Surgical procedures for acute appendicitis and its complications are one of the commonest emergency surgeries performed in our center. Previous studies across Nigeria have reported a high incidence of complications in need of immediate laparotomy.9–11
In this study, 13.9% patients presented with complications that required immediate laparotomy, while 6 from the LA group had complications requiring open laparotomy. This high incidence of complications is partly due to patients utilizing overthe-counter drugs at the onset of the symptoms while for others there may have been a delay in referral from their primary care physicians.
Most the procedures (102 of 139) were performed by the open approach. This is because most residents performing these procedures are not yet experienced in laparoscopic surgery, especially in the emergency department setting. Patients selected for the laparoscopic approach included young females in the reproductive age group with suspected pelvic conditions, patients presenting with signs not specific to appendicitis, and older patients with features of acute appendicitis. We found dense adhesions between pelvic organs and terminal ileum in 1 patient, a solid ovarian mass in a 23-y-old female patient and ruptured ovarian cysts with limited hemoperitoneum in another 2. The appendix in these 4 patients appeared normal; hence, they were not eligible for laparoscopic appendectomy. Earlier reports have highlighted several benefits of initial diagnostic laparoscopy in these group of patients.12–14
In Nigeria, negative appendectomy rate ranges between 15% and 30% and is more common among women.9,15,16
We believe that LA, if embraced across Nigeria and other similar developing settings, would reduce this incidence of negative appendectomy.
The mean duration of operation time was significantly longer in the laparoscopy group compared with the open group (P
= .032). The initial period of our learning curve contributed significantly to the longer duration of the procedure in the early period of this study. This, however, declined considerably over time as reported in . The mean operation time for LA in our study is similar to that reported in other countries.7,17,18
Postoperatively, 4.8% of patients who had OA developed prolonged ileus lasting beyond 48 h, while this was not observed in the LA group. This factor probably contributed to a statistically significant difference observed in the duration of hospital stay between the 2 groups.
Different studies have shown that wound infection rates are lower following LA compared with OA.19,20
A meta-analysis of randomized controlled trials found a slightly higher incidence of intraabdominal abscesses in LA patients.5
In this study, surgical site infection was recorded in 6.4% of LA patients compared with 10.8% of the OA group. This difference was not statistically significant though the grades of infection were higher in the OA group. The 2 port-site infections recorded in the LA group were superficial, but deep SSI were recorded in 4 patients along with 2 incidences of residual abscesses in the OA group. This may be because most patients with urgent need for surgery were immediately offered the open option. The percentage of postoperative wound infections following OA ranged between 8% and 26% as reported in hospitals throughout Nigeria.9,15
The present study has its limitations. To adequately compare the outcome of these 2 groups in our setting, a randomized study would have been ideal. As more surgeons and trainees in our center become more proficient in laparoscopic surgery, we will be able to design a randomized comparison of the 2 procedures, without the inherent selection bias of the current study. A number of studies have also compared the cost implications of OA and LA in different settings.21,22
Our study is unable to offer such a detailed comparison, because the LA procedure is currently subsidized in our hospital. The cost of laparoscopy in our center has reduced drastically with the adoption of reuseable instruments as well as alternatives to reduce the number of consumables required for surgery. For instance, a tray of disposable hand instruments for one laparoscopic cholecystectomy was purchased by our hospital for the equivalent of 1050 US Dollars. A set of reuseable hand instruments purchased for the equivalent of 3800 US Dollars have been used for approximately 200 different procedures with minimal additional costs for resterilization. Our supply of preformed endoloop sutures was irregular and also added to the direct cost of the procedure. This prompted us to adopt routine extracorporeal ligation of the appendix base. We also limited the use of retrieval bags in patients with inflamed or purulent specimens, while in other cases we have drawn the appendix into the 11-mm trocar for extraction. Another inexpensive option is a simple tripolar forceps with a blade that can be activated to divide between the bipolar ends of the electrocautery and aid the division of the mesoappendix. A number of authors from other developing settings have described different modifications and improvisations that could reduce cost and encourage the feasibility of LA in such situations.7,23
For this study, we have also focused on training the surgical team in laparoscopic procedures. While a number of surgeons in our hospital have been exposed to training in laparoscopic surgery outside Nigeria, many residents, nurses and other support staff had no prior exposure to the procedures. Internal training of our staff has had a positive impact on the success of our laparoscopy cases. We are currently introducing the use of laparoscopy in the operative management of patients with complicated appendicitis as well as those with generalized peritonitis. We believe that through constant evolution of laparoscopy and other forms of minimally invasive surgery patient outcome will continue to improve.