1

Short-term outcome of Laparoscopic

Appendicectomy and Open

Appendicectomy in acute

appendicitis- a comparative study.

Dr. Masfique Ahmed Bhuiyan

FCPS (General Surgery) Part-II

Mobile phone # 01739981650

Department of Surgery,

Dhaka Medical College Hospital, Dhaka

2014

This primary data-based dissertation is submitted in partial fulfillment of the

requirements of the fellowship of the college of Physicians and Surgeons (FCPS)

General Surgery Part-II Examination of Bangladesh College of Physicians and

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Surgeons (BCPS). The research work was done during 1.7.2013 to 30.06.2014 in

Dhaka Medical College Hospital.

No portion of the work referred to in this dissertation has been submitted in support of

an application for another degree or qualification in this or any other institution of

learning.

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Certified that Dr. Masfique Ahmed Bhuiyan carried out this research work titled

“Short-term outcome of Laparoscopic Appendicectomy and Open

Appendicectomy in acute appendicitis- a comparative study” and prepared this

dissertation under my direct supervision. I have found that the work and the dissertation

satisfactory for partial fulfillment of the requirements of the Fellowship of the College of

Physicians and Surgeons (FCPS) General Surgery Part-II Examination of Bangladesh

College of Physicians and Surgeons (BCPS).

________________________________________

Signature of the Supervisor

Dr. M. A. Hashem Bhuiya, FCPS, FRCS________________________________________

(Name)

ProfessorSurgery Unit (SU) – i

, Departmental head of Surgery Dhaka Medical College Hospital

________________________________________(Designation)

Certified that this dissertation titled “Short-term outcome of Laparoscopic

Appendicectomy and Open Appendicectomy in acute appendicitis- a comparative

study” submitted by Dr. Masfique Ahmed Bhuiyan has been examined by me and

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found to be satisfactory for partial fulfillment of the requirements of the Fellowship of the

College of Physicians and Surgeons (FCPS) General Surgery Part-II Examination of

Bangladesh College of Physicians and Surgeons (BCPS).

________________________________________

Signature of the Examiner

________________________________________

(Name)

________________________________________

(Designation)

Abstract

Introduction: Appendectomy, though being performed by both open and laparoscopic methods, there is a lack of consensus regarding which is the most appropriate method.2

Keeping in mind this background and the fact that studies comparing laparoscopic and

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open appendectomy are fewer in third-world countries like Bangladesh, this prospective study will document important variables and parameters to compare therapeutic benefit of LA and OA.

Objective: The present study aimed at comparing the short- term outcome of laparoscopic appendicectomy and open appendicectomy in cases of acute appendicitis, in terms of postoperative pain and complications, hospital stay, recovery and return to normal activities and to assess important parameters affecting clinical outcomes in LA and OA.

Study settings: Dhaka Medical College Hospital, Dhaka from July, 2013 to June, 2014.

Study population: 200 patients with acute appendicitis fulfilling the inclusion and exclusion criteria with half of them undergoing open appendicectomy and other half undergoing laparoscopic appendicectomy admitted in different surgical wards of Dhaka Medical College Hospital.

Methods: Whenever there was clinical suspicion of acute appendicitis, the patient was initially attended and admitted by the on-duty physician. The patient was attended within 12 hours of admission by the investigator, relevant history was recorded and clinical examination was conducted, necessary laboratory and imaging studies were performed and patient satisfying the inclusion and exclusion criteria was included in the study. The appendicectomy procedure was attended by the investigator and all relevant perioperative data were recorded.

Results: Post operative pain was mostly mild in LA group (40%), while in OA, it was mostly severe (38%) and moderate (34%). Postoperative complications were significantly higher in OA than in LA. Hospital stay was longer in OA (7.03 days) than LA (3.49 days). Early recovery and return to full normal activity was noted in LA (5.56 days) than in OA (11.26 days). Moreover, operative time was shorter in LA (56.37 min), than in OA (71.86 min).

Conclusion: From this prospective study comparing short term outcome of open and laparoscopic appendicectomy, we conclude that laparoscopic appendicectomy have clear advantages over open appendicectomy in respect to short term results .

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Table of contents

THE FRONT MATTER

a. Title page……………………………………..….……………..…………i

b. Declaration page………………………………………………..……….ii

c. Forwarding page………………………………………………..…….…iii

d. Approval page……………………………………………………………iv

e. Abstract……………………………………………………………………v

f. List of tables……………………………………………………...………xi

g. List of figures……………………………………………………..………xii

h. Acknowledgements…………………………..…………………......…..xiii

THE BODY

CHAPTER ONE: INTRODUCTION

1:1.0 Background/ context……………………………………2

1:2.0 Rational of the study……………………….…………...5

1:3.0 Objective of the study……………………………….….6

1:3.1 General objective

1:3.2 Specific objectives

1:4.0 Review of literature…………………………….……….7

CHAPTER TWO: MATERIALS AND METHODS

2:1.0 Study design…………………………………………….10

7

2:2.0 Period of study…………………………………..….…….10

2:3.0 Study place…………………………………….….…….…10

2:4.0 Study population………………………………….…..…..10

2:5.0 Sampling technique………………………………..…….10

2:6.0 Sample size………………………………………......……10

2:7.0 Methods of data collection………………………..…….10

2:8.0 Methods of data processing and analysis…….….….11

2:9.0 Inclusion criteria………………………………………….11

2:10.0 Exclusion criteria………………………………….……12

2:11.0 Ethical implication……………………………….……..12

2:12.0 Consent…………………………………………………..12

CHAPTER THREE:

RESULTS…………………………………………………………..13

CHAPTER FOUR:

DISCUSSION……………………………………………………..25

CONCLUSION……………………………………..……………..31

RECOMMENDATION…………………………..………………..32

THE BACK MATTER

8

REFERENCES………………………………………………..……….33

APPENDIX…...………………………………………………………..xiii

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List of Tables

3.1 Demographics of 200 patients

3.2 Distribution of patients by clinical symptoms and signs (n=200)

3.3 Distribution of patients by per operative findings in LA and OA patient groups (n=200)

3.4 Distribution of patients by post operative pain in LA and OA patient groups

3.5 Distribution of patients by post operative complications in LA and OA patient groups (n=200)

3.6 Different important parameters related to per operative and post operative course of patients in different patient groups (n=200)

List of Figures

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3.1. Pie chart of male- female ratio of LA and OA patient groups

3.2. Graphical presentation of case distribution of patients with different Body Mass Index (BMI) in LA and OA patient groups

3.3. Graphical presentation of case distribution of patients who had prophylactic antibiotic in LA and OA patient groups

3.4. Graphical presentation of case distribution of patients who needed conversion to OA while undergoing LA

3.5. Visual Analogue Score (VAS)

3.6. Graphical presentation of case distribution of patients who needed relaparotmy at a later date following LA or OA in different patient groups

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Acknowledgements

All praises goes to almighty Allah the most merciful, most benevolent to man and his

actions.

I am highly indebted to my honorable teacher Dr. M. A. Hashem Bhuiya, FCPS, FRCS,

Head of Surgery Unit–II, Dhaka Medical College Hospital, Dhaka, for his active

guidance and valuable suggestions in preparing this dissertation. Without his thoughtful

guidance, this work would not be possible.

I am thankful to the doctors and staff in the department of Clinical Pathology, Radiology,

Anesthesiology and ICU, DMCH, for their help in different aspects of my work.

I also like to thank my senior and junior colleagues who helped me a lot during the

whole study process. They encouraged me and shared their knowledge in this study

area.

I must express my thanks and gratefulness to the individuals whose participation

contributed towards successful completion of the work.

Dr. Masfique Ahmed Bhuiyan

Dhaka Medical College Hospital

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Introduction

1:1.0 Background/ context

Appendicectomy, being the

most common surgical procedure

performed in general surgery, is still

being performed by both open and

laparoscopic methods due to

a lack of consensus as to which is the

most appropriate method.2 Three

small incisions, little pain, and quick

recovery – the advantages of

laparoscopy for acute appendicitis are

easily explained to the patient, and

its use for the treatment of acute

appendicitis has gained great popularity

since its introduction.16

Appendicitis is one of the most common

surgical emergencies requiring

appendectomy, with a life-

time risk of 6%. The overall mortality rate

for open appendectomy (OA) is around

0.3% and morbidity about 11%.1

Factors like age, nutritional status, gross

per- operative appearance of

appendix during surgery, duration of

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surgery, wound/port infection, intra-abdominal

abscess, visual analogue score on 1st postoperative

day, hospital stay, etc. which significantly affect

short-term outcome in appendicectomy patients,7

themselves tend to be influenced by the choice of

either LA or OA.

Open appendicectomy has been the treatment of

choice for more than a century since its introduction

by McBurney in 1894, and the procedure is

standardized among surgeons.2

Approximately 7%–10% of the general population

develops acute appendicitis with the maximal

incidence being in the second and third decades of

life.[3,4] The incidence of appendicitis seems to have

risen greatly in the first half of this century,

particularly in Europe, America and Australasia, with

up to 16% of the population undergoing

appendicectomy. In the past 30 years, the incidence

has fallen dramatically in these countries, such that

the individual lifetime risk of appendicectomy is 8.6%

and 6.7% among males and females respectively.5

Laparoscopic appendicectomy (LA) was first

described by Semm in 1983.6

Appendicitis is confirmed at operation in 80 – 95

percent of patients. A high diagnostic accuracy can

be achieved by preoperative ultrasonography or

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computed tomography, but these may not be available round the clock and surgery may

be delayed.7

Laparoscopic appendicectomy has been shown to be feasible and safe in randomized

comparisons with open appendectomy. Laparoscopic appendectomy has improved

diagnostic accuracy along with advantages in terms of fewer wound infections,8 less

pain,8,9 faster recovery and earlier return to normal activity.8-10 On the contrary, operating

time of laparoscopic appendectomy is longer.8,9 Also hospital cost is more.10 The

laparoscopic approach has been supported as an alternate to open appendectomy by

many comparative studies.11 Some studies failed to demonstrate clear advantages of

laparoscopic over open appendectomy.12,13

No consensus exists as to whether laparoscopy should be performed in select patients

or routinely for all patients with suspected acute appendicitis.2

Keeping in mind this background and the fact that studies comparing laparoscopic and

open appendicectomy are fewer in third-world countries like Bangladesh, this

prospective study will document important variables and parameters to compare

therapeutic benefit of LA and OA.

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1:2.0 Rational of the study

Given to the sheer burden of patients undergoing surgeries for acute appendicitis in

general surgical wards of DMCH, it appears quite practical to conduct a study with

shrewd insight into the suitability and benefit of either LA or OA that have potentials to

significantly improve the choice of management and predicting outcome. The proposed

study will take into account the different parameters of patients’ health, nutritional

status, clinical and biochemical profile, underlying pathology and other important

laboratory investigations during hospital stay and compare short-term outcome of

patients having different sets of these parameters undergoing either LA or OA. Present

studies in the perspective of Bangladesh highlighting the issue appear to be much fewer

than enough considering the gravity of the issue. This study would, in the long run, help

to point out recommendations directed at better management and predicting better

outcome of appendicectomy patients as well as addressing important parameters

influencing the choice of either LA or OA to a clinically significant extent.

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1:3.0 Objective of the study

1:3.1 General objective:

To compare the short- term outcome of laparoscopic appendicectomy over open

appendicectomy in proven cases of acute appendicitis.

1:3.2 Specific objectives:

In order to fulfill the above general objective, the following specific objectives were

set for the present study:

1. To study postoperative pain and complications in LA and OA.

2. To compare hospital stay between two groups.

3. To compare recovery and return to normal activities after LA and OA.

4. To assess important parameters affecting clinical outcomes in LA and OA.

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1:4.0 Review of literature

There are several high quality studies including meta-analyses comparing different

parameters of LA and OA. The clinical advantages of laparoscopic appendectomy have

been shown in numerous trials and two systematic reviews. Most of these advantages

are small and of limited clinical relevance.14 Additionally, improvement in the outcomes

of laparoscopy with increasing laparoscopic experience is shown but open surgery

appears to still confer benefits, especially in terms of intra-abdominal abscess

incidence.15

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Materials and Methods

Study design: Cross-sectional study

Period of study: July, 2013 to June, 2014

Study place: Dhaka Medical College Hospital

Study population: All patients (Bangladeshi male and female above 12 years of age)

admitted to emergency department with clinical diagnosis of acute appendicitis.

Sampling technique: Conventional and purposive

Sample size:100 consecutive cases for open appendicectomy and 100 consecutive

cases for laparoscopic appendicectomy.

Methods of data collection:

Whenever there was clinical suspicion of acute appendicitis, the patient was initially

attended and admitted by the on-duty physician. The patient was attended within 12

hours of admission by the investigator, relevant history was recorded and clinical

examination was conducted, necessary laboratory and imaging studies were performed

and patient satisfying the inclusion and exclusion criteria was included in the study. The

appendicectomy procedure was attended by the investigator and all relevant

perioperative data were recorded.

Complete blood count was performed in the hospital laboratory with Procyte Dx

Analyzer. Ultrasonography was done using Sonosite Titan 2-D Ultrasound System

available at the radiology department and reports were reviewed by the departmental

head.

Patients included in this study were followed up daily during their hospital stay period to

assess postoperative course and relevant outcome variables were assessed and

recorded.

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Informed written consent was taken from each patient who was included in this study.

All aspects including confidentiality, right not to participate and decisions to discontinue

further cooperation in the study by patients were duly considered.

Methods of data processing and analysis:

Data analysis and interpretation were done using IBM SPSS Statistics 21 statistical

software package. Qualitative and quantitative variables were analyzed with Student’s t

test and Pearson’s Chi-squared test. Correlations were demonstrated using Pearson’s

correlation coefficient test. Quantitative data were presented in tables using mean,

median, mode, standard deviation (SD), etc. and qualitative data were presented in

charts and figures. Discussion was added with comparison on related study done at

home and abroad. Most of the discussion was covered by citation of appropriate

references and limitations of the study will be stated. The back matter of the study was

enriched by referencing and addition of other appendices.

Inclusion criteria:

1. Patients admitted with features of acute appendicitis in DMCH

2. Patients consenting to undergo appendectomy and entering the study

3. Patients fit for general anesthesia

Exclusion criteria:

1. Patients with comorbid conditions like cardiac failure, COPD, asthma, etc.

2. Patients having contraindications for creating pneumoperitoneum like extensive

abdominal adhesions, hiatus hernia, acute peritonitis, ileus, intestinal obstruction,

etc.

3. Age below 12 years

4. Patients with clinically palpable lumps

5. Patients with perforated appendix with diffuse peritonitis except those with local

peritonitis

6. Patients with normal appendix.

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Ethical implication:

Prior to commencement of the study, the research protocol was ethically reviewed and

approved by the Ethical Review Committee of Dhaka Medical College Hospital.

Institutional clearance was obtained from the Principal/Hospital Director of Dhaka

Medical College Hospital. Consent was taken from each patient after informing them the

objectives of the study, the risks and benefits, confidential handling of personal

information, the voluntary nature of participation and the rights to withdraw from study.

Detailed study related information was read out and explained in printed hand-out.

Consent:

Informed written consents were taken from all the patients.

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Results

Study profile

Between July 2013 to June 2014 , a total of 200 patients were included in the present study. Some 50% of the patients underwent conventional appendecectomy (OA), and in the other 50% the operation was performed laparoscopically (LA).

Patient characteristics

Demographics for the two groups are sown in Table 3.1. The groups had an identical median age (33 years). The OA groups consisted of more women (55%), while the LA group was dominated by men (55%). Case distribution of patients with different Body Mass Index (BMI) in LA and OA patient groups are shown in figure 3.2. Most patients of both groups were within normal range of BMI. Distribution of patients by clinical symptoms and signs (n = 200) are shown in table 3.2. Nausea, fever dominates in terms of symptoms and rovsing sign remains most frequent among signs.

Table 3.1 Demographic of 200 patientsAge

(in years)

Laparoscopic

(n=100)

Open

(n=100)

P value

Male Female Male Female

14-25 25 (45.45%) 15 (33.33%) 13 (28.29%) 25 (45.45%)

26-40 24 (43.64%) 21 (46.67%) 23(51.11%) 22 (40%)

41-50 6 (10.91%) 6 (13.33%) 8 (17.78%) 8 (14.55%)

51-60 _ 3(6.67%) 1 (2.22%) _

Median age 33yrs 33yrs 33 yrs 33yrs

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Table 3.2 Distribution of patients by clinical symptoms and signs (n = 200)

Count Column N %

Fever 134 67.0%

Nausea/vomiting 162 81.0%

Diarrhea 8 4.0%

Constipation 61 30.5%

Psoas sign 16 8.0%

Rovsing sign 95 47.5%

Obturator sign 10 5.0%

n: Number of patients

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Operative characteristics

Preoperative antibiotic was given to all patients of OA group and only 1% of LA group was not given prophylactic antibiotic, rest was given. Graphical presentation of case distribution of patients who had prophylactic antibiotics in LA and OA patient groupsShown in figure 3.4. Per-operative findings in LA and OA patient groups (n = 200) is demonstrated in table 3.3.Grossly appendix was inflamed 28% in LA, whereas 23% in OA. Adhesion being the most common per operative finding in both groups (68% in LA, 35% in OA). Lump (4% in LA, 9% ion), distended appendix (4% in LA, 15% in OA), Perforated appendix (18% ion) was less common per operative findings. Appendix was found retrocaecal in position in most of cases (46% in LA, 56% in OA). Other positions were pelvic (26%in LA, 17% in OA), Iliac (15% in LA, 20% in OA), Subhepatic (12% in LA, 5% in OA), Anterior (1% in LA, 2% in OA) and lateral (none). Peroperative assessment revealed local inflammation in 77% cases of LA and 66% in OA group. It was normal in 23% of LA and 34% of OA cases. Peritoneal fluid was increased with no pus in most cases (71% in LA, 46% in OA). Increased fluid with pus was found in 8% LA cases, in39% OA cases. It was found normal in 21% of LA and 15% patients of OA group. Inflammation in and around appendix was found in 64% of LA, 33% of OA cases. Only appendix was inflamed in 32% of LA, 34% of OA cases. Appendicular lump was found in 3% of LA, 28% of OA cases. Abscess was found in small number of patients (1% of LA, 5% of OA). Macroscopically, appendix was found phlegmonous in 31% of LA, 32% of Open cases. Gangrenous appendix was not very uncommon (63% in lA, 28% in OA). Perforated append ix was found in 5% of LA and 40% of OA patients. According to table 3.4 operative time was greater (71.86 min) in Open procedure than Laparoscopic procedure (56.37 min). Figure 3.5 shows, only 2% of patients undergoing LA needed conversion to open procedure.

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Table 3.3 Distribution of patients by per-operative findings in LA and OA patient groups (n = 200)

Patient group

Laparoscopic appendicectomy

Open appendicectomy

Count Column N % Count Column N %

Gross specimen

Inflamed Appendix 28 28.0% 23 23.0%

Adhesion 64 64.0% 35 35.0%

Lump 4 4.0% 9 9.0%

Distended appendix 4 4.0% 15 15.0%

Perforated appendix / Gangrene

0 0.0% 18 18.0%

Position of Appendix

Retrocecal 46 46.0% 56 56.0%

Pelvic 26 26.0% 17 17.0%

Iliac 15 15.0% 20 20.0%

Subhepatic 12 12.0% 5 5.0%

Anterior 1 1.0% 2 2.0%

Internal/ lateral 0 0.0% 0 0.0%

Peritoneal appearance

Normal 23 23.0% 34 34.0%

Local inflammation 77 77.0% 66 66.0%

Abdominal fluid

Normal 21 21.0% 15 15.0%

Increased (no pus) 71 71.0% 46 46.0%

Increased with pus 8 8.0% 39 39.0%

Inflammation around appendix

Only in the appendix 32 32.0% 34 34.0%

In and around the appendix

64 64.0% 33 33.0%

Inflammatory mass 3 3.0% 28 28.0%

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Abscess 1 1.0% 5 5.0%

Macroscopic grading of appendicitis

Phlegmonous 31 31.0% 32 32.0%

Gangrenous 64 64.0% 28 28.0%

Perforated 5 5.0% 40 40.0%

n : Number of patients

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Short-term results

In the short- term, results varied between the two groups (Table 3.4, 3.5 and 3.6). Post operative pain, assessed on 1st post-operative day by VAS (Visual Analogue Scale) ( Figure 3.5) , was mostly mild in severity in LA group. While in OA, most patients (38%) complained severe pain (Table 3.4). Open appendecectomy led to a longer mean postoperative hospital stay (7.03 days) than in the LA group (3.49 days; p=<0.001). Although, in our institution, admission to operation period was longer (12.87 days) in LA tan in OA(5.64 days). But operation to discharge period is considerably shorter (2.98 days) in laparoscopic than in (6.05 days)open technique. Switching from perenteral to oral diet and medication took shorter period (23.99 hrs) after LA, than in OA(39.38 hrs). In terms of resume to normal activity after operation, LA showed better outcome (5.57 days) than (11.26 days) OA (p=<0.001). Moreover, patients in OA group ad more post-operative complications than LA group as shown in Table3.6. This is true for atelactasis (LA= 2%, OA=5%), wound/port infection/dehiscence (LA=13% , OA=29% ), RTI (LA=7%, OA=25%), sepsis (LA=0%, OA=18%), postoperative ileus (LA=15%, OA=42%), intra-abdominal abscess (LA-0, OA=8), intestinal obstruction(LA=0, OA=1), secondary haemorrhage (LA=1%, OA=2%).However, only port site bleeding is higher in LA (4%) than in OA. Postoperative UTI was equal in both the groups (2%).No patient after LA, required relaparotomy in short -term. Whereas 1 patient (0.5%) required relaparotomy after OA (Figure 3.7)

No Worst Possiblepain pain

Post operative pain

LA (n=100) OA (n=100) P value

Mild 40% 28% 0.480Moderate 36% 34% 0.450Severe 24% 38% 0.023

Table 3.4 Distribution of patients by post- operative pain in LA and OA patient groups

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Table 3.5 Different important parameters related to per-operative and postoperative course of patients in different patient groups (n = 200)

Mean ± Std.

Deviation

Std. Error Mean

Mean Difference

Std. Error Differenc

e

95% Confidence

Interval of the Difference

P value*

Lower Upper

Operative time (in minutes)

OA: 71.86 ± 10.988

OA: 1.099

15.490 1.623 12.289 18.691 <0.001

LA: 56.37 ± 11.948

LA: 1.195

Admission to Operation (in days)

OA: 5.64 ± 1.411

OA: .141

-7.230 .370 -7.961 -6.499 <0.001LA: 12.87 ± 3.416

LA: .342

NPO to General Diet (in hours)

OA: 39.38 ± 13.114

OA: 1.311

15.390 1.564 12.303 18.477 <0.001LA: 23.99 ± 8.520

LA: .852

Operation to discharge (in days)

OA: 6.05 ± 5.818

OA: .582

3.070 .672 1.742 4.398 <0.001LA: 2.98 ± 3.372

LA: .337

Hospital Stay (in days)

OA: 7.03 ± 5.800

OA: .580

3.540 .600 2.352 4.728 <0.001LA: 3.49 ± 1.527

LA: .153

To Full Activity (in

OA: 11.26 ± 6.458

OA: .646

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days) 5.694 .674 4.359 7.029 <0.001LA: 5.57 ± 1.923

LA: .193

n : Number of patients

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Table 3.6 Distribution of patients by postoperative complications in LA and OA patient groups (n = 200)

Patient group

Laparoscopic appendicecto

my

Open appendicectomy

Count Column N % Count Column N %

Atelectasis 2 2.0% 5 5.0%

Wound/port infection/dehiscence

13 13.0% 29 29.0%

RTI 7 7.1% 25 25.0%

UTI 2 2.0% 2 2.0%

Sepsis 0 0.0% 18 18.0%

Postoperative ileus 15 15.0% 42 42.0%

Intra-abdominal abscess

0 0.0% 8 8.0%

Intestinal obstruction 0 0.0% 1 1.0%

Fistula 0 0.0% 8 8.0%

Secondary hemorrhage 1 1.0% 2 2.0%

Bleeding from port 4 4.0% 0 0.0%

n : Number of patients

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Discussion

Open appendectomy has been the treatment of choice for more than a century.

Laparoscopic appendectomy has been shown to be feasible and safe in randomized

comparisons with open appendectomy in many studies.2

In this comparative study, in assessment of factors affecting clinical outcome of both

laparoscopic and open procedures, we have found that, more patients in LA groups

were male, whereas in OA groups majority were female. In most of studies, it seemed to

be opposite.2, 7 It is due to institutional preference towards female patients for

laparoscopic procedure and also to exclude other pathology of female genital tracts. But

here we have explained each and every patient the benefit, risk of both the procedures

in details and without any bias, let the patient to choose any one of the procedure either

open or laparoscopy by themselves. Most of the patients in both groups were within

normal limit of body mass index (BMI) also. Regarding presenting symptoms nausea,

vomiting predominate, whereas after Mc Burney’s sign, Rovsing sign seemed to most

frequent among all other signs. All the patients received prophylactic antibiotic prior to

operation. After admission, it took 7 days longer for the LA group to be operated than

OA group, due to limited resource in comparison to huge number of patient awaiting for

laparoscopic procedure.

Regarding the duration of operation, open technique was more time consuming than

laparoscopic technique in this study. Total operative time in this series was significantly

shorter in the laparoscopic group (mean ±SD, 56.37 ± 11.948 minutes) than in the open

group (mean ±SD, 71.86 ± 10.988 minutes), which was measured as actual skin-to-

skin time. Mean difference was 15.490 minutes between operative period of these two

groups, which is statistically significant (p<0.0001). Our findings seemed a bit different

from other studies.8,9,13 According to a prospective, randomized study by Ortega, the

mean operative times for the procedures were 66 +/- 24 minutes (LAS), 68 +/- 25

minutes (LAL), and 58 +/- 27 minutes (OA).8 In a prospective randomized multicentre

study of A. Hellberg, operating time was significantly longer in the laparoscopic group

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(60 versus 35 min, P< 0·01). 9 Moreover, a prospective randomized double-blind study

by Katkhouda N and Mason RJ, operating time was significantly longer in the

laparoscopic group (80 minutes versus 60 minutes; P = 0.0001) 13. These differences of

results in regard to operative time, owes to the fact that, in a tertiary level government

hospital like DMCH, most OA was performed by trainees, whereas, most of the LA were

performed by seniors (professor or associate professor). Longer operating room times

results in higher costs that can be compensated by shorter hospital stay. The cost was

not included in this study, because this study was conducted in a public hospital where

subjects undergoing both procedures are not required to pay.

Only 2% patient undergoing LA required conversion. This also indicates the experience

and skill of surgeons performing LA here.

Per-operative findings were somewhat different between two groups. Appendix was

grossly inflamed and phlegmonous in both groups. But adhesion and gangrenous

specimen was predominant in LA groups. On the other hand, distended appendix, lump,

perforated appendix was more among OA patients. Retrocaecal. Iliac, anterior position

of appendix was slightly higher in OA, but pelvic and subhepatic appendix was found

more during LA. Also local peritoneal inflammation was frequent in LA group. Increased

abdominal fluid with no pus during LA and with pus during OA was more frequently

encountered.

In terms of postoperative outcome, significant difference was noted between the two

groups. LA group was switched to oral diet and medication within 24 hrs, whereas OA

group required longer. Very few studies are available that have compared

tolerance to oral intake between the 2 groups. Some studies have shown

significantly less time to tolerate oral intake in laparoscopic

groups compared with open groups, while others show no significant

difference.13,17  In this study, significantly less time was needed for patients

to tolerate oral intake with a mean (±SD) 23.99 ± 8.52 hours in the

laparoscopic group compared with a mean (±SD) 39.38 ± 13.114 in the open

group.

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Post operative pain was measured by VAS (Visual Analogue Scale) on 1st post-

operative day and found to be mostly mild (40%) and moderate (36%) in severity n LA

group, but was mostly severe (38%) and moderate (34%) in OA group. Although both

groups received same protocol of analgesics post-operatively. Our finding is in

agreement with findings of many other studies that demonstrate less pain and less

analgesic requirements in laparoscopic groups.8,19

Length of hospital stay is a very important variable that directly influences the economy

and well-being of the patient. Our study shows a significant short hospital stay (3.49 ±

1.527 days) in the laparoscopic group compared with that in the open group (: 7.03 ±

5.800 days, P≤0.001). Our results are consistent with those of early publications115 as

well as recent studies18 that demonstrate a significantly short hospital stay. Mean

difference of hospital stay was 3.54 days longer in OA group than in LA group, which

is significant in terms of statistical analysis.

In this study, mean time to full recovery, i.e., time to resumption of work, was 3.49 ±

1.527 days in the laparoscopic group and 11.26 ± 6.458 days in the open

appendectomy group with mean difference of 5.694 days (P≤0.001), which is

statistically significant. Our finding is in agreement with a similar study by Hellberg et

al9 that demonstrates median time to full recovery as 13 days in the laparoscopic group

and 21days in the open group (P≤0.001) and other randomized clinical trials and meta-

analysis.19 However, other studies20,18, show no difference with respect to performance of

daily activities and time to full recovery. Generally, there are more expectations to

resume work earlier after appendectomy, especially after laparoscopic appendectomy.

These expectations make some sense, because laparoscopic procedures being

minimally invasive should allow a short hospital stay, quicker recovery, and earlier

return to work. Return to activity after appendectomy has remained a subject of intense

debate. In many meta analyses, results are statistically “highly heterogeneous” because

of variable definitions of activity. We used the return to work as an end point, because in

our population group there was not much employment heterogeneity. Our population

group being a lower income group wanted to resume work earlier; therefore, we thought

it would be a more reflective end point.

40

Regarding the postoperative complications, there was significant difference between the

two groups in our study. Laparoscopic appendectomy has been attributed to a low

incidence of complications compared with open appendectomy by many

studies.8,9,20 Our study is also in agreement with these studies. One study13

demonstrates the same rate of complications in both groups.

Wound infections may not be serious complications per se but represent a major

inconvenience to the patient, impacting his or her convalescence time and quality of life.

The majority of studies have concluded that wound infections are significantly lower

after laparoscopic appendectomy.1,19, 22 Furthermore, laparoscopic surgery is associated

with better preservation of the immune system than open surgery is. This results in a

decreased incidence of infectious complications.23 In our series, 13 patients (13%) in the

laparoscopic group and 29 (29%) in the open group had wound/port infections/ wound

dehiscence. Wound infections were more common in the open group. One study13

shows no statistically significant differences in infectious complications between the

laparoscopic and open group.

Postoperative ileus was more than twice in OA group than in LA group. Only 15 patients

of laparoscopic and 42 patients of open group ad this post-operative complication.

Intra-abdominal abscess formation is a serious complication and can potentially be life

threatening. Intra-abdominal abscess and sepsis were absent in any of LA patient

(0%) postoperatively, while these two modality of complications were significantly high

in OA patients(8%) . This finding is contrary to findings in other studies that show an

increased risk of intra-abdominal abscess after laparoscopic appendectomy compared

with open surgery,10 while others have reported the opposite.21 However, this finding is

not statistically significant. Moreover, this difference of findings in our study may be

influenced by the learning period of trainees doing OA, in contrast to skilled consultants

doing LA..

UTI was same in both groups. Port site bleeding was noted to be the only complication.

In statistical analysis, mean difference between these two groups was significant as p

value was < 0.0001 in all the parameters. None of the LA patient required relaparotomy,

41

whereas, only 1 patient ( 0.5%) of OA group warranted relaparotomy, due to secondary

haemorrhage.

It is encouraging to find that our conclusions are supported by other very recent studies

in which laparoscopic appendectomy was performed on another subset of patients.

These studies have concluded that laparoscopy should be used routinely for all young

females presenting with right iliac fossa pain,24 that laparoscopic appendectomy is not

associated with an increase in morbidity in elderly patients,25 and that laparoscopic

appendectomy is safe for advanced appendicitis in children.26 Furthermore, patients'

preference (during counseling/consent) and satisfaction after the surgery (follow-up) in

the laparoscopic group is evidence that the laparoscopic approach may be adopted

safely in cases of suspected appendicitis.

Although many researchers have found no significant difference between LA and OA, in terms short term outcome 7, the present study aimed at comparing the short- term outcome of laparoscopic appendicectomy and open appendicectomy in cases of acute appendicitis demonstrated proven advantages of LA over OA in terms of post operative pain, complications, hospital stay, and full recovery and return to normal activity.

42

Conclusion

From this prospective study comparing short term outcome of open and laparoscopic

appendicectomy, we conclude that laparoscopic appendicectomy have clear

advantages in respect to short term results.

Important parameters (e.g. demographic data- age, sex etc, other factors like BMI,

presenting symptoms, signs, preoperative findings)all that affects clinical outcomes of

laparoscopic and open appendicectomy, was assessed and clear comparison was

shown. In terms of postoperative pain and complications, hospital stay, recovery and

return to normal activities, the therapeutic outcome is proved better in Laparoscopic

appendicectomy than Open appendicectomy here and touched statistical significance

as well.

43

Recommendation

Although laparoscopic appendicectomy showed advantages over open counterpart in

short term outcome, but it is not clear, whether it will show similar result in long term

outcome or not. Based on the results of this study, firstly, we would like to recommend

further trials comparing LA and OA not only for short term outcome, but also for long

term outcome. Further study needs to be undertaken to clearly demonstrate the long

term outcome of both the procedures. Secondly, where the facilities and expertise is

available for LA, the choice for treating acute appendicitis with laparoscopic procedure,

can be safely decided by the patient and the operating surgeon.

44

45

References

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study of laparoscopic versus open appendicectomy. Br J Surg. 1999;86:48–53.

10.Heikkinen TJ, Haukipuro K, Hulkko A. Cost-effective appendectomy. Open or

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11.Tate JJ, Chung SC, Dawson J, et al. Conventional versus laparoscopic surgery

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versus open appendectomy: a prospective randomized double-blind study. Ann

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Long-Term Results of Open Versus Laparoscopic Appendectomy. World J Surg

(2011) 35:1221–1226.

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16.Bauwens K, Schwenk W, Bohm B et al. Recovery and duration of work disability

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17. . Utpal De. Laparoscopic versus open appendicectomy: An Indian perspective. JMAS. 2005;1:15–20.

18.Yong JL, Law WL, Lo CY, Lam CM. A comparative study of routine laparoscopic versus open appendectomy. JSLS. 2006;10:188–92. 

19. . Pedersen AG, Petersen OB, Wara P, Rønning H, Qvist N, Laurberg S. Randomized clinical trial of laparoscopic versus open appendicectomy. Br J Surg. 2001;88:200–205. 

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Appendix

Data collection Sheet

Short-term outcome of multiport Laparoscopic Appendicectomy and Open

Appendicectomy in acute appendicitis in a tertiary level hospital

General DataSerial no: Date: Time: am/pmPatient's Name : Age/Sex: Weight: kgAddress with phone: Religion: Occupation:Ward: Bed No: Socioeconomic status:

HistoryAbdominal Pain: Of duration ___

hr(s)1st site of pain:Migration to: ____ site in ____

hr(s)Same type of pain experienced before?

❑Yes ❑ No

When: ____ months before

Analgesics taken:

___ minutes prior

Antibiotics (if any)Previous surgery (if any)

_________ for _____________

Other co morbidity (if any):Altered bowel habit:

❑Yes ❑ No

Burning micturation:

❑Yes ❑ No

Family Hx of appendectomy:

❑Yes ❑ No

LMP for female:Provisional

49

Diagnosis:Proposed Plan : ❑ Observed ❑

Conservative❑ OA ❑ LA

Vital signsPulse: ____/minBlood pressure: ____ mmHgRespiratory rate: ____ /minTemperature: ____ oF

Signs and symptomsFever ❑ Nausea/vomiting

❑Diarrhea ❑ Constipation ❑Psoas sign ❑ Rovsing sign ❑Leucocytosis

❑Obturator sign

❑

Laboratory examinationCBC: ___________________Urine R/M/E:

___________________

USG W/A: ___________________Serum creatinine:

___________________

CT scan of abdomen

___________________

Operative findings and complicationOperation: Date: _______

Time: _______am/pm

Duration: _______ hrsGross specimen:

Inflamed Appendix ❑Adhesion ❑Lump ❑Distended appendix❑Perforated appendix / Gangrene ❑

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Position of Appendix:

Retrocecal ❑Pelvic ❑Ileac ❑Subhepatic ❑Anterior ❑Internal/ Lateral ❑

Peritoneal appearance

Normal❑

Local inflammation ❑Abdominal fluid

Normal❑

Increased (no pus) ❑Increased with pus ❑

Inflammation around appendix

Only in the appendix❑

In and around the appendix ❑Inflammatory mass ❑Abscess

❑Macroscopic grading of appendicitis

Phlegmonous❑

Gangrenous ❑Perforated ❑

Conversion: If done: ❑Reason:_______________

Injury to other organs:

Postoperative complicationsAtelectasis ❑Wound /port infection ❑RTI ❑UTI ❑Sepsis ❑Postoperative ileus ❑Intra-abdominal abscess ❑

Postoperative course in the wardAdmission to Operation (d):

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Parenteral Analgesia (d):Oral Analgesia (d):Visual analogue score on 1st postoperative day:NPO to General Diet (d):Operation to discharge (d):Hospital Stay (d):To Full Activity (d):Operative Time (mins):Antibiotic Prophylaxis: