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Surg Endosc (2017) 31:199–205 and Other Interventional Techniques

DOI 10.1007/s00464-016-4957-z

Comparison of clinical outcome of laparoscopic versus open


appendectomy for complicated appendicitis
P. Horvath1 • J. Lange1 • R. Bachmann1 • F. Struller1 • A. Königsrainer1 •

M. Zdichavsky1

Received: 2 February 2016 / Accepted: 18 April 2016 / Published online: 18 May 2016
Ó Springer Science+Business Media New York 2016

Abstract Conclusions The laparoscopic approach for complicated


Background Laparoscopic appendectomy is now the appendicitis is a safe and feasible procedure. Surgeons
treatment of choice in uncomplicated appendicitis. To date should be aware of a potentially higher incidence of
its importance in the treatment of complicated appendicitis intraabdominal abscess formation following LA. Use of
is not clearly defined. endobags , inversion of the appendiceal stump and care-
Methods From January 2005 to June 2013 a total of 1762 fully conducted local irrigation of the abdomen in a supine
patients underwent appendectomy for the suspected diag- position may reduce the incidence of abscess formation.
nosis of appendicitis at our institution. Of these patients
1516 suffered from complicated appendicitis and were Keywords Complicated  Appendicitis  Laparoscopy 
enrolled. In total 926 (61 %) underwent open appendectomy Intraabdominal abscess
(OA) and 590 (39 %) underwent laparoscopic appendec-
tomy (LA). The following parameters were retrospectively Since its first description in the early 1980s laparoscopic
analyzed: age, sex, operative times, histology, length of appendectomy (LA) has advanced to the treatment of choice
hospital stay, 30-day morbidity focusing on occurrence of for uncomplicated appendicitis, with increasing numbers of
surgical site infections, intraabdominal abscess formation, procedures performed per year [1]. Several studies have
postoperative ileus and appendiceal stump insufficiency, demonstrated the superiority of LA compared to open
conversion rate, use of endoloops and endostapler. appendectomy (OA) in uncomplicated appendicitis [2–10].
Results A statistically significant difference in operative Compared to OA many advantages of LA have been high-
time was observed between the laparoscopic and the open lighted, such as reduced postoperative pain, better cosmetic
group (64.5 vs. 60 min; p = 0.002). Median length of results and faster return to physical activity, thus increasing
hospitalization was significantly shorter in the laparoscopic the chance of early discharge. The importance of LA in the
group (p \ 0.000). Surgical site infections occurred therapy of complicated appendicitis (CA) is still not clearly
exclusively after OA (38 vs. 0 patients). Intraabdominal defined as reflected by controversial findings in the past lit-
abscess formation occurred statistically significantly more erature [7, 11, 12]. However, more recent studies conveyed
often after LA (2 vs. 10 patients; p = 0.002). There were the superiority of LA in complicated appendicitis [13–16].
no statistical significances concerning the occurrence of Opponents of LA for complicated appendicitis state that in
postoperative ileus (p = 0.261) or appendiceal stump the presence of abdominal wall perforation and abscess
insufficiencies (p = 0.076). formation the laparoscopic approach represents a relative
contraindication [12]. On the other hand, especially in
severely ill patients with perforated appendicitis, LA might
& P. Horvath offer various clinical benefits, such as reducing the risk of
philipp.horvath@med.uni-tuebingen.de extensive laparotomy [13]. Our study aimed to present the
1
Department of General, Visceral and Transplant Surgery,
clinical outcome regarding postoperative morbidity in
Comprehensive Cancer Center, University of Tübingen, patients with CA treated by either LA or OA.
Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany

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200 Surg Endosc (2017) 31:199–205

Materials and methods Results

From January 2005 to June 2013 1762 patients underwent From January 2005 to June 2013 926 patients underwent
LA or OA for the suspected diagnosis of appendicitis and OA and 590 patients LA for CA (Table 1; Fig. 1). In the
were retrospectively considered for this study. In total 1516 OA group 13 % and in the LA group 9 % of the patients
patients with CA defined as a phlegmonous, necrotic or were categorized as perforated appendicitis. There were
gangrenous transformation of the appendix, perforation of significantly more male patients in the OA than in the LA
the appendiceal wall (macroscopic or microscopically group (p \ 0.000). Median age in both groups was com-
proven by histological report) and presence of abscess parable (28.9 vs. 28 years).
formation were enrolled. The conversion rate in the LA group was 0.86 %
Prior to surgery all patients were subjected to clinical (n = 5/590 patients). In all cases impaired visualization of
examination, blood and urine screening and ultrasonography the right lower quadrant was the reason for conversion.
of the abdomen. In selected patients with unclear symptoms For appendiceal stump closure in 84 % of the patients
a priori, computed tomography (CT) scan was conducted to Roeder knots and in 16 % of the patients a stapler device
ensure correct diagnosis. All patients diagnosed with com- was used in the LA group. In 53 % of the patients with
plicated appendicitis were scheduled for immediate opera- perforated appendicitis (Fig. 2) in the LA group a stapler
tion. All operations were performed by a team of two device was used. Usually the reason for stapler use was an
surgeons, one resident and one consultant who were expe- inflamed appendix base.
rienced in the open as well as the laparoscopic approach. In 16 % of the patients in the OA and in 12 % of the
Prior to surgery each patient was given intravenous single- patients in the LA group a drain was inserted.
shot antibiotic treatment consisting of a third-generation Median operative time in the OA group was 64.5 min
cephalosporine, and in cases of perforation, gangrene and/or (range 16–239 min) and in the LA group 60 min (range
abscess formation metronidazole was added. 11–185 min) (p = 0.002). In the case of perforated
OA and LA were performed as a standardized procedure appendicitis operative time was extended to 77 min (range
as described in our previous publication [14]. In all cases of 32–234 min) in the OA group and to 76 min (range
LA an endobag was used to remove the specimen from the 28–310 min) in the LA group (p = 0.631).
abdominal cavity. Median hospital stay in the OA group was 4 days (range
Surgical site infections (SSI), intraabdominal abscess 1–44 days) and in the LA group 3 days (range 1–27 days)
formation (IAA), postoperative ileus (PI) and appendiceal (p \ 0.000).
stump insufficiency (ASI) were retrospectively assessed. Of the patients with phlegmonous appendicitis 5 and
According to the classification from the Centers of Disease 2 % and of the patients with perforated appendicitis 13 and
Control and Prevention (CDC) SSI were divided into 11 % suffered from any kind of complication within the
superficial incisional and deep incisional SSI [19]. IAA was first 30 postoperative days in the OA and the LA group,
defined as an intraabdominal fluid collection diagnosed respectively (Table 1; Fig. 3). SSI occurred exclusively in
radiologically accompanied by elevated inflammation the OA group. All 38 patients with SSI of the OA group
markers and deterioration of the patient’s clinical condition. required bedside wound treatment. In 16 % of these
PI was defined as the presence of nausea, vomiting, pro- patients intravenous antibiotic treatment consisting of
gressive abdominal pain and absence of bowel movement. ciprofloxacin and metronidazole was commenced for at
Definite diagnosis was sought radiologically. ASI was least 5 days. Furthermore, daily wound inspection and
defined as intraoperatively proven insufficiency of the change of wound dressing were conducted. SSI were
appendiceal stump with a pericecal fluid collection and/or classified according to the Clavien–Dindo classification as
peritonitis. All complications were graded using the Cla- group I (no antibiotic treatment; n = 32/38; 84 %) or as
vien–Dindo classification of surgical complications [15]. group II (antibiotic treatment; n = 32/38; 84 %). All four
patients requiring antibiotic treatment suffered from deep
incisional SSI according to CDC classification. The
Statistics remaining SSI were categorized as superficial incisional.
Two and ten patients developed postoperative IAA in
SPSS ver. 12.0 (SPSS Inc. Chicago, IL, USA) was used for the OA and the LA group, respectively (p = 0.002). In the
statistical analysis. A p \ 0.05 was considered statistically OA group IAA was diagnosed on postoperative days 11
significant when using the Chi-square test and the T test. and 15. The first patient was primarily treated with a CT-
The Chi-square test was used for nominal variables and the targeted drain, but without improvement in clinical status
T test for continuous variables. so that re-operation was scheduled for resection of the right

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Surg Endosc (2017) 31:199–205 201

Table 1 Clinicopathological
Characteristics OA (n = 926) LA (n = 590) p value
characteristics in complicated
appendicitis in the OA and the Age (year) 0.381
LA group (yr years, US
ultrasound, CT computed Median 28.9 28
tomography, min minutes, dy Range 15–88 16–91
days, SSI surgical site infection, Sex (n) \0.000
IAA intraabdominal abscess
Male 527 215
formation, PI postoperative
ileus, ASI appendiceal stump Female 399 375
insufficiency) Preoperative diagnostic
US 855 548 0.691
CT 187 88 0.009
US ? CT 100 59 0.622
Operative time (min)
Median 64.5 60 0.002
Range 16–239 11–310
Histology (n) 0.015
Phlegmonous 805 537
Perforated 121 37
Median hospital stay (dy) 4 3 \0.000
30-day morbidity n (%)
SSI 38 (4) 0 (0) \0.000
IAA 2 (0.2) 10 (1.7) 0.002
PI 5 (0.5) 1 (0.17) 0.263
ASI 0 (0) 2 (0.4) 0.076
Endo-GIA (n) Not applicable 95
Roeder knots (n) Not applicable 495
Operative time (min) Endo-GIA versus Roeder knots
Range Not applicable 63.5 vs. 53 \0.000
Median Not applicable (26–172) vs (11–185)
Conversion rate (n) 0 5 0.005
Drain insertion (n) 151 71 0.021

Fig. 1 Numbers of OA and LA 200


from 2005 to 2013
180

160

140

120
paents

100 OA
80 LA
60

40

20

0
2005 2006 2007 2008 2009 2010 2011 2012 Jan.-Jun.
2013

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202 Surg Endosc (2017) 31:199–205

Five patients in the OA group developed PI (acute


abdominal pain, nausea and vomiting, elevated markers of
inflammation) and needed re-operation (Clavien–Dindo
IIIb) between postoperative days 3 and 7. In none of the
patients was bowel resection necessary. In the LA group
one patient suffered from PI and re-laparoscopy became
necessary on postoperative day 3 (Clavien–Dindo IIIb).
Intraoperatively an abscess in the lesser pelvis was found.
Adhesiolysis and abscess evacuation were performed.
One patient in the OA group showed clinical signs of
lower gastrointestinal bleeding on postoperative day 7.
Fig. 2 Laparoscopic view of perforated appendicitis (black arrow)
Coronary heart disease made postoperative anticoagulation
with abscess formation in the background (black star) with acetylsalicylic acid and clopidogrel necessary.
Emergency colonoscopy showed acute bleeding on the
appendiceal stump, which was graded Clavien–Dindo IIIa.
40
Hemostasis was achieved endoscopically.
35
Two patients in the LA group suffered from ASI on
30 postoperative days 5 and 8. Initially, Roeder knots were
25
paents

used in one patient and a stapler device in the other patient.


20 OA In both patients laparotomy and resection of the ileocecal
LA region in the first and of the right hemicolon in the second
15

10
patient were necessary (Clavien–Dindo IIIb).
5

0
SSI IAA PI ASI
Discussion

Fig. 3 Comparison of OA and LA regarding incidence of SSI, IAA, The first clinical reports of LA for uncomplicated appen-
PI and ASI dicitis were published in the 1980s, and today LA is still
the treatment of choice. Superiority of LA over OA has
been demonstrated in several studies [2–10]. The benefits
hemicolon. The second patient underwent re-laparotomy of LA are reduced operative trauma, less postoperative
due to interenteric abscess formation with abdominal pain, quicker return to physical activity and better cosmetic
lavage but without bowel resection. results [13, 16]. These features constitute the main reasons
In the LA group IAA was diagnosed on days 3, 4, 5, 7, 10, why the laparoscopic approach has been adopted as the
10, 12, 17, 26 and 29 postoperatively. Of ten patients seven gold standard for many other surgical procedures. Never-
were primarily treated with CT-targeted drain. In one of theless, the value of LA in the treatment of CA is still not
these patients percutaneous drainage was not sufficient so clearly defined, which may be due to controversial findings
that a laparotomy was performed. The remaining three in the earlier literature, associating LA with either a clear,
patients required re-operation. The first patient was pri- marginal or no clinical benefit over OA for CA.
marily treated with intravenous antibiotics, but clinical The aim of this study was to evaluate the outcome of LA
deterioration made re-laparoscopy and lavage and drainage in the treatment of CA in comparison with the open
of the abdomen necessary. Ten days later fever, abdominal approach. In agreement with other studies we were able to
pain and elevated inflammation markers called for laparo- demonstrate that LA is a feasible and safe procedure [15,
tomy and resection of the ileocecal region. The second 16]. At our institution LA was started in 2005, and
patient suffered from IAA and postoperative ileus, so that re- nowadays, the vast majority of appendicitis cases, either
laparoscopy, adhesiolysis and drainage were performed. In uncomplicated or complicated, are operated on laparo-
the last patient re-laparoscopy and lavage of the abdomen scopically. Consistent with other studies [17–24] SSI
were performed on postoperative day 12. All patients occurred more often in the OA group, reaching statistical
received intravenous antibiotic treatment with ciprofloxacin significance in our study population. The main reasons for
and metronidazole. IAAs were classified according to the the significantly larger number of SSI in the OA group
Clavien–Dindo classification as groups IIIa (CT-targeted might be the direct trauma to the wound and the fact that
drain) and IIIb (re-operation). Further clinicopathologic during LA the specimen is removed using an endobag. In
characteristics are shown in Tables 2 and 3. order to perform the resection during OA the inflamed

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Table 2 Clinical characteristics


Characteristics IAA in OA group (n = 2) IAA in LA group (n = 10) p value
of patients with IAA in the OA
and the LA group Age (year) 0.634
Median 41.5 56.6
Range 18–65 18–91
Sex (n) [1.000
Male 1 5
Female 1 5
Comorbidity (n)
Hypertension 1 2 0.454
Diabetes mellitus 0 1 0.640
Chronic renal failure 0 1 0.640
Pathological finding (n)
Phlegmonous 0 5 0.274
Perforated 2 5 0.601

Table 3 Intraoperative and complication-management characteristics of patients suffering from IAA in the OA and the LA group (POD
postoperative day)
Characteristics IAA in OA group (n = 2) IAA in LA group (n = 10) p value

Intraoperative characteristics (n)


Roeder knot Not applicable 7
Endo-GIA Not applicable 3
Operative time (min) 0.293
Median 108 72
Range 78–138 58–143
Drainage insertion 2 8 0.480
Surgeon: resident 0 1 0.640
Surgeon: consultant 2 9 0.640
Type of complication (n)
Pericecal abscess formation 2 6 0.784
Interenteric abscess formation 0 4 0.784
Time point of complication (n)
POD 0–3 0 1 0.640
POD 4–7 0 3 0.371
POD 8–11 1 2 0.371
POD 12–15 1 1 0.729
POD 16–22 0 1 0.640
POD 23–30 0 2 0.488
Interventions (n)
Percutaneous CT-guided drainage 1 6 0.793
Re-operation 2 5 (one patient had two operations) 0.601
Re-laparoscopy Not applicable 3
Laparotomy 2 2 0.171

appendix has to be luxated out of the abdomen, which may Regarding further postoperative complications this
contribute to contamination of the surrounding tissue. study shows that patients undergoing LA for CA developed
Furthermore, the laparoscopic approach creates a far IAA statistically significantly more often than did patients
smaller operative trauma than does OA. None of the undergoing an open procedure. These findings go along
patients had to be re-operated due to SSI, but were man- with results of other studies [25–27]. In total ten patients in
ageable with antibiotics and bedside wound treatment. our LA group postoperatively developed IAA. Histology

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revealed five phlegmonous and five perforated appendices. perforation the operative times were synchronously
In seven out of ten patients Roeder knots were used. In the extended in both groups (77 min for LA and 76 min for
vast majority of patients abscesses were able to be evacu- OA).
ated by inserting a CT-guided drain. In comparison, only Only five of 590 patients who were operated on
two patients in the OA group suffered from IAA. The first laparoscopically for CA were converted to an open pro-
aspect that might explain this phenomenon is the fact that cedure because of impaired visualization of the right lower
during OA the appendiceal stump is completely inverted, quadrant, all of whom showed no postoperative compli-
which prevents further postoperative contamination of the cations. Compared to other reports with conversion rates of
abdominal cavity. In our study Roeder knots were used in up to 13 % for LA in CA our conversion rate seems to be
the vast majority of cases, also in the presence of perfo- quite low [30].
rated appendicitis, without routinely conducted appen- In conclusion, LA constitutes a safe and feasible pro-
diceal stump inversion. The second aspect might be the cedure for the treatment of CA. In the case of CA, endo-
patient’s position during laparoscopy and irrigation of the bags and endostapler should be used or the appendiceal
abdomen after removal of the specimen. Usually patients stump should be inverted after applying Roeder knots.
undergoing LA are positioned in a trendelenburg position Furthermore, local irrigation in supine position should be
in order to optimize visualization of the right lower quad- performed carefully in order to further minimize the
rant. Irrigation of the abdomen conducted in this position occurrence of IAA in LA.
might facilitate the intraabdominal spread of contaminated
Compliance with ethical standards
fluids, thus promoting intraabdominal (i.e., subhepatic and
interenteric) abscess formation. This is why a routinely Disclosures Dr. Philipp Horvath, Dr. Jessica Lange, Dr. Robert
conducted appendiceal stump inversion during LA, the use Bachmann, Dr. Florian Struller, Dr. Alfred Königsrainer and Dr. Marty
of endobags to further minimize contamination and the Zdichavsky have no conflicts of interest or financial ties to disclose.
cautious only local irrigation of the right lower quadrant
preferably in supine position should be given consideration
[25–27]. A large retrospective study from the Netherlands
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