Laparoscopic versus open surgery for suspected appendicitis.
BACKGROUND
Laparoscopic surgery has been proposed to have diagnostic and therapeutic advantages over conventional surgery.


OBJECTIVE
To compare the diagnostic and therapeutic effects of laparoscopic and conventional 'open' surgery in the treatment of suspected acute appendicitis.


METHODS
We searched for original articles and abstracts published until end of 2000. As main search tools we employed the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE and SciSearch. CCTR and MEDLINE searches were repeated until 10 October 2001, all other databases were searched 10 October 2000. We also handsearched the congress proceedings of endoscopic surgical societies.


METHODS
We included clinical trials that assessed either: (1) Therapeutic effects of laparoscopic appendectomy (LA) versus open appendectomy (OA) in adults, (2) Therapeutic effects of LA versus OA in children, (3) Diagnostic effects of diagnostic laparoscopy (LAP) followed by LA or OA if necessary versus immediate OA, (4) Therapeutic effects of diagnostic laparoscopy (LAP) followed by OA if necessary versus immediate OA. We included only randomized studies and excluded those with unconcealed allocation.


METHODS
Two reviewers independently assessed each study's eligibility and quality. One reviewer extracted the data, 10% of which were later cross-checked by a second reviewer. Abstract authors and authors of articles lacking important information on trial design or results were contacted.


RESULTS
We included 45 studies, of which 39 compared LA (with or without diagnostic laparoscopy) vs. OA in adults. Wound infections were about half as likely (Peto OR 0.47; 95%-CI 0.36 to 0.62) after LA than after OA, but intraabdominal abscesses were increased nearly threefold after LA (Peto OR 2.77; 95%-CI 1.61 to 4.77). The duration of surgery was 14 minutes (95%-CI 10 to 19) longer for LA. Pain on day 1 after surgery was reduced after LA by 8 mm (95%-CI 3 to 13 mm) on a 100 mm VAS. Hospital stay was reduced by 0.7 days (95%-CI 0.4 to 1.0). Return to normal activity, work, and sport were 6 days (95%-CI 4 to 8), 3 days (1 to 5), and 7 days (3 to 12) earlier after LA than after OA. While the operation costs of LA were significantly higher than that of OA, the costs outside hospital were reduced. Strong heterogeneity was found for most outcomes, but not for wound infections and intraabdominal abscesses. In children, much less data were available, but the result do not seem to be much different when compared to adults. Pain which was measured blindly in two paediatric trials, was similar after LA and OA (-1 mm VAS; 95%-CI -8 to +7 mm). In trials on unselected patients, diagnostic laparoscopy led to large but variable reductions in the rate of negative appendectomies (RR 0.21; 95%-CI 0.13 to 0.33). In parallel, the rate of unestablished diagnoses was significantly decreased after laparoscopy (RR 0.34; 95%-CI 0.22 to 0.53). In fertile women, these effects were even more pronounced: rate of negative appendectomies: RR 0.19; 95%-CI 0.11 to 0.34; rate of patients without a final diagnosis established: RR 0.24; 95%-CI 0.15 to 0.38.


CONCLUSIONS
In those clinical settings where surgical expertise and equipment are available and affordable, diagnostic laparoscopy and LA (either in combination or separately) seem to have various advantages over OA. Some of the clinical effects of LA, however, are small and of limited clinical relevance. In spite of the mediocre quality of the available research data, we would generally recommend to use laparoscopy and LA in patients with suspected appendicitis unless laparoscopy itself is contraindicated or not feasible. In gangrenous or perforated cases, however, LA may possibly carry a higher risk of intraabdominal infections.
Sauerland
S
S
Biochem. & Exptl. Dept., 2nd Dept. of Surgery, University of Cologne, Osterheimer Strasse 200, Cologne, Germany, D 51109. s.sauerland@uni-koeln.de
Lefering
R
R
Neugebauer
E A
EA
D000208:Acute Disease; D001064:Appendicitis / Q000175:diagnosis* / Q000601:surgery; D006801:Humans; D010535:Laparoscopy; D016032:Randomized Controlled Trials as Topic