Laparoscopic Appendectomy For Acute Appendicitis Research Articles

Does the Use of Newer Technology to Divide the Mesoappendix Result in Less Bleeding? A Retrospective Analysis

Background: Various methods have been used to seal and divide the mesoappendix, such as endoscopic linear cutting staples, the Harmonic Scalpel and even monopolar coagulation. The goal of this study was to determine whether using any of these energy sources versus any non-energy source would be superior in terms of post-operative complications (primarily bleeding), hospital length of stay and cost. Methods: This study included all patients who underwent laparoscopic appendectomy for acute appendicitis between January 2007 and April 2010 at a community hospital system with two large hospitals. The primary outcomes measured were bleeding, post-operative anemia, blood transfusion requirements, length of stay and cost. Results: Laparoscopic appendectomy was performed on 838 patients. An energy source was used on 503 patients and a non-energy source was used on 335 patients. No statistically significant differences were found regarding post-operative complications or length of stay. There was, however, a financial difference found, in that it was much less expensive to use a non-energy source versus an energy source when handling and controlling the mesoappendix. Conclusions: Using a non-energy source is as safe as an energy source for dividing and sealing of the mesoappendix. This study supports the use of a non-energy source as a comparable method when compared to a non-energy source, with no difference in main outcomes. J Curr Surg. 2014;4(1):6-9 doi: http://dx.doi.org/10.14740/jcs198w

妊娠中の急性虫垂炎に対して腹腔鏡下虫垂切除術を施行した5症例

妊婦の急性虫垂炎に対しては従来開腹による虫垂切除術が一般的であったが，近年の腹腔鏡下手術の技術の進歩，経験の蓄積に伴い，当院では腹腔鏡下手術をより積極的に導入している．2011年7月～2013年3月までに妊婦5例に対して腹腔鏡下虫垂切除術を行った．術中は体位およびポートの挿入位置を工夫して視野を確保し，麻酔科・産婦人科と協力して周術期の管理を行うことで経過は良好で，全例で妊娠を継続，出産できた．妊娠初期～妊娠後期までの症例を経験し，妊婦の急性虫垂炎に対して腹腔鏡下虫垂切除術が有効な治療法となりうると考えられたため，若干の文献的考察を加えて報告する．

Incidental GIST after appendectomy in a pediatric patient: a first instance and review of pediatric patients with CD117 confirmed GISTs

A 7-year-old boy underwent uncomplicated laparoscopic appendectomy for acute appendicitis. Incidentally, he was found to have a spindle cell tumor with CD117 immunopositivity, consistent with gastrointestinal stromal tumor (GIST) in the appendix. Although commonly reported in adults, pediatric GISTs are rare gastrointestinal malignancies that occur in only 1.4-2.7% of children and adolescents. Due to the paucity of reports, data are insufficient to adequately characterize tumor behavior, recurrence, and survival. We present the first case of pediatric GIST in the appendix. In addition, a review of the literature for CD117 confirmed pediatric GISTs was conducted to summarize its clinical features and current treatment options.

Endostapler or endoloops for securing the appendiceal stump in laparoscopic appendectomy: a retrospective cohort study

Laparoscopic appendectomy is the treatment of choice for appendicitis provided sufficient laparoscopic expertise is available. The endostapler possibly provides an easier and safer closure of the appendiceal stump, but at greater expense. This study aimed to compare two strategies for closure of the appendiceal stump in a large retrospective cohort of patients. This study reviewed patients who underwent laparoscopic appendectomy for acute appendicitis in three academic hospitals and two regional hospitals in The Netherlands during the period 1 January 2007 to 30 June 2011. The endostapler was routinely used in two hospitals and selectively used in the remaining three hospitals. Both strategies were compared for complications according to the Clavien-Dindo classification. A total of 1,036 patients were analyzed according to the strategy followed. The 571 patients in the first group were routinely treated with the endostapler. For the 465 patients in the second group, the intentional method of stump closure was with endoloops. The endostapler was used when indicated for 69 of these patients. The patient characteristics did not differ between the two groups. The groups also did not differ significantly in number of intra- and postoperative complications. In both groups, 4.3% of the patients had complications classified as grade 3 or higher. There were no significant differences in the prevalence of intraabdominal abscesses (3.2% vs. 4.3) or wound infections (0.4 and 1.5%). In a multivariate analysis, the chosen strategy for stump closure was not a significant predictor for postoperative complications. Routine use of the endostapler showed no clinical advantages over the use of endoloops with selective endostapler closure. The latter strategy is preferable because it is more cost effective.

Risk factors of converting to laparotomy in laparoscopic appendectomy for acute appendicitis

PurposeLaparoscopic appendectomy (LA) for acute appendicitis has several advantages over open appendectomy (OA). In cases of complicated appendicitis, LA is converted to OA at a constant rate, though converting appendectomy (CA) has several disadvantages. We retrospectively determined preoperative risk factors for failure of LA and subsequent conversion to OA.MethodsConsecutive cases of preoperative computed tomography (CT) and attempted LA were retrieved from our hospital database and grouped by procedure (LA versus CA). Patients with negative appendectomies (n = 28), opened appendectomy (n = 210), delayed interval appendectomy (n = 3), or who were <14 years of age were excluded.ResultsAverage patient age, preoperative C-reactive protein (CRP) level, and diffuse peritonitis were significantly different between the groups. CT inflammation and occurrence of complicated appendicitis were significantly higher in CA than LA. Conversion to OA was mostly because of dense adhesions, diffuse peritonitis, and difficulties in excision of the appendix due to perforation or severe inflammation from surgical point of view. Postoperative complications were significantly lower in LA than CA, although the rate of intraoperative abscess was not different.ConclusionMost patients with acute appendicitis can be successfully treated with LA. We identified the following significant risk factors of CA: CT inflammation grade 4 or 5; complicated appendicitis; higher preoperative CRP level; and diffuse peritonitis.

Transumbilical Single-incision Laparoscopic Appendectomy Using Conventional Instruments

This study aimed to evaluate the feasibility, safety, and cosmetic results of a novel technique, transumbilical single-incision laparoscopic appendectomy (TSILA), using a single working channel with conventional instruments. The study enrolled 84 consecutive patients undergoing laparoscopic appendectomy for acute appendicitis. To test the advantages of TSILA on the management of patients with acute appendicitis, a prospective randomized clinical trial was conducted. Surgical outcomes such as operation time, complication, and hospital stay of 42 patients undergoing TSILA were analyzed and compared with those of 42 patients undergoing classic 3-port appendectomy. All patients received a follow-up visit for 3 to 12 months. The study consisted of 42 patients undergoing TSILA and 42 patients undergoing classic 3-port laparoscopic appendectomy with an average age of 34.1 and 34.9 years, respectively. The mean operative time of TSILA did not show any difference when compared with the classic procedure (84.8 vs. 77.9 min, P=0.271). No operative complications occurred in patients undergoing TSILA, whereas 2 patients undergoing the classic procedure showed incisional infection. The average postoperative hospital stay was 2.7 days in the TSILA group and 2.9 days in the classic procedure group with no difference (P=0.316). At the follow-up visit, no patient showed any evidence of incisional hernia. The transumbilical incisions were visible minimally, and the cosmetic scores given by patients undergoing TSILA was higher than that given by patients undergoing the classic procedure (4.5 vs. 3.9, P<0.001). The results of the study demonstrate that laparoscopic appendectomy can be achieved through a single umbilical incision and a single working channel using conventional instruments and that this approach is successful, safe, economic, and esthetic.

Water, water everywhere, but not a drop in sight: the impact of drug shortages on Canadian anesthesia care

A 38-yr-old mother of three presents for a laparoscopic appendectomy for acute appendicitis. She is a non-smoker and has a history of motion sickness. Her attending anesthesiologist advises her that she is at high risk for postoperative nausea and vomiting and that the most commonly used intravenous antiemetics are currently unavailable. The patient develops intractable vomiting in the postoperative care unit and requires three days of hospitalization as a result of a gastrointestinal hemorrhage secondary to a Mallory-Weiss type esophageal injury. Both the anesthesiologist and the patient are upset over the outcome of the anesthetic care. Although this is a fictitious case, in April of 2012, this type of scenario was very possible in institutions across Canada. In the survey of Canadian anesthesiologists reported by Hall et al. in this issue of the Journal, 53 (20.6%) of the 258 respondents during April 15 to June 4, 2012 noted a shortage of antiemetic agents. Shortages of anesthetic agents have been reported to cause life-threatening illness. During the 2010 propofol shortage in the United States, contamination of propofol single-use vials used inappropriately for multiple patients led to an outbreak of hepatitis C infection and the need for approximately 40,000 patients to be tested for potential infection. The global pharmaceutical market is valued in excess of US$880 billion dollars. Canadian pharmaceutical sales had an annual growth of 6.4% per year over the period 2006 to 2010, and Canada is the fourth fastest growing pharmaceutical market globally. In spite of this growth in the pharmaceutical industry, over this same period, drug shortages have become an increasingly serious and prevalent problem in Canada and internationally. Since 2009, the Canadian Anesthesiologists’ Society (CAS) has lobbied the federal government to work in cooperation with provincial and territorial governments and industry to a) develop a nationwide strategy to anticipate, identify, and manage shortages of essential medications; b) mandate that drug manufacturers report any planned disruption or discontinuation in production to Health Canada in a timely manner; and c) expedite the review process to ensure that safe and effective medications are made available to the Canadian public. This initiative was championed by CAS Past President, Dr. Richard Chisholm. In March 2012, Dr. Chisholm gave a presentation on drug shortages to the House of Commons Standing Committee on Health on behalf of the CAS. In June 2012, this committee tabled a report, Drug Supply in Canada: a Multi-Stakeholder Responsibility. The recommendations in this report are well aligned with those of the CAS, but as yet, the federal government has not moved

Trans-umbilical laparoscopic appendectomy for acute appendicitis without raising skin-flaps: An easy-to-use modification applied to the series of 164 patients from a rural institute of central India

Background:Laparoscopic appendectomy (LA) is widely used and generally an accepted method for managing appendicitis. And the recent invention of laparoscopic trans-umbilical-appendectomy is a further improvement of LA. However, it requires expensive instruments with the requisite expertise. We discuss a useful modification of trans-umbilical appendectomy for acute appendicitis using routine instruments.Materials and Methods:From August 2009 to March 2011, 164 patients were operated by this method at our rural center. Out of them, 102 were males and 62, females. Mean age for males was 27.5 years (range, 14-51) and females, 31.2 years (range, 17-48). Mean body mass index was 21.7 kg/m2 (range, 16.2-29) and 23.2 kg/m2 (range, 17.4-30) for males and females respectively. Acute appendicitis patients wherein surgery was deemed essential were offered this technique. Three umbilical ports (one 10 mm and two 5 mm) were strategically placed to dissect out appendix. Routine laparoscopic instruments were used for all.Results:Mean operativetime was 45 min (range, 30-90) with 1.8% conversion-rate to conventional laparoscopy. Average blood-loss was 15 ml (range, 10-25). We had one caecal electrosurgical injury, which was managed expectantly. Umbilical sepsis and seroma were 3% and 6.1% respectively. Patients were discharged after an average 1.3 days (range, 1-4). The scars had receded in the umbilicus giving a near-scarless abdomen.Discussion:Recently developed technique of single-port appendectomy has primarily been used for chronic appendicitis. Moreover, >1 inch incision inducted per-umbilicum rises the attendant morbidity. We study a surgeon-friendly simple technique applied to acute appendicitis.Conclusion:Method described here is feasible and safe for managing acute appendicitis. It can be learnt rather easily (learning curve of 15 cases) by a laparoscopic surgeon and avoids expensive instrumentation. Thus, it may stand out in providing benefits of modern surgery to population of developing countries.

Laparoscopic Appendectomy for Acute Appendicitis versus Chronic Appendicitis

ABSTRACTBackground: The advantage or disadvantage of laparoscopic appendectomy for acute appendicitis remains unclear. Patients and Methods: Data were collected prospectively from 129 consecutive patients with appendicitis between June 2008 and December 2009. The clinical outcomes of acute appendicitis after laparoscopic and open operation were compared. Furthermore, the outcomes of laparoscopic procedure for acute and chronic appendicitis were compared. Results: The length of hospitalization and incidence of intra-abdominal abscess were significantly decreased in patients with laparoscopic group after operation as compared to open operation. The mean operation time, the time of first anal exsufflation, and oral intake after operation were longer for acute appendicitis patients than for chronic appendicitis in laparoscopic group. The incidence of postoperative intestinal obstruction in patients with acute appendicitis was higher after laparoscopic surgery than after open procedure. Conclusions: Laparoscopic appendectomy for acute appendicitis is feasible and safe. However, laparoscopic appendectomy for acute appendicitis might cause more postoperative complications including intra-abdominal abscess and small intestinal obstruction compared to laparoscopic appendectomy for chronic appendicitis. These complications could potentially be avoided by improving techniques in operation.

The feasibility of short-stay laparoscopic appendectomy for acute appendicitis: a prospective cohort study

Short-stay laparoscopic appendectomy for acute appendicitis (AA) has not yet been validated. This study was designed to prospectively evaluate the hospital length of stay (LOS) after laparoscopic appendectomy for AA and to determine predictive factors for successful short-stay surgery (LOS <24 h). Between January and December 2010, all consecutive adults admitted for AA were prospectively treated with LOS <24 h as a patient management goal. The proportion of patients with LOS <24 h was analyzed for the intention-to-treat (ITT) population and for the population eligible for short-stay surgery. Predictive factors for LOS <24 h were analyzed. Of the 123 patients included in this study, 71.5 % (88/123) were eligible for short-stay surgery. The proportion of LOS <24 h cases was 52 % (64/123) in the ITT population and 72.7 % (64/88) in the eligible population. LOS <12 h was achieved in 17.8 % (22/123) in the ITT patients and 25 % (22/88) of the eligible patients. The main cause of unexpected readmission was postoperative pain (n = 10, 8.1 %). Age <23 years and a serum C-reactive protein level <18 mg/l had a positive predictive value of 100 % for LOS <24 h. Of the eligible patients, 27.2 % (24/88) were subject to unplanned overnight admissions and postsurgery readmissions. LOS <24 h was feasible for 52 % of patients admitted for AA and for 72.7 % of the patients eligible for short-term surgery. Low age and a low preoperative serum CRP level are predictive factors for the feasibility of short-stay laparoscopic appendectomy for AA.

Laparoscopic Appendectomy Outcomes on the Weekend and During the Week are no Different: A National Study of 151,774 Patients

The "weekend effect" is defined as increased morbidity and mortality for patients admitted on weekends compared with weekdays. It has been observed for several diseases, including myocardial infarction and renal insufficiency; however, it has not yet been investigated for laparoscopic appendectomy in acute appendicitis-one of the most prevalent surgical diagnoses. The present study is based on the Nationwide Inpatient Sample (NIS) from 1999 to 2008. The following outcomes were compared between patients undergoing laparoscopic appendectomy for acute appendicitis admitted on weekdays versus weekends: severity of appendicitis, intraoperative and postoperative complications, conversion rate, in-hospital mortality, and length of hospital stay. Unadjusted and risk-adjusted generalized linear regression analyses were performed. Overall, 151,774 patients were included, mean age was 39.6 years, 52.6% (n = 79,801) were male, and 25.3% (n = 38,317) were admitted on weekends. After risk adjustment, the conversion rate was lower [odds ratio (OR): 0.94, p = 0.004, number needed to harm (NNH): 244], whereas pulmonary complications (OR: 1.12, p = 0.028, NNH: 649) and reoperations (OR: 1.21, p = 0.013, NNH: 1,028) were slightly higher on weekends than on weekdays. Overall postoperative complications (OR: 1.03, p = 0.24), mortality (OR: 1.37, p = 0.075) and length of hospital stay (mean on weekday: 2.00 days, weekends: 2.01 days, p = 0.29) were not statistically different. The present investigation provides evidence that no clinically significant "weekend effect" for patients undergoing laparoscopic appendectomy exists. Therefore, hospital or staffing policy changes are not justified based on the findings from this large national study.

A prospective study of safety and satisfaction with same-day discharge after laparoscopic appendectomy for acute appendicitis

Background/PurposeThis study examines the safety and patient satisfaction in discharging children undergoing laparoscopic appendectomy (LapAppy) for acute appendicitis on the day of surgery. MethodsAfter institutional review board approval, data were collected prospectively for 158 consecutive patients undergoing LapAppy for simple appendicitis. Time from operation to discharge and complications were analyzed. At follow-up, parents completed a satisfaction survey. The Student t test was used for statistical analysis. ResultsLaparoscopic appendectomy was performed in 158 children ranging from age 2 to 19 years (mean, 12 years) over a 6-month period. Single-port, single-instrument LapAppy was possible in 152 patients (96%). Eighty percent of patients (n = 126) were discharged on the day of surgery, a mean of 4.8 hours postoperatively (range, 1-12 hours). Of the remaining 32, 24 (75%) were admitted because the operation ended too late for postoperative discharge; 3 (9%), for medical reasons; and 5 (16%), when the families declined to leave. One hundred nine parents (87%) whose children went home postoperatively stated that they were happy with the expeditious discharge, whereas 17 (13%) felt nervous. In addition, 116 parents (92%) stated that, in retrospect, same-day discharge was preferable, whereas 10 parents (8%) were not sure that it was the best decision. None, however, would insist on admission if faced with the situation again. There were no major complications and no significant difference in the rate of umbilical wound infections for same-day discharge patients (2%) and admitted patients (3%). ConclusionRoutine same-day discharge after pediatric LapAppy for acute appendicitis is safe, with good parent satisfaction.

Hematocele After Laparoscopic Appendectomy

Laparoscopic appendectomy is one of the most common laparoscopic surgeries performed. We report an unusual complication of hematocele after laparoscopic appendectomy. A 48-y-old male presented with swelling and discomfort in his right scrotum 11 d after he underwent laparoscopic appendectomy for acute appendicitis. Before the surgery, he had no scrotal swelling or inguinal hernia.

Single-Incision Laparoscopic Appendectomy

Single-Incision Laparoscopic Appendectomy

Late caecal fistula after laparoscopic appendectomy managed mini-invasively - case report.

Laparoscopic appendectomy is being performed increasingly, worldwide. The laparoscopic approach is associated with a lower complication rate and a shorter period of disability but some major complications still occur. We present a case of a 22-year-old woman who underwent laparoscopic appendectomy for acute appendicitis. In 3 weeks time after surgery, after physical activity the patient presented acute abdomen. Exploratory laparoscopy revealed peritonitis caused by caecal fistula. Laparoscopic lavage and drainage of the peritoneal cavity with formal caecostomy was performed. The postoperative course was uneventful. The stoma was closed in 6 months’ time without other complications. In our opinion laparoscopy is proven to be a safe and good option for diagnostics and treatment of some complications of appendectomy.

Gastrointestinal: A gastrointestinal stromal tumour (GIST) arising in a Meckel's diverticulum

A 39-year-old man who had 4 years previously undergone a laparoscopic appendicectomy for acute appendicitis was admitted with sudden onset severe lower abdominal pain. Initial examination revealed focal peritonism in the right iliac fossa, temperature of 39°C and tachycardia (96 bmp). White blood cell count was 16 × 109/l. Contrast enhanced abdominal CT was done 10 hrs after admission. The coronal reformatted image of the CT scan (Figure 1) demonstrated a segment of thickened ileum, inseparable from which was a blind ending loop of small bowel with a mixed attenuating mass within the lumen (arrow). There were no features of small bowel obstruction or free intraperitoneal fluid or air. A diagnosis of an inflamed Meckel's diverticulum or a small bowel tumour was suggested. At laparotomy, a large inflamed Meckel's Diverticulum was seen arising from the antemesenteric border of the ileum (Figure 2a). The diverticulum was resected along with a segment of ileum and a side-to-side ileo-ileal anastomosis was performed. Histological examination with haematoxylin and eosin stain (Figure 2b, magnification ×40) revealed a well-circumscribed lesion in the wall of the small bowel composed of fascicles of bland spindle cells with a central cystic area lined by inflamed small intestinal and pyloric epithelium. Immunohistochemistry confirmed an intermediate risk gastrointestinal stromal tumour (GIST) with positive staining with antibodies to CD34, CD117 and delay of gestation 1 (DOG1) antigen (Figure 2c, magnification ×10), and a Ki-67 proliferation index of 5%. A connection of the central cyst to the bowel lumen was not demonstrable, but in view of the appearance and position of the lesion the features were thought to be consistent with a GIST originating in a Meckel's diverticulum and occluding the neck of the diverticulum. Well differentiated endocrine carcinoma (carcinoid) is the most common tumour in this location and only 11 cases of GIST arising in a Meckel's diverticulum have been reported in the last decade. In the majority of histologically suspected GISTs a combination of CD117 and DOG1 immunostaining is sufficient to confirm the diagnosis. Modes of presentation including gastrointestinal bleeding, perforation, paraneoplastic deep vein thrombosis and incidental finding upon imaging or laparotomy. The patient made an uncomplicated recovery and as the GIST was completely excised and had a low proliferation index, no further therapy was necessary. He remains well two years postoperatively. Contributed by

Metal endoclips for the closure of the appendiceal stump in laparoscopic appendectomy

Closure of the appendiceal stump in laparoscopic appendectomy is the most crucial part of the procedure. In this retrospective clinical study, we describe a technique for laparoscopic appendectomy, in which the appendiceal stump is secured by metal endoclips. Medical data of the patients who underwent laparoscopic appendectomy for acute appendicitis between January 2005 and January 2011 at our institution were reviewed. The patients who had their appendiceal stump secured by metal endoclips were recruited for the study. The outcome measures were the rate of intraoperative and postoperative complications, operative time, and the length of hospital stay. A total of 233 patients were included to the study. The rate of intraoperative and postoperative complications, the mean operative time, and median length of hospital stay were 3 and 4%, 31.1 (15-75) min, and 18 (8-96) h, respectively. The closure of the appendiceal stump with metal endoclips in laparoscopic appendectomy is simple, quick, and safe with outcomes comparable to those of other methods.

Laparoscopic drainage of intraabdominal abscess after appendectomy: an alternative to laparotomy in cases not amenable to percutaneous drainage

Purpose Postoperative abscesses after appendectomy occur in 3% to 20% of cases and are more common in cases of perforated appendicitis. Smaller abscesses are often amenable to antibiotic therapy, but surgical drainage remains the mainstay of treatment for larger collections. Surgical options generally include percutaneous drainage and open laparotomy. Laparoscopic drainage of these abscesses has not been well characterized in the pediatric population. Objective The aim of this study was to describe our experience with laparoscopic drainage of postappendectomy abscesses that were not amenable to percutaneous drainage. Methods This study is a retrospective review of all pediatric patients who underwent laparoscopic appendectomy for acute appendicitis at a tertiary pediatric medical center during a 4-year period (2006-2009). The review focuses on patients who developed abscesses after appendectomy, were unable to undergo percutaneous drainage, and were treated with laparoscopic abscess drainage. Results Twelve patients (7 male and 5 female) underwent laparoscopic drainage of postappendectomy abscesses. The mean age was 8.5 years old (range, 3-14 years). A clinical diagnosis of postoperative abscess was made when fevers, pain, and leukocytosis persisted despite broad-spectrum antibiotics. Computed tomography was performed in all patients. Abscesses ranged between 3 and 11 cm in size. The mean length of time between initial appendectomy and drainage procedure was 10 days. There were no complications specifically related to the laparoscopic drainage procedure. The mean length of the drainage procedure was 77 minutes (range, 30-196 minutes). The mean hospital length of stay after laparoscopic drainage was 6.5 days (range, 3-13 days) with patients maintained on intravenous antibiotics until afebrile and without leukocytosis. Conclusion Laparoscopic drainage is a safe and effective alternative for intraabdominal abscesses that occur after laparoscopic appendectomy. We recommend it as an alternative to open laparotomy when percutaneous drainage is not an option.

Laparoscopic appendectomy for acute appendicitis is more favorable for patients with comorbidities, the elderly, and those with complicated appendicitis: a nationwide population-based study

Laparoscopic appendectomy (LA) is not routinely performed for appendicitis because the costs associated with that procedure are higher than those for open appendectomy (OA). However, few studies have investigated the economic influence of LA and OA on specific subpopulations including the elderly, patients with comorbidities, and patients with complicated appendicitis. This population-based study was designed to investigate determinants of costs and hospital length of stay (LOS) for patients undergoing appendectomy. Furthermore, the differences in costs and LOS were compared between LA and OA for various subpopulations. Inpatients who underwent LA or OA for appendicitis during the period 2001-2008 were identified from claims data obtained from Taiwan's National Health Insurance program. Costs and LOS were evaluated by multiple linear regression models for various subpopulations stratified according to age, number of comorbidities, and severity of appendicitis. Between 2001 and 2008, 22,252 patients (13.3%) underwent LA and 14,4438 (86.7%) had OA. Age, comorbidity, and severity of appendicitis were determinants of costs and LOS for both LA and OA. Although the costs and LOS for appendectomy increased with age and number of comorbidities, a sharper increase was noted for OA patients. Laparoscopic appendectomy mildly decreased LOS at the expense of significantly higher costs for young patients, those without comorbidities, and patients with uncomplicated appendicitis. In contrast, compared with OA, LA was associated with comparable costs and reduced LOS for the elderly, patients with comorbidities, and those with complicated appendicitis. In addition, hospital mortality and readmission rates for postoperative complications did not differ significantly between LA and OA. Considering costs and LOS, patients older than 65years, patients with comorbidities, and patients with complicated appendicitis benefit more from the laparoscopic approach for the treatment of appendicitis.

Improving Outcomes After Laparoscopic Appendectomy

Laparoscopic appendectomy for acute appendicitis has become increasingly used over the past decade. The objective of this trend analysis is to assess whether clinical outcomes after laparoscopic appendectomy have improved over the past 12 years. This analysis is based on the prospective database of the Swiss Association of Laparoscopic and Thoracoscopic Surgery. All patients undergoing emergency laparoscopic appendectomy for acute appendicitis from 1995 to 2006 were included. The following outcomes were assessed for each of the 12 years: conversion rates, intraoperative complications, surgical postoperative complications, general postoperative complications, rate of reoperations, and length of hospital stay. Unadjusted and risk-adjusted multivariable analyses were performed. Statistical significance was set at a level of P < 0.05. All statistical tests were 2-sided. Data from 7446 patients undergoing laparoscopic appendectomy for acute appendicitis were prospectively collected. Over the period of observation, the conversion rate decreased significantly from 2.2% to 1.2% (P(trend)< 0.001), as did intraoperative complications (from 3.1% to 0.7%; P(trend)< 0.001), surgical postoperative complications (from 6.1% to 1.9%; P(trend)< 0.001), general postoperative complications (from 4.9% to 1.5%; P(trend)< 0.001), and rates of reoperations (from 3.4% to 0.7%; P(trend)< 0.001). Average postoperative length of hospital stay also significantly decreased from 4.9 to 3.5 days (P(trend)< 0.001). Our investigation provides compelling evidence that intraoperative complications, surgical and general postoperative complications, conversion rates, rates of reoperations, and average length of hospital stay have significantly decreased over the past decade in patients undergoing surgery for acute appendicitis. The present trend analysis is the first one in the literature encompassing more than a decade and reporting clinical outcomes after laparoscopic appendectomy for acute appendicitis, which represents an important quality control.