J. Med. Res.
Vol. 42 No.1, 2003
versus open appendectomy
Kamal, Khalid Hussain Qureshi
of Surgery, Nishtar Medical College,
appendectomy is a new procedure as
compared to laparoscopic
cholecystectomy is now considerd a
standard method of performing
cholecystectomy and has replaced the
old method generally throughout the
world, while appendectomy could not
achieve the similar popularity. In this
paper a prospective study was done to
see the merits and demerits of both
laparoscopic and open appendectomy.
Key word: Laparoscopic cholecystectomy (LC), Laparoscopic appendectomy (LA), Open appendectomy (OA).
was first recognized as a disease entity
in sixteenth century and was called
perityphlitis. McBurne in 1889 described
the clinical features of acute
appendicitis. Open appendectomy is used
since last century. In 1983, a German
Gynecologist Semm performed the first
Laparoscopic surgery is now
a well established and advanced
method of performing general surgical
procedures. In some teaching hospitals
all patients with pain right iliac fossa
have to undergo laproscopy before
proceeding to appendectomy1,2.
Laparoscopic appendectomy has gained
some ground but is not as popular as
Laparoscopic Cholecystectomy. Some
surgeons purposed that the new technique
of laparoscopic appendectomy should be
the preferred treatment for acute
appendicitis. Another group of surgeons
have a lot of reservations about this
This study compared open to
order to compare the two techniques,
patients undergoing laparoscopic
appendectomy were compared to patients
undergoing open appendectomy over a
period of 4 years. Those patients were
excluded who had perforated
undergoing laparoscopic appendectomy
(N=42) had an average age of 25.7±1.5
(range 16-59). These patients were
compared to 53 patients undergoing open.
The patient is in supine
position, arms tucked at the side. The
surgeon stands on the left side of the
patient with the scrub nurse-camera
holder-assistant. A pneumoperitoneum is
obtained in the usual fashion. Three
trocars are inserted: Two trocars
5mm–10mm at right upper quadrant and
Umbilicus respectively and one 5 mm (Suprapubic).
In some cases where appendix is
difficult the telescope is used
alternatively between the RUQ and the
Umbilical trocar for better view and
dissection. An atraumatic grasper is
inserted via the RUQ trocar. The cecum
is retracted upward toward the liver,
this maneuver elevates the appendix in
the optical field of the telescope. The
appendix is grasped at its tip with a 5
mm grasper via the suprapubic trocar. It
is held in upward position. Steps of
laparoscopic appendectomy are shown in
fig 1 to fig 6.
of laparoscopic appendectomy
of inflamed appendix
mesentry held in atraumatic forceps
divided after coagulation.
Catgut extra corporeal loop
the appendix placed around the
End result showing small stump
of appendix .
the end of procedure the base of the
appendix is inspected for homeostasis.
The appendix is pulled into the right
upper trocar. Both the appendix and
trocar are removed in such a fashion
that the appendix should not touch the
abdominal wall. Trochar is replaced,
abdominal washed with saline and a drain
is placed in right lower quadrant.
is done by standard grid Iron Incision.
Steps are shown below.
appendix delivered from a right
appendix being removed after ligature of
evaluated were operating room time, days
until patient tolerated a regular diet,
days of hospitalization, postoperative
pain and wound infection rate. Results
are tabulated below:
appendectomy is relatively a new
procedure as compared to laparoscopic
cholecystectomy. A lot of discussion and
analysis are being performed through out
the world regarding laparoscopic versus
open appendectomy. Unlike LC, LA is not
“Gold standard”. Some
surgeons believe that laparoscopy has
the advantage that if a patient who has
LC and his appendix was found to be
inflamed, he can have appendectomy at
the same time without any extension of
incision or instruments3,4.
Clear and magnified visions of appendix
with more space to maneuver through a
small hole like incision are great
advantages of laparoscopic surgery. Some
surgeons with equal safety and ease in
OA do “Button hole” surgery. Hence
regarding incision any advantage to LA
is likely to be small and difficult to
great diagnostic value specially
in acute abdomen .It plays a significant
in young females where at times
it is nearly impossible to differentiate
between acute appendicitis and
gynecological clinical conditions like
"Pelvic Inflammatory disease",
"Twisted ovary " and ectopic
laparoscopic procedures carry less
postoperative pulmonary complications as
compared to open surgery on abdomen7,8,9,10.
To adopt a new technique and leave the
old one, which is well established since
more than a century one needs to show
clearly some outstanding advantages,
which are lacking in the old technique.
Possible advantages of LA are its better
vision of organs, shorter hospital stay,
fewer wound infection, less post
operative pain and
less days off work.
The results of a meta analysis
comparing LA and OA shows clearly that
LA results in significantly less post
operative pain, shorter hospital stay
and quick resumption to work.
have a setup to perform LA at least one
million rupees are required whereas OA
can be done in an environment with no
special equipment at even at basic
health unit. Hence the initial cost is
very high as compared to OA. The
operative cost is also very high if the
disposable staplers are used. This cost
can be reduced to the cost of OA by
using extra corporeal knotting and a
knot pusher or disposable catgut loops
with knot pusher.
our Asian society it is usually seen the
only one person earns while all the rest
sit back and eat. In such cases early
return of patient to normal productive
life is a big advantage for the patient.
time is the period, which starts from
the moment the patient is anesthetized
till the patient comes out of
Mean operation time was longer in
LA (55minutes) as compared to OA (30
minutes). Main reason for the delay,
which we noted, was not during operation
rather before starting the actual
operation in position the patient.
Adjusting different tubes, cables and
video apparatus around the patient.
infection regarding skin was almost
zero, as the appendix was pulled into
the trocar before removing. This
maneuver minimizes the chances of wound
infection to the skin. On the other hand
the incidence of intra abdominal
abscesses was higher (3 cases) as
compared to none in OA. Similar findings
were seen by Goheb et al in a meta
operative pain and discomfort is
difficult to measure. We used an
indirect method by noting how many days
took to mobilize freely and how many
days the patient used narcotic
analgesics. Our study showed that on
average after 12 hours the patient were
fully mobilized and did not require any
narcotic analgesic where as in OA group
this average time was 36 hours. This
finding is common in almost all the
studies done up to date.
hospital stay was nearly 1/3rd
in LA. The patients were discharged home
after 24 hours in LA where as in OA the
patient left the hospital on the third
surgery is a well established branch of
general surgery. It is beyond doubt that
in coming times it may emerge as a
The results and satisfaction that
was achieved in LC cannot be reached in
LA. In general laparoscopy has a lot of
advantages over open surgery as
discussed before but LA is not easier,
quicker or safer, nor does it obviates
Furthermore the operating room cost for
LA are considerably higher than for OA.
The operative and post operative
complications are more serious
(e.g.: intra abdominal abscesses
& perforation of bowel) as compared
have to analyze very critically that do
we need a
procedure which gives us a small
scar which is more cosmetic and
acceptable with minimum, hospital stay
BUT serious postoperative
complications or should we stick to the
previous gold standard and well
established method of OA with lesser
chances of intra-abdominal abscesses /
perforation of bowel.
believe it would be very early and
immature to say that LA is superior or
can replace OA.
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