INTRODUCTION

Appendicitis 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 appendectomy.  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 appendectomy^1,2. 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 new technique.  This study compared open to laparoscopic appendectomy. 

MATERIAL AND METHOD 

 In 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 appendicitis. 

PATIENTS 

Patients 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.

METHODS  

The Position:  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. 

Steps of laparoscopic appendectomy 

 1.Tip of inflamed appendix

 2.Appendicular mesentry held in atraumatic forceps divided after coagulation.  

 3. Catgut extra corporeal loop 

 4. Base of  the appendix placed around the base ligated 

5. Appendix  divide

 6. End result showing small stump  of appendix .

At 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. 

Open appendectomy

It is done by standard grid Iron Incision. Steps are shown below.

Open appendectomy steps 

Inflamed  appendix delivered from a right iliac  fossa incision.

Inflamed appendix being removed after ligature of appendicular mesentery.

RESULTS

Variables 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: 

DISCUSSION

Laparoscopic 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 regarded as  “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 instruments^3,4. 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 prove ^5,6.

Laparoscopy has a  great diagnostic value specially in acute abdomen .It plays a significant role  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 pregnancy etc.                 

Generally laparoscopic procedures carry less postoperative pulmonary complications as compared to open surgery on abdomen^7,8,9,10. 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.               

To 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.               

In 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.               

Operating time is the period, which starts from the moment the patient is anesthetized till the patient comes out of anesthesia.  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.               

Wound 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 analysis.               

Post 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.

Mean hospital stay was nearly 1/3^rd in LA. The patients were discharged home after 24 hours in LA where as in OA the patient left the hospital on the third day. 

CONCLUSION 

Laparoscopic surgery is a well established branch of general surgery. It is beyond doubt that in coming times it may emerge as a separate specialty.  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 general anesthesia¹¹. 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 to OA.               

We 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 & off  work  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. 

We believe it would be very early and immature to say that LA is superior or can replace OA. 

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