Risk for Bowel Obstruction Following Laparoscopic and Open Appendectomy

Abstract

The study BLaparoscopic approach to appendectomy reduces the incidence of shortand long-term post-operative bowel obstruction: systematic review and pooled analysis^ was published in a previous issue of the Journal of Gastrointestinal Surgery. The authors have searched for published evidence on the incidence of bowel obstruction following laparoscopic or open appendectomy. The structured review process and the rigorous data collection are to be commented on and represent, to our view, the strengths of this work. The article concludes that bowel obstruction occurs more frequently after open than after laparoscopic appendectomy. The authors suggest that the laparoscopic approach should be considered in all cases of acute appendicitis, when technically feasible. We would disagree with the latter statement, as we consider that it is inconsistent with the study findings, the strength and the quality of the provided evidence. First, it may be assumed that the authors pool cases of midline laparotomy, paramedian incisions, McBurney’s and Lanz incisions, in the Bopen^ treatment group. As the authors correctly note, the incidence of bowel obstruction may be higher after large laparotomy incisions, as compared to minilaparotomies. It is thus reasonable to suggest that the relative risk for bowel obstruction after having used the laparoscopic and the mini-laparotomy incision is unknown. The included articles were unfortunately not assessed regarding their methodological and reporting quality. Sensitivity analyses including high methodological quality papers would enhance the authors’ conclusions. The majority of studies did not have a randomized design and is thus prone to significant selection bias. There is a higher possibility that more complex cases were treated with open midline laparotomy, than with laparoscopy. Similarly, it is more likely that patients with previous laparotomy incisions, an independent risk factor for bowel obstruction, have been subjected to open than laparoscopic appendectomy. Furthermore, one could presume that the laparoscopic approach was preferred in younger patients. If the mean age of the laparoscopic treatment group is lower than that of the open group, it is more likely for the latter to have a higher proportion of patients with a history of laparotomy and thus a higher possibility to develop bowel obstruction. Unfortunately, comparative demographic data of the included studies, as suggested by the Preferred Reporting Items in Systematic Reviews and MetaAnalyses (PRISMA) statement standards, were not provided. It may thus be not reasonable to recommend the laparoscopic approach in all cases of acute appendicitis, but rather to recognize the need for identification of those patient groups which may benefit the most from the laparoscopic approach. The cited article does not provide any evidence on the superiority of the laparoscopic approach over the open approach via a McBurney’s or Lanz incision in terms of bowel obstruction, at least for uncomplicated appendicitis.