JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES

Volume 19, Number 6, 2009

ª Mary Ann Liebert, Inc.
DOI: 10.1089=lap.2009.0167

Outcomes After Laparoscopic Treatment

of Complicated Versus Uncomplicated Acute Appendicitis:
A Prospective, Comparative Trial

Antonio M. Malagon, MD, Ivan Arteaga-Gonzalez, MD, and Lucrecia Rodriguez-Ballester, MD

Abstract

Background: Laparoscopic treatment of simple acute appendicitis (AA) is a safe procedure; however, there are
doubts about its safety in cases of complicated AA. The aim of this study was to determine the differences in
results of laparoscopic treatment between cases of complicated versus simple AA.
Materials and Methods: We prospectively included all patients treated for suspected AA by two surgeons of our
service between May 2002 and May 2007. Of 221 patients, 20 were excluded from the study because the laparo-
scopic approach was not posible; 116 of 201 had uncomplicated AA, 57 complicated AA, 12 gynecologic ethiology,
11 negative appendectomy, and 5 other causes; patients without acute appendicitis were also excluded from the
study. In all cases, laparoscopy was the first treatment option. The following variables were considered: mean
surgical time, reconversions, emergency readmissions, emergency reinterventions or invasive procedures, mean
postoperative hospital stay, and postoperative complications (i.e., infectious or noninfectious).
Results: Our results showed statistically significantly worse results, in terms of surgical time, postoperative stay,
reconversions, and infectious complications, for patients with complicated versus uncomplicated AA; however,
no differences were observed regarding noninfectious complications, emergency readmissions, and emergency
reinterventions or invasive procedures.
Conclusions: We consider that laparoscopic treatment of complicated AA may be safely used, despite worse
results than in cases of simple AA, since the differences in numbers of severe postoperative complications
requiring emergency readmission, reintervention, or invasive procedures were not statistically significant.

Introduction
ince its introduction in 1983,1 laparoscopic treatment
S of acute appendicitis (AA) has been controversial, espe-
cially in cases of complicated AA, owing to the publication of
studies2–5 showing a high incidence of infectious complica-
tions (e.g., intra-abdominal abcesses). In these cases, open
surgery has been proposed as a safer option, while the lapa-
roscopic approach has been considered a safe procedure in
uncomplicated AA. However, more recent publications have
shown that laparoscopic treatment is a valid option even
in evolved cases, with complication rates that are similar or
lower than those of open surgery.6–9 The percentage of in-
fectious complications secondary to laparoscopic appendec-
tomy in complicated AA varies widely in the literature, from
19 to 28%,10 and doubts, therefore, remain about the safety
of this procedure. In both open and laparoscopic apendi-
cectomy, it is accepted that the greater the degree of evolution
of AA, the worse the short-term results and the higher the
rate of infectious complications. However, few published re-
ports11 have addressed to what extent the degree of evolution
of AA affects the results of laparoscopic appendectomy and
what variables are most affected on comparing treated cases
of uncomplicated versus complicated AA. This was the aim of
the present study.
Materials and Methods
We prospectively included all patients >14 years of
age treated for suspected AA by two surgeons of our service
between May 2002 and May 2007. Data from interventions
were retrospectively analyzed. Two hundred twenty-one
patients with suspected AA were treated. In all cases, lapa-
roscopic intervention was the first treatment option, which
was used in 201 cases. In the remaining 20 cases, open surgery
was performed for reasons including nonavailability of the

Department of General Surgery, Hospital Universitario de Canarias, La Laguna, Canary Islands, Spain.

721
722
laparoscopic device, nonfamiliarity of the available nursing
staff with the procedure, or the procedure was counter-
indicated by the anesthetist; these patients were excluded
from the study.
During the 5-year study period, variations in surgical
technique were introduced. The pneumoperitonium was al-
ways performed with a Veress needle at the umbilicus. Until
2004, appendectomies were performed with three ports: an
11-mm umbilical, a 5-mm suprapubic, and a 12-mm port in-
serted in the right hypochondrium (RH). After 2004, the
12-mm RH port was changed to the left iliac fossa (LIF), and
the RH port was only used when the appendectomy was
technically difficult or when a subhepatic cecal appendix was
found; in these cases, a fourth 5-mm port was used. In most
cases (191 of 201), three ports were used. In 7 cases, a fourth
RH port was necessary due to the technical difficulty of the
appendectomy; in 2 cases, only two ports were used, since the
cause of pain was clearly identified as being due to ovarian
follicule rupture, and the appendectomy was not performed;
and in the remaining case, only one trocar was inserted, re-
vealing diffuse peritonitis, which motivated early conversion
to open surgery. Transection of the appendix base was always
performed by using an endostapler with blue cartridges,
while the mesoappendix was transected by using different
methods (e.g., white cartridge endostapler, monopolar elec-
trocautery, vessel sealer, clips, or ultrasonic scalpel), de-
pending mainly on the thickness and inflammation of the
mesoappendix.
When the mesoappendix was thin and easily transectable,
clips, monopolar electrocautery, or white cartridges were
used; when enlarged, an ultrasonic scalpel or vessel sealer was
used. Transection of the mesoappendix was always performed
as near to the appendix as possible so that the appendix could
be extracted via the 12-mm port. If this was not possible, a
specimen bag was used. On occasions, it was necessary to
widen the port site.
After reviewing the last 20 cm of the terminal ileum, the
intra-abdominal cavity was irrigated thoroughly (right-lower
quadrant, pelvis, and around the terminal ileum) with normal
saline until the surgeon considered that no purulent material
remained, then fluids were suctioned, leaving as little liquid
in the cavity as possible. Port-site closure was only performed
if it had been widened to remove the appendix. Before
appendectomy, no blood cultures or intra-abdominal fluid
cultures were done by routine. Antibiotic treatment consisted
of 1 preoperative and 3 postoperative doses of amoxicillin=
clavulanic acid. If the patient presented fever after interven-
tion, blood cultures were extracted and antiobiotic treatment
was continued until the patient remained afebrile during 48
hours.
Different variables were recorded, including: mean surgical
time, reconversions, emergency readmissions and emergency
reinterventions and invasive procedures, mean postoperative
hospital stay, and postoperative complications (i.e., infectious
or noninfectious). The data were analyzed to determine to
what extent these variables were affected by the degree of
evolution of the AA. Operative findings were classified ac-
cording to the opinion of the operating surgeon and subse-
quently confirmed by pathologic study, and there were no
differences between the operative classification and the final
pathologic diagnosis. Cases of catarrhal or phlegmonous ap-
pendicitis were considered as simple or uncomplicated
MALAGON ET AL.
(UCAA), while the following cases were considered as com-
plicated (CAA): gangrenous appendix, perforated appendix,
appendicular mass palpable in the abdomen after anetheti-
zation, or those with diffuse peritonitis. If the cause of pain
was not evident, it was considered as negative appendectomy
(NEG). If the cause was gynecologic, it was classified as such
(GYN). Cases not classifiable as one of the above were con-
sidered as other (OTHER). Patients of the GYN, NEG, and
OTHER groups were also excluded from the study.
Statistical analysis
Statistical analysis was carried out by using SPSS 15.0
(SPSS, Inc., Chicago, IL). The Student’s t-test was used to
compare independent variables, and a P-value of <0.05 was
considered as significant.
Results
The study included 69 women (40%) and 104 men (60%)
(mean age, 34
14 years), 77% of whom had American So-
ciety of Anesthesiologists classification 1 (ASA 1), 16% ASA 2,
and 7% ASA 3. With regard to operative findings, 67% were
classified as UCAA and 33% as CAA. Table 1 shows the de-
mographic and clinical characteristics of the CAA and UCAA
groups. Comparing each group, we found no significant dif-
ferences, except for age, which was higher in the UCAA
group. With regard to the short-term results of laparoscopic
treatment of AA, the degree of evolution of AA clearly
influenced them, as shown in Table 2.
Surgical time
Mean surgical time for all procedures was 60.3
22.6
minutes. Mean surgical time for the UCAA and CAA groups
is shown in Table 2 and was clearly longer in the CAA than in
the UCAA group. The difference between each group was
statistically significant (P < 0.01).
Intraoperative complications and reconversions
No serious intraoperative complications were recorded in
our series. There were no incidences in 154 cases (89%). Re-
conversion to open surgery was necessary in 11 patients (6%),
and all conversions were due to technical difficulties. Finally,
in 8 patients (5%), intraoperative bleeding occurred after
withdrawal of the trocar situated at LIF: This was controlled
in 7 cases by monopolar coagulation or transmural sticthes,
Table 1. Demographic and Clinical
Characteristics of Groups
Characteristic UCAA CAA P-value
N (%) 116 (67) 57 (33)
Mean age (years) 33
14 38
15 0.04
Male, n (%) 66 (57) 38 (67) 0.25
Previous abdominal 11 (9) 6 (11) 0.79
surgery, n (%)
ASA 3, n (%) 7 (6) 5 (9) 0.53
ASA 3, American Society of Anesthesiologists classification 3;
UCAA, uncomplicated acute appendicitis; CAA, complicated acute
appendicitis.
OUTCOMES AFTER LAPAROSCOPIC APPENDECTOMY 723

Table 2. Short-Term Results According to Groups

UCAA CAA P-value

Mean surgical time (minutes) 54.6
19.5 71.8
24 <0.01

% reconversions (n=total) 0.8 (1=116) 17.5 (10=57) <0.01
Mean postoperative stay (nights) 3.1
1.8 5.9
3.7 <0.01
% total complications (n=total) 10.3 (12=116) 28.07 (16=57) 0.003
% emergency readmissions (n=total) 5.1 (6=116) 0 (0=57) 0.08
% emergency reinterventions or invasive procedures (n=total) 1.7 (2=116) 7 (4=57) 0.07

UCAA, uncomplicated acute appendicitis; CAA, complicated acute appendicitis.

and 1 patient left the operating room with a Foley catheter
capping and compressing the port site, which was removed
48 hours later without evidence of renewed bleeding. Table 2
shows how reconversion percentages varied with operative
findings. Reconversion was required in only 1 of 116 UCAA
patients (<1%), as opposed to 10 of 57 CAA patients (17.54%),
where most reconversions were recorded (10=11). The dif-
ference in reconversions between the CAA and UCAA groups
was statistically significant (P < 0.01).
Postoperative stay
Mean postoperative stay was 4
2.9 nights. In the CAA
group, it was 5.9
3.7 nights, significantly higher than the
3.1
1.8 nights of the UCAA group (P < 0.01) (Table 2).
Postoperative complications
No mortality was recorded. As shown in Table 2, morbidity
in the CAA group was relatively high (16=57; 28.07%),
whereas in the UCAA group it was substantially lower
(12=116; 10.3%); this difference was statistically significant
(P ¼ 0.003). Complications are shown in Table 3. The most
frequent was prolonged fever without evidence of intra-
abdominal fluid collection (n ¼ 14), which required delaying
discharge or readmission. All these cases were satisfactorily
treated with antibiotics. There were only 5 cases of intra-
abdominal abscess, 3 of which required percutaneous drain-
age, while the other 2 cases resolved with antibiotic therapy.
The 2 cases of surgical wound infection occurred in re-
conversions to open surgery; this complication was not ob-
served in any cases where the intervention was entirely
laparoscopic. The 2 cases of port-site hernia ocurred in the
CAA group, but they were not related to infectious compli-
cations of the wound. One patient presented a large hema-
toma in one of the port sites and needed a blood transfusion.
The main cause of morbidity in this series was com-
plications of an infectious nature (24=27), including: intra-
abdominal abscess, persistent fever without intra-abdominal
fluid collection, surgical wound infection, or infected intra-
abdominal hematoma. A breakdown of complications
comparing the CAA and UCAA groups (Table 3) showed a
significant difference in infectious complications: CAA
22.81% versus UCAA 9.48% (P ¼ 0.017), but no significant
difference was found in noninfectious complications (P ¼ 0.07).
In those patients with infectious complications, there were
no differences between these two groups regarding intra-
abdominal abscess (P ¼ 0.2), but the CAA group showed a
higher percentage of persistent fever without intra-abdominal
fluid collection, and the difference was slightly statistically
significant (P ¼ 0.04). Despite the higher frequency of infec-
tious complications in the CAA than the UCAA group, these
did not appear to be more severe, since no significant differ-
ences were observed between the two groups (Table 3) in the
number of patients requiring emergency invasive treatment
(i.e., percutaneous drainage or reintervention; P ¼ 0.5) or in
those only requiring prolonged antibiotic therapy (P ¼ 0.13).

Table 3. Comparison of Postoperative Complications Between UCAA and CAA Groups

UCAA CAA P-value

% uncomplicated patients (n=total) 89.6 (104=116) 71.9 (41=57) 0.003

% total complications (n=total) 10.3 (12=116) 28.07 (16=57) 0.003
% infectious complications (n=total) 9.48 (11=116) 22.81 (13=57) 0.017
% noninfectious complications (n=total) 0.86 (1=116) 5.26 (3=57) 0.07
% intra-abdominal abscess (n=total) 1.72 (2=116) 5.26 (3=57) 0.2
% fever without fluid collection (n=total) 5.17 (6=116) 14.04 (8=57) 0.04
% surgical wound infection (n=total) 0 (0=116) 3.5 (2=57) 0.2
% infected intra-abdominal hematoma 1.72 (2=116) 0 (0=57) 0.3
% surgical wound hematoma (n=total) 0.86 (1=116) 0 (0=57) 0.8
% port-site hernia (n=total) 0 1.75 (2=57) 0.15
% other complications (n=total) 0.86 (1=116) 1.75 (1=57) 0.6
% invasive treatment for infectious complications (n=total) 1.72 (2=116) 3.51 (2=57) 0.5
% prolonged antibiotic therapy (n=total) 9.48 (11=116) 17.54 (10=57) 0.13

UCAA, uncomplicated acute appendicitis; CAA, complicated acute appendicitis.

724 MALAGON ET AL.

Table 4. Emergency Reinterventions=Invasive patients with complicated, as compared with the uncompli-
Procedures cated acute appendicitis group, considering the variables of
mean surgical time, reconversion, mean postoperative stay,
Procedure=cause UCAA CAA and percentage of total and infectious postoperative compli-
cations. However, no significant differences were observed
Complete appendectomy=first 1 0
appendectomy incomplete between the two groups regarding noninfectious complica-
Hernioplasty=port-site hernia 0 1 tions, emergency reinterventions or invasive procedures, and
Laparoscopic drainage 0 1 emergency readmissions, which were not affected by the de-
removal=drainage tube rupture gree of evolution of acute appendicitis.
on extraction Surgical intervention time was clearly affected, being sig-
Percutaneous drainage=infected 1 2 nificantly longer in the CAA group, where mesoappendix
intra-abdominal collection enlargement and a tendency to bleeding was frequently found;
Emergency reinterventions=invasive 2=116 4=57 hemostasis in this group required careful, time-consuming
rocedures (total) management. In addition, the number of inflammatory ad-
UCAA, uncomplicated acute appendicitis; CAA, complicated herences was higher, requiring greater dissection, which slo-
acute appendicitis. wed the procedure time. However, we consider a mean time of
71 minutes for laparoscopic treatment of CAA (complicated
cases) is not a sufficient reason to reject the technique—it may
Readmissions and reinterventions still be considered a fairly short intervention. In the cases of
Data on readmissions and reinterventions are shown in uncomplicated appendicitis with less tissue inflammation,
Tables 4 and 5. Three patients required emergency reinter- mean surgical time was only 54 minutes.
vention and another 3 required percutaneous drainage of Although our total percentage of reconversions (6%) is
intra-abdominal abscesses. The reinterventions included 1 similar to that reported by other prestigious teams,12 there
patient whose first appendectomy was incomplete and was was a great difference in reconversions between complicated
readmitted with a new episode of acute appendicitis, 1 patient and uncomplicated cases (0.89 versus 17.54%), with most
with an incarcerated port-site hernia, and the third re- (10=11) occurring in the CAA group. We believe this may be
intervention was the laparoscopic extraction of an abdominal due to the fact that in the first years of the study, the me-
drainage tube that ruptured during the extraction maneuver. soappendix was always transected by using an endostapler,
The total percentage of emergency reinterventions or invasive which required greater dissection, since a vessel sealer was
procedures was 3.4%. Six patients were readmitted, 1 whose not employed. This variable may also be greatly influenced by
first appendectomy was incomplete and required reinter- the learning curve. Laparoscopic appendectomy in cases of
vention and 5 patients with fever. Of these 5, 3 patients had UCAA is a simple procedure and may be safely performed by
persistent fever without intra-abdominal fluid collection, 1 surgeons with little experience of laparoscopy; however, in
had an intra-abdominal abscess, and the other presented with cases of CAA, the procedure may be complex and require
an infected intra-abdominal hematoma; all resolved with more skills, which may be reflected in the high number of
conservative treatment. The total percentage of readmissions reconversions recorded at the beginning of the study.
was 2.98%. No significant differences between the CAA and Mean postoperative stay was significantly higher in the
UCAA groups were found for readmissions and reinterven- CAA group, as compared with the other groups (Table 2), due
tions (Table 2). to a higher frequency of infectious complications observed
in the CAA patients. Overall postoperative morbidity of
Discussion 16% was also similar to that reported by other well-known
groups.12 Differentiated by groups, morbidity was clearly
The analysis of findings from this series shows that lapa- higher in the CAA, compared to the UCAA, group. This dif-
roscopic appendectomy for the treatment of acute appen- ference was entirely based on persistent postoperative fever in
dicitis yielded significantly worse results for the group of the CAA group, since no significant differences were found in
the number of intra-abdominal abscesses or noninfectious
complications in this study. Previous studies have reported
Table 5. Emergency Readmissions greater risk of intra-abdominal abscessses in CAA patients,11
which was not found in our series.
Emergency readmissions=cause UCAA CAA
The most frequent complication in our CAA group was
Acute appendicitis 1 0 postoperative fever without intra-abdominal fluid collection,
first=appendectomy incomplete which cannot be considered severe, given that 100% of these
Fever=infected intra-abdominal 1 0 cases resolved with prolonged antibiotic therapy. However, it
hematoma did contribute to increasing the mean postoperative hospital
Fever=intra-abdominal abscess 1 0 stay and was also the cause of some readmissions. Despite
Fever=fever without 3 0 its frequency and consequences in our series, this complica-
intra-abdominal abscess tion after laparoscopic appendectomy is rarely reported in
(3 cases) the literature. Perhaps, postoperative fever without intra-
Total emergency readmisions 6=116 0=57 abdominal abscess can be minimized by thorough irrigation
(total)
of the surgical site and maximum efforts to remove liquid or
UCAA, uncomplicated acute appendicitis; CAA, complicated remains of blood from the abdominal cavity. As for read-
acute appendicitis. missions and reinterventions, we found no significant differ-
OUTCOMES AFTER LAPAROSCOPIC APPENDECTOMY
ences between the CAA and UCAA groups. As stated, this is
attributable to the fact that most of the observed postoperative
complications were not severe.
In summary, the major conclusions of this study were
that laparoscopic treatment of evolved versus uncomplicated
acute appendicitis showed worse short-term results in terms of
surgical time, postoperative stay, reconversions, and infec-
tious complications, but no difference was observed regarding
noninfectious complications, readmissions, and reinterven-
tions or invasive procedures. The high rate of reconversion
may be reduced by the use of advanced hemostatic instru-
ments. No significant differences in intra-abdominal abscesses
were observed between the UCAA and CAA groups. Despite
these worse results, we consider that lapaoroscopic appen-
dectomy remains a safe procedure in cases of CAA, without
severe complications, with acceptable surgical time and post-
operative stay. The most frequent complication in our CAA
group was persistent postoperative fever without intra-
abdominal abscess, which resolved in all cases with antibiotic
therapy.
Disclosure Statement
No competing financial interests exist.
References
1. Semm K. Endoscopic appendectomy. Endoscopy 1983;15:
59–64.
2. Paik PS, Towson JA, Anthone GJ, Ortega AE, Simons AJ,
Beart RW. Intra-abdominal abscesses following laparoscopic
and open appendectomies. J Gastrointest Surg 1997;1:188–
193.
3. Slim K, Pezet D, Chipponi J. Laparoscopic or open appen-
dectomy? Critical review of randomised, controlled trials.
Dis Colon Rectum 1998;41:398–403.
4. Krisher SL, Browne A, Dibbins A, Tkacz N, Curci M. Intra-
abdominal abscess after laparoscopic appendectomy for
perforated appendicitis. Arch Surg 2001;136:438–441.
725
5. Sauerland S, Lefering R, Neugebauer EA. Laparoscopic
versus open surgery for suspected appendicitis. Cochrane
Database Syst Rev. 2004;(4):CD001546.Available at: www
.update-software.com (last accessed November 5, 2008).
6. So JB, Chiong EC, Chiong E, Cheah WK, Lomanto D, Goh P,
Kum CK. Laparoscopic appendectomy for perforated ap-
pendicitis. World J Surg 2002;26:1485–1488.
7. Stoltzing H, Thon K. Perforated appendicitis: Is laparoscopic
operation advisable? Dig Surg 2000;17:610–616.
8. Wullstein C, Barkhausen S, Gross E. Results of laparoscopic
versus conventional appendectomy in complicated appen-
dicitis. Dis Colon Rectum 2001;44:1700–1705.
9. Khalili TM, Hiatt JR, Saver A, Lau C, Margulies DR. Perfo-
rated appendicitis is not a contraindication to laparoscopy.
Am Surg 1999;65:965–967.
10. Piskun G, Kozik D, Rajpal S, Shaftan G, Fogler R. Compar-
ison of laparoscopic, open, and converted appendectomy for
perforated appendicitis. Surg Endosc 2001;15:660–662.
11. Korlacki W, Dzielicki J. Laparoscopic appendectomy for sim-
ple and complicated appendicitis in children—safe or risky
procedure. Surg Laparosc Endosc Percutan Tech 2008;18:
29–32.
12. Katkhouda N, Mason RJ, Towfigh S, Gevorgyan A, Essani R.
Laparoscopic versus open appendectomy: A prospective,
randomized, double-blind study. Ann Surg 2005;242:439–
448.
Address correspondence to:
Antonio M. Malagon, MD
Department of General Surgery
Hospital Universitario de Canarias
Ofra s=n La Cuesta
La Laguna 38320
S=C de Tenerife
Canary Islands
Spain
E-mail: ammalagon@hotmail.com