Laparoscopic Versus Open Appendectomy: Prospective Randomized Trial:

Role of serum levels of tumour necrosis factor-like weak inducer of apoptosis (TWEAK) in predicting severity of acute appendicitis

Objectives

One of the most prevalent abdominal crises is acute appendicitis (AA). Clinical diagnosis, even for skilled surgeons, is frequently challenging, as indicated by the high proportion of negative investigations. The purpose of this study was to see if serum TWEAK levels might be used to diagnose acute appendicitis.

Material and Methods

Between June 2017 and May 2019, all patients who had surgery with the original diagnosis of AA were included in the study. TWEAK, WBC, CRP, and bilirubin levels were compared.

Results

The levels of WBC, CRP, and bilirubin were compared to pathology. All three blood indicators increased significantly in AA patients. However, no statistically significant difference in the levels of all three blood indicators was seen between individuals with simple AA and those with severe AA. TWEAK plasma concentrations were considerably greater in patients with severe AA than in the healthy control and NAA groups. TWEAK levels were significantly greater in individuals with severe AA compared to patients with simple AA.

Conclusion

Serum TWEAK levels that are elevated may be used to diagnose acute appendicitis as well as prognostic indicators for the severity of appendicitis.

Conversion rate and risk factors of conversion to open in laparoscopic appendicectomy

PURPOSE

Laparoscopic appendicectomy (LA) has several advantages over conventional open appendicectomy (OA). However, about 5% to 10% of LA patients still need to be converted to open surgery. Identifying risk factors that contribute to conversion to OA allows for early identification of patients who may benefit from primary OA. This study aimed to determine the conversion rate of LA to OA and to identify its associated risk factors among patients with acute or perforated appendicitis.

METHODS

A retrospective review of medical records was performed among patients with acute or perforated appendicitis who underwent LA between December 2015 and January 2017. With the use of multivariable logistic regression analyses, the predictors of conversion from laparoscopic to OA were investigated.

RESULTS

Out of 120 patients, 33 cases were converted to OA which gives a conversion rate of 27.5%. Among 33 patients who were converted to OA, 27 patients (81.8%) had perforated appendix, while in the LA group, perforated appendix cases consisted of 34.5% (P<0.001). Histopathology of the appendix was the predictor of conversion from LA to OA (adjusted odds ratio, 8.82; 95% confidence interval, 3.13-24.91; P<0.001).

CONCLUSION

The result from our study shows that the overall conversion rate for the study period was high. Patients with perforated appendicitis had a higher risk of conversion to OA. Therefore, preoperative diagnosis of perforated appendicitis may be paramount in predicting conversion to OA.

Single-Port Needlescopic Appendectomy in Children Using a Mediflex Needle: A New Simplified Technique

Background: Laparoscopic appendectomy is among the most common surgical procedures. Needlescopic appendectomy (NA) is an acceptable, safe technique in children, but with many drawbacks such as a high conversion rate and long operative time. We present a new technique for NA in children using only a single port, Mediflex^® facial closure needle, and vascular access cannula (VAC). Patients and Methods: Single-port NA was attempted in 117 patients (51 boys, 66 girls). Under general anesthesia, a 5-mm camera port was inserted through the umbilicus. Two Mediflex needles and a 14-gauge VAC were introduced. The appendix was grasped and dissected from the surrounding tissues using Mediflex needles. In case of a mobile cecum, the appendix was pulled through the umbilical port, then an extracorporeal appendectomy was performed. In cases with a fixed cecum or severely inflamed appendix, a complete intracorporeal appendectomy was done. The suture was knotted in a sliding reef knot using a single instrument. Results: NA was completed in 117 patients (51 boys, 66 girls) with an average age of 10 years. Thirty patients underwent extracorporeal appendectomy. Eighty seven patients were treated by intracorporeal appendectomy. The mean operative time was 15 ± 3 and 25 ± 4 minutes for extracorporeal and intracorporeal appendectomy respectively. The hospital stay was 1.2 days on average (ranging 8 hours to 2 days). There was no single case of conversion. Family satisfaction was achieved in 97% of cases. Conclusion: The presented unique method for single-port NA using Mediflex^® appears to be a safe, acceptable technique for appendectomy in children that allows for excellent cosmetic results.

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.

Identification of preoperative risk factors associated with the conversion of laparoscopic to open appendectomies

Our goals were to (1) identify risk factors associated with conversion from laparoscopic to open appendectomies and (2) establish criteria that predict the possibility of conversion to an open technique. We did a retrospective chart review of all patients who underwent laparoscopic appendectomies during a 5-year period (2004-2008). Preoperative risk factors, intraoperative findings, and postoperative complications were compared. We found that of 763 patients who had undergone laparoscopic appendectomy, 44 patients were converted to open technique (conversion rate of 5.8%). For these 44 patients, the male to female ratio was 2 to 1, and the men were older (45 versus 37 years of age, P < 0.001). Conversion rates decreased with time (8.7% in 2004 versus 3.5% in 2008). Past surgical history was insignificant. However, a duration of symptoms of >5 days as well as a white blood cell count >20,000 were found to have a direct correlation. Incidence of postoperative complications did not increase in converted patients. The conversion rate is highest in male patients above 45 years of age, with over 5 days' duration of symptoms, leukocytosis >20,000, and ruptured appendicitis on computed tomography scan. The presence of 3 to 4 of these risk factors should lower the threshold for consideration of conversion to open appendectomy.

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.

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.

Prevention of postoperative peritoneal adhesions: a review of the literature

BACKGROUND

postoperative adhesions are a significant health problem with major implications on quality of life and health care expenses. The purpose of this review was to investigate the efficacy of preventative techniques and adhesion barriers and identify those patients who are most likely to benefit from these strategies.

METHODS

the National Library of Medicine, Medline, Embase, and Cochrane databases were used to identify articles related to postoperative adhesions.

RESULTS

ileal pouch-anal anastomosis, open colectomy, and open gynecologic procedures are associated with the highest risk of adhesive small-bowel obstruction (class I evidence). Based on expert opinion (class III evidence) intraoperative preventative principles, such as meticulous hemostasis, avoiding excessive tissue dissection and ischemia, and reducing remaining surgical material have been published. Laparoscopic techniques, with the exception of appendicitis, result in fewer adhesions than open techniques (class I evidence). Available bioabsorbable barriers, such as hyaluronic acid/carboxymethylcellulose and icodextrin 4% solution, have been shown to reduce adhesions (class I evidence).

CONCLUSIONS

postoperative adhesions are a significant health problem with major implications on quality of life and health care. General intraoperative preventative techniques, laparoscopic techniques, and the use of bioabsorbable mechanical barriers in the appropriate cases reduce the incidence and severity of peritoneal adhesions.

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.

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.

Choice of approach for appendicectomy: a meta-analysis of open versus laparoscopic appendicectomy

Although laparoscopic appendicectomy has been performed since 1983, the optimal approach for appendicectomy is still under debate. A systematic review and meta-analysis of all randomized controlled trials between 1995 and 2006 was undertaken. Studies were analyzed overall and in 2 subgroups (pre-2000 and post-2000) to examine for changes in outcomes with increased laparoscopic experience. Operation time was significantly longer for laparoscopy and hospital stay was shorter. Operating time reduced markedly for laparoscopy on subgroup analysis. The risks of postoperative ileus and wound infection are lower for laparoscopy. Perhaps paradoxically, the risk of intra-abdominal abscess development is significantly raised with laparoscopy with an odds ratio of 2.26 (P=0.0002). Laparoscopic appendicectomy is a safe and effective method of treating acute appendicitis. This meta-analysis shows improvement in the outcomes of laparoscopy with increasing laparoscopic experience but open surgery appears to still confer benefits, especially in terms of intra-abdominal abscess incidence.

Explaining insurance-related and racial disparities in the surgical management of patients with acute appendicitis

BACKGROUND

Race and insurance status influence the likelihood of undergoing laparoscopic appendectomy (LA) versus open appendectomy for the treatment of acute appendicitis. We hypothesized that these disparities are caused by presenting hospitals' use of LA.

METHODS

The analysis included 26,104 appendectomies for acute appendicitis in New York State during 2003 and 2004. Multiple logistic regression was used to determine independent predictors for undergoing LA versus open appendectomy.

RESULTS

Before adjustment for individual hospital use of LA, both white patients (odds ratio [OR] = 1.28, 95% confidence interval [CI] 1.21-1.36; P < .0001] and privately insured patients (OR = 1.52, 95% CI 1.44-1.61; P < .0001) were more likely to undergo LA. Controlling for differential hospitals' use of LA decreased the OR for laparoscopic surgery to 1.08 (95% CI 1.01-1.15; P = .04) for white patients and to 1.22 (95% CI 1.15-1.31; P < .0001) for privately insured patients.

CONCLUSIONS

Differences in presenting hospitals' use of LA maintain racial and, to a lesser extent, insurance-related disparities in the surgical management of patients with acute appendicitis.

Laparoscope-assisted appendectomy in adults: the two-trocar technique

BACKGROUND

Open appendectomy is still the most common method of treating appendicitis. Laparoscopic procedures for removal of the appendix by the "in" technique as an alternative to conventional appendectomy have gained wide popularity, but have been criticized for their technical difficulty and high cost. We assessed the safety and efficacy of the laparoscope-assisted appendectomy (the two-trocar technique) in adults.

PATIENTS AND METHODS

We retrospectively studied 129 patients who had appendectomy using the laparoscope-assisted two-trocar technique between July 2002 to December 2003. The procedures were done by consultants and surgeons-in-training with experience in minimally invasive and open techniques. Locally modified endoloop and reusable trocars were used to reduce the cost. Appendectomy was performed extra-abdominally after the appendix was identified by using a laparoscope through one port and then delivered outside through the second port using reusable laparoscopy instruments.

RESULTS

The two-trocar technique was successful in 101 (78.3%) cases; 14 (10.8%) needed a third trocar to complete the operation extra-abdominally, 6 (4.6%) were converted to open surgery, and 5 (3.8%) had an intra-abdominal laparoscopic appendectomy. The mean operation time was 35 minutes (range, 30-90 minutes). Six cases (4.6%) had infection. The mean hospital stay was 2.8 days (range, 2-7 days). No case of port hernia was reported during the follow-up period (range, 14-30 months).

CONCLUSION

The laparoscope-assisted two-trocar technique for removal of the appendix can be performed as safely and efficiently as the open technique, but at a lower cost than the complete laparoscopic "in" method and does not need much technical expertise. This method is recommended as an alternative procedure to open appendectomy or the complete laparoscopic "in" technique in adults.

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.

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.

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.

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.

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.