Discussion
LA has become the approach of choice by many surgeons in the treatment of both simple and complicated cases of acute appendicitis. The rate of LA between 1998 and 2008 increased from 20.6% to 70.8%, becoming the prevalent approach to treat acute appendicitis since 2005. In addition to the clinical benefits described in several studies, the laparoscopic approach allows a full exploration of the peritoneal cavity, thus representing an important diagnostic tool in case there is only suspicion of acute appendicitis. Several diseases such as pelvic inflammatory disease, endometriosis, ovarian cysts, ectopic pregnancy, cholecystitis and colonic perforation may mimic appendicitis. In young fertile women 50% of the surgical procedures performed for suspected acute appendicitis turn out not to be acute appendicitis, unless proper imaging was performed. A definite diagnosis is obtained in 96% of patients undergoing LA compared with 72% of those undergoing open procedures.
The LA has been proposed as the preferred technique in obese patients with suspected acute appendicitis, including the elderly patients. In these patients the laparoscopic approach is associated with reduced hospital stay, less postoperative morbidity, and lower cost compared to open approach.
Despite the obvious advantages described, the advantage of LA still remains a matter of debate because of concerns about possible longer operative time, higher rate of postoperative intra-abdominal abscesses, and higher costs compared to OA. Because of all of the above, the open approach appears to be still widely used in clinical practice.
In our study the mean operative time was similar for the two different procedures, with a difference of 2.9 min in favor of OA group that was not found to be statistically significant. Probably, as suggested in other studies, this finding is related to the experience of the surgeon who performs the laparoscopic procedure, especially in the case of complicated appendicitis, in which the laparoscopic dissection can be technically more complex and therefore time-consuming. A worldwide spread of training in laparoscopic techniques lead to a significant reduction in difference of operative time compared to open procedures after 2000, as evidenced by several meta-analyses.
The present study confirmed a significant lower incidence of postoperative complications in the cohort of patients treated by laparoscopic approach. This result is consistent with the data shown in a recent meta-analysis, which reported a lower rate of postoperative complications, especially surgical wound infection rate, after LA.
Although the infection of the surgical wound is not per se a life-threatening condition, it worsens the quality of life in the early postoperative period and prolongs the recovery time. The reduction of wound infection rate is a significant advantage of LA. The extraction of specimen with a bag and through a trocar port rather than directly through the surgical wound as in open procedures, can explain this reduction in incidence. Moreover, the smaller size of the laparoscopic incisions reduces the probability of infection, especially in obese patients.
The occurrence of an intra-abdominal abscess after appendectomy represents a potentially life-threatening event. Several meta-analyzes of randomized controlled trials (RCT) published in recent years have shown an increased risk of intra-abdominal abscesses after LA. It has been suggested that this complication may be related mainly to an improper laparoscopic technique, such as an aggressive handling of infected appendix or an excessive use of irrigation fluids, which could lead to significant contamination of the peritoneal cavity. However, the most recent meta-analysis of RCT published shows a low incidence of intra-abdominal infections, with no significant difference between the laparoscopic and the open approach. In our opinion, this finding might be due to an increase in the laparoscopic skills of the surgeons performing the procedure as previously suggested by some authors. In our study, the intra-abdominal abscess rate was very low (1.3%) and there was no significant difference between the two different approaches. These findings are probably related to exclusion from our study of patients with clinical signs of perforated appendix and also to the high laparoscopic skills of surgeons that carried out the LA.
In our study, the difference of duration of postoperative ileus between the two different approaches was statistically significant. Recovery of the bowel function was faster in the LA group (1.2 days vs 1.4 days, p Value 0.02). Factors such as reduced manipulation of the ileum and the cecum in the hands of a skilled surgeon, as well as a minor abdominal trauma and less pain due to the smaller extension of the incision of the trocars, and an early postoperative mobilization of the patient can be invoked to explain these data.
In our experience, the length of the hospital stay was about 1 day shorter in the LA group than in the OA group (p value 0.011). This result is comparable to the results of the meta-analysis by Wei et al., which also showed that patients undergoing LA return earlier to work and to normal daily activities. The reduction in length of hospital stay seen in the LA group has a direct impact on costs. Although the cost of the laparoscopic approach can be higher than cost of open approach because of the use of disposable instruments and ports, the difference in total costs between the two procedures is decreased by the shorter length of stay experienced by patients who underwent LA.
Our analysis showed a no significant difference in terms of total hospital costs between the two procedures. Nakhamiyayev and Varela reported that the total hospital costs was comparable between the two procedures or even lower for the laparoscopic group when the subgroup of obese patients was analyzed. Wei et al. in their meta-analysis including 8 RCTs performed an analysis of the costs across different countries and age groups using the hospital cost ratio to compare the total cost of LA and OA. The total hospital costs for LA were higher by 11% when compared to OA, but the difference was found to be no statistically significant. However, these data are in contrast with those recently published by McGrath et al., who compared the costs between LA and OA in 2,887,823 patients undergoing surgery in the period between 1998 and 2008. Despite the LA was associated with a lower incidence of complications and a shorter hospital stay compared to OA, it was significantly more expensive in both simple and complex cases. The cases of conversion were associated with a higher postoperative morbidity and higher costs. The cost of OA was lower when postoperative complications occurred, but the cost difference between the two procedures was no significant when there was at least one complication in complex cases, and more than one complication in simple cases. The authors believe that the costs of laparoscopy remain still higher because of the increased operative time and the higher cost of laparoscopic instruments. However, the study did not include the analysis of the complications occurred after discharge and the rate of readmission, and instead included cases performed by surgeons with no laparoscopic training.
A limitation of our study is its retrospective nature. It also does not take into account the long-term complications and their effect on health care costs. The two groups of patients analyzed, however are homogeneous. The bias on the choice of treatment is minimized by the fact that the operating surgeons are different for each group and the choice of treatment did not occur according to the characteristics of the patient but to operator preference for one of the two techniques. Ours is a small district hospital and each operator had 10 years expertise for the surgical procedure of his choice.