Health Comparative study of outcome of open vs laparoscopic appendectomy

Comparative study of outcome of open vs laparoscopic appendectomy

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Introduction:

One of the most common cause of pain in abdomen requiring surgery is appendicitis. The life time risk of which remains about 7 to 9 %.1 Appendectomy constitutes 1% of all the general surgical procedures. 2 With invent of minimal access surgery it is possible for surgeons to make the diagnosis and treat the cause in one procedure. 3 The advantages of laparoscopy are well known in terms of less post-operative pain, reduced hospital stay, decrease wound infection and better cosmetic results. Moreover the surgeon is able to explore entire peritoneal cavity (diagnostic laparoscopy) and can not only establish a diagnosis but can also do peritoneal lavage and suck any puss pockets effectively without extending any incision. 3 The trend of Laparoscopic appendectomy is increasing for female patients as it is easy to deal any gynecological pathology that contributes to pain in right iliac fossa via laparoscope. 4

Although laparoscopic appendectomy if favored by most of the surgeons yet some remain skeptical in doing the procedure via minimal access technique and prefer open appendectomy. The obvious disadvantages of laparoscopic appendectomy include increase in operative time and increase in cost of procedure. 5 While some of the studies prove that there can be an increased risk of intra-abdominal abbesses after laparoscopic appendectomy. In this study we tried to compare the outcomes the laparoscopic and open appendectomy

Methods:

The study was carried out in Department of Surgery unit 2, Bahawal Victoria Hospital Bahawalpur, form Jan 2017 to Dec 2017. One hundred patients were selected from 313 patients who presented to us with pain in RIF. 50 of them underwent open appendectomy while the other 50 were treated via laparoscopic appendectomy. All those patients were excluded from the study were there was history of any previous abdominal surgery, TLC count more than 13000, appendicular mass, perforation peritonitis or pelvic puss was suspected. The selected patients were operated under general anesthesia after taking informed consent.

Laparoscopic appendectomy was carried out via 3 ports. One in umbilicus, one suparapubic and last one in mid-clavicular line just above the level of umbilicus. Pnemoperitonium was created through open technique. Appendix was grasped and meso-appendix was cauterized. Base of appendix was ligated through a standard endo-loop and appendix was cut. The appendix was then retrieved through umbilical port.

Open appendectomy was done via Grid iron incision. Muscles were retracted and appendix was found. Meso-appendix was ligated and base of appendix was tied with catgut number 1. Appendix was cut and was retrieved. Wound closed in reverse order.

All the appendectomies were done by a consultant and a senior resident. Patients were admitted in ward where they were managed post operatively.

Results:

In total 100 patients underwent open or laparoscopic appendectomy during our study period. Of these 50 underwent laparoscopic appendectomy and other 50 underwent open laparoscopic appendectomy. 29 females and 21 males underwent laparoscopic appendectomy (total 50) while 23 females and 27 males underwent open appendectomy

Table 1. Gender distribution

Operation Female patients Male Patients Total
Lap appendectomy 29 21 50
Open appendectomy 23 27 50
  100

 

The mean age of the patients who underwent laparoscopic appendectomy was 28 while the mean age of the other group was 29.68

Table 2. Age distribution

Operation Mean age Range Standard Daviation
Lap appendectomy 28 16-50 8.325
Open appendectomy 29.68 15-50 9.131

 

As demonstrated in the table below, most of the patients were discharged in first 3 post-operative days. While the patients in other group had longer hospital stay. 49 out of 50 patients who underwent lap. appendectomy were discharged in first 3 post-operative days. The mean hospital stay in these patients was 1.42 days. While the 34 out of 50 patients who underwent open appendectomy were discharged between 4 to 6 days. And the rest were discharged between 7 to 9 days. The mean hospital stay in this group was 6.1 days.

Table 3. Duration of Hospital Stay

Duration of hospital stay.

Range(Days)

Lap. Appendectomy Open Appendectomy
1-3 49 0
4-6 1 34
7-9 0 16
Mean hospital stay 1.42 6.1

 

Both of these procedures were done in general anesthesia and required post-operative analgesics. The patients were shifted in surgical ward where they were closely monitored for post-operative pain management.  40 out of 50 patients in laparoscopic group required iv analgesia only for 1 to 2 hours while the remaining 10 required analgesia up to 4 hours of surgery. While the patients in the open appendectomy group required longer duration of analgesia. 15 required analgesia for 3 to 4 hours, 32 required iv analgesia for 5 to 6 hours and remaining 3 required analgesia for more than 6 hours after surgery.

Table 4. Post-operative intra venous analgesia requirement (hours)

Post-operative analgesia requirement (hours) Laparoscopic appendectomy Open appendectomy
1-2 hours 40 0
3-4 hours 10 15
5-6 hours 0 32
>6 hours 0 3

 

Although all the patients in our study receive pre-operative antibiotics (1 g Ceftriaxone and 500mg of metronidazole). Only one out of 50 patients who underwent laparoscopic appendectomy had port site infection while 5 patients in the other group had wound infection.

While only one patient had intra-abdominal abscess after open appendectomy.

 

Table 5. Post-operative complications.

Complications Laparoscopic appendectomy (n = 50) Open appendectomy

(n = 50)

Wound infection 1 5
Intra-abdominal abscess. 0 1

 

The mean time duration of laparoscopic appendectomy was 44.24 minutes while the mean time for open appendectomy was 27.26 minutes

Table 6. Time duration of surgery

Operative time in mins Laparoscopic appendectomy Open appendectomy
< 20 0 1
20 – 40 10 48
41 – 60 40 1
>60 0 0
Mean time in mins 44.24 27.26

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