Lap vs Open Appendectomy

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    SHORT-AND LONG-TERM

    RESULTS OF OPENVERSUSLAPAROSCOPICAPPENDECTOMY

    H. A. Swank E. J. Eshuis M. I. van Berge

    Henegouwen W. A. Bemelman

    Department of Surgery, University of

    Amsterdam, The Netherlands

    World J Surg

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    INTRODUCTION

    Advantages of laparoscopy

    y Three small incisions

    y little pain

    y quick recovery

    laparoscopic appendectomy/ diagnostic

    laparoscopy

    Most of the advantages are small and oflimited clinical relevance

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    OBJECTIVES

    To compare short- and long-term results

    of

    y conventional appendectomy with or without

    prior diagnostic laparoscopy (OA)

    y laparoscopic appendectomy (LA)

    Hypothesis-

    y higher complication rates in the short term

    for laparoscopic appendectomy are

    compensated in the long term by lower

    reoperation rates for incisional hernia and

    adhesions

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    PATIENTS AND METHODS

    >18 years of age

    1 January 1995 until 31 December 2005

    retrospective study

    Primary outcomey long-term complications

    y Readmissions

    y reinterventions (>30 days postoperatively)

    Secondary outcomey short-term complications

    y Readmissions

    y reinterventions (

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    PATIENT CHARACTERISTICS

    Prior abdominal surgery, in 16.3% (OA) and

    16.2% (LA) of the patients (NS)

    mean follow-up of the two groups: 9.0 years (OA)

    vs. 8.7 years (LA; p = 0.321).

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    OPERATIVE CHARACTERISTICS

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    The skin was left open in 19% (OA) and 4% (LA)

    of the patients (p

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    Median hospital stay longer in OA (4 vs 3 days; p

    = 0.093). Postoperative diagnostic investigations: fewer in

    OA group

    y CT scanning (3% vs 9%; p = 0.001)

    y abdominal echography (6 vs. 12%; p

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    Abscess

    y 23 patients

    y Most were men (65%, ns), with median age 7 yrs

    older (ns)

    significant risk factors in multivariate analysis-

    duration of surgery (OR 1.01 CI 1.001.03) and

    peritonitis- both local (OR 2.8 CI 1.17.1) and

    generalised (OR 4.1 CI 1.214.0)

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    LONG-TERM RESULTS

    No mortality; small bowel obstruction

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    DISCUSSION

    Laparoscopic appendectomy did not have clear

    advantages with respect to reduced short- and

    long-term morbidity.

    higher rate of intra-abdominal abscesses adverse events in the group of converted patients,

    giving rise to significantly more diagnostic and

    therapeutic interventions.

    long-term morbidity and reoperation for

    incisional hernia repair was low and not

    significantly different

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    laparoscopic group was dominated by women-

    hospital policy for starting with a laparoscopicapproach in women to exclude gynecological

    pathology

    Attending consultants prefer laparoscopic

    approach The operative time for both OA and LA was,

    respectively, 15 and 12 min longer than found by

    Sauerland et al.s meta-analysis- from Cochrane

    database.- reason- operations performed in the

    teaching setting, limited surgical or laparoscopicexpertise

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    Among short-term outcomes, significantly differentparametersy Postoperative stay

    y Short-term abdominal abscesses

    y Readmissions

    y Diagnostics

    y Reinterventions

    postoperative stay was one day shorter after LA

    compared with cochrane database review high rate of abdominal abscess in the LA group

    y significantly associated with purulent peritonitis and longduration of surgery.

    y Male gender and a higher age were correlated, but notsignificantly.

    Fleming et al had shown in a large series thatpatients with a high wound class, systematic illness,sepsis, male gender, a history of smoking, andoperative time of more than 60 min have asignificantly greater risk of abdominal abscess afterthe laparoscopic procedure

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    Conversion -7%

    y only significant risk factor was presence of

    generalized purulent peritonitisy previous abdominal surgery had higher risk - not

    significant

    y The converted patients were at risk for relaparotomy

    and incisional hernia

    We expected the incidences of incisional hernia

    and small bowel obstruction to be higher in the

    open appendectomy group

    y reoperation for incisional hernias after open

    appendectomy was 1.1% (vs 0.120.7% in availableliterature)

    y Incisional hernia in laparoscopic group only in cases

    of conversion

    y Not significant

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    Small bowel obstruction

    y None in this study

    y 1.02.8% in literature

    y small bowel obstruction can present many years after

    surgery

    y

    Andersson et al. showed the prevalence increasedfrom 0.63% after 1 year, to 0.97% after 10 years, to

    1.30% after 30 years of follow-up

    y follow-up with a minimum of three years has been

    too short

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    The Achilles heel of laparoscopic appendectomyremains the increased incidence of intra-

    abdominal abscesses

    Risk factors

    y male gender

    y long operative duration

    y purulent peritonitis

    Benefits

    y cosmetic expectations of the patient

    y limited clinical benefits in the short term

    y possible lower risk of incisional hernia in the long

    term

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    Will be the standard of care in future

    problem of abdominal abscess therefore needs to

    resolved and further research should be directed

    on this topic

    One direction for future research is the use of the

    Endo Staplery Two systematic reviews have advised the use of this

    device instead of endoloops - Sajid et al in 2009,

    Kazemier et al in 2006

    y Staplers most likely reduce fecal spill and provide a

    more secure stump closure

    Properly designed studies must be conducted

    addressing the cost-effectiveness of this

    technique.