Discussion and compared the open and laparoscopic techniques

DiscussionAcute appendicitis is the commonest cause of Acute abdomen in teens requiring emergency intervention 8. The possibility of appendicitis must be considered in any patient presenting with lower abdominal pain and such diagnosis is still a challenge in obese patients 9, 10. Although more than 20 years have elapsed since the introduction of laparoscopic appendectomy (performed in 1983 by Semm, a gynecologist), open appendectomy is still the widely practiced procedure. Some authors consider emergency laparoscopy as a precise tool for the treatment of abdominal emergencies like appendicitis especially in females of reproductive age groups  11, 12. Several studies 13, 14, 15 reflect that laparoscopic appendectomy is associated with faster restoration of normal activities with fewer wound Sequele. These findings have been contradicted by many researchers who showed no significant difference in the outcome between the two procedures, and more expenses with laparoscopic appendectomy.

  Recent meta-analyses of randomized controlled trials comparing laparoscopic versus conventional appendectomy depicted that acute appendicitis can be dealt with with open and laparoscopic approach safely 16,17. Obesity is a prevalent medical condition in western societies and also affects a great percentage of common people undergoing appendectomy in our social setups. A popular myth that laparoscopic appendectomy should be “Gold Standard” in obese patients stands on the presumption that the increased abdominal wall thickness is a technical challenge during open appendectomy limiting accurate hand movements and visibility. More dissection required which ends up with prolong recovery time. Recently, published papers have considered laparoscopic approach as a better option in obese.

Our study  focused on the obese  patients and compared the open and laparoscopic techniques for appendectomy. Most of the patients in our series were having BMI more than 30 with a female preponderance in the age group of 20-30 years. Surgical time is considered as important predictor of the procedural outcome. Most studies mentioned a long surgery time with laparoscopic approach .The likely explanation of this finding may be learning curve of the surgeons spending more time than conventional appendectomy.

The longer operation time in laparoscopic appendectomy may be due to additional steps like setup of instruments, insufflations, making ports under vision and a phase of diagnostic laparoscopy. By contrast, in our series the impact of learning curve was almost nil as all surgeons performed the procedure were senior consultants..  Clarke et al.,6 reported a markedly elevated value for the laparoscopic appendectomy group. Our observations are different to a previously published meta-analysis by Markar et al.18  who investigated surgical time based on data available in3,19and detected no significant difference between laparoscopic and open appendectomy in normal patients.

Best services for writing your paper according to Trustpilot

Premium Partner
From $18.00 per page
4,8 / 5
Writers Experience
Recommended Service
From $13.90 per page
4,6 / 5
Writers Experience
From $20.00 per page
4,5 / 5
Writers Experience
* All Partners were chosen among 50+ writing services by our Customer Satisfaction Team

But in our series in obese patients, this finding is different20  which demonstrated a significant decrease of surgical time in the laparoscopic appendectomy group (P <0.001).The short hospital stay observed for patients treated by laparoscopic approach is not clinically significant, but it has bearing on the bed availability and hospital finances .Nonetheless, faster return to the normal activities cannot be attributed to short hospital stay only, because this vary from person to person attitude and job nature.

Masoomi et al.4 emphasized the advantage of laparoscopic appendectomy by reporting a lower intra-abdominal abscess formation rate in the laparoscopic appendectomy group. we observed the same that the residual abscess formation rate in obese was lower in LA  as compared to open appendectomies . These findings are contradictory with other studies that showed an increased risk of residual abscesses after laparoscopic appendectomy compared with open surgery 21,22. Several hypotheses have been postulated to find possible justifications: mechanical spread of bacteria in the peritoneal cavity promoted by carbon dioxide insufflations, especially in perforated appendix , inadequate learning curve 22, the extensive washouts, instead of simple suction of the infected area in case of perforation, that results in soiling of the entire abdominal cavity, which is difficult to manage subsequently. Prophylactic Antibiotics were given before in all cases and afterwards in case of peritoneal contamination.Similarly the wound sepsis was encountered more in open appendectomy group .Wound infection could cause financial burden on the patient as well as on hospital by prolonging the Hospital stay.

Wound dehiscence is more common in open group especially in complicated appendicitis despite receiving same antibiotics in pre and postoperative phase. Second reason may be the use of endobag for retrieval of appendix in LA Group. According to Mason et al23 main advantage of laparoscopic surgery in obese patients with acute appendicitis is reduced wound related sequele.We compared the pain intensity in postoperative period with the help of visual analogue score and analgesia requirement on the charts to seek the difference. We  used Parenteral doses of NSAIDS in routine and Parenteral narcotics on need base to compare both the groups .

In accordance to many studies 14,24 the Parenteral Narcotic analgesia requirement was less in LA group. .This effect is same in laparoscopic surgery performed in obese as well as in normal BMI patients but has significantly reduced (P<0.001) requirement as compare to conventional open appendectomy.Postoperative ileus was more prolonged in case of open appendectomy group due to more handling but this fact was insignificant statistically(p= 0.09 ) .

Mainly the advantage of less ileus is not only due to laparoscopic approach but also due to less use of narcotic analgesia in postoperative phase. The mortality rate was negligible in our series. In General appendectomy performed either through laparoscopic or open route is a safe procedure as revealed by many studies 25.   CONCLUSIONLaparoscopic approach is advantageous compared to open appendectomy in terms of less postoperative pain, ileus, short hospital stay, less wound sepsis and operation time in obese patients, but a large prospective trial is necessary to prove the better surgical outcomes of laparoscopic appendectomy.CONFLICT OF INTERESTNo conflict of interest.ACKNOWLEDGEMENTWe are thankful to the statistical department, Tertiary care hospital for keeping record inline.AUTHURS CONTRIBUTIONDr Saeed awan and Dr Khurram Niaz contributed in the concept and research work needed for drafting of this article.

Dr Munawar Jameel did the statistical analysis.Dr Iqra took part in the data Acquision on Proformas.        REFERENCES1.

 Sauerland S, Jaschinski T, Neugebauer EA. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev. 2010;10:CD001546. PubMed2. Towfigh S, Chen F, Katkhouda N, Kelso R, Sohn H, Berne TV, et al.

Obesity should not influence the management of appendicitis. Surg Endosc. 2008;22:2601–5. PubMed3. Corneille MG, Steigelman MB, Myers JG, Jundt J, Dent DL, Lopez PP, et al. Laparoscopic appendectomy is superior to open appendectomy in obese patients. Am J Surg. 2007;194:877–80.

PubMed4. Masoomi H, Nguyen NT, Dolich MO, Wikholm L, Naderi N, Mills S, et al. Comparison of laparoscopic versus open appendectomy for acute nonperforated and perforated appendicitis in the obese population.

 Am J Surg. 2011;202:733–8. PubMed5. J. M. Eom, J.

H. Hong, S. W. Jeon et al., “Safety and clinical efficacy of laparoscopic appendectomy for pregnant women with acute appendicitis,” Annals Academy of Medicine Singapore, vol.

41, pp. 82–85, 2012.  6.

 Clarke T, Katkhouda N, Mason RJ, Cheng BC, Olasky J, Sohn HJ, et al. Laparoscopic versus open appendectomy for the obese patient: A subset analysis from a prospective, randomized, double-blind study. Surg Endosc. 2011;25:1276–80. PubMed7. Enochsson L, Hellberg A, Rudberg C, Fenyö G, Gudbjartson T, Kullman E, et al.

Laparoscopic vs open appendectomy in overweight patients. Surg Endosc. 2001;15:387–92.

 PubMed 8. M. Worni, T. Ostbye, M. Gandhi et al., “Laparoscopic appendectomy outcomes on the weekend and during the week are no different: a national study of 151,774 patients,” World Journal of Surgery, vol.

36, no. 7, pp. 1527–1533, 2012.9. Bhangu A, Søreide K, Di Saverio S, Assarsson JH, Drake FT. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet. 2015;386:1278–1287.

doi: 10.1016/S0140-6736(15)00275-5. PubMed Cross Ref10.

 Di Saverio S, Birindelli A, Kelly MD, Catena F, Weber DG, Sartelli M, et al. WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis. World J Emerg Surg.

 2016;11:34. doi: 10.1186/s13017-016-0090-5. PMC free article PubMed Cross Ref11. Di Saverio S, Mandrioli M, Birindelli A, Biscardi A, Di Donato L, Gomes CA, Piccinini A, Vettoretto N, Agresta F, Tugnoli G, Jovine E. Single-Incision Laparoscopic Appendectomy with a Low-Cost Technique and Surgical-Glove Port: “How To Do It” with Comparison of the Outcomes and Costs in a Consecutive Single-Operator Series of 45 Cases.

 J Am Coll Surg. 2016;222:e15–e30. doi: 10.1016/j.

jamcollsurg.2015.11.019. PubMed Cross Ref12. Di Saverio S. Emergency laparoscopy: a new emerging discipline for treating abdominal emergencies attempting to minimize costs and invasiveness and maximize outcomes and patients’ comfort. J Trauma Acute Care Surg.

 2014;77:338–350. doi: 10.1097/TA.0000000000000288. PubMed Cross Ref13. Garbutt JM, Soper NJ, Shannon W, Botero A, Littenberg B.

Meta-analysis of randomized controlled trials comparing laparoscopic and open appendectomy. Surg Laparosc Endosc. 1999;9:17–26. doi: 10.1097/00019509-199901000-00004.

 PubMed Cross Ref14. Towfigh S, Chen F, Mason R, Katkhouda N, Chan L, Berne T. Laparoscopic appendectomy significantly reduces length of stay for perforated appendicitis. Surg Endosc.

 2006;20:495–499. doi: 10.1007/s00464-005-0249-8. PubMed Cross Ref 15.

 Di Saverio S, Mandrioli M, Sibilio A, Smerieri N, Lombardi R, Catena F, Ansaloni L, Tugnoli G, Masetti M, Jovine E. A cost-effective technique for laparoscopic appendectomy: outcomes and costs of a case–control prospective single-operator study of 112 unselected consecutive cases of complicated acute appendicitis. J Am Coll Surg. 2014;218:e51–e65. doi: 10.

1016/j.jamcollsurg.2013.12.003. PubMedCross Ref16. Min-Hyun Baek, Shin-Wha Lee, Jeong-Yeol Park et alFeasibility and Safety of Laparoscopic Surgery for Obese Korean Women with Endometrial Cancer: Long-Term Results at a Single InstitutionJ Korean Med Sci.

2014 Nov; 29(11): 1536–1543.17. M. N. Andersson and R.

E. Andersson, “Causes of short-term mortality after appendectomy: a population-based case-controlled study,” Annals of Surgery, vol. 254, no. 1, pp. 103–107, 2011.18.

 Markar SR, Venkat-Raman V, Ho A, Karthikesalingam A, Kinross J, Evans J, et al. Laparoscopic versus open appendicectomy in obese patients. Int J Surg. 2011;9:451–5. PubMed19. American Obesity Association.

AOA Fact sheets. Accessed May, 20, 2013. Available from http://www.obesity.org/resources-for/what-is-obesity.htm .20.

 Tan-Tam C, Yorke E, Wasdell M, Barcan C, Konkin D, Blair P. The benefits of laparoscopic appendectomies in obese patients. Am J Surg. 2012;203:609–12. PubMed21 C. G.

Chiu, N. H. Nguyen, and S.

W. Bloom, “Single-incision laparoscopic appendectomy using conventional instruments: an initial experience using a novel technique,” Surgical Endoscopy and Other Interventional Techniques, vol. 25, no. 4, pp. 1153–1159, 2011.

 22. Wei B, Qi CL, Chen TF: Laparoscopic versus open appendectomy for acute appendicitis: a metaanalysis. Surg Endosc. 2011, 24: 1199-120823. Mason RJ, Moazzez A, Moroney JR, Katkhouda N.

Laparoscopic vs open appendectomy in obese patients: Outcomes using the American College of Surgeons National Surgical Quality Improvement Program database. J Am Coll Surg. 2012;215:88–99. PubMed24. M. Carron M.

Gasparetto V. Vindigni M. Foletto .Laparoscopic surgery in a morbidly obese, high-risk cardiac patient: the benefits of deep neuromuscular block and sugammadex. BJA 2014;113: 186–187.25. H.

Masoomi, S. Mills, M. O. Dolich et al., “Does laparoscopic appendectomy impart an advantage over open appendectomy in elderly patients,” World Journal of Surgery, vol. 36, no.

7, pp. 1534–1539, 2012.