|Year : 2022 | Volume
| Issue : 3 | Page : 299-303
Laparoscopic versus open appendectomy in patients with acute appendicitis
Mohamed A Kamel, Mohamed Abdelfattah, Gamal G Shimy
Department of General Surgery, Faculty of Medicine, Al-Azhar University, Assiut, Egypt
|Date of Submission||15-Feb-2022|
|Date of Decision||05-Apr-2022|
|Date of Acceptance||06-May-2022|
|Date of Web Publication||11-Oct-2022|
Mohamed A Kamel
Source of Support: None, Conflict of Interest: None
Background and aim There were numerous previous studies comparing open appendectomy (OA) with laparoscopic appendectomy (LA). Although most of these have concluded that the LA is good as OA, there has been considerable controversy as to whether LA is superior to OA or not.
The goal of this study was to compare the results of the previous two surgical methods and determine if LA is better than OA.
Patients and methods A prospective research, including 40 patients with a suspected acute appendicitis, was conducted between January 2018 and May 2019. The LA group had 20 patients, while the OA group had 20 cases. LA was performed using three trocars/cannulas to create pneumoperitoneum with CO2, whereas OA was done using the Mc Burney incision (Clinical trial registration number : PACTR202203884835048).
Results Appendectomies were done on 14 males and 26 women for a total of 40 appendectomies. In LA, the mean operative time was 45.50±13.26 min, whereas in OA, it was 53.50±14.78 min (P=0.001). In the LA group, none of the patients experienced intraoperative problems, but four individuals in the OA group did. Postoperative problems were observed in four (20%) patients in the LA group and five (25%) patients in the OA group. Compared with those who had OA, those who had LA had a considerably shorter hospital stay (14.60±5.45 vs. 24.10±5.60 h, P=0.001).
Conclusions LA is just as safe and successful as OA, with key advantages such as less discomfort, fewer wound infections, and shorter hospital stays.
Keywords: acute appendicitis, laparoscopic appendectomy, open appendectomy
|How to cite this article:|
Kamel MA, Abdelfattah M, Shimy GG. Laparoscopic versus open appendectomy in patients with acute appendicitis. Al-Azhar Assiut Med J 2022;20:299-303
|How to cite this URL:|
Kamel MA, Abdelfattah M, Shimy GG. Laparoscopic versus open appendectomy in patients with acute appendicitis. Al-Azhar Assiut Med J [serial online] 2022 [cited 2023 Jan 27];20:299-303. Available from: http://www.azmj.eg.net/text.asp?2022/20/3/299/358032
| Introduction|| |
In the Western world, appendicitis is one of the most prevalent causes of acute abdomen and one of the most common reasons for abdominal surgery. It affects 7–12% of the general population, and while it can affect anyone at any age, it is most frequent in those aged 10–19 .
Surgical and nonsurgical treatment options for appendicitis vary, depending on the pathologic stage, including laparoscopic appendectomy (LA) or open appendectomy (OA), primary antibiotic therapy, or percutaneous draining of peri-appendiceal abscesses .
For almost a century, the sole conventional therapy for appendicitis was an OA. Recent European trials have revealed that uncomplicated appendicitis can be treated nonoperatively with antibiotics alone .
The laparoscopic method is regarded to be preferable in terms of a decreased risk of wound infections, less discomfort on the first postoperative day, and a shorter hospital stay. Perhaps more crucially, it allows for a thorough examination of the whole intra-abdominal cavity, allowing for the detection of alternative reasons that resemble appendicitis, as well as less short-term and long-term adhesion-bowel blockages .
Meanwhile, open surgery is linked to a reduced risk of intra-abdominal abscesses, a little quicker operation, and cheaper expenses, but this may alter as laparoscopy becomes more widely used and advances . Despite the fact that multiple independent investigations and meta-analyses of those research have been completed, the final word has yet to be spoken.
The goal of this study was to compare the results of the previous two surgical methods and determine if LA is better than OA.
| Patients and methods|| |
A randomized controlled experiment was undertaken at the Al-Azhar University Hospital in Assiut and Assiut University Students’ Hospital, Department of General Surgery. The research was conducted from January 2018 to May 2019.
Sample size: all the patients presented with acute appendicitis in this period are included in the study.
Clinical trial registration number : PACTR202203884835048.
Approval of the study was obtained from the Research Ethics Committees of Faculty of Medicine and conducted in accordance with the Code of Good Practice and the guidelines of Declaration of Helsinki, 7th revision, 2013. All patients were informed about the study and a written consent was obtained from each patient.
The study included 40 individuals who had clinical, laboratory, and radiographic signs of acute appendicitis. The following criteria were used to diagnose appendicitis: right lower-quadrant pain or periumbilical pain migrating to the right lower quadrant with nausea and/or vomiting, fever greater than 38°C and/or leukocytosis greater than 10 000 cells/ml, right lower-quadrant guarding, and tenderness on physical examination. Also, by investigations that exclude other causes of acute abdomen and exclude any other cause for right iliac fossa pain, for example, ileocecal intussusception. Any patient with an acute Alvarado score of 7 or more was administered.
Simple randomization was carried out using sequentially numbered opaque envelopes and random numbers ([Table 1]), with 20 patients divided into two groups: OA group (group A) and LA group (group B). For OA, surgery was done using a standard Mc Burney incision. The incision was centered over the point of maximal tenderness (Mc Burney’s point). The appendix was delivered and mesoappendix ligated and divided, then, the appendix was ligated and divided at the base. The terminal ileum, ovaries, and fallopian tube in females were looked out for any alternative pathology. For LA ([Figure 1]): in our study, we used the closed technique by Veress needle to enter the abdomen and create the pneumoperitoneum. Ten-millimeter port is inserted at the umbilicus for the laparoscope. The abdomen was insufflated with CO2 to an intra-abdominal pressure of 15 mmHg, as insertion of the first trocar (10 mm) at the umbilicus for the camera was done. The second trocar (10 mm) was placed into the left iliac fossa (2 cm above and medial to the left anterior–superior iliac spine). The third trocar (5 mm) was put in the suprapubic area (to the left of the midline, 1 cm above the pubic ramus). Diagnostic laparoscopy is recommended prior to proceeding to the appendectomy. Mesoappendix coagulation has been achieved by using the diathermy or harmonic or ligature to extract the mesoappendix. We protect in an extracorporeal way the base of the appendix by pushing a knot pusher across the port at the right-hand side with two successive links of Vicryl 2/0. The appendix is inserted in an extraction sac from the abdomen. The appendix is removed through the umbilical tube. This can be achieved by moving the laparoscope to the suprapubic position and using a claw grasper to grab the Endo bag via the umbilical site.
|Figure 1 (a) Insertion of laparoscopic trocars. (b) Application of clip to the appendicular artery and stapler division of appendix and mesoappendix.|
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From skin incision up to wound closure, the operating time is measured in minutes. Intraoperative problems and transition into opening procedure, postoperative complications, morbidity, including infection with the wound, general operating implications, collecting intraperitoneally, postoperative discomfort and time required to return to work, duration of stay at hospital, and The visual analog scale is a 10-cm long line that represents a visual analog score for postoperative pain. The line’s endpoints represent the maximum amount of pain a patient may tolerate as a result of external stimulation, with no discomfort at one end and the most acute agony at the other. Patients were asked to mark the 10-cm line in the first 24 h to indicate the level of postoperative discomfort.
The Statistical Programme for Social Sciences, version 20.0, was used to analyze the data (SPSS Inc., Chicago, Illinois, USA). The mean and SD of quantitative data were calculated and compared using the Student test. The χ2 test was used to compare qualitative data given as frequency and percentage. Because the level of confidence was held at 95%, a P value of 0.05 was considered significant.
| Results|| |
The mean age of the LA group was 31.20±8.61 years, with a mean BMI of 26.10±3.30 kg/m2, while the mean age of the OA group was 27.55±7.45 years, with a mean BMI of 26.74±3.25 kg/m2. Females made up the majority of both groups (55% in the LA group and 75% in the OA group).
Operative time and complications among studied groups
Both groups had insignificant difference as regards operative time (45.50±13.26 vs. 53.50±14.78 min, P=0.08). None of patients underwent LA-developed intraoperative complications, while four patients of OA group had intraoperative complications in the form of serosal tear (two patients), slipped mesoappendix (one patient), and bleeding (one patient) ([Table 2]).
Postoperative complications among studied patients
It was found that two patients underwent LA-developed port-site bleeding and another two patients developed paralytic ileus, and none of the patients of this group had wound infection. Five (25%) patients underwent OA-developed wound infection. In terms of postoperative complications, there was a significant difference between the two groups (P=0.02) ([Table 3]).
Postoperative visual analog scale and hospital stay among studied groups
In contrast to those who had OA, patients who had LA had a lower visual analog score (3.80±0.83 vs. 4.60±0.68, P=0.001) and a shorter hospital stay (14.60±5.45 vs. 20.10±5.60 h, P=0.001) ([Table 4]).
|Table 4 Postoperative visual analog scale and hospital stay among the studied groups|
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Postoperative recovery and return to daily activity among studied groups
Patients who underwent LA returned to their daily activity within significantly shorter duration in comparison with those who underwent OA (5.20±0.83 vs. 7.55±1.67 days, P<0.001) ([Table 5]).
|Table 5 Postoperative recovery and return to daily activity among the studied groups|
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| Discussion|| |
Only a few studies comparing OA and LA have been published. Abass et al.  found 239 (72.9%) and 185 (83.3%) female patients in the OA and LA groups, respectively, which is similar to the current study. In terms of baseline data, the authors found no significant differences between the two groups.
We reported that both groups had insignificant difference as regards operative time (45.50±13.26 vs. 53.50±14.78 min, P=0.08). LA has considerably longer operative times, according to preliminary investigations ,. Ibraheem et al.  showed a highly statistically significant decrease of mean operative time of OA (34.50±11.48 min) compared with LA (56.42±8.69 min). The range of operative time of OA is 20–60 min compared with the range of LA (30–70 min).
The latter research, on the other hand, found no correlation between length and results. The length of the operation is determined by the surgeon’s expertise and the competency of the operating team ,. While Mantoğlu et al.  reported decreased operative time of LA (mean 41.42±10.32 min) compared with OA (mean 46.25±18.84 min) and explained that may be attributed to the fact that their team has enough experience with LA. In the current situation, in terms of postoperative complications, there was a significant difference between the two groups (P=0.02). In line with these findings, Shirazi et al.  found that the rate of total postoperative problems was considerably lower in the LA patients’ group (LA: 15%, OA: 31.8%, P=0.0001).
Another study found that following LA, the wound-infection rate was significantly reduced, which was associated with the lower perforation incidence . Other studies found no significant differences in postoperative wound infection or intra-abdominal infections between the two groups ,,.
In the current study, the average pain score was 3.62±1.10 in the open group as opposed to 2.12±0.56 in the laparoscopic group, with P=0.001 being significant. Pain was qualitatively classified into mild, moderate, and severe, according to the visual analog scale .
This finding is also consistent with a research by Pogorelic et al. , which found that the number of analgesics utilized was fewer in LA patients compared with OA patients (P=0.042). In addition, Liu et al.  found that from the 2nd to the 26th day following the surgery, the pain-intensity score in the laparoscopic group was significantly lower than in the OA group (P=0.04).
All prior hospital-stay data from the studies cited are comparable to our findings, which demonstrated that the average length of stay in the LA group was much shorter . The average length of hospital stay was lower in the LA group (34 13 h in LA vs. 40 11 h in OA, P=0.01), according to Ali et al. . According to Svensson et al. , LA resulted in a reduced median postoperative length of stay, 43 versus 57 h (P=0.05). In Italian research, the laparoscopic group had considerably shorter hospital stays (mean 1.40.6 days) than the OA group (P=0.015), with patients’ laparoscopically treated early bowel motions, leading to faster hospital meals and release .
According to Talha et al. , the average time to resume normal work for laparoscopic procedures was 15.33.4 days, whereas the average time for open procedures was 22.33.7 days, indicating that the laparoscopic group resumed usual work sooner than the open group. Compared with OA, current retrenching cohort studies or chart investigations have indicated that LA has a shorter hospital stay . In OA, the time to return to regular operations ranged from 7 to 25 days (mean 14.8 days), whereas in LA, the time ranged from 7 to 15 days (mean 9.8 days) . There was no death in this research. This experience is in line with the bulk of previous reports .
Limitations and recommendations
The current study has some limitations, including a limited sample size, short-term follow-up of both groups, and the lack of cost analysis in both procedures. It is suggested that such research be carried out on a wide scale in numerous locations. Future research is needed to compare the cost analyses of OA and LA.
The study revealed that patients who underwent LA had significantly lower postoperative complications, lower pain score, and shorter hospital stay. Also, those patients were returned earlier to their normal activity in comparison with those patients who underwent OA.
Financial support and ponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]