Value of Laparoscopic Appendectomy in the Elderly

Abstract

The correct surgical approach in the treatment of acute appendicitis continues to be a source of debate and a ground for comparative studies, as physicians and surgeons seek to define the optimal management of this common and ‘‘simple’’ illness. Surely the place of laparoscopy in the treatment of appendicitis is still controversial, despite a major trend in this direction. Because this disease is so prevalent, it is possible to examine different subgroups separately, and this is what was done by Kirshtein et al. [1] in their report of elderly patients, 60 years old and older. Then, the question is twofold: Does the laparoscopic treatment of acute appendicitis differ between the young and the old? And how does the laparoscopic treatment in the elderly compare with the open approach? The authors address the first question, which has mainly academic interest because of the inherent differences between the young and the old. Discussion can only indirectly suggest whether laparoscopic appendectomy is justified in the older age group. The second question is more interesting clinically, and should be addressed separately, ideally in a prospective way, unlike this study. How does one decide whether the laparoscopic approach for a certain procedure is acceptable or even preferable? The potential for a laparoscopic procedure to be advantageous starts with the ratio between the access size and the magnitude of the task. If a large incision is required to remove a small and a simple organ (like the gallbladder), the advantages of minimizing abdominal wall trauma and the peritoneal exposure are obvious. If the incision is a relatively small part of a complicated task with many potential postoperative problems (like pancreaticoduodenectomy), then laparoscopy is much less appealing: Because it is time consuming and technically difficult, and it may lead to additional complications, the patient is less likely to benefit from the smaller access. At present, the role of laparoscopy remains to be established in smaller procedures (small incision/simple task), as the potential advantage of laparoscopy is less prominent, but may still exist. Appendectomy certainly belongs in this group of procedures. Evaluation may require larger series and optimal methodology to prove a small benefit—or perhaps disprove it or even demonstrate inferiority of the approach. Some early studies, for example, have claimed to find more pelvic abscesses in patients undergoing laparoscopic appendectomy, although many other studies have failed to support this claim. Furthermore, within the diverse group of patients with appendicitis, certain subgroups may differ in regard to the preferred surgical approach, because of different factors, such as stage of inflammation at presentation, or age. The present study, by Kirshtein et al., adds some information to our understanding of this question. Despite its admitted limitations, like incomparability of the groups (more complicated cases in the older age group, leading to more conversions), the two groups still had a similar rate of postoperative complications. Although this suggests that laparoscopic appendectomy in the elderly is acceptable, there is no way to infer from this kind of study whether an open approach would have been different in these patients—a direct comparison is mandatory. Should we offer laparoscopic appendectomy to our patients? Should a patient’s age have any influence on our decision? These questions cannot be answered from this study. It is probably okay; no major harm is done, but we D. Rosin (&) General Surgery & Transplantation, Sheba Medical Center, Tel Aviv University, Tel Hashomer 52621, Israel e-mail: drosin@mac.com