|Year : 2013 | Volume
| Issue : 2 | Page : 55-58
Laparoscopic appendectomy in complicated appendicitis: Is it safe?
Ashraf A Mohamed, Khaled M Mahran
Department of General Surgery, Minia University Hospital, Minia City, Egypt
|Date of Submission||28-Feb-2012|
|Date of Acceptance||24-May-2012|
|Date of Web Publication||22-Apr-2013|
Ashraf A Mohamed
Department of General Surgery, Minia University Hospital, Minia City
Source of Support: None, Conflict of Interest: None
Background: Because of lack of good evidence supporting laparoscopic approach for complicated appendicitis, we carried out this study to evaluate efficacy of laparoscopic appendectomy (LA) in management of patients with complicated appendicitis. Materials and Methods: This study was carried out in Surgical Department, Minia University, Egypt involving 214 patients underwent appendectomy for complicated appendicitis over three years. 132 patients underwent LA and remaining 82 patients underwent OA. Parameters studied included operating time, return to oral feeding, postoperative pain, wound infection, intra-abdominal abscess, duration of abdominal drainage and hospital stay. Results: There were four conversions, two due to extensive cecal adhesions and two due to friable appendix. LA took longer time to perform (p = 0.0002) but with less use of analgesics (p < 0.0001), shorter hospital stay (p < 0.0001), shorter duration of abdominal drainage (p < 0.0001) and lower incidence of wound infection (p = 0.0005). Nine patients in LA and seven patients in OA group developed intra-abdominal abscess treated successfully with sonographic guided percutaneous drainage. Postoperative ileus was recorded in two patients in LA group and three patients in OA group, chest infection in one patient in OA group, hernia in one patient in LA and fecal fistula was present in one patient in OA. Overall complications were significantly lower in laparoscopy group and managed conservatively with no mortality in either group. Conclusions: LA in complicated appendicitis is feasible and safe with lower incidence of complications than OA and should be the initial choice for all patients with complicated appendicitis.
Keywords: Appendicitis, complicated appendicitis, laparoscopic appendectomy, open appendectomy
|How to cite this article:|
Mohamed AA, Mahran KM. Laparoscopic appendectomy in complicated appendicitis: Is it safe?. J Min Access Surg 2013;9:55-8
| ¤ Introduction|| |
A large number of studies comparing laparoscopic versus open appendectomy (OA) were conducted since the first report of laparoscopic appendectomy (LA) by Semm in 1983. ,,,,, Better access and good visualisation of the peritoneal cavity through small incisions give LA advantage when compared with OA. Accordingly, complicated appendicitis is better managed by LA.  OA for complicated appendicitis, compared with that for uncomplicated appendicitis, requires a larger abdominal incision and longer operating time, giving more surgical stress to the patients. Moreover, the wound is exposed to contaminated fluid which may result in an increased rate of wound infections. Hence, it is logical that LA could have advantages over OA in patients with complicated appendicitis, because LA is associated with less wound surface area exposed to contamination and potentially facilitates direct visualisation during peritoneal lavage.  However, whereas several studies have assessed the role of laparoscopy in complicated appendicitis, the results are controversial. ,,,, Other systematic reviews and meta-analyses have documented advantages of LA in complicated appendicitis. ,,, These benefits of LA, however, still clinically limited or questionable, and consensus concerning the advantages of each procedure when compared with the other has not yet been reached. ,,, Again, the role of LA in the management of complicated appendicitis remains controversial. Moreover, LA when compared with OA needs higher technical demand, longer operative time and is associated with higher incidence of intra-abdominal collections. ,,
The aim of this study was to evaluate the difference between LA and OA in management of patients with complicated appendicitis.
| ¤ Materials and Methods|| |
Between September 2006 and September 2009, 954 patients coming to Emergency Unit (Surgical Department, Minia University, Egypt) were treated for acute appendicitis, of which 214 (22.4%) with complicated appendicitis suspected clinically and proved on computer tomography (CT) scan were included in our study. Those with appendiceal masses confirmed on imaging were managed non-operatively and excluded from the study. Complicated appendicitis is defined as acute appendicitis in which perforation or an intra-abdominal abscess is present.  Patients with non-complicated appendicitis, patients with generalised peritonitis, previous history of open abdominal or pelvic operations and patients with medical conditions that precluded them from pneumoperitoneum were excluded from the study. From September 2007 most of patients with appendicitis were treated laparoscopically. While 82 patients underwent OA for complicated appendicitis during the first 12 months, the remaining 132 patients underwent LA thereafter. From the 132 patients who treated laparoscopically, 4 patients were converted to open, 2 patients due to extensive cecal adhesions interfering with mobilisation of the appendix and 2 patients due to extensive friable appendix. Pre-operative single dose of intravenous antibiotics (3rd generation cephalosporins) were given to all patients. Foley's catheter was used in some patients. In our study we collected the data of those patients retrospectively and compared both groups regarding operating time, length of hospital stay and post-operative complications. In LA group pneumoperitoneum induced by the use of Veress needle. A 3-trocar technique using 5- and 10-mm cannulas was used to perform LA. Mesoappendix was dissected using an electrocautery and stump was controlled using pre-tied suture loops. Appendix was retrieved inside disposable bag to avoid contamination. Peritoneal lavage with warm saline was performed until the drainage fluid became clear and then pelvic drains were placed. OA was performed using a lower midline incision. Post-operative intravenous antibiotics (3 rd generation cephalosporins) were given. Analgesics Non-steroidal anti-inflammatory drugs (NSAIDs) were given as intramuscular injection or as a suppository (paracetamol especially in children) to all patients during their hospital stay. Oral intake was started with return of bowel function in both groups. Patients were discharged after adequate oral intake and mobilisation except those with post-operative complications. Oral antibiotics (ciprofloxacin in adults and augmentin in children) and metronidazole were given for 1 week after discharge. The follow up in the outpatient's clinic was at 1 week, 2 weeks and at 1 month intervals for 6 months according to clinical course of every patient. Patients were instructed to report back immediately for any complication related to the surgery irrespective of the duration of follow-up. Complications recorded were wound infections (purulent discharge from wound), chest infections, intra-abdominal abscess (symptomatic post- operative collection in the peritoneal cavity), ileus (absence of peristaltic activity beyond 48 h), fecal fistula and post-operative hernia (trocar).
Signed consent was obtained from the patients after discussion for them regarding the nature of the surgery, the outcome and the possible complications.
Student's t-test and chi-square test were used to compare results between groups, using SPSS for Windows version 13 (SPSS, Inc). A two-tailed test with P value < 0.05 was considered to be statistically significant.
| ¤ Results|| |
Between September 2006 and September 2009, 82 patients underwent OA and 132 patients underwent LA during the study period. There were two conversions due to extensive cecal adhesions interfering with mobilisation of the appendix and two due to extensive friable appendix. Patient details and operative outcomes are shown in [Table 1] and post-operative complications are shown in [Table 2].
There were no significant differences between the two groups with respect to mean age, sex and degree of appendicitis. In the OA group, the procedure was able to be completed requiring only spinal anaesthesia in 61 patients (74.4%), while in 21 patients (25.6%) general anaesthesia was needed. LA took longer time to perform (P = 0.0002) but was associated with significantly less use of analgesics (P < 0.0001) and shorter hospital stay (P < 0.0001). Return of oral intake was early in LA group (2 days) than OA group (3 days) but the difference was statistically insignificant. The duration of abdominal drainage was significantly shorter in LA than in OA (P < 0.0001). Pus collection in right paracolic gutter, pelvis or both was found in 31 patients with gangrenous appendix and 38 with perforated appendix in LA group, and in 12 patients with gangrenous appendix and 30 with perforated appendix in OA group had associated pus collection. Hence, pus collection that needed a wash was found in 52.3% (n = 69) of patients in LA group and 51.2% (n = 42) in OA group. The incidence of wound infection was lower in LA than in OA (LA, 8.3%; OA, 24.4%; P = 0.0005). All wound infections were at skin level only without wound dehiscence. The four converted patients developed wound infection. All wound infections were managed conservatively with dressings except two patients in LA group and eight in OA group who required secondary suturing. Nine patients in LA (6.8%) and seven patients in OA group (8.5%) developed intra-abdominal abscess (P > 0.05). All those patients were treated successfully with sonographic guided percutaneous drainage. Neither re-exploration nor re-laparoscopy was required for any complication. Post-operative ileus was recorded in two patients in LA group (1.5%) and three patients in OA group (3.6%) that delayed their oral intake, but the difference was statistically insignificant. One patient in OA group had post-operative chest infection that resolved by antibiotics. Overall complications were significantly lower in laparoscopy group. There was no mortality. Post-operative hernia (trocar) occurred in one patient in LA (0.7%). Fecal fistula was present in one patient in OA (1.2%) 4 days after operation, managed conservatively and healed within 2 weeks.
| ¤ Discussion|| |
Complicated appendicitis is associated with a higher risk of post-operative complications and has been considered a relative contraindication for laparoscopy. ,, However, this concept has been challenged in some studies which compared surgical outcomes of LA for complicated appendicitis. ,,
There is lack of good evidence supporting laparoscopic approach for complicated appendicitis.  Although some studies comparing LA and OA have shown equivalence of the two procedures as regard morbidity and mortality,  most studies reported significant advantages in the laparoscopic group, such as, decreased post-operative pain, rapid recovery, shorter hospital stay, ,, availability of inspection of the entire peritoneal cavity, good debridement, adequate irrigation and lavage under direct visualisation, better cosmesis, less immunologic compromise and fewer chest complications. 
A major advantage of LA is the decrease in incidence of wound infections.  In our study, LA group had less post-operative wound infections (8.3%). This may be due to avoiding direct contact with the trocar wounds as the appendix was removed inside a disposable bag and thorough aspiration of the infected fluid through the laparoscopic approach. However, the infection rate was higher in OA (24.4%). This may be due to inability to avoid contact of the abdominal incision with both the appendix and infected fluid. Similar results were demonstrated in other studies. ,,
We reported lower incidence of intra-abdominal abscess in both groups with no statistically significant difference between them. This lower incidence may be attributed to sufficient pre-operative resuscitation, appropriate peri- operative antibiotics and use of standardised surgical techniques. These results were similar to those reported by Temple et al., Krukowski et al. and Reid et al. ,, when they studied OA and also those reported by Alvarez and Voitk  who insisted on the importance of a standardised technique to reduce the incidence of intra- abdominal abscess when they studied LA.
Many studies reported reduced analgesic requirements and decreased post-operative pain in LA. ,,,, This agrees with the current study where significantly less analgesic use was required in LA when compared with OA (P < 0.0001).
The operating time in this study was longer in LA than in OA which may be due to time consumed for peritoneal lavage and tying of base. Longer operating time of LA when compared with OA was also reported in many studies. ,,,,,,, However, Yau et al.  reported shorter operative time in LA and attributed this to longer time taken in OA to extend small grid-iron incision and close it.
Duration of drainage and hospital stay was significantly shorter in LA than in OA. These results was comparable to many previous studies. ,,,,,,,,,, Additionally, there was earlier return of oral intake in LA than in OA but statistically insignificant as reported by Fukami et al. and Garg et al. ,
There was no significant statistical difference between the two groups as regard post-operative ileus and chest infection agreeing with Garg et al.,  fecal fistula agreeing with Ball et al.,  and post-operative hernia agreeing with Fukami et al.  No mortality was recorded in our study.
In conclusion, our study demonstrated that treatment of complicated appendicitis laparoscopically is feasible, safe and can offer a low incidence of infectious complications, less post-operative pain, rapid recovery and better cosmesis on the expense of longer operating time than OA. We recommend that LA should be the initial choice for all patients with complicated appendicitis.
| ¤ References|| |
|1.||Semm K. Endoscopic appendectomy. Endoscopy 1983;15:59-64. |
|2.||Cox MR, McCall J, Toouli J, Padbury R, Wilson T, Wattchow D, et al. A prospective randomized comparison of open versus laparoscopic appendectomy in men. World J Surg 1996;20:263-6. |
|3.||Mutter D, Vix M, Bui A, Evrard S, Tassetti V, Breton J, et al. Laparoscopy not recommended for routine appendectomy in men: Results of a prospective randomized study. Surgery 1996;120:71-4. |
|4.||Williams MD, Collins JN, Wright TF, Fenoglio ME. Laparoscopic versus open appendectomy. South Med J 1996;89:668-74. |
|5.||Laine S, Rantala A, Gullichsen R, Ovaska J. Laparoscopic appendectomy-is it worthwhile? Surg Endosc 1997;11:95-7. |
|6.||Reiertsen O, Larsen S, Trondsen E, Edwin B, Faerden AE, Rosseland AR. Randomized controlled trial with sequential design of laparoscopic versus conventional appendectomy. Br J Surg 1997;84:842-7. |
|7.||Garg CP, Vaidya BB, Chengalath MM. Efficacy of laparoscopy in complicated appendicitis. Int J Surg 2009;7:250-2. |
|8.||Fukami Y, Hasegawa H, Sakamoto E, Komatsu S, Hiromatsu T. Value of laparoscopic appendectomy in perforated appendicitis. World J Surg 2007;31:93-7. |
|9.||Piskun G, Kozik D, Rajpal S, Shaftan G, Fogler R. Comparison of laparoscopic, open, and converted appendectomy for perforated appendicitis. Surg Endosc 2001;15:660-2. |
|10.||So JB, Chiong EC, Chiong E, Cheah WK, Lomanto D, Goh P, et al. Laparoscopic appendectomy for perforated appendicitis. World J Surg 2002;26:1485-8. |
|11.||Senapathi PS, Bhattacharya D, Ammori BJ. Early laparoscopic appendectomy for appendicular mass. Surg Endosc 2002;16:1783-5. |
|12.||Guller U, Hervey S, Purves H, Muhlbaier LH, Peterson ED, Eubanks S, et al. Laparoscopic versus open appendectomy: Outcomes comparison based on a large administrative database. Ann Surg 2004;239:43-52. |
|13.||Mancini GJ, Mancini ML, Nelson HS. Efficacy of laparoscopic appendectomy in appendicitis with peritonitis. Am Surg 2005;71:1-5. |
|14.||Chung R, Rowland DY, Li P, Diaz J. A meta-analysis of randomized con trolled trials of laparoscopic versus conventional appendectomy. Am J Surg 1999;177:250-6. |
|15.||Garbutt JM, Soper NJ, Shannon WD, Botero A, Littenberg B. Meta-anal ysis of randomized controlled trials comparing laparoscopic and open ap pen dec tomy. Surg Laparosc Endosc 1999;9:17-26. |
|16.||Temple LK, Litwin DE, McLeod RS. A meta-analysis of laparoscopic versus open appendectomy in patients suspected of having acute appendicitis. Can J Surg 1999;42:377-83. |
|17.||Apelgren KN, Molnar RG, Kisala JM. Laparoscopic is not better than open appendectomy. Am Surg 1995;61:240-3. |
|18.||Katkhouda N, Mason RJ, Towfigh S, Gevorgyan A, Essaniet R. Laparoscopic versus open appendectomy: A prospective randomized double-blind study. Ann Surg 2005;242:439-50. |
|19.||Moberg AC, Berndsen F, Palmquist I, Petersson U, Resch T, Montgomery A. Randomized clinical trial of laparoscopic versus open appendicectomy for confirmed appendicitis. Br J Surg 2005;92:298-304. |
|20.||Frizelle FA, Hanna GB. Pelvic abscess following laparoscopic appendectomy. Surg Endosc 1996;10:947-8. |
|21.||Merhoff AM, Merhoff GC, Frankin ME. Laparoscopic versus open ap pen dec tomy. Am J Surg 2000;179:375-8. |
|22.||Al-Omran M, Mamdani MM, McLeod RS. Epidemiologic features of acute appendicitis in Ontario, Canada. Can J Surg 2003;46:263-8. |
|23.||Golub R, Siddiqui F, Pohl D. Laparoscopic versus open appendectomy: A meta-analysis. J Am Coll Surg 1998;186:545-53. |
|24.||Sauerland S, Lefering R, Neugebauer EA. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev 2004;18:CD001546. |
|25.||Pokala N, Sadhasivam S, Kiran RP, Parithivel V. Complicated appendicitis-is the laparoscopic approach appropriate? A comparative study with the open approach: Outcome in a community hospital setting. Am Surg 2007;73:737-41. |
|26.||Yau KK, Siu WT, Tang CN, Yang GP, Li MK. Laparoscopic versus open appendectomy for complicated appendicitis. J Am Coll Surg 2007;205:60-5. |
|27.||Shelton T, McKinlay R, Schwartz RW. Acute appendicitis: Current diagnosis and treatment. Curr Surg 2003;60:502-5. |
|28.||Lintula H, Kokki H, Vanamo K. Single-blind randomized clinical trial of laparoscopic versus open appendicectomy in children. Br J Surg 2001;88:510-4. |
|29.||Esposito C, Borzi P, Valla JS, Mekki M, Nouri A, Becmeur F, et al. Laparoscopic versus open appendectomy in children: A retrospective comparative study of 2,332 cases. World J Surg 2007;31:750-5. |
|30.||Menezes M, Das L, Alagtal M, Haroun J, Puri P. Laparoscopic appendectomy is recommended for the treatment of complicated appendicitis in children. Pediatr Surg Int 2008;24:303-5. |
|31.||Cueto J, D'Allemagne B, Vazquez-Frias JA, Gomez S, Delgado F, Trullenque F, et al. Morbidity of laparoscopic surgery for complicated appendicitis: An international study. Surg Endosc 2006;20:717-20. |
|32.||Tate JJ. Laparoscopic appendicectomy. Br J Surg 1996;83:1169-70. |
|33.||Temple CL, Huchcroft SA, Temple WJ. The natural history of appendicitis in adults: A prospective study. Ann Surg 1995;221:278-81. |
|34.||Krukowski ZH, Irwin ST, Denholm S, Mathewson NA. Preventing wound infection after appendectomy: A review. Br J Surg 1998;75:1023-33. |
|35.||Reid RI, Dobbs BR, Frizelle FA. Risk factors for post-appendectomy intra-abdominal abscess. Aust N Z J Surg 1999;69:373-4. |
|36.||Alvarez C, Voitk AJ. The road to ambulatory laparoscopic management of perforated appendicitis. Am J Surg 2000;179:63-6. |
|37.||Long KH, Bannon MP, Zeitlow SP, Helgeson ER, Harmsen WS, Smith CD, et al. A prospective randomized comparison of laparoscopic appendectomy with open appendectomy: Clinical and economic analyses. Surgery 2001;129:390-400. |
|38.||Kazemier G, Steyerberg EW, Bonjer HJ. Meta-analysis of randomized clinical trials comparing open and laparoscopic appendectomy. Surg Endosc 1997;11:170. |
|39.||Slim K, Pezet D, Chipponi J. Laparoscopic or open appendectomy? Critical review of randomized, controlled trials. Dis Colon Rectum 1998;41:398-403. |
|40.||Sauerland S, Lefering R, Holthausen U, Neugebauer EA. Laparoscopic vs conventional appendectomy-a meta-analysis of randomized controlled trials. Langenbecks Arch Surg 1998;383:289-95. |
|41.||Milewczyk M, Michalik M, Ciesielski M. A prospective, randomized, unicenter study comparing laparoscopic and open treatments of acute appendicitis. Surg Endosc 2003;17:1023-8. |
|42.||Ball CG, Kortbeek JB, Kirkpatrick AW, Mitchell P. Laparoscopic appendectomy for complicated appendicitis: An evaluation of postoperative factors. Surg Endosc 2004;18:969-73. |
[Table 1], [Table 2]
|This article has been cited by|
||Laparoscopic versus open surgery for complicated appendicitis: a randomized controlled trial to prove safety
| ||John-Edwin Thomson,Deirdré Kruger,Christine Jann-Kruger,Akos Kiss,J. A. O. Omoshoro-Jones,Thifheli Luvhengo,Martin Brand |
| ||Surgical Endoscopy. 2014; |
|[Pubmed] | [DOI]|