Evidence-based surgery for laparoscopic appendectomy: A stepwise systematic review

The use of dilating trocars minimizes perioperative complications involving the abdominal wall as well as the frequency with which fascial defects need to be closed. When fascial closure is necessary, a suture passer or other closure device provides superior outcomes to hand-sewn closure. In conclusion, laparoscopic appendectomy constitutes one of the most common procedures performed globally. Evidence-guided standardization and optimization of operative steps provide a unique opportunity to improve surgical outcomes for a large number of patients. Our systematic evaluation of the literature sought to review the data informing best practices in LA and make recommendations for additional research where necessary. Table 2 contains a summary of our findings, recommendations, and areas for additional research. Table 2 PICO questions and conclusions Table 2 PICO question Recommendation 1. In adults undergoing LA for uncomplicated appendicitis, what is the best method to establish pneumoperitoneum to minimize perioperative morbidity? There is no significant difference in perioperative morbidity among direct optical entry, Hasson technique, and Veress needle, although lower-quality evidence favors direct trocar entry. 2. In adults undergoing LA for uncomplicated appendicitis, what is the preferred port placement strategy to optimize surgical outcomes? Single port provides improved cosmesis, although the clinical implications of these changes are unclear. 3. In adults undergoing LA for uncomplicated appendicitis, what is the best method to divide the mesoappendix to minimize perioperative morbidity (significant bleeding requiring transfusion or reoperation) and mortality? Insufficient data to make a recommendation 4. In adults undergoing LA for uncomplicated appendicitis, what is the best method to divide the appendix to minimize perioperative morbidity (appendiceal stump blowout, abscess formation, need for antibiotic therapy, need for IR, or reoperation) and mortality? Insufficient data to make a recommendation 5. In adults undergoing LA for uncomplicated appendicitis, what is the best method to extract the divided appendix from the abdomen to minimize perioperative morbidity (intra-abdominal abscess, surgical site infection)? The use of a specimen extraction bag decreases the risk of IAA and SSI 6. In adults undergoing LA for uncomplicated appendicitis, what is the best fascial closure method to minimize the risk of port site hernia/other complications? The use of dilating trocars leads to fewer perioperative complications involving the abdominal wall and reduces the need for port site closure. Port site closure with a suture passer or other device results in superior outcomes. PICO questions and conclusions The following are the supplementary data related to this article. Supplemental File 1 Search strategy used for each PICO question Supplemental File 1 Supplemental Table 1 Evidence-based recommendations for efficiency of abdominal entry Supplemental Table 1 Search strategy used for each PICO question Evidence-based recommendations for efficiency of abdominal entry

Drs Bessoff and Choi conceived the study, critically reviewed the literature, and participated in writing and editing the manuscript. Drs Wolff, Kashikar, Carlos, and Caddell and Ms Khan critically reviewed the literature and participated in writing the manuscript. Dr Choi and Mr Stave developed and executed the search strategy. Drs Spain and Forrester assisted with the conceptual design of the study and provided critical analysis and editing.

No funding was received for the preparation of this manuscript.

Research questions were framed using population, indication, comparison, outcome (PICO) format. We examined intraoperative steps of LA and did not examine other aspects of appendicitis management such as diagnosis, nonoperative management, or postoperative care. Six key operative steps were identified by consensus among authors (KB, JC, JF): (1) abdominal entry, (2) placement of laparoscopic ports, (3) division of mesoappendix, (4) division of appendix, (5) removal of appendix, and (6) fascial closure ( Fig 1 ). Fig 1 Key steps in laparoscopic appendectomy. Fig 1 Key steps in laparoscopic appendectomy. A research librarian (CS) designed and performed extensive searches of 3 bibliographic databases [PubMed (includes MEDLINE), EMBASE, and the Cochrane Library] for the 6 PICO questions corresponding to key intraoperative steps ( Supplemental File 1 ). Eligible articles included experimental and observational studies in the English language published from database inception to April 10, 2020. We included studies evaluating adult (age ≥ 18 years) patients with a diagnosis of acute appendicitis. We excluded case reports, commentaries, reviews, and animal studies. Database results were uploaded to Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia). Studies examining abdominal entry (PICO 1) and fascial closure (PICO 6) in the context of any laparoscopic procedure were included to augment the quality of the data available to answer these PICO questions. Two authors (KB and JC) identified studies relevant to each PICO question. Only randomized controlled trials (RCTs) were included for a PICO question evaluated by ≥ 3 RCTs. Observational studies were included for PICO questions evaluated by < 3 RCTs. Disagreement was resolved by consensus. Additional articles discovered during further research were included in the analysis as appropriate. Evidence quality and certainty were assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) definition [ 9 ]. All studies were evaluated using a standardized data extraction template. This study did not meet criteria for IRB review because it was an analysis of previously published work.

The PRISMA flow diagram is provided in Figure 2 . We identified a total of 5,033 manuscripts, from which 28 full text articles underwent evidence synthesis (PICO 1: n = 5; PICO 2: n = 5; PICO 3: n = 6; PICO 4: n = 6; PICO 5: n = 3; and PICO 6: n = 3). Fig 2 PRISMA flow diagram. Fig 2 PRISMA flow diagram.

The authors have no conflicts to declare.

Appendicitis is a common surgical emergency. Lifetime disease risk in the United States is approximately 8% and appears to be increasing in many low and middle Human Development-Index Countries (LMHDICs) [ 1 ]. Appendectomy has become one of the most commonly performed emergency abdominal operations since its description by McBurney in the 1890s [ 2 ]. Laparoscopic appendectomy (LA), first introduced in the early 1980s, is associated with shorter hospitalization and lower complication rates compared to open appendectomy for uncomplicated appendicitis [ 3 , 4 ]. Benefits of LA persist in high-risk patient populations (eg, obese and elderly patients and those with medical comorbidities) as well as in LMHDIC cohorts [ 5 ]. Multiple surgical societies now recommend LA as first-line treatment for uncomplicated appendicitis [ 3 , 4 , 6 ]. However, there remains incomplete consensus on the sequence and execution of key technical steps to optimize clinical outcomes and minimize resource utilization during LA. Critical evaluation of published literature for each step of an operation has been useful to standardize other common surgical procedures like cesarean delivery [ 7 , 8 ]. Our review aims to critically evaluate published literature examining key intraoperative steps of LA to identify best practices for each intraoperative step.

Authors received no funding/financial support associated with this work.