The enormous continuous development of minimally invasive surgery is justified by the many advantages this method provides: Minimal surgical trauma, less postoperative pain, rapid postoperative recovery, exploration of entire abdominal cavity, management of unexpected findings, and better cosmetic results with rapid return to normal activities. Despite all these proposed advantages and increasing popularity, LA has not yet been demonstrated to have a clear advantage over its open counter-part over the past two decades.[14
] On the other hand, it has also been argued that the advantages of LA are marginal compared to OA performed by an experienced surgeon through a short, cosmetically acceptable incision, which is associated with minimal complications and short hospital stay.[15
] The results of our study indicate that patients who underwent LA had significantly lesser requirement for narcotic analgesics, with similar postoperative outcome.
Analysis of our data demonstrated that despite the availability of equipment and expertise for both techniques, large number of patients underwent open appendectomy as compared to laparoscopic procedure. This reflects the personal preference of the staff surgeon in our set-up, probably in view of lesser cost for the patient. The median operative time in our study was 82 minutes for LA, which is relatively longer than that reported by other studies.[20
] This is probably related to the surgical practices in our university hospital where most of the procedures are performed by the surgical trainee under the direct supervision of the attending surgeon.
The hospital cost was also influenced by the duration of surgery in our hospital, which shows parallel increase for LA. The issue of residents′ training resulting in increasing healthcare cost remains an area of great concern in academic institutions.[23
]This is particularly relevant in developing countries without proper healthcare support like ours where it has direct impact on the patient.
In accordance with other studies,[24
] there were fewer wound infections in the laparoscopy group in our study, but this difference was not statistically significant. A reduction in wound infection can be achieved by extraction of the specimen through a port, or by using an endobag. This finding has also been highlighted in the recent Cochrane review which consisted of more than 5000 patients. [14
] According to their findings, patients undergoing LA were half as likely to have wound infection as after OA. This seems to be a significant advantage because wound infection is the commonest complication after open appendectomy. On the other hand, the same reviewers noted that the incidence of intraabdominal abscesses was threefold higher after LA, as compared to OA.[14
]We didn′t have any postoperative intraabdominal abscess in our study population.
The question of whether laparoscopic appendectomy decreases the length of hospitalization has been a matter of great debate over the past decade.[24
] In our study, the length of stay was comparable in both the groups and the results are in keeping with the other studies.[20
] Broadly speaking, the length of hospital stay has declined dramatically in the recent years, and the differences between open and laparoscopic cases are only marginal.[27
] The duration of stay is mainly determined by the pathological status of the appendix and the clinical status of the patient, rather than the open or laparoscopic access used for the procedure. [21
]It seems that pathological status of the appendix also contributes to the postoperative septic complications. This is reflected in the fact that five out of 6 patients who developed wound infection in OA group and two out of 3 patients with prolonged ileus in laparoscopic group had perforated appendix at the time of surgery. Development of standardized protocols for discharge of patients from the hospital after LA may further optimize the care and reduce the cost at our hospital.
Although suggested by other studies[14
] we were not able to assess the cosmetic results and time to return to normal activity due to limitation of the available data. It has also been suggested that beside the therapeutic effects of LA, laparoscopy per se may offer valuable diagnostic opportunities. The issue of removal of an uninflamed, normal looking appendix has also been debated and it has been proposed not to remove the appendix in those situations where other pathologies can be diagnosed during laparoscopy. Some surgeons, therefore, have used laparoscopy as a diagnostic tool only, and perform conventional appendectomy after laparoscopy in those patients, where the appendix macroscopically has an abnormal appearance. However, it is not yet clarified in which situations a normal looking appendix should be left in place, although non-randomized studies indicate this.[28
Another issue that remains yet to be conclusively answered is the appropriateness of the laparoscopic approach for complicated appendicitis. A number of studies in the past have recommended open surgery for perforated appendicitis.[29
]In keeping with these recommendations, the patients in our study who were found to have perforated appendix with abscess formation at the time of laparoscopy were converted to open laparotomy for better drainage and wash-out. A number of recent reports, however, question this approach and the results indicate that patients with complicated appendicitis may be as effectively managed by laparoscopic approach.[31
]Further randomized trials might help resolve this issue.