title: Are There Specific Indications for Laparoscopic Appendectomy? A Review and Critical Appraisal of the Literature.
abstract: BACKGROUND
  Laparoscopic appendectomy (LA) has proven to be a feasible alternative to open appendectomy (OA). However, as some of the purported advantages of LA (versus OA) are marginal, evidence is accumulating that appendectomy may not be necessary for uncomplicated appendicitis and there is concern about using laparoscopy for all patients with suspected acute appendicitis. In spite of widespread popularity and use, the literature reporting the indications is sparse and sometimes misleading (i.e., containing distorted deductions or conclusions, also called "spin"). This study aimed to determine subsets of patients for whom LA may present real advantages over OA and to analyze the validity of specific indications for LA (instead of OA).
  
  
  METHODS
  A systematic review and critical analysis of the literature were conducted.
  
  
  RESULTS
  We analyzed 90 retrospective reviews, prospective studies, meta-analyses, and cohort and prospective randomized studies, presenting a total of approximately 390,000 patients, concerning potentially specific advantages of LA in the elderly, the obese, during pregnancy, and complicated appendicitis, including diffuse peritonitis and ectopic appendices. Overall, LA was associated with (1) lower overall complication rates (and notably less decompensated comorbidities), mortality, and costs, as well as shorter duration of hospital stay, in the elderly, (2) decreased morbidity (notably parietal) in the obese, and (3) potential (diagnostic) advantages in pregnancy (even though LA is associated with a higher rate of fetal loss than in OA). In complicated or ectopic appendicitis, LA is feasible and safe and, if performed without conversion, should lead to less short- and long-term parietal morbidity. However, published data are very heterogeneous, there are few sound controlled trials, and conclusions found in the literature are often based on misleading deductions or a very low level of evidence.
  
  
  CONCLUSIONS
  LA is a safe and effective method to treat acute appendicitis in specific settings such as the elderly and the obese, as well as in ectopic appendices, with potentially specific parietal advantages in these subsets of patients. Further randomized studies and robust meta-analyses are necessary before recommending LA for complicated appendicitis and peritonitis, as well as in pregnancy.
authors.affiliation: 1 University of Medicine and Pharmacy "Carol Davila" Bucharest, University Emergency Hospital , Bucharest, Romania .
authors.forename: Dorin
authors.initials: D
authors.lastname: Popa
authors.affiliation: 2 I. Chirurgicka Klinika, University of Pavol Jozef Safarik , Kosice, Slovak Republic.
authors.forename: Marek
authors.initials: M
authors.lastname: Soltes
authors.affiliation: 3 Section of Surgical Research, Department of Surgery, Medical University of Graz , Graz, Austria .
authors.forename: Selman
authors.initials: S
authors.lastname: Uranues
authors.affiliation: 3 Section of Surgical Research, Department of Surgery, Medical University of Graz , Graz, Austria .|4 First Department of Surgery, University of Athens, Hippokration University Hospital , Athens, Greece .
authors.forename: Abe
authors.initials: A
authors.lastname: Fingerhut
mesh_terms: D000208:Acute Disease; D001062:Appendectomy / Q000379:methods*; D001064:Appendicitis / Q000453:epidemiology / Q000601:surgery*; D015897:Comorbidity; D003657:Decision Making; D014943:Global Health; D006801:Humans; D015994:Incidence; D010535:Laparoscopy / Q000379:methods*; D009765:Obesity / Q000453:epidemiology; D011183:Postoperative Complications / Q000453:epidemiology; D012307:Risk Factors