Randomized controlled trial comparing laparoscopic and open appendicectomy

Laparoscopic versus open surgery for suspected appendicitis

BACKGROUND

The removal of the acute appendix is one of the most frequently performed surgical procedures. Open surgery associated with therapeutic efficacy has been the treatment of choice for acute appendicitis. However, in consequence of the evolution of endoscopic surgery, the operation can also be performed with minimally invasive surgery. Due to smaller incisions, the laparoscopic approach may be associated with reduced postoperative pain, reduced wound infection rate, and shorter time until return to normal activity.This is an update of the review published in 2010.

OBJECTIVES

To compare the effects of laparoscopic appendectomy (LA) and open appendectomy (OA) with regard to benefits and harms.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE and Embase (9 February 2018). We identified proposed and ongoing studies from World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov and EU Clinical Trials Register (9 February 2018). We handsearched reference lists of identified studies and the congress proceedings of endoscopic surgical societies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing LA versus OA in adults or children.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed the risk of bias, and extracted data. We performed the meta-analyses using Review Manager 5. We calculated the Peto odds ratio (OR) for very rare outcomes, and the mean difference (MD) for continuous outcomes (or standardised mean differences (SMD) if researchers used different scales such as quality of life) with 95% confidence intervals (CI). We used GRADE to rate the quality of the evidence.

MAIN RESULTS

We identified 85 studies involving 9765 participants. Seventy-five trials included 8520 adults and 10 trials included 1245 children. Most studies had risk of bias issues, with attrition bias being the largest source across studies due to incomplete outcome data.In adults, pain intensity on day one was reduced by 0.75 cm on a 10 cm VAS after LA (MD -0.75, 95% CI -1.04 to -0.45; 20 RCTs; 2421 participants; low-quality evidence). Wound infections were less likely after LA (Peto OR 0.42, 95% CI 0.35 to 0.51; 63 RCTs; 7612 participants; moderate-quality evidence), but the incidence of intra-abdominal abscesses was increased following LA (Peto OR 1.65, 95% CI 1.12 to 2.43; 53 RCTs; 6677 participants; moderate-quality evidence).The length of hospital stay was shortened by one day after LA (MD -0.96, 95% CI -1.23 to -0.70; 46 RCTs; 5127 participant; low-quality evidence). The time until return to normal activity occurred five days earlier after LA than after OA (MD -4.97, 95% CI -6.77 to -3.16; 17 RCTs; 1653 participants; low-quality evidence). Two studies showed better quality of life scores following LA, but used different scales, and therefore no pooled estimates were presented. One used the SF-36 questionnaire two weeks after surgery and the other used the Gastro-intestinal Quality of Life Index six weeks and six months after surgery (both low-quality evidence).In children, we found no differences in pain intensity on day one (MD -0.80, 95% CI -1.65 to 0.05; 1 RCT; 61 participants; low-quality evidence), intra-abdominal abscesses after LA (Peto OR 0.54, 95% CI 0.24 to 1.22; 9 RCTs; 1185 participants; low-quality evidence) or time until return to normal activity (MD -0.50, 95% CI -1.30 to 0.30; 1 RCT; 383 participants; moderate-quality evidence). However, wound infections were less likely after LA (Peto OR 0.25, 95% CI 0.15 to 0.42; 10 RCTs; 1245 participants; moderate-quality evidence) and the length of hospital stay was shortened by 0.8 days after LA (MD -0.81, 95% CI -1.01 to -0.62; 6 RCTs; 316 participants; low-quality evidence). Quality of life was not reported in any of the included studies.

AUTHORS' CONCLUSIONS

Except for a higher rate of intra-abdominal abscesses after LA in adults, LA showed advantages over OA in pain intensity on day one, wound infections, length of hospital stay and time until return to normal activity in adults. In contrast, LA showed advantages over OA in wound infections and length of hospital stay in children. Two studies reported better quality of life scores in adults. No study reported this outcome in children. However, the quality of evidence ranged from very low to moderate and some of the clinical effects of LA were small and of limited clinical relevance. Future studies with low risk of bias should investigate, in particular, the quality of life in children.

Optimal stump management in laparoscopic appendectomy: A network meta-analysis by the Minimally Invasive Surgery Synthesis of Interventions and Outcomes Network

BACKGROUND

Laparoscopic appendectomy is the predominant method of treatment of acute appendicitis. There is insufficient evidence on the most effective management of the appendix stump. The aim of this study was to investigate the relative effectiveness and provide a treatment ranking of different options for securing the appendix stump.

METHODS

Electronic databases were searched to identify randomized controlled trials comparing ligation methods of the appendix. The primary outcomes were organ/space infection and superficial operative site infection. We performed a network meta-analysis and estimated the pairwise relative treatment effects of the competing interventions using the odds ratio and its 95% confidence interval. We obtained a hierarchy of the competing interventions using rankograms and the surface under the cumulative ranking curve.

RESULTS

Forty-three randomized controlled trials were eligible and provided data for >5,000 patients. Suture ligation seemed to be the most effective treatment strategy, in terms of both organ/space infection and superficial operative site infection. Statistical significance was reached for the comparisons of clip versus endoloop (odds ratio 0.56, 95% confidence interval, 0.32-0.96) for organ/space infection; and suture versus clip (odds ratio 0.20, 95% confidence interval 0.08-0.55) and clip versus endoloop (odds ratio 2.22, 95% confidence interval 1.56-3.13) for superficial operative site infection. The network was informed primarily by indirect treatment comparisons.

CONCLUSION

The use of suture ligation of the appendix in laparoscopic appendectomy seems to be superior to other methods for the composite parameters of organ/space and superficial operative site infection.

Laparoscopic versus open surgery for complicated appendicitis: a randomized controlled trial to prove safety

BACKGROUND

To date, no randomized control trial has been performed comparing open appendectomy (OA) to laparoscopic appendectomy (LA) in complicated appendicitis. A systematic review and meta-analysis in 2010 concluded LA is advantageous to OA with less surgical site sepsis in complicated appendicitis; however, the level of evidence is weak (level 3a). The aim of the study was to determine whether LA is safe in the treatment of complicated appendicitis. Primary outcome included all-cause mortality and procedure-related mortality; secondary outcomes included intra-operative duration, rates of wound sepsis and re-intervention, length of hospital stay and re-admission rates.

METHODS

One hundred and fourteen patients were randomized prospectively to either OA or LA using a computer-generated blind method. Patients who were either less than 12 years of age, had previous abdominal surgery or were pregnant were excluded. A team of senior surgeons capable of doing both OA and LA performed all procedures.

RESULTS

The intra-operative duration, the rate of wound sepsis, the number of re-operations, the length of hospital stay and the rate of re-admissions between the OA and LA groups did not differ statistically.

CONCLUSION

Laparoscopic appendectomy is safe in complicated appendicitis. Current Control Trials (ISRCTN92257749).

Laparoscopy for the management of acute lower abdominal pain in women of childbearing age

BACKGROUND

This is an updated version of the original review, published in Issue 1, 2011, of The Cochrane Library. Acute lower abdominal pain is common, and making a diagnosis is particularly challenging in premenopausal women, as ovulation and menstruation symptoms overlap with symptoms of appendicitis, early pregnancy complications and pelvic infection. A management strategy involving early laparoscopy could potentially provide a more accurate diagnosis, earlier treatment and reduced risk of complications.

OBJECTIVES

To evaluate the effectiveness and harms of laparoscopy for the management of acute lower abdominal pain in women of childbearing age.

SEARCH METHODS

The Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, PsycINFO, LILACS and CINAHL were searched (October 2013). The International Clinical Trials Registry Platform (ICTRP) was also searched. No new studies were included in this updated version.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that included women of childbearing age who presented with acute lower abdominal pain, non-specific lower abdominal pain or suspected appendicitis were included. Trials were included if they evaluated laparoscopy with open appendicectomy, or laparoscopy with a wait and see strategy. Study selection was carried out by two review authors independently.

DATA COLLECTION AND ANALYSIS

Data from studies that met the inclusion criteria were independently extracted by two review authors and the risk of bias assessed. We used standard methodological procedures as expected by The Cochrane Collaboration. A summary of findings table was prepared using GRADE criteria.

MAIN RESULTS

A total of 12 studies including 1020 participants were incorporated into the review. These studies had low to moderate risk of bias, mainly because allocation concealment or methods of sequence generation were not adequately reported. In addition, it was not clear whether follow-up was similar for the treatment groups. The index test was incorporated as a reference standard in the laparoscopy group, and differential verification or partial verification bias may have occurred in most RCTs. Overall the quality of the evidence was low to moderate for most outcomes, as per the GRADE approach.Laparoscopy was compared with open appendicectomy in eight RCTs. Laparoscopy was associated with an increased rate of specific diagnoses (seven RCTs, 561 participants; odds ratio (OR) 4.10, 95% confidence interval (CI) 2.50 to 6.71; I(2) = 18%), but no evidence was found of reduced rates for any adverse events (eight RCTs, 623 participants; OR 0.46, 95% CI 0.19 to 1.10; I(2) = 0%). A meta-analysis of seven studies found a significant difference favouring the laparoscopic procedure in the rate of removal of normal appendix (seven RCTs, 475 participants; OR 0.13, 95% CI 0.07 to 0.24; I(2) = 0%).Laparoscopic diagnosis versus a 'wait and see' strategy was investigated in four RCTs. A significant difference favoured laparoscopy in terms of rate of specific diagnoses (four RCTs, 395 participants; OR 6.07, 95% CI 1.85 to 29.88; I(2) = 79%), but no evidence suggested a difference in rates of adverse events (OR 0.87, 95% CI 0.45 to 1.67; I(2) = 0%).  

AUTHORS' CONCLUSIONS

We found that laparoscopy in women with acute lower abdominal pain, non-specific lower abdominal pain or suspected appendicitis led to a higher rate of specific diagnoses being made and a lower rate of removal of normal appendices compared with open appendicectomy only. Hospital stays were shorter. No evidence showed an increase in adverse events when any of these strategies were used.

Meta-analysis of the results of randomized controlled trials that compared laparoscopic and open surgery for acute appendicitis

PURPOSE

We conducted a meta-analysis to evaluate and compare the outcomes of laparoscopic and open surgery for the treatment of patients with acute appendicitis.

METHODS

We searched MEDLINE, EMBASE, Science Citation Index, and the Cochrane Controlled Trial Register for relevant papers published between January 1990 and February 2012. We analyzed 22 outcomes of laparoscopic and open surgery for acute appendicitis.

RESULTS

We identified 39 papers reporting results from randomized controlled trials that compared laparoscopic surgery with open surgery for acute appendicitis. Our meta-analysis included 5,896 patients with acute appendicitis; 2,847 had undergone laparoscopic surgery, and 3,049 had undergone open surgery. Compared with open surgery, laparoscopic surgery was associated with longer operative time (by 13.12 min). However, compared with open surgery, laparoscopic surgery for acute appendicitis was associated with earlier resumption of liquid and solid intake; shorter duration of postoperative hospital stay; a reduction in dose numbers of parenteral and oral analgesics; earlier return to normal activity, work, and normal life; decreased occurrence of wound infection; a better cosmesis; and similar hospital charges.

CONCLUSIONS

Laparoscopic surgery may now be the standard treatment for acute appendicitis.

The necessity for prospective evidence for single-site umbilical laparoscopic surgery

During the past 10 years, the minimally invasive technique has become the standard approach for many thoracic, abdominal, and pelvic procedures in adults and children. We now know there are well-defined benefits to this approach. However, when it was introduced, the laparoscopic technique was quickly adopted without appropriate clinical evidence to justify its advantages over open surgery. With continued efforts to increase the benefits of minimally invasive surgery for their patients, surgeons have developed new techniques to further decrease the trauma of the operation and improve the postoperative cosmetic appearance for the patient. These innovations range from decreasing the size of the ports and instruments to the current group of techniques termed "scarless" surgery. In today's era of evidence-based medicine, it is important to scientifically evaluate the benefits of a new approach or technique. This article seeks to review the history of laparoscopic surgery, apply lessons learned during the past 10 years to the evolution of single incision laparoscopic surgery, and urge for sound prospective evaluation for the use of laparoscopic surgery using a single umbilical incision.

Laparoscopic versus open appendicectomy: An Indian perspective

BACKGROUND

Laparoscopic appendicectomy though widely practiced has not gained universal approval. Laparoscopic appendicectomy in India is relatively new and the literature is scant. This study was aimed to compare laparoscopic with open appendicectomy and ascertain the therapeutic benefit, if any, in the overall management of acute appendicitis.

MATERIALS AND METHODS

The study group consisted of two hundred and seventy nine patients suffering from acute appendicitis. One hundred patients underwent laparoscopic appendicectomy (LA) and one hundred seventy nine patients underwent open appendecectomy (OA). Comparison was based on length of hospital stay, operating time, postoperative morbidity, duration of convalescence and operative cost in terms of their medians. The Mann-Whitney statistics (T) were calculated and because of large samples, the normal deviate test (Z) was used.

RESULTS

Of the hundred patients, six patients (6%) had the procedure converted to open surgery. The rate of infections and overall complications (LA: 15%, OA: 31.8%, P < 0.001) were significantly lower in patients undergoing LA. The median length of stay was significantly shorter after LA (3 days after LA, 5 days after OA, P < 0.0001) than after OA. The operating time was shorter {OA: 25 min (median), LA: 28 min (median), 0.01< P < 0.05} in patients undergoing open appendicectomy compared to laparoscopic appendicectomy.

CONCLUSION

Hospital stay for LA is significantly shorter and the one-time operative charges appear to be almost the same. LA is also associated with increased clinical comfort in terms of fewer wound infections, faster recovery, earlier return to work and improved cosmesis.

Laparoscopic management of appendicular mass

BACKGROUND

Laparoscopic appendectomy is becoming the preferred technique for treating acute appendicitis. However, its role in the treatment of complicated appendicitis is controversial. This study was undertaken to assess the feasibility of laparoscopic appendectomy for appendicular mass.

MATERIALS AND METHODS

A retrospective review was performed of all the patients who were treated laparoscopically for appendicular mass from March 2007 to October 2009.

SETTING

Tertiary care hospital.

RESULTS

A total of 120 patients were treated for appendicitis. A retrospective review of the patients' records demonstrated that 19 patients (15.8%) had appendicular mass at the time of admission. The average operative time was 95 minutes (range 45-140 minutes). Pathological evidence of appendicitis was present in all the patients. The average length of hospital stay was six days (rang 6-9 days). Three patients (15.7%) had post- operative complications. Two patients developed wound infections and one patient was re-admitted with pain and a lump below the umbilical port.

CONCLUSION

The findings suggest that laparoscopic appendectomy is feasible in patients with appendicular mass. The authors propose a prospective, randomized trial to verify this finding.

Laparoscopy for the management of acute lower abdominal pain in women of childbearing age

BACKGROUND

Acute lower abdominal pain is common and making a diagnosis is particularly challenging in premenopausal woman as ovulation and menstruation symptoms overlap with the symptoms of appendicitis and pelvic infection. A management strategy involving early laparoscopy could potentially provide a more accurate diagnosis, earlier treatment and reduced risk of complications.

OBJECTIVES

To evaluate the effectiveness and harms of laparoscopy for the management of acute lower abdominal pain in women of childbearing age.

SEARCH STRATEGY

The  Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, PsycINFO, LILACS and CINHAL were searched (to April 2010).

SELECTION CRITERIA

Randomised controlled trials (RCTs) that included women of childbearing age who presented with acute lower abdominal pain, nonspecific lower abdominal pain or suspected appendicitis were included.

DATA COLLECTION AND ANALYSIS

Data from studies that met the inclusion criteria were independently extracted by two authors and the risk of bias assessed.

MAIN RESULTS

Laparoscopy was compared with open appendicectomy in eight RCTs. Laparoscopy was associated with an increased rate of specific diagnoses (7 RCTs, 561 participants; OR 4.10, 95% CI 2.50 to 6.71; I(2) 18%) but there was no evidence of reduced rate for any adverse event (8 RCTs, 623 participants; OR 0.46, 95% CI 0.19 to 1.10; I(2) 0%).Laparoscopic diagnosis versus a 'wait and see' strategy was investigated in four RCTs. There was a significant difference favouring laparoscopy in the rate of specific diagnoses (4 RCTs, 395 participants; OR 6.07, 95% CI 1.85 to 29.88; I(2) 79%) but there was no evidence of a difference in the rates of adverse events (OR 0.87, 95% CI 0.45 to 1.67; I(2) 0%).  

AUTHORS' CONCLUSIONS

The advantages of laparoscopy in women with nonspecific abdominal pain and suspected appendicitis include a higher rate of specific diagnoses being made and a lower rate of removal of normal appendices compared to open appendicectomy only. Hospital stays were shorter. There was no evidence of an increase in adverse events with any of the strategies.

Laparoscopic versus conventional appendectomy--a meta-analysis of randomized controlled trials

Background

Although laparoscopic surgery has been available for a long time and laparoscopic cholecystectomy has been performed universally, it is still not clear whether open appendectomy (OA) or laparoscopic appendectomy (LA) is the most appropriate surgical approach to acute appendicitis. The purpose of this work is to compare the therapeutic effects and safety of laparoscopic and conventional "open" appendectomy by means of a meta-analysis.

Methods

A meta-analysis was performed of all randomized controlled trials published in English that compared LA and OA in adults and children between 1990 and 2009. Calculations were made of the effect sizes of: operating time, postoperative length of hospital stay, postoperative pain, return to normal activity, resumption of diet, complications rates, and conversion to open surgery. The effect sizes were then pooled by a fixed or random-effects model.

Results

Forty-four randomized controlled trials with 5292 patients were included in the meta-analysis. Operating time was 12.35 min longer for LA (95% CI: 7.99 to 16.72, p < 0.00001). Hospital stay after LA was 0.60 days shorter (95% CI: -0.85 to -0.36, p < 0.00001). Patients returned to their normal activity 4.52 days earlier after LA (95% CI: -5.95 to -3.10, p < 0.00001), and resumed their diet 0.34 days earlier(95% CI: -0.46 to -0.21, p < 0.00001). Pain after LA on the first postoperative day was significantly less (p = 0.008). The overall conversion rate from LA to OA was 9.51%. With regard to the rate of complications, wound infection after LA was definitely reduced (OR = 0.45, 95% CI: 0.34 to 0.59, p < 0.00001), while postoperative ileus was not significantly reduced(OR = 0.91, 95% CI: 0.57 to 1.47, p = 0.71). However, intra-abdominal abscess (IAA), intraoperative bleeding and urinary tract infection (UIT) after LA, occurred slightly more frequently(OR = 1.56, 95% CI: 1.01 to 2.43, p = 0.05; OR = 1.56, 95% CI: 0.54 to 4.48, p = 0.41; OR = 1.76, 95% CI: 0.58 to 5.29, p = 0.32).

Conclusion

LA provides considerable benefits over OA, including a shorter length of hospital stay, less postoperative pain, earlier postoperative recovery, and a lower complication rate. Furthermore, over the study period it was obvious that there had been a trend toward fewer differences in operating time for the two procedures. Although LA was associated with a slight increase in the incidence of IAA, intraoperative bleeding and UIT, it is a safe procedure. It may be that the widespread use of LA is due to its better therapeutic effect.

Laparoscopic versus open surgery for suspected appendicitis

BACKGROUND

Laparoscopic surgery for acute appendicitis has been proposed to have advantages over conventional surgery.

OBJECTIVES

To compare the diagnostic and therapeutic effects of laparoscopic and conventional 'open' surgery.

SEARCH STRATEGY

We searched the Cochrane Library, MEDLINE, EMBASE, LILACS, CNKI, SciSearch, study registries, and the congress proceedings of endoscopic surgical societies.

SELECTION CRITERIA

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.

DATA COLLECTION AND ANALYSIS

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.

MAIN RESULTS

We included 67 studies, of which 56 compared LA (with or without diagnostic laparoscopy) vs. OA in adults. Wound infections were less likely after LA than after OA (OR 0.43; CI 0.34 to 0.54), but the incidence of intraabdominal abscesses was increased (OR 1.87; CI 1.19 to 2.93). The duration of surgery was 10 minutes (CI 6 to 15) longer for LA. Pain on day 1 after surgery was reduced after LA by 8 mm (CI 5 to 11 mm) on a 100 mm visual analogue scale. Hospital stay was shortened by 1.1 day (CI 0.7 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. Seven studies on children were included, but the results 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).

AUTHORS' 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. Especially young female, obese, and employed patients seem to benefit from LA.

Laparoscopic versus open appendectomy for acute appendicitis: a metaanalysis

BACKGROUND

Currently, laparoscopic appendectomy (LA) provides a safe and effective alternative to open appendectomy (OA), but its use remains controversial. This study aimed to evaluate the efficiency and safety of LA through a metaanalysis.

METHODS

Randomized controlled trials (RCTs) comparing LA and OA published between January 1992 and February 2010 were included in this study. Strict literature appraisal and data extraction were carried out independently by two reviewers. A metaanalysis then was performed to evaluate operative time, hospital cost, postoperative complications, length of analgesia, bowel function recovery, day liquid diet began, hospital stay, and return to work and normal activity.

RESULTS

The metaanalysis comprised 25 RCTs involving 4,694 patients (2,220 LA and 2,474 OA cases). No significant differences were found between the LA and OA groups in terms of age, gender, body mass index (BMI), or type of appendiceal inflammation. Compared with OA, LA showed advantages of fewer postoperative complications (odds ratio [OR], 0.74; 95% confidence interval [CI], 0.55-0.98; p = 0.04), less pain (length of analgesia: weighted mean difference [WMD], -0.53; 95% CI, -0.91 to -0.15; p = 0.007), earlier start of liquid diet (WMD, -0.51; 95% CI, -0.75 to -0.28; p < 0.0001), shorter hospital stay (WMD, -0.68; 95% CI, -1.02 to -0.35; p < 0.0001), and earlier return to work (WMD, -3.09; 95% CI, -5.22 to -0.97; p = 0.004) and normal activity (WMD, -4.73; 95% CI, -6.54 to -2.92; p < 0.00001), but a comparable hospital cost (WMD of LA/OA ratio, 0.11; 95% CI, -0.18 to 0.40; p = 0.47) and a longer operative time (WMD, 10.71; 95% CI, 6.76-14.66; p < 0.00001).

CONCLUSION

Despite the longer operative time, LA results in less postoperative pain, faster postoperative rehabilitation, a shorter hospital stay, and fewer postoperative complications than OA. Therefore, LA is worth recommending as an effective and safe procedure for acute appendicitis.

Comparison of outcomes after laparoscopic versus open appendectomy for acute appendicitis at 222 ACS NSQIP hospitals

BACKGROUND

The benefit of laparoscopic (LA) versus open (OA) appendectomy, particularly for complicated appendicitis, remains unclear. Our objectives were to assess 30-day outcomes after LA versus OA for acute appendicitis and complicated appendicitis, determine the incidence of specific outcomes after appendectomy, and examine factors influencing the utilization and duration of the operative approach with multi-institutional clinical data.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database (2005-2008), patients were identified who underwent emergency appendectomy for acute appendicitis at 222 participating hospitals. Regression models, which included propensity score adjustment to minimize the influence of treatment selection bias, were constructed. Models assessed the association between surgical approach (LA vs OA) and risk-adjusted overall morbidity, surgical site infection (SSI), serious morbidity, and serious morbidity/mortality, as well as individual complications in patients with acute appendicitis and complicated appendicitis. The relationships between operative approach, operative duration, and extended duration of stay with hospital academic affiliation were also examined.

RESULTS

Of 32,683 patients, 24,969 (76.4%) underwent LA and 7,714 (23.6%) underwent OA. Patients who underwent OA were significantly older with more comorbidities compared with those who underwent LA. Patients treated with LA were less likely to experience an overall morbidity (4.5% vs 8.8%; odds ratio [OR], 0.60; 95% confidence interval [CI], 0.54-0.68) or a SSI (3.3% vs 6.7%; OR, 0.57; 95% CI, 0.50-0.65) but not a serious morbidity (2.6% vs 4.2%; OR, 0.86; 95% CI, 0.74-1.01) or a serious morbidity/mortality (2.6% vs 4.3%; OR, 0.87; 95% CI, 0.74-1.01) compared with those who underwent OA. All patients treated with LA were significantly less likely to develop individual infectious complications except for organ space SSI. Among patients with complicated appendicitis, organ space SSI was significantly more common after laparoscopic appendectomy (6.3% vs 4.8%; OR, 1.35; 95% CI, 1.05-1.73). For all patients with acute appendicitis, those treated at academic-affiliated versus community hospitals were equally likely to undergo LA versus OA (77.0% vs 77.3%; P = .58). Operative duration at academic centers was significantly longer for both LA and OA (LA, 47 vs 38 minutes [P < .0001]; OA, 49 vs 44 minutes [P < .0001]). Median duration of stay after LA was 1 day at both academic-affiliated and community hospitals.

CONCLUSION

Within ACS NSQIP hospitals, LA is associated with lower overall morbidity in selected patients. However, patients with complicated appendicitis may have a greater risk of organ space SSI after LA. Academic affiliation does not seem to influence the operative approach. However, LA is associated with similar durations of stay but slightly greater operative times than OA at academic versus community hospitals.

Laparoscopic appendectomy is the preferred approach for appendicitis: a retrospective review of two practice patterns

BACKGROUND

This study aimed to compare the results of laparoscopic appendectomy (LA) and open appendectomy (OA).

METHODS

A retrospective analysis of 264 patients who underwent appendectomy (155 LA and 109 OA) over an 8-year period was performed. The variables analyzed included patient data (white blood cell count [WBC], duration of symptoms, American Society of Anesthesiology [ASA] score), operating data (length of the procedure and pathology), postoperative data (postoperative complications and length of hospital stay), and total costs.

RESULTS

Patient demographic data (age and sex), preoperative WBC, duration of symptoms, and pathology all were similar in the two study groups. Six cases were converted to OA and included in the LA group data. There was no statistical difference in the average operative time between the LA (mean, 55.7 + or - 22.3 min; range, 20-128 min) and OA (mean, 58.9 + or - 23.7 min; range, 29-135 min) groups (95% confidence interval [CI] -8.8-2.43; p = 0.26). The overall incidence of minor and major complications was significantly less in the LA group (3.2%, five incidents) than in the OA group (17.4%, 19 incidents; p = 0.0043). The median length of hospital stay (LOS) was significantly shorter in the laparoscopic group (median, 2 days; range, 1-8 days) than in the open group (median, 3 days; range, 1-11 days; p < 0.001). The mean total cost was $5,663 in the laparoscopic group and $6,031 in the open group (non-significant difference of -$368; 95% CI, -$926-$190; p = 0.19).

CONCLUSION

The findings show that LA is associated with fewer complications and similar total costs compared with OA. Therefore, LA can be recommended as a preferred approach to appendectomy.

Laparoscopic appendectomy for acute appendicitis: Is this a feasible option for developing countries?

BACKGROUND/AIM

The role of laparoscopic appendectomy is still not well defined in the literature. This study was conducted to evaluate the feasibility of laparoscopic appendectomy at a university hospital in a developing country.

MATERIALS AND METHODS

Patients undergoing laparoscopic appendectomy (LA) from August 2002 to August 2006 were identified. For each case, a control was selected from patients undergoing open appendectomy (OA) during the same year by systematic sampling. The groups were compared in terms of duration of surgery, requirement of narcotic analgesia, length of hospital stay, postoperative complications and the overall cost for each patient.

RESULTS

A total of 68 patients underwent laparoscopic appendectomy during the study period. Median duration of surgery was 82 minutes in LA group and 70 minutes in OA group (P < 0.001). Forty-five patients in LA group and 64 in OA group required narcotic analgesia (P 0.001). Median length of hospital stay (P = 0.672) and postoperative complications (P = 0.779) were comparable in both groups. Median cost of hospital stay was Pakistani Rupees (PKR) 47121/in LA group and PKR 39318/in OA group, the difference being significant (P = 0.001).

CONCLUSIONS

Laparoscopic appendectomy is feasible in developing countries with similar postoperative outcome and less requirement of narcotic analgesia. The duration of surgery and overall cost were significantly higher and efforts should be made to develop expertise and reduce operative time with resultant decrease in cost. Development of standardized protocols for discharge of patients from the hospital after LA may further reduce the cost and benefit patients in developing countries.

Video-assisted laparoscopic extracorporeal appendectomy versus open appendectomy

OBJECTIVES

Laparoscopic appendectomy (LA) is categorized into intracorporeal appendectomy (ICA) and video-assisted extracorporeal appendectomy (VAECA). This study is conducted to compare feasibility and effectiveness of video-assisted extracorporeal appendectomy (VAECA) with open appendectomy (OA).

PATIENTS AND METHODS

This was a comparative descriptive study conducted at the Department of Surgery of Liaquat University of Medical and Health Sciences (Jamshoro, Pakistan) from June 2003 to November 2007. Two hundred and eighty-three patients of acute appendicitis were included and categorized into two groups: A and B. Group A included 150 (53%) patients operated on by the OA technique, while group B included 133 (47%) patients in whom VAECA was performed. VAECA was accomplished through three ports in the majority of patients (89%), while a few cases (11%) were completed by two ports only. Patients below 10 years of age and with suspected appendicular mass were excluded from the study. Both operative techniques and their merits and demerits were explained to all the patients and, depending upon their choice or by a simple flip of a coin, they were operated on by either of the techniques. A well-informed written consent was also taken from every patient. The results of both the groups were collected on a proforma and were compared in terms of cosmesis, total operative time, operative and postoperative complications, and total duration of hospital stay.

RESULTS

The mean operating time was much shorter in group B (p < 0.001), compared to group A patients. The incidence of postoperative infection was comparatively higher in OA, compared to VAECA. The rate of operative complications (p < 0.001), postoperative complications (p < 0.01), and duration of hospital stay (p < 0.001) were all significantly lower in the VAECA group. Cosmetic results were excellent in VAECA, compared to OA, as assessed by length of incision and the postoperative scar formation.

CONCLUSION

VAECA can be a good alternate option in simple cases without much adhesions or mass formation.

Laparoscopic appendicectomy versus open appendicectomy: a comparative study of clinical outcome and cost analysis - Institutional experience

BACKGROUND

Laparoscopic appendicetomy had not gained importance against open appendicectomy and it remains controversial in Indian perspective.

AIM

Compare the clinical outcome and cost effectiveness of Laparoscopic Appendicectomy (LA) versus Open Appendicectomy (OA).

METHODS

A prospective study for a period of 21 months from Oct. 2005 to June 2007, 249 patients underwent appendicectomy and 200 patients were included in the study. 114 underwent Open appendicectomy and 86 underwent laparoscopic appendicectomy. Duration of surgery, postoperative complications, postoperative hospital stay, postoperative pain and requirement of analgesia, resumption of oral feeds, cost of hospital stay and return to normal activities was compared and noted.

RESULT

Laparoscopic appendicectomy was better than open appendiectomy with respect to the wound infection rate, early resumption of oral feeds, postoperative pain, lesser use of analgesics, postoperative hospital stay (3.13 days after LA, 4.36 days after OA, P < 0.0001) and return to normal activities (LA group to OA group; 13.86 days to 19.44 days P< 0.0001). Although above mentioned advantages were at the cost of slightly increased duration of surgery (58.29 min in OA group to 74.13 min in LA group P < 0.0001HS) and cost of surgery {LA: OA Rs.4225.81: Rs.5560.92 (P <0.0001)}.

CONCLUSION

Laparoscopic appendicectomy was better than open appendiectomy with respect to wound infection rate, early resumption of oral feeds, postoperative pain, lesser use of analgesics, postoperative hospital stay and return to normal activities. Although above mentioned advantages were at the cost of slightly increased duration of surgery and cost of surgery.

Laparoscopic appendectomy without clip or ligature. An experimental study

BACKGROUND

We aimed to test the efficacy and safety of closure of the appendeceal stump with only laparoscopic bipolar electrocautery in rats.

METHODS

In this study, 40 female Wistar-Albino rats were used. In group I (n = 10), appendix vermiformis, approximately 1 cm in width, was completely ligated with 3/0 silk suture close to cecum, and removed. In group II (n = 20) and group III (n = 10), the appendeceal stump was coagulated by bipolar cautery. The coagulation of 70 mA took 10 s, and was repeated one more time. The stump was divided, and checked to ensure complete occlusion. Groups I and II underwent relaparotomy at 15 days, cecum was taken out, and the burst pressure of the stump was measured. Group III did not undergo relaparotomy; the burst pressure was measured during the first laparotomy.

RESULTS

All rats survived. At relaparotomy, no intra-abdominal complications were detected, including intestinal obstruction, abscess, and leakage. Omentum and fatty tissue of uterus was adhered to the appendix stump in group I, but only fatty tissue of uterus was adhered on the stump in group II. Although the intracecal pressure reached 30 cmH(2)O, at which pressure the cecum was highly stretched, ligated (group I) or coagulated (group II) stumps did not burst or opened. In group III, the burst or opening pressure of the stump (11.2 +/- 2.7 cmH(2)O) was significantly lower than in groups I and II (p < 0.001). Of group II rats, 80% had complete epithelial regeneration at the coagulated stump sites in contrast to ligated rats (p < 0.001) with severe inflammatory changes, abscess, and necrosis.

CONCLUSIONS

At late course, coagulated stumps did not allow the leakage or burst, unlike ligated stumps. However, coagulation of the stump seemed to contribute more to epithelial healing. This experimental model suggests that the closure of the stump with only bipolar coagulation was a safe and feasible method.

Laparoscopic versus open appendectomy for complicated appendicitis

BACKGROUND

Laparoscopic appendectomy has been widely practiced for uncomplicated appendicitis; various reports demonstrated its merits in assisting diagnosis, reducing postoperative pain, analgesic requirement, and incidence of wound infection. The role of laparoscopy in management of complicated appendicitis, ie, gangrenous, perforated appendicitis and appendiceal abscess, remains undefined. Currently, the choice of operative approach is mostly at the surgeons' discretion. A retrospective study was conducted in our institution to review the feasibility, safety, and efficacy of laparoscopic appendectomy for patients with complicated appendicitis.

STUDY DESIGN

From January 1999 to January 2004, records of patients older than 14 years of age with diagnosis of appendicitis were retrieved from computer database for analysis. All patients underwent diagnostic laparoscopy to confirm diagnosis of complicated appendicitis, and patients subsequently underwent either laparoscopic or open appendectomies. Patients' demographics data and perioperative outcomes from the two groups were compared.

RESULTS

During the study period, 1,133 patients with acute appendicitis underwent operations in our institution. Two hundred forty-four patients (21.5%) with complicated appendicitis were identified by laparoscopy, of which 175 underwent laparoscopic appendectomy (LA) and 69 had open appendectomy (OA). Both groups of patients were comparable in demographics. Mean operative time was 55 minutes for LA group and 70 minutes for the OA group (p<0.001). Mean hospital stay was 5 days and 6 days for LA and OA group respectively (p<0.001). There was one conversion patient (0.6%) in the LA group who suffered from wound infection, and there were seven (10%) wound infections in the OA group (p=0.001). There were 10 cases (5.7%) of intraabdominal collection in the LA group and 3 (4.3%) in the OA group (p=0.473). There was no mortality in the current series.

CONCLUSIONS

Laparoscopic appendectomy for complicated appendicitis is feasible and safe. It is associated with a significantly shorter operative time, lower incidence of wound infection, and reduced length of hospital stay when compared with patients who had open appendectomy.

The benefits of virtual reality simulator training for laparoscopic surgery

PURPOSE OF REVIEW

Virtual reality is a computer-generated system that provides a representation of an environment. This review will analyse the literature with regard to any benefit to be derived from training with virtual reality equipment and to describe the current equipment available.

RECENT FINDINGS

Virtual reality systems are not currently realistic of the live operating environment because they lack tactile sensation, and do not represent a complete operation. The literature suggests that virtual reality training is a valuable learning tool for gynaecologists in training, particularly those in the early stages of their careers. Furthermore, it may be of benefit for the ongoing audit of surgical skills and for the early identification of a surgeon's deficiencies before operative incidents occur. It is only a matter of time before realistic virtual reality models of most complete gynaecological operations are available, with improved haptics as a result of improved computer technology.

SUMMARY

It is inevitable that in the modern climate of litigation virtual reality training will become an essential part of clinical training, as evidence for its effectiveness as a training tool exists, and in many countries training by operating on live animals is not possible.

Laparoscopic Appendectomy in a Patient with Acute Myelogenous Leukemia with Neutropenia

The management of acute myelogenous leukemia is often complicated by infections due to neutropenia, but the appendix is not a common site of infection in adult patients with acute myelogenous leukemia. The diagnosis of acute appendicitis may be delayed or even missed because of the lack of characteristic signs and symptoms associated with acute appendicitis in neutropenic patients. Moreover, urgent surgery may lead to high postoperative complications and mortality rates in these patients. The case presented here is of a 33-year-old Hispanic man with acute myelogenous leukemia who developed severe diffuse acute abdominal pain with positive signs of rebound tenderness, fever, and hypotension ten days after receiving reinduction chemotherapy. The patient was at his nadir, with a white blood cell count of 0.2 x 10(9)/L, platelet count of 20 x 10(9)/L, and hemoglobin of 7 g/dL. A computed tomography scan of the abdomen was suspicious for acute appendicitis. The patient underwent a laparoscopic appendectomy that revealed gangrenous appendicitis. No perioperative complications occurred. The patient was discharged on postoperative day 7 and his chemotherapy was continued as scheduled. Laparoscopic appendectomy may be considered a primary approach in neutropenic patients because it can be associated with less postoperative infection, hemorrhagic complications, and a lower mortality rate.

Laparoscopic appendectomy is a favorable alternative for complicated appendicitis in children

Laparoscopic appendectomy in children is a generally accepted procedure for the treatment of non-complicated acute appendicitis. Nevertheless, the role of laparoscopy in complicated appendicitis is more controversial. The objective of this study was to examine the safety, efficacy and complications of laparoscopy in children with complicated appendicitis. This is a retrospective review of the children who underwent laparoscopic appendectomy for complicated appendicitis at King Khalid University Hospital, Riyadh, Saudi Arabia between January 1998 and March 2006. Complicated appendicitis includes perforated appendicitis, gangrenous appendicitis and appendicular masses found intra-operatively. Data collected include demographic, duration of symptoms, operative time, analgesia, complications, length of hospitalization and histopathology. Laparoscopic appendectomy was done by three trocar technique in all cases. During the study period, 59 children aged 3-12 years underwent laparoscopic appendectomy for complicated appendicitis. There were 34 patients with perforated appendicitis, 12 patients with gangrenous appendicitis and 13 patients with appendicular mass. The average operating time was 62 min. The average length of hospitalization was 5 days. The post-operative narcotic analgesic requirement was minimal. Laparoscopy was converted to open surgery in two patients (3.38%). These two cases were excluded from further analysis. Four out of 57 patients (7.01%) had post-operative complications. Three patients (5.26%) developed wound infection. One patient (1.75%) developed haematoma at umbilical port site. There was no post-operative intra-abdominal collection. Laparoscopic appendectomy is a safe alternative for the treatment of complicated appendicitis. It does not increase the incidence of complications even with complicated appendicitis. Contrary to the previous studies, we did not have increased incidence of intra-abdominal collection in this review. However, prospective randomized controlled trials are needed to verify these findings.

Classificação laparoscópica da apendicite aguda: correlação entre graus da doença e as variáveis perioperatórias

OBJETIVO: Apresentar a classificação laparoscópica da apendicite aguda e verificar a relação entre os graus da doença com o tempo de sintomas, tempo operatório, permanência hospitalar, complicações infecciosas e uso de antimicrobianos. MÉTODO: Estudo prospectivo, transversal, envolvendo 105 pacientes com diagnóstico de apendicite aguda e submetidos a apendicectomia laparoscópica entre Janeiro de 2000 e Julho de 2001. A doença foi classificada em grau 0 - Normal; 1 - Hiperemia e edema; 2 - Exsudato fibrinoso; 3 - Necrose segmentar; 4A - Abscesso; 4B - Peritonite regional; 4C - Necrose da base do apêndice; 5 - Peritonite difusa. RESULTADOS: A distribuição dos pacientes segundo a classificação foi: grau 0 (10,4%); 1 (40%); 2 (29,5%); 3 (2,9%); 4A (1,9%); 4B (4,8%); 4C (3,8%) e 5 (6,7%). O tempo médio de início de sintomas acima de 40 h correlacionou-se com possibilidade de necrose e peritonite. O tempo operatório variou de 18 a 126 minutos, média de 31,4 minutos. A permanência hospitalar variou de 12 a 192 h, média de 39,5 h. A maior incidência de complicações Infecciosa ocorreu nos graus 4 e 5. O antimicrobiano foi de uso profilático graus 0, 1 e 2 e terapêutico nos demais. A laparotomia foi necessária duas (1,9%) vezes e não houve óbito. CONCLUSÕES: A classificação laparoscópica da apendicite aguda contemplou todas as formas clínicas da doença, possibilitou correlação com os tempos início de sintomas, operatório e de permanência hospitalar. Permitiu ainda, prever complicações infecciosas e racionalizar o uso de antimicrobianos.

[Appendicitis: yes or no to laparoscopic approach?]

Whether or not there is a benefit to laparoscopy versus open surgery in the management of acute appendicitis remains a subject of controversy despite the publication of numerous randomized studies. Operative time is longer for the laparoscopic approach. The incidence of abdominal wall abscess is decreased for laparoscopy but the incidence of deep intra-abdominal abscess may be increased, especially in the case of complicated appendicitis. Post-operative pain is diminished and resumption of normal activity is quicker with the laparoscopic approach. Hospitalization is shorter but the cost of hospital care is higher; nevertheless, the global cost may be less - particularly for patients whose return to work is hastened by a laparoscopic approach. Laparoscopy diminishes the number of normal appendectomies, particularly in women of reproductive age where the diagnosis may be unclear. Laparoscopic appendectomy is practicable and has advantages over open appendectomy under certain circumstances. These advantages are most evident in the young female, the working patient, and the obese patient. Overall, the advantages of laparoscopy are, at best, modest and clinical benefit is not always demonstrable. The risk of deep abscess, particularly in patients with perforated or gangrenous appendicitis, remains an unknown and should be evaluated by further studies.

Open versus laparoscopic appendicectomy: a critical review

BACKGROUND

The benefit of laparoscopic appendicectomy remains unclear. We have analysed available randomised studies comparing laparoscopic and open appendicectomy regarding their clinical pitfalls and statistical relevance.

METHODS

Thirty eight studies were analysed in terms of the following aspects: A. clinical problems (e.g., expertise of the surgeons, pre- and postoperative antibiotic treatment, definition of complications, blinding of outcomes) and B. statistical problems (e.g., definition of primary and secondary outcomes, power and sample size, statistical methods, confidence intervals, comparability of groups and studies).

RESULTS

Most of the studies have clinical and statistical pitfalls. The most important pitfalls are the uncertain expertise of the operating surgeons, blinding, and the exploratory nature of the studies. Our analysis aims at giving useful information for the appraisal of existing studies and the conduct of further studies. It also gives some preliminary results.

CONCLUSIONS

More than twenty years after Semm performed the first laparoscopic appendicectomy, it is necessary to clarify the superiority of laparoscopic or open appendectomy with well-defined, carefully designed randomised studies.

The value of virtual reality–simulator training in the development of laparoscopic surgical skills

OBJECTIVE

To determine the effectiveness of virtual reality (VR) training in improving the surgical skills of medical students and gynecologic trainees.

DESIGN

A prospective observational study to assess the changes observed in objectively measured surgical performance after VR training.

SETTING AND POPULATION

University teaching hospital and the laboratories of the University of Western Australia.

PARTICIPANTS

Fifteen 5th-year medical students, six junior-doctor trainees (years 1-3), and eight senior trainees (years 4-6).

INTERVENTIONS

Standard gynecologic procedures before and after VR training were undertaken on sheep. The procedures were video-recorded and edited to blind the scorer as to identity and seniority of the operator. The procedures were scored using a combination of operative time and penalties for surgical errors. The surgical scores were correlated with the VR scores.

MEASUREMENTS AND MAIN RESULTS

Operative skills were assessed using a combination score compiled from scores obtained while undertaking salpingectomy, salpingotomy, and tubal clipping. Virtual reality scores were also a combination score derived from summation of various computer-calculated measures of time and accuracy in undertaking two standardized exercises.

RESULTS

The baseline VR scores were significantly related to the overall pre-training scores (salpingectomy p = .032). A better initial VR score was also predictive of better surgical performance. The initial VR score was also predictive of improvement observed between baseline and post-training (p = .004).

CONCLUSION

Virtual reality training is of value in improving surgical skills in the clinical environment. It appears to be of most value in the earliest stages of training. These data suggest that serious consideration should be given to incorporating VR training into the training program of obstetricians and gynecologists at an early stage.

Morbidity of laparoscopic surgery for complicated appendicitis: an international study

BACKGROUND

Although laparoscopic appendectomy has some advantages over open appendectomy, some reports do show more postoperative intraabdominal abscesses.

METHODS

A retrospective review of complicated appendicitis managed surgically by eight surgical groups from six countries was undertaken. Among 3,433 patients with appendicitis, 1,017 (29.5%) had complicated appendicitis, which included perforated or gangrenous appendicitis with or without localized or disseminated peritonitis. There were 74 preoperative abscesses (7.4%) and 5 small bowel obstructions.

RESULTS

One patient died. There were 29 postoperative intraabdominal abscesses (2.8%) and 112 mostly minor complications. Conversion to laparotomy was necessary for 28 patients (2.7%). The surgical time ranged from 32 to 132 min (mean, 62 min), and the hospital stay ranged from 1 to 18 days (mean, 3.5 days).

CONCLUSIONS

The morbidity rates, particularly for intraabdominal abscesses, were less for laparoscopic appendectomy in complicated appendicitis than those reported in the literature for open appendectomy, whereas operating times and hospital stays were similar.

Minimally invasive: minimally reimbursed? An examination of six laparoscopic surgical procedures

It is generally believed that minimally invasive surgery (MIS) results in less postoperative pain, fewer complications, and shorter recovery periods compared with open procedures. Yet despite these benefits, the level of reimbursement assigned to the surgeon by United States health-care payers is often lower than that for open procedures. Furthermore, the cost of performing a MIS may be higher vs an open procedure because specialized equipment, increased surgical time, or both may be required. In this report, we examine the issue by comparing reimbursements for MIS with open procedures, summarizing the medical literature on MIS vs open surgical procedures, and offering recommendations for payers who establish reimbursement policies. The review is focused on six MIS procedures where outcomes data exist: laparoscopic cholecystectomy (lap chole), laparoscopic colectomy (LC), laparoscopic fundoplication (LF), laparoscopic hysterectomy (LH), laparoscopic ventral hernia repair (LVHR), and laparoscopic appendectomy (LA). Outcomes summarized were length of hospital stay (LOS), operating room time, operating room costs, complications, and return to work or normal activities. The level of scientific evidence was assigned to each study using predetermined criteria. A total of 112 articles were reviewed: 14 for lap chole, 26 for LC, 7 for LF, 19 for LH, 9 for LVHR, and 37 for LA. The data demonstrate that these procedures result in reduced hospital stay, reduced hospital costs, and faster return to work or normal activities. Yet, the operating room time and costs are frequently higher for MIS. These findings suggest that as both the outcomes value and level of operating room resources are greater, MIS warrants reimbursement that meets or exceeds that of open procedures.

Laparoscopic versus open appendectomy in West Bengal, India

OBJECTIVE

Laparoscopic appendectomy, although widely practiced, has not gained universal approval. Laparoscopic appendectomy in India is relatively new, and reports regarding its use are few. The aim of this study was to compare laparoscopic with open appendectomy and ascertain its therapeutic benefit, if any, in the overall management of acute appendicitis.

METHODS

The study group consisted of 279 patients suffering from acute appendicitis. One hundred patients underwent laparoscopic appendectomy (LA) and 179 patients underwent open appendectomy (OA). Comparisons were based on median values for length of hospital stay, operating time, postoperative morbidity, duration of convalescence and operative cost. Mann-Whitney statistics (T) were calculated and, because of the large sample size, the normal deviate test (Z) was used.

RESULTS

Of the 100 patients who were to receive LA, six patients (6%) had the procedure converted to open surgery. The rate of overall complications (LA 15%vs OA 31.8%; P < 0.001) was significantly lower in patients undergoing LA. The median length of stay was significantly shorter after LA (3 days after LA vs 5 days after OA; P < 0.0001) than after OA. The operating time was shorter (median values: OA 25 min vs LA 28 min; 0.01 < P < 0.05) in patients undergoing OA compared with LA.

CONCLUSION

For LA, hospital stay was significantly shorter, and the one-time operative cost appeared to be marginally the same as open surgery. Furthermore, LA was associated with increased clinical comfort in terms of fewer wound infections, faster recovery, earlier return to work and improved cosmesis.

Laparoscopic versus open appendectomy: a prospective randomized double-blind study

SUMMARY BACKGROUND DATA

The value of laparoscopy in appendicitis is not established. Studies suffer from multiple limitations. Our aim is to compare the safety and benefits of laparoscopic versus open appendectomy in a prospective randomized double blind study.

METHODS

Two hundred forty-seven patients were analyzed following either laparoscopic or open appendectomy. A standardized wound dressing was applied blinding both patients and independent data collectors. Surgical technique was standardized among 4 surgeons. The main outcome measures were postoperative complications. Secondary outcome measures included evaluation of pain and activity scores at base line preoperatively and on every postoperative day, as well as resumption of diet and length of stay. Activity scores and quality of life were assessed on short-term follow-up.

RESULTS

There was no mortality. The overall complication rate was similar in both groups (18.5% versus 17% in the laparoscopic and open groups respectively), but some early complications in the laparoscopic group required a reoperation. Operating time was significantly longer in the laparoscopic group (80 minutes versus 60 minutes; P = 0.000) while there was no difference in the pain scores and medications, resumption of diet, length of stay, or activity scores. At 2 weeks, there was no difference in the activity or pain scores, but physical health and general scores on the short-form 36 (SF36) quality of life assessment forms were significantly better in the laparoscopic group. Appendectomy for acute or complicated (perforated and gangrenous) appendicitis had similar complication rates, regardless of the technique (P = 0.181).

CONCLUSIONS

Unlike other minimally invasive procedures, laparoscopic appendectomy did not offer a significant advantage over open appendectomy in all studied parameters except quality of life scores at 2 weeks. It also took longer to perform. The choice of the procedure should be based on surgeon or patient preference.

Comparison of needlescopic appendectomy versus conventional laparoscopic appendectomy: a randomized controlled trial

Laparoscopic appendectomy has been shown to improve postoperative recovery when compared with open appendectomy. The present randomized trial was conducted to evaluate any further difference in outcome between needlescopic appendectomy (NA) and conventional laparoscopic appendectomy (CLA) in the management of acute appendicitis. Patients with the clinical diagnosis of acute appendicitis were randomized to either NA (instrument size < or = 3 mm) or CLA (instrument size > or = 5 mm). Standardized anesthetic technique and perioperative management were adopted. The primary end point was length of postoperative hospital stay. Other parameters such as conversion rate, postoperative pain score and analgesic requirement, return of bowel function, resumption of normal activities, complication rate, and length of the final scars were also assessed and compared. A total of 363 patients (NA: 174, CLA: 189) were recruited. Both approaches could accurately arrive at the diagnosis (NA: 98.3%; CLA: 100%). Compared with CLA, NA resulted in a significantly longer operation time (P = 0.015) and a higher conversion rate (P < 0.001). The final scars of the NA group were significantly shorter when compared with the CLA group (P < 0.001). Otherwise, there was no statistical difference between the 2 groups in terms of complication rate, postoperative pain score, length of postoperative stay, and other recovery parameters. NA resulted in a longer operation time and higher conversion rate. Except for a smaller scar, the present study was unable to demonstrate any other short-term benefits. Thus, the technique cannot be routinely recommended.

Cost perspectives of laparoscopic and open appendectomy

BACKGROUND

Despite multiple studies comparing laparoscopic and open appendectomies, the clinically and economically superior procedure still is in question. A cost analysis was performed using both institutional and societal perspectives.

METHODS

A decision analytic model was developed to evaluate laparoscopic and open appendectomies. The institutional perspective addressed direct health care costs, whereas the societal perspective addressed direct and indirect health care costs. Baseline values and ranges were taken from randomized controlled trials, meta-analyses, and Medicare databases.

RESULTS

From the institutional perspective, open appendectomy is the least expensive strategy, with an expected cost of $5,171, as compared with $6,118 for laparoscopic appendectomy. The laparoscopic approach is less expensive if open appendectomy wound infection rates exceed 23%. From the societal perspective, laparoscopic appendectomy is the least expensive strategy, with an expected cost of $10,400, as compared with $12,055 for open appendectomy.

CONCLUSIONS

The decision analysis demonstrated an economic advantage to the hospital of open appendectomy. In contrast, laparoscopic appendectomy represents a better economic choice for the patient.

Insurance status and race represent independent predictors of undergoing laparoscopic surgery for appendicitis: secondary data analysis of 145,546 patients

BACKGROUND

Studies have shown that racial and socioeconomic differences lead to inequality in access to health care. It is unknown whether insurance status and race affect the choice of surgical treatment for patients presenting with appendicitis.

STUDY DESIGN

Patients with primary ICD-9 procedure codes for laparoscopic and open appendectomy were selected from the 1998, 1999, and 2000 Nationwide (US) Inpatient Samples. The primary predictor variables were insurance status (private, Medicare, Medicaid, other) and race (Caucasian, African American, Hispanic, other). Multiple logistic regression models were used to assess whether insurance status and race are associated with the choice of surgical procedure for patients presenting with appendicitis.

RESULTS

Discharge abstracts of 145,546 patients were used for our analyses. There were 32,407 patients (22.3%) who underwent laparoscopic appendectomy and 113,139 patients (77.7%) who had open appendectomy. Although 24.2% of privately insured patients underwent laparoscopic appendectomy, only 16.9% of Medicare patients, 17.4% of Medicaid patients, and 19.6% of patients in the "other" insurance category were treated using the laparoscopic procedure (p < 0.001). Caucasian patients underwent laparoscopic surgery in 24.8%, African Americans in 18.6%, Hispanics in 19.6%, and other ethnicities in 18.8% of patients (p < 0.001). Compared with the Medicaid subset, and after adjusting for potential confounders such as age, gender, race, patient comorbidity, median ZIP code income, hospital location and teaching status, and presence of abscess or perforation, privately insured patients (odds ratio [OR] = 1.26, 95% [CI [1.20, 1.33], p < 0.001) and Medicare patients (OR = 1.17, 95% CI [1.05, 1.30], p = 0.004) were significantly more likely to undergo laparoscopic surgery. Caucasian patients (OR = 1.42, 95% CI [1.33, 1.51], p < 0.001) and Hispanics (OR = 1.12, 95% CI [1.04, 1.20], p = 0.002) were significantly more likely to have laparoscopic appendectomy, compared with African Americans, even after adjusting for the previously mentioned confounders and insurance status.

CONCLUSIONS

Even after adjusting for potential confounders, insurance status and race are marked independent predictors of having laparoscopic surgery in patients treated for appendicitis in this sample.

Laparoscopic versus open surgery for suspected appendicitis

BACKGROUND

Laparoscopic surgery for acute appendicitis has been proposed to have advantages over conventional surgery.

OBJECTIVES

To compare the diagnostic and therapeutic effects of laparoscopic and conventional 'open' surgery.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, SciSearch, the congress proceedings of endoscopic surgical societies.

SELECTION CRITERIA

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.

DATA COLLECTION AND ANALYSIS

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.

MAIN RESULTS

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).

REVIEWERS' 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. Especially young female, obese, and employed patients seem to benefit from LA.

No Clip, No Ligature Laparoscopic Appendectomy

Laparoscopic appendectomy (LA) is one of the common procedures being carried out in general surgery. The technique of bipolar coagulation (BC) has been effectively employed in obstetric and gynecologic procedures but has not been used for intestines. We present the technique of LA using BC at our center. The technique consisted of identifying the appendix and coagulating the appendicular stump with bipolar coagulation until there were no bubbles at the cautery site, and a constriction ring formed at the site of coagulation. Sixty patients with acute or recurrent appendicitis underwent the procedure. The median duration of BC was 90 seconds. The median duration of surgery was 25 minutes, postoperative hospital stay was 3 days, and time to oral feeds was 12 hours. The technique of laparoscopic appendectomy by bipolar coagulation is very simple and economical. The duration of surgery is less than for the standard technique of laparoscopic appendectomy; no clip applicators, needle holders or knot pushers are required, and no foreign materials like ligatures or clips are needed.

Laparoscopic appendectomy in the elderly

BACKGROUND

Evidence suggests that laparoscopic appendectomy (LA) has advantages over open appendectomy (OA) in the treatment of appendicitis. It remains, however, unclear whether LA is indicated in the elderly patient population.

METHODS

Patients with primary International Classification of Diseases, revision 9, procedure codes for LA (n=32406 patients) and OA (n=112884 patients) were selected from the 1998, 1999, and 2000 Nationwide Inpatient Samples. The end points that were under investigation were the length of hospital stay, the rate of routine discharge, and in-hospital morbidity and mortality rates. Multiple linear and logistic regression analyses were performed to assess the risk-adjusted association between the surgery type and the patient outcomes. Stratified analyses were performed according to age (65 years and older; less than 65 years old) and to the presence of appendiceal perforation or abscess.

RESULTS

After risk adjustment, patients who underwent LA had a significantly shorter mean length of stay (LA, 2.45 days; OA, 3.71 days; P <. 0001), higher rate of routine discharge (odds ratio, 2.80; P <.0001), lower overall complication rate (odds ratio, 0.92; P=.03), and mortality rate (odds ratio, 0.23; P=.001) compared with OA patients. Similar benefits of LA were found in the strata of patients who were less than 65 years old, in elderly patients, and in patients with appendiceal perforation or abscess.

CONCLUSION

LA has statistically significant advantages over OA with respect to the length of hospital stay, the rate of routine discharge, and postoperative morbidity and mortality rates for patients who are less than 65 years old, in elderly patients, and in patients with appendiceal abscess or perforation.

Outcome after intra- and extra-corporeal laparoscopic appendectomy techniques

BACKGROUND

This study aimed to assess the outcome after intracorporeal (IC) and extracorporeal (EC) laparoscopic appendectomy technique in a single institution over a 5-year period.

METHODS

Records of all children ( n = 60) who underwent laparoscopic appendectomy at the Royal Aberdeen Children's Hospital between February 1997 and March 2002 were retrieved and evaluated. Observations were made regarding operative technique, anesthetic time, intra- and postoperative complications, postoperative analgesic requirement, and postoperative hospital stay.

RESULTS

There were 30 children in each group who had a similar demographic profile. The magnitude of appendicitis severity in both groups was similar. The mean anesthetic time was 67.8 min for the IC group and 50.7 min for the EC group (p = 0.001). There were no recorded intraoperative complications, although a single case in the EC group required conversion to open procedure. The postoperative analgesic requirement in both groups was similar. The mean postoperative stay was 2.1 days in the IC group and 2.5 days in the EC group. Two postoperative complications were noted in the IC group; one intraperitoneal collection and one postoperative chest infection. Four complications occurred in the EC group; one intraperitoneal collection and three minor port-site wound infections.

CONCLUSIONS

The authors' experience shows the EC technique to be significantly quicker, although with a slightly increased complication rate. Either technique can be applied safely for acute appendicitis.

Laparoscopic versus open appendectomy: outcomes comparison based on a large administrative database

OBJECTIVE

To compare length of hospital stay, in-hospital complications, in-hospital mortality, and rate of routine discharge between laparoscopic and open appendectomy based on a representative, nationwide database.

SUMMARY BACKGROUND DATA

Numerous single-institutional randomized clinical trials have assessed the efficacy of laparoscopic and open appendectomy. The results, however, are conflicting, and a consensus concerning the relative advantages of each procedure has not yet been reached.

METHODS

Patients with primary ICD-9 procedure codes for laparoscopic and open appendectomy were selected from the 1997 Nationwide Inpatient Sample, a database that approximates 20% of all US community hospital discharges. Multiple linear and logistic regression analyses were used to assess the risk-adjusted endpoints.

RESULTS

Discharge abstracts of 43757 patients were used for our analyses. 7618 patients (17.4%) underwent laparoscopic and 36139 patients (82.6%) open appendectomy. Patients had an average age of 30.7 years and were predominantly white (58.1%) and male (58.6%). After adjusting for other covariates, laparoscopic appendectomy was associated with shorter median hospital stay (laparoscopic appendectomy: 2.06 days, open appendectomy: 2.88 days, P < 0.0001), lower rate of infections (odds ratio [OR] = 0.5 [0.38, 0.66], P < 0.0001), decreased gastrointestinal complications (OR = 0.8 [0.68, 0.96], P = 0.02), lower overall complications (OR = 0.84 [0.75, 0.94], P = 0.002), and higher rate of routine discharge (OR = 3.22 [2.47, 4.46], P < 0.0001).

CONCLUSIONS

Laparoscopic appendectomy has significant advantages over open appendectomy with respect to length of hospital stay, rate of routine discharge, and postoperative in-hospital morbidity.

CT predictors of failed laparoscopic appendectomy

PURPOSE

To identify computed tomographic (CT) signs that may help predict possible failure of laparoscopic appendectomy and subsequent conversion to open appendectomy.

MATERIALS AND METHODS

Of 234 consecutive patients who underwent preoperative CT and in whom laparoscopic appendectomy was attempted, 26 required conversion to open appendectomy. Conversion was correlated with the following CT findings: appendix location, appendicolith, cecal wall thickening involving the base of the appendix, lymphadenopathy, and appendiceal diameter. The extent of inflammation was graded by using a six-point scale: 0 meant normal appendix; 1, possibly abnormal appendix (6-mm diameter without other abnormality); 2, abnormal appendix (diameter > or = 6 mm with wall enhancement) without adjacent fat stranding; 3, abnormal appendix surrounded by fat stranding; 4, abnormal appendix surrounded by fat stranding and fluid; and 5, inflammatory mass or abscess. Student t and chi2 tests were used for statistical analysis of interval and nominal values, respectively.

RESULTS

Although there was a significant difference in appendiceal diameter between the patients in whom laparoscopic appendectomy was successfully completed (11.3 mm +/- 3.5 [SD]) and those who required conversion (12.9 mm +/- 3.9), no distinct cutoff point was identified. Of the five CT findings evaluated, none was a significant predictor of conversion to open appendectomy. Eleven (7%) of 164 patients with a CT inflammation grade of 0-3 required conversion, whereas 15 (21%) of 70 patients with a grade of 4 or 5 required conversion (P <.04).

CONCLUSION

The majority of patients with appendicitis can be treated with laparoscopic appendectomy. Nevertheless, patients who require conversion to open appendectomy tend to have high CT inflammation grades of 4 or 5, which indicate the presence of periappendiceal fluid or an inflammatory mass or abscess.

Factors determining the return to normal activity after appendicectomy

BACKGROUND

The ability of a patient to return to their normal activities is an important outcome of an operation. The present study was designed to identify and rank factors that are important in determining this return to normal activity (RTNA) after appendicectomy.

METHODS

Consecutive patients were identified prospectively following appendicectomy at North Shore Hospital between February and April 2000. Data regarding 25 different factors were obtained by a structured patient interview before and after discharge from hospital and by review of the medical records. Statistical analysis involved analysis of variance and logistic regression analysis.

RESULTS

There were 98 patients (median age 28, range 15-69 years, male : female ratio 48:50) who had an appendicectomy. An open appendicectomy was performed in 74 patients, a laparoscopic appendicectomy in 22 patients and a laparotomy in two patients. This includes the 16 patients who were converted from laparoscopic to open appendicectomy (conversion rate 42% 16/38). Acute appendicitis was confirmed by histology in 67 (68%) patients. The significant independent variables identified by anova were ranked by logistic regression analysis. The most important determinant for the time to RTNA was what the doctor advised (chi-squared 43.7, P < 0.0001). The other determinants were the physical activity of their primary occupation (chi-squared 21.5, P < 0.017), the need for strong postdischarge analgesia (chi-squared 21.1, P < 0.13), the American Society of Anesthesiologists (ASA) category (chi-squared 13.6, P < 0.018) and the total sick leave obtained (chi-squared 9.6, P < 0.08).

CONCLUSION

It has been shown that the most significant factor in determining the RTNA after appendicectomy was the advice given by the doctor, and that this was more important than the surgical approach, pathology, complications, age or occupation of the patient.