Comparative study of Laparoscopic Appendectomy and Open Appendectomy in a Tertiary Care Hospital in South Karnataka, India
Sunil Kumar B.B., Basavaprabhu Achappa, Soundarya Mahalingam
1. Assistant Professor, Department of Surgical Gastroenterology, J S S Medical College, Mysore. 2. Associate Professor, Department of General Medicine, Kasturba Medical College, Mangalore (Affiliated to Manipal University). 3. Associate Professor, Department of Paediatrics, Kasturba Medical College, Mangalore (Affiliated to Manipal University).
Correspondence Address :
Dr. Basavaprabhu Achappa
Department of General Medicine,
Kasturba Medical College
Attavar, Mangalore - 575001.
: Appendicitis is a common cause of acute abdomen and appendectomy is the treatment of choice, which can be done either by open or laparoscopic approach. Controversies till exist as to which is the better choice among the two surgical procedures for treating appendicitis. So, this study was conducted to compare the laparoscopic appendectomy with open appendectomy.
Materials and Methods: This study was done in a tertiary care medical hospital in South Karnataka. 100 consecutive patients who were diagnosed to have appendicitis and requiring surgical intervention were selected after obtaining their informed consent to participate in the study. 50 patients each were randomly chosen to undergo either open or laparoscopic appendectomy. Data was collected from each patient on the basis of clinical, preoperative findings as well as postoperative recovery and follow up. Statistical analysis was done using SPSS Version 14.0.
Results: 59% of patients were male and 60% were under 25 years of age. Nausea and vomiting were the common symptoms. Laparoscopic appendectomy took more time than open appendectomy (42.8 mins Vs 54.3 mins). Pain was significantly lower in laparoscopic appendectomy compared to open appendectomy. Post operative complications, length of stay, time to return back to work were all lesser among patients who underwent laparoscopic appendectomy.
Conclusion: The laparoscopic appendectomy was better than open appendectomy with respect to wound infection rate, pain score, lesser use of antibiotics and analgesics, duration of postoperative hospital stay and return to normal activity.
|Keywords : Appendicitis, Laparoscopy appendectomy, Iliac fossa, tertiary care|
Appendicitis is a common, sometimes confusing and often treacherous cause of acute abdomen at all ages, which requires utmost skill and care of the attending surgeon besides good clinical evaluation (1).
Approximately 6% of the population suffers from acute appendicitis during their lifetime; therefore much effort has been directed towards early diagnosis and treatment (2). In appendicitis, appendectomy is the treatment of choice, which can be done either by open or laparoscopic approach.
Conventional appendectomy is a highly effective procedure, but despite its success there have been numerous attempts to improve the diagnostic accuracy and outcome of patients with acute appendicitis because the negative appendectomy rate in most series is still in the range of 25-30%. Laparoscopic appendectomy is nowadays the best studied procedure; perhaps the most scrutinized surgical procedure ever (3).
In cholecystitis, laparoscopic cholecystectomy has emerged as the gold standard, but in appendectomy it is still controversial.
The objective of this study is therefore, to clear some of the issue. So this study was conducted with the aim of comparing patient’s duration of postoperative hospital stay, pain, recovery, complications between open and laparoscopic appendectomy.
|MATERIAL AND METHODS|
The study subjects consisted of 100 patients, who underwent appendectomy at a tertiary care hospital in Karnataka, India for appendicitis. These patients were divided into two groups of 50 each on random basis, Open or Conventional appendectomy (OA) and Laparoscopic appendectomy (LA).
Informed consent was taken from all patients.
Approval was obtained from the institutional ethics committee before commencing the study
Diagnosis of appendicitis was based on clinical findings, blood counts and ultrasonography.
Data was collected from each patient on the basis of clinical, preoperative findings as well as postoperative recovery and follow up.
After ruling out other differential diagnosis and concluding preoperatively as appendicitis, treatment was planned. preoperative preparation consisted of bed rest, nil per oral, intravenous fluids, and preoperative dose of antibiotics.
Anaesthesia was either general or spinal.
In open appendectomies, abdomen was opened either by Mcburney’s or lanz incision or occasionally by right paramedian incision. In some cases appendicular stump was ligated and invaginated and in some others stump was ligated alone.
In laparoscopic appendectomies base of appendix was ligated using end loop (catgut) and the specimen delivered out using endobag.
Intraoperative findings were noted down.
The final diagnosis of appendicitis was confirmed by histopathology report. The appendicular specimen was examined and reported by the pathologist.
Post operatively patients were managed as follows: parenteral antibiotic, intravenous fluids, analgesics, parenteral nutrition until bowel activity returned, monitoring of temperature, pulse, blood pressure and respiratory rate.
Operating time (time from initial incision to closure), intraoperative findings and complications were recorded.
Postoperative pain was quantified 24 hours after the surgical procedure using Visual Analogue Scale (VAS, 0 to 100, 0 being no pain and 100 unbearable pains).
Time of resuming oral feeds and length of postoperative hospital stay were recorded. Stitches were removed on 7th postoperative day. On discharge patients were advised for regular follow-up.
Time until return to work or normal activities was determined by the examination of the discharge summary sheet or outpatient cards and 3-4 weeks postoperative follow up.
Following statistical methods were employed
• Frequencies/Descriptives • Contingency coefficient (Cross Tabs) • Independent samples ‘t’ test
All the statistical calculations were done through SPSS (Statistical Presentation System Software) for Windows Version 14.0 Evaluation version (SPSS, 2005. SPSS Inc, New York).
In this study, as per (Table/Fig 1) attack of appendicitis was seen in patients aged less than 25 years constituting 60%.
In this study, the difference in incidence of appendicitis among male and female patients was not statistically significant, as shown in (Table/Fig 2). Incidence was 59% in male patients and 41% in female patients.
As per (Table/Fig 3), the mean age of male patients presenting with appendicitis is around 26 years and of the female patients is 23 years.
In the study conducted, presence of nausea or vomiting was found in 63% of patients. Nausea alone was a predominant symptom constituting 34% as mentioned in (Table/Fig 4).
At the time of surgery, the appendix appeared inflamed in 81% of patients, perforated in 11% and gangrenous in 5% of the patients. In 3% of patients, the appendix appeared normal as per (Table/Fig 5).
As per (Table/Fig 6), histopathological examination of the appendiceal specimen showed evidence of inflammation in 87% of patients.
As per (Table/Fig 7), the mean duration of surgery in open appendectomy was 42.80 min as compared to 54.30 min for laparoscopic appendectomy, which is highly significant (p < 0.000).
Pain score was 47.00 in the open group as compared to 39.50 for laparoscopic appendectomy that is highly significant (p < 0.001) as mentioned in (Table/Fig 8).
As per (Table/Fig 9), it took on an average of 2.12 days to start oral feeds in laparoscopic group as compared to 3.28 days in the open appendectomy group that is highly significant (p =<0.000).
As per (Table/Fig 10), there were no postoperative complications in the laparoscopic group. Whereas 10% of the patients in open appendectomy group had postoperative complications all of which were wound infections.
The mean duration of postoperative hospital stay was 5.88 days in open group as compared to 3.62 days for laparoscopic group that is highly significant (p < 0.000) as shown in (Table/Fig 11).
Return to normal work postoperatively was on an average 13.34 days in open group as compared to 8.02 days for the laparoscopic group, which is highly significant (p < 0.000) as shown in (Table/Fig 12).
Laparoscopic surgery is a major surgical advance that has enabled the general surgeon to stretch his super specialty era. The controversy that currently exists over the potential benefits of laparoscopic appendectomy moderated us to analyse our experience with this procedure. The relative advantages and disadvantages of open and laparoscopic appendectomy are measured in terms of duration of surgery, need for conversion into open appendectomy, treatment of coexisting pathology, intraoperative and postoperative complications, postoperative pain assessment and recovery, return to normal work and cost factors involved in both groups are compared on random basis.
The mean duration of surgery in the laparoscopic group was 54.30 minutes as compared to 42.80 minutes in the open group (p<0.000). Similar observation of laparoscopic appendectomy taking more time have been reported by other studies [4-11]. (Tate J J et. al. (12), 67.03 v/s 46.5 min; Vallina et. al. (14) 61±41 min and 43±2.9 min for laparoscopic and open appendectomy respectively).
In the study, there was no conversion of laparoscopic appendectomy to open in contrast to higher conversion rate of Pendersen AG et.al.(14), (65 out of 282 patients) and 14(20%) reported by Tate JJ et. al.(12).
There was no coexisting pathology in the study series.
Wound infection rate in our study was 5(10%) in the open group and none in the laparoscopic group (p<0.022), with no other intraoperative or postoperative complications. Austin et. al. (4) have reported infection rate of 11% in open and 4% in laparoscopic group. Higher wound infection has also been reported in open group by other (6),(11),(15),(16),(17),(18).
Pain score (VAS) was 47.00 in open group as compared to 39.50 in laparoscopic appendectomy (p < 0.001), because of longer incision, stretching or cutting of muscles and wound infection. Similar observations have also been reported by other authors (8),(19),(20).
In postoperative recovery, oral feeds were resumed after surgery on an average of 3.28 days in open group compared to 2.12 days in laparoscopic group (p = 0.000).
Duration of postoperative hospital stay was 5.88 days v/s 3.62 days in open and laparoscopic group respectively (p < 0.000). Austin et al (4) has reported mean postoperative stay as 4.8 days and 2.2 days for open and laparoscopic group respectively. Other workers (5),(6),(9),(14),(20),(21),(22) also have reported longer postoperative hospital stay in open group as compared to laparoscopic group
Return to normal activity was 13.34 days in open group as compared to 8.02 days in the laparoscopic group (p < 0.000). Pendersen AG et al (14) reported the median time to return to normal activity as 7 v/s 10 days in laparoscopic and open group respectively. Others (7),(9),(11),(19),(23) have also shown that laparoscopic group patients returned to normal work earlier.
On analyzing thedata,we foundadefinitedifference in outcome between conventional and laparoscopic appendectomy in properly selected patients. The laparoscopic appendectomy was better than open appendectomy with respect to wound infection rate, pain score, lesser use of antibiotics and analgesics, duration of postoperative hospital stay and return to normal activity.
|TABLES AND FIGURES|
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