title: Laparoscopy may be lowering the threshold to operate on patients with suspected appendicitis.
abstract: BACKGROUND
  Although several randomized trials have compared postoperative outcomes in patients undergoing open and laparoscopic appendectomy, few have examined whether laparoscopy has affected preoperative decision making. We hypothesized that surgeon enthusiasm for laparoscopic appendectomy would lower the threshold to operate on patients with possible appendicitis. To examine this question we designed a retrospective cohort study in the setting of a tertiary care medical center.
  
  
  METHODS
  We studied a consecutive series of 130 patients taken to the operating room with preoperative diagnoses of appendicitis between 1 January 1997 and 31 December 1999. We excluded pregnant patients, those under 18 or over 75, those admitted electively for chronic symptoms, and those undergoing appendectomy incidental to another procedure. Measures included the proportion of patients with normal appendices or acute appendicitis (perforated and nonperforated), as determined from the pathology report. Other clinical and demographic data were obtained by review of the medical records.
  
  
  RESULTS
  During the study period, 87 patients (67%) underwent open appendectomy and 43 patients (33%) underwent laparoscopic appendectomy. Women were more likely to receive the laparoscopic approach than men (43% vs 24% p = 0.021). Preoperative use of advanced imaging tests (computed tomography or ultrasound) was more prevalent in the laparoscopic group (40% vs 30%, p = 0.271). Patients undergoing the laparoscopic procedure were considerably less likely to have acute appendicitis than those undergoing an open one (67% vs 92%, p <0.001). However, among patients with confirmed appendicitis, those undergoing laparoscopic surgery were less likely to be perforated than those who had an open procedure (4.6% vs 25% p = 0.004).
  
  
  CONCLUSIONS
  At our hospital, the availability of the laparoscopic approach to appendectomy may have lowered the threshold to operate on patients with possible appendicitis, as reflected in higher negative exploration rates and lower rates of perforated appendicitis.
authors.affiliation: Institute at Dartmouth for Endoscopy and Advanced Laparoscopy, Department of Surgery, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA. james.m.mcgreevy@hitchcock.org
authors.forename: J M
authors.initials: JM
authors.lastname: McGreevy
authors.forename: S R G
authors.initials: SR
authors.lastname: Finlayson
authors.forename: R
authors.initials: R
authors.lastname: Alvarado
authors.forename: W S
authors.initials: WS
authors.lastname: Laycock
authors.forename: C M
authors.initials: CM
authors.lastname: Birkmeyer
authors.forename: J D
authors.initials: JD
authors.lastname: Birkmeyer
mesh_terms: D000208:Acute Disease; D000328:Adult; D001062:Appendectomy / Q000379:methods / Q000706:statistics & numerical data; D001064:Appendicitis / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000601:surgery*; D015331:Cohort Studies; D019992:Databases as Topic; D003657:Decision Making; D005260:Female; D006780:Hospitals, Rural; D006801:Humans; D007416:Intestinal Perforation / Q000209:etiology; D007431:Intraoperative Complications / Q000209:etiology; D010535:Laparoscopy / Q000379:methods* / Q000706:statistics & numerical data; D008297:Male; D011300:Preoperative Care / Q000379:methods / Q000706:statistics & numerical data; D011877:Radionuclide Imaging; D012189:Retrospective Studies; D012737:Sex Factors; D014057:Tomography, X-Ray Computed / Q000379:methods / Q000706:statistics & numerical data; D014463:Ultrasonography