EBM

APPENDECTOMY
 APPRAISAL

Evaluation of the laparoscopic versus the open

approach in patients with complicated appendicitis
CLINICAL QUESTION

WHICH IS THE BETTER OPTION FOR

MANAGEMENT OF APPENDICITIS, OPEN
APPENDECTOMY OR LAPAROSCOPIC
APPENDECTOMY?
 DIRECTNESS
JOURNAL CLINICAL QUESTION

POPULATION PATIENT’S AGE GROUP NOT 17 YEAR OLD FEMALE

STATED IN ARTICLE (BOTH
SEXES)

EXPOSURE OPEN APPENDECTOMY VS. OPEN APPENDECTOMY

LAPAROSCOPIC
APPENDECTOMY

OUTCOME BETTER OPTION FOR BETTER OPTION FOR

APPENDICITIS MANAGEMENT APPENDICITIS MANAGEMENT
 VALIDITY
1. Were patients randomized to treatment groups?

Yes, however subgroups were not randomized since they were based on operative findings

Eighty-eight patients were included in the study and were divided into two groups: group A − the
laparoscopic appendectomy group − which included 33 patients; and group B − the open appendectomy
group − which included 55 patients. The patients were randomly allocated to the groups based on the
fixed admission days.

Each group were divided into five subgroups according to the operative findings into the following:
subgroup A − appendicular abscess, subgroup B − appendicitis with purulent reaction, subgroup C −
gangrenous appendix, subgroup D − appendicular mass, and subgroup E − appendicitis with pelvic
abscess.

(Page 2, Patients and Methods Paragraph 2)

2. Was randomization concealed?

No

All patients participating in the study signed informed consent, as mandated by

the Ethical Committee of the Faculty of Medicine, Ain Shams University.
3. Was follow-up rate adequate?

Yes

No indication of any dropouts

Tables suggest a 100% participations rate 33/33 (group a), 55/55 (group b)
4. Were patients analyzed under the groups to which they were originally
randomized?

Not indicated
5. Were patients blinded to group allocation?
6. Were clinicians blinded to group allocation?
7.Were outcome assessors blinded to group allocation?

No
No indication of blinding of anybody involved in the study
Patients were asked to sign an informed consent
8. Were patients in the treatment and control groups similar with respect to
known prognostic variables?

No, there were minimal criteria to maintain homogeneity of participants were made and some
treatment were given on a need basis which may imply a difference in prognostic variables of the
patient.

“It involved the patients presenting at the emergency room who were suspected clinically of having
complicated appendicitis, which was later confirmed by using ultrasound or computed tomography
scan or both. Patients with non complicated appendicitis, generalized peritonitis, history of open
abdominal or pelvic operations, and medical conditions that preclude pneumoperitoneum were
excluded from the study.”

“All patients of both groups received preoperative intravenous third-generation cephalosporins and
metronidazole, and, also, Foley’s catheter was inserted as needed.”

(Page 2, patients and methods, paragraphs 1 & 4)

RESULTS

The operative time, rate of conversion to open approach, drain application, early and late
complications, frequency of analgesics administration, time to start oral feeding, length of
hospital stay, and time of returning to normal daily activity
 1. How large was the treatment effect?

SSI

RR 20.8% relative risk of SSI in laparoscopic

ART/ARC = [(1/33)/(8/55)] appendectomy in comparison with open
0.208 appendectomy

RRR 79.2% reduction in the relative risk of SSI in

(ARC – ART) / ARC = [(0.145-0.03)/0.145 laparoscopic appendectomy in comparison
0.792 with open appendectomy

ARR
ARC – ART = 0.145-0.03
0.115
ILEUS

RR 55.6% relative risk of ileus in laparoscopic

ART/ARC = [(1/33)/(3/55)] appendectomy in comparison with open
0.556 appendectomy

RRR 44.4% reduction in the relative risk of ileus in

(ARC – ART) / ARC = [(0.055-0.03)/0.055 laparoscopic appendectomy in comparison
0.444 with open appendectomy

ARR
ARC – ART = 0.145-0.03
0.024
Obstruction due to post op adhesion

RR No relative risk of Obstruction due to post op

ART/ARC = [(0/33)/(1/55)] adhesion in laparoscopic appendectomy in
0 comparison with open appendectomy

RRR 100% reduction in the relative risk of

(ARC – ART) / ARC = [(0.055-0)/0.055 Obstruction due to post op adhesion in
1 laparoscopic appendectomy in comparison
with open appendectomy

ARR
ARC – ART = 0.145-0.03
0.018
Operative time: (p value = <0.001)

Group a: 110.91±19.50 min (range: 65–160 min)

Group b: 88.09±28.16 min (range: 45–145 min)

The rate of conversion from the laparoscopic approach to open: 6% (2 cases)

Postoperative pain (use of analgesics): (p value = 0.015)

Group a: 4.09±1.96

Group b: 5.18±2.03
Return to oral feeding (p value = 0.012)

Group a: 21.45±14.22 h

Group b: 32.04±20.9 h,

Hospital stay (p value = 0.003)

Group a: 3.03±2.01 days

Group b: 4.69±3.07 days

return to normal activity: (p value = 0.000006)

Group a: 17.42±8.31 days

Group b: 27.95±10.79 days

2. How precise was the estimate of the treatment effect?

Level of confidence: 95%

Alpha: 0.05

All criterias tested with the exception of early and late complications are statistically
significant (<0.05)

Laparoscopic appendectomy significantly “reduces time required to return to normal activity”,

“shorter hospital stay”, “time required for return to oral feeding”, “less postoperative pain”
but with “longer time of surgery”

Laparoscopic appendectomy reduces but not to a significant level “post op adhesions”, “post
op ileus”, “”surgical site infections”
 How can you apply the results to patient care?

The Journal article concluded that Laparoscopic appendectomy is considered to be superior in

comparison to the open approach as it involves less postoperative pain, shorter hospital stay, and
fewer postoperative complications.
1. Does the study provides a direct enough answer to your clinical question in
terms of type of patients, intervention and outcomes?

The Journal article provided a direct answer to the clinical question “WHICH IS THE BETTER
OPTION FOR MANAGEMENT OF APPENDICITIS, OPEN APPENDECTOMY OR LAPAROSCOPIC
APPENDECTOMY?”

Laparoscopic appendectomy is considered to be superior in comparison to the open

approach as it involves less postoperative pain, shorter hospital stay, and fewer
postoperative complications in addition to the possibility of exploring the whole abdomen
without the need for midline incision.
 2. Were the study patients similar to the patients in your practice?

YES the patients are similar.