|Year : 2020 | Volume
| Issue : 2 | Page : 171-174
A comparison of laparoscopic appendicectomy versus open appendicectomy
Rayeez P Abdul Nazir, Santhosh John Abraham
Department of General Surgery, Lourdes Hospital, Kochi, Kerala, India
|Date of Submission||27-Jul-2020|
|Date of Decision||13-Aug-2020|
|Date of Acceptance||14-Oct-2020|
|Date of Web Publication||07-Nov-2020|
Dr. Rayeez P Abdul Nazir
Department of General Surgery, Lourdes Hospital, Kochi, Kerala
Source of Support: None, Conflict of Interest: None
Introduction: Laparoscopic appendicectomy is being adopted by majority of general surgeons, but its advantages over open appendicectomy, considering the cost difference, have not been established. This study aims to describe the difference in outcome between the two procedures and compare the costs involved. Materials and Methods: Seventy patients were studied with 35 in both laparoscopic and open appendicectomy groups. The two groups were compared for operation time, post-operative complications, pain, duration of hospital stay, days to return to work, quality of scar and costs involved. Results: Laparoscopic appendicectomy group had shorter operation times, lower post-operative pain, shorter hospital stays and better scars, whereas the open appendicectomy group had lower costs. No significant difference was observed in days to return to work or post-operative complications. Conclusion: Laparoscopic appendicectomy offers considerable advantages compared to open appendicectomy despite the higher costs.
Keywords: Appendicectomy, Laparoscopy, Open Appendicectomy
|How to cite this article:|
Abdul Nazir RP, Abraham SJ. A comparison of laparoscopic appendicectomy versus open appendicectomy. Kerala Surg J 2020;26:171-4
| Introduction|| |
Appendicectomy is the most common emergent general surgery operation done all over the world. Even though it is considered a simple surgery, the complications of the disease and lack of timely medical care, especially in rural India, make the disease a potentially life-threatening one. Over the past 10 years, surgeons have debated the merits of laparoscopic appendectomy versus the time-proven conventional open surgery. Laparoscopic surgery offer advantages such as better visualisation and examination of the entire peritoneal cavity to exclude other intra-abdominal diseases that may present similarly such as diverticulitis or tubo-ovarian abscess. The cost of laparoscopy equipment continues to be prohibitive.
| Materials and Methods|| |
The paper tries to quantify the differences in outcome between laparoscopic appendectomy and open appendicectomy to determine whether there is a significant advantage of one over the other and to describe and statistically analyse the outcome in terms of factors relevant to the patient, duration of surgery, pain after surgery, complications, getting back to work or school, intensity of scar, cost involved and benefit between the laparoscopic and open appendicectomy. It intends to counsel patients better based on the institutional results of laparoscopic versus open appendicectomy study outcome.
This was an observational, descriptive, analytical study comparing the ratio of patients with specific outcome in laparoscopic surgery versus those in open surgery group. Patients of all ages and sex, presenting with acute appendicitis and underwent appendicectomy surgery (open or laparoscopic) in Lourdes Hospital, Cochin, were included in this study. Patients were excluded if the symptoms had lasted >3 days, if the patient had contraindications to general anaesthesia, if the appendicitis had progressed to an appendicular mass or appendicular perforation or peritonitis or if the patient was in shock. A convenience non-probability sampling strategy was used for selecting the patients for this study. The sample size was determined by using the following formula: n > z2 pq/d2, where n = sample size, P = rate of prevalence, q = 1 − p, d = error of the estimate; as per published P = 6%, with a confidence of 95% and an error of 0.6%, the minimum sample size as per the above formula was worked out to be 61. The sample size for the present study was 70. Unpaired t-test for comparison of groups and Chi-square analysis for testing independence of attributes were performed. The data were collected using a pro forma meeting the objectives of the study from seventy patients from August 2017 to May 2019.
| Results|| |
The collected data were compiled and analysed for drawing conclusion using t-test and Chi-square test. All patients in the study group were younger than 30 years. The two cases of emergency appendicectomy done in our institute had delayed (>72 h) presentation with recurrent episodes of pain and hence were not included in the study. Of the seventy cases included, 35 had laparoscopic appendicectomy and 35 had open appendicectomy. Of the 35 laparoscopic appendectomy cases, 21 were in the age group of 10–20 and 30 and 13 in the age group of 20–30 years. The open appendicectomy group had 25 patients in the age group of 10–20 years and eight patients in the age group of 20–30 years. In the laparoscopic appendicectomy group, 20 patients were male and 15 were female, whereas in the open surgery group, 18 were male and 17 were female.
The mean operation time of laparoscopic appendicectomy was 28.4 ± 8.6 min against that of open appendicectomy, which was 35.85.5 min, with P < 0.05, showing statistically significantly lower operating time for laparoscopic appendicectomy compared to open surgery. There was no significant difference in complication rates between open and laparoscopic appendicectomy (χ2 = 0.54, P = 0.4624). Wound infection was the only complication encountered. Neither group developed any other complication such as abscess formation, peritonitis, post-operative bleeding, intraoperative injury to other organs, prolonged paralytic ileus or intestinal obstruction. The only long-term post-operative complication observed in either group was a case of incisional hernia in a female patient who underwent open appendicectomy, who presented 8 months after surgery. There was no conversion of laparoscopic appendicectomy to open surgery in the observed sample.
Pain was recorded at the time of admission as well as on each day of admission postoperatively by using Visual Analogue Scale pain scoring system. The details are noted in [Table 1]. Pain at the time of admission showed no statistically significant difference between the two groups, thus indicating that the two groups are comparable. While there was no significant difference in pain between the two groups on the 1st post-operative day, there was significantly better outcome in laparoscopic appendicectomy as compared to open surgery, with patients having much less pain on post-operative day 2 and also 2 weeks postoperatively.
Post-operative analgesia requirement by the mean number of tablets of paracetamol 1 g needed during the first 2 post-operative days was 4.64 for laparoscopic patients and 6.51 for open surgery patients, showing a statistically significant lower analgesic requirement in the laparoscopic group as compared to the open group with a mean difference of 1.87 and P < 0.0001. Twenty laparoscopic surgery patients were discharged on the 1st post-operative day and 15 on the 2nd post-operative day, whereas ten open surgery patients were discharged on the 1st post-operative day, 21 on the 2nd post-operative day, 3 on the 3rd post-operative day and 1 on the 4th post-operative day. There was a statistically significant difference (P < 0.0001) in the duration of hospital stay between the open and laparoscopic groups, with the laparoscopic group having shorter stays (mean difference: 0.43 days). There was no statistically significant difference in the average days to return to work or school between the laparoscopic and the open surgery groups (10.65 days vs. 11.59 days), with P = 0.36. Perception of scar was based on the Patient and Observer Scar Assessment Scale (POSAS) scale. The mean of patient scale and observer scale from 1 to 10, with 1 being normal skin and 10 being worst scar imaginable, was recorded. The laparoscopic group had a mean POSAS score of 5.21 against the open surgery group with a score of 6.1 (P = 0.0015), showing thereby that that open appendicectomy produces perceivably worse scars as compared to laparoscopic appendicectomy. The overall cost incurred during admission, including the operation theatre charges (anaesthesia, consumables and equipment charges), and total hospital stay charges (inpatient care and medications) worked out to Rs. 52,544/- for laparoscopic and Rs. 31,205/- for open procedure. This was statistically very highly significant (P < 0.001), as detailed in [Table 2]. While the mean total operation theatre charges were significantly higher for laparoscopic surgery, the total hospital stay charges were higher for open appendicectomy. However, the difference in operation theatre charges (mean difference = Rs. 22,427) was considerably more than the total hospital stay charges (mean difference = Rs. 1088). Hence, the total cost was considerably higher for the laparoscopic surgery as compared to open appendicectomy.
| Discussion|| |
The operating time was significantly shorter in the laparoscopic group. This is contrary to other studies,,, which found significantly higher operating times for laparoscopic appendicectomy. In our study, there was no significant difference in complication rates between open appendicectomy and laparoscopic appendicectomy groups. A meta-analysis of laparoscopic versus open appendicectomy randomised controlled studies by Garbutt et al. found that laparoscopic surgery decreased the chances of wound infection by 3.2%. Analysis of long-term complications in our study group showed only one case of incisional hernia following open appendicectomy. Andersson et al. conducted a cohort study on the fertility patterns of female children who had appendicectomy in childhood and concluded that perforated appendix in childhood did not seem to have any negative influence on female fertility.
We had zero conversion of laparoscopic appendicectomy to an open procedure due to complications. A retrospective study by Sakpal et al. found that the overall conversion rate for laparoscopic appendicectomy was 4.16%, with the major causes being severe acute inflammation (38.7%) and adhesions (25.1%). Our study showed no significant difference in pain measured in a Visual Analogue Scale on post-operative day 1 between the two groups, however the pain score was significantly lower on post-operative day 2 (by 1.12 points) and also 2 weeks (by 0.35 points) after the surgery. A study by Garbutt et al. found a decreased post-operative pain in laparoscopic group at 24 h by 1.12 points in the same scale. However, a study by Macarulla et al. found no significant difference in post-operative pain between the two groups.
Our study also showed a statistically significantly lower analgesia requirement in the laparoscopic group as compared to the open group, 4.64 versus 6.51 doses of 1 g paracetamol in the first 2 post-operative days (P < 0.001). Studies by Bellia et al. (P < 0.0001) and Macarulla et al. showed a similarly decreased analgesia requirement in the laparoscopic group. Patients in the laparoscopic group were found to have shorter hospital stays by 0.43 days as compared to that of the open surgery group. Other studies ,, have shown similar shorter stays for the laparoscopic surgery group. Appendicectomy scar by the open technique was found to be perceivably worse as compared to the smaller scars of the laparoscopic group in the POSAS scale. Patients in the laparoscopic appendicectomy group were more satisfied with their scars. However, another study by Sucullu et al. in 2009 on body image and cosmesis showed no significant difference between laparoscopic and open techniques. Laparoscopic appendicectomy was significantly more expensive than open appendicectomy; the high operation theatre charges were mostly attributable to the equipment and consumable charges.
From our study, it has been observed that laparoscopic appendicectomy is considerably more expensive, but it offers advantages to patients in terms of shorter hospital stay (1.85 days for laparoscopic vs. 1.42 days for open surgery), lower post-operative pain and better scar. However, no significant differences were observed in terms of days to return to work of school or complication rates (short and long term). Our conclusion was hence similar that laparoscopic surgery is a better procedure overall and it is our recommendation if the patient can afford it.
| Conclusion|| |
The benefits of laparoscopic surgery include lesser operative time, lesser post-operative pain and analgesia requirement, shorter duration of hospital stay and perceivably better scars. There was no significant difference between the two groups in the rate of short- or long-term complications or in terms of number of days taken to return to work or school. There were no reported cases of infertility after the surgery. On the other hand, open appendicectomy is considerably cheaper than the laparoscopic procedure, with most of these costs attributable to operation theatre charges. This amount is not offset by the shorter duration of hospital stay. However, in view of the other advantages, laparoscopic appendicectomy is viewed the better procedure for treatment of patients with acute appendicitis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]