Offene Appendektomie

Abstract

Acute appendicitis is the most common emergency visceral surgical procedure in Germany with 130,000 appendectomies. The question of which operational procedure should be used must therefore be discussed at regular intervals. In many centers of minimal invasive surgery, laparoscopic appendectomy (LA) is the standard procedure. Nearly 30 years after introduction of LA, it is believed that open appendectomy (OA) is needed only on rare occasions, but the actual percentage of OAs carried out in 2006 was 46% of all appendectomies. This high percentage documents that OA is still the standard procedure in many German hospitals. A review of the literature shows that there are still some situations in which OA is superior to LA. Infants younger than 5 years old have a more difficult basic requirement for LA due to the small abdominal cavity, therefore OA is the procedure of choice in most cases. During pregnancy OA has a lower risk for the fetus than LA. Cost analyses show that OA is less expensive for the hospital in material costs, whereas LA is the better economic choice due to an earlier return to work. In summary, there are only marginal differences between the two procedures since both offer a fast patient recovery. Advantages in favor of both LA and OA exist in subgroup analyses and the possible subgroups that can benefit from OA are discussed in this article.

The Evolution of the Appendectomy: From Open to Laparoscopic to Single Incision

“…While LA encompasses the majority of appendectomies, the high amount of OAs still performed is quite surprising. A German study in 2009 reported nearly half of all appendectomies were open (46%) and questioned whether LA is really the standard of practice in German hospitals [8]. The surprisingly high usage of OA seen today can likely be equated to the fact that the conventional open approach has yet to be shown to be inferior to LA, as it provides reliable clinical results in a more affordable way compared to LA [9].…”

“…The rate of conversion from LA to OA is 8.6%, but this number is slowly decreasing as surgeons gain more experience with LA [7]. In pediatric patients under the age of 5, where the abdomen is too small for the basic physical requirement of LA, and in pregnancy, due to the risk to the fetus from LA, laparotomy is also still preferred over laparoscopy [8]. …”

Review of Operative vs. Non-Operative Management of Appendicitis in Pregnancy

“…However, there was no difference in length of hospitalization, wound infection rate or APGAR scores between the two surgical techniques [93]. One study also calculated open appendectomy to be less expensive [94]. The latest Cochrane systematic review in 2014 determined that although there was no high grade evidence to support either laparoscopic or open appendectomy as the safer approach for treatment; however, there was low grade evidence that showed a higher rate of fetal loss [95].…”

“…Arguments for laparoscopic appendectomy include improved accuracy of diagnosis and preventing complications related to delayed diagnosis [14,71] in a population with many confounding diagnoses and incorrect preop diagnosis in as many as a quarter of the patients [16,102] as well as ability to identify other intra-abdominal pathology which may mimic appendicitis and harbor fetal loss [96]. Also, other studies show benefits of laparoscopic technique in other fields can be applied to these patients, including shorter hospital stay than for open [71,94,103] and shorter time to first flatus, earlier time to oral intake than for open appendectomy [101], less operating time, less use of post-operative analgesics [104] and lower rate of wound infection [93]. By 2004, some authors had termed it the "new standard of care" [105].…”

Kindliche Appendizitis

“…Appendicitis · Pediatrics · Open appendicectomy · Laparoscopic appendicectomy · Specialized visceral surgical clinic [1,7,9,13,17,19,24,25]. Grund für die Konversionen waren neben ausgepräg ten gangränösen Befunden und Mitbefall angrenzender Darmstrukturen auch eine maligne Erkrankung, die mittels Laparo tomie onkologisch operativ versorgt wer den musste.…”