Submit a Manuscript: http://www.wjgnet.com/esps/ World J Gastrointest Surg 2015 October 27; 7(10): 267-272 Help Desk: http://www.wjgnet.com/esps/helpdesk.aspx ISSN 1948-9366 (online) DOI: 10.4240/wjgs.v7.i10.267 © 2015 Baishideng Publishing Group Inc. All rights reserved. ORIGINAL ARTICLE Prospective Study Laparoscopic vs mini-incision open appendectomy Fatih Çiftçi Fatih Çiftçi, Vocational School of Health Services, Istanbul Abstract Gelisim University, Istanbul 34306, Turkey AIM: To compare laparoscopic vs mini-incision open Author contributions: Çiftçi F designed research; performed appendectomy in light of recent data at our centre. research; contributed to new reagents or analytic tools; analyzed data; wrote the paper; performed surgical operations. METHODS: The data of patients who underwent appendectomy between January 2011 and June 2013 Supported by General Surgery Department Safa Hospital, were collected. The data included patients’ demographic Istanbul, Turkey. data, procedure time, length of hospital stay, the need for pain medicine, postoperative visual analog scale of Institutional review board statement: The study was reviewed pain, and morbidities. Pregnant women and patients and approved by the Safa Hospital Institutional Review Board. with previous lower abdominal surgery were excluded. Informed consent statement: All study participants, or their Patients with surgery converted from laparoscopic legal guardian, provided informed written consent prior to study appendectomy (LA) to mini-incision open appendectomy enrollment. (MOA) were excluded. Patients were divided into two groups: LA and MOA done by the same surgeon. The Conflict-of-interest statement: Çiftçi F hasn’t received fees for patients were randomized into MOA and LA groups a serving as a speaker, any of organisations. Çiftçi F hasn’t received computer-generated number. The diagnosis of acute research funding from any of organisations. Çiftçi F isn’t any appendicitis was made by the surgeon with physical employee of organisations. examination, laboratory values, and radiological tests (abdominal ultrasound or computed tomography). All Open-Access: This article is an open-access article which was operations were performed with general anaesthesia. selected by an in-house editor and fully peer-reviewed by external The postoperative vision analog scale score was recorded reviewers. It is distributed in accordance with the Creative at postoperative hours 1, 6, 12, and 24. Patients were Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this discharged when they tolerated normal food and work non-commercially, and license their derivative works on passed gas and were followed up every week for three different terms, provided the original work is properly cited and weeks as outpatients. the use is non-commercial. See: http://creativecommons.org/ licenses/by-nc/4.0/ RESULTS: Of the 243 patients, 121 (49.9%) underwent MOA, while 122 (50.1%) had laparoscopic appendectomy. Correspondence to: Fatih Çiftçi, MD, Assistant Professor, There were no significant differences in operation time Vocational School of Health Services, Istanbul Gelisim University, between the two groups (P = 0.844), whereas the visual Basaksehir Mah., Erciyes Sok. No 15, Daire 24, Basaksehir, analog scale of pain was significantly higher in the open Istanbul 34306, Turkey. oprdrfatihciftci@gmail.com appendectomy group at the 1st hour (P = 0.001), 6th hour Telephone: +90-505-6164248 (P = 0.001), and 12th hour (P = 0.027). The need for Fax: +90-212-4627056 analgesic medication was significantly higher in the MOA March 27, 2015 group (P = 0.001). There were no differences between Received: Peer-review started: March 28, 2015 the two groups in terms of morbidity rate (P = 0.599). First decision: April 24, 2015 The rate of total complications was similar between the Revised: May 10, 2015 two groups (6.5% in LA vs 7.4% in OA, P = 0.599). All Accepted: August 28, 2015 wound infections were treated non-surgically. Six out Article in press: September 7, 2015 of seven patients with pelvic abscess were successfully Published online: October 27, 2015 treated with percutaneous drainage; one patient required WJGS|www.wjgnet.com 267 October 27, 2015|Volume 7|Issue 10| Çiftçi F. Appendicitis surgical drainage after a failed percutaneous drainage. appendicitis cases[2,4,5,8]. Therefore, there is no There were no differences in the period of hospital stay, consensus in the literature about whether LA should be operation time, and postoperative complication rate chosen as a routine procedure for all acute appendicitis between the two groups. Laparoscopic appendectomy cases or only for selected cases such as young women, decreases the need for analgesic medications and the obese patients, and professional workers[3,7,9]. visual analog scale of pain. CONCLUSION: The laparoscopic appendectomy should be MATERIALS AND METHODS considered as a standard treatment for acute appendicitis. Our hypothesis is that for treatment of AA, whether Mini-incision appendectomy is an alternative for a select complicated or not, in all adult patients, LA is superior group of patients. to mini-incision open appendectomy (MOA) in terms Key words: Appendicitis; Surgical wound infections; of safety and effectivity. The longer operation time Laparoscopic surgical procedure; Abdominal abscess; and higher intra-abdominal abscess rate in LA will Mini-incision open appendectomy improve in advanced laparoscopic surgical centres with increased laparoscopic experience. Therefore, we © The Author(s) 2015. Published by Baishideng Publishing compared the shorter and longer outcomes of LA and Group Inc. All rights reserved. MOA in patients with AA. Core tip: Acute appendicitis is mostly encountered Patients disease in a daily routine. Researchs regarding decreasing From January 2011 to June 2013, the data of patients morbidity and mortality are still needed, although it is very who underwent MOA and LA were recorded at the well known. Hospital stay, operation time, postoperative general surgery department of Safa Hospital. Patients complication rates are important for the management with completed follow-up were included in the study. of acute appendicitis. Therefore, we suggest that Pregnant women and patients with previous lower laparoscopic appendectomy should be accepted as a abdominal surgery were excluded. The patients were standard treatment for acute appendicitis. Mini-incision randomized into MOA and LA groups a computer- appendectomy is an alternative for a select group of generated number. Patients with surgery converted patients. from LA to MOA were excluded. Patients were divided into two groups: LA and MOA done by the Çiftçi F. Laparoscopic vs mini-incision open appendectomy. same surgeon. All patients gave their informed World J Gastrointest Surg 2015; 7(10): 267-272 Available from: consent. Patients’ demographic data, procedure time, URL: http://www.wjgnet.com/1948-9366/full/v7/i10/267.htm histopathologic reports, the need for analgesics, DOI: http://dx.doi.org/10.4240/wjgs.v7.i10.267 postoperative visual analog scale (VAS) score at 1, 6, 12 and 24 h, the hospital stay period, the period of time to return to daily activity, morbidity, and mortality were recorded. The diagnosis of AA was made by INTRODUCTION the surgeon with physical examination, laboratory values, and radiological tests (abdominal ultrasound or The most common reason for admission to the emer- computed tomography). All operations were performed gency room is acute appendicitis (AA), and app- with general anaesthesia. endectomy is a daily surgical procedure performed around the world[1,2]. Open appendectomy (OA) is accepted as a standard treatment for (AA); its Methods morbidity and mortality are very low[1,2]. However, LA was performed based on the three trocars laparoscopic appendectomy (LA) has recently become technique: a 10 mm port was placed at the umbilical more accepted[1,2]. Many advantages of LA have been area for the scope; a 5 mm port was placed in the shown such as lower hospital stay, shorter recovery left lower quadrant; a 5 mm port was inserted in the period, shorter period for returning to daily activities, suprapubic area. The mesoappendix was transected lower postoperative pain, and lower postoperative with ultrasonic energy, and the appendix was tied infections[1-6]. In spite of these advantages, there is at the radix. Appendectomy was completed by endo controversy over the best model of appendectomy scissors and was removed from the abdomen through techniques in the literature. Any extra potential a 10 mm port in the umbilical area in an endo-loop advantages resulting from the laparoscopic approach (EndoLoop, Vicryl Coated Ligature, Ethicon UK Ltd., are hard to prove because OA has the advantages of Edinburgh, United Kingdom). The appendix stump minimally invasive surgery such as a small incision, was not embedded. A drain tube was placed in the faster return to daily activities, and short hospital rectovesical area when considered necessary. stays[3,7]. Moreover, there are some discouragements MOA was performed as a standard treatment. for LA such as longer operation time, higher intra-abdo- A 3 cm Mc Burney incision was made to enter the minal abscess, and higher failure rate in complicated peritoneum. Appendectomy was completed followed WJGS|www.wjgnet.com 268 October 27, 2015|Volume 7|Issue 10| Çiftçi F. Appendicitis n two groups, either MOA (n = 121) or LA (n = 122). Table 1 Patients’ characteristics and operative data (%) Five patients who had undergone conversion from LA LA (n = 122) MOA (n = 121) P value to OA were excluded from the study. As shown in Table Age (yr)1 25.9 ± 9.6 28.8 ± 11.1 0.249 1, there were no statistical differences in demographics (median, range) (26.91-99) (29.81-97) between the two groups. The data of the operations are Gender (F/M) 56/66 50/70 0.3892 shown in Table 1. The mean operating time was similar ASA score 108/16/3 106/11/4 0.449 in both groups. Between the two groups, diagnoses BMI3 (kg/m2) 24.1 ± 2.9 24.6 ± 3.1 0.998 Operative time (min) 51.0 ± 13.9 50.9 ± 19.9 0.844 of gangrenous, inflamed, and perforated appendicitis Surgeon 122 121 histopathologically were normally distributed. However, Appendix the rate of false appendicitis was statistically lower in the Normal 8 (6.5) 18 (14.8) 0.009 LA group (P = 0.009). The early postoperative VAS was Gangrenous 14 (11.4) 11 (9.0) 0.149 Phlegmonous 93 (76.2) 86 (71.0) 0.079 statistically lower in LA, whereas the differences were Perforated 7 (5.7) 6 (4.9) 0.073 similar at the postoperative 24 h mark (P = 0.056, Table 2). The need for analgesics in the LA group was lower 1Students’ t test; 2χ 2 test; 3mean ± SD. BMI: Body mass index; ASA: American in the postoperative period (P = 0.001). The length of Society of Anaesthesiology; MOA: Mini-incision open appendectomy; LA: hospital stay was lower in LA, but the difference was not Laparoscopic appendectomy. statistically significant (P = 0.071, Table 2). The rate of total complications was similar between the two groups by tying off of the mesoappendix and radix of the (6.5% in LA vs 7.4% in OA, P = 0.599). All wound appendix. The appendix stump was embedded. A infections were treated non-surgically. Six out of seven drain tube was placed in the rectovesical area when patients with pelvic abscess were successfully treated considered necessary. All appendectomy specimens with percutaneous drainage; one patient required were sent for histopathological examination. All patients surgical drainage after a failed percutaneous drainage received intravenous 3rd generation cephalosporin as a (Table 2). There were no other complications such as prophylactic antibiotic (Seftriakson - Novosef, 1000 mg bowel obstruction or incisional hernia. The follow-up iv, Zentiva, İstanbul, Türkiye). Patients with complicated period was similar in both groups (14.7 mo for OA and AA received both 3rd generation cephalosporin and 15.6 mo for LA, P = 0.449). No mortality was reported metronidazole (Biteral, 500 mg iv, Deva, Istanbul, in the follow-up period. Turkey) as prophylactic antibiotics. All patients received a dose of analgesic medication (diclofenac sodium, 75 mg im, Deva, İstanbul, Turkey) prior to intubation DISCUSSION in the operating room. In the postoperative period, As a minimally invasive technique, controversy reg- patients received analgesic medication based on the arding the superiority of LA over OA has existed for need for pain medication. The postoperative VAS score several years[1,9,10]. Because there are no differences was recorded at postoperative hours 1, 6, 12, and 24. in surgical outcomes between the two groups, OA Patients were discharged when they tolerated normal is considered the better option due to lower cost[3]. food and passed gas and were followed up every week However, lower postoperative pain, diagnostic accuracy, for three weeks as outpatients. Sutures were removed especially in women and the elderly, shorter periods one week after surgery. Follow-ups for complications of healing, and better cosmetic results have been occurred in postoperative weeks two and three. Patients considered advantages of LA over OA[2,4,9]. There were with complications were admitted to the hospital. different protocols in previous studies, which resulted in various outcomes reported in the literature[3]. The Statistical analysis longer operating time required for LA is a factor in Results for categorical variables are given as comparing the two groups, and it extends farther frequencies and proportions (%), and results for in laparoscopic procedures done by inexperienced continuous variables are given as mean ± SDs. Results surgeons[1,4,9]. A previous study reported that operating for categorical variables were compared by χ 2 tests; time is shorter if the procedure is performed by an results for continuous, normally distributed variables experienced surgeon due to better exposure[11]. were compared by student t-tests; and results for Because our surgical team has laparoscopic procedure non-normally distributed continuous variables were experience, we have concluded that the operating times compared using a Mann Whitney U test. Variables were for LA and MOA are similar. In our institution, ultrasonic considered statistically significant if the P-value ≤ 0.05 energy is used for transsecting the mesoappendix. But was in the 95%CI. Statistical analyses used SPSS for it is not actually mandatory, electro-cautery and other SPSS 16.0 software (SPSS Inc., Chicago, Illinois, United devices can be preferred[12-14]. Moreover, the similar States). operating time should be considered a positive factor for LA. The hospital stay period is directly dependent on a patient’s general condition[4], and a shorter hospital RESULTS stay in LA has been shown in previous studies; this The study’s 243 patients were randomly divided into outcome was proven by meta-analysis studies[3,6,7,9]. WJGS|www.wjgnet.com 269 October 27, 2015|Volume 7|Issue 10| Çiftçi F. Appendicitis Table 2 Result of mini-incision open appendectomy vs laparoscopic appendectomy n (%) LA (n = 122) OA (n = 121) P value Hospital stay (h)3 25.61 ± 23.72 28.92 ± 21.93 0.0714 Return to daily activities (d) 4 (2–12) 5 (3-15) Overall morbidity 8 (6.5) 9 (7.4) 0.5992 Mortality 0 0 - VAS score3 1st hour 7.1 ± 0.5 7.6 ± 0.7 0.0011 6th hour 3.9 ± 1.1 4.5 ± 1.2 0.0011 12th hour 2.6 ± 1.3 3.1 ± 1.4 0.0271 24th hour 2.4 ± 0.7 2.9 ± 0.9 0.0561 Number of analgesics 1 33 (27.0) 18 (14.8) 2 46 (37.7) 42 (34.7) 3 25 (20.4) 27 (22.3) 0.004 4 17 (13.9) 33 (27.2) Postoperative complications Pelvic abscess 4 3 Wound infection 1 5 Atelectasis 1 - 1Student’s t test; 2χ 2 test; 3mean ± SD; 4Mann-Whitney test. LA: Laparoscopic appendectomy; OA: Open appendectomy. The 48 h discharge policy recommended for both due to the lower incidence of wound infections. There OA and LA by previous studies has caused confusion is considerable controversy regarding the occurrence due to different policies of individual hospitals[3,9]. of intra-abdominal abscess after appendectomy, which Many studies list hospital stay periods by the number is a serious and life threating complication[9]. Some of days vs hours because They may be affected by studies in the literature have shown that the rate social standards, insurance systems, and hospital of intra-abdominal abscess is higher in OA[1-3,5,15,16]. discharge policies[3,4,9,15]. In this study, we used hours Moreover, some studies have favoured LA in terms to define hospital stay periods to reflect differences of these complications. The laparoscopic technique between the two groups. The hospital stay period has some advantages such as the removal of intra- was shorter by three hours in LA; it is unclear if this is abdominal infected fluid with suction. However, it can clinically significant. A meta-analysis done by Cochrane spread infected fluid into the peritoneum, especially in Colorectal Cancer Group revealed that returning to perforated appendicitis and when using more irrigation. daily activities in a shorter amount of time is considered as an advantage for LA[3,9,16] Additionally, carbon dioxide insufflation can spread . Minimal trauma to the bacterial contamination into the peritoneum[3,9,13]. It is abdominal wall is considered the main reason for faster believed that using advanced surgical techniques and healing and lower pain for LA[3,11,17-28]. Early mobilisation gaining more laparoscopic experience may decrease the after LA is another advantage, and this is achieved by intra-abdominal abscess rate in LA[3]. Overall, the lower minimal manipulation of the cecum and ileum during rate of wound infection is an advantage for LA because the procedure[3]. While the recovery period was shorter in LA, it was not considered significant. the infected appendix can be removed from a small [3,4,9] Postoperative pain on day one was evaluated by incision in an endobag . The economical analysis the need for analgesics and VAS[3]. Evaluating pain of these two techniques is another issue that must be was difficult due to the use of different analgesics, addressed. Although there are many studies about the administration of those analgesics in different forms, cost analysis between LA and OA [29,30], we did not make and different cultures’ perceptions of pain. Therefore, an actual consideration, which needs to be addressed to obtain a better result in regard to pain evaluation, in further studies. In this study, pregnancy group was we used two methods. Many previous studies have excluded, because we believe in that MOA vs LA in the shown lower needs for analgesics and VAS[3,9]. In this pregnant should be evaluated in a separate study [31]. study, postoperative pain was measured by VAS, and In conclusion, LA has a similar hospital stay, opera- the need for analgesics was statistically lower in the ting time, and rate of postoperative complications as LA group. All of these results supported LA as the MOA, yet decreases the need for analgesics and VAS. preferred option for AA. The presence and degree of Therefore, LA should be the suggested treatment for postoperative complications are generally considered AA. MOA is still a viable alternative for selected patients. as safety indicators for a procedure. The most common complications of AAs are wound infections, intra- abdominal abscess, and ileus[9]. It has been shown that ACKNOWLEDGEMENTS postoperative complications are lower in LA vs OA[3,4,7,9]. The authors express their gratitude to all of the Lower complications in LA, as shown in this study, are participating patients and clinical staff. WJGS|www.wjgnet.com 270 October 27, 2015|Volume 7|Issue 10| Çiftçi F. Appendicitis COMMENTS Surg Today 2012; 42: 1165-1169 [PMID: 22426772 DOI: 10.1007/COMMENTS s00595-012-0163-3] Background 9 Gurrado A, Faillace G, Bottero L, Frola C, Stefanini P, Piccinni G, Laparoscopic appendectomy is still not accepted as a standard management Longoni M. Laparoscopic appendectomies: experience of a surgical for acute appendicitis due to longer operation time and higher cost. In the unit. Minim Invasive Ther Allied Technol 2009; 18: 242-247 [PMID: literature, there are few studies on surgical treatment comparing laparoscopic 20334502 DOI: 10.1080/13645700903053840] and mini-incision open appendectomy. 10 McGrath B, Buckius MT, Grim R, Bell T, Ahuja V. Economics of appendicitis: cost trend analysis of laparoscopic versus open appendectomy from 1998 to 2008. 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Ann Ital Chir 2014; 85: 606-609 [PMID: 25712546] regarding decreasing morbidity and mortality are still needed, although it is 13 Yeh CC, Jan CI, Yang HR, Huang PH, Jeng LB, Su WP, Chen very well known. There were no differences in the period of hospital stay, HC. Comparison and efficacy of LigaSure and rubber band operation time, and postoperative complication rate between the two groups. ligature in closing the inflamed cecal stump in a rat model of acute appendicitis. Biomed Res Int 2015; 2015: 260312 [PMID: 25699264 Laparoscopic appendectomy decreases the need for analgesic medications DOI: 10.1155/2015/260312] and the visual analog scale of pain. Therefore, the author suggests that 14 Shaikh FM, Bajwa R, McDonnell CO. Management of appendiceal laparoscopic appendectomy should be accepted as a standard treatment for stump in laparoscopic appendectomy-clips or ligature: a systematic acute appendicitis. 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Surgery 2010; 148: 625-635; discussion 635-637 [PMID: 282-288 [PMID: 25760205] P- Reviewer: Casarotto A, Olijnyk JG S- Editor: Yu J L- Editor: A E- Editor: Lu YJ WJGS|www.wjgnet.com 272 October 27, 2015|Volume 7|Issue 10| Published by Baishideng Publishing Group Inc 8226 Regency Drive, Pleasanton, CA 94588, USA Telephone: +1-925-223-8242 Fax: +1-925-223-8243 E-mail: bpgoffice@wjgnet.com Help Desk: http://www.wjgnet.com/esps/helpdesk.aspx http://www.wjgnet.com © 2015 Baishideng Publishing Group Inc. All rights reserved.