Saudi Journal of Gastroenterology
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Year : 2011  |  Volume : 17  |  Issue : 4  |  Page : 225-226
Laparoscopic versus open appendectomy

1 Liver Disease Research Centre, King Saud University, Riyadh, Saudi Arabia
2 Department of Surgery, King Saud University, Riyadh, Saudi Arabia

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Date of Web Publication30-Jul-2011

How to cite this article:
Ali SM, Hassanain M. Laparoscopic versus open appendectomy. Saudi J Gastroenterol 2011;17:225-6

How to cite this URL:
Ali SM, Hassanain M. Laparoscopic versus open appendectomy. Saudi J Gastroenterol [serial online] 2011 [cited 2022 Jan 20];17:225-6. Available from:

Appendectomy is the most common emergent operative procedure performed worldwide. [1] Almost 6-7% of individuals will develop acute appendicitis during their lifetime. Appendectomy has been the standard care for the treatment of acute appendicitis since it was introduced in 1894 by McBurney. The first laparoscopic appendectomy (LA) was performed in 1981 by German gynecologist, Semm. [2] Many studies comparing laparoscopic versus open appendectomy (OA) have been focused on inpatient outcomes. [3],[4],[5],[6],[7] Furthermore, the benefits of LA remain imperceptible, [8],[9],[10],[11],[12] and not as obvious as in the case of laparoscopic cholecystectomy. [13],[14],[15]

The study by Khalil et al,[16] in the Saudi Journal of Gastroenterology is a randomized control trial that attempted to examine the differences between laparoscopic and open appendectomy in terms of primary outcome measures including operative duration, length of hospital stay, and postoperative complications. Here, 147 patients were randomized into a LA group (72 patients) or an OA group (75 patients). The authors found a longer operative duration in LA group which was statistically significant. This has been shown in many previous studies and mostly attributed to additional steps involved in laparoscopic surgery. [17] The study reported no significant difference in the length of hospital stay in both groups, also reflected by two large studies done in Europe. [18],[19] The authors concluded that LA was an equivalent procedure and not superior to OA in terms of primary outcome measures.

The main drawback of the study was the small number of patients included. The size of the study population was not justified by any sample size calculations to examine any given primary outcome. Thus, it is likely that the results obtained are not an accurate representation of the true figures. The assessment of pain and other outcomes should be done in a blinded manner. As mentioned by the authors, investigator blinding was not done. Hence, this could have led to bias in conducting the procedures by the surgeon. Bias could also have been introduced in the postoperative course of patients, especially that the authors did not follow a postoperative pathway for their management. This is crucial for comparing postoperative pain and length of hospital stay. Furthermore, the authors used the visual analog scale which as an instrument which is not sensitive enough to detect differences. Further grouping of the scores into arbitrary groups leads to additional quantification errors which could be why no differences in pain were noted. Assessing the need for pain medication may also have strengthened the pain analysis.

Although the authors reported a non-statistically significant difference in wound infections, this could have been due to the small number of patients they had. In a recent Cochrane review, it was shown that, from nearly 6000 operated cases, wound infections were about half as likely after LA than after OA. [17] Moreover, they failed to report data on deep infections which have been reported to be nearly threefold higher after LA. [17] It would also have been more valuable if the authors had compared the time taken to return to normal activity between the two groups. This has been shown to be significantly shorter in the LA group versus the OA group. [18],[20],[21],[22]

Despite these drawbacks, Khalil et al,[16] made a reasonable effort in assessing the usefulness of LA in developing countries like Pakistan. Similar studies should include larger number of patients supported with sample size calculations in order to draw more accurate conclusions. The Cochrane review suggests that LA for suspected appendicitis has diagnostic and therapeutic advantages compared to conventional surgery. OA should not be considered unbeneficial since the difference between the two techniques is small and depends on the treating surgeon's expertise and patient characteristics. [17] Moreover, although the overall benefits of LA may seem small currently, it should be employed in special cases such as a young female or obese patients as the diagnostic and therapeutic advantages of laparoscopy are larger in these cases. [19] As the costs of LA are an important factor in developing countries, more studies should be done to assess the need for LA in such healthcare settings.

   References Top

1.Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 1990;132:910-25.  Back to cited text no. 1
2.Semm K. Endoscopic appendectomy. Endoscopy 1983;15:59-64.  Back to cited text no. 2
3.Fingerhut A, Millat B, Borrie F. Laparoscopic versus open appendectomy: Time to decide. World J Surg 1999;23:835-45.  Back to cited text no. 3
4.Guller U, Hervey S, Purves H, Muhlbaier LH, Peterson ED, Eubanks S, et al. Laparoscopic versus open appendectomy: Outcomes comparison based on a large administrative database. Ann Surg 2004;239:43-52.  Back to cited text no. 4
5.Long KH, Bannon MP, Zietlow SP, Helgeson ER, Harmsen WS, Smith CD, et al. A prospective randomized comparison of laparoscopic appendectomy with open appendectomy: Clinical and economic analyses. Surgery 2001;129:390-400.  Back to cited text no. 5
6.Maxwell JG, Robinson CL, Maxwell TG, Maxwell BG, Smith CR, Brinker CC. Deriving the indications for laparoscopic appendectomy from a comparison of the outcomes of laparoscopic and open appendectomy. Am J Surg 2001;182:687-92.  Back to cited text no. 6
7.Peiser JG, Greenberg D. Laparoscopic versus open appendectomy: Results of a retrospective comparison in an Israeli hospital. Isr Med Assoc J 2002;4:91-4.  Back to cited text no. 7
8.Ali R, Khan MR, Pishori T, Tayeb M. Laparoscopic appendectomy for acute appendicitis: Is this a feasible option for developing countries? Saudi J Gastroenterol 2010;16:25-9.  Back to cited text no. 8
[PUBMED]  Medknow Journal  
9.Katkhouda N, Mason RJ, Towfigh S, Gevorgyan A, Essani R. Laparoscopic versus open appendectomy: A prospective randomized double-blind study. Ann Surg 2005;242:439-48.  Back to cited text no. 9
10.Olmi S, Magnone S, Bertolini A, Croce E. Laparoscopic versus open appendectomy in acute appendicitis: A randomized prospective study. Surg Endosc 2005;19:1193-5.  Back to cited text no. 10
11.Pirro N, Berdah SV. Appendicitis: Yes or no to laparoscopic approach?. J Chir (Paris) 2006;143:155-9.  Back to cited text no. 11
12.Sauerland S, Lefering R, Holthausen U, Neugebauer EA. Laparoscopic vs conventional appendectomy--a meta-analysis of randomised controlled trials. Langenbecks Arch Surg 1998;383:289-95.  Back to cited text no. 12
13.Faiz O, Clark J, Brown T, Bottle A, Antoniou A, Farrands P, et al. Traditional and laparoscopic appendectomy in adults: Outcomes in English NHS hospitals between 1996 and 2006. Ann Surg 2008;248:800-6.  Back to cited text no. 13
14.Paterson HM, Qadan M, de Luca SM, Nixon SJ, Paterson-Brown S. Changing trends in surgery for acute appendicitis. Br J Surg 2008;95:363-8.  Back to cited text no. 14
15.Van Hove C, Hardiman K, Diggs B, Deveney C, Sheppard B. Demographic and socioeconomic trends in the use of laparoscopic appendectomy from 1997 to 2003. Am J Surg 2008;195:580-3.  Back to cited text no. 15
16.Khalil J, Muqim R, Rafique M, Khan M. Laparoscopic Versus Open Appendectomy: A comparison of primary outcome measures. Saudi J Gastroenterol 2011;17:236-40.  Back to cited text no. 16
[PUBMED]  Medknow Journal  
17.Sauerland S, Jaschinski T, Neugebauer EA. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev 2010;10:CD001546.  Back to cited text no. 17
18.Pedersen AG, Petersen OB, Wara P, Ronning H, Qvist N, Laurberg S. Randomized clinical trial of laparoscopic versus open appendicectomy. Br J Surg 2001;88:200-5.  Back to cited text no. 18
19.Hellberg A, Rudberg C, Enochsson L, Gudbjartson T, Wenner J, Kullman E, et al. Conversion from laparoscopic to open appendicectomy: A possible drawback of the laparoscopic technique? Eur J Surg 2001;167:209-13.  Back to cited text no. 19
20.Hellberg A, Rudberg C, Enochsson L, Gudbjartson T, Wenner J, Kullman E, et al. Conversion from laparoscopic to open appendicectomy: A possible drawback of the laparoscopic technique? Eur J Surg 2001;167:209-13.  Back to cited text no. 20
21.Kaplan M, Salman B, Yilmaz TU, Oguz M. A quality of life comparison of laparoscopic and open approaches in acute appendicitis: A randomised prospective study. Acta Chir Belg 2009;109:356-63.  Back to cited text no. 21
[PUBMED] Diego M, Peiro JL, Vallribera F, Martin B. Laparoscopic treatment for gastroesophageal reflux in children. Cir Pediatr 2003;16:34-6.  Back to cited text no. 22

Correspondence Address:
Mazen Hassanain
Department of Surgery, King Saud University, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-3767.82571

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