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Chirurgia (2014) 109: 518-522

No. 4, July - August
Copyright© Celsius

Laparoscopic versus Open Appendectomy: Where Are We Now?
G. Cipe1, O. Idiz2, M. Hasbahceci1, S. Bozkurt1, H. Kadioglu1, H. Coskun1, O. Karatepe1, M. Muslumanoglu1
1
Bezmialem Vakif University, Faculty of Medicine, Department of General Surgery, Istanbul, Turkey
2
Ministry of Health Yunak State Hospital, Department of General Surgery, Yunak-Konya, Turkey

Rezumat Concluzii: Cele douã tehnici operatorii sunt similare în ceea ce
priveæte perioada de internare, durata operaåiei æi complicaåiile
Apendicectomia prin abord laparoscopic versus abord
postoperatorii. Apendicectomia laparoscopicã reduce nevoia
deschis: pentru ce optãm?
de analgezice æi scorurile VAS; aceasta ar trebui prin urmare
Scop: Deæi avantajele procedurilor laparoscopice au fost intens luatã în considerare ca standard de aur în tratamentul chirur-
studiate pe parcursul ultimelor douã decenii, apendicectomia gical al apendicitei acute.
laparoscopicã nu a putut fi desemnatã ca procedurã standard
de tratament din cauza unor dezavantaje de tipul timpilor Cuvinte cheie: apendicitã, apendicectomie, procedurã
operatori æi al costurilor crescute. Obiectivul studiului nostru laparoscopicã, abces abdominal, infecåia plãgii chirurgicale
este de a reevalua rezultatele pe termen lung ale abordului
laparoscopic versus cel chirurgical deschis pentru aceastã
patologie pe baza datelor actuale.
Metode: Datele pacienåilor supuæi apendicectomiei între
ianuarie 2012 æi iulie 2012 au fost analizate prospectiv. Abstract
Datele demografice ale pacienåilor, durata procedurii, Purpose: Although the advantages of laparoscopic procedures
perioada de internare, nevoia de analgezice, scorul VAS æi has been well studied over the last two decade, laparoscopic
rata mortalitãåii au fost înregistrate. appendectomy could not to be a standard therapy due to some
Rezultate: Din 241 de pacienåi, 120 (49.8%) au suferit inter- disadvantages such as longer operative time and higher cost.
venåie deschisã æi 121 (50.2%) au fost operaåi laparoscopic. The objective of our study is to re-evaluate the outcomes of
Perioada intervenåiei a fost similarã între cele douã grupuri laparoscopic versus open appendectomy with current data.
(p=0.855). Scorurile VAS dupã prima orã (p=0.001), dupã Methods: Between January 2012 and July 2012, the data of the
6 (p=0.001) æi dupã 12 ore de la operaåie (p=0.028) au fost patients who had appendectomy were recorded prospectively.
mai mari în grupul de apendicectomii prin abord deschis Patients’ demographics, duration of procedure, length of
(p=0.001). Nu au existat diferenåe statistice vizând ratele de hospital stay, need of analgesics, postoperative visual analogue
morbiditate între grupul prin abord deschis æi cel prin abord scale scores and morbidity were assessed.
laparoscopic (p=0.617). Results: Of 241 patients, 120 (49.8%) underwent open and
121(50.2%) laparoscopic appendectomy. The operating time
was similar for both groups (p=0.855). The visual analog scale
scores of 1st (p=0.001), 6th (p=0.001) and 12th (p=0.028) hours
Corresponding author: Mustafa Hasbahceci MD were higher in open the appendectomy group. The total need
Bezmialem Vakif University of analgesics significantly was higher in open group (p=0.001).
Faculty of Medicine There was no statistical difference in terms of total morbidity
Department of General Surgery, Istanbul
Vatan Str, 34093, Fatih, Istanbul, Turkey rate between open and laparoscopic appendectomy groups
E-mail: hasbahceci@yahoo.com (p=0.617).

Therefore. operative time. The mesoappendix was ligated. therefore. VAS score evaluations were University Faculty of Medicine Department of General Surgery performed by telephone contact for the patients who were were recorded prospectively. (diclofenac sodium. laparoscopic The consultant surgeons who were qualified to perform appendectomy (LA) has gradually gained acceptance (2). no consensus exists as to in the standard fashion. Eczacibasi. concern with increased incidence of intra-abdominal area. study. 1000 mg IV. The specimen was extracted with an and short hospital stay (2. Mustafa Nevzat. Pregnant patients and patients who have had it should be considered as the gold standard for surgical history of lower abdominal surgery were excluded from the treatment of acute appendicitis. faster recovery laparoscopic scissors.05. abscesses. Any additional potential benefits resulting from devices transected the mesoappendix. Turkey) in the operating theatre before extubation. and whether laparoscopy should be performed in selected patients. Patients were discharged research and ethics committee at the Bezmialem Vakif when they tolerated a regular diet and were afebrile. improved wound healing. Istanbul. data of the patients who upon patients’ request. the rectovesical area. 12th and 24th hours. abdominal abscess. For that reason. mg IV. surgical wound infection a computer-generated number. laboratory and imaging tech- (OA) has been accepted as the standard treatment of choice for niques including ultrasonography and/or computed tomography. Patients with conversion to open approach were also excluded from the study. additional analgesics (diclofenac sodium. if necessary. Acute appendicitis (AA) accounts for the commonest length of hospital stay. and employed patients or stump was not buried in the cecum. IM. Turkey) were conducted Between January 2012 and July 2012. of LA (1. the study. Turkey) was customized according we undertook a prospective randomized study to compare the to the clinical situation of each patient. Introduction histopathological diagnoses. 500 experience in an advanced laparoscopy center.8). faster recovery and earlier return to full activity. Informed written consent was gained from all of them. We hypothesized that LA is a safe and effective approach All specimens underwent histopathological examination. However. The study was approved by the discharged before the first 24 hours. AA with low mortality and morbidity rates. bidity and mortality were recorded. The such as young female. Short standardized LA and OA or the residents under their supervi- hospital stay. was ligated and divided between 2 endo-loops (EndoLoop because it is believed that OA has most of the advantages of Vicryl Coated Ligature. A drain was placed into routinely for all patients with suspected AA (4. UK) with minimally invasive surgery such as small incision. some researchers also extraction bag through the suprapubic trocar. 3-6). Turkey). A drain was placed into the rectovesical times.30. During postopera- Methods tive follow up period. length of hospital stay. 12th and 24th hour visual analog scale (VAS) score. LA including longer operative time and increased incidence of In patients with complicated AA. Energy appendectomy.BAV. 6th. short and long-term outcomes of patients who were operated All patients had one dose of parenteral analgesics on for AA either by open or laparoscopic approaches. 75 mg. Although open appendectomy on history. and was performed by a three-trocar technique. Ethicon UK Ltd. Abdi Ibrahim. if necessary. need of analgesics.5.7). IM. and the patients who did not offer their consent were excluded from the study. Diagnosis of AA was decided by the attending surgeon based cedure performed worldwide (1). and appendectomy is the most common emergent operative pro. and antibiotic regimen of first generation cephalosporine (cefazolin it may be possible to overcome the potential disadvantages of sodium -Sefazol. either complicated or uncomplicated. in Bezmialem Vakif operative 1st. sion performed all operations under general anesthesia. Edinburgh.0.2. obese patients. Istanbul. mor- indication for emergency visits during daily surgical practice. the appendix was divided at the base and removed. Additionally. Istanbul. Istanbul. duration of the procedure. 519 Conclusion: Two operative techniques are similar in terms of University Faculty of Medicine (Number: B. Abdi Ibrahim. Key words: appendicitis. Laparoscopic appendectomy reduces the The patients who completed follow-up were included in need for analgesics and visual analog scale scores. laparoscopic surgical The patients were randomized into LA and OA groups via procedure. and suspicious applicability in cases of complicated OA was performed through a 3-4 cm McBurney incision appendicitis (1. appendectomy. 75 mg. A 10 mm port was lower wound infection rates have been offered to be the benefits placed at the umbilicus for the 30 degree angled laparoscope. complications. with superior outcomes compared with OA in the management All patients received a standard prophylactic intravenous of all AA in adults. a continuing controversy still remains a 5 mm port was placed in the left lower abdominal quadrate in the literature regarding the most appropriate method of and a 10 mm port was placed in the suprapubic area. . VAS scores were calculated at the post- had appendectomy either as OA or LA.7). LA decreased postoperative pain. postoperative 1st. feature of the surgeon as consultant or resident. 6th. and postoperative 05/251). antibiotic treatment with intra-abdominal abscesses with the advent of laparoscopic first generation cephalosporine and metronidazole (Flagyl. and the appendix base the laparoscopic approach would be really difficult to prove. physical examination.4. The appendicular tend to disapprove LA because of significantly longer operative stump was not buried.7. The data including patients’ demographics. return to normal daily activities.

but the Student’s t-test was used for analysis of normally difference was not statistically significant.074β μ : student’s t test.118β Consultant 38 (31. USA). Operative data OA (n=120) LA (n=121) p value Operative time (min)¥ 51.3%.2%) Appendix Normal 17 (14.5%) 92 (76%) 0.011β Phlegmonous 87 (72.7±12.7 0. Results Only one patient needed surgical drainage because of the unsuccessful percutaneous intervention in LA group (Table 4).4±9. further surgical intervention.16-63) Sex (F/M) 49/71 56/65 0. p=0.1±20.6 months for OA vs. gangrenous and perforated appendicitis complications after that. was shorter in the LA group than the OA group. The histopathological diag- week. β: chi-square test. Sutures were removed at the features.1%) 13 (10. Length of hospital stay using SPSS 16.011). 121 patients remained in the LA group readmission for intestinal obstruction and incisional hernia for after the exclusion. VAS scores of LA group were confidence level of 0.8%) Resident 82 (68.255μ (median.6 52. β: chi-square test. 246 patients were There was no significant difference in the mean follow-up randomized to either OA (n = 120) or LA (n = 126). OA 8.80 with a (chi-square test. range) (30. μ ASA: American Society of Anesthesiology Table 2. The LA group expressed as frequencies and percentages of an appropriate needed fewer parenteral analgesics in the overall postoperative denominator. Patients’ OA (n=120) LA (N=121) p value demographics Age (years)¥ 29.1±14. Therefore. There was no mortality in approach and were excluded from the study due to protocol the early postoperative or the follow-up period. p=0. time was similar in the two groups. ¥: mean±SD. Differences (Table 3).855μ Surgeon 0.4±2.451). were distributed uniformly between the groups.0%) 8 (6.5 months patients (4%) initially to have LA were converted to open for LA (chi-square test. All of the statistical analyses were performed period compared with the OA group. descriptive continuous variables.4%) 74 (61.and third.05 with a 95% confidence interval. No statistically significant differences were both groups. 14. end of the first week. however the difference did not reach as mean ± standard deviation (SD).. Table 1. p = 0.4% vs. Chicago.6%) 0.0%) 8 (6. chi-square test.5 0. p=0.520 Patients were followed-up regularly in an outpatient clinic noted between the two groups in terms of demographic at weekly intervals for 3 weeks.8%) 0.394β BMI¥ 24. BMI: body mass index (kg/m2).0 software (SPSS Inc. The percentage of OA performed by treatment groups. Illinois. Patients were informed to report for development of any noses of phlegmonous. All of the wound infections could be managed were considered statistically significant if the p value was equal conservatively by opening the wound and did not require any to or less than 0. ¥: mean±SD .155β Perforated 6 (5. as shown in Table 1. as shown in Table 3.617) test were used to compare qualitative variables. Between January 2012 and July 2012. Categorical variables were statistical significance in 24 hour (Table 3). which were The overall postoperative complication rate was similar for expressed as mean ± SD.19-65) (27.3 0.8 26. distributed.997μ ASA score 1/2/3 105/12/3 107/17/2 0. significantly less than that of OA group during the early post- Normally distributed continuous variables were expressed operative period. except normal Power calculations were performed for testing the appendix which was significantly low in the LA group (chi- hypotheses related to the comparisons between the square test.6%) 0.9 23.118). Percutaneous drainage was successfully performed in nine of ten patients for pelvic abscess. There was no violations. Chi-square test and Mann-Whitney both groups (LA 7.95 to compare two treatment groups.6%) 47 (38.455β : student’s t test.7±2. The mean operative development of any complications in the second. The sample sizes of at least 120 for each residents was higher than LA without statistical significance group provided power of approximately 0. Five period of the two groups: 13. and patients were observed for Operative data are shown in Table 2.081β Gangrenous 11 (9.

5%) 4 32 (26. Although laparoscopy has unique advantages in several areas Length of hospital stay is a very important factor that of daily surgical practice as a minimally invasive technique.5 2.6.4. β: chi-square test.9.8%) 45 (37.7. Generally. degree of . which was supported by a large scale meta-analysis by degree of experience and better visualization during conducted by the Cochrane Colorectal Cancer Group laparoscopy (11). which might be explained LA. the amount of the comparison of these two approaches. But these findings have not been uniformly days. proposed by several authors for appendectomy either by open increased diagnostic accuracy in certain groups including or laparos-copic approaches and different hospital discharge older and female patients. less postoperative pain.001μ 6th hour 4.3 2.9). In several cosmetic appearance are accepted as the main advantages of studies. the various kinds of analgesics. A 48-hour discharge policy which was issues favoring OA (3).4.9). shorter operative Early recovery to full activity is another advantage of time during LA was also reported. We may think wall during trocar placement causes less pain and a faster that this practice may cause similar outcomes with regard to recovery (14).7%) 16 (13.001μ 12th hour 3.85±22.028μ 24th hour 3. 1 Various pain scores and number of analgesics after LA have ¥ : One patient required further surgery due to inability of percutaneous been shown to be low in comparison to open approach in drainage many previous studies (3. it is decrease in the mean length of hospital stay for the LA accepted that laparoscopic procedures may take longer times group was almost 3 hours. Early mobilization following LA was another operative time both in OA and LA groups.3%) 26 (21. In the present study.7±1. Although one day earlier no longer than its open counterpart. Outcomes of OA OA (n=120) LA (n=121) p value versus LA VAS score¥ 1st hour 7.4%) 0. most probably influenced by social standards. recovery was seen in the LA group. directly influences the well-being of the patient (4). routes of administration and Table 4.072α Return to normal activities (days) 6 (3-16) 5 (2-13) 0. early recovery and improved criteria may also cause this controversy (3. insurance gained in the previously performed studies because of the systems and hospital discharge policies (3. the length of hospital stay was calculated as hours to Longer operative time during LA is another issue in highlight the difference.3%) 9 (7. In this heterogeneity of their protocols (3).4±1. Nevertheless.325μ Mortality 0 0 - Overall morbidity 10 (8.3 4.13). significant difference between groups.9).8±0. In superiority of LA to open approach has been discussed for previous studies.1 0.9. Furthermore. it was shown that length of hospital stay is many years (1.1%) 2 43 (35.56±24. However.63 0.2±1. inexperienced surgeons (1-4.0±1.2%) 34 (28. study. there was no statistically after gaining experience in laparoscopic techniques. the time periods for discharge were mentioned as LA (2.2%) 3 28 (23.2%) Hospital stay (hours)¥ 29. 521 Table 3.10).9±1. operative times for LA. we appealing advantage. as in the present study.98 26. Therefore. Atelectasis . α: Mann-Whitney test. resulting from minimal manipulation believe that it is possible to perform LA with operative times of the cecum and the ileum (3). ¥: mean±SD Discussion than that of OA should be accepted as a criterion favoring feasibility and efficacy of this operation.9). most probably without clinical especially during early learning periods. Nevertheless.617β μ : student’s t test. It is believed that minimal trauma to the abdominal advanced laparoscopic procedures in our center. The surgical staff has performed basic and (9.001α 1 17 (14.9 7. Similar results with regard to surgical shorter with LA which was also confirmed by several meta- and cosmetic outcomes and low cost are the important analyses (3.2 0.4 0.12). we aimed to use both Pelvic abscess 4 6¥ assessment methods to clarify this issue more efficiently.3±0. For that reason.6±1.057μ Number of analgesics 0. which are no longer Postoperative pain can be assessed quantitatively by the daily requirements for analgesics and qualitatively by means of VAS scores on the first postoperative day (3). However.7 0.9). Postoperative complications perception of pain by the patients under the influence of their OA (n=120) LA (n=121) cultural beliefs make it more difficult to estimate degree and Wound infection 6 2 relief of the pain. when performed by significance.

18(4):242-7. Poultsidi A. Surg Endosc. Halil Coskun states that he has no financial 15.81(5):321-5. Fahrner R. Sauerland S. Hu BG.4. Cohen ME.9. Swank HA. 2011. 2012. Yang GP. these findings also favor LA for the treatment of AA. Comparison of clinical outcomes and hospital cost between Gokhan Cipe states that he has no financial interest or open appendectomy and laparoscopic appendectomy. Ketana N. Bindra SS. Sakpal SV. Esposito TJ. Chu Z. of the infected appendix. J Korean Surg Soc. J Surg Res. Li MK. Schöb O. et al. Therefore. Park JH. World J Surg. 2011. Muqim R. . Baloyiannis I. Laparoscopic appen- incidence of such complication. et al. interest to report.(10):CD001546. Eshuis EJ. there were several reports 4.9). Shaikh GA.7. The reduc- 8. McGrath B. Zhang J. Pritts TA. 10.205(1):60-5. Carmichael JC. Frola C. 2012. Siu WT. Surgery. A interest or conflict of interest to report. Suleyman Bozkurt states that he has no 14.10:129. Stefanini P.13). In this respect. Lee HJ. 2010. especially for complicated AA cases (1-3. It is believed that increased mastery of the Nguyen NT. time. Khan M. Short. Saudi J Gastroenterol. all 1. Huseyin versus open appendectomy: a comparison of primary outcome Kadioglu states that he has no financial interest or conflict of measures. In the literature. Laparoscopic appendectomies: experience of a surgical scores together with similar length of hospital stay. J Am Coll Surg.148(4):625-35. Qi CL. et al. Kim JI. Laparoscopic versus open appendectomy for acute appendicitis: Conclusion a metaanalysis. J Korean Soc Coloproctol. Huang JL. 9. Clinical outcomes of showing higher incidence of intra-abdominal abscess formation laparoscopic versus open appendectomy. of interest to report.15. easily via laparoscopy. Ko CY. et al. Chung IY. Gurrado A. cavity (3. Comparison of outcomes of laparoscopic learning curve and the use of standardized and experienced versus open appendectomy in adults: data from the Nationwide Inpatient Sample (NIS). Bell T. Li X. Surg Today. intra-abdominal abscess 2010 Aug 24. 2006-2008. Cochrane Database Syst of the controlled removal of the inflamed appendix via trocar or Rev. it should be 11. Khalil J. et al. Masoomi H. Epub 2011 Jul 2. 2009. Mustafa WA. operative unit. Epub of appendectomy are wound infection. protective bag and smaller port-site wounds (3. Epub 2011 Jul 23. 27(6):293-7. Chen TF. 2010.24(12): lower incidence of wound infections after laparoscopy as in 2987-92. incidence of intra-abdominal abscess after LA (3). the mechanical diffusion of bacteria inside the peritoneal 7.25(4):1199-208. conflict of interest to report.and long-term results of open versus laparoscopic Hasbahceci states that he has no financial interest or conflict appendectomy. Rafique M. 2009. and postoperative ileus (9). Surg Endosc. Grim R. versus open appendectomy for complicated appendicitis. et al. Wei B.42(12):1165-9. There were also studies favoring LA with regard to lower 5. discussion 635-7. Spyridakis overall incidence of postoperative complications was lower in M. Minim Invasive Ther Allied Technol. 574-80. Chamberlain RS.13(4): following LA. Piccinni LA reduces the number of postoperative analgesics and VAS G. Heo TG. Epub 2010 Jun 15. 2011. as a serious and potentially life-threatening complication is a 2010. Shaikh AR. 2010. Mills S. 2007. BMC Gastroenterol. Laparoscopic appendectomy as a interest or conflict of interest to report. increased use of irrigation fluid. controversial issue (9). Neugebauer EA. surgical techniques can cause a significant reduction in the 15(12):2226-31. Park SH. causing more abscess formations such as aggressive manipulation 6.17(4):236-40. Buckius MT. Tzovaras G. 2011. et al.35(6):1221-6. J Gastrointest Surg. 2011. Laparoscopic financial interest or conflict of interest to report. Sang L. Choi PW. Bottero L. Sangrasi AK.a meta- Intra-abdominal abscess formation following appendectomy analysis of randomized controlled trials. Ahn EJ. Park JM. Park YH.9). and both differences were statistically significant. Bemelman financial interest or conflict of interest to report. this study. Yau KK. Ingraham AM. Zhang W. Symeonidis D. Conflict of interest statement 12.16). Kim SY. and postoperative complications. Comparison of outcomes after laparoscopic versus Postoperative complications usually are considered as an open appendectomy for acute appendicitis at 222 ACS NSQIP assessment of a procedure’s safety. Economics of appendicitis: cost trend analysis of laparoscopic possibly producing greater contamination of the peritoneal versus open appendectomy from 1998 to 2008. Laparoscopic considered as the gold standard for surgical treatment of AA. Ahuja V. Oguz Idiz states that he has no 13. Zheng ZH. Li X. Dolich MO. report. Generally it was shown that the 2. Oguzhan Karatape teaching procedure: experiences with 1197 patients in a states that he has no financial interest or conflict of interest to community hospital. Tang CN. clinical comparison of laparoscopic versus open appendectomy for complicated appendicitis.4.176(1):42-9. Bilimoria KY. Laparoscopic versus tion of wound infection is a significant advantage of LA because open surgery for suspected appendicitis.171(2):e161-8. The common complications hospitals. cavity and carbon dioxide pneumoperitoneum contributing to 2011. Mahmut Muslumanoglu states that he has no financial 16. This difference usually comes from a men: a prospective randomized trial. there may be some confounding factors J Surg Res. Faillace G. JSLS. Lim SG. Kouritas V. Epub 2011 Aug 5. Laparoscopic versus conventional appendectomy . Jaschinski T.522 the postoperative pain measured by VAS scores and total References requirement for analgesics were lower in LA group. van Berge Henegouwen MI. Although controlled lavage for dectomy conversion rates two decades later: an analysis of sur- removal of the inflammatory fluid collections can be performed geon and patient-specific factors resulting in open conversion. Laparoscopic versus open appendectomy in LA patients (3. 2011. 3.