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8/6/2019 Lap vs Open Appendectomy
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SHORT-AND LONG-TERM
RESULTS OF OPENVERSUSLAPAROSCOPICAPPENDECTOMY
H. A. Swank E. J. Eshuis M. I. van Berge
Henegouwen W. A. Bemelman
Department of Surgery, University of
Amsterdam, The Netherlands
World J Surg
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INTRODUCTION
Advantages of laparoscopy
y Three small incisions
y little pain
y quick recovery
laparoscopic appendectomy/ diagnostic
laparoscopy
Most of the advantages are small and oflimited clinical relevance
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OBJECTIVES
To compare short- and long-term results
of
y conventional appendectomy with or without
prior diagnostic laparoscopy (OA)
y laparoscopic appendectomy (LA)
Hypothesis-
y higher complication rates in the short term
for laparoscopic appendectomy are
compensated in the long term by lower
reoperation rates for incisional hernia and
adhesions
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PATIENTS AND METHODS
>18 years of age
1 January 1995 until 31 December 2005
retrospective study
Primary outcomey long-term complications
y Readmissions
y reinterventions (>30 days postoperatively)
Secondary outcomey short-term complications
y Readmissions
y reinterventions (
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PATIENT CHARACTERISTICS
Prior abdominal surgery, in 16.3% (OA) and
16.2% (LA) of the patients (NS)
mean follow-up of the two groups: 9.0 years (OA)
vs. 8.7 years (LA; p = 0.321).
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OPERATIVE CHARACTERISTICS
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The skin was left open in 19% (OA) and 4% (LA)
of the patients (p
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Median hospital stay longer in OA (4 vs 3 days; p
= 0.093). Postoperative diagnostic investigations: fewer in
OA group
y CT scanning (3% vs 9%; p = 0.001)
y abdominal echography (6 vs. 12%; p
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Abscess
y 23 patients
y Most were men (65%, ns), with median age 7 yrs
older (ns)
significant risk factors in multivariate analysis-
duration of surgery (OR 1.01 CI 1.001.03) and
peritonitis- both local (OR 2.8 CI 1.17.1) and
generalised (OR 4.1 CI 1.214.0)
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LONG-TERM RESULTS
No mortality; small bowel obstruction
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DISCUSSION
Laparoscopic appendectomy did not have clear
advantages with respect to reduced short- and
long-term morbidity.
higher rate of intra-abdominal abscesses adverse events in the group of converted patients,
giving rise to significantly more diagnostic and
therapeutic interventions.
long-term morbidity and reoperation for
incisional hernia repair was low and not
significantly different
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laparoscopic group was dominated by women-
hospital policy for starting with a laparoscopicapproach in women to exclude gynecological
pathology
Attending consultants prefer laparoscopic
approach The operative time for both OA and LA was,
respectively, 15 and 12 min longer than found by
Sauerland et al.s meta-analysis- from Cochrane
database.- reason- operations performed in the
teaching setting, limited surgical or laparoscopicexpertise
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Among short-term outcomes, significantly differentparametersy Postoperative stay
y Short-term abdominal abscesses
y Readmissions
y Diagnostics
y Reinterventions
postoperative stay was one day shorter after LA
compared with cochrane database review high rate of abdominal abscess in the LA group
y significantly associated with purulent peritonitis and longduration of surgery.
y Male gender and a higher age were correlated, but notsignificantly.
Fleming et al had shown in a large series thatpatients with a high wound class, systematic illness,sepsis, male gender, a history of smoking, andoperative time of more than 60 min have asignificantly greater risk of abdominal abscess afterthe laparoscopic procedure
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Conversion -7%
y only significant risk factor was presence of
generalized purulent peritonitisy previous abdominal surgery had higher risk - not
significant
y The converted patients were at risk for relaparotomy
and incisional hernia
We expected the incidences of incisional hernia
and small bowel obstruction to be higher in the
open appendectomy group
y reoperation for incisional hernias after open
appendectomy was 1.1% (vs 0.120.7% in availableliterature)
y Incisional hernia in laparoscopic group only in cases
of conversion
y Not significant
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Small bowel obstruction
y None in this study
y 1.02.8% in literature
y small bowel obstruction can present many years after
surgery
y
Andersson et al. showed the prevalence increasedfrom 0.63% after 1 year, to 0.97% after 10 years, to
1.30% after 30 years of follow-up
y follow-up with a minimum of three years has been
too short
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The Achilles heel of laparoscopic appendectomyremains the increased incidence of intra-
abdominal abscesses
Risk factors
y male gender
y long operative duration
y purulent peritonitis
Benefits
y cosmetic expectations of the patient
y limited clinical benefits in the short term
y possible lower risk of incisional hernia in the long
term
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Will be the standard of care in future
problem of abdominal abscess therefore needs to
resolved and further research should be directed
on this topic
One direction for future research is the use of the
Endo Staplery Two systematic reviews have advised the use of this
device instead of endoloops - Sajid et al in 2009,
Kazemier et al in 2006
y Staplers most likely reduce fecal spill and provide a
more secure stump closure
Properly designed studies must be conducted
addressing the cost-effectiveness of this
technique.