The laparoscopic approach for perforated appendicitis, including cases complicated by abscess formation

Perforated appendicitis treated with laparoscopic appendicectomy or open appendicectomy: A meta-analysis

Aim

This analysis compared the impact of laparoscopic appendicectomy (LA) and open appendicectomy (OA) on treating adult perforated appendicitis (PA).

Methods

Articles relating to LA and OA in treating PA were retrieved from databases including PubMed, Cochrane Library and Embase since their founding to January 2022. These articles were independently filtered based on the inclusion and exclusion criteria by two investigators. The quality of these articles was assessed and article data were extracted. Dichotomous data were presented in the form of odd's ratio (OR), whereas continuous data were in the form of weighted mean difference (WMD). The included articles reported at least one of the following outcomes: intra-abdominal abscess (IAA), wound infection, operative time, hospital stay and complications.

Results

Three randomised control trials (198 LA cases vs. 205 OA cases) and 12 case - control trials (914 LA cases vs. 2192 OA cases) were included. This analysis revealed that although the IAA formation rate was similar in the LA and OA groups (OR: 1.28, 95% confidence interval [CI]: 0.87-1.88), the wound infection rate was lower in the LA group (OR: 0.38, 95% CI: 0.28-0.51). Furthermore, LA was associated with shorter hospital stay (WMD: -1.43 days, 95% CI: -2.33--0.52) and fewer complications than OA (OR: 0.40, 95% CI: 0.28-0.57).

Conclusion

LA has significant benefits in treating PA and is associated with better post-operative outcomes such as shorter hospital stay, lower incidence of wound infection and other complications. However, more studies with randomised and large-sample populations are still required to determine the clinical benefit of LA in treating PA.

Laparoscopic appendicectomy is superior to open surgery for complicated appendicitis

BACKGROUND

Over the last three decades, laparoscopic appendicectomy (LA) has become the routine treatment for uncomplicated acute appendicitis. The role of laparoscopic surgery for complicated appendicitis (gangrenous and/or perforated) remains controversial due to concerns of an increased incidence of post-operative intra-abdominal abscesses (IAA) in LA compared to open appendicectomy (OA). The aim of this study was to compare the outcomes of LA versus OA for complicated appendicitis.

METHODS

A systematic literature search following PRISMA guidelines was conducted using MEDLINE, EMBASE, PubMed and Cochrane Database for randomised controlled trials (RCT) and case-control studies (CCS) that compared LA with OA for complicated appendicitis.

RESULTS

Data from three RCT and 30 CCS on 6428 patients (OA 3,254, LA 3,174) were analysed. There was no significant difference in the rate of IAA (LA = 6.1% vs. OA = 4.6%; OR = 1.02, 95% CI = 0.71-1.47, p = 0.91). LA for complicated appendicitis has decreased overall post-operative morbidity (LA = 15.5% vs. OA = 22.7%; OR = 0.43, 95% CI: 0.31-0.59, p < 0.0001), wound infection, (LA = 4.7% vs. OA = 12.8%; OR = 0.26, 95% CI: 0.19-0.36, p < 0.001), respiratory complications (LA = 1.8% vs. OA = 6.4%; OR = 0.25, 95% CI: 0.13-0.49, p < 0.001), post-operative ileus/small bowel obstruction (LA = 3.1% vs. OA = 3.6%; OR = 0.65, 95% CI: 0.42-1.0, p = 0.048) and mortality rate (LA = 0% vs. OA = 0.4%; OR = 0.15, 95% CI: 0.04-0.61, p = 0.008). LA has a significantly shorter hospital stay (6.4 days vs. 8.9 days, p = 0.02) and earlier resumption of solid food (2.7 days vs. 3.7 days, p = 0.03).

CONCLUSION

These results clearly demonstrate that LA for complicated appendicitis has the same incidence of IAA but a significantly reduced morbidity, mortality and length of hospital stay compared with OA. The finding of complicated appendicitis at laparoscopy is not an indication for conversion to open surgery. LA should be the preferred treatment for patients with complicated appendicitis.

Systematic Review and Meta-Analysis of Laparoscopic Versus Open Appendicectomy in Adults with Complicated Appendicitis: an Update of the Literature

AIMS

To review and compare the outcomes of laparoscopic (LA) versus open appendicectomy (OA) in complicated appendicitis in adult patients, eight years after the last literature review.

METHODS

The PRISMA guidelines were adhered to. Pre-defined inclusion and exclusion criteria were used to search the PubMed, Scopus and Cochrane databases and extract relevant data. Methodological and quality assessment was undertaken with outcome meta-analysis and subgroup analyses of methodological quality, type of study and year of study. Assessment of clinical and statistical heterogeneity and publication bias was conducted.

RESULTS

Three randomised control trials (RCTs) (154LA vs 155OA) and 23 case-control trials were included (2034LA vs 2096OA). Methodological quality was low to average but with low statistical heterogeneity. Risk of publication bias was low, and meta-regression indicated shorter length of hospital stay (LOS) in more recent studies, Q = 7.1, P = 0.007. In the combined analysis LA had significantly less surgical site infections [OR = 0.30 (0.22,0.40); p < 0.00001] with reduced time to oral intake [WMD = -0.98 (-1.09,-0.86); P < 0.00001] and LOS [WMD = -3.49(-3.70,-3.29); p < 0.00001]. There was no significant difference in intra-abdominal abscess rates [OR = 1.11(0.85,1.45); p = 0.43]. Operative time was longer during LA [WMD = 10.51 (5.14,15.87); p = 0.0001] but did not reach statistical significance (p = 0.13) in the RCT subgroup analysis.

CONCLUSIONS

LA appears to have significant benefits with improved morbidity compared to OA in complicated appendicitis (level of evidence II).

Laparoscopic versus open surgery for complicated appendicitis in adults: a randomized controlled trial

BACKGROUND

The aim of this study was to assess whether laparoscopic appendectomy (LA) for complicated appendicitis (CA) effectively reduces the incidence of postoperative complications and improves various measurements of postoperative recovery in adults compared with open appendectomy (OA).

METHODS

This single-center, randomized controlled trial was performed in the Nagoya Daini Red Cross Hospital. Patients diagnosed as having CA with peritonitis or abscess formation were eligible to participate and were randomly assigned to an LA group or an OA group. The primary study outcome was development of infectious complications, especially surgical site infection (SSI), within 30 days of surgery.

RESULTS

Between October 2008 and August 2014, 81 patients were enrolled and randomly assigned with a 1:1 allocation ratio (42, LA; 39, OA). All were eligible for study of the primary endpoint. Groups were well balanced in terms of patient characteristics and preoperative levels of C-reactive protein. SSI occurred in 14 LA group patients (33.3 %) and in 10 OA group patients (25.6 %) (OR 1.450, 95 % CI 0.553-3.800; p = 0.476). Overall, the rate of postoperative complications, including incisional or organ/space SSI and stump leakage, did not differ significantly between groups. No significant differences between groups were found in hospital stay, duration of drainage, analgesic use, or parameters for postoperative recovery except days to walking.

CONCLUSION

These results suggested that LA for CA is safe and feasible, while the distinguishing benefit of LA was not validated in this clinical trial.

Single institution's experience in laparoscopic appendectomy as a suitable therapy for complicated appendicitis

PURPOSE

Although laparoscopic appendectomy (LA) for acute appendicitis (AA) is widely performed, the value of LA for the treatment of complicated appendicitis (CA) is still controversially discussed.

METHODS

In a retrospective study, we analyzed the clinical records of 404 patients who underwent LA or conversion (intention-to-treat group) or open appendectomy (OA) for AA or CA at the Alfried Krupp Hospital Essen-Rüttenscheid, Germany between January 2007 and December 2010.

RESULTS

AA was treated in 64.2 % by LA and in 35.8 % by OA; the LA-to-OA conversion rate amounts to 3.7 %. CA was treated in 56 % by LA and in 44 % by OA. The LA-to-OA conversion rate here is 13.1 %, and compared to AA, it is significantly (P < 0.01) higher. Comparing LA with OA in both patient groups, we find no significant difference in the overall complication rate, the rate of postoperative intraabdominal abscesses and postoperative ileus. However, in both patient groups, the wound infection rate was significantly lower in patients who had undergone LA (AA P < 0.05 versus CA P < 0.01). In contrast to patients suffering from AA, patients with CA needed significantly less resurgery when treated by LA as compared to OA (P < 0.001). While the duration of surgery for the treatment of AA and CA was similar, the hospitalization time was significantly shorter with LA than with OA (AA P < 0.05 versus CA P < 0.001).

CONCLUSIONS

The data suggest that LA is advantageous not only in the treatment of AA, but also in the therapy of CA. Thus, LA may become a proper and safe routine method if performed by an experienced surgeon.

Laparoscopic appendectomy for complicated acute appendicitis does not result in increased surgical complications

BACKGROUND/OBJECTIVES

Septic postoperative complications are debated in patients with complicated acute appendicitis treated with laparoscopic appendectomy (LA). The aim of this study was to investigate the results of LA in both complicated and uncomplicated cases of acute appendicitis.

METHODS

From January to December 2009, 94 patients with acute appendicitis underwent LA by the same surgeon using the three-port technique. Data were accumulated and compared between complicated and uncomplicated acute appendicitis.

RESULTS

Of the 94 patients (45 women and 49 men), 19 had complicated and 75 uncomplicated acute appendicitis. The group with complicated acute appendicitis, as compared to the uncomplicated group, was significantly older (55.7 ± 20.5 years vs. 41.0 ± 18.0 years), and had a significantly increased operation time (117.6 ± 45.5 minutes vs. 78.2 ± 39.4 minutes), longer length of hospital stay (9.0 ± 3.3 days vs. 5.2 ± 6.0 days) and higher conversion rate (21.1% vs. 2.7%). No increase in surgical complications was noted in patients with complicated acute appendicitis, as compared to those with uncomplicated acute appendicitis.

CONCLUSION

This study demonstrated no increase in surgical complications after LA in patients with complicated acute appendicitis when compared with those who had uncomplicated disease. Therefore, LA may be considered the first-choice treatment option for both uncomplicated and complicated acute appendicitis.