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A PROSPECTIVE COMPARATIVE STUDY OF LAPAROSCOPIC APPENDICECTOMY VERSUS OPEN APPENDICECTOMY.

BACKGROUND

The human vermiform appendix is usually referred to as "A Vestigial Organ with no known Function. [1]" Appendicular pathology presenting as acute appendicitis is the most frequent cause of persisting progressive lower abdominal pain in all age groups of patients. [1] There is no way to prevent the development of appendicitis. The only way to reduce the morbidity is to perform appendicectomy before perforation or gangrene has occurred. [1]

Several authors have proposed that laparoscopic appendicectomy should be the preferred method of surgery for acute appendicitis. [2-12]

Open appendicectomy has been safe and effective for acute appendicitis for more than a century. McBurney's point McArthur (Gridiron) incision for open appendicectomy remained the procedure of choice until 1983, when Kurt Semm performed "laparoscopic appendicectomy" for the first time. Since then both the conventional open and laparoscopic methods are being practised and several comparative studies have been reported. [2,5,7-30] Most of the studies show that laparoscopic appendicectomy is safe with improved diagnostic accuracy compared to the open method. [4-24,26-30,31-34,35,36-37] Others however mention the drawbacks of laparoscopy in the background of complicated appendicitis and in presence of intraabdominal adhesions. [23,25,35] Laparoscopic technique, in the hands of experienced laparoscopic surgeons takes no longer than open appendicectomy. [6-8,10,25-28] However, most of the studies have shown that laparoscopic method is more time consuming, though patients enjoy the benefits of a faster postoperative recovery. [5.6,8,9,11,15,18,21,23-28,30,37]

Aims and Objectives

The present study was undertaken to compare the open and laparoscopic methods of appendicectomy in general surgical practice in terms of operating time and certain postoperative parameters. These parameters included postoperative pain, wound infection, intraabdominal sepsis, adhesive ileus and intestinal obstruction. The length of hospital stay and total period of convalescence in terms of resumption of normal and strenuous activities were also considered.

MATERIALS AND METHODS

This non-randomised controlled trial study was carried out in the Department of General Surgery at Calcutta National Medical College over a period of one year from 01.01.2016 to 01.01.2017.

The study included 73 patients (Age group between 18-60 yrs.). The patients were placed in two groups. Patients placed in Group-A had laparoscopic appendicectomy, while patients of Group-B had open appendicectomy.

The study was carried out as a non-randomised single centre study.

Every adult patient coming to the surgical OPD or emergency who was subsequently diagnosed as acute appendicitis and planned for operation was numbered 1, 2, 3, 4, 5 and so on.

All patients were selected irrespective of age, sex, comorbid factors and odd numbered patients (1, 3, 5, 7 etc.) were selected for lap appendicectomy and even numbered patients (2, 4, 6, 8 etc.) were selected for open appendicectomy.

Each patient was explained in detail about the operative modalities and postoperative morbidity of both laparoscopic and open appendicectomy, but the patients were not given the opportunity to voluntarily opt for any of the two operative procedures. However, informed consent was taken from all the patients. The sample size was taken as per our convenience. At the end of the study period, we had 73 patients with 37 patients selected for laparoscopic appendicectomy and 36 patients for open appendicectomy. However, during surgery one patient undergoing laparoscopic surgery needed conversion to open method, so that at the end of the study actually 36 patients had laparoscopic appendicectomy (Group-A) and 37 patients had open appendicectomy (Group-B).

The two treatment groups were well matched with regard to age, sex but not for severity of appendiceal pathology. Histopathological examination was performed on all the specimens of surgically removed appendix.

Each patient underwent thorough clinical history taking. In clinical history details of onset, duration, radiation and severity of pain were noted. Presence of other symptoms like nausea, vomiting and fever were documented. In females of childbearing age, gynaecological history was taken thoroughly to exclude pelvic inflammatory disease or disturbed ectopic pregnancy. A history of dysuria and haematuria was taken from all patients to rule out urinary tract pathology. A general survey and clinical examination was performed to establish the clinical diagnosis of acute appendicitis. This was followed by routine haematological and biochemical investigations. Abdominal ultrasonography was performed on all the patients to confirm the clinical diagnosis. All the patients underwent pre-anaesthetic checkup. Once the patients were declared fit for surgery under anaesthesia, appendicectomy was performed on all the patients under general anaesthesia. Patients having severe cardiopulmonary disease, generalised peritonitis, known pre-existing gastrointestinal or gynaecological pathology were excluded from the study. Pregnant patients were not included. The data derived from our study were statistically analysed using [X.sup.2] Chi-square test and Mann-Whitney U test. P<0.05 was taken as the level of significance.

RESULTS

DISCUSSION

The demographic profile of the patients consisted of 44 males and 29 females with both groups having a comparatively larger number of male patients (Table-1). The mean age of patients in both groups were almost the same (34-35 years).

In our study, the laparoscopic procedure had a longer operative time (60 minutes) compared to the traditional open method (30 minutes) (Table-2). Various studies have reported a similar difference with a mean or median operating time ranging from 8.3 to 29 minutes. Laparoscopic method took a longer time in all these studies. [5,9,11,15,18,21,23,24,26,27,37] However, no difference in operating time was reported in few studies. [7,10,16,30]

In the present study' postoperative pain was assessed after 12 hours and 24 hours. Opiate analgesics were used in both groups (Table-3).

A visual analogue scale was used to assess the postoperative pain' which was found to be less in the laparoscopy group. Postoperative pain and analgesic requirement were significantly less after laparoscopic appendicectomy in several reported studies. [7,9,11,12,14,24] A similar retrospective study of assessment of postoperative pain showed no significant difference in pain scores for both open and laparoscopic appendicectomy. [32] None of the studies showed comparatively less postoperative pain in cases having open surgery.

Laparoscopic procedure produces a small, cosmetically acceptable scar. [17-20,22,28,31-36] Laparoscopic appendicectomy was assessed using a visual analogue scale in our patients and was associated with improved cosmesis (p < 0.01) (Table-2).

In the present study, there were fewer (8.33%) wound infections following laparoscopy compared to the open method (21.62%). The difference was significant (p < 0.05) (Table-3). Theoretically, a reduction in wound infection rate following laparoscopy may be achieved by extracting the specimen using an Endobag. Other studies have reported similarly reduced rate in wound infection following laparoscopic appendicectomy. [5,7,10,12,18,21,34,35] However, we had few cases of intraabdominal abscess following laparoscopic surgery associated with gangrenous or perforated appendix. The prevalence of intraabdominal abscess following laparoscopic appendicectomy has been reported by others. [27,30,32]

The rate of development of adhesive ileus after laparoscopic appendicectomy was comparatively more after open appendicectomy in our study (p < 0.05). Two of the patients required surgery for relief of band obstruction. Adhesive ileus after open surgery was relieved by conservative treatment and did not require surgery. (Table-3). Other studies have reported adhesion related intestinal obstruction as the main source of long-term morbidity following open appendicectomy. [10,30] Others have reported that the incidence of bowel obstruction did not differ between the two groups. [31]

Postoperative pneumonia has been reported in other studies as a postoperative complication. [10] However, our study did not have any case of postoperative pneumonia.

The duration of hospital stay for our patients was 3 days and 5 days following laparoscopic and open appendicectomy respectively (Table-2). Some of the recent studies found laparoscopic appendicectomy associated with significantly shorter hospital stay. [9,10,18,21,23,24,27,37] Others did not report any difference. [4,5,6,30] Most studies showed a median hospital stay of 2 to 5 days following either of the procedures. [5,9,10,18,21,23,24,27,30,37]

In the present study, both groups of patients were allowed to resume their normal as well as strenuous activities according to their convenience. Results have shown that the time to resume heavy strenuous activity was significantly shorter following laparoscopic surgery (Table-2). Less pain in the postoperative period was probably the major contributing factor. Several studies have reported a shorter period of postoperative convalescence and quicker return to normal activity and work following laparoscopic appendicectomy. [5,7,11,14,16,18,21,24] Most authors however have reported that the duration of resumption of normal activity depends on simple or complicated appendicular pathology irrespective of the open or laparoscopic approach. [2-4, 6,9,15,17,20,25,28,35,36] Limitation of Study

1. Sample size--A larger sample size would have been more informative.

2. Observer bias--Different surgeons have examined the different patients included in the study, both in the preoperative and postoperative period.

3. Operator bias--experience and skills of different surgeons have influenced the surgical and postsurgical outcome.

CONCLUSION

Both laparoscopic and open methods of appendicectomy are feasible, safe and effective for treating appendicitis. In our study, postoperative pain, wound infection and duration of hospital stay were less after laparoscopic surgery. However, the operative time for the laparoscopic method was longer. Therefore, in our study, laparoscopic appendicectomy was found to enjoy an overall advantage in terms of postoperative recovery.

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Joy Roy (1), Arunima Mukhopadhyay (2)

(1) RMO-cum-Clinical Tutor, Department of General Surgery, Calcutta National Medical College, Kolkata, West Bengal, India.

(2) Associate Professor, Department of General Surgery, Calcutta National Medical College, Kolkata, West Bengal, India.

'Financial or Other Competing Interest': None.

Submission 21-05-2018, Peer Review 28-07-2018, Acceptance 04-08-2018, Published 13-08-2018.

Corresponding Author:

Dr. Arunima Mukhopadhyay, 836 Block-P, New Alipore, Kolkata-700053, West Bengal, India.

E-mail: ram_arunima@yahoo.co.in

DOI: 10.14260/jemds/2018/821
Table 1. Demographic Profile

                     Laparoscopic          Open
Variable            Appendicectomy    Appendicectomy
                        n = 36            n = 37

Mean Age (years)      34.9 years        35.4 years
Sex Ratio (F: M)        12: 21            17: 23

Table 2. Postoperative Course

                     Laparoscopic          Open         Probability
Randomised          Appendicectomy    Appendicectomy
                        (Days)            (Days)           Value

Hospital Stay *         3 (3-8)          5 (3-10)           <0.1
Convalescence
 a) Normal            5.4 (4 -14)       7.1 (2-10)         <0.05
    Activity *
 b) Strenuous        12.2 (10-21)       16.8 (2-20)        <0.01
    Activity *

Cosmesis (VAS) *        1 (0-3)           2(1-8)           <0.01

Operation Time        60 (15-100)       30 (30-60)         <0.001
                        Minutes           Minutes

Values are median. * VAS-Visual Analogue scale.

Table 3. Postoperative Morbidity

 Randomised      Laparoscopic          Open         Probability
                Appendicectomy    Appendicectomy       Value
                    (n=36)            (n=37)

    Wound              3                 8             <0.05
  Infection
   Intra-
  abdominal            3                 1             <0.05
   Abscess
 Caecal Leak           0                 1              Non-
                                                    significant
  Adhesive             2                 1             <0.05
    Ileus
  Pneumonia                                             Non-
                       0                 0          significant
Pain (VAS) *
 A) After 12       12 (MCSD)         11 (MCSD)       > 0.05 not
    Hours           (12-20)           (9-15)        significant
 B) After 24      10 (5-20)          10 (5-25)       > 0.05 not
    Hours                                           significant

MCSD--Minimum Clinically Significant Difference.
Visual Analogue Scale.
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Title Annotation:Original Research Article
Author:Roy, Joy; Mukhopadhyay, Arunima
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Geographic Code:9INDI
Date:Aug 13, 2018
Words:2673
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