Laparoscopic versus Open Appendectomy: Time to Decide

Abstract

Although widely practiced, laparoscopic appendectomy (LA) has not met with universal approval. Several controlled trials have been conducted, some in favor, others not. The goal of this review was to ascertain (1) if laparoscopy was capable of improving the diagnostic and therapeutic difficulties encountered during open appendectomy (OA) and (2) if the introduction of laparoscopy in the overall management of acute appendicitis has changed anything in practice. Analysis and criticism of 17 controlled studies (nearly 1800 patients) on laparoscopic appendectomy and 2 randomized studies dealing with diagnostic laparoscopy are reported. Because of the questionable quality of randomized controlled trials (number of patients, exclusions, withdrawals, blinding, intention-to-treat analysis), publication biases, local practice variations (hospital stay, rate of enrollment), results regarding analgesia requirements, return to activity and work, duration of hospital stay, outcome, follow-up, and antibiotic prophylaxis the studies must be interpreted with caution. The real world of appendicitis probably differs greatly from the atmosphere under which controlled trials comparing LA and OA have been performed. Statistical significance is contrary to the clinical significance of the results. Consistently longer operating times [the difference ranging from 8 minutes (NS) to 29 minutes (p < 0.0001)], a minimal reduction in hospital stay [0. 1 day (NS) to 2.1 days (p < 0.007)], and, somewhat more controversial, an earlier return to normal activity were reported for LA. Data on analgesic requirements were confusing, but wound complications were more frequent after OA [pooled odds ratio for 10 studies: 2.6 (95% CI 1.3-5.2)]. Unsolved problems include national behavioral problems, age and experience of operating surgeons (LA or OA), and emergency conditions (availability of staff, instruments). Results of cost analysis vary according to the standpoint of disease, the patient, the surgeon, the treatment center, industry, and society. Three questions remain: Because of the competition of LA versus OA, OA has improved greatly. Can it be improved any more? Is there a place or need for further randomized controlled trials? Should we not conclude once and for all that LA is out?

The comparison of open and laparoscopic appendectomy in uncomplicated appendicitis. A prospective randomized clinical trial.

“…[1] In 1983, however, Semm introduced laparoscopic appendectomy (LA), which has since become increasingly popular. [2] SAGES strongly recommends LA only for female patients of child-bearing age because the advantages of minimal invasive surgery, such as shorter length of hospital stay, better cosmetic appearance, faster recovery and return to normal activities, and less postoperative pain, are considered to be relative for appendectomy, in patients with uncomplicated appendicitis in particular.…”

“…[2] SAGES strongly recommends LA only for female patients of child-bearing age because the advantages of minimal invasive surgery, such as shorter length of hospital stay, better cosmetic appearance, faster recovery and return to normal activities, and less postoperative pain, are considered to be relative for appendectomy, in patients with uncomplicated appendicitis in particular. [1,[3][4][5][6] LA is not favored because of longer operative times, greater hospital costs, and most importantly, increased incidence of postoperative abscess formation. [7] However, operative times have dramatically decreased with increasing experience.…”

Comparison of open versus laparoscopic appendectomy

“…However, at operation fewer than 70% of the patients with right lower quadrant pain actually have some form of appendiceal disease warranting removal, 15% have no obvious pathology and another 15% have another pathology that does not always require surgical treatment. 2 For more than a century open appendectomy has been the gold standard for acute appendicitis. [2] It is considered safe and effective procedure for acute appendicitis with low morbidity, short hospitalisation and minimal postoperative discomfort.…”

“…2 For more than a century open appendectomy has been the gold standard for acute appendicitis. [2] It is considered safe and effective procedure for acute appendicitis with low morbidity, short hospitalisation and minimal postoperative discomfort. Variability in the inflammatory Introduction of minimal invasive surgical technique in the form of laparoscopic surgery revolutionised the way surgeries are being performed today.…”

“…As it offers not only through visualization of the abdominal cavity which helps in finding even ectopic appendix and facilitating other differential diagnosis but also reduces post-op pain, early mobility and better cosmesis. 2 Laparoscopic appendectomy was first described by Semm in 1983 in Germany.…”