[Laparoscopic versus open appendectomy: which factors influence the decision between the surgical techniques?].
BACKGROUND
Although in hospitals focussing on minimal invasive surgery laparoscopic appendectomy (LA) is widely practiced as method of choice in patients with acute appendicitis, the decision for the laparoscopic or the conventional technique (OA) is usually ensued by individual viewpoints. Aim of this prospective observation study was to analyse the decision algorithm for both procedures in patients with the presumptive diagnosis "appendicitis".


METHODS
Between January 1996 and July 2001 512 patients with the presumptive diagnosis "acute appendicitis" underwent surgery and, assigned by intention-to-treat, were subdivided in a laparoscopic (I) and a conventional group (II). The choice of surgical procedure was analysed with regard to patient characteristics (age, gender, comorbidity), severity of appendicitis (clinical manifestation, preoperative inflammation signs), surgeon (clinical experience) and daytime (during the day, in the evening, at night). Furthermore, the outcome of either method was related to postoperative diagnosis, perioperative morbidity, analgesia, length of hospital stay and cosmetic results.


RESULTS
In group I 265 patients and in group II 247 patients underwent surgery. Conversion from LA to OA was necessary in 6.4 %. Group I consisted of significantly more female (67.9 % vs. 45.7 %) and younger patients (21 yrs. vs. 30 yrs.) with less medical history as well as minor severity of tissue inflammation and significantly lower preoperative serum inflammation parameters (leukocytes (1000/ml): 10.6 +/- 4.3 vs. 13.5 +/- 4.9; CRP (mg/l): 2.3 +/- 3.3 vs. 5.6 +/- 7.5, I vs. II: p < 0.001). In group I more patients underwent surgery during day-time as well as by more laparoscopic-experienced surgeons. In the postoperative histopathologic evaluation there were significantly fewer cases with complicated appendicitis (33.2 % vs. 52.2 %, p < 0.001). Additionally, patients after LA revealed a lower postoperative complication rate (9.3 % vs. 18.3 %), length of hospital stay (median 3 vs. 4 days) and duration of analgesia (2.1 +/- 1.8 vs. 4.1 +/- 7.1 days).


CONCLUSIONS
Important factors for decision algorithm between a laparoscopic or an open appendectomy include severity of appendicitis, gender, day-time as well as the surgeon's individual laparoscopic experience. With appropriate indication for each technique, both procedures are of equal value in the treatment of acute appendicitis. Furthermore the positive patient selection for laparoscopic appendectomy contributed to a better postoperative outcome in this study.
Horstmann
R
R
Abteilung für Allgemein- und Viszeralchirurgie, Herz-Jesu-Krankenhaus Münster. horstmann@herz-jesu-kh-ms.de
Tiwisina
C
C
Classen
C
C
Palmes
D
D
Gillessen
A
A
D000208:Acute Disease; D000328:Adult; D000465:Algorithms; D001062:Appendectomy / Q000379:methods*; D001064:Appendicitis / Q000473:pathology / Q000601:surgery*; D001065:Appendix / Q000473:pathology; D002097:C-Reactive Protein / Q000378:metabolism; D002940:Circadian Rhythm; D003661:Decision Support Techniques; D005260:Female; D005500:Follow-Up Studies; D005858:Germany; D006801:Humans; D010535:Laparoscopy; D007902:Length of Stay; D007958:Leukocyte Count; D008297:Male; D010043:Outcome and Process Assessment, Health Care; D017060:Patient Satisfaction; D011183:Postoperative Complications / Q000175:diagnosis / Q000473:pathology
D002097:C-Reactive Protein