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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 2  |  Page : 554-559

Laparoscopic versus open appendectomy in complicated acute appendicitis


1 General Surgery Department, Faculty of Medicine, Menoufia University, Shebein El-Kom, Egypt
2 General Surgery Department, Shebein El-Kom Teaching Hospital, Shebein El-Kom, Egypt

Date of Submission11-Feb-2018
Date of Acceptance24-Mar-2018
Date of Web Publication25-Jun-2019

Correspondence Address:
Aiman HM Alsegaey
Ebshaway Elmalaq, Qotor, Gharbia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_78_18

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  Abstract 


Objective
To compare between laparoscopic appendectomy (LA) and open appendectomy (OA) in complicated acute appendicitis to determine which procedure is better.
Background
OA is the standard operation for patients with complicated acute appendicitis. Recently, LA was introduced. LA could become a great method to treat complicated acute appendicitis.
Patients and methods
A prospective equivalence randomized study was conducted in 40 patients who were divided into two groups. One of the group was operated using ordinary open technique, and the other group was operated using laparoscopic technique. They were admitted to the emergency room in the Menoufia University and Shebein El Kom Teaching Hospitals during the period from September 2014 to November 2015.
Results
OA and LA was performed in 40 patients (20 patients for each procedure). The laparoscopic technique was better in operative time (P = 0.014), less intraoperative complication, less postoperative complications (7.5% of all patients had complications postoperatively all in open group), less length of hospital stay (P = 0.025), and less oral intake time (P = 0.365).
Conclusion
LA is a safe and feasible option in the management of complicated acute appendicitis.

Keywords: complicated acute appendicitis, laparoscopic appendectomy, open appendectomy


How to cite this article:
Soltan HM, El-Tatawy AG, Alsegaey AH. Laparoscopic versus open appendectomy in complicated acute appendicitis. Menoufia Med J 2019;32:554-9

How to cite this URL:
Soltan HM, El-Tatawy AG, Alsegaey AH. Laparoscopic versus open appendectomy in complicated acute appendicitis. Menoufia Med J [serial online] 2019 [cited 2019 Sep 20];32:554-9. Available from: http://www.mmj.eg.net/text.asp?2019/32/2/554/260921




  Introduction Top


The documented benefits of the laparoscopic appendectomy (LA) procedure have led to its increasing acceptance for the treatment of appendicitis, it is nonetheless considered more expensive to perform than a traditional open appendectomy (OA)[1]. There are persistent doubts about the advantages and disadvantages in using LA for complicated appendicitis[2].

Although adopted by many centers as a gold standard, benefits of LA over OA are still in debate by many surgeons. This may be attributed to the simplicity of OA – which is relatively easy to perform – low morbidity and cosmetic problems are low. Many studies failed to demonstrate the benefits of LA compared to OA, but this might be explained by the fact that these studies were performed in the learning period[3],[4].

Recently many studies show that LA provides considerable benefits over OA, including a shorter hospital stay, less postoperative pain, earlier postoperative recovery, and lower complication rate[5].

The introduction of laparoscopy provides an opportunity to visualize the entire abdominal cavity in cases of diagnostic dilemmas[6].

The aim of this study was to compare between LA and OA in complicated acute appendicitis to determine which procedure is better.

Patients and methods

After the ethical committee's approval and informed consent, a prospective equivalence randomized study was conducted on 40 patients with suspected complicated acute appendicitis, and the equivalence study was randomly submitted to OA or LA. The suspicion of acute appendicitis to be complicated was achieved by the following criteria: history of present illness more than 3 days, fever more than 39°C, total leukocytic account more than 11 000, and signs of complications in investigations in sonar or computed tomography scan.

The patients were admitted to the emergency room in Menoufia University, and Shebein El Kom Teaching Hospitals during the period from September 2014 to November 2015.

The patients were equivalently randomized in two groups.

Group A: including 20 patients for whom LA was done.

Group B: including 20 for whom OA was done.

In OA, the mesoappendix was divided between clamps and tied using 2–0 absorbable suture, and for the appendix itself, two hemostatic clamps were placed at its base. The clamp closest to the caecum was removed, having crushed the appendix at that site. Two heavy, absorbable sutures were used to doubly ligate the appendix, and the appendix was subsequently divided proximal to the second clamp.

In LA, the mesoappendix was secured either by harmonic or multiple large clips. The absorbable 2/0 tie was used to ligate the appendix at its base at two sites, either by endoloops or intracorporeal suture, and then divided.

We conducted a prospective study comparing differences between patients who underwent LA and OA, as regard to: operating room time, intraoperative events and complication, drain insertion, postoperative complications, time of oral intake, and length of hospital stay.

Statistical analysis

Data were fed to the computer and analyzed using IBM SPSS software package version 20.0 (IBM Corp., Armonk, New York, USA). Qualitative data were described using number and percentage. The Kolmogorov–Smirnov test was used to verify the normality of distribution. Quantitative data were described using range (minimum and maximum), mean, SD, and median. Significance of the obtained results was judged at the 5% level.

The used tests were: χ2-test, Fisher's exact or Monte Carlo correction, and Student's t-test.


  Results Top


Forty patients with suspected complicated acute appendicitis underwent OA (20 patients) and LA (20 patients). In open group (n = 20) 11 (55%) patients were male and nine (45%) patients were female, whereas in laparoscopic group (n = 20) eight (40%) patients were male and 12 (60%) patients were female. The average age was 35.85 ± 11.147, ranging between 15 and 50 years in the open group, whereas the average age was 34.05 ± 11.66, ranging between 17 and 53 years in the laparoscopic group [Table 1]. The operating duration in OA and LA were 47–90 min (mean 60.1) and 45–70 min (mean 51.7), respectively. Less time was used in LA with a P value 0.014 [Table 2]. We put drain in 65% (13 cases) of OA group (n = 20), whereas 80% (16 cases) in laparoscopic group [Table 2]. We had three (15%) cases that had intraoperative complications in the open group, in contrast to one (5%) case in the laparoscopic group [Table 2]. For postoperative complications, we found that 15 (75%) cases had complications in the open group (n = 20), in contrast to five (25%) cases in the laparoscopic group (n = 20) [Table 3]. The time of oral intake – in days – for the open group was 1.0–3.0 days with a mean of 1.80 ± 0.83, whereas for the laparoscopic group, it was 1.0–2.0 days with a mean of 1.60 ± 0.50 [Table 3]. The time of hospital stay – in days – for the open group was 1.0–4.0 days with a mean of 2.70 ± 1.13, whereas for the laparoscopic group, it was 1.0–3.0 days with a mean of 1.95 ± 0.89 [Table 3].
Table 1: Comparison between the studied groups according to demographic data

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Table 2: Comparison between the studied groups according to operating room time in minutes, drain insertion and intraoperative complications

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Table 3: Comparison between the studied groups according to postoperative complications, time of oral intake and length of hospital stay

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  Discussion Top


Approximately 6% of the populations develop appendicitis in their life time, with peak incidence between the ages of 10 and 30 years, thus making appendectomy the most frequently performed abdominal operation[7].

The treatment of acute appendicitis remained essentially unchanged since its first description by Charles McBurney in 1889. Appendectomy by McBurney's incision remained the procedure of choice for nearly a century until 1983 when Kurt Semm offered an alternative, 'laparoscopic appendectomy', but as McBurney's operation is well-tolerated with less comorbidity, the benefits of LA have been difficult to establish[8].

The technique of LA was started by gynecologists and was adopted later by the general surgeons[9].

Although adopted by many centers as a gold standard, LA's benefits over OA are still in debate by many surgeons. This may be attributed to the simplicity of OA – which is relatively easy to perform – low morbidity and cosmetic problems are low. Many studies failed to demonstrate the benefits of LA compared to OA, but this might be explained by the fact that these studies were performed in the learning period[3],[4].

Recently many studies show that LA provides considerable benefits over OA, including a shorter hospital stay, less postoperative pain, earlier postoperative recovery, and lower complication rate[5].

There have been numerous retrospective and uncontrolled series of LA, as well as many prospective randomized studies published to date. Although most of these have concluded that the laparoscopic technique is as good as OA, there has been considerable controversy as to whether LA is superior[10].

One of the most important benefits of laparoscopy in appendicitis is the possibility of detecting other pathologies during formal exploration, but this was not demonstrated in this study as no other pathologies were detected in any patient.

Esposito in his study found 33 concomitant pathologies out of 1506 (2.2%) cases and dealt with them accordingly in his LA group, compared to nine out of 826 (0.9%) cases in his OA group; highlighting the benefit of the wide visual scope of laparoscopy in cases of acute appendicitis[11].

In this study and during formal abdominal exploration, we recorded the mean operative time taken for OA and the mean operative time taken for LA, the mean operative time was about 9 min longer in the OA group (mean = 60.10 min), as compared to the LA group (mean = 51.70 min). This is comparable to other study reporting about 15 min shorter mean operative time for the LA group. A study comparing LA with OA was conducted in 1133 patients by Yau et al.[12].

Yagmurlu et al.[13] carried a comparative study between LA and OA for perforated appendix, no statistical significance was proved concerning the operative time. The mean time for LA was 61 min and OA was 57 min, but this is considered to be extremely long, when compared to other studies.

The operating time of LA also depends on the experience of the surgeon and the competence of their team[14].

In considering the operating time, the exact identification of the timing at the start of the procedure and its conclusion vary. In general, the time should be calculated from the insertion of first trocar to the end of skin suturing. Cox et al.[15] defined the operating time as the time from incision to wound closure.

Tate[16] calculated the time at the use of anesthesia to the administration of the reversal agent.

Generally all laparoscopic procedures are more time consuming for the following reasons: inherent nature of slow maneuver of laparoscopic techniques, time taken by careful slow insufflation, and routine diagnostic laparoscopy before starting any laparoscopic procedure[17].

During the intraoperative period, we reported three cases of intraoperative complications (two cases with serosal tear to the cecum and one case with iatrogenic injury to the ilium) in the OA group, and a case of serosal tear to cecum in the LA group. Laparoscopic technique proved to be safe and rapid.

During the postoperative period, we enlisted the major complications typically extending the hospital stay or necessitating readmission. These included wound infections, bowel obstruction, and readmission. Minor complications defined as the appearance of mild abdominal pain, tenderness, signs of peritoneal irritation in the right lower abdominal quadrant, and moderately elevated WBC count after the patient was discharged were not analyzed.

The reduction of wound infection is a significant advantage of LA. The chance of wound infection is greater in OA partly because the inflamed appendix is removed from the abdominal cavity directly through the wound, whereas in LA it is extracted through a trocar. In addition, the port-site wounds in LA are smaller, compared to the longer wounds of OA.

The wound infection rate in the present study is lower in LA, as five (25%) cases (one case with seroma and four cases as mild wound infection), compared to OA, where 15 (75%) cases (five cases with seroma, four cases where mild wound infection, five cases with severe wound infection, and one case with burst abdomen and readmission which dealt with).

Other studies showed infection rates (0–4%) for the LA group and (9–11%) for the OA group, which is statistically significant[18],[19].

Mishra et al.[17], reported higher wound infection rates after LA, but most of the literature supports the view that wound infection is less common after a laparoscopic procedure. It should be cautioned that the definition of wound infection varies between studies.

In the laparoscopic group of the present study, the appendices were removed completely and covered in a 10 mm port, a procedure that has been adopted by De[20], with a port site infection rate of 20%. On the other hand, Klingler used endobag for retrieval of the appendix to avoid its contact with the anterior abdominal wall; his port site infection rate was 6%.

In the present study, no cases (0%) in the laparoscopic group were unable to tolerate oral feeding, in comparison with two (10%) cases in the open group that developed ileus. Other studies conducted on 100 patients, reporting two (4%) cases in LA versus 12 (24%) cases in OA, complained about prolonged paralytic ileus for more than 48 h[7].

There were several explanations for the reduction of ileus following LA. Firstly, decreased handling of the bowel during the procedure leads to less postoperative adhesion, and such adhesion may be responsible for ileus. Secondly, patients after LA had less opiate analgesics, which inhibited bowel movements in the postoperative period. Lastly, earlier mobilization after LA may also contribute to the reduction of adhesion[5].

It has been shown that those patients who underwent successful LA have a better postoperative recovery. The reduced trauma to the abdominal wall is a very significant factor in postsurgical discomfort. The better mobility of the abdominal musculature and the earlier ambulation reduces the risk of early postoperative complications of pneumonia and embolism. A prospective randomized multicenter study was performed to compare the outcome of LA and OA in patients with suspected acute appendicitis by Vernon et al.[21] Patients having LA recovered more quickly than their open counterpart, but interestingly, there was no significant difference in sick leave than after laparoscopic operation.

The hospital stay is the time lapse between surgery and discharge. Decreasing the postoperative inpatient period of surgical procedures is one of the main advantages laparoscopy has provided to surgery in general.

Through the comparison of the mean hospital stay time between LA and OA in the present study, we found that the stay time declined significantly with LA. The mean postoperative hospital stay in the LA group was 1.95 ± 0.89 days, whereas in the OA group, it was 2.70 ± 1.13 days.

Vernon in his comparative study between LA and OA in pediatrics did not agree with our finding, as he found that there was no significant difference between both groups regarding the hospital stay[21].

Oka et al.[6], mentioned that the length of hospital stay in the OA group was 5.2 days and for the LA group, it was 4.3 days, and this was statistically insignificant.

Esposito et al.[11], mentioned in a study of 2332 cases, that the records for the median hospital stay for LA was 3 days in case of simple appendicitis and 5.2 days in case of peritonitis (range: 1–12). For OA, the median hospital stay was 4.3 days in case of simple appendicitis and 8.3 days in case of peritonitis (range: 2–22).

Statistical analysis showed a significant difference in the length of hospital stay between the two groups in favor of LA[11].

In our study only one case (OA) group had Burst abdomen and readmitted.

Yang et al.[22] reported no readmissions in his study, comprising of 15 patients with acute appendicitis that have undergone LA using Ligasure, neither did Aydogan et al.[23], when comparing Ligasure with endoclips. Ponsky and Rothenberg[24] also did not report any readmissions, they solely depended on medical diathermy (MD) in the devascularization step.

In the present study, no cases were converted from LA to OA. Yang and colleagues converted two out of 15 cases into OA, one due to bleeding and the other due to inability to dissect the extensively inflamed retrocecal appendix.


  Conclusion Top


From the previous study we conclude that: LA is a safe and feasible option in the management of complicated acute appendicitis. LA has the advantage of producing less intraoperative and early postoperative complications, earlier postoperative recovery, and shorter hospital stay.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Yagmurlu A, Vernon A, Barnhart DC, Georgeson KE, Harmon CM. Laparoscopic appendectomy for perforated appendicitis: a comparison with open appendectomy. Surg Endosc 2006; 20:1051–1054.  Back to cited text no. 13
    
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Cox M, McCall JL, Tooli J, Padbury RTA, Wilson TG, Wattchow DA, et al. Prospective randomized comparison of open versus laparoscopic appendectomy in men. World J Surg 1996; 20:263–266.  Back to cited text no. 15
    
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