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Laparoscopic appendectomy


Newer surgical techniques are sometimes unfairly criticised for not having been subjected to what has been called the 'purifying heat' of a randomised controlled trial. This criticism cannot be levelled at laparoscopic appendectomy, and a new meta-analysis has pulled together all the studies to give us a pretty good picture of the results of this new technique [1].

Searching


The review had a heroic search strategy, which included contacting many people for unpublished results (including abstracts submitted to meetings) and sending them data and information forms to complete and return. The authors used randomised trials with pre-specified outcome measures of operation time, complications (wound infections, intra-abdominal abcesses), postoperative pain, length of hospital stay and return to full activity.

Results


The analysis was on 28 randomised trials with 2877 patients. Only two trials were blinded (not unexpected). There was a wide range of inclusion and exclusion criteria in the studies, like sex, age and whether the appendix had burst or not.

On average 8% of operations which started as laparoscopy were converted to open appendectomy (range 0% to 27%). Operating time was 16 minutes longer for laparoscopy (Figure 1).

The length of hospital stay was an average of 15 hours less, and return to full activity 6.5 days earlier than with conventional appendectomy.

Wound infections were significantly less frequent with laparoscopic techniques; 36/1309 (2.8%) of laparoscopies had a wound infection compared with 93/1187 (7.8%) in conventional surgery.

This is a NNT of 20 (95% confidence interval 15 to 31). The risk of developing an intra-abdominal abcess was 22/745 (3.0%) with laparoscopic and 10/653 (1.5%) with convention surgery, with a relative risk of 1.8 (0.9 to 3.5).

Comment


This is a thoughtful review which gives not only outcome data but an interesting discussion of issues of technical importance to surgeons and others. It could form an interesting base for discussing whether the benefits of a 5% reduction in wound infection was balanced by a 2% increase in intra-abdominal abcesses. Such a discussion could include issues about severity (how much worse is an average intra-abdominal abcess than an average wound infection), and how much weight should be put on the non-significant (just, statistically) incidence of abcesses. Important when as many as 1 in 12 of us will have our appendix out in our lifetime. The discussion ends with a quote "Laparoscopic appendectomy is an excellent operation, but we don't need it." Enjoy!

Reference:


  1. S Sauerland, R Lefering, U Holthausen, EA Neugebauer. Laparoscopic vs conventional appendectomy - a meta-analysis of randomised controlled trials. Langenbeck's Archives of Surgery 1998 383: 289-295.




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