Laparoscopic versus Open Appendectomy for Acute Appendicitis in Obese Patients: A Prospective Randomized Study

Laparoscopic versus Open Appendectomy for Acute Appendicitis in Obese Patients: A Prospective Randomized Study

Mohamed I Kassem, MD; Maher M Elzeiny, MD.

Department of Surgery, Gastrointestinal Surgery Unit, Faculty of Medicine, Alexandria University.

Objective: Currently, laparoscopic appendectomy is widely practiced for the management of acute appendicitis. Our aim was to compare the safety and the advantages of laparoscopic versus open appendectomy in obese patients in a prospective randomized study.

Patients and methods: This prospective study was carried on 80 patients from April 2013 to November 2014. Patients were randomly divided into two groups. The group A: 40 patients were subjected to laparoscopic appendectomy (LA), whereas the group B: 40 patients were subjected to open appendectomy (OA). The demography and the primary outcome measures of the patients such as operative duration, hospital stay, post-operative pain, post-operative complications and patient’s satisfaction about cosmesis result were recorded and analyzed.

Result: Eighty obese patients with clinical diagnosis of acute appendicitis were included. Operative time was longer in group A (LA) with mean of (77.20 ± 23.04) in comparison with group B (OA) (68.40 ± 6.67). Operative difficulties were encountered in 10% and 20% of cases in group A and B respectively. No conversion in LA was performed in any case. Patients in group A started feeding earlier (7.30 ± 2.45 hours) than group B (18.10 ± 13.25 hours). Mean comparison of postoperative pain by visual analogue scale on day 1, was significantly lower in Group A (4.0 ± 1.89) compared with Group B (6.40 ± 1.71). Length of hospital stay was shorter in Group A (1.35 ± 0.58 days) than Group B (2.40 ± 0.57 days). Chest infection was slightly higher in group B (10%) in comparison to group A (7.5%). The rate of wound infection was higher in OA 20% in comparison with LA 5% (especially in perforated appendicitis cases). Patient’s satisfaction in term of cosmesis was highler in group A in comparison to group B.

Conclusion: Laparoscopic appendectomy is safe and superior to OA in obese patients with respect to an early discharge, lesser postoperative pain, decreased wound infection, early return to work and a better cosmetic scar. Laparoscopic appendectomy also improves diagnostic ability and excludes other causes of abdominal pain and gives the ability to manage other pathology at the same session.

Key words: Laparoscopy, appendicitis, obesity, laparoscopic appendectomy.

Introduction:

Appendicitis  is  the  most  common surgical abdominal emergency all over the world and the second frequently performed abdominal surgery next to cholecystectomy, most  commonly  occurring  in  adolescents and  young  adults  with  a  peak  incidence in the second and third decades of life; however appendicitis may affect all ages.1

Also,  appendicitis  is  higher  among  males

(male to female ratio of 1.4:1).2 The rate of

appendectomy for appendicitis has remained constant at 10 per 10,000 patients per year. During  their  lifetime,  6-7%  of  individuals will develop acute appendicitis.3

For almost a century, open appendectomy (OA), as described by McBurney,2 was the gold   standard   treatment   for   appendicitis. In the early 1983s, the first laparoscopic appendectomy (LA) was performed and described by Semm.3 Since its introduction, the role of laparoscopy for appendicitis has

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been controversial. Several retrospective and prospective studies have shown advantages for LA when compared with OA,4 other studies could not demonstrate superiority of the laparoscopic approach.

With the advent of laparoscopy, Laparoscopic surgical techniques have transformed much of surgery over recent decades, minimal access techniques allow extensive operations to be performed with little trauma.5 The well established advantages of the laparoscopic approach have enabled this procedure to gain rapid worldwide acceptance over open procedures.6

LA  has  been  an  increasingly  used surgical procedure for acute appendicitis since its introduction in 19833 it provides better   diagnostic   accuracy,   reduced   use of analgesics, shorter hospital stay, earlier return to daily activities, and a lower rate of wound  infection in  comparison  to  OA.7-12

Some investigations have also revealed that elderly patients, morbidly obese patients, and fertile women can take advantage of LA to treat acute appendicitis.13-15 In addition, LA is cosmetically beneficial.

However, there is a debated issue regarding septic postoperative complications (e.g., intra- abdominal abscess) following LA, especially in cases with complicated appendicitis.16-18

Although   some   studies   have   concluded that LA is a safe and effective treatment for complicated acute appendicitis.19-23

The aim of this work was to compare laparoscopic     and     open     appendectomy for acute nonperforated and perforated appendicitis in obese patients regarding:

• Operative time.

• Technical difficulties.

• Time to tolerate feeding.

• Post-operative pain.

• Post-operative hospital stay.

• Post-operative complication.

• Patient satisfaction regarding cosmesis.

Patients and methods:

This  prospective  study  was  conducted in the Gastrointestinal Surgery Unit, the Alexandria Main University Hospital, from April 2013 to November 2014. Patients with a

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clinical diagnosis of acute appendicitis were randomized to either LA or OA to reduce the bias of surgical approach. Eighty obese patients with BMI >30, their age ranged between 18-54 years with features suggestive of acute nonperforated and perforated appendicitis, were included in the study. The patients were followed through their hospital course and subsequently for 2-week and then monthly through the outpatient follow-up visits.

Exclusion criteria:

● Appendicular mass.

● Appendicular abscess.

● Previous lower midline abdominal surgery and unfit for laparoscopy.

A detailed history of the patients was taken, and physical examination, a complete blood analysis, urine examination and ultrasound of the abdomen were routinely performed in all the cases. Computerized tomography (CT) was selectively performed in patients with difficult diagnosis.  The  risks  and  benefits of  the  two  procedures  were  explained  to the patients and their informed consent was obtained. All the patients were randomly divided  into  group  A  [LA]  and  group  B [OA], each 40 patients, and the patients were operated under spinal anaesthesia or general anaesthesia.

LA was performed through a three port technique and carbon dioxide was used to create the pneumoperitoneum. The Open Hasson technique or the Veress needle or Visiports optical trocar were used for creating the pneumoperitoneum, followed by a 10mm trocar insertion at the supra-umbilical or umbilical  region  and  the  other  two  5mm ports were placed in Lt iliac fossa and supra- pubic region. The dissection and mobilization of the appendix were performed by using unipolar coagulation or harmonic shear Figures (1, 2) or Ligature. The appendix was divided at its base between the two endoloops Figure (3),  or  3  extracorporeal  knots  or  3 clips Figures (4,5). The retrieval of the resected inflamed appendix or the inflamed perforated appendix was performed through the umbilical port Figures (6,7,8). OA was performed  through  a  Grid  iron  incision

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Figure (1): Monopolar diathermy was used to control and dissection the mesoappendix.

Figure (3): The base of the appendix was ligated using endoloop.

Figure (5): Show applying of clip over appendicular base.

Figure (7): Extraction of specimen inside glove through umbilical port with synchronous withdrawn of laparoscope.

Figure (2): The Harmonic scalpel was used to control mesoappendix.

Figure (4): The base of the appendix was ligated using extracorporeal knot.

Figure (6): Extraction of specimen inside glove through umbilical port with using of 5 mm lens in Lt iliac fossa trocar.

Figure (8): Extraction of specimen through umbilical trocar after using 5 ml camera in LT iliac fossa port.

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Table (1): Comparison between the studied groups according to pre-operative variables.

χ21: value of Chi square

MC: Monte Carlo test.

Table (2): Comparison between the studied groups according to operative time.

Table (3) : Comparison between the two studied groups according to operative difficulties.

Table (4): Comparison between the two studied groups according to post-operative pain

score.

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Table (6): Comparison between the two studied groups according to hospital stay.

MW: Mann Whitney test.

Table  (7):  Comparison  between  the  two  studied  groups  according  to  postoperative complications.

χ2p: p value for Chi square test for comparing between the two studied groups.

at   McBurney   point.   The   appendix   was sent postoperatively for histopathological examination. All the operative details including operative time were recorded. The patients were kept nil by mouth till the return of the bowel sounds. A soft diet, followed by regular diet, was introduced when the patients tolerated the liquid diet. The pain was measured qualitatively by using a visual analog scale. The length of the hospital stay was  determined  as  the  number  of  nights which   were   spent   in   the   hospital.  The patients were discharged after they resumed a regular diet, were afebrile and had good pain relief and after removal of drain if present. Patients were followed for post-operative complications were followed during the hospital stay and then every 2 weeks, then monthly. The patients were asked about their

satisfaction regarding the cosmesis and gave a score out of 10 where zero was the least satisfaction and 10 was complete satisfaction.

Complicated perforated appendicitis was encountered in 5 patients (12.5%) whom LA was attempted; while perforated appendicitis was  found  in  6  patients  (15%)  managed with OA. Use of irrigation fluids to decrease contamination of peritoneal cavity and decrease manipulation of inflamed perforated appendix after both LA or OA followed by drain.

Statistical analysis: the data were analyzed by using the Statistical Package for Social Sciences.    Continuous   variables    such    as age, hospital stay, and operative time were presented as mean ±SD, while the categorical variables such as gender and post-operative

complication  were  expressed  as  frequency

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and percentages by using a 90% confidence interval.   The   Student’s   t-test   was   used to compare the means of the continuous variables,  while  the  categorical  variables were compared by using the Chi-square χ2 and value of Chi-square χ2 or the Fisher’s exact test FE as appropriate. A probability which was equal to or less than 0.05 (P< 0.05) was considered as significant.

Results:

The comparisons of the patient’s demographics and BMI are summarized in Table (1). No significant statistical differences were noted in both groups with respect to age, sex and BMI. The operative details and the postoperative characteristics are noted in Tables (2-6). The median operative time in the OA [66 min] group was slightly shorter than that in the LA [70 min] group Table (2).

The operative difficulties were encountered in 6 patients (15 %) and 8 patients (20%) in LA and OA respectively Table (3). In group  A  (LA),  another  trocar  was  added in only 1 patient of the laparoscopic group which helped in traction of caecum in long subhepatic retrocecal appendix. In another patient, adherent omentum to previous paraumbilical  hernioplasty  incision  was found  which  obscured  and  narrowed  the field of laparoscope and led to difficulty in the retrieval of the appendix. Four cases of the five perforated appendicitis were difficult in manipulations and resection of appendix and abdominal lavage. The operations of LA (perforated and nonperforated appendicitis) were completed in all cases without converting any to open surgery. In group B (OA), two patients had long, retrocecal and subhepatic appendicitis; the caecum was fixed with deeply seated gangrene of the appendix was extending to the base in one patient; and the ligature of the appendicular artery was slipped  and  control  of  bleeding  was  done in another one patient. The remaining four cases from the six patients who presented with perforated appendicitis were difficult in manipulation of the appendix and abdominal lavage; ( all required extension of wound by muscle cutting and needed longer operative

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time to complete the procedure safely).

Post-operative  pain  was  qualitatively noted according to the visual analog scale (VAS), it was significantly less in LA than in OA [P<0.001], Table IV. Patients in LA started feeding earlier (7.30 ±2.45 hours) than OA (18.10 ±13.2 hours) and this was statistically significant (P<0.001), Table V. Two patients in OA got post–operative ileus for 48 hours and were managed conservatively. The post- operative hospital stay was (1.35 ±0.58 days) in the LA group as compared to (2.40 ±0.57 days) in the OA group, which was statistically significant (p<0.0010),Table VI.

There was no statistically significant difference in chest infection rate between LA and OA. The difference between the wound infection  rates  was  significantly higher  in OA (20%) in comparison to LA (5%). Six patients in the OA group had abdominal wall abscess which required drainage and frequent dressing. Table VII, all cases of perforated appendicitis in OA group complicated by wound infection and abscess.

Patient’s satisfaction to final cosmetic result was highly significant LA 9 in comparison to OA 4.5 according to the visual analog scale (VAS). Five cases had gall bladder disease and 4 cases ovarian cysts which were managed at the same procedure.

Postoperative follow up: All patients were subjected to postoperative follow up regularly to     detect     postoperative     complications and   access   their   satisfaction   according to cosmesis. The follow up time ranged monthly for 12 months. In the laparoscopic group, 4 patients got wound infection immediate postoperatively (all presented with complicated perforated appendicitis) and were managed conservatively. In the open group, 16 cases got wound infection and 3 of them developed subcutaneous abscess which required drainage, packing and dressing twice daily with finally healing (the 6 patients with acute perforated appendicitis, 3 complicated by wound abscess and 3 complicated by wound infection).

Discussion:

In the last two decades, Laparoscopy has

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gained a lot of popularity around the world and became the most preferred surgical procedure for many abdominal surgeries like (gastro- oesophageal reflux disease and gall bladder disease). Similarly, the same procedure is widely applied for appendectomy. In spite of a lot of case series and a large number of randomized  clinical  trials  over  more  than two  decades,  the  benefits of  LA over  OA are still controversial.24–26 With increasing prevalence of obesity all over the world, reaching a level of one third of populations, thus  resulting  in  increasing  numbers  of obese patients will present for laparoscopic surgery. The open surgery usually result in high morbidity in obese patients like chest complications, deep vein thrombosis (DVT) and wound complications, beside technical difficulties to access through adipose tissue which result in inadequate visualization.27–29

In the early ages of laparoscopy, obesity was actually considered a contraindication for many operations including cholecystectomy. Despite these early concerns, with the laparoscopic  approach  has  since  become the gold standard approach for abdominal surgery in patients with increased body mass index.30–37

The results of the present study clearly demonstrated the superiority of laparoscopic appendectomy over open appendectomy in obese patients regarding the postoperative pain, hospital stay, cosmetic results, the functional status and the complication rates.

In  the  present  study,  LA  could  be safely performed in all cases, despite some operative  difficulties  is  noted  in  3  cases (the operations were complete in all cases without  conversion  to  OA).  The  results were comparable to and were less than other series.25,26 In five cases of LA, gall bladder disease  was  managed  at  the  same  session with laparoscopic cholecystectomy and the two procedures were done safely. In other 4 cases we found ovarian cyst and fenestration was done at same procedure. The peritoneal cavity can be completely visualized, examined, thus avoiding missing other pathology for abdominal pain.38 The high rate of misdiagnosis in females may be due

to gynaecological problems and the female functional  abnormalities.  So,  in  a  patient with  suspected  appendicitis,  LA  improves the diagnostic accuracy and also avoids unnecessary appendectomy.31

The operative duration in the present study was longer in the LA group as compared to that in the OA group. In most of the literature, the operating time in laparoscopic appendectomy was found to be more than that in open appendectomy; the difference of the mean time ultimately depends upon the experience of the surgeon and the competence of the team. The  reasons  for  the  prolongation  include the extra steps for the setup (insufflations, trocar insertion and position modification), diagnostic laparoscopy and dealing with other pathologies. Our study was comparable with the following series of articles with respect to the operative duration.27,28,31 In Corneille et  al  study,25   operative  time  in  OA  was longer than LA which explained by increase experience of surgeons in laparoscopy and adding converted cases to open group

The hospital stay in the present study was significantly less in LA than in OA [>24hours] and this was similar to the findings of other reported series.24–28,31 Li et al27 meta- analyses study showed the laparoscopic approach led to a reduction in postoperative stay of 0.6 days. This may be explained by patients  in  LA  started  feeding  early  ,less tissue manipulation ,less pain perception and avoiding large incisions in OA.

In the present study the post-operative pain is assessed by means of a VAS on the first day and this was quantitatively assessed by the daily requirements of analgesics. The pain was significantly less in the LA group. Meta analyses by Li et al27 in 2010 supported the present study, mainly due to the less invasive nature of the procedure. Minimal trauma and less pain following LA allowed an early recovery. Fast resumption of a normal diet in LA was another added advantage due to the minimal handling of the bowel. This was similar to the findings of other reported27 series but in Clarke et al study35 it showed no difference.

In the present study chest infection was

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slightly higher in OA than LA and this was similar to series.33,34 This is due to early ambulation,   less   pain,   less   cutting   and trauma to abdominal muscles in LA. Wound infection was high in OA than LA due to bigger incision in poorly vascularized adipose tissue, direct contamination to wound edges by inflamed appendix and infected fluid, muscle cutting in some cases and increase rate of DM in obese patients in comparison to minimal incisions and tissue trauma in LA. This was similar to studies comparing the two approaches.24–28,31,34

Many  literature  searches  and  meta analyses showed that there was high risk of intra-abdominal abscess in LA than OA26,32 studies, but we did not have any intra- abdominal abscesses in the present study. Clarke et al study,35 believed that mastery of the learning curve and the use of the standard guide lines definitely reduced the incidence of the intra-abdominal abscesses.

As regard patient satisfaction about final cosmetic result, it was higher in LA in comparison to OA when assessed by VAS

.This may be explained by small incisions in LA two of them are hidden in natural camouflages (umbilicus and suprapubic hair) and less wound complications in comparison to OA with large incision. This is similar to series.27,32,39

Conclusion:

The present study concluded that: the change in surgical approach in managing acute perforated and nonperforated appendicitis is safe and effective. The present study shows that LA provides considerable benefits over OA and was found to be superior to OA in obese patients with respect to the postoperative pain, hospital stay, early recovery, cosmesis and lower complication rate. Laparoscopic appendectomy also improves diagnostic ability and excludes other  causes  of  abdominal  pain  and  gives the ability to manage other pathology at the same session. The widespread use of LA is recommended in hospitals where laparoscopic expertise and equipments are available.

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