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Laparoscopic Appendectomy Does Not Change the Incidence of Postoperative Infectious Complications
LAPAROSCOPY
Laparoscopic Appendectomy Does Not Change the Incidence of Postoperative Infectious Complications Anton Klingler, PhD, Innsbruck, Austria, Klaus P. Henle, MD, Siegfried Beller, MD, Jordan Rechner, MD, Andreas Zerz, MD, Bregenz, Austria, Gerold J. Wetscher, MD, Innsbruck, Austria, Gerhard Szinicz, MD, Bregenz, Austria
BACKGROUND: It is not clear whether the laparoscopic approach does decrease the incidence of postoperative infectious complications after appendectomy. METHODS: One hundred sixty-nine patients were randomized, 87 with laparoscopic (LA) and 82 with open appendectomy (OA). Patients in the OA group had a McBurney incision; LA was performed in the lithotomy position. RESULTS: Acute appendicitis was confirmed in 75% of patients. The appendix was perforated in 5 patients of the LA versus 2 patients of the OA group. No conversion to the open procedure was necessary. The median operating time was 35 minutes in the LA group and 31 minutes in the open group (P 5 0.58). The median postoperative hospital stay was shorter after laparoscopic than after open surgery (3 days versus 4 days, P 5 0.026), whereas the time required for return to work was not significantly different (14 versus 15 days). There were 5 (6%) patients with superficial wound infection following LA and 6 (7%) after OA (P 5 0.67). Intra-abdominal fluid collections were found in 2 (2%) patients following LA and 3 (4%) patients following OA (P 5 0.60). In the LA group, 3 patients presented with intra-abdominal hemorrhage and another 3 developed a paralytic ileus that was treated conservatively. CONCLUSIONS: Laparoscopic appendectomy is as safe and as effective as the open procedure; however, it does not decrease the rate of postoperative infectious complications. Am J Surg. 1998; 175:232–235. © 1998 by Excerpta Medica, Inc.
I
n the continuing debate about laparoscopic (LA) versus open (OA) appendectomy, the laparoscopic approach still has to prove its efficacy and safety in clinical trials. The lower incidence of postoperative infectious complica-
From the Department of General Surgery II, (AK, GJW), Division of Theoretical Surgery, (AK), University of Innsbruck, Innsbruck, Austria, and Department of Surgery (KPH, SB, JR, AZ, GS), LKH Bregenz, Bregenz, Austria. Requests for reprints should be addressed to Anton Klingler, PhD, Department of General Surgery II, Division of Theoretical Surgery, Schoepfstrasse 41, A-6020 Innsbruck, Austria. Manuscript submitted May 28, 1997 and accepted in revised form November 6, 1997.
232
© 1998 by Excerpta Medica, Inc. All rights reserved.
tions has been pointed out as an important argument for LA by several authors.1– 4 Moreover it has been considered that LA causes less postoperative pain,3 results in a shorter hospital stay5,6 and earlier recovery,7 and offers the possibility of accurate investigation of the abdominal cavity.8 In a recent review,9 the difference in wound complication rates is emphasized to be one of the major benefits of LA. Other authors have recently found an increased incidence of wound complications and/or intra-abdominal abscesses in retrospective studies following LA10,11—particularly in the case of perforated appendicitis. The present study was designed to investigate the benefits of LA with particular emphasis on the incidence and nature of postoperative infectious complications in the setting of a regional hospital with extensive experience in laparoscopic techniques and under routine conditions.
MATERIALS AND METHODS Between July 1992 and April 1994, 169 patients with an age between 14 and 70 years, ASA classification I, II, or III,12 and both sexes were included in this prospective, randomized trial. In the same time period, 127 patients were not included in this trial since they did not fulfill inclusion criteria (105 with age ,14 or .70 years, 3 with ASA IV, 18 refusing informed consent, 1 pregnancy). In 1 very obese patient OA was converted to LA and this patient was excluded from all analyses. Randomization resulted in 82 patients with open and 87 patients with laparoscopic appendectomy. No conversion from LA to OA was necessary. Both study groups were comparable with respect to age, gender, body weight (median 68 kg), ASA classification (79% ASA I, 19% ASA II, 2% ASA III), and preoperative white blood cell counts (Table I). One hundred eighteen patients (69% LA and 70% OA) had acute appendicitis and the appendix was perforated in 5 patients of the LA and 2 patients of the OA group. Fifteen patients in the laparoscopic and 14 in the open group had signs of local peritonitis with purulence. Eleven registrars and 4 experienced surgical residents participated in this trial. In the OA group patients had a McBurney incision. LA was performed in a lithotomy position using three trocars (12 mm umbilical, 5 mm right lateral, 10 mm suprapubic). The assistant guiding the camera stood between the patient’s legs, the surgeon at the left-hand side of the patient. The Endogia stapler (USSC, Norwalk, Connecticut) was used for dividing the appendix. Preoperative antibiotics and the use of an Endo-Bag (USSC) for removal of the appendix were not mandatory, 0002-9610/98/$19.00 PII S0002-9610(97)00286-9
LAPAROSCOPIC APPENDECTOMY/KLINGLER ET AL
TABLE I Patient Demographics and Operative Findings Number of patients Gender (% male, % female) Median age (years) Median preoperative WBC (G/l) Histological diagnosis (n, %) Normal or chronic Acute appendicitis Perforated appendicitis Carcinoid Local peritonitis with purulence (n) Antibiotic prophylaxis Removal of appendix with Endo-Bag
LA
OA
P Value
87 51, 49 30 12.9
82 48, 52 24 13.6
NS NS NS NS NS
21 (24%) 60 (69%) 5 (6%) 1 (1%) 15 (17%) 16 (18%) 31 (36%)
22 (27%) 58 (71%) 2 (2%) — 14 (18%) 7 (9%) —
NS NS NS NS
LA 5 laparoscopic appendectomy; OA 5 open appendectomy; NS 5 not significant.
but usually applied in the case of severe appendicitis. If an Endo-Bag was not used, the inflamed appendix was brought through the trocar by means of an extraction tube whenever possible and otherwise extracted through the wound. Piritramide and tramadol were used as analgetic medication and given on the patient’s demand. Beginning with the second postoperative day, patients were discharged after reaching full mobility and if clinical examinations as well as body temperature and white blood cell counts were normal. Five and 30 days after surgery, all patients were interviewed to determine recovery and clinical course. Absence from work and sports activities were registered. As subjective measures of recovery, patients were asked how long symptoms probably related to surgery (eg, wound pain, fatigue) lasted and to judge their satisfaction with the operative procedure and postoperative outcome on a 3-point scale (definitely satisfied, satisfied, insufficiently satisfied). Seventy-one patients (42%) attended our follow-up investigation 6 to 26 months (median 6 months) postoperatively. The sample size of this study was calculated in order to detect a difference of 15% versus 3% with a statistical power of 80% (two-sided chi-square test, a 5 5%). We performed a source data verification with a randomly selected sample of 20% of cases and detected no significant errors. The Statistical Analysis System (SAS Release 6.11) was used for all analyses. Statistical significance was calculated by means of nonparametric tests (chi-square and Fisher’s exact test for nominal data, Wilcoxon-MannWhitney for ordinal data). A P value of ,0.05 was considered to be significant.
RESULTS Intraoperative Course There was no bowel perforation or injury of deep vessels in the laparoscopic group. In 3 patients (1 OA and 2 LA) a remarkable bleeding in the operative field had to be managed. Fragmentation of the appendix during surgical manipulation occurred in 1 patient in each group. Operative access and dissection of the appendix were difficult in 6 patients (1 OA, 5 LA) owing to adhesions. Additional findings (adnexitis or endometriosis) were established in 3
female patients during LA. The median operating time (from incision to wound closure) was 31 minutes in the OA group and 35 minutes in the LA group (P 5 0.06, Table II). Postoperative Complications Five patients (6%) had wound infections after LA—all of them at the umbilical incision—and 6 (7%) after OA (Table II). Wound opening and lavage were performed in 8 (73%) of these patients, 3 (27%) were treated conservatively. Only 1 patient had perforated appendicitis (OA), but intraperitoneal purulence was intraoperatively found in 3 (2 OA, 1 LA). Antibiotic prophylaxis had been administered in 2 patients in each group and an Endo-Bag had been used for removal of the appendix in 2 patients of the laparoscopic group. Two patients in each group (2% OA, 2% LA) developed an intra-abdominal abscess (Table II), of which two were treated conservatively. One of the patients in the OA group without acute appendicitis had to be reoperated on twice. Another patient in the LA group with perforated appendicitis and local peritonitis developed a pelvic abscess, and 1 patient after OA with acute appendicitis had an intra-abdominal seroma; both had to be drained. Two patients in the LA group presented with intra-abdominal hemorrhage on the first and second postoperative day (Table II); 1 of them required laparoscopic reoperation. Another 3 patients after LA, 2 with perforated appendicitis, developed paralytic ileus and were treated conservatively. These complications did not occur following OA. Recovery We could not demonstrate any significant difference regarding administration or total dosage of analgetic and antibiotic medication (Table II). The median postoperative hospital stay was significantly shorter after laparoscopic surgery (3 versus 4 days). The duration of symptoms related to surgery was shorter and sport activities were resumed earlier after LA, but there was no difference regarding the return to work (Table II). The follow-up investigations of 71 patients (42%, 32 OA and 39 LA) revealed no further pathologic findings. Patients in this
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TABLE II Postoperative Course and Complications LA Duration of operation, median (range) Number of complications, total (%) Wound infections (%) Intra-abdominal abscess (%) Intra-abdominal hemorrhage (%) Transient paralytic ileus (%) Hematoma, Seroma (%) Postoperative analgesic treatment Number of patients (%) Duration, median (range) Postoperative antibiotic treatment Number of patients (%) Duration, median (range) Length of hospital stay, median (range) Duration of surgery related symptoms, median (range) Return to sport activities, median (range) Return to work, median (range)
OA
P Value
31 9 6 2
(15–107) min (11%) (7%) (2%) — — 1 (1%)
NS NS NS
40 (46%) 2 (1–5) days
46 (56%) 2 (1–6) days
NS NS
12 4.5 3 7 13 14
14 3 4 11 20 15
35 14 5 2 3 3 1
(10–140) min (16%) (6%) (2%) (3%) (3%) (1%)
(14%) (1–10) (2–23) (0–40) (5–40) (5–45)
days days days days days
(17%) (1–10) days (1–24) days (1–35) days (11–35) days (6–37) days
NS NS 0.026 0.008 0.002 NS
LA 5 laparoscopic appendectomy; OA 5 open appendectomy; NS 5 not significant.
subgroup were significantly more satisfied with the laparoscopic procedure (P 5 0.003): 84% versus 46% of patients were definitively satisfied, 8% versus 42% were satisfied, and 8% versus 13% were insufficiently satisfied with the surgical procedure and the postoperative course.
COMMENTS A decreased incidence of wound infections has been considered to be a major advantage of laparoscopic appendectomy.9 During LA the inflamed appendix may be dissected without direct contact with the wound surface, thus avoiding wound infections. However, results of various studies are controversial. Kum et al1 showed that patients after LA had fewer wound infections (0% versus 9%), required less analgetic medication, had a shorter hospital stay, and were earlier back to social activities or work than patients after open appendectomy. Similar results were demonstrated by Ortega et al3 and by Hansen et al.4 In the studies of Martin et al,5 Attwood et al,6 Frazee et al,7 Tate et al,13 and Cox et al,14 the rate of postoperative infectious complications was not decreased following LA. Frazee et al17 and Tang et al15 even demonstrated an increased risk of intra-abdominal abscess formation following LA in patients with perforated appendicitis. In our study, LA did not improve the results regarding infectious complications and the consumption of antibiotic medication was similar as following open appendectomy. All of our infected wounds were situated at the incision where the appendix was removed, suggesting that these wound were contaminated intraoperatively. In 2 cases even the use of an Endo-Bag apparently could not prevent contamination. It is not known whether these results are due to an increased risk of wound complications in patients with perforated appendicitis, since the incidence of this entity was too low in our series precluding statistical analysis. Laparoscopy may provide benefits in terms of accurate diagnosis, especially in female patients with abdominal pain of unclear origin.8,16 –18 Our rate of patients with 234
normal appendix or chronic appendicitis (25%) demonstrates the well-known need for improving diagnostic accuracy in patients with acute abdominal pain. We established additional diagnostic findings in 3 female patients during laparoscopic appendectomy, but 2 of them had acute appendicitis. Thus, the clinical value of these additional findings seems questionable. Laparoscopic appendectomy did not result in intraoperative complications related to the laparoscopic approach such as bowel injury or severe hemorrhage due to injury of major vessels, and the operating time was not significantly longer than that of OA. Several published reports demonstrate the higher risk of such intraoperative complications, especially in the learning phase of laparoscopic techniques. Our results were achieved despite the fact that most of the procedures were performed by residents with low experience in laparoscopic surgery. Thus, it may be concluded that laparoscopic appendectomy is safe and suitable as a teaching operation if assisted by an experienced laparoscopic surgeon. The hospital stay was shorter following laparoscopic than after open appendectomy, which is in accordance with previous studies.3,5,6 However, there was no difference in the consumption of analgetic medication between the study groups. Thus, one might argue that the difference in hospital stay is due to the fact that discharge criteria may not have been the same for the two groups. This opinion is supported by the study of Hansen et al,4 who found an equal length of hospital stay for the laparoscopic and open procedure. We used the same criteria of discharge in both groups. Patients were discharged from hospital if the clinical investigations and the white blood cell count were normal, and patients were free of fever. Patients were earlier back at sports activities following LA than following OA, perhaps because wound pain lasted longer after the open procedure. However, there was no difference regarding the return to work. This may be explained by the
THE AMERICAN JOURNAL OF SURGERY® VOLUME 175 MARCH 1998
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Austrian health system during the study period in which no difference is made between laparoscopic and open surgery regarding the certification of temporary disablement for work. Our study demonstrates that laparoscopic appendectomy is as safe and as effective as the open procedure. It is beneficial regarding a shorter hospital stay and earlier recovery, but the differences found in our study were only small. Moreover, laparoscopic appendectomy does not decrease the rate of wound complications. From the clinical point of view, neither technique is really superior to the other, and the preferred method is therefore a subjective decision of the surgeon and the patient. Since laparoscopic appendectomy may also be more cost intensive than the open procedure,19 and there is no striking clinical advantage, it cannot be generally recommended as the treatment of first choice. It is still acceptable to perform the open procedure, especially in hospitals without large laparoscopic experience.
REFERENCES 1. Kum CK, Ngoi SS, Goh PMY, et al. Randomized controlled trial comparing laparoscopic and open appendicetomy. Br J Surg. 1993; 80:1599 –1600. 2. Mompean JAL, Campos RR, Paricio PP, et al. Laparoscopic vs. open appendicectomy: a prospective assessment. Br J Surg. 1994; 81:133–135. 3. Ortega AE, Hunter JG, Peters JH, et al. A prospective, randomized comparison of laparoscopic appendectomy with open appendectomy. Am J Surg. 1995;169:208 –212. 4. Hansen JB, Smithers MB, Schache D, et al. Laparoscopic versus open appendectomy: prospective randomized trial. World J Surg. 1996;20:17–21. 5. Martin LC, Puente I, Sosa JL, et al. Open versus laparoscopic appendectomy. A prospective randomized comparison. Ann Surg. 1995;222:256 –262.
6. Attwood SEA, Hill DK, Murphy PG, et al. A prospective randomized trial of laparoscopic vs. open appendicectomy. Surgery. 1992;112:497–501. 7. Frazee RC, Roberts JW, Symmonds RE, et al. A pospective randomized trial comparing open vs. laparoscopic appendectomy. Ann Surg. 1994;219:725–731. 8. Schirmer BD, Schmieg RE, Dix J, et al. Laparoscopic versus traditional appendectomy for suspected appendicitis. Am J Surg. 1993;165:670 – 675. 9. Tate JJT. Laparoscopic appendicectomy. Br J Surg. 1996;83: 1169 –1170. 10. Paik PS, Towson JA, Anthone GJ, et al. Intra-abdominal abscesses following laparoscopic and open appendectomies. Gastroenterology. 1996;110:A1409. 11. Frazee RC, Bohannon WT. Laparoscopic appendectomy for complicated appendicitis. Arch Surg. 1996;131:509 –512. 12. American Society of Anesthesiologists. New classification of physical status. Anesthesiology. 1963;24:111. 13. Tate JJT, Dawson JW, Chung SCS, et al. Laparoscopic versus open appendicectomy: prospective randomised trial. Lancet. 1993; 342:633– 637. 14. Cox MR, McCall JL, Toouli J, et al. Prospective randomized comparison of open versus laparoscopic appendectomy in men. World J Surg. 1996;20:263–266. 15. Tang E, Ortega AE, Anthone GJ, Beart BW. Intraabdominal abscesses following laparoscopic and open appendectomies. Surg Endosc. 1996;10:327–328. 16. Welch NT, Hinder RA, Fitzgibbons RJJ. Laparoscopic incidental appendectomy. Surg Laparosc Endosc. 1991;1:116 –118. 17. Olsen JB, Myren CJ, Haahr PE. Randomized study of the value of laparoscopy before appendectomy. Br J Surg. 1993;80: 911–923. 18. Connor TJ, Garcha IS, Ramshaw BJ, et al. Diagnostic laparoscopy for suspected appendicitis. Am Surg. 1995;61:187–189. 19. McCahill E, Pellegrini CA, Wiggins T, Helton WS. A clinical outcome and cost analysis of laparoscopic versus open appendectomy. Am J Surg. 1996;171:533–537.
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Laparoscopic Appendectomy Does Not Change the Incidence of Postoperative Infectious Complications Anton Klingler, PhD, Innsbruck, Austria, Klaus P. Henle, MD, Siegfried Beller, MD, Jordan Rechner, MD, Andreas Zerz, MD, Bregenz, Austria, Gerold J. Wetscher, MD, Innsbruck, Austria, Gerhard Szinicz, MD, Bregenz, Austria
BACKGROUND: It is not clear whether the laparoscopic approach does decrease the incidence of postoperative infectious complications after appendectomy. METHODS: One hundred sixty-nine patients were randomized, 87 with laparoscopic (LA) and 82 with open appendectomy (OA). Patients in the OA group had a McBurney incision; LA was performed in the lithotomy position. RESULTS: Acute appendicitis was confirmed in 75% of patients. The appendix was perforated in 5 patients of the LA versus 2 patients of the OA group. No conversion to the open procedure was necessary. The median operating time was 35 minutes in the LA group and 31 minutes in the open group (P 5 0.58). The median postoperative hospital stay was shorter after laparoscopic than after open surgery (3 days versus 4 days, P 5 0.026), whereas the time required for return to work was not significantly different (14 versus 15 days). There were 5 (6%) patients with superficial wound infection following LA and 6 (7%) after OA (P 5 0.67). Intra-abdominal fluid collections were found in 2 (2%) patients following LA and 3 (4%) patients following OA (P 5 0.60). In the LA group, 3 patients presented with intra-abdominal hemorrhage and another 3 developed a paralytic ileus that was treated conservatively. CONCLUSIONS: Laparoscopic appendectomy is as safe and as effective as the open procedure; however, it does not decrease the rate of postoperative infectious complications. Am J Surg. 1998; 175:232–235. © 1998 by Excerpta Medica, Inc.
I
n the continuing debate about laparoscopic (LA) versus open (OA) appendectomy, the laparoscopic approach still has to prove its efficacy and safety in clinical trials. The lower incidence of postoperative infectious complica-
From the Department of General Surgery II, (AK, GJW), Division of Theoretical Surgery, (AK), University of Innsbruck, Innsbruck, Austria, and Department of Surgery (KPH, SB, JR, AZ, GS), LKH Bregenz, Bregenz, Austria. Requests for reprints should be addressed to Anton Klingler, PhD, Department of General Surgery II, Division of Theoretical Surgery, Schoepfstrasse 41, A-6020 Innsbruck, Austria. Manuscript submitted May 28, 1997 and accepted in revised form November 6, 1997.
232
© 1998 by Excerpta Medica, Inc. All rights reserved.
tions has been pointed out as an important argument for LA by several authors.1– 4 Moreover it has been considered that LA causes less postoperative pain,3 results in a shorter hospital stay5,6 and earlier recovery,7 and offers the possibility of accurate investigation of the abdominal cavity.8 In a recent review,9 the difference in wound complication rates is emphasized to be one of the major benefits of LA. Other authors have recently found an increased incidence of wound complications and/or intra-abdominal abscesses in retrospective studies following LA10,11—particularly in the case of perforated appendicitis. The present study was designed to investigate the benefits of LA with particular emphasis on the incidence and nature of postoperative infectious complications in the setting of a regional hospital with extensive experience in laparoscopic techniques and under routine conditions.
MATERIALS AND METHODS Between July 1992 and April 1994, 169 patients with an age between 14 and 70 years, ASA classification I, II, or III,12 and both sexes were included in this prospective, randomized trial. In the same time period, 127 patients were not included in this trial since they did not fulfill inclusion criteria (105 with age ,14 or .70 years, 3 with ASA IV, 18 refusing informed consent, 1 pregnancy). In 1 very obese patient OA was converted to LA and this patient was excluded from all analyses. Randomization resulted in 82 patients with open and 87 patients with laparoscopic appendectomy. No conversion from LA to OA was necessary. Both study groups were comparable with respect to age, gender, body weight (median 68 kg), ASA classification (79% ASA I, 19% ASA II, 2% ASA III), and preoperative white blood cell counts (Table I). One hundred eighteen patients (69% LA and 70% OA) had acute appendicitis and the appendix was perforated in 5 patients of the LA and 2 patients of the OA group. Fifteen patients in the laparoscopic and 14 in the open group had signs of local peritonitis with purulence. Eleven registrars and 4 experienced surgical residents participated in this trial. In the OA group patients had a McBurney incision. LA was performed in a lithotomy position using three trocars (12 mm umbilical, 5 mm right lateral, 10 mm suprapubic). The assistant guiding the camera stood between the patient’s legs, the surgeon at the left-hand side of the patient. The Endogia stapler (USSC, Norwalk, Connecticut) was used for dividing the appendix. Preoperative antibiotics and the use of an Endo-Bag (USSC) for removal of the appendix were not mandatory, 0002-9610/98/$19.00 PII S0002-9610(97)00286-9
LAPAROSCOPIC APPENDECTOMY/KLINGLER ET AL
TABLE I Patient Demographics and Operative Findings Number of patients Gender (% male, % female) Median age (years) Median preoperative WBC (G/l) Histological diagnosis (n, %) Normal or chronic Acute appendicitis Perforated appendicitis Carcinoid Local peritonitis with purulence (n) Antibiotic prophylaxis Removal of appendix with Endo-Bag
LA
OA
P Value
87 51, 49 30 12.9
82 48, 52 24 13.6
NS NS NS NS NS
21 (24%) 60 (69%) 5 (6%) 1 (1%) 15 (17%) 16 (18%) 31 (36%)
22 (27%) 58 (71%) 2 (2%) — 14 (18%) 7 (9%) —
NS NS NS NS
LA 5 laparoscopic appendectomy; OA 5 open appendectomy; NS 5 not significant.
but usually applied in the case of severe appendicitis. If an Endo-Bag was not used, the inflamed appendix was brought through the trocar by means of an extraction tube whenever possible and otherwise extracted through the wound. Piritramide and tramadol were used as analgetic medication and given on the patient’s demand. Beginning with the second postoperative day, patients were discharged after reaching full mobility and if clinical examinations as well as body temperature and white blood cell counts were normal. Five and 30 days after surgery, all patients were interviewed to determine recovery and clinical course. Absence from work and sports activities were registered. As subjective measures of recovery, patients were asked how long symptoms probably related to surgery (eg, wound pain, fatigue) lasted and to judge their satisfaction with the operative procedure and postoperative outcome on a 3-point scale (definitely satisfied, satisfied, insufficiently satisfied). Seventy-one patients (42%) attended our follow-up investigation 6 to 26 months (median 6 months) postoperatively. The sample size of this study was calculated in order to detect a difference of 15% versus 3% with a statistical power of 80% (two-sided chi-square test, a 5 5%). We performed a source data verification with a randomly selected sample of 20% of cases and detected no significant errors. The Statistical Analysis System (SAS Release 6.11) was used for all analyses. Statistical significance was calculated by means of nonparametric tests (chi-square and Fisher’s exact test for nominal data, Wilcoxon-MannWhitney for ordinal data). A P value of ,0.05 was considered to be significant.
RESULTS Intraoperative Course There was no bowel perforation or injury of deep vessels in the laparoscopic group. In 3 patients (1 OA and 2 LA) a remarkable bleeding in the operative field had to be managed. Fragmentation of the appendix during surgical manipulation occurred in 1 patient in each group. Operative access and dissection of the appendix were difficult in 6 patients (1 OA, 5 LA) owing to adhesions. Additional findings (adnexitis or endometriosis) were established in 3
female patients during LA. The median operating time (from incision to wound closure) was 31 minutes in the OA group and 35 minutes in the LA group (P 5 0.06, Table II). Postoperative Complications Five patients (6%) had wound infections after LA—all of them at the umbilical incision—and 6 (7%) after OA (Table II). Wound opening and lavage were performed in 8 (73%) of these patients, 3 (27%) were treated conservatively. Only 1 patient had perforated appendicitis (OA), but intraperitoneal purulence was intraoperatively found in 3 (2 OA, 1 LA). Antibiotic prophylaxis had been administered in 2 patients in each group and an Endo-Bag had been used for removal of the appendix in 2 patients of the laparoscopic group. Two patients in each group (2% OA, 2% LA) developed an intra-abdominal abscess (Table II), of which two were treated conservatively. One of the patients in the OA group without acute appendicitis had to be reoperated on twice. Another patient in the LA group with perforated appendicitis and local peritonitis developed a pelvic abscess, and 1 patient after OA with acute appendicitis had an intra-abdominal seroma; both had to be drained. Two patients in the LA group presented with intra-abdominal hemorrhage on the first and second postoperative day (Table II); 1 of them required laparoscopic reoperation. Another 3 patients after LA, 2 with perforated appendicitis, developed paralytic ileus and were treated conservatively. These complications did not occur following OA. Recovery We could not demonstrate any significant difference regarding administration or total dosage of analgetic and antibiotic medication (Table II). The median postoperative hospital stay was significantly shorter after laparoscopic surgery (3 versus 4 days). The duration of symptoms related to surgery was shorter and sport activities were resumed earlier after LA, but there was no difference regarding the return to work (Table II). The follow-up investigations of 71 patients (42%, 32 OA and 39 LA) revealed no further pathologic findings. Patients in this
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TABLE II Postoperative Course and Complications LA Duration of operation, median (range) Number of complications, total (%) Wound infections (%) Intra-abdominal abscess (%) Intra-abdominal hemorrhage (%) Transient paralytic ileus (%) Hematoma, Seroma (%) Postoperative analgesic treatment Number of patients (%) Duration, median (range) Postoperative antibiotic treatment Number of patients (%) Duration, median (range) Length of hospital stay, median (range) Duration of surgery related symptoms, median (range) Return to sport activities, median (range) Return to work, median (range)
OA
P Value
31 9 6 2
(15–107) min (11%) (7%) (2%) — — 1 (1%)
NS NS NS
40 (46%) 2 (1–5) days
46 (56%) 2 (1–6) days
NS NS
12 4.5 3 7 13 14
14 3 4 11 20 15
35 14 5 2 3 3 1
(10–140) min (16%) (6%) (2%) (3%) (3%) (1%)
(14%) (1–10) (2–23) (0–40) (5–40) (5–45)
days days days days days
(17%) (1–10) days (1–24) days (1–35) days (11–35) days (6–37) days
NS NS 0.026 0.008 0.002 NS
LA 5 laparoscopic appendectomy; OA 5 open appendectomy; NS 5 not significant.
subgroup were significantly more satisfied with the laparoscopic procedure (P 5 0.003): 84% versus 46% of patients were definitively satisfied, 8% versus 42% were satisfied, and 8% versus 13% were insufficiently satisfied with the surgical procedure and the postoperative course.
COMMENTS A decreased incidence of wound infections has been considered to be a major advantage of laparoscopic appendectomy.9 During LA the inflamed appendix may be dissected without direct contact with the wound surface, thus avoiding wound infections. However, results of various studies are controversial. Kum et al1 showed that patients after LA had fewer wound infections (0% versus 9%), required less analgetic medication, had a shorter hospital stay, and were earlier back to social activities or work than patients after open appendectomy. Similar results were demonstrated by Ortega et al3 and by Hansen et al.4 In the studies of Martin et al,5 Attwood et al,6 Frazee et al,7 Tate et al,13 and Cox et al,14 the rate of postoperative infectious complications was not decreased following LA. Frazee et al17 and Tang et al15 even demonstrated an increased risk of intra-abdominal abscess formation following LA in patients with perforated appendicitis. In our study, LA did not improve the results regarding infectious complications and the consumption of antibiotic medication was similar as following open appendectomy. All of our infected wounds were situated at the incision where the appendix was removed, suggesting that these wound were contaminated intraoperatively. In 2 cases even the use of an Endo-Bag apparently could not prevent contamination. It is not known whether these results are due to an increased risk of wound complications in patients with perforated appendicitis, since the incidence of this entity was too low in our series precluding statistical analysis. Laparoscopy may provide benefits in terms of accurate diagnosis, especially in female patients with abdominal pain of unclear origin.8,16 –18 Our rate of patients with 234
normal appendix or chronic appendicitis (25%) demonstrates the well-known need for improving diagnostic accuracy in patients with acute abdominal pain. We established additional diagnostic findings in 3 female patients during laparoscopic appendectomy, but 2 of them had acute appendicitis. Thus, the clinical value of these additional findings seems questionable. Laparoscopic appendectomy did not result in intraoperative complications related to the laparoscopic approach such as bowel injury or severe hemorrhage due to injury of major vessels, and the operating time was not significantly longer than that of OA. Several published reports demonstrate the higher risk of such intraoperative complications, especially in the learning phase of laparoscopic techniques. Our results were achieved despite the fact that most of the procedures were performed by residents with low experience in laparoscopic surgery. Thus, it may be concluded that laparoscopic appendectomy is safe and suitable as a teaching operation if assisted by an experienced laparoscopic surgeon. The hospital stay was shorter following laparoscopic than after open appendectomy, which is in accordance with previous studies.3,5,6 However, there was no difference in the consumption of analgetic medication between the study groups. Thus, one might argue that the difference in hospital stay is due to the fact that discharge criteria may not have been the same for the two groups. This opinion is supported by the study of Hansen et al,4 who found an equal length of hospital stay for the laparoscopic and open procedure. We used the same criteria of discharge in both groups. Patients were discharged from hospital if the clinical investigations and the white blood cell count were normal, and patients were free of fever. Patients were earlier back at sports activities following LA than following OA, perhaps because wound pain lasted longer after the open procedure. However, there was no difference regarding the return to work. This may be explained by the
THE AMERICAN JOURNAL OF SURGERY® VOLUME 175 MARCH 1998
LAPAROSCOPIC APPENDECTOMY/KLINGLER ET AL
Austrian health system during the study period in which no difference is made between laparoscopic and open surgery regarding the certification of temporary disablement for work. Our study demonstrates that laparoscopic appendectomy is as safe and as effective as the open procedure. It is beneficial regarding a shorter hospital stay and earlier recovery, but the differences found in our study were only small. Moreover, laparoscopic appendectomy does not decrease the rate of wound complications. From the clinical point of view, neither technique is really superior to the other, and the preferred method is therefore a subjective decision of the surgeon and the patient. Since laparoscopic appendectomy may also be more cost intensive than the open procedure,19 and there is no striking clinical advantage, it cannot be generally recommended as the treatment of first choice. It is still acceptable to perform the open procedure, especially in hospitals without large laparoscopic experience.
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