Laparoscopic Versus Open Appendectomy in Females in
Childbearing Period
Tarek Osama Hegazy MD,MRCS, Department of General Surgery, Cairo University.
Salah Said Soliman MD,MRCS, Department of General Surgery, Fayoum University.
Abstract: Appendectomy is the most common surgical procedure performed in
general surgery. For almost a century, open appendectomy, first described by Charles
McBurney in 1889, has remained the gold standard treatment for acute appendicitis.
Laparoscopic appendectomy has emerged as a safe procedure with potential
advantages including diagnostic and therapeutic values especially in females in their
reproductive age.
This study included 40 female patients who presented to Kasr EL-Ainy Faculty
of medicine, Cairo University, causality department, from July 2011 to November
2011.Patiens were allocated in two groups , Group A : laparoscopic appendectomy
and Group B : open appendectomy by gridiron incision at McBurney's point.
The mean operative time in laparoscopic appendectomy was longer than that in
the open approach (57.95 minutes in laparoscopic group versus 48.15 min in open
group). The overall post operative complications were similar in the 2 groups but the
incidence of wound infection was less in laparoscopic group (5% versus 25%). The
mean hospital stay was shorter in laparoscopic patients than open appendectomy
patients (1.9 days versus 3.3 days). The use of laparoscope in suspected appendicitis
is better than the open method especially in equivocal cases to reach an exact
diagnosis.
Key words: appendectomy, laparoscopic appedictomy, McBurney's .
Introduction:
The standard for management of non-perforated acute appendicitis remains
appendectomy. Because prompt treatment of acute appendicitis is important in
preventing further morbidity and mortality, a margin of error in over-diagnosis is
acceptable. Currently, the rate of negative appendectomies is approximately 20
percent (1).
1
Open appendectomy (OA), has been the standard treatment for decades for both
acute and complicated appendicitis and has proven safe and effective (2).
The putative advantages of the laparoscopic approach are quicker and less
painful recovery, fewer postoperative complications and better cosmesis. It allows
better assessment of other intra-abdominal pathologies. But because the validity of
these points remains unconvincing and also because of shortage of laparoscopic sets
in some hospitals, laparoscopic appendectomy is not practiced widely (3).
There have been numerous retrospective and uncontrolled series of laparoscopic
appendectomy (LA), as well as many prospective randomized studies published to
date. Although most of these have concluded that the laparoscopic technique is as
good as open appendectomy (OA), there has been considerable controversy as to
whether LA is superior or not (4).
However there have been several studies suggesting that the laparoscopic
approach results in possible increased length of operating time and postoperative
complications compared to the open approach. These observations have been reported
in both adults and children (5-6). LA can have extra benefits for female patients as
decreasing adhesions and fertility problems and better cosmetic results (7).
The
role
of
laparoscopic
appendectomy has
not
yet
been
clearly
defined. Numerous factors need to be considered in deciding the ideal, and most
appropriate surgical technique for acute appendicitis.
Moreover to clarify the
advantages of laparoscopic appendectomy over open technique as a diagnostic and
therapeutic method in females in childbearing period with suspected appendicitis to
find out whether the laparoscopic approach could be adopted as the standard
procedure for appendectomy when acute appendicitis is clinically suspected. And
considering the few studies comparing laparoscopic and open appendectomy in our
country this study was designed to compare the prospective outcomes of LA with
OA(8-10).
Patients and methods
This study was conducted in Kasr EL-Ainy Faculty of medicine, Cairo
University, causality department, from July 2011 to November 2011. The study was
conducted on 40 female patients aged from 14 to 45 years with suspected
appendicitis. The Exclusion criteria were hemodynamic instability, chronic medical or
2
psychiatric illness,Cirrhosis and /or ascites,Coagulation disorders, previous
laparotomy for small bowel obstruction, Pregnancy and if acute appendicitis is
proven to be complicated by ultrasound .
The Patients were randomly allocated into two groups 20 patients each: Group
(A):had laparoscopic appendectomy,(LA). Group (B): had open appendectomy, (OA)
through McBurney’s girdiron incision.
All patients were subjected to: History taking, Clinical examination including
PR, Routine Laboratory investigations including Urine analysis, abdomino-pelvic
Ultrasound examination and gynecological consultation where Transvaginal US done
in some cases.
Patients were fully informed about the risks and benefits of the two procedures.
Informed consent was obtained from every patient.
Prior to the surgery, all patients received a standard prophylactic regimen of
intravenous antibiotics (1.5 gm of ampicillin, salbactam and 500 mg of
Metronidazole).
Procedure Description:
Open appendectomy was performed through a McBurney’s girdiron incision.
The mesoappendix was ligated then the appendix was ligated at the base and divided
with or without inversion of the appendiceal stump. Irrigation and insertion of a drain
were done only in complicated cases. The abdominal wall was closed in layers.
Laparoscopic appendectomy was performed where the patient was placed supine
in a 15º Trendelenburg position with both arms tucked. Rotation to the left was done.
The surgeon stood on the patient’s left side. The first assistant stood on the surgeon’s
left side also on the left side of the patient. The monitor was on the patient’s right
side. After the induction of general anesthesia, a urinary catheter and a nasogastric
tube were placed. A pneumoperitoneum was created in standard fashion, using either
the Veress needle technique or the open technique according to the surgeon
preference. The first trocar (10 mm) was introduced at the lower margin of the
umbilicus. The intraperitoneal pressure was set to be 14 mmHg. Laparoscopy was
then performed with "zero" angle viewing laparoscope to ensure the clinical diagnosis
and identify the position of the appendix so as to determine the best site of insertion of
the other trocars. A second 10 mm suprapubic trocar was inserted. A third operating
3
trocar was inserted in the left iliac fossa. In 2 cases 4th trocar in the right upper
quadrant was inserted to facilitate dissection of retrocecal appendix.
After insertion of the ports, a quick diagnostic laparoscopy was performed in
order to confirm the diagnosis and assess other pathologies. The surgeon's left hand
held a Babcock grasper to retract the cecum and subsequently expose the appendix.
Cautery scissors were used to incise the retroperitoneal attachments of the cecum in
difficult cases. The surgeon's right hand operated a dissecting instrument or cautery
scissors, which were used to create a window in the mesoappendix at the base of the
appendix. The mesentery and base of the appendix were secured and divided
separately using clips or bipolar diathermy for mesoappendix and clips or endoloop
technique for appendiceal base.
After transection, the appendiceal stump mucosa was carefully cauterized. The
appendix was pulled into the umbilical port and withdrawn with the whole port or was
placed in an impermeable retrieval bag before its removal. Irrigation and insertion of a
drain were done only in complicated cases. Trocars were removed under direct vision.
Fascia at the 10-mm trocar site was closed, and all wounds were closed primarily.
Post operative care for the both groups was the same in where
Patients with
non-perforated appendix didn't receive postoperative antibiotics but in patients with
complicated appendicitis, antibiotics were not discontinued but were modified
according to the culture results and continued for 7 to 10 days till the patient was
afebrile.
Patients were given sips of water after passing flatus or feces or after hearing
intestinal sounds.
Postoperatively all patients received analgesics in the form of NSAIDs for 24
hours, then analgesics were given upon the patient request.
The discharge criteria are met once the patients were afebrile, with audible
bowel sounds and were able to tolerate a liquid diet and oral analgesia. The specimens
were sent for pathology for assessing pathological diagnosis.
The comparison between the 2 groups includes the following criteria: Patient’s
age, operative time (from skin incision to wound closure), intraoperative findings,
intraoperative complications, conversion to open procedure, Postoperative morbidity
including wound infection, general complications of surgery, postoperative hospital
4
stay, postoperative pain (the need for analgesia), and the time needed to return to
work.
Data were analyzed using SPSS v16 the tests used: t-test, crosstab: chi-square
and Mann-Whitney test.
5
Results
The patient’s ages ranged from 14- 45 years with median age 27 years in Group A
and 27.5 years in Group B and mean age 28± 9.03 years in Group A and 27.85±8.46
years in Group B.
The Intraoperative findings of the appendix from both groups showed in table (1)
Table (1): Intraoperative findings.
(Group A) (Group B) Total
Finding
Parameter
Lap
Open
(20 (40
(20
patients)
patients)
7
6
13
35.0%
30.0%
32.5%
10
8
18
50.%
40.0%
45.0%
0
2
2
.0%
10.0%
5.0%
3
4
7
15.%
20.0%
17.5%
patients)
Number
Grossly
normal
%
within
group
Number
Inflammed
%
within
group
Number
Gangrenous
%
within
group
Number
Perforated
%
within
group
The operative time was significantly longer P<0.001 in the laparoscopic group
(Group A) with mean time 57.95±10.96 minutes than open group (Group B) with mean
time 48.15±23.03 figure (1). The median time in Group A is 57.5 minutes ranged from
(44-80) minutes and in Group B the median time is 40 minutes ranged from (31 – 68)
minutes.
6
Figure (1) :Comparison between time in both groups.
The mesoappendix was ligated in all open cases, but different methods are used in
laparoscopic cases the mesoappendix was coagulated with bipolar diathermy in 12 cases
and clipped with Clips in 6 cases. The appendiceal base was ligated with in all open cases
but was clipped with Clips in 14 cases figure (2) cases and tied with Endoloop in 4 cases
with the laprascopic group.
Figure (2): Laparoscopic division of mesoappendix between clips
7
In Group A (Lap) 2 cases had bleedings from mesoappendix that was controlled
by clips and a Bleeding after puncture of ovarian cyst controlled by diathermy. In Group
B (Open) 2 cases with caecal serosal tears were repaired primarily by absorbable sutures.
And one case of iatrogenic ovarian injury was also repaired primarily by absorbable
sutures.
Two cases of laparoscopic appendectomies were converted to open procedures,
the 1st was a case of ruptured ectopic pregnancy (right salpingo-oophrectomy was done)
and the 2nd was a case of perforated appendix due to technical difficulties.
Overall post operative complications showed no significant difference between
the 2 groups with P=0.127. However, post operative wound infection was significantly
higher in the open group (B) than the laparoscopic group (A), (25% infected in open
cases and only 5% infected in laparoscopic cases) with P=0.031 table 2. While there was
no significant difference between Group A and Group B regarding pelvic abcess, fecal
fistula and incisional hernia.
Table (2): Wound infection in both groups
Group
Laparoscopic(20
% within
Count the group
1
5%
%
within
post
operative
complication
16.7%
Patients)
Open ( 20 Patients)
P value
0.031
5
25%
83.3%
The median time for hospital stay in Group A (lap) is 1 day and in Group B (open)
3 days (minimum 1 day). The median time for work return in Group A (lap) is 4 days
(minimum 3 days) and in Group B (open) 6.5 days (minimum 5 days).
The Mean Time interval for analgesia needed in Group A (lap) is
15.60±7.30hours and in Group B (open) the Mean Time interval for analgesia needed is
8.10±2.19 hours.
There was a significant difference between both groups regarding post operative
hospital stay figure (3), analgesia needed and time needed to return to work with P
=0.002, 0.000 and 0.001 respectively. All of them were significantly lower in
8
laparoscopic group. There was no significant difference between both groups regarding
post operative time needed for fluid tolerance with P=0.146.
Figure (3): Comparison between hospital stay in both groups
Discussion
Approximately 6% of the population develops appendicitis in their life time, with
peak incidence between the ages of 10 and 30 years, thus making appendectomy the most
frequently performed abdominal operation (11).
The treatment of acute appendicitis remained essentially unchanged since its first
description by Charles McBurney in 1889 then when in 1983 Kurt Semm offered an
alternative, "laparoscopic appendectomy”, but as McBurney's operation is well tolerated
with less co-morbidity the benefits of laparoscopic appendectomy have been difficult to
establish (12).
Clear and magnified visions of appendix with more space to maneuver through a
small hole like incision are great advantages of laparoscopic surgery. Some surgeons with
equal safety and ease in OA do “Button hole” surgery. Hence regarding incision any
advantage to LA is likely to be small and difficult to prove (13).
9
This study was conducted to compare the outcomes of laparoscopic appendectomy
versus open appendectomy in female patients with suspected acute appendicitis and to
evaluate the effectiveness and safety of laparoscopic appendectomy over conventional
"open" appendectomy in the treatment of acute appendicitis
This study revealed that there was a significant difference regarding operative time
with P=0.001(mean time was 57.95 minutes in the LA and 48.15 minutes in the OA).
This was in accordance to the study by Meroao A. 1999 who showed that the mean
operative time for the LA group was significantly longer (79.6 min) than the OA (53.4
min) with P < 0.0001, Similarly other studies confirms that that the mean operation time
was longer in LA (50,80minutes) as compared with OA (30,60 minutes) with P = 0.000
(14,13,11 ). On the other hand, Alfredo et al, 2004, found no difference in the operative
time between the LA and OA, (mean time 51.1 and 51.5 minutes respectively).This may
be related to the experience of the surgeon as the operative time decreased successively
throughout this work with increase in the learning curve (15).
This study showed that there were less post operative pain and less need for
analgesia in LA group. The difference was significant (P=0. 00). This was in compliance
with other studies that found the need of analgesia and postoperative narcotic is
significantly less in the LA group (15, 16,17). Other study that used linear analogue
pain scores were recorded in 135 patients blinded to the procedure of operation by special
dressing and confirms pain score was very less in laparoscopic group compared to open
(18).This was in contrary to the study done by Katkhouda et al (2005), showed that the
severity of pain experienced and its influence on activity were similar for both groups.
Narcotic medication usage to control postoperative pain was also equivalent between the
2 groups. These results may be related to different pain threshold and different pain
perception among the studied groups of different authors (8).
10
This study revealed that there was a significant decrease in hospital stay in the
laparoscopic group (1.9 days), than the open group (mean hospital stay was 3.3 days),
(P=0.002). Also returen to work in a shorter time (there was significant difference with
PV=0.001). But, regarding fluid tolerance and return to normal diet, although occurred
earlier in the laparoscopic group, the difference was insignificant (P=0.146).
Similarly, in a study done by Wei Hong-Bo et al in 2010 reported that laparoscopic
appendectomy remained associated with a shorter time until return to a general diet (LA,
20.2 ± 12.4 h vs. OA, 36.5 ± 10 h; p < 0.05), to normal activity (LA, 9.1 ± 4.2 days vs.
OA, 13.7 ± 5.8 days; p < 0.05), and to work (LA, 21.2 ± 3.5 days vs. OA, 27.7 ± 4.9
days; p < 0.05). Same was documented in similar studies regarding return to a regular
diet faster (1.6 versus 2.3 days, P = 0.002). However, there no significant differences
were found with regard to time to return to work (19,16). These differences between
different authors may be related to the surgeon preference.
In this study, although the overall postoperative complications were higher in the
OA group (35%) than LA group (10%), the result was statistically insignificant
(P=0.127) and Similarly, Katkhouda et al (2005) showed that there was no significant
difference in the overall complication rates (18.5% in the LA group versus 17.1% in the
OA group) (P = 1.00). Also Long et al found that no significant difference regarding
overall complications. Similarly, Alfredo et al (2004), showed that there was no
significant difference regarding overall post operative complications between OA group
and LA group although the incidence of complications was higher in the OA group( 8%
in the OA versus 3.6% in the LA) (8,16,15).
On the other hand, a study done by Shirazi et al reported that the rate of overall
complications (LA: 15%, OA: 31.8%, P < 0.0001) was significantly lower in patients
undergoing LA (20). Similarly, Guller et al showed that overall complications were
significantly lower in laparoscopic group (P = 0.002) (21). This difference in the
significance of overall post operative complications may be related to number of studied
cases and the pathology present in the appendix.
11
A meta-analysis of randomized controlled trials has been reported with outcomes of
2877 patients included in 28 trials. Overall complication rates were comparable, but
wound infections were definitely reduced after laparoscopy (2.3% to 6.1%) (22).
Kamal and Qureshi compared 42 patients who had laparoscopic appendectomy to
53 patients who had open appendectomy. Wound infection regarding skin was zero in
laparoscopic group and 3 wound infections in open group (13). previous results of
mentioned studies regarding wound infection are comparable to this study as this study
revealed that there was a significant decrease in wound infection in LA group
(PV=0.031).
Early reports centered on the use of the laparoscope to increase diagnostic accuracy
and decrease the negative appendectomy rate which ranges in some series from 20 to
30% (26). Laparoscopy has a great diagnostic value especially in acute abdomen. It plays
a significant role in young females where at times it is nearly impossible to differentiate
between acute appendicitis and gynecological clinical conditions like "Pelvic
Inflammatory disease", "Twisted ovary" and ectopic pregnancy etc (13).
Sauerland et al showed that diagnostic laparoscopy reduced the risk of a negative
appendectomy, but this effect was stronger in fertile women (relative risk 0.20;
confidence interval 0.11 to 0.34) as compared to unselected adults (relative risk 0.37;
confidence interval 0.13 to 1.01) (24).
Most surgeons agree on the use of laparoscopy when a patient is a young female
with vague lower abdominal pain and its progress to appendectomy.
There are
innumerable reports showing that laparoscopy improves diagnosis and reduces
unnecessary appendectomies in fertile women (17).
One study was done in Dublin on 100 premenopausal women who were admitted
with abdominal pain. After final assessment, patients were placed in following
diagnostic categories; gynecological (30%); non-specific abdominal pain (29%); acute
appendicitis (23%); renal (9%) and miscellaneous (9%).The mean duration of hospital
stay for patient with non specific abdominal pain was 6.7 days and one third of these
patients, underwent appendectomy for normal appendix
Abdominal pain in
premenopausal women is often psychosomatic and the laparoscopic intervention may be
12
considered in these women with non-specific pain abdomen to prevent removal of a
normal appendix (25).
However, this last sentence of O'Byrne et al (to prevent removal of a normal
appendix) is not agreed by most of the authors because the normal appendix should be
removed: first, to be biobsied and the second cause to eliminate acute appendicitis from
the differential diagnosis of subsequent abdominal pain (17, 24, 26).
In this study: laparoscopy revealed gynecological pathology in 4 patients (20%), 3
of them were dealt with laparoscopically and one was opened with Pfannenstiel incision
for salpengectomy for ectopic pregnancy. While in open procedure, associated pathology
was found in 2 patients, (10%). In both of them, the incision was converted to midline
exploratory one to be able to deal with the pathology.
In conclusion The results of this study clarify the importance of laparoscopy as a
diagnostic and therapeutic tool to deal with other causes of acute abdomen. This
advantage permits the surgeons to manage even gynecological cases without extending or
changing incisions with the least post operative complications.
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