Acute appendicitis is the most common intra-abdominal condition requiring emergency surgery[26
]. Although more than 20 years have elapsed since the introduction of laparoscopic appendectomy, there is no consensus on its advantages and disadvantages compared to the conventional technique.
Recent studies have shown significant advantages of laparoscopic appendectomy with respect to the length of hospital stay, postoperative pain and infectious complications[5,8,12,14,18
]. These findings have been challenged by other authors who observed no significant difference in the outcome between the two procedures, and moreover noted higher costs with laparoscopic appendec-tomy[3,17,19,25,27
Bearing in mind that laparoscopic appendectomy, unlike other laparoscopic procedures, has not been found superior to open surgery for acute appendicitis, we designed the present study to determine any possible benefits of the laparoscopic approach.
Operation time remains a topic of much debate among experts. Preliminary studies[28-30
] have shown significantly longer operative times for laparoscopic appendectomy. The inexperience of the surgeons with the new technique may contribute to the longer duration of the operation in the early studies. However, recent studies[16-18
] have supported the initial findings. Because in these studies, most of the operations were performed by residents, the longer operation times can be attributed to the learning curve. By contrast, in the present study, the operation times were nearly similar in the two techniques, and the learning curve effect was minimal as the surgeons performing the procedures were highly experienced with a wide spectrum of laparoscopic procedures, including laparoscopic bariatric surgery and laparoscopic colectomy. This experience is reflected in our study by the relatively narrow range of operative times in the laparoscopic group (44.3 ± 24).
Previous studies have given conflicting results with respect to the length of hospital stay after laparoscopic appendectomy. Guller et al[12
] in a population- based analysis using a national administrative data base showed that laparoscopic appendectomy is associated with significantly shorter hospital stay. These findings were supported by the Cochrane Collaboration large scale meta-analysis[24
]. In agreement with these studies, we found that hospital stay was significantly shorter in patients subjected to laparoscopic appendectomy (P
= 0.004). In the present study, bowel movements were observed significantly earlier in patients managed laparoscopically, leading to earlier feeding and discharge from hospital.
In the present study, pain was assessed both subjectively via
a visual analogue scale and objectively by the tabulation of analgesic use. Although some studies have reported less pain in the first 48 h after laparoscopic appendectomy[20,21,24,25,31
], in our series there was no difference between the two groups with respect to either the visual analogue scores or the use of analgesics. Our study suffered from the drawback that it was not blinded. As a result, the perception of pain may have been influenced by the patient’s enthusiasm for a novel technique.
There was no mortality in our study. This is consistent with the majority of previous publications. It has been reported that the mortality rate is 0.05% and 0.3% in laparoscopic and open appendectomy respectively[12
]. The low mortality rates indicate that appendectomy, especially in the absence of complicated disease, is a safe procedure regardless of the technique used.
In the present study, the overall complication rates were 10.6% and 8.1% for open and laparoscopic appendectomy respectively. These results are in agreement with previous reports, which vary from 5.7% to 25.8% for open appendectomy and 3% to 19% for laparoscopic appendectomy[13-15,20-23
Complicated appendicitis was initially considered as a contraindication to laparoscopic appendectomy[32,33
]. However, recent studies have shown that laparoscopic approach in complicated disease is feasible and may even be superior to the conventional approach[6,7,10
In our series, 28.5% patients in the open group and 29.7% in the laparoscopic group had complicated disease. These patients are considered to be at increased risk of postoperative infections such as wound infection and intra-abdominal abscess formation[34,35
]. According to the Cochrane systemic review of the literature[24
], wound infection is about one-half after laparoscopic appendectomy, while intra-abdominal abscess formation is 3 times higher after laparoscopic appendectomy.
In the present study, the rate of wound infection in patients with complicated disease was significantly lower after laparoscopic appendectomy (5.3% vs 12.8%, P = 0.03). Placement of the detached appendix into an endobag before its removal from the abdominal cavity reduces contact with the fascial surfaces and minimizes contamination.
Intra-abdominal abscess formation was more common after laparoscopic appendectomy in complicated disease (5.3% vs
= 0.002). It has been suggested that carbon dioxide insufflation may promote mechanical spread of bacteria in the peritoneal cavity, especially in cases of ruptured appendix[21,36-38
]. In order to decrease the bacterial load and hence the risk of abscess formation, we advocate extensive irrigation of the abdominal cavity. However, in our practice, we observed that meticulous irrigation was unnecessary and even more dangerous as it leads to contamination of the entire abdominal cavity, which is difficult to aspirate latter. That was the case in two patients with severe peritonitis where intra-abdominal abscess formation occurred. Ever since we have changed our practice to simple suctioning of the infected area, we have not observed any postoperative abscess formation, even in patients with severe peritonitis.
The higher cost of laparoscopic appendectomy compared to the conventional technique is considered as an obstacle to its greater use. However, hospital charges for laparoscopic appendectomy have reduced dramatically over the past several years[39
]. Surgical expertise and the abundance of laparoscopic equipment have significantly reduced the economical mismatch in favor of the conventional technique. In addition, Moore and coworkers, using a decision analysis model, have demonstrated an economic benefit of laparoscopic appendectomy from a social perspective, since shorter hospital stay and earlier return to daily activities is very important, especially for patients who are young and lead a productive life[40
In the present study, the operative costs for laparoscopic appendectomy were only 370 € higher. The greater cost of laparoscopic appendectomy observed in various studies[3,14,25
] can be attributed to the use of disposable laparoscopic instruments and the longer operative time. In our series, we were able to minimize the operative costs, mainly by employing reusable laparoscopic instruments.
Although there is no consensus with regard to the advantages of the laparoscopic approach compared to the conventional technique, the use of laparoscopic appendectomy has increased significantly in the last several years. In the present study, we were able to demonstrate the superiority of the laparoscopic approach in terms of hospital stay and wound infection, with only marginally higher hospital costs. Although the incidence of intra-abdominal abscess formation was higher after laparoscopic appendectomy, all complications occurred early in our practice. Greater experience and improvements in our technique has made it possible to eradicate this catastrophic complication.
Provided that surgical experience and equipment are available, laparoscopic appendectomy is safe and equally efficient compared to the conventional technique. However, as long as there is no consensus to the best approach for appendicitis, the choice of the procedure will be based on the preference of the surgeons and patients.