Laparoscopic 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.

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 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.

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.