{"paper_id":"9087811f-3d87-4c3e-9d36-87f911f4256d","body_text":"~ 400 ~ \nInternational Journal of Surgery Science 2019; 3(3): 400-402 \n \nE-ISSN: 2616-3470 \nP-ISSN: 2616-3462 \n© Surgery Science \nwww.surgeryscience.com \n2019; 3(3): 400-402 \nReceived: 11-05-2019 \nAccepted: 15-06-2019 \n \nDr. Raju SRH \nAssociate Professor, Akash \nInstitute of Medical Science and \nResearch Center, Bengaluru, \nKarnataka, India \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nCorrespondence \nDr. Raju SRH \nAssociate Professor, Akash \nInstitute of Medical Science and \nResearch Center, Bengaluru, \nKarnataka, India \n \nComparison between open and laparoscopic appendectomy: \nA systematic review \n \nDr. Raju SRH \n \nDOI: https://doi.org/10.33545/surgery.2019.v3.i3g.201  \n \nAbstract \nIntroduction: Open appendectomy (OA) has been the treatment of choice for acute appendicitis since its \nintroduction by Mc -burney in 1884. Laparoscopic appendectomy (LA) though widely practiced, has not \ngained universal approval. LA was first described in 1983. Some early studies showed equivocal results \nabout benefit of LA. Recent studies showed overall benefit in favour of LA. So, we decided to do this study \nwith a view to evaluate the therapeutic benefit of LA by comparing with conventional OA.  \nMaterials and methods: We collected data of 100 appendectomies done in Chamarajanagara institute of \nmedical sciences & hospital from  for a period of 15 months. Out of them 50 had conventional OA and 50 \nhad LA. We compared the mean operation time, time of first oral feeding, narcotic analgesic requirement, \nand duration of post-operative hospital stay. \nResults: We found that mean operation  time was 33±5.8 minute and 37± 7.5 minute in LA and OA \nrespectively. Duration of post-operative hospital stay was 1.2 days shorter in Laparoscopic group. LA \nrequired 1.1 shots of less analgesic than OA. Oral feeding was resumed 21 hours earlier following LA \ncompared to OA. Laparoscopic appendectomy was safely performed in paediatric patient without any \nadverse effect. We also found that, in female patient, concurrent ovarian cysts, tubal pregnancy and \nendometriosis can be diagnosed and managed laparoscopically in the same sitting.  \nConclusion: Our study found that laparoscopic appendectomy is an effective and safe procedure \nirrespective of age and sex of the patient. LA has added advantage of early return of bowel movement, less \npost-op hospital stay and less requirement of narcotic analgesic. \n \nKeywords: Acute appendicitis; laparoscopic appendectomy; open appendectomy; laparoscopic vs open \nappendectomy \n \nIntroduction  \nAcute appendicitis is a common cause of acute abdominal pain with a life -time incidence \nbetween 7 –9%. As a direct result, appendectomy is one of the most frequently performed \nsurgical procedures. The open approach to appendectomy was originally described by \nMcBurney. It has become the standard treatment of choice for acute appen dicitis, remaining \nmainly unchanged for 100 years due to its favorable efficacy and safety. Since the advent of \nlaparoscopy, appendectomy has increasingly been performed using a minimally invasive \napproach, following the first report by Semm in 1983. Altho ugh laparoscopic appendectomy \n(LA) has gained much popularity among some surgeons, others remain skeptical with regard to \nreplacing the relatively straightforward open appendectomy (OA). Criticism of LA includes \nincreased operative cost, primarily due to t he use of disposable laparoscopic instruments, \nincreased operation time, and concerns about a higher incidence of intra -abdominal abscesses, \nparticularly after perforated appendicitis.  Proponents of LA, however, claim that the advantages \nof the procedure i nclude improved wound healing, reduced postoperative pain and, ultimately, \nearlier discharge from hospital, all translating to an earlier return to normal activity. Therefore, \nthe use of LA remains controversial, in contrast to the wide acceptance of lapar oscopic \ncholecystectomy since its innovation. \nMeta-analysis is a useful statistical tool that can be used to evaluate the existing literature in \nboth quantitative and qualitative ways by comparing and integrating the results of different \nstudies, taking into account variations in characteristics that can influence the overall estimate of \nthe outcome of interest. Previous meta -analyses have demonstrated a reduced incidence of \nsurgical site infection and length of hospital stay following LA in adults.  Some studies, however, \nhave suggested that LA is associated with higher rates of intra-abdominal abscess formation,\n\n\nInternational Journal of Surgery Science  http://www.surgeryscience.com \n~ 401 ~ \nLonger operative times, and higher surgical costs when \ncompared to OA. LA, however, is currently not universally \naccepted as the standard of care f or the treatment of acute \nappendicitis in children and differences in the patient population \nmean that direct extrapolation of adult data to children is invalid. \nAlthough much research has been done to compare results from \nLA and OA in children, conclusion s have been difficult to draw \nbecause of small study size, the presence of only a handful of \nrandomized trials, and possible heterogeneity in patient \ncharacteristics, surgical practice, and severity of appendicitis \nbetween these studies. At present, there is no consensus between \npediatric surgeons as to the benefits of LA over OA. \nIn order to guide future management decisions, we decided to \nconduct a meta -analysis of randomized controlled trials (RCTs) \ncomparing LA and OA in adult and pediatric patients.  \n \nMaterials and Methods \nInclusion Criteria \nPatients with appendicitis were included in the study performed \nat Chamarajanagara institute of medical sciences & hospital, for \na period of 15months. The diagnosis of appendicitis was made \non the following criteria: History of right lower quadrant pain or \nperiumbilical pain migrating to the right lower quadrant with \nnausea and/or vomiting, fever of more than 38°C and/or \nleukocytosis above 10,000 cells per mL, right lower quadrant \nguarding, and tenderness on physical  examination. All patients \nincluded were 16 years of age or older. \n \nExclusion Criteria \nPatients were excluded if the diagnosis of appendicitis was not \nclinically established and if they had a history of symptoms for \nmore than 5 days and/or a palpable mass in the right lower \nquadrant, suggesting an appendiceal abscess treated with \nantibiotics and possible percutaneous drainage. Patients with the \nfollowing conditions were also excluded: history of cirrhosis and \ncoagulation disorders, generalized peritonitis, shock on \nadmission, absolute contraindication to laparoscopic surgery \n(large ventral hernia, history of laparotomies for small bowel \nobstruction, ascites with abdominal distension), contraindication \nto general anesthesia (severe cardiac and/or pulmonary di sease), \ninability to give informed consent due to mental disability, and \npregnancy. \n \nResults and Discussion \n7 (7%) of our patients were children. We used the same trocar \npositions in children as in adults. We inserted camera trocar \nslightly above the umbil icus in very small children. The CO2 \npressure was kept at 11 or 12mm of Hg in children. We did not \nencounter any difficulty while operating on children, except \ncrowding of instruments. There are many studies done on lap \nappendectomy on children. No differe nce in mortality or major \ncomplication rate was observed between LA and OA among \nchildren. 10 of our patients were above 60 years. No special \nproblem was encountered during operating in these patients. But \nwe did not attempt LA on patients with COPD and he art failure, \nas increased intra -abdominal pressure may compromise \ncardiovascular hemodynamics. We rarely found very obese \npatient in Chamarajanagara Institute of Medical Sciences and \nHospital. OA in obese patient is particularly difficult through \nMcBurney’s incision and often require s larger incision. LA in \nobese patient has extra  advantage in this regard. As concomitant \npelvic pathology can be diagnosed and managed very effectively \nduring laparoscopy, we have managed cases of ruptured ectopic \npregnancy and ovarian\nCysts during this p eriod in women of reproductive age group. \nAny patient of reproductive age having suspected appendicitis \nshould have laparoscopic appendectomy as any concomitant \npelvic pathology can be dealt with in the same laparoscopic \nsession. We also removed gall bladd ers for USG proved gall \nstones during laparoscopic appendectomies. In these cases we \nused conventional 4 ports as in laparoscopic cholecystectomies \nand did not insert any extra port for removal of appendices. \nComplications following LA are less than in OA.  Although \nsome studies show higher intra -abdominal abscess formation in \nLA, others report no significant difference between LA and OA. \nDuring the early period of our study we were inserting double \nligature at the base of the appendix to secure the stump. L ater on \nwe started practicing single loop to secure appendix base as \nthere was no difference in post -operative mortality and \nmorbidity between the use of single loop and double loop in LA. \nAs a result operation time was reduced by few minutes. When \nwe came  across to perforated appendix and pus collection, we \nused suction only to clean the pus from the peritoneal cavity. We \ndid not use irrigation at all. A prospective randomized trial was \npublished in the literature, which concluded that there is no \nsignificant difference in outcome between suction and irrigation \ncombined and suction alone during LA in case of perforated \nappendicitis18. In this study the incidence of residual abscess \nwas found to be same in both group with perforated appendicitis. \nDuration of hospital stay was also not different. Here we like to \nmention that we tend to discharge patient slightly later in this \nrural based medical college hospital. Our patients come from \ndistant places. As a result they cannot come to the hospital at \nodd hours o f the day in case any post -op emergency arises at \nhome. Adhesion formation is now one of the common \ncomplications following intra -abdominal operation. A study has \nshown that rate of adhesion is about 80% in OA compared to \n10% in LA three months after the s urgery. Regarding the \nindication of LA we may include females of reproductive age \ngroup, doubtful diagnosis of appendicitis, recurrent appendicitis, \nhigh working class, and obese patient, cirrhosis of liver, sickle \ncell disease and immuno -compromised patie nt. General \nAnaesthesia and pneumoperitoneum required for laparoscopic \nprocedure poses risks to certain group of patients with cardio -\nrespiratory compromise. So LA is not recommended for patients \nwith COPD or cardiac disease. LA should also be avoided in \nprevious lower abdominal surgery, generalized peritonitis and \nstump appendicitis. Laparoscopic appendicectomy in pregnancy \nis associated with a low rate of intra -operative complications in \nall trimesters. However, LA in pregnancy is associated with a \nsignificantly higher rate of fetal loss compared to open \nappendicectomy. Open appendicectomy would appear to be the \nsafer option for pregnant women for whom surgical intervention \nis indicated. \n \nConclusion \nLaparoscopic appendectomy is an effective and safe option  and \nthe procedure of choice for most patients regardless of age, sex \nand BMI. It requires less operative time, has minimal \ncomplications and less hospital stays and has the advantage of \nmanaging concomitant pathologies. The laparoscopic approach \nis a safe and efficient operative procedure in appendectomy and \nit provides clinically beneficial advantages over open method \n(including shorter hospital stay, decreased need for \npostoperative analgesia, early food tolerance, earlier return to \nwork, lower rate of w ound infection) against only marginally \nhigher hospital costs. \n \n\nInternational Journal of Surgery Science  http://www.surgeryscience.com \n~ 402 ~ \nReference \n1. Shirazi B, Ali N, Shamim MS. Laproscopic versus open \nappendectomy: A comparative study. J Pak Med Assoc. \n2010; 60:901-904.  \n2. Moberg AC, Berndsen F, Palmquist I. Randomized clinical \ntrial of laparoscopic versus open appendicectomy for \nconfirmed appendicitis. Br J Surg. 2005; 92:298-304.  \n3. Kaplan, M, Salman B, Yilmaz TU. 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