Has laparoscopic approach replaced the open technique to perform appendectomy?—evolution over more than a decade
Original Article

Has laparoscopic approach replaced the open technique to perform appendectomy?—evolution over more than a decade

Muhammad Tayyab-ul-Hasan Siddiqui1, Rizwan Sultan2, Hasnain Zafar3, Umar Farooq Bhatti4, Fatima Shaukat5, Noman Shahzad6

1Resident General Surgery, Aga Khan University Hospital Karachi, Karachi, Pakistan; 2Consultant General Surgeon, Islamabad Medical Complex, Islamabad, Pakistan; 3Consultant General Surgeon, 4Research Associate, 5Resident Radiation Oncology, Aga Khan University Hospital Karachi, Karachi, Pakistan; 6Registrar General Surgery, East Kent Hospitals University NHS Foundation Trust, Kent, UK

Contributions: (I) Conception and design: MT Ul Hasan Siddiqui, R Sultan, H Zafar, N Shahzad; (II) Administrative support: R Sultan, H Zafar, N Shahzad; (III) Provision of study materials or patients: H Zafar, N Shahzad; (IV) Collection and assembly of data: MT Siddiqui, R Sultan, UF Bhatti, F Shaukat; (V) Data analysis and interpretation: N Shahzad; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Noman Shahzad. Registrar General Surgery, East Kent Hospitals University NHS Foundation Trust, Flat 139, Block 8, The Nightingales, Ramsgate Road, Margate CT9 4BW, UK. Email: drns01@hotmail.com.

Background: Approximately 8% of the population suffers from acute appendicitis during the second and third decade of life. Appendectomy remains the recommended treatment for patients suffering from acute appendicitis. Lack of laparoscopic surgical expertise and relatively high cost have hindered the adoption of laparoscopic approach to appendectomy especially in developing countries. Objective of our study is to report adaptation trend of laparoscopic appendectomy over a period of 12 years and lessons learnt from it.

Methods: All adult patients of age 16 years and above, admitted with acute appendicitis and underwent laparoscopic appendectomy from January 01, 2004 to December 31, 2015 were included in the study. Data was entered and analyzed using SPSS version 22.

Results: A total of 1,163 patients underwent laparoscopic appendectomy during the study period out of which 831 met inclusion criteria. Proportion of patients who underwent laparoscopic appendectomy as opposed to open surgery increased over time. In 2004 only 13% of the cases were attempted laparoscopically while this proportion was 100% in 2015 (P<0.001). Conversion to open was done in 7% [59] cases mainly due to dense adhesions of the appendix to surrounding structures. Mean duration of surgery was 64.5 (+/−23) minutes. Overall negative appendectomy rate was 7.82%. Surgical site infection was the most common post-operative complication affecting 4.5% [37] of our patients; this included 19 (2.28%) patients with intra-abdominal abscess.

Conclusions: Laparoscopic appendectomy has replaced open technique as treatment of acute appendicitis and results are favorable.

Keywords: Laparoscopic appendectomy; conversion to open; operative duration; surgical site infection


Received: 07 January 2019; Accepted: 23 April 2019; Published: 27 May 2019.

doi: 10.21037/ales.2019.04.08


Introduction

Acute appendicitis is the most common surgical emergency requiring early operative intervention (1-3). Approximately 8% of the population suffers from acute appendicitis during the second and third decade of life (4,5), with slight male preponderance (1). Appendectomy remains the recommended treatment for patients suffering from acute appendicitis. With advent of laparoscopic approach to abdominal surgical problems, laparoscopic appendectomy has also progressively gained popularity since 1982 when it was performed first time by Semm et al. (6-9).

Better cosmetic outcomes, rapid recovery, short hospital stay, fewer complications and less narcotic requirement are among the advantages of laparoscopic approach over open technique (10,11). However, unlike laparoscopic cholecystectomy that attained the status of “standard of care” in a very short time span, laparoscopic appendectomy is yet to find that place (12).

Lack of laparoscopic surgical expertise and relatively high cost have hindered the adoption of laparoscopic approaches especially in developing countries (13). The Aga Khan University Hospital (AKUH) in Karachi, Pakistan introduced laparoscopy in 1990 and the first laparoscopic cholecystectomy was performed in 1992. However, it was not until 2004 that the first laparoscopic appendectomy was performed. At present, laparoscopy is the preferred approach for appendectomy and standard for cholecystectomy.

Objective(s)

To report adaptation trends of laparoscopic appendectomy over a period of 12 years and lessons learnt from it.


Methods

We conducted retrospective cohort study at Department of Surgery at the Aga Khan University Hospital (AKUH) Karachi. AKUH is a 650-bed tertiary care hospital with seven general surgeons credentialed to perform laparoscopic appendectomy.

Selection criteria

All adult patients of age 16 years and above, admitted with acute appendicitis and underwent laparoscopic appendectomy from January 01, 2004 to December 31, 2015 were included in the study. Patients with missing data, incomplete records and those who underwent two simultaneous procedures were excluded from the study.

Data collection procedure

Medical records of patients included in the study were retrieved using International Classification of Disease (ICD) codes. The data was collected on a specifically designed questionnaire. Demographics like age, gender, comorbidities, length of stay, radiological workup, type of surgery (laparoscopic or laparoscopic converted to open), reason for conversion, operative findings, duration of surgery, post-operative complications and histopathological findings were recorded. Approval was sought from institutional review board before start of the study. Approval number granted is 3748-Sue-ERC-15.

Statistical analysis

Data was entered and analyzed using SPSS version 22. Qualitative variables are reported as numbers, percentages or proportions. Quantitative variables are reported as means with standard deviations or medians with inter-quartiles ranges depending upon the distribution of data. Chi-square test was used to compare qualitative variables across the groups while ANOVA was applied to compare quantitative variable. P value of <0.05 was considered as statistically significant.


Results

A total of 1,163 patients underwent laparoscopic appendectomy during the study period out of which 831 met inclusion criteria while 332 were excluded based on the exclusion criteria. About 2/3rd (64.0%) of our patients were males. The median age of our patients was 28 years (IQR, 22–37). Baseline characteristics of patients are as given in Table 1.

Table 1
Table 1 Baseline characteristics of patients in three groups with respect to year of presentation
Full table

Proportion of patients who underwent laparoscopic appendectomy as opposed to open surgery increased over time. In 2004 only 13% of the cases were attempted laparoscopically while this proportion was 100% in 2015 (P<0.001). Year wise details are as shown in Figure 1.

Figure 1 Percentages of laparoscopic and open appendectomies over time

Of all the cases attempted laparoscopically, conversion to open was done in 7% [59] cases mainly due to dense adhesions of the appendix to surrounding structures resulting in difficult anatomy. Perforation at the base of appendix accounted for conversion to open in 5 cases while two cases were converted to open surgery because of iatrogenic injuries. The conversion rate, however, decreased over the years from 10.2% in initial 4 years to 5% in last 4 years of study duration (P=0.062).

Mean duration of surgery was 64.5 (+/−23) minutes. A statistically significant (P<0.001) decrease in duration of surgery was noticed, from the mean of 74 minutes in initial 4 years to the mean of 60.5 minutes in last 4 years of the study period. Overall negative appendectomy rate was 7.82%. Similar to other findings, results demonstrated a falling trend in negative appendectomy rates from 22.4% in initial 4 years to 4.98% in last 4 years of the study period (P<0.001). Details of the results are as shown in Table 2.

Table 2
Table 2 Comparison of operative characteristics over time
Full table

Surgical site infection was the most common post-operative complication affecting 4.5% [37] of our patients; this included 19 (2.28%) patients with intra-abdominal abscess. Re-admission rate was 1.6% (13). Only two patients required redo surgery for intra-abdominal collection wash out while rest of patients were managed by drain placement radiologically.


Discussion

Appendectomy is the standard of care for acute appendicitis. The laparoscopic approach is becoming the preferred way among an increasing number of surgeons worldwide, though the open technique is still more common because of its low cost and shorter duration of surgery (14,15). Furthermore, change in surgical practice depends upon multitude of factors in addition to cost and skills (16).

Duration of surgery is an important determinant of surgical outcomes. Studies have shown that laparoscopic appendectomy takes much longer than open technique (17,18). This factor keeps the laparoscopic technique from becoming the standard of care. As the experience of a surgeon increases, the duration of operation decreases (13). Our findings are in synchrony with this argument, since over time the duration of laparoscopic appendectomies performed at our institute has decreased significantly. The mean duration of surgery is 64.5 minutes which is comparable to that illustrated by the study done by Kouhia et al. (19).

The rate of conversion from laparoscopic to open appendectomy is another area that has direct impact on surgical outcomes. Our data showed that 7% of the cases were converted to open technique which is comparable to the rate demonstrated in another study (19). However, our conversion rate is much higher than the rate reported by the study done by Bozkurt et al. in Istanbul, Turkey and this can be explained by the fact that Bozkurt et al. excluded all complicated cases of appendicitis (20). Our trend shows a consistent improvement in conversion rate (21).

Superiority of laparoscopic appendectomy to open appendectomy has consistently been reported so far as early post-operative pain, length of hospital stays and early return to work is concerned. Recent meta-analysis by Jaschinski et al. also confirmed that post-operative pain, length of hospital stays, wound infection, return to work and quality of life are improved after laparoscopic appendectomy as compared to open appendectomy (22). However, risk of post-operative intra-abdominal abscess formation especially after appendectomy for complicated appendicitis is high after laparoscopic appendectomy than open approach (22,23). Risk of intra-abdominal abscess formation was only 1.10% in multicenter cohort study reported by Lasek et al. Complicated appendicitis was the only predictive factor for post-operative intra-abdominal abscess formation (24). In this sub-group of patients with ruptured or gangrenous appendicitis open approach may be superior due to ability to give a through wash out during operation.

Despite proven advantages of laparoscopic appendectomy over open surgery for uncomplicated appendicitis, open appendectomy is still offered frequently as first treatment option. Multiple factors are involved in resistance to change in surgical practice. Lack of resources, lack of skills, cost of care, mistaken beliefs of non-superior outcome, operative duration and lack of external validity of certain technique are few of the factors involved. Recent survey of Polish surgeon about their awareness and practice of laparoscopic hernia repair reported that 19.2% do not inform patients about laparoscopic repair option and 61.6% surgeon perform staged open repair of bilateral inguinal hernia (25). These factors result in dissonance between evidence and practice (16).


Conclusions

Laparoscopic appendectomy has potential to replace open technique as treatment option for acute appendicitis given the advantages of laparoscopic surgery especially for uncomplicated appendicitis.


Acknowledgments

None.


Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

Ethical Statement: Approval was sought from institutional ethical review board before start of study. Approval number is 3748-SUR-ERC-15.


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doi: 10.21037/ales.2019.04.08
Cite this article as: Siddiqui MT, Sultan R, Zafar H, Bhatti UF, Shaukat F, Shahzad N. Has laparoscopic approach replaced the open technique to perform appendectomy?—evolution over more than a decade. Ann Laparosc Endosc Surg 2019;4:48.