Randomized controlled trial comparing laparoscopic and open appendicectomy

Laparoscopic versus open appendectomy: a prospective comparative study of 227 patients

BACKGROUND

Although laparoscopic appendectomy is widely practiced in developed countries, still there are many questions regarding the advantages and disadvantages of this approach in the treatment of acute appendicitis. Several controlled trials have been conducted, some in favor of laparoscopic appendectomy others not. The aim of this study was to evaluate laparoscopic appendectomy in comparison with open appendectomy, with special emphasis on postoperative septic complications.

METHODS

For this study, 227 consecutive patients (159 males and 68 females) with a diagnosis of suspected appendicitis between 1995 and 1999 were assigned either to laparoscopic appendectomy (n = 108) or open appendectomy (n = 119). The patients were assigned according to insurance company approval and patient preference. There were no exclusion criteria and no age limits in this study.

RESULTS

Wound infection was significantly higher in the open group (incidence, 7.6%) than in the laparoscopic group (incidence, 0%; p <0.003). Intraabdominal infections were equal in both groups. Hospital stay was significantly shorter in the laparoscopic group (p <0.046), but operative time was little longer than in the open group (p <0.002). Conversion to open surgery was necessary in one case.

CONCLUSIONS

Laparoscopic appendectomy is as safe and effective as the open procedure. It significantly reduces the rate of postoperative wound infection. However, it is still acceptable to perform the open procedure, especially in hospitals without a large amount of laparoscopic experience.

Laparoscopic appendectomy for perforated appendicitis

Although laparoscopic appendectomy for uncomplicated appendicitis is feasible and safe, its application to perforated appendicitis is uncertain. A retrospective study of all patients with perforated appendicitis from 1992 to 1999 in a university hospital was performed. A series of 231 patients were diagnosed as having perforated appendicitis. Of these patients, 85 underwent laparoscopy (LA), among whom 40 (47%) required conversion to an open procedure. An open appendectomy (OA) was performed in 146 patients. The operating time was similar for the two groups. Return of fluid and solid diet intake were faster in LA than OA patients (p < 0.01). Postoperative infections including wound infections and abdominal abscesses occurred in 14% of patients in the laparoscopy group and in 26% of those with OA (p < 0.05). The surgeon's experience correlated with the conversion rate. Laparoscopic appendectomy is associated with a high conversion rate for perforated appendicitis. If successful, it offers patients faster recovery and less risk of infectious complications.

Laparoscopic appendectomy in modern gynecology

Gynecologists frequently manage women with acute or chronic pain in the right iliac fossa. Appendicitis is one of the common conditions encountered in this setting. From the gynecologic perspective, issues regarding the role of laparoscopic appendectomy include radioimaging and laparoscopic diagnosis, operative technique, advantages and disadvantages, and laparoscopic appendectomy in pregnancy and in complicated appendicitis. Most studies are in favor of the procedure, and it seems reasonable to include it in training programs in gynecology.

Factors associated with conversion to laparotomy in patients undergoing laparoscopic appendectomy

BACKGROUND

Laparoscopic appendectomy (LA) has been increasingly adopted for its advantages over the open technique, but there is a possibility of conversion to open appendectomy (OA) if complications occur or the extent of inflammation prohibits successful dissection. This study aimed to identify the preoperative predictors for conversion from laparoscopic to open appendectomy.

STUDY DESIGN

Medical records of 705 consecutive patients who underwent surgery for suspected appendicitis were reviewed retrospectively. LA was attempted in 595 patients by 25 different surgeons. Factors evaluated were age, gender, body mass index, previous abdominal surgery, previous appendicitis attack, pain, nausea, vomiting, fever, duration of symptoms, local or diffuse tenderness, leukocyte count and surgeon's experience in LA.

RESULTS

Conversion to OA occurred in 58 patients (9.7%). The most common reason for conversion was dense adhesions due to inflammation, followed by localized perforation and diffuse peritonitis. Based on 261 patients evaluated by CT scan preoperatively, significant factors in the final multivariate analysis associated with conversion to OA were age > or = 65 [Odds ratio (OR) = 3.78, 95% CI:1.11-12.84], diffuse tenderness on physical examination (OR = 11.32, 95% CI: 1.32-96.62), and a surgeon with less experience in LA (< or = 10 operations, OR = 3.38, 95% CI:1.02-11.17). The presence of significant fat stranding associated with fluid accumulation, inflammatory mass or localized abscess in CT scan also significantly increased the possibility of conversion (OR = 5.60, 95% CI:2.48-12.65).

CONCLUSIONS

Identifying the potential factors for conversion preoperatively may assist the surgeons in making decisions concerning the management of patients with appendicitis and in the judicious use of LA.

Laparoscopic versus open surgery for suspected appendicitis

BACKGROUND

Laparoscopic surgery has been proposed to have diagnostic and therapeutic advantages over conventional surgery.

OBJECTIVES

To compare the diagnostic and therapeutic effects of laparoscopic and conventional 'open' surgery in the treatment of suspected acute appendicitis.

SEARCH STRATEGY

We searched for original articles and abstracts published until end of 2000. As main search tools we employed the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE and SciSearch. CCTR and MEDLINE searches were repeated until 10 October 2001, all other databases were searched 10 October 2000. We also handsearched the congress proceedings of endoscopic surgical societies.

SELECTION CRITERIA

We included clinical trials that assessed either: (1) Therapeutic effects of laparoscopic appendectomy (LA) versus open appendectomy (OA) in adults, (2) Therapeutic effects of LA versus OA in children, (3) Diagnostic effects of diagnostic laparoscopy (LAP) followed by LA or OA if necessary versus immediate OA, (4) Therapeutic effects of diagnostic laparoscopy (LAP) followed by OA if necessary versus immediate OA. We included only randomized studies and excluded those with unconcealed allocation.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed each study's eligibility and quality. One reviewer extracted the data, 10% of which were later cross-checked by a second reviewer. Abstract authors and authors of articles lacking important information on trial design or results were contacted.

MAIN RESULTS

We included 45 studies, of which 39 compared LA (with or without diagnostic laparoscopy) vs. OA in adults. Wound infections were about half as likely (Peto OR 0.47; 95%-CI 0.36 to 0.62) after LA than after OA, but intraabdominal abscesses were increased nearly threefold after LA (Peto OR 2.77; 95%-CI 1.61 to 4.77). The duration of surgery was 14 minutes (95%-CI 10 to 19) longer for LA. Pain on day 1 after surgery was reduced after LA by 8 mm (95%-CI 3 to 13 mm) on a 100 mm VAS. Hospital stay was reduced by 0.7 days (95%-CI 0.4 to 1.0). Return to normal activity, work, and sport were 6 days (95%-CI 4 to 8), 3 days (1 to 5), and 7 days (3 to 12) earlier after LA than after OA. While the operation costs of LA were significantly higher than that of OA, the costs outside hospital were reduced. Strong heterogeneity was found for most outcomes, but not for wound infections and intraabdominal abscesses. In children, much less data were available, but the result do not seem to be much different when compared to adults. Pain which was measured blindly in two paediatric trials, was similar after LA and OA (-1 mm VAS; 95%-CI -8 to +7 mm). In trials on unselected patients, diagnostic laparoscopy led to large but variable reductions in the rate of negative appendectomies (RR 0.21; 95%-CI 0.13 to 0.33). In parallel, the rate of unestablished diagnoses was significantly decreased after laparoscopy (RR 0.34; 95%-CI 0.22 to 0.53). In fertile women, these effects were even more pronounced: rate of negative appendectomies: RR 0.19; 95%-CI 0.11 to 0.34; rate of patients without a final diagnosis established: RR 0.24; 95%-CI 0.15 to 0.38.

REVIEWER'S CONCLUSIONS

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. In gangrenous or perforated cases, however, LA may possibly carry a higher risk of intraabdominal infections.

Needlescopic, laparoscopic, and open appendectomy: a comparative study

SUMMARY

The benefits of laparoscopic appendectomy appear to be controversial. Since 1994, several abdominal procedures have been completed by using the needlescopic technique, but there appear to be no prospective studies to demonstrate the perceived benefits of needlescopic appendectomy. The authors compared open, laparoscopic, and needlescopic appendectomy in a randomized fashion with regard to duration of surgery, length of hospitalization, analgesic dosage, and surgery-associated complications. From March to July 1998, 75 patients admitted at the emergency station of the authors' hospital with a final diagnosis of acute appendicitis without tumor formation were randomized to receive one of the three treatment categories: open (OA), laparoscopic (LA), and needlescopic (nLA) appendectomy. Laparoscopic and needlescopic appendectomy were performed by using a three-port technique, although the size of the trocar used varied. There were 26 patients in the OA group, 23 in the LA group, and 26 in the nLA group. The mean operation durations for the OA, LA, and nLA groups were 55.4 +/- 28.0 minutes, 69.1 +/- 48.8 minutes, and 62.3 +/- 26.3 minutes, respectively, and these were not significantly different from one another. The mean number of the analgesic doses (Pethidine 1 mg/kg) required was 1.3 +/- 1.2 mg/kg, 0.5 +/- 0.8 mg/kg, and 0.2 +/- 0.6 mg/kg, respectively. Significant differences were noted when comparing the OA with the LA or nLA groups (OA vs. LA, P = 0.02; OA vs. nLA, P = 0.0002; LA vs. nLA, P = 0.06). The mean oral intake durations were 32.2 +/- 16.9 hours, 21.0 +/- 14.6 hours, and 20.8 +/- 16.4 hours, respectively, after surgery for the OA, LA, and nLA groups, and the between-group differences were statistically significant for the OA versus LA group ( P = 0.004) and for the OA versus nLA group ( P = 0.003). The mean durations of hospitalization for the OA, LA, and nLA groups were 3.6 +/-1.8 days, 2.8 +/- 1.4 days, and 2.4 +/- 0.9 days, and difference was detected between the OA and the nLA groups ( P = 0.02). The OA group rendered a greater wound-complication rate and ileus than did the other two groups, but the differences were not detected between the three categories ( P = 0.065, 0.6935). The result of the current study confirmed that the nLA procedure is a feasible and safe one. The nLA procedure provided substantial advantages over the OA procedure in the contexts of diminished postoperative pain and shorter hospital stay without significant increases in postoperative complication rate or surgical time.

Alterations in the immune system and tumor growth in laparoscopy

BACKGROUND

The explosion in the use of therapeutic laparoscopy during the past decade has focused much research interest on finding a basic scientific support for the clinically apparent attenuation of the stress response to surgery. In particular, the potential impact that attenuation of the immune response to surgery may have on laparoscopy for the cure of malignancy has attracted much attention.

METHODS

A review of the published literature on the stress response to laparoscopic surgery and the impact of laparoscopy on tumor growth was performed.

RESULTS

Evidence favors an attenuation of the immune response to surgery with laparoscopic cholecystectomy. Whether this is true also of more major procedures such as laparoscopically assisted colectomy for malignancy is currently unclear. In animal models, tumor growth after laparoscopic surgery is less than after laparotomy and depends on the insufflation agent used.

CONCLUSIONS

Laparoscopic cholecystectomy appears to be associated with attenuation of the immune response to surgery. The implications of these findings for the future use of laparoscopic surgical techniques for malignant disease remain unclear.

Randomized clinical trial of laparoscopic versus open appendicectomy

BACKGROUND

Laparoscopy in patients with a clinical suspicion of acute appendicitis has not gained wide acceptance, and its use remains controversial.

METHODS

In a randomized controlled trial of laparoscopic versus open appendicectomy, 583 of 828 consecutive patients consented to participate. Three hundred and one patients were allocated to open appendicectomy and 282 patients to laparoscopy, 65 of whom required conversion to open appendicectomy. Length of stay in hospital was the primary endpoint, while operating time, postoperative morbidity, duration of convalescence and cosmesis were secondary endpoints.

RESULTS

Intention-to-treat analysis revealed an equally short hospital stay in the two groups (median 2 days). The median time to return to normal activity (7 versus 10 days) and work (10 versus 16 days) was significantly shorter following laparoscopy. Laparoscopy was associated with fewer wound infections (P < 0.03) and improved cosmesis (P < 0.001), but the operating time was longer (60 versus 40 min). Laparoscopy was associated with more intraperitoneal abscesses (5 versus 1 per cent) but, adjusted for a greater number of gangrenous or perforated appendices in this group, the difference failed to reach statistical significance.

CONCLUSION

Hospital stay was equally short, whereas laparoscopic appendicectomy was associated with fewer wound infections, faster recovery, earlier return to work and improved cosmesis.

Intraabdominal abscess rate after laparoscopic appendectomy

BACKGROUND

Studies suggest increased intraabdominal abscess (IA) rates following laparoscopic appendectomy (LA), especially for perforated appendicitis. Consequently, an open approach has been advocated. The aim of our study is to compare IA rates following LA performed by a laparoscopic surgery and a general surgical service within the same institution.

METHODS

Data of LA patients treated at Los Angeles County-University of Southern California (LAC-USC) Medical Center between March 1992 and June 1997 were reviewed. The main outcome measure was postoperative IA.

RESULTS

In all, 645 LA were reviewed. A total of 413 LA (285 acute, 61 gangrenous, 67 perforated appendicitis) were performed by three general surgical services (10 attendings). Ten abscesses occurred postoperatively (2.4%), 6 with perforated appendicitis. After the laparoscopic service was introduced, 232 standardized LA (126 acute, 46 gangrenous, 60 perforated) were performed by two attendings. One IA occurred (gangrenous appendicitis). The IA rate for perforated appendicitis was significantly lower on the laparoscopic service (P = 0.025). There was no difference in IA rates for acute and gangrenous appendicitis. There was no mortality in either group.

CONCLUSION

IA rate following LA for perforated appendicitis was significantly reduced on the laparoscopic service. Mastery of the learning curve and addition of specific surgical techniques explained this improved result. Therefore, laparoscopic appendectomy for complicated appendicitis may not be contraindicated, even for perforated appendicitis.

Introducing diagnostic laparoscopy for patients with suspected acute appendicitis

BACKGROUND

The diagnostic accuracy in patients with suspected acute appendicitis varies from 60% to 90% depending on age and gender. The aim of this study was to evaluate the use of diagnostic laparoscopy for diagnostic purposes in patients with suspected acute appendicitis to prevent unnecessary laparotomy and to leave a macroscopically normal appendix in place.

METHODS

For this study, 500 consecutive patients with suspected acute appendicitis admitted between January 1994 and October 1996 were included prospectively in a surgical training program set to provide diagnostic laparoscopy on a 24-h-a-day basis. Primary open operation was performed when no laparoscopically trained surgeon was available. Short-term outcome measurements were recorded, and a retrospective long-term follow-up evaluation was performed.

RESULTS

We succeeded in performing a diagnostic laparoscopy in 376 patients and a primary open operation in 124 patients. The overall appendicitis rate was 78%. A diagnostic laparoscopy alone was performed in 66 patients (56 of which were fertile women), with a median operating time of 36 min and a complication rate of 0%. The overall complication rate was 8.0%. During a median follow-up period of 19 months one patient returned on a later occasion with appendicitis. At completion of the study, 85% of the surgeons were skilled in diagnostic laparoscopy.

CONCLUSIONS

Substantial education effort is needed to introduce diagnostic laparoscopy on a 24-h-a-day basis. Diagnostic laparoscopy has a high rate of accuracy, short operating time, and low associated morbidity, and prevents unnecessary laparotomy. It is possible to leave a macroscopically normal-appearing appendix in place.

Laparoscopic interval appendectomy for periappendicular abscess

BACKGROUND

Laparoscopic appendectomy was first described in the early 1980s and is currently widely used for the treatment of acute appendicitis. The application of laparoscopic techniques to interval appendectomy and the value of this procedure as compared to open elective interval appendectomy remains uncertain. Therefore, we set out to assess the usefulness of interval laparoscopic appendectomy following periappendicular abscess.

METHODS

This study analyzes the data for 10 patients who underwent interval laparoscopic appendectomy 8-10 weeks following documented periappendicular abscess in the period between January 1996 and June 1998.

RESULTS

Laparoscopic appendectomy was completed successfully in all 10 patients. Nine patients were discharged 1 day after the operation; one patient was discharged on the evening of the operative day. There were no complications and no wound infections.

CONCLUSION

We conclude that the laparoscopic approach is the preferable treatment for interval appendectomy. It is associated with minimal or no morbidity and a very short hospital stay.

Laparoscopic versus open appendectomy

BACKGROUND

Laparoscopic appendectomy is commonly performed and has been presumed to offer economic benefits similar to those of laparoscopic cholecystectomy. This study was done to examine that premise.

METHODS

Two surgical groups contributed consecutively operated patients with a clinical diagnosis of appendicitis. One group did all appendectomies open and the other group did them laparoscopically. Hospital expenses were compared using a single billing formula. Hospital length of stay, time to return to work, and complications were analyzed.

RESULTS

Operating room times were longer for the laparoscopic group, median 80 minutes, versus median 50 minutes for the open group. Hospital length of stay and return to work were the same, median 1 day and median 10 days, respectively. Wound complications were less common in the laparoscopic group, 0 of 30, than in the open group, 3 of 18; however, there was 1 intra-abdominal abscess in the laparoscopic group. Median cost of the laparoscopic group was $2,915 versus $1,747 for the open group.

CONCLUSIONS

Laparoscopic appendectomy is more expensive than appendectomy but does not reduce hospital length of stay nor change the time to return to work; however, wound complications are less common.

A state-wide evaluation of appendectomy in children

BACKGROUND

Traditional management of appendicitis in children involves open appendectomy (OA), an operation that is relatively inexpensive and carries few risks and complications. However, little information is available regarding the use, cost, and complication of laparoscopic appendectomy (LA) in children.

METHODS

Our initial aim was to determine if LA is frequently performed in children (<15 years). We then compared the surgical results of OA versus LA. In conjunction with the Missouri Department of Health, we evaluated 793 children treated for appendicitis throughout the state between January 1997 and June 1997. The authors were blinded to the patient, surgeon, and hospital; no children were excluded.

RESULTS

LA was infrequently performed in children with advanced disease. Overall, children undergoing LA were older and had a shorter hospitalization but no difference in hospital charge. When separated by child age, LA was associated with a shorter length of stay in all groups (0 to 5, 6 to 10, and 11 to 15 years) but only children in the 6 to 10 year range had a lower hospital charge when compared with patients undergoing OA.

CONCLUSIONS

LA is becoming a common surgical approach for older children with simple appendicitis. Furthermore, these data suggest that LA, independent of individual surgeon or medical center, is associated with a decreased length of hospitalization without a significant difference in hospital charge.

Videoendoscopy: an effective and efficient way to perform multiple visceral biopsies in small animals

Because major surgery is usually required to obtain biopsies of abdominal organs, regulations tend to limit the number of procedures on individual animals to one. This study was conducted to develop a more humane, minor, comparatively cost-effective, minimally invasive surgical procedure, which reduces surgical trauma and the number of animals used. Biopsy techniques were developed in two nonsurvival rabbit surgeries. Safety and efficacy of multiple procedures were assessed in survival studies on four rabbits. Anesthesia was induced with ketamine/xylazine and maintained with isoflurane. Initial carbon dioxide insufflation (6 mmHg) was achieved through a Veress needle. A triangulated 5-mm port technique allowed introduction of pediatric 3.5- to 5.0-mm laparoscopic instruments. Biopsies of liver, spleen, kidney, and full-thickness bowel were obtained and evaluated for suitability (size) for polymerase chain reaction, in-situ hybridization, and histopathology studies. Animals in survival studies were assessed for infection, pain, bleeding, adhesion development, bowel function, and intestinal stenosis. All had normal appetite and stools within 48 h postoperatively. Biopsies obtained from either a Tru-Cut Biopsy Needle, 3.5- to 5.0-mm biopsy cups, or with the aid ofa pre-tied loop were adequate for all studies. There was no postoperative bowel obstruction, wound infection, or bleeding. Mean hematocrit decrease at 24 h postoperative was 3.4% +/- 6.7%. Adhesions formed at 9/52 (17%) evaluable sites. Multiple visceral organ biopsy under videoendoscopic guidance constitutes a minor procedure and is a promising means for longitudinal studies in animals. Utility for ill animals remains to be determined.

Fertility patterns after appendicectomy: historical cohort study

OBJECTIVE

To examine fertility patterns in women who had their appendix removed in childhood.

DESIGN

Historical cohort study with computerised data and fertility data for this cohort and for an age matched cohort of women from the Swedish general population. The cohorts were followed to 1994.

SETTING

General population.

PARTICIPANTS

9840 women who were under 15 years when they underwent appendicectomy between 1964 and 1983; 47 590 control women.

MAIN OUTCOME MEASURES

Diagnoses at discharge. Distributions of age at birth of first child among women with perforated and non-perforated appendix and women who underwent appendicectomy but were found to have a normal appendix compared with control women by using survival analysis methods. Parity distributions at the latest update of the registry were also examined.

RESULTS

Women with a history of perforated appendix had a similar rate of first birth as the control women (adjusted hazard ratio 0.95; 95% confidence interval 0.88 to 1. 04) and had a similar distribution of parity at the end of follow up. Women who had had a normal appendix removed had an increased rate of first births (1.48; 1.42 to 1.54) and on average had their first child at an earlier age and reached a higher parity than control women.

CONCLUSION

A history of perforated appendix in childhood does not seem to have long term negative consequences on female fertility. This may have important implications for the management of young women with suspected appendicitis as the liberal attitude to surgical explorations with a subsequently high rate of removal of a normal appendix is often justified by a perceived increased risk of infertility after perforation. Women whose appendix was found to be normal at appendicectomy in childhood seem to belong to a subgroup with a higher fertility than the general population.

A meta-analysis of randomized controlled trials of laparoscopic versus conventional appendectomy

BACKGROUND

Despite many randomized controlled trials, the merits of laparoscopic appendectomy remain unclear. A meta-analysis may provide insights not evident from any individual studies.

DATA SOURCES

Systematic literature search yielded 17 trials (1,962 subjects) of true randomized design with usable statistical data comparing laparoscopic and conventional appendectomy in adults. The effect sizes for operating time, hospitalization, postoperative pain, return to normal activity, wound infection, and intra-abdominal abscess were calculated, using the random effects model to allow for heterogeneity. An estimate of the robustness of all positive findings was also calculated.

RESULTS

Modest but statistically significant effect sizes were found for four of the six outcome measures. Laparoscopic appendectomy takes 31% longer to perform, but results in less postoperative pain, faster recovery (by 35%), and lower wound infection rates (by 60%).

CONCLUSION

Laparoscopic appendectomy offers significant improvement in postoperative outcomes at the cost of a longer operation.

Prospective randomized multicentre study of laparoscopic versus open appendicectomy

BACKGROUND

A prospective randomized multicentre study was performed to compare the outcome of laparoscopic and open appendicectomy in patients with suspected acute appendicitis.

METHODS

A total of 523 patients was randomized, but because of 23 withdrawals the outcome in 500 patients is reported, 244 in the laparoscopic group and 256 in the open group.

RESULTS

Patients having laparoscopic appendicectomy recovered more quickly than those having open surgery (13 versus 21 days, P < 0.001). There was no significant difference in duration of sick leave after operation (laparoscopic group 11 days versus open group 14 days). Postoperative pain (at 24 h, 7 days and 14 days) was less after laparoscopic operations and a functional index 1 week after operation was more favourable in these patients (P < 0.001). Operating time was significantly longer in the laparoscopic group (60 versus 35 min, P < 0.01). Hospital stay and complications did not differ between the groups. Thirty laparoscopic procedures (12 per cent) were converted to open appendicectomy.

CONCLUSION

Laparoscopic appendicectomy is as safe as open appendicectomy and has the advantage of allowing a quicker recovery.

[How can pain of surgery be limited?]

Postoperative pain is due to direct stimulation of nociceptors by surgical trauma, and by algogenic substances produced by damaged tissues. Control of surgical pain can be obtained by limiting the extent of damage to tissues as well as the choice of incision. Endoscopic or video-assisted surgery is an effective mean to reduce pain caused by surgical approach. It is widely used in abdominal, thoracic, orthopaedic surgery, and urology. Many studies have shown a reduction of postoperative pain by laparoscopy for gynaecological surgery and cholecystectomy, but for other procedures the potential advantage of laparoscopic surgery has not yet been established. Conventional open surgery is still widely used. It has been suggested that transverse laparotomies are less painful than midline incisions, and that incision by electrocautery was less painful than with scalpel; but this has not been strictly established. Infiltration of wounds or nerves with local anaesthetic agents is a way of clinical research, which merits further investigation. Whether delicacy in surgery is capable of minimising pain by limiting tissue attrition remains to be demonstrated. Finally, drains and catheters, particularly the naso-gastric tube, which are responsible for pain, could be abandoned when not essential.

[Does a means exist for prevention of postoperative pain?]

Postoperative pain can be prevented through pharmacological and non pharmacological means. The influence of the interval between therapy and surgical stimulus, which corresponds to "pre-emptive analgesia" in English-speaking countries (comparison of preoperative administration with pre- and postoperative administration of the same analgesic) has been assessed by numerous studies of good methodological quality. In spite of the initial promising results, most of the results published at present are negative. In an enlarged concept of postoperative pain prevention, various trials have demonstrated the benefits of the choice of the surgical approach, as well as the psychological preparation of the patient for surgery.

[Laparoscopic appendectomy in the adult]

AIM OF THE STUDY

The benefits of laparoscopic appendectomy remain controversial. The aim of the study was to evaluate the advantages and disadvantages of this technique.

MATERIAL AND METHODS

Four hundred and forty-eight patients operated on for suspected appendicitis during a 5-year period were analysed in a retrospective study. The preoperative diagnosis was corrected in 21.4% of the cases (8.1% for males and 28.7% for females) and the conversion rate was 9.7%. There were 17 patients with generalized peritonitis and 28 with localized peritonitis. During the past year, this surgical method was introduced in another hospital and a prospective study included 92 consecutive patients operated on for appendicitis. The operating time was 53 minutes and the conversion rate was 7.6%. There were five patients with generalized peritonitis and eight with localized peritonitis.

RESULTS

There were no postoperative deaths. In the first period, the morbidity rate was 2.3% in the laparoscopic group without conversion. After pathological examination, there was a 14.2% rate of normal appendix. The mean hospital stay was 4.3 days. In the second period, there were only three minor complications and the mean hospital stay was 4.19 days.

CONCLUSION

The choice of laparoscopic approach is associated with some advantages: corrections of the diagnosis (mainly in young women) and simplification of the postoperative course, provided that the surgeon has sufficient experience.

Laparoscopic versus open appendectomy: a metaanalysis

BACKGROUND

There have been numerous retrospective and uncontrolled series of laparoscopic appendectomy (LA), as well as 16 prospective randomized studies published to date. Although most of these have concluded that the laparoscopic technique is as least as good as open appendectomy (OA), there has been considerable controversy as to whether LA is superior. To help clarify this issue, we performed a metaanalysis of the randomized prospective studies.

STUDY DESIGN

A metaanalysis of all formally randomized prospective trials of LA versus OA in adults.

RESULTS

A total of 1,682 patients were analyzed. When compared with OA, LA results in significantly less postoperative pain, earlier resumption of solid foods, a shorter hospital stay, and a faster return to normal activities. The wound infection rate in the LA patients is less than one half the rate in patients undergoing OA. LA, however, requires longer operating times and the incidence of intraabdominal abscess is higher, but this failed to reach statistical significance. There were no differences in complications or hospital charges.

CONCLUSIONS

LA offers considerable advantages over OA, primarily because of its ability to reduce the incidence of wound infections and shorten recovery times. Its widespread acceptance should be considered. The trend toward increased intraabdominal abscess formation is worrisome, however, and demands further investigation.

Laparoscopic or open appendectomy? Critical review of randomized, controlled trials

PURPOSE

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Laparoscopic appendectomy does not change the incidence of postoperative infectious complications

BACKGROUND

It is not clear whether the laparoscopic approach does decrease the incidence of postoperative infectious complications after appendectomy.

METHODS

One hundred sixty-nine patients were randomized, 87 with laparoscopic (LA) and 82 with open appendectomy (OA). Patients in the OA group had a McBurney incision; LA was performed in the lithotomy position.

RESULTS

Acute appendicitis was confirmed in 75% of patients. The appendix was perforated in 5 patients of the LA versus 2 patients of the OA group. No conversion to the open procedure was necessary. The median operating time was 35 minutes in the LA group and 31 minutes in the open group (P = 0.58). The median postoperative hospital stay was shorter after laparoscopic than after open surgery (3 days versus 4 days, P = 0.026), whereas the time required for return to work was not significantly different (14 versus 15 days). There were 5 (6%) patients with superficial wound infection following LA and 6 (7%) after OA (P = 0.67). Intra-abdominal fluid collections were found in 2 (2%) patients following LA and 3 (4%) patients following OA (P = 0.60). In the LA group, 3 patients presented with intra-abdominal hemorrhage and another 3 developed a paralytic ileus that was treated conservatively.

CONCLUSIONS

Laparoscopic appendectomy is as safe and as effective as the open procedure; however, it does not decrease the rate of postoperative infectious complications.

Have the evaluation and treatment of acute appendicitis changed with new technology?

The evaluation and treatment of acute appendicitis remain essentially unchanged for the majority of individuals who present with this disease. Although advancements have been made in laboratory analysis as well as imaging via ultrasonography and CT, nothing can replace careful evaluation by an experienced surgeon. Appendicitis remains a diagnosis based primarily on history and physical examination, with further studies being useful adjuncts in atypical cases--more likely to occur in the very young or very old and most cost effective when ordered by the surgical consultant. Improvement in outcomes has not been demonstrated with routine use of "new technology." The treatment of acute appendicitis continues to be early surgical intervention. Although laparoscopic appendectomy may offer advantages in women of childbearing age and in obese individuals, its routine use is not indicated based upon current reports in the literature. Debate continues regarding the optimal treatment of the periappendiceal mass. Further clinical research regarding early operation compared with intravenous antibiotics with or without drainage, as well as comparison of outcomes with or without interval appendectomy, needs to be performed. With continued research and definition of populations likely to benefit from advances in technology, a more focused application will be possible. This will lead to improved outcomes and decreased overall cost. The issue of delay in treatment, a major determinant of morbidity associated with appendicitis, warrants further evaluation and should be addressed on a population-specific basis. Emphasis should remain on the early clinical diagnosis of acute appendicitis with its associated low morbidity and mortality.

The role of minimal access surgery in the acute abdomen

The improvement in surgical decision-making for patients with abdominal pain but an uncertain diagnosis using DL has now been shown to decrease both negative and nontherapeutic laparotomy rates. Once the diagnosis is established, DL can be taken a step further in many cases, as therapeutic intervention via laparoscopy is possible for a number of these conditions without resorting to a laparotomy. Conditions amenable to therapeutic laparoscopy include appendicitis, perforated peptic ulcer, diverticulitis, small bowel obstruction, acute cholecystitis, diaphragmatic rupture, and splenic or hepatic injuries, to name but a few. However, a number of unanswered questions remain such as: Who should perform emergency laparoscopic procedures? What should the selection criteria be? What are the cost implications? and Is patient outcome actually better with laparoscopy? Only randomized controlled trials can answer these questions. Until such data are available, it is important that common sense prevail. Laparoscopy should be incorporated into the general surgeon's armamentarium for the management of patients with abdominal pain as just another tool to be used selectively when indicated. It is also important that new technologies be carefully evaluated in an unbiased manner under strict protocol so that objective data can be obtained which can be used to devise guidelines for safe and effective use of new devices.

Should laparoscopic appendectomy be avoided for complicated appendicitis in children?

BACKGROUND/PURPOSE

Laparoscopic appendectomy is becoming the preferred technique for treating acute appendicitis. However, recent literature on adults suggests that laparoscopic appendectomy may increase the risk for postoperative infectious complications in complicated (gangrenous or perforated) cases. This study was undertaken to compare the results of open versus laparoscopic appendectomy for complicated appendicitis in children.

METHODS

A retrospective review from two institutions was performed for all children treated operatively for complicated appendicitis from January 1994 through November 1996.

RESULTS

Fifty-six cases were identified. Twenty-seven children underwent laparoscopic appendectomy, whereas 22 underwent open appendectomy. Seven children underwent conversion from laparoscopic to open surgery. Operating times and length of hospital stay did not differ significantly between the laparoscopic and open groups. Postoperative complications developed in 24 children (42.8%). Complications were more frequent after laparoscopic appendectomy compared with open appendectomy (56% v 18%, P = .002). A postoperative intraabdominal abscess (IAA) developed in 14 children (25%). An IAA occurred in two children after open appendectomy compared with 11 children after laparoscopic appendectomy (9% v 41%, P = .01).

CONCLUSION

The findings suggest that laparoscopic appendectomy should be avoided in children who have complicated appendicitis because of the increased risk for postoperative intraabdominal abscesses. The authors propose a prospective, randomized trial to verify this finding.

Diagnostic laparoscopy for chronic right iliac fossa pain: a pilot study

BACKGROUND

The aim of this study was to determine the value of diagnostic laparoscopy in patients with chronic right iliac fossa pain.

METHODS

A retrospective study at Echuca Hospital involving case-note review and telephone questionnaire of patients who had undergone diagnostic laparoscopy for chronic right iliac fossa pain at least 12 months earlier (September 1992 to August 1995) was carried out.

RESULTS

Forty-one cases were identified and followed up 12-40 months postoperatively (median 21 months). Eleven cases had positive findings at laparoscopy, of whom eight obtained lasting relief after treatment. Of the remaining 30 patients 17 had a normal-looking appendix removed and 12 were cured; these were younger patients with episodic symptoms and localized signs. Of eight patients who had adhesions divided, four with adhesions beneath old scars obtained relief. Altogether 32 of the 41 patients considered the laparoscopy worthwhile even though in some cases it did not relieve their chronic pain.

CONCLUSIONS

Diagnostic laparoscopy is worthwhile for patients with chronic right iliac fossa pain. Concurrent appendicectomy should be considered in young patients with episodic, well-localized symptoms associated with systemic malaise while adhesiolysis may be beneficial for viscero-parietal adhesions beneath abdominal wall scars.

Stump appendicitis--a potential problem after laparoscopic appendicectomy

Appendicitis is now commonly diagnosed and treated using laparoscopic techniques. Laparoscopic appendicectomy has the potential to result in incomplete removal of the appendix stump and subsequent risk of stump appendicitis. This article reports such a case, requiring laparotomy 5 months after the original appendectomy.

Laparoscopic stapler appendectomy. A prospective study of 267 consecutive cases

BACKGROUND

The value of laparoscopic appendectomy remains controversial. Therefore, we investigated the accuracy of diagnostic laparoscopy in detecting acute appendicitis and tested the applicability and safety of stapling appendectomy as a routine procedure.

METHODS

Data from 267 consecutive patients with suspicion of acute appendicitis were recorded prospectively.

RESULTS

Histopathological examination revealed nonperforated and perforated appendicitis in 63.3% and 13.1%, respectively, and no inflammation in 10.8%. Other pathological findings were observed in 12.7%. Diagnostic laparoscopy detected appendicitis with a sensitivity and specificity of 95.6% and 96.6%, respectively; the positive and negative predictive value were 99.5% and 74.3%, respectively. Morbidity was 10.2% in total and 40% for perforated appendicitis. Planned laparoscopic reexploration reduced morbidity by 23.4% in patients with perforated appendicitis and substantial peritonitis. Mortality was 0.4%.

CONCLUSIONS

Laparoscopy improves diagnostic accuracy for acute appendicitis and laparoscopic stapling appendectomy is a safe and efficient procedure for all forms of appendicitis.

Laparoscopy not recommended for routine appendectomy in men: results of a prospective randomized study

BACKGROUND

Laparoscopic appendectomy has now gained wider acceptance in clinical practice, particularly in the treatment of women with right iliac fossa pain. However, the precise role of laparoscopic appendectomy in men is unclear, and this study was therefore undertaken to examine this specific issue in a prospective randomized trial.

METHODS

One hundred men between the ages of 16 and 65 years who had suspected appendicitis were recruited and randomized to undergo either open or laparoscopic appendectomy. Both groups were compared in terms of their clinical parameters, duration of anesthetic and operation times, postoperative pain, duration of ileus, and length of hospital stay.

RESULTS

The histologic confirmation of appendicitis was present in 94% of the cases for both groups of patients. Laparoscopic appendectomy required significantly longer anesthetic time (72.5 minutes versus 55 minutes) and actual operating time (45 minutes versus 25 minutes) compared with open appendectomy. Postoperative pain as measured by visual analog scale on postoperative days 1 and 2 were not significantly different between the patients who underwent laparoscopic and open surgery with values of 4.7 versus 4.4 and 2.1 versus 2.2, respectively. Also no significant difference was seen between the laparoscopic and open appendectomy groups in the recovery of bowel function (24.7 hours versus 21 hours) and in the length of hospital stay (4.9 days versus 5.3 days).

CONCLUSIONS

The results of this prospective randomized trial showed that there were no significant advantages of laparoscopic appendectomy over open appendectomy for the treatment of male patients with suspected appendicitis. We recommend that the use of laparoscopy be limited to men with atypical pain of uncertain diagnosis and in obese patients.