country.
CONCLUSION: Laparoscopic surgery is emerging in Nigeria. The overall negative appendicectomy, perforation, and mortality rates are substantially low, suggesting improving health systems and quality metrics. Clinicians in the rural settings of tropical sub-Saharan Africa require a high index of suspicion. There is a critical need to consider differential diagnoses such as abdominal tuberculosis, amoebiasis, helminthiasis, and schistosomiasis when treating patients with acute abdomen. Finally, an aggressive healthcare financing in the form of Community -Based Health Insurance Scheme, will be highly beneficial at this stage to all Nigerians.
... Now laparoscopic appendicectomy (LA) has become common and an acceptable approach in the management of acute appendicitis (5) . LA is associated with decreased postoperative pain, more rapid return to daily activities, and improved cosmetic results (6) . However, the literature has shown the association of laparoscopy with specific adverse events such as increased intra-abdominal abscess and hospital costs (6) . ...
... LA is associated with decreased postoperative pain, more rapid return to daily activities, and improved cosmetic results (6) . However, the literature has shown the association of laparoscopy with specific adverse events such as increased intra-abdominal abscess and hospital costs (6) . ...
... For example, the incidence of acute appendicitis is 75 per 100 000 from recent data in Canada [1]. Although numerous clinical studies and metaanalyses of data remain debatable whether conventional open appendectomy (OA) or laparoscopic appendectomy (LA) is the most efficient and effective surgical approach in acute appendicitis [2][3][4][5][6][7][8][9]. ...
... Conclusions from most of the studies on the advantages of LA over OA in the largest hospitals with experienced surgeons and available equipment are undeniable [9]. Concerns about surgical techniques refer to the surgical complications documented after LA and, in particular, the threefold increase in postoperative intra-abdominal abscesses. ...
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Scopus Journal Metrics:
CiteScore 2018 - 0,30
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Index Copernicus Value:
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back to 2021 Oct-Dec;27(4)
Journal of IMAB - Annual Proceeding (Scientific Papers)
Publisher: Peytchinski Publishing Ltd.
ISSN: 1312-773X (Online)
Issue: 2021, vol. 27, issue4
Subject Area: Medicine
-
DOI: 10.5272/jimab.2021274.4084
Published online: 12 November 2021
Original article
J of IMAB. 2021 Oct-Dec;27(4):4084-4086
RISK FACTORS AND OUTCOMES FOR SEPTIC COMPLICATIONS AFTER LAPAROSCOPIC APPENDECTOMY
Konstantin KostovORCID logo Corresponding Autoremail,
Department of General, Visceral and Emergency Surgery, UMHATEM "N. I. Pirogov" – Sofia, Bulgaria.
ABSTRACT:
Purpose: The aim of the study is to investigate the postoperative infectious complications after laparoscopic appendectomy of patients with acute appendicitis in UMHATEM "N.I.Pirogov".
Material and Methods: For a period of one year from 1.1.2018 to 31.12.2018. a total of 218 patients with acute appendicitis were operated in the General, Visceral and Emergency Surgery Department of UMHATEM "Pirogov". Of these, 143 were laparoscopic apendectomy. Indicators characterizing basic clinical and pathological features (epidemiology, demography, degree of pathological disability), surgical approach and outcomes (postoperative complications, duration of the postoperative period) were analyzed.
Results: Of the 143 of the patients- women are 79 (55.24%), male -51 (44.76%). The age of the patients varies from 18 to 79 years. The laparoscopy time interval is 21-117min., and in some cases, with a prolonged operation, the conversions are included. The hospital stay ranged from 2 to 8 days. Postoperative complications were recorded in 13 cases (9.09%) - wound infection in nine (treated with VAC dressing), two patients with (0.92%) intra-abdominal abscess (PTC drained) and other 2-with ileus (with conservative treatment).
Conclusion: Aggressive manipulations on infected appendix and irregular lavage can spread bacterial contamination. Compliance with standardized laparoscopic appendectomy rules and systematized training of specialists will significantly improve postoperative results.
... 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. ...
... In our study, most cases took 90 minutes duration, it may be due to time taken for peritoneal lavage and suturing the base of the appendix. A study reported significantly low operating time in LA group (7) Ball et al., (19) strongly emphasized that appendectomies frequently are performed as an emergency procedure during the night, and if the resident staff does not have the experience, skills, and guidance to perform such surgery, then residual sepsis will follow. Sometimes, when technical difficulties appear, an inexperienced surgeon will choose an ''early conversion,''. ...
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.
... 1,2 Laparoscopic appendectomy (LA) has become the gold-standard treatment for AA because it offers numerous advantages over the conventional approach such as a shorter hospital stay, lesser postoperative pain, earlier return to normal activity, and lower rate of wound complications. [3][4][5] LA is one of the most common procedures performed by surgical trainees. Interestingly, as conventional appendectomy is now rarely performed, most residents lack experience in open appendectomy before performing LA. [6][7][8] Although numerous studies exist regarding the safety of LA performed by surgical trainees, 6,[9][10][11] scarce data are available of LA performed by surgical interns. ...
... Laparoscopy has become the standard approach in most abdominal operations, mostly due to its proven benefits such as decreased postoperative pain, shorter LOS, quicker return to normal activity, and fewer abdominal wall complications. 4,5 Every surgical resident is required to acquire robust training in laparoscopy and LA is indeed one of the most common laparoscopic procedures performed by trainees. However, there is concern that the procedures performed by inexperienced trainees could result in higher postoperative morbidity. ...
Background: Laparoscopic appendectomy (LA) is a common procedure among surgical trainees. However, first-year residents’ involvement in this procedure is scarcely studied. We aimed to determine the safety and outcomes of LA performed by surgical interns early in their first year of surgical training.
Methods: A retrospective review of all patients who underwent LA for acute appendicitis from 2006 to 2019 was performed. All patients operated by surgical interns were included. The sample was divided into two groups: LA performed during the first (G1) and last three months (G2) of their first year of residency. Demographics, operative variables, and postoperative outcomes were compared between groups.
Results: A total of 2,009 LA were performed during the study period; 1,647 (82%) were done by surgical interns. Nine hundred and thirty-four LA were performed at both ends of the year; 505 belonged to G1 and 429 to G2. Each surgical intern performed a mean of 40 LA. Demographics, complicated appendicitis rates, and presence of peritonitis were comparable between groups. Operative time was longer in G1 (G1: 61 vs. G2: 52 minutes, p<0.0001). Major morbidity (G1: 2.1% vs. G2: 3.4%, p=0.2), postoperative intra-abdominal abscess rates (G1: 2.8% vs. G2: 2.8%, p=0.66), median length of hospital stay (G1: 1.9 vs. G2: 1.8 days, p=0.59), and readmission rates (G1: 1.6% vs. G2: 2%, p=0.73) were similar between groups. There was no mortality in the series.
Conclusion: LA can be safely performed by supervised surgical interns early in their training. Despite a longer operative time, postoperative outcomes were favorable and similar as those achieved at the end of surgical internship.
... The benefits of LA remain controversial. Laparoscopic surgery offers many proven advantages over conventional open sur-gery for many procedures [5], [6], [7]. The benefits include: i) minimal surgical trauma, ii) less postoperative pain, iii) rapid postoperative recovery, iv) exploration of the entire abdominal cavity, v) management of unexpected findings, vi) better cosmetic outcomes, and vii) prompt return to normal activities [5], [6], [7], [8], [9], [10], [11]. ...
... Laparoscopic surgery offers many proven advantages over conventional open sur-gery for many procedures [5], [6], [7]. The benefits include: i) minimal surgical trauma, ii) less postoperative pain, iii) rapid postoperative recovery, iv) exploration of the entire abdominal cavity, v) management of unexpected findings, vi) better cosmetic outcomes, and vii) prompt return to normal activities [5], [6], [7], [8], [9], [10], [11]. These advantages have increased the utilization and acceptability of laparoscopy. ...
BACKGROUND: The first laparoscopic procedures were performed well for over thirty years in Europe. Mostly, these include appendectomy and cholecystectomy. However, in Nigeria and other developing countries, the practice commenced only recently and with encouraging results in many centers. Laparoscopic appendectomy (LA) in the low resource setting remains controversial. AIM: We audit the procedures; highlight the cost-saving technique, and the practical skills transfer model for laparoscopic appendectomy performed at Lagoon Hospitals in Lagos, Nigeria. METHODS: We review the hospital records per case of appendectomy done from January 2012 through December 2016 at the Lagoon Hospitals, Lagos-Nigeria. RESULTS: Two hundred and fifty-eight 258 patients were diagnosed with acute appendicitis (AA) within the study period. (Number-n=97; 37.6%) Patients had open appendectomy (OA). Then (n=16; 6.2%) patients that presented with clinical and radiological diagnosis of complicated AA eventually had an open laparotomy. Meanwhile, (n=145; 56.2%) cases had LA. In the laparoscopy group, (n=4; 1.6%) patients who had initial diagnostic laparoscopy revealed a normal appendix in addition to other operative findings that precluded appendectomy. Subsequently, an estimated (n=141; 54.6%) patients underwent LA, for which conversion to open laparotomy was inadvertently required in (n=2; 0.8%) of these cases. The median time for the LA procedure was higher than that observed for OA (49.5 vs. 34.5 min). Patients in the LA group had a shorter median postoperative stay (1.5 vs. 2.5 days). CONCLUSION: LA reduced the rate of unnecessary appendectomy, and postoperative hospital stays in our patients, potentially reducing crowding in our surgical wards. The complications were very similar to those seen in other facilities elsewhere. LA is safe, average cost, and gradually gaining acceptance among Surgeons in Nigeria. For effective training of qualified surgeons on site, short but repetitive hands-on training sessions has been advocated as appropriate. LA is achievable in resource-constrained settings.
... Historically, the right lower quadrant incision of open appendicectomy (OA) has persisted essentially unchanged since it was pioneered by McBurney in the 19th century [1,2]. ...
... The use of diagnostic laparoscopy allows one to accelerate the initiation of causal treatment, but also to avoid unnecessary laparotomy during the emergency call, which is associated with increased incidence of postoperative complications, reaching up to 22% of patients [21,22]. The value of diagnostic laparoscopy is particularly visible in women of childbearing age and allows the frequency of unnecessary laparotomies and appendectomies to be reduced [23,24]. ...
Introduction
Over the past three decades, almost every type of abdominal surgery has been performed and refined using the laparoscopic technique. Surgeons are applying it for more procedures, which not so long ago were performed only in the classical way. The position of laparoscopic surgery is therefore well established, and in many operations it is currently the recommended and dominant method.
Aim
The aim of the preparation of these guidelines was to concisely summarize the current knowledge on laparoscopy in acute abdominal diseases for the purposes of the continuous training of surgeons and to create a reference for opinions.
Material and methods
The development of these recommendations is based on a review of the available literature from the PubMed, Medline, EMBASE and Cochrane Library databases from 1985 to 2022, with particular emphasis on systematic reviews and clinical recommendations of recognized scientific societies. Recommendations were formulated in a directive form and evaluated by a group of experts using the Delphi method.
Results and conclusions
There are 63 recommendations divided into 12 sections: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia, acute cholecystitis, acute appendicitis, acute mesenteric ischemia, abdominal trauma, bowel obstruction, diverticulitis, laparoscopy in pregnancy, and postoperative complications requiring emergency surgery. Each recommendation was supported by scientific evidence and supplemented with expert comments. The guidelines were created on the initiative of the Videosurgery Chapter of the Association of Polish Surgeons and are recommended by the national consultant in the field of general surgery. The first part of the guidelines covers 5 sections and the following challenges for surgical practice: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia and acute cholecystitis. Contraindications for laparoscopy and the ERAS program are discussed.
... In laparoscopic group the hospital stay was recorded to be short that is 1.4 ± 0.6 days 2 . However, significantly shorter hospital stay for LA was noted by some other studies 3,17 . An earlier study reported the postoperative stay of patients who undergone LA to be 43 hours 18 . ...
Objective: To assess the postoperative outcomes of laparoscopic appendectomy in terms of compli- cations and to compare them on gender basis. Methods: This was the prospective observational study conducted at department of General Surgery Chandka Medical College Hospital Larkana with non-probability convenient sampling technique. The duration of study was one year from January 2013 till December 2013. 150 patients were selected that were diagnosed with acute appendicitis. Patients were followed up for 2 weeks and their compli- cations were observed. All data was entered and analysed on SPSS version 20. Inferential analysis was performed using chi-square test whereas the significance level was set at 0.05. Results: The study results showed that 14 male (18.7%) and 16 female (21.4%) patients developed complications (p=0.094). 5 male (6.6%) and 8 female (10.6%) patients developed paralytic ileus (p=0.384). 5 male (6.6%) and 3 female (4%) patients developed urinary retention (p=0.471) whereas 2 male (2.6%) and 6 female (8%) patients complained to have wound infection (p=0.146). The overall frequency of patients that did not develop any complications among 150 patients was 121 (80.6%) while 13 (8.6%), 8 (5.3%) and 8 (5.3%) were reported to develop paralytic ileus, urinary retention and wound infection respectively. Conclusion: Laproscopic appendectomy is safer and clinically advantageous technique. The differ- ence in the complications of the laproscopic appendectomy with respect to the gender was insignifi- cant. However, significant difference existed on visual analogue pain scale.
... Günlük bağırsak temizliği yapılması gereken gerçek fekal inkontinansı olan bazı hastalarda (anorektal malformasyon, Hirschsprung hastalığı, kontrol edilemeyen kabızlık, spinal sorunlar, spina bifida vb.) anterior kontinans enema (ACE) uygulamaları yapılması gerekebilir. Birçok teknik tanımlanmış olmasına karşın, minimal invaziv teknik, daha kısa hastanede kalış süresi, daha hızlı iyileşme, iyi kozmetik sonuçlar nedeni ile tercih edilebilir (30)(31)(32) . Göbeğe yapılan "V" şeklindeki insizyon yerinden kamera yerleştirilir. ...
... The most common complications are wound infection, ileus caused by intraabdominal adhesions and intraabdominal abscess formation. These vary in frequency between open and laparoscopic appendicectomy 20,21 . The overall complication rates for open and laparoscopic appendicectomy are 11.1% and 8.7% respectively, with an overall mortality rate of less than 0.5% 22 . ...
Acute appendicitis is a common surgical presentation usually managed with laparoscopic appendicectomy. There has been long-standing debate as to whether conservative management of acute appendicitis could provide a superior alternative to surgical management. COVID-19 infection emerged in December 2019 and was labelled as a pandemic by the World Health Organisation in March 2020. Re-structuring as a result of the pandemic forced rapid changes in guidelines from recommending surgical management to advocating for medical management in all cases of uncomplicated acute appendicitis. Mr C had a delayed presentation of complicated acute appendicitis as a result of anxiety about being in a clinical environment during the pandemic. This was successfully managed with surgery and a 4-day inpatient stay. This case report evaluates the best approach for the treatment of acute appendicitis, evaluates whether a change in management was appropriate in the case of a pandemic and details how to avoid more cases of delayed and complex presentation as a result of COVID-19.
... Laparoscopic appendectomy markedly reduced the post-operative complication rate as observed in other similar studies [13,14,17,21]. In a Cochrane review that consisted of 5000 patients, it was revealed that patients undergoing LA were half as likely to develop wound infection postoperatively; however, on the other hand, they were three times more likely to develop intra-abdominal abscess formation [22]. Other studies also showed an increased risk of intra-abdominal abscess after laparoscopic appendectomy [13,14]. ...
Introduction: Several studies have demonstrated the superiority of Laparoscopic appendicectomy in managing acute appendicitis. Acute appendicitis has been managed solely by open appendicectomy at the University Teaching Hospital (UTH). This was the first study that looked at the management of acute appendicitis by laparoscopy at UTH. This study aimed to determine the outcomes of laparoscopic appendicectomy at UTH. Materials and Methods: This was a prospective cohort study that included patients that were diagnosed with acute uncomplicated appendicitis. All patients admitted between August 2015 to March 2016 were included in the study. Variables analyses were patient’s data (age, gender, previous surgery, WBC count, symptoms, signs, symptoms), operating time, intra\post operative complications, and length of stay. Results: A total of 9 laparoscopic appendicectomies were performed during the study period. The patients had an average age of 31.8 years and were predominantly female (70%). One case was converted to open appendicectomy and was not included in the laparoscopic data group. The mean operative time for the procedure was 75.5 min (range 50-110min). The length of stay was on average 2.3 days (range 2-3 days). The patients in the study had no complications noted during the follow-up period. No patient developed an intraabdominal abscess during the study period. Conclusion: Laparoscopic appendicectomy for uncomplicated acute appendicitis resulted in good surgical outcomes in this institution compared to the regional statistics as a reference point. It may be preferred in patients presenting with uncomplicated appendicitis or where the diagnosis is equivocal. Laparoscopic appendicectomy is recommended, especially for the young female patients in our setting.
... Complicated appendicitis is linked with a superior hazard of post-operative complications and has been measured a qualified contraindication for laparoscopy [23][24][25]. Nevertheless, this thought has been faced in various researches which compared surgical results of LA for complicated appendicitis [22,26,27]. ...
Background: Appendicitis is the commonest abdominal surgical emergency in the world which may lead to complications like appendicular abscess or mass, gangrene, perforation and peritonitis. Present research aimed to evaluate the wellbeing and the effectiveness of laparoscopy for managing complicated appendicitis. Material and methods: Present study was carried out on 50 patients at tertiary care institution of Chhattisgarh in Central India for the period of 2 year. This study is including patients of complicated appendicitis undergoing laparoscopic management. Parameters studied included Age, Gender, WBC count, wound infection and hospital stay. Results: There was increase of total leucocytic count in most of the patients; Mean WBCs was 12.71±5.37. 33 patients had pus free IPF collection and perforated appendicitis (PA), 11 patients had turbid free IPF collection with AA (highly inflamed appendix), 2 case was mucocele of the appendix, 2 cases of appendicular abscess (3.3%) and 2 cases of gangrenous appendix. Conclusion: Management of complicated appendicitis laparoscopically is practicable, secure and can present a small occurrence of infectious impediments, fewer post-operative pain, fast revival and improved cosmesis on the cost of extended operating time than Open Appendectomy
... However, several studies was found in literature like Guller et al., (20) Roviaro et al., (21) , several trials of Ortega et al., (22) ; Ignacio et al., (23) and meta-analyses of Wei et al., (24) ; Sauerland et al., (25) comparing laparoscopic with open appendectomy have provided some conflicting results. Some of these studies have showed a better clinical outcome with the laparoscopic approach, while other studies have shown minor or no clinical benefits and higher cost to preform (26) . ...
... Nevertheless, with the evolution of laparoscopy and after Kurt Semm (2), a German gynecologist, performed the first laparoscopic appendicectomy in 1983, many surgeons have started to favor the minimally invasive approach (3,4). A recent Cochrane meta-analysis of randomized control trials has recommended laparoscopy and laparoscopic appendicectomy as being superior to the open technique in terms of postoperative pain, complication rate, hospital stay and return to normal activities (5). However, despite the breadth of data and the widespread adoption of the laparoscopic technique, there continues to be controversy regarding the advantages of this approach, since other studies have failed to prove the benefit of the minimally invasive technique (6). ...
... Доцільність використання ЛА залишається предметом дискусій не тільки серед дитячій, але й дорослій хірургії, хоча ще у 2004 р. S. Sauerland зі співавторами вважали, що «… за тих клінічних умов, де наявні хірургічні навички, знання та обладнання, ми зазвичай рекомендуємо використовувати лапароскопію та ЛА у всіх пацієнтів з підозрою на ГА, якщо сама по собі лапароскопія не є протипоказаною або неможливою» [63]. ...
Introduction. The typical clinical picture of acute appendicitis (AA) is absent in most of patients, that lead for the high frequency of misdiagnosis with the increase of complicated forms of AA. Due to that, it is necessary to establish the new available laboratory markers, which permitted with the high level of reliability distinguish children not only with AA, but also is appendix perforation. The question what method of appendectomy should be choose – the conventional or mini-invasive – are still under debate. Aim of the study was to summarize the results of diagnosis and treatment of AA in children with the applying of various laboratory markers, ultrasonography (US), and laparoscopy. Materials and methods. This study based on the results of surgical treatment of 3171 children with AA, which were operated during 2009–2018 years. Diagnosis was established on the data of anamnesis, results of objective and laboratory investigation. US was performed in 1183 (37.3%) of patients. Open appendectomy (OA) was performed in 2879 (90.8%) and laparoscopic (LA) – in 292 (9.2%) of patients. With the aim to evaluate the results the methods of variative statistic, determination of specificity, sensitivity, positive (PPV) and negative (NPV) predictive value, etc. were applied. Results. Among the laboratory markers, the best results for the diagnosis of AA showed the neutrophil to lymphocytes ratio (NLR) with the sensitivity – 84.9%, specificity – 67.1%, PPV – 17.8%, and NPV – 98.9%. NLR (sensitivity – 82.5%, specificity – 84%, PPV – 98.5%) and sodium blood level (sensitivity – 90.3%, specificity – 89.9%, PPV – 98.9%) had the best results for the diagnostic of perforated AA. US is the important compound of diagnostic of AA in children with the high level of sensitivity, specificity, PPV, and NPV – 93%, 85%, 86%, and 92%, correspondingly. By the frequency of complications in the early postoperative period, OA and LA had no statistically significant differences, but at follow-up after surgery, LA revealed the sufficient advantages over OA. Conclusions. Among the various laboratory markers, NLR had the better prognostic value for the diagnosis of AA and indices of plasma sodium concentration and NLR for the preoperative diagnosis of perforated appendicitis. US with the high degree of reliability allows to confirm or exclude the diagnosis of AA in children with acute abdominal syndrome. Laparoscopic appendectomy is the real alternative for conventional methods of AA treatment. Besides of the well-known advantages of mini-invasive surgery, the laparoscopic appendectomy had an advantage at the follow-up period. No conflicts of interest was declared by the authors. Key words: acute appendicitis, children, diagnostic, treatment, laparoscopy.
... But many different studies presented that laparoscopic technique resulted shorter hospital stay. 18,19 We found in our study that 11 (9.2%) patients in Group II in which 5.83% had Superficial SSI and 3.7% had Deep SSI. 9 (7.5%) patients 5% superficial and 2.5% Deep SSI in Group I had developed surgical site infection with no significant difference (p=0.41). Between both groups no significant difference was observed (p=>0.05). ...
Aim: The aim of this study is to compare the surgical site infection, hospital stay and time duration of procedure in patients undergoing laparoscopic and open appendectomy. Study Design: Prospective/ Observational Place & Duration: Department of Surgery, Pak Red Crescent Medical and Dental college, Dina Nath, during from Jan 2020 to March 2021. Methods: In this study 240 patients of both genders with ages >10 years presented with acute appendicitis were included. Patients demographic including age, sex and body mass index were recorded after written consent. Patients were equally divided into two groups. Group I consist of 120 patients and received laparoscopic appendectomy and Group II with 120 patients received open appendectomy. Outcomes such as surgical site infection, hospital stay and time duration of procedure were examined and compare the results between both groups. Data was analyzed by SPSS 23.0. P-value <0.05 was set as significant. Results: There were 140 (58.3%) patients (70 Group I, 70 Group II) were male with mean age 25.7+6.54 years while 100 (41.7%) patients (50 Group I, 50 Group II) were females with mean age 26.9+3.12 years. No significant difference regarding BMI between both groups p=>0.05. There was a significant difference in term of surgery time duration between both groups 48.24+9.59 minutes Vs 35.74+6.86 minutes; P=0.001. No significant difference observed in term of hospital stay (p=0.345). 11 (9.2%) patients in Group II in which 5.83% had Superficial SSI and 3.7% had Deep SSI. 9 (7.5%) patients 5% superficial and 2.5% Deep SSI in Group I had developed surgical site infection with no significant difference (p=0.41). Conclusion: We concluded in this study that open appendectomy is better in term of operative time as compared to laparoscopic appendectomy. We found no significant difference regarding surgical site infection and hospital stay. Keywords: Acute appendicitis, Appendectomy, Laparoscopic, Open, Outcomes
... There are several drawbacks, such as, lack of instruments availability, intraluminal invasion of the hollow organs, and failed sutures, which fails the idea of cost benefit analysis. 20,21 Single-incision laparoscopic surgery applies a single multiluminal port, or multiple monoluminal ports, through a single skin incision. Although this technique has been embraced by surgeons worldwide, instruments and procedure are under fundamental stage of investigation. ...
... 5 The well established advantages of the laparoscopic approach have enabled this procedure to gain rapid worldwide acceptance over open procedures. 6 LA has been an increasingly used surgical procedure for acute appendicitis since its introduction in 1983 3 it provides better diagnostic accuracy, reduced use of analgesics, shorter hospital stay, earlier return to daily activities, and a lower rate of wound infection in comparison to OA. [7][8][9][10][11][12] Some investigations have also revealed that elderly patients, morbidly obese patients, and fertile women can take advantage of LA to treat acute appendicitis. [13][14][15] In addition, LA is cosmetically beneficial. ...
... In children, they found no differences in the pain intensity (on day one) and incidences of intra-abdominal abscesses or time until return to normal activity [6]. Despite this fact, LA is still struggling to prove its superiority over OA in many scenarios which showed equivocal or marginally more benefits and similar or higher cost than an open approach [6,[8][9][10][11][12]. Many times, the surgical approach needs to be determined taking into consideration the disease condition, socio- ...
Background: Appendicitis is a common surgical emergency with a lifetime risk of appendectomy being 9.6 to 9.8 %. Open and laparoscopic approaches are being advocated with similar benefits. Aim and Objective: Our study aims to compare the outcomes in open and laparoscopic appendectomies in a teaching hospital in rural Maharashtra. Material and Methods: This is an observational study of 114 consecutive patients who underwent appendectomy from August 2017 to July 2020 in the department of surgery at a rural medical college and teaching institute. Sixty-eight patients of open appendectomy (43 acute cases and 25 chronic cases) and 46 of laparoscopic appendectomy (20 acute cases and 26 chronic cases) were included in the study. We investigated operative time, length of hospital stays, postoperative pain, intravenous analgesia complication rate and cost between the two groups. Results: We observed longer operative time (51.26 ± 11.67 vs 33.69 ± 10.27 minutes for open, P < 0.0001) and shorter postoperative stay (LA vs OA: 3.67 ± 0.92 vs 5.71 ± 1.49 days respectively P < 0.0001) for the laparoscopic surgery(LA) group as compared to open appendectomy(OA). Postoperative intravenous analgesic use was less in the laparoscopy group (2.38 days vs 4.10 days, P < 0.0001). The cost difference was not statistically significant. There was no significant perioperative morbidity in either group. Conclusion: Laparoscopic appendicectomy is associated with lesser use of postoperative analgesics, fewer complications, shorter hospital stay, early return to routine work. Laparoscopic appendicectomy was found to have longer duration of surgery.
... Since its introduction into clinical practice in 1983, laparoscopic appendectomy (LA) has proven to be a feasible and safe procedure and has gained worldwide acceptance [12,13]. The advantages of LA are considered to be less postoperative pain, early discharge, less wound infection, better cosmetic results, and faster return to normal school and daily life [14][15][16][17][18][19][20]. However, several retrospective studies, randomized studies, and meta-analyses comparing open appendectomy (OA) and LA have shown mixed results [21][22][23][24][25]. ...
Background
Appendicitis is the most common cause of acute abdomen. Although emergency surgery used to be the standard treatment for both simple and complex appendicitis, there are now options for interval surgery, laparoscopic surgery, and even non-surgical treatment. In this study, we aimed to establish better treatment strategies for pediatric acute appendicitis and to find out whether minimally invasive treatment is superior to the traditional open approach. We retrospectively reviewed the cases of acute appendicitis treated in our hospital during the period from 2013 to 2018. The patients who underwent appendectomy were divided into four groups. Group 1 underwent early appendectomy with open approach, group2 underwent interval appendectomy with open approach, group 3 underwent early appendectomy with laparoscopic approach, and group 4 underwent interval appendectomy with laparoscopic approach. In addition to the above groups, the non-surgical treatment group was also studied. Clinical presentation, laboratory findings, imaging results, operative time, morbidity, and length of hospital stay were reviewed.
Results
One hundred six children’s records were reviewed. Thirty-five of them were selected for non-surgery as they were cases with no fecal stone and first onset appendicitis, and 15 of these 35 patients (42.9%) relapsed after antibiotic treatment. As for the appendix diameter, the relapse group was significantly larger than the non-relapse group ( p =0.007). In cases of surgery, group 4 had significantly less intraoperative blood loss than group 1 ( p <0.001). Group 4 had significantly fewer postoperative complications than groups 1 and 2 [group 4 vs. group 1 ( p =0.009), group 4 vs. group 2 ( p =0.034)]. The postoperative hospital stay in groups 2 and 4 were significantly shorter than group 1 [group 1 vs. group 2 ( p =0.015), group 1 vs. group 4 ( p <0.001)]. On the contrary, group 1 had significantly shorter total hospital stay than groups 2 and 4 [group 1 vs. group 2 ( p =0.029), group 1 vs. group 4 ( p <0.001)].
Conclusion
Interval laparoscopic appendectomy and non-surgical treatment were safe and effective in children. From the viewpoint of avoiding unnecessary emergency surgery and prolonged hospitalization, we believe that interval laparoscopic appendectomy or non-surgical treatment should be performed after identifying patients who do not require surgery, paying attention to the risk factors for relapse.
... Proportion of patients with complications in both groups.Ling L et al performed a case study and reported similar results for small incision appendectomy. 14 Saurland et al in the Cochrane database review analyzed 54 studies comparing laparoscopic appendectomy versus open appendectomy and observed that the operative time and cost in laparoscopic is significantly higher.15 Shah B et al concluded that small incision open appendectomy is better than laparoscopic appendectomy in terms of operative time, time to return to daily activity and complications and that the cost was higher in laparoscopic group compared to small incision open appendectomy group.16 ...
Background: Open appendectomy is practiced for more than a century and in the recent times small incision appendectomy is also practiced frequently. The efficacy of conventional appendectomy and small incision appendectomy in terms of pain, operating time and duration of hospital stay and have produced conflicting results. Hence this study was conducted to assess the same. Methods: A hospital based randomized controlled trial study was conducted among the patients with appendicitis undergoing surgical intervention for the same in department of general surgery in Sri Muthukumaran Medical College Hospital and Research Institute, Chennai, during the study period from January 2017 to December 2019. A total of eighty cases with acute appendicitis were included in the study. Group A (n=40) includes conventional open appendectomy cases and group B (n=40) includes small incision open appendectomy cases. Data entry was done using Microsoft excel and data was analyzed using SPSS version 17. Results: Blood loss, post-operative pain scores on day 1 and day 2, duration of hospital stay were found to be reduced in Small incision open appendectomy group compared to conventional open appendectomy group. Duration taken to resuming the normal activities and the complications were found to be similar in both conventional and small incision appendectomy group and small incision open appendectomy group. Conclusions: Small incision open appendectomy is superior to conventional open appendectomy in terms of length of hospital stay, return to normal activity, blood loss and postoperative pain scores, which are considered the major advantages of minimally invasive surgery.
... Complicated appendicitis is linked with a superior hazard of post-operative complications and has been measured a qualified contraindication for laparoscopy. [27][28][29] nevertheless, this thought has been faced in various researches which compared surgical results of LA for complicated appendicitis. [30][31][32] Even though a few researchs comparing LA and OA have revealed similarity of the two events as observe morbidity and mortality, [33] most researches accounted important compensation in the laparoscopic group, such as, reduced post-operative pain, quick revival, little hospital reside, [34][35][36] accessibility of inspection of the whole peritoneal cavity, superior debridement, sufficient irrigation and lavage under straight apparition, improved cosmesis, fewer immunologic cooperation and less chest impediments. ...
Background: Present research aimed to evaluate the wellbeing and the effectiveness of laparoscopy for managing complicated appendicitis. Subjects and Methods: Present descriptive research was carry out on 50 patients at tertiary care institution of Gujarat for the period of 1 year. This study is including patients of complicated appendicitis undergoing laparoscopic management. Parameters studied included Age, Gender, WBC count, wound infection and hospital stay. Results: There was increase of total leucocytic count (leukocytosis) in most of the patients; Mean WBCs was 12.71 5.37. 33 patients had pus free IPF collection and perforated appendicitis (PA), 11 patients had turbid free IPF collection with AA (highly inflamed appendix), 2 case was mucocele of the appendix, 2 cases of appendicular abscess (3.3%) and 2 cases of gangrenous appendix. Conclusion: management of complicated appendicitis laparoscopically is practicable, secure and can present a small occurrence of infectious impediments, fewer post-operative pain, fast revival and improved cosmesis on the cost of extended operating time than OA.
... However, several studies was found in literature like Guller et al., (20) Roviaro et al., (21) , several trials of Ortega et al., (22) ; Ignacio et al., (23) and meta-analyses of Wei et al., (24) ; Sauerland et al., (25) comparing laparoscopic with open appendectomy have provided some conflicting results. Some of these studies have showed a better clinical outcome with the laparoscopic approach, while other studies have shown minor or no clinical benefits and higher cost to preform (26) . ...
... [2] Since then, many studies have shown its advantage over open approach (OA) with better cosmesis, shorter hospital stay, less pain, and recovery. [3,4] However, although the surgical technique of LA appendectomy has been well established, various technical aspects still need to be evaluated and standardized, especially regarding the closure of the appendiceal stump. It is established that inappropriate management of appendiceal stump can lead to serious postoperative complications, such as stercoral fistulas, postoperative peritonitis, and intra-abdominal infection. ...
Purpose:
Laparoscopy has become the treatment of choice for acute appendicitis. The aim of the study was to compare open (OA) and laparoscopic (LA) approaches in all forms of acute appendicitis.
Methodology:
Two hundred and ninety-two children underwent appendectomy (238 LA/54 OA). 3/238 patients required conversion. LA surgical technique has been modified by closing also the distal stump of appendix (DSC) before removing it.
Results:
Early experience: 130 appendectomy, 44 by OA (34%), and 86 by LA (66%). The mean operative time was similar for both techniques. Complicated appendicitis (CA) was observed in 14 patients (11%). 10 patients treated with OA (10/14 = 71%) and 4 with LA (4/14 = 29%). Complications occurred mainly in the LA group without statistical significance.
Late experience:
One hundred and sixty-two appendectomy, 10 OA (6.17%), and 152 LA (93.8%). Thirty-eight children (23.4%) had CA. The mean operative time was lower in LA group without reaching statistical significance. Total complication rate (CR) was 7.4%. CR in patients with DSC was null and significantly lower when compared to patients without DSC.
Conclusion:
Our results demonstrated that nearly all cases of appendicitis may be managed by laparoscopy. Ligature of distal appendiceal stump is a trick that may significantly improve outcomes during LA appendectomy.
... 10,13 Some authors consider that perioperative antibiotic administration which allows primary closure of all appendectomy wounds, despite data suggesting that contaminated wounds have a higher rate of wound infection. 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. ...
... It has lower rates of complications, lower post-operative pain and better patient satisfaction. 7,8 Single incision multiport laparoscopic appendectomy is a new minimal access technique which results in lesser post-operative pain, better cosmoses and better patient satisfaction. It is longer time taking and technically challenging for the surgeons. ...
Single incision laparoscopic surgery is an emerging branch of minimally assess surgery to reduce scar and post-operative pain. Appendicitis is a common general surgical problem encountered in day to day practice. Different methods of appendectomy have been described by different surgeons from open to laparoscopic and now single incision laparoscopic surgery has been practised. This is a prospective study carried out in our Department of General Surgery SCB Medical College, Cuttack from February 2019 to March 2020; 60 patients had undergone the procedure and the results are published noted under headings of post-operative pain at (6 hours, 12 hours, 24 hours and 48 hours), post-operative requirement of analgesia (diclofenac) at (6 hours, 12 hours, 24 hours and 48 hours), operative time, days to resume bowel activity, days of hospital stay, post-operative complication in accordance to Clavien-Dindo classification.
... LA involves a minimally invasive surgical procedure compared to OA, resulting in less pain, shorter hospital stay, fewer complications and better cosmetic outcomes [2][3][4][5][6][7]. While studies report that the average length of hospital stay after LA is marginally decreased compared to OA [8], LA increases the chance of incidence of the intra-abdominal abscess (IAA) in complicated appendicitis [9][10][11][12]. However, with advancements in technology and the technical proficiency of surgeons, LA is now extensively used in complicated appendicitis [13][14][15], where it confers significant benefits in terms of wound healing. ...
Objectives: Laparoscopic appendectomy (LA) is preferred to open appendectomy (OA), as it is less invasive. However, it is debatable whether LA is more cost-effective. We compared the cost-benefits of LA with OA, using the entire pediatric inpatient hospital data in USA.
Methods: The Kids' Inpatient Database (KID) shows that 51,007 pediatric patients were subjected to laparoscopic appendectomy and 12,668 to open appendectomy during 2010-12 across the USA. This dataset was used to assess the cost-effectiveness of LA and OA, while controlling for the demographic characteristics of patients (e.g. age and gender), their background (e.g., place of residence), and complexity of surgery (e.g., number of procedures).
Results: We found that patients with laparoscopic surgery saved ~0.46 days of hospital stay, but paid $3641 more compared to patients with open surgery.
Conclusions: Surgeons prefer to use the technologically advanced laparoscopic appendectomy (80% of patients). Our analysis shows that the cost-benefit of laparoscopic appendectomy is marginal. Hence, for making a fully informed decision, patients should be provided with both clinical and cost comparison data.
... They concluded that there were small but real advantages to LA, particularly in women and obese or employed individuals. 7 Growing surgical experience leads to improved results with decreased incidence of intraabdominal abscesses after laparoscopic appendectomy. 8 Conclusion of various studies favor laparoscopic approach over open one. ...
Background: To compare operative time of procedure and post-operative pain after laparoscopic (LA) versus open appendectomy (OA).
Methods: In this randomized control trial 98 patients who presented in emergency department with signs and symptoms of acute appendicitis were randomly allocated into two groups for open (OA) and laparoscopic appendectomy (LA). Laparoscopic appendectomy was performed via 3 ports, an infra- or supraumbilical 11-mm port inserted by the closed (veress needle) and a 45 degree laparoscope were inserted to examine the abdomen. Two additional ports were inserted under direct vision in the right iliac fossa and either the left iliac fossa or above the pubis. The appendix was then transected by a stapler. The specimen was removed by extractor. In case of an open appendectomy, a Gridiron or Lanz incision was made in right iliac fossa.The appendix base was closed by Vicryl 1 ligature.Operative time for both the procedures was measured in minutes starting from time of incision and ending at closure of the skin. Postoperatively, pain was assessed by visual analogue scale four hours after surgery . All quantitative data (operative time) was compared by independent sample test. All qualitative data(post-operative pain) was compared by chi square test. A p-value < 0.05 was considered statistically significant.
Results: Out of 98 patients (49 patients in each group), there were 37 male and 61 female.. The mean age in OA group was 20.18+7.56, and in LA group 22.24+6.96.The mean operative time in OA group was 33.84 +13.20 minutes while in LA group it was 37.67+ 11.07 minutes. Patients in LA group experienced less postoperative pain as compared to OA group. Mean VAS in OA group was 7.08 +1.93 and in LA group was 3.84+ 1.84 which is statistically significant (p
Laparoscopic appendectomy (LA) was performed mostly on uncomplicated appendicitis due to opinions about its safety when it was first introduced. Nevertheless, there are still concerns about surgical difficulties in managing complicated appendicitis with laparoscopy, possible post-op complications and conversion to an open appendectomy (OA) during the surgery. Aims and Objectives: To study outcomes of laparoscopy in complicated appendicitis and chances of conversion to open appendicectomy. Methods:The study consists of 50 patients who underwent laparoscopic appendectomy in department of General Surgery at Navodaya Medical College hospital and research center, Raichur.. The study population was enrolled after fulfilling the selection criteria from department of General Surgery. Informed consent was taken from all the patients who are involved in this study. Patients diagnosis was based on clinical findings, complete blood counts, abdominal sonography and CT in selected cases. Result: Fifty patients underwent laparoscopic appendectomy for complicated appendicitis. Of the 50 patients, perforated appendix cases are 31, gangrenous appendix are 15, acute appendicitis with abscess were 4 cases.Three patients were converted to open appendicectomy. Post operation wound infection, conversion rate and hospital stay rate are very less. Conclusions: The present study proved that laparoscopic appendectomy is the best approach in complicated appendicitis. Most cases of complicated appendicitis can be treated laparoscopically. Laparoscopic appendicectomy is a useful method for reducing hospital stay, post operativepain,complications and return to normal activity.
Objectives: Laparoscopic appendectomy (LA) is preferred to open appendectomy (OA), as it is less invasive. However, it is debatable whether LA is more cost-effective. We compared the cost-benefits of LA with OA, using the entire pediatric inpatient hospital data in USA.Methods: The Kids' Inpatient Database (KID) shows that 51,007 pediatric patients were subjected to laparoscopic appendectomy and 12,668 to open appendectomy during 2010-12 across the USA. This dataset was used to assess the cost-effectiveness of LA and OA, while controlling for the demographic characteristics of patients (e.g. age and gender), their background (e.g., place of residence), and complexity of surgery (e.g., number of procedures). Results: We found that patients with laparoscopic surgery saved ~0.46 days of hospital stay, but paid $3641 more compared to patients with open surgery. Conclusions: Surgeons prefer to use the technologically advanced laparoscopic appendectomy (80% of patients). Our analysis shows that the cost-benefit of laparoscopic appendectomy is marginal. Hence, for making a fully informed decision, patients should be provided with both clinical and cost comparison data.
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.
A 27-year-old previously healthy male presented to the emergency room with a 36-h history of periumbilical pain that migrated to his right lower quadrant. He denied nausea or vomiting but had no appetite. He denied fever or chills. Positive clinical findings included right lower quadrant tenderness and right lower quadrant referred pain when palpating his left lower quadrant. Laboratory values were notable for a leukocytosis of 16,000 cells/L and an elevated C-reactive protein of 12 mg/L. An abdominal ultrasound was non-diagnostic, but the computed tomography (CT) scan showed a dilated appendix with periappendiceal fat stranding.
Background
Although obesity is a popular reason for choosing laparoscopic appendectomy (LA) versus open appendectomy (OA), however, the question of whether there is a difference remains. Our goal is to investigate if there is a difference between OA and LA in obese patients.
Methods
Fifty-eight obese patients diagnosed with acute appendicitis according to ALVARDO score at department of surgery at Suez Canal university hospitals from March 2020 till August 2021 were included. The study participants were assigned in two groups LA and OA. This study aimed to comparing between LA and OA regarding intraoperative complications, length of hospital stays, post -operative pain, and rate of post-operative complications. Meanwhile, using SF-36 scoring questionnaire, the quality of life was compared between both groups.
Results
A total of 58 patients were included in the present study (LG = 29 patients and OG = 29 patients). The early post-operative complications (within 30 days after surgery) were significantly lower in the LA group (5 patients out of 29) than the OA (11 patients out of 29). Additionally, lower incidence of complications was noticed in the LA group (2 out of 29 patients) compared to OA (6 patients out of 29) beyond 30 days after operation. Patients with laparoscopic surgery had statistically significant higher overall quality of life scores (SF-36) (72 ± 32) compared to open surgery patients (66 ± 35) 2 weeks after operation .
Conclusion
The laparoscopic procedure was associated with lower incidence of post operative complications. However , open appendectomy was superior for a shorter operative time. Laparoscopic approach is not only used for therapeutic purposes, but also it has a diagnostic role.
Introducción. La apendicitis aguda es la patología quirúrgica más frecuente en Colombia y en el mundo, con un riesgo de presentación del 7-8 % en la población general. El tratamiento de elección es la apendicectomía, la cual puede realizarse por vía convencional o por vía laparoscópica. El objetivo de este estudio fue comparar los desenlaces clínicos y costos de un modelo de estandarización en el manejo de la apendicitis aguda versus la no estandarización.
Métodos. Estudio observacional, analítico, para comparar el manejo de atención estandarizado y no estandarizado. Se incluyeron pacientes mayores de 18 años, que ingresaron al servicio de urgencias con diagnóstico de apendicitis aguda en el período de enero de 2016 a diciembre de 2018, y quienes fueron llevados a apendicectomía convencional o laparoscópica en la institución.
Resultados. Se incluyeron 1392 pacientes, 591 que cumplieron los criterios del modelo estandarizado y 801 que cumplieron los criterios del modelo no estandarizado. Al comparar los procesos de estandarización y no estandarización, se encontraron diferencias estadísticamente significativas en los resultados crudos de estancia hospitalaria y costos totales. En los estimativos ajustados por variables de confusión no se encontraron diferencias en los costos totales.
Discusión. El modelo de estandarización demostró una disminución en los días de hospitalización. No encontró diferencias en términos de costos totales.
PurposeWe have described the epidemiology, diagnostic modality, treatment patterns, and outcomes of acute appendicitis during pregnancy.Methods
Using a nationwide claim-based database in Japan, we analyzed the data of pregnant patients who were diagnosed with appendicitis between January 2005 and May 2019. Patient characteristics, imaging studies, length of hospital stay, proportion of fetal losses, complications, and type of antibiotics were examined.ResultsThe study included 169 patients, of whom 113 patients (67%) underwent conservative management, and appendectomies were performed on 56 patients (open 25% and laparoscopic 8%). The proportion of ultrasonography, computed tomography, and magnetic resonance imaging were 97%, 17%, and 5% (for conservative management); 88%, 39%, and 13% (for appendectomy); 86%, 38%, and 21% (for open appendectomy); and 93%, 43%, and 14% (for laparoscopic appendectomy), respectively. The proportion of complicated appendicitis was 6% in conservative management and 41% in appendectomy (40% in open appendectomy and 43% in laparoscopic appendectomy), respectively.The incidence of fetal loss was 4% in conservative management, 5% in appendectomy (2% in open appendectomy, and 14% in laparoscopic appendectomy). However, there was only one fetal loss (in laparoscopic appendectomy) in the same case of hospitalization. There were no maternal deaths or serious complications after any treatment.Conclusion
All treatments showed acceptable outcomes in appendicitis during pregnancy. Conservative management is considered an acceptable option, especially in uncomplicated cases of appendicitis in pregnant women.
Objective: To evaluate the perception of the students about CBL in clinical subjects.
Study Design: Cross Sectional study.
Place and Duration of Study: This study was conducted at the Al-Tibri Medical College and Hospital, between
January 2019 and October 2019.
Materials and Methods: A total of 150 numbers of students, 50 from different disciplines like Gynae & Obstetrics, Ophthalmology, and ENT, were included on the bases of convenient sampling. After taking ethical approval, the data was collected through a well-designed questionnaire with the students' verbal consent. At the end of the clinical
posting, the questionnaire was filled, and data was presented in the form of frequency and percentage, Chi-square
test was applied to evaluate the qualitative data through SPSS. The level of significance was taken P=<0.05.
Results: Both genders participated. The study results showed no significant difference among the students of Gynae
& Obstetrics. Ophthalmology and ENT about the acceptance of CBL is an optimal learning strategy and a welladopted
component of self-directed Learning, particularly in clinical reasoning and case solving.
Conclusion: CBL (Case-Based Learning) is a widely accepted learning strategy and helps develop essential skills
required to be an excellent clinician in the future. It is considered the gold standard for Learning and implementing
in clinical sciences in the field of medicine early on in students' medical careers. The educationist should incorporate
the CBL in their medical sciences curriculum for the development of clinical reasoning and problem-solving skills.
Key Words: CBL, Self-directed Learning, Ophthalmology, ENT, Gynae & Obstetric.
The growth of new clinical knowledge continues to challenge how surgery is practiced, and several types of literature reviews attempt to consolidate this expansion of information. Systematic reviews and meta-analysis are common methodologies that integrate findings on the same subject collected from different studies. Unlike a systematic review, a meta-analysis arrives at a conclusion backed by quantitative analysis. This chapter provides an overview of the principles, application, and limitations of these methods, which is fundamental to interpreting and critiquing their results.
A simple and miniaturized optical tactile sensor for integrating with robotic and manual minimally invasive surgery graspers is proposed in this study. For better miniaturization, the sensing principle of constant-bending-radius light intensity modulation was replaced with a variable-bending-radius modulation principle, and the pertinent theoretical formulation was derived. Afterward, a finite element model of the sensor was optimized using response surface optimization technique. The optimized sensor design was 14.0 mm long, 1.8 mm wide and 4 mm high. Next, the sensor was prototyped using SLA 3D printing technique. Also, the sensor was calibrated using a rate-dependent learning-based support-vector-regression algorithm. Calibration was 96% linear with a goodness-of-fit of 93% and mean absolute error of 0.085±0.096 N. Furthermore, the sensor was tested under cyclic triangular compression with a 3 sec pause between loading and unloading as well as manual grasping. Mean absolute error of 0.12±0.08 N, the minimum force of 0.14 N, and repeatability of 0.07 N showed the acceptable performance of the proposed sensor for surgical applications. Moreover, the sensor showed the capability of working under combined dynamic and static loading conditions with low hysteresis, i.e., 0.057
$\frac {N}{\textit {cycle}}$
.
Laparoscopic surgery has been established as the standard therapy for symptomatic cholecystolithiasis. Now, single-port cholecystectomy is a surgical option. Due to the need of special laparoscopic instruments and devices, the cost of the surgery is significantly increased, limiting its popularity in most medical centers in developing countries, especially in rural areas. This paper's objective was to show the safety, reproducibility, and feasibility of single-port laparoscopic cholecystectomy using conventional laparoscopic equipment, a wound retractor, and a sterile glove in a rural hospital in Mexico. A prospective study was carried out from July to October 2014. Patients diagnosed with uncomplicated cholecystolithiasis who agreed to participate were operated with this technique. Complications, operative time, bleeding, evolution, and length of hospital stay were recorded. A total of 24 women went onto surgery under this approach. A mean follow-up of 71 days was completed. No incisional hernias, bile duct injuries, wound infection, nor death was presented. Surgical time and cost were not significantly increased compared to conventional laparoscopic approach. Most patient discharge was done the same day of the surgery. Single-port laparoscopic cholecystectomy is a cost-effective procedure, which can be performed in all hospitals where an Alexis retractor and conventional laparoscopic equipment is available. There was no increase of surgical morbidity. The single-port cholecystectomy is a technically feasible and safe surgical option in selected patients and can be easily performed in rural hospitals at a low cost, providing the benefits of the single incision.
Objective: Appendectomy, being the most common surgical procedure performed in general surgery, is still being performed by both open and laparoscopic methods due to a lack of consensus as to which is the most appropriate method. Because further trials are necessary and few such studies have been performed in developing countries, we decided to evaluate the outcomes of the 2 procedures to share our experience with others. Methods: Prospectively collected data from 618 consecutive patients with appendicitis were studied. These comprised of 340 patients who underwent conventional open appendectomy and 260 patients treated laparoscoplcally&18 were excluded because of protocol violations. The two groups were compared with respect to operative time, length of hospital stay, postoperative pain, return to normal work, complication rate and cost. Results: There were no statistical differences regarding patient characteristics between the two groups. Conversion to laparotomy was necessary in 5 patients (1.88%). Laparoscopic appendectomy was associated with a shorter hospital stay (1.5 d vs 2.5 d), lower incidence of wound infection (3.07% vs 8.29%,) &less analgesia requirement. The operative time was more (45.6 vs 24.5 min) and the cost of treatment was higher in the laparoscopic group. Conclusion: The laparoscopic technique is a safe and clinically beneficial operative procedure. It provides certain advantages over open appendectomy, ·including short hospital stay, decreased requirement .of postoperative analgesia, early food tolerance, and earlier return to normal activities, Where feasible, laparoscopy should be undertaken as the initial procedure of choice for most cases of appendicitis. Journal of Surgical Sciences (2013) Vol. 17 (1) : 7-13
Laparoscopic appendectomy has the advantage of providing better access and good visualization of the peritoneal cavity through small incisions, as compared to open appendectomy. we evaluated the safety, outcome and feasibility of laparoscopic appendicectomy in patients presenting with or withput complications. we observed Appendicular lump was predominantly seen in male patients presenting after 48 hours of acute onset of abdominal pain with associated history of leukocytosis and fever.Laparoscopic appendectomy may potentially have more prominent clinical advantages over conventional surgery, when compared with the impact of LA on uncomplicated appendicitis.
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.
This article discusses the question of whether open or laparoscopic appendectomy is preferable in today's clinical routine. The article is based on data from randomized studies, evaluation of meta-analyses, and data from nonrandomized, multicentric studies evaluating the treatment of appendicitis in routine clinical practice. According to the data analysis, open appendectomy (OA) offers advantages with regard to a significantly shorter operative time and lower hospital costs. Laparoscopic appendectomy (LA) is characterized by a significantly decreased rate of failed septic wound healing and faster recovery. Both procedures can be performed with the same degree of safety and comparable outcome for acute appendicitis. Laparoscopic appendectomy offers significant advantages for establishing a precise diagnosis in young fertile women and overweight patients suffering from lower abdominal pain. The currently available data do not provide precise guidelines for the treatment of perforating appendicitis. However, we found significant evidence indicating an increased rate of postoperative intra-abdominal abscess after laparoscopic appendectomy. Thus, a laparoscopic approach cannot be regarded as a standard technique in advanced appendicitis.
Objective: Funnel plots (plots of effect estimates against sample size) may be useful to detect bias in meta-analyses that were later contradicted by large trials. We examined whether a simple test of asymmetry of funnel plots predicts discordance of results when meta-analyses are compared to large trials, and we assessed the prevalence of bias in published meta-analyses. Design: Medline search to identify pairs consisting of a meta-analysis and a single large trial (concordance of results was assumed if effects were in the same direction and the meta-analytic estimate was within 30
There are many questions regarding the advantages and disadvatanges of a videolaparoscopic approach in the treatment of acute appendicits. The authors present the results of a non-randomized, prospective study with 496 patients admitted between January 1992 and March 1998 by the General Surgery Service of São Rafael Hospital -Salvador - BA - Brazil. The patients were submitted for appendicectomy by video laparoscopy or by the traditional open method, and variables such as surgery duration, morbidity, mortality, costs, and length of stay (LOS) were compared. The results demonstrate that laparoscopic appendicectomy is a safe alternative for treatment of acute appendicitis; however, there are several disadvantages that gradually must be overcome.
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.
The investigation of heterogeneity is a crucial part of any meta-analysis. While it has been stated that the test for heterogeneity has low power, this has not been well quantified. Moreover the assumptions of normality implicit in the standard methods of meta-analysis are often not scrutinized in practice. Here we simulate how the power of the test for heterogeneity depends on the number of studies included, the total information (that is total weight or inverse variance) available and the distribution of weights among the different studies. We show that the power increases with the total information available rather than simply the number of studies, and that it is substantially lowered if, as is quite common in practice, one study comprises a large proportion of the total information. We also describe normal plots that are useful in assessing whether the data conform to a fixed effect or random effects model, together with appropriate tests, and give an application to the analysis of a multi-centre trial of blood pressure reduction. We conclude that the test of heterogeneity should not be the sole determinant of model choice in meta-analysis, and inspection of relevant normal plots, as well as clinical insight, may be more relevant to both the investigation and modelling of heterogeneity. © 1998 John Wiley & Sons, Ltd.
In laparoscopic appendectomy several variants of technique have been proposed. In a randomized prospective trial we compared three common techniques: 1. application of two endoloops, 2. application of two endoloops and additional manual stump sinking 3. application of endo-cutter. The study included 150 patients, 50 each per technique. The application of two endoloops with additional manual stump sinking as well as the cutter technique were associated with a low risk for complications. In contrast, appendectomy by two endoloops without stump sinking was associated with a higher risk for local complications. The manual stump sinking requires a high level of manual experience, whereas the cutter technique can be learned rapidly by surgical residents. Therefore, we recommend the cutter technique as standard procedure, because it allows laparoscopic appendectomy to be performed with high reliability by experienced surgeons as well as by novice surgical residents.
This is a prospective randomized study designed to evaluate the place of peritoneal drainage in cases with perforated appendicitis. The fourty-four patients included in the study received a double antibiotic prophylaxis preoperatively which consisted of ampicillin-sulbactam and ornidazole. The operations were performed by using a standard method including peritoneal irrigation with saline and removal of necrotic tissues and fibrin. The patients were divided into two groups: the first group consisted of 22 patients with an intraperitoneal drain placed and no drainage procedure was applied in the remaining half of the patients as the second group. The first group consisted of 10 patients with localized peritonitis, 10 patients with generalized peritonitis and two patients with retrocecal abscess. In the second group there were 13 patients with localized peritonitis, eight patients with generalized peritonitis and one patient with a retrocecal abscess. Postoperatively, no intraperitoneal abscess formation was observed in any of the patients. The two patients with wound infection were in the first group having intraabdominal drains placed. The mean hospital stay was 4.1 days in the first and 7 days in the second group. Additionally the cost of hospital stay was higher in the first group than in the second one. As a conclusion peritoneal drainage was not effective in preventing intraabdominal abscess formation in patients with perforated appendicitis but it apparently resulted in a longer hospital stay and a higher hospital cost.
Appendectomy is one of the most frequent operation in the world, often performed without reason. Aim of this study was to evaluate the impact of laparoscopy on unnecessary appendectomy, and comparison of laparotomic and laparoscopic appendectomy in patients with proven acute appendicitis. From January 1995 to January 1996 220 patients (140 M, 80 F ; mean age 22 , range 10 - 46) were operated on for suspected appendicitis in our department. One-hundred-fifty patients (82 M, 68 F ; mean age 17, range 10 - 40) were randomized to either conventional (75 patients) or laparoscopic (75 patients) appendectomy. Two patients in the group with laparoscopic approach were converted to open laparotomy because was disclosed a cecal neoplasm while another patient was converted for adhesions. In the group with conventional treatment eight appendectomies were proven unnecessary, compared to three in the laparoscopic group. One patient died after embolism in the group treated with laparoscopy. The postoperative hospital stay was twelve days (range 5-38) for conventional appendectomy, and ten days (range 3 - 20). The duration of operation was shorter in the conventional approach (20 vs 55 minutes). In the conventional group there were fewer minor complications (7 vs 14). The major complications were similar in the two groups. Nonetheless less unnecessary appendectomy with laparoscopic approach, data are not statistically significative. So we can conclude that laparoscopic approach determines a reduction in postoperative convalescence and an increase in duration of operation but nothing about the impact of laparoscopy on the management of unnecessary appendectomies.
Appendicectomy using a small muscle-splitting incision in the right iliac fossa is the traditional operation for acute appendicitis and already a minimally invasive approach. Therefore it does not wonder, that laparoscopic appendicectomy has not gained the same acceptance like laparoscopic cholecystectomy. However, results of several nonrandomised and randomised studies comparing open and laparoscopic appendicectomy have shown some benefits of laparoscopic surgery in terms of improved diagnostic accuracy, diminished postoperative pain, reduced wound infection and early discharge and return to normal physical activity. In an own prospective but nonrandomised evaluation of 413 patients suffering from acute appendicitis laparoscopic procedure (n = 196) was compared with open appendicectomy (n = 184). Conversion from laparoscopic to open appendicectomy was necessary in 33 patients (14%), who had advanced forms of appendiceal inflammation. The laparoscopic group had a slight but not statistically significant longer median operating time (55 vs. 50 min.), fewer wound infections (3.1% vs. 8.7%) particularly in obese patients (2.0% vs. 18%) and a shorter hospital stay (5 vs. 8 days). There were no significant disadvantages to laparoscopic compared to open appendicectomy. Stratifying male and female patients with normal body weight from those with overweight, obese fertile women benefit mostly from the laparoscopic approach. We conclude that the decision between a laparoscopic or an open appendicectomy should be made on individual features and preferences of patient and surgeon.
Sixty-five unselected patients admitted for acute appendicitis between March 1991 and August 1992 were assigned to two different groups of surgical treatment. The first group included 38 patients in whom a standard open appendicectomy was carried out. The 27 patients of the second group underwent laparoscopic appendicectomy. Results from the two groups in terms of mean operative time, morbidity and postoperative hospital stay were analyzed and compared. Patients undergoing laparoscopic appendicectomy had a much lower complication rate (11.1%) than those treated by standard open appendicectomy (36.8%) (p < 0,05). They also were discharged from the hospital sooner (3.0 ± 0.5) days versus 5.2 ± 0.5 days) (p < 0.01). Though the mean operative time required for the laparoscopic procedure was slightly longer (36 ± 2.5 minutes versus 32.7 ± 1.7 minutes), the difference was not statistically significant. Based on these favorable results, we conclude that laparoscopic appendicectomy should be considered the procedure of choice for patients with acute appendicitis.
The aim of the randomized prospective study was a comparison of postoperative complications in 80 conventional (42 cases) and laparoscopic (38 cases) appendectomies performed in patients with acute appendicitis. In the postoperative period patients developed complications. These included two cases of intraabdominal abscesses and one of bleeding from appendix artery in patients after laparoscopic procedures, three cases of wound infections and one of bleeding from appendix artery, intestinal obstructions and superior mesenteric vein thrombosis after surgical procedures. It was observed that the number postoperative complications was lower in patients undergoing laparoscopic appendectomies.
Recent reports have suggested that laparoscopic appendicectomy (LA) confers some advantages over open appendicectomy (OA). In a prospective study we compared the results of the first 75 patients undergoing LA with 50 patients undergoing OA. Post-operative recovery, complications, and return to normal activities were compared in the two groups. Although the overall complications were similar in the two groups, three patients developed major postoperative complications following LA. These included small bowel perforation due to a diathermy injury, right iliac fossa haematoma, and small bowel obstruction. Hospital stay was significantly reduced after LA. Follow-up demonstrated a shorter convalescent period at home and faster return to normal activity. In conclusion this study demonstrates that LA is superior to OA in terms of hospital stay and return to normal activity. However, in less experienced hands the potential hazards of significant complications remain a concern. The presence of one major complication related to the laparoscopic technique in this study highlights the importance of training if the widespread introduction of this approach is to be advocated.
Objective. Comparison of efficacy and morbidity of laparoscopic and conventional appendectomy. Design. Randomized clinical trial. Setting. St. Clara Hospital Rotterdam, University Hospital Rotterdam Dijkzigt, Rotterdam, the Netherlands. Methods. Patients with suspected acute appendicitis were randomized either for laparoscopic or conventional appendectomy. Operating time, operative findings, postoperative pain and complications and hospital stay were recorded. Analysis was by 'intention-to-treat'. Results. Conventional appendectomy was performed in 1O4, laparoscopic appendectomy in 97 patients. Conventional appendectomy required less operating time (42 versus 61 min. p < 0.001). Patients after conventional appendectomy had more pain (p < 0.001) and a higher need of analgetics (p < 0.005). Wound infection occurred more frequently after conventional appendectomy (p < 0.001). Hospital stay was similar in both groups (mean 4.4 versus 3.7 days). Conclusion. Laparoscopic appendectomy was associated with less postoperative pain and a lower incidence of wound infection but requires more operating time.
The discussion about laparoscopic appendectomy has increased since the introduction of this method. Randomized comparisons are still feasible, whereas this cannot be stated for other laparoscopic procedures (e.g., laparoscopic cholecystectomy). This randomized controlled trial included 170 patients. Open appendectomy was employed in 83 patients, and 87 were treated laparoscopically. The treatment groups were comparable regarding age, sex, Broca index, ASA classification, preliminary operations, and preoperative leucocytes. No statistically significant differences could be found with respect to surgical and general complications, operating time, consumption of analgesics and antibiotics, and return to work. The analysis revealed a statistically significant shorter hospital stay, a shorter time until return to normal physical activity, and a shorter duration of complaints for the laparoscopic group. We were unable to demonstrate any statistically significant advantage in using the open procedure.
Background
The discussion about laparoscopic appendectomy as surgical therapy in acute appendicitis is controversially. As a part of this discussion we present herein the results of our prospective study.
Methods
From June 1990 to November 1993 we performed in our institution 408 appendectomies with all clinical signs and symptoms of acute appendicitis. Laparoscopic appendectomy was performed in 168 (41.2%) and open appendectomy in 240 patients (58.8%). The biographical data in both patients groups were similar. We compared the histological inflammation, the postoperative intensity of pain and the consumption of pain-drugs, the wound infection rate, the hospital stay, the point of return to normal activities and the cosmetic appearance.
Results
The inflammation confirmed histological was not different in both groups (89.4% vs. 88.5%). The complication rate was 3.6% (6/168) for laparoscopic and 4.6% (11/240) for open appendectomy. 7 of 175 laparoscopic operations were converted to an open procedure (4.0%). The mean postoperative stay for laparoscopic operation was 3.7 (median 2) days and for the open route 4.9 (median 4) days (p<0.05). Significantly reduced were the intensity of pain and the requirement for analgesia, the point of return to normal activities and the cosmetic outcome (p<0.05).
Conclusions
The results suggest, that laparoscopic appendectomy is a practicable and reasonable alternative to routine surgery. The laparoscopic appendectomy is superior to open procedure in discribed terms above. This technique seems likely to find a role in the future management of acute appendicitis.
Einleitung: 1980 wurde die erste laparoskopische Entfernung der Appendix durch den Gynäkologen Semm durchgeführt. Nach anfänglicher Zurückhaltung findet die laparoskopische Appendektomie in den letzten Jahren auch vermehrte Anwendung in der Chirurgie. Eine prospektiv-vergleichende Untersuchung zur operativen Therapie der kindlichen Appendizitis liegt bislang nicht vor. Patienten und Methoden: Ziel der Studie war es, die Sicherheit und die Effektivität der laparoskopischen und konventionellen Appendektomie bei Kindern über einen Zeitraum von zwei Jahren zu vergleichen. Ergebnisse: Im Studienzeitraum (01/97-12/98) wurden 52 Kinder (Altersmedian: 9,6 Jahre) laparoskopisch [LA] (n = 28) oder konventionell [KA] (n = 24) appendektomiert. Die histologischen, mikrobiologischen und antibiotischen Befunde wurden dokumentiert. Die perioperativen Komplikationen wurden mittels modifizierter „Kölner Klassifikation” erfaßt: Klasse I (keine Komplikation): LA = 92,8 %, KA = 83,3 %; Klasse II: LA und KA: 0 %; Klasse III: LA = 7,2 %, KA = 12,5 %; Klasse IV: LA = 0 %, KA = 4,2 %; Klasse V: LA und KA: 0 %. Die mediane OP-Dauer betrug: LA = 44 Minuten, KA = 35 Minuten. Die Konversionsrate war 0 %. Die postoperative stationäre Aufenthaltsdauer betrug: LA = 6,8 Tage, KA = 9,3 Tage bei einem mittlerem Analgetikagebrauch von: LA = 1,3 Tage, KA = 2,2 Tage. Die Rückkehr zur präoperativen Aktivität betrug: LA = 14,6 Tage, KA = 17,4 Tage. Schlußfolgerung: Die gefundenen Ergebnisse decken sich mit denen von Meta-Analysen großer Erwachsenenkollektive und mit den Resultaten von Retrospektivuntersuchungen an Kindern. Wir erachten daher die laparoskopische Appendektomie der konventionellen Appendektomie im Kindesalter als zumindest gleichwertig unter Berücksichtigung von Effektivität und Sicherheit.
Laparoscopic versus open appendectomy in children - a 2-year prospective study
Summary
Introduction: Laparoscopic appendectomy, first performed by the gynaecologist Semm in 1980, has increased in popularity for both complicated and ruptured appendicitis among surgeons. A prospective controlled study comparing laparoscopic and open appendectomy in children has not been done. Objective and methods: To compare safety and efficiency the outcome of laparoscopic versus open appendectomy in children suspected of acute appendicitis was evaluated over a period of 2 years, from 1/97-12/98. Results: A total of 52 children (median age 9.6 years) were analysed prospectively, open appendectomy (OA) was performed in 24 patients and laparoscopic appendectomy (LA) in 28 patients. The histological, microbiological and antibiotic findings were documented. The perioperative complications were analysed using a modified “Cologne Classification”: class I (no complications) LA = 92.8 %, OA 83.3 %; class II: LA and OA: 0 %; class III: LA = 7.2 %, OA = 12.5 %; class IV: LA = 0 %, OA 4.2 %; class V: LA and OA: 0 %. The median operating time was: LA = 44 minutes, OA = 35 minutes. Analgesic usage averaged: LA = 1.3 days, OA = 2.2 days. The conversionrate was 0 %. The length of hospital stay averaged: LA = 6.8 days. LA = 14.5 days and OA = 17.4 days were needed to return to preoperative activities. Conclusion: The results of our study agree with other meta-analysis involving larger number of adults and with the retrospective studies in children. We consider the laparoscopic and open appendectomy in children as equal in terms of efficiency and safety.
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.
Laparoskopische („Minimal-invasive”) Operationstechniken finden derzeit zunehmend Eingang auch in die Kinderchirurgie. In einer Reihe von Studien an Erwachsenen konnten die mit diesem Verfahren verbundenen Veränderungen respiratorischer und kardiozirkulatorischer Parameter gezeigt werden. In der vorliegenden Untersuchung wurde der Einfluß des Kapnoperitoneums auf Parameter der Beatmung bei 15 Kindern mit einem Alter zwischen 3,5 und 10 Jahren sowie einem Gewicht zwischen 13,5 und 30 kg im Vergleich zu einer Kontrollgruppe ohne Kapnoperitoneum geprüft. Es wurden Erhöhungen der Beatmungsdrücke und eine entsprechende Verminderung der Compliance von ca. 28 - 48 % bzw. 30 % gemessen. Der petCO2 stieg von einem Ausgangswert von 35 mmHg auf 41 ± 2 mmHg an. Ein Temperaturabfall trat bei keinem Kind auf. Laparoskopische Operationen bei Verdacht auf Appendizitis oder bei unklarer Bauchsymptomatik werfen aus Sicht des Anästhesisten bei Kindern ab 13,5 kg Körpergewicht bei Operationen bis zu einer Stunde keine Probleme auf, die klinisch auffällig werden. Die gemessene Erhöhung des Beatmungsdruckes legt nahe, die Beatmungsparameter (Flow, Druckbegrenzung, Atemfrequenz, Atemzeitverhältnis) so zu wählen, daß keine Werte über 20 mbar erreicht werden, indem z.B. ein Anfangstidalvolumen von 8ml/kgKG eingestellt wird oder von vornherein eine druckgesteuerte Beatmung verwendet wird, um den pCO2 über die Atemfrequenz zu regeln. Selbstverständlich muß darüber hinaus weiter besonderes Augenmerk auf die Beobachtung aller bei dieser Operationsmethode möglichen Komplikationen wie z. B. Hautemphysem oder Pneumothorax gelegt werden.
Summary
The purpose of our study was to show the effects of laparoscopic procedures on the ventilation of children. We measured an increase of ventilation pressures (Pmax, Pplat and Pmean) of 28, 35 and 48 % respectively. petCO2 rose from 35 to 41 ± 2 mmHg. There was no loss of body temperature in any child. Laparoscopic procedures as seen here for appendectomy or diagnostic exploration in children of 13.5 kg body weight or more caused no problems that were clinically evident. The increase of ventilation pressure could be attenuated by choosing the parameters of ventilation (e.g. flow, l:E ratio) in such a way that Pmax does not exceed 20 mbar. Alternatively, pressure-controlled ventilation may be used, adjusting petCO2 by ventilation frequency. In any case there must be a strict control of all possible side effects of laparoscopy, such as cutaneous emphysema or pneumothorax.
The aim of the present study was to elucidate whether laparoscopic or open appendectomy is the better therapeutic approach in acute appendicitis. The results of 19 randomized controlled clinical trials published after 1995 were summarized in a meta-analysis. Advantages of open appendectomy were a shorter operating time and lower operating costs. However, laparoscopic appendectomy is as safe as the open approach. After laparoscopic appendectomy, a significantly lower incidence of wound infections and lower postoperative pain are described. A distinct advantage of minimally invasive surgery is a sooner total recovery by which the higher operating costs can be compensated and the socioeconomic damage can be reduced compared with open appendectomy. However, because of the presented results and the problems discussed in this review, laparoscopic appendectomy currently is not the standard or the method of choice for removal of the appendix. The minimally invasive procedure is an alternative especially in patients in whom it offers specific advantages. These are obese patients and, due to better intraoperative differential diagnostic possibilities, premenopausal women.
Background: The aim of this randomized study was to assess the postoperative acute-phase response of laparoscopic appendectomy and to compare its results with those of open appendectomy. Methods: 81 patients admitted to our emergency service with acute appendicitis were randomized to laparoscopic and open appendectomy groups. Preoperative and postoperative values for acute-phase reactants of white blood-cell count, erythrocyte sedimentation rate, C-reactive protein, and fibrinogen in blood samples were recorded. We also collected data concerning age and gender, total anesthesia time, operation time, time of oral intake, and hospital stay time of the study groups. Results: Although total anesthesia time was significantly longer in the laparoscopic group than in the open group (p < 0.05), there was no significant difference in operation time between both groups (p > 0.05). We found oral intake and hospital stay time to be significantly lower in the laparoscopic appendectomy group than in the open appendectomy group (p < 0.05). The acute-phase reactant levels were significantly lower in the laparoscopic appendectomy group than in the open appendectomy group (p < 0.05). Conclusion: Laparoscopic appendectomy causes relatively less trauma and less tissue damage than the open procedure and appears to have distinct advantages over open appendectomy.
Some statements are made concerning the diagnostic strategy and decision making in acute appendicitis. Ultrasound, although available and applied in many clinical studies, is currently an option for enthusiasts. Diagnostic scoring systems have not fulfilled their theoretical promise. Maybe they are only ‘scientific poetry’. Conservative treatment of acute appendicitis is a viable option for lateral thinkers in surgery. Finally, a more liberal indication for diagnostic laparoscopy more or less including laparoscopic appendectomy should be promoted, provided that the adequate safety standard of this procedure is respected.
To analyse the reasons for, and outcome of, conversion from laparoscopic to open appendicectomy and to identify factors that may predict the need for conversion.
Subgroup analysis from a randomised multicentre study.
One university hospital and four county hospitals, Sweden.
A total of 500 patients were randomised to laparoscopic (n = 244) or open (n = 256) appendicectomy. Thirty operations (12%) were converted to open appendicectomy.
Reasons for conversion, outcome, and preoperative predictive variables.
Difficult anatomy or the presence of an abscess were the main reasons for conversion (25/30). The incidence of perforated appendicitis was higher among patients who required conversion compared with both the open and laparoscopic group. Operating time, anaesthetic time, and duration of hospital stay were longer after conversion. Time to full recovery and length of sick leave were also longer, except for patients with perforated appendicitis. There was no difference in the complication rate. No predictive factors were identified.
The main reasons for conversion were difficult anatomy and the presence of an abscess. After conversion patients recovered more slowly than those operated on laparoscopically or by primary open operation.
More than one-third of all appendicectomies are unnecessary. A study was directed towards reducing the misdiagnosis of appendicitis, thus preventing needless operations. Thirty-six women in the fertile age group and with a diagnosis of appendicitis were subjected to laparoscopy before surgery. All women had undergone a gynaecological examination to rule out disease of the female genitalia. As a result of the laparoscopy, surgery was cancelled in one-third of the cases, which were found to have acute gynaecological disease not requiring surgery.
The investigation of heterogeneity is a crucial part of any meta-analysis. While it has been stated that the test for heterogeneity has low power, this has not been well quantified. Moreover the assumptions of normality implicit in the standard methods of meta-analysis are often not scrutinized in practice. Here we simulate how the power of the test for heterogeneity depends on the number of studies included, the total information (that is total weight or inverse variance) available and the distribution of weights among the different studies. We show that the power increases with the total information available rather than simply the number of studies, and that it is substantially lowered if, as is quite common in practice, one study comprises a large proportion of the total information. We also describe normal plots that are useful in assessing whether the data conform to a fixed effect or random effects model, together with appropriate tests, and give an application to the analysis of a multi-centre trial of blood pressure reduction. We conclude that the test of heterogeneity should not be the sole determinant of model choice in meta-analysis, and inspection of relevant normal plots, as well as clinical insight, may be more relevant to both the investigation and modelling of heterogeneity. © 1998 John Wiley & Sons, Ltd.
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?
To evaluate whether laparoscopic appendectomy shortens the convalescence and the postoperative period until return to work when compared to conventional appendectomy, a prospective randomized trial was performed. The major endpoint of the study was the time until return to work; minor endpoints were postoperative pain, fatigue, operative time and postoperative morbidity. In all, 54 patients with a mean age of 29.5 ± 10.1 years were randomized to open (n = 28) or laparoscopic appendectomy (n = 26). Age, sex, body mass index (BMI), American Society of Anesthesiology (ASA) rating, job status as well as histologic degree of inflammation of the appendix were comparable in the two groups. Operative time was 59.2 ± 15.8 min for laparoscopic and 59.8 ± 24.4 min for conventional appendectomy (P = 0.9). Some 16 laparoscopic appendectomies (62 %) were performed by board-certified surgeons, while 23 conventional appendectomies (82 %) were performed by residents (P = 0.003). Postoperative morbidity was comparable between the two groups. After laparoscopic appendectomy, pain was rated significantly lower on the first, second and fourth postoperative day when compared to the conventional group. There were no difference in postoperative fatigue between the groups. Time to return to work was 17.0 ± 6.2 days in the laparoscopic group and 18.2 ± 6.0 days in the conventional group (p = 0.5). Laparoscopic appendectomy has no advantages in terms of convalescence and time to return to work when compared to open appendectomy and should therefore be limited to selected cases.
Laparoscopy reduces the risk of performing unnecessary appendectomies and offers the advantages of minimal invasive surgery when appendectomy is needed. We report our experience comparing open (Group A) with laparoscopic (Group B) appendectomy.
There were 20 patients in each group. Age, sex, signs, symptoms, evolution, laboratory, stage of disease, drains, duration of surgery, antibiotics, oral intake restart, postoperative pain at 24, 48 and 72 hours, complications, hospital stay, return to normal activities and cosmesis were reviewed. Statistical differences were determined using Student's t test (two tailed) or chi-square with Yates correction. Surgical technique is described.
In both groups most variables were similar (p = ns). Group B presented earlier oral intake restart (p < 0.001), and less postoperative pain at 24 (p < 0.001), 48 (p < 0.01) and 72 hours (p < 0.001). Hospitalization stay was shorter (p < 0.001) and return to normal activities was earlier (p < 0.001) in group B. Better cosmetical appearance was observed in Group B (16 vs. 0 "excellent" -p < 0.001).
Laparoscopic approach may reduce unnecessary appendectomies and it allows to perform appendectomy in a safe and effective way. In this study, laparoscopic was better than open appendectomy regarding early restart of oral intake, less postoperative pain, shorter hospitalization stay, earlier return to normal activities and better cosmetic appearance.
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.
Aachen, Techn. Hochsch., Diss., 1997.
A prospective evaluation of laparoscopic surgery for acute appendicitis over a 6-month period is reported. Sixty-five patients with signs and symptoms of appendicitis necessitating surgery were assigned to open (n = 36) or laparoscopic (n = 29) appendicectomy. Thirty-seven patients were female (22 open) and 28 were male (14 open). The median age was 24 (range 14-64) years for open appendicectomy and 18 (range 14-60) years for the laparoscopic procedure. The mean postoperative stay for open operation was 4.8 (range 1-21) days and for the laparoscopic route 2.2 (range 1-11) days (P < 0.05). Inflammation was confirmed histologically in 72 per cent of the open cases and in 74 per cent of the laparoscopic cases (P not significant). The wound infection rate was 11 per cent (n = 4) for open and 4 per cent (n = 1) for laparoscopic appendicectomy (P < 0.05). The median anaesthesia time was 52 (range 15-90) min for open appendicectomy and 48 (range 20-120) min for laparoscopic surgery (P not significant). After open appendicectomy patients had a median of 5 (range 2-12) intramuscular injections of analgesia compared with a median of 1 (range 0-5) in the laparoscopic group (P < 0.05). Two laparoscopic operations were converted to an open procedure. The results suggest that emergency laparoscopic appendicectomy should be explored further as an alternative to open surgery for acute appendicitis.
Laparoscopy has been performed in 43 patients aged up to 18 years with suspected appendicitis; 20 were children 8-15 years and 23 adolescents 16-18 years of age. Diagnostic laparoscopy was successful in 36 (84%) patients; in 7 (16%) subsequent laparotomy was necessary to establish the diagnosis, in 4 (9%) because the appendix was not visualized. Laparoscopic appendectomy was done in 33 (77%) patients, additional laparoscopic adhesiolysis in four and inversion of a diverticulum in one. Changing to laparotomy during the laparoscopic operation was necessary in one patient because of a technical problem and in another because of bleeding of the appendicular artery. Laparoscopy was totally free of complications in 33 (77%) patients; another 9 (21%) had surgical or technical problems without negative outcome for the patient. In one (2%) patient a wound infection led to a negative outcome; there were no other laparoscopy-related events. The mean intensity of pain on the first day after laparoscopic appendectomy was 31 points (Visual Analogue Scale with 100 points) and decreased to nearly zero on the third day; 37% of patients needed opioids on the first and none on the third day. There was no statistical difference for pain intensity and consumption of analgesics after appendectomy via laparoscopy versus laparotomy. We conclude that diagnostic and therapeutic laparoscopy in children and adolescents with suspected appendicitis is a safe and effective procedure.
Although laparoscopic procedures are currently in vogue in general surgery, the role of this approach in children has not been prospectively evaluated in the United States using the new instrumentation now available to us. To assess the value of laparoscopic appendectomy (LA) in childhood, we prospectively compared 14 LAs with 50 open appendectomies (OA) over 6 months in a single children's hospital. Antibiotic usage was at the discretion of the surgeon regardless of the procedure performed and was not different between groups. LA was performed under the direction of a single laparoscopy-trained surgeon and patient selection was based on parental consent. A three-puncture LA technique was used; children from this group were allowed to return to full activities as soon as they were comfortable. There were no significant differences between groups for severity of disease, age, weight, hospital cost, or complications. The types of complications that developed were comparable in both groups. The percent of complicated appendicitis (gangrene or perforation) was 32% in the OA group and 36% in the LA group. Patients in the LA group spent significantly fewer days in the hospital and returned to unrestricted activities (school, athletics, etc) faster than patients in the OA group. LA is approximately $1,000 more expensive than OA, the differences being easily explainable by the cost of the disposable supplies necessary for the procedure (laser fibers, trocars, etc), but because of the shorter hospital stay in the LA group the mean total cost for each group was comparable. These data suggest that although there appears to be no cost advantage, LA shortens the hospital stay and allows children to return to unrestricted activity sooner than OA.(ABSTRACT TRUNCATED AT 250 WORDS)
Overviews of clinical trials are an efficient and important means of summarizing information about a particular scientific area. When the outcome is a continuous variable, both treatment effect and variance estimates are required to construct a confidence interval for the overall treatment effect. Often, only partial information about the variance is provided in the publication of the clinical trial. This paper provides heuristic suggestions for variance imputation based on partial variance information. Both pretest-posttest (parallel groups) and crossover designs are considered. A key idea is to use separate sources of incomplete information to help choose a better variance estimate. The imputation suggestions are illustrated with a data set.
We considered using a randomized trial to assess the value of laparoscopic cholecystectomy in the treatment of symptomatic gallstones. The pros and cons for the timing of such a trial were in favour of not beginning the trial until surgeons learned to use the new procedure safely and effectively, and until key endpoints and outcome indices could be identified and assessed using valid measures. Instead an observational study was implemented to monitor the learning curve of surgeons as they mastered the laparoscopic equipment and procedures, and to assess the responses of the patients to the procedure. In the first 100 patients, the procedure proved to be as safe and feasible to use as conventional surgery, and there were strong benefits in terms of quicker recovery of the patients with less pain, discomfort, and a reduced length of hospital stay. The responses of the surgeons and the patients to the new procedure now place ethical constraints on the planning of a randomized controlled trial. Currently, comprehensive surveillance and monitoring of laparoscopic cholecystectomy is the only realistic method with which to assess the impact of this new technology in our clinic.
Our initial experience of using laparoscopy to perform appendicectomy for appendicitis has shown that the operation is feasible, safe and as effective as open surgery in early appendicitis. The precise role of laparoscopic appendicectomy will need to be defined by a prospective randomised trial.
To describe the epidemiology of appendicitis and appendectomy in the United States, the authors analyzed National Hospital Discharge Survey data for the years 1979-1984. Approximately 250,000 cases of appendicitis occurred annually in the United States during this period, accounting for an estimated 1 million hospital days per year. The highest incidence of primary positive appendectomy (appendicitis) was found in persons aged 10-19 years (23.3 per 10,000 population per year); males had higher rates of appendicitis than females for all age groups (overall rate ratio, 1.4:1). Racial, geographic, and seasonal differences were also noted. Appendicitis rates were 1.5 times higher for whites than for nonwhites, highest (15.4 per 10,000 population per year) in the west north central region, and 11.3% higher in the summer than in the winter months. The highest rate of incidental appendectomy was found in women aged 35-44 years (43.8 per 10,000 population per year), 12.1 times higher than the rate for men of the same age. Between 1970 and 1984, the incidence of appendicitis decreased by 14.6%; reasons for this decline are unknown. A life table model suggests that the lifetime risk of appendicitis is 8.6% for males and 6.7% for females; the lifetime risk of appendectomy is 12.0% for males and 23.1% for females. Overall, an estimated 36 incidental procedures are performed to prevent one case of appendicitis; for the elderly, the preventive value of an incidental procedure is considerably lower.
Removal of a normal appendix because of suspected appendicitis occurs most frequently in women of reproductive age. We investigated the value of laparoscopy in the diagnostic evaluation for possible appendicitis in women of childbearing age. Fifty-one women were entered in a management protocol, which included diagnostic laparoscopy in instances with atypical features. Twenty patients underwent immediate appendectomy because of history and physical findings classical for appendicitis; 31 women with atypical history and physical findings underwent an initial diagnostic laparoscopy. In the group of patients who underwent immediate appendectomy because of classical presentation, five of the appendices removed were normal. At laparoscopy, appendicitis was diagnosed in five patients, another disease in 15 and no diagnostic abnormality was found in six. Five patients had a normal appendix removed, two because of questionable inflammation and three because of nonvisualization of the appendix. There were no false-negative examination results. Twenty-one patients required no further operative intervention after laparoscopy. The negative appendectomy rate remained unchanged (ten negative appendectomies of 30 performed). Definitive diagnoses of eight instances of pelvic inflammatory disease, six of ruptured ovarian cysts and one instance of ileitis of the small intestine were made earlier than would have been possible without diagnostic laparoscopy in this setting. Diagnostic laparoscopy permits earlier definitive diagnosis and prompt institution of appropriate therapy for disease of the female reproductive tract that simulates appendicitis. Caution is advised, however, when diagnostic laparoscopy is applied more frequently than right lower quadrant exploration in the management of probable appendicitis. The improvement in diagnostic accuracy may be offset by an increased number of negative appendectomies resulting from nonvisualization and false-positive inflammation.