Acute appendicitis: position paper, WSES, 2013
World Journal of Emergency Surgery
Acute appendicitis: position paper, WSES, 2013
Ferdinando Agresta 0
Luca Ansaloni 2
Fausto Catena 1
Luca Andrea Verza 0
Daniela Prando 0
0 Department of General Surgery, ULSS19 del Veneto , Piazzale Etruschi, 9, Adria 45011, RO , Italy
1 Department of Emergency Surgery, University of Parma , Parma , Italy
2 General Surgery I, Papa Giovanni XXIII Hospital , Bergamo , Italy
Appendectomy is one of the most frequently performed operative procedures in general surgery departments of every size and category. Laparoscopic Appendectomy - LA - as compared to Open Appendectomy - OA - was very controversial at first but has found increasing acceptance all over the World, although the percentage of its acceptance is different in the various single National setting. Various meta-analyses and Cochrane reviews have compared LA with OA and different technical details. Furthermore, new surgical methods have recently emerged, namely, the single-port/ incision laparoscopic appendectomy and NOTES technique. Their distribution among the hospitals, however, is unclear. Using laparoscopic mini-instruments with trocars of 2-3.5 mm diameter is proposed as a reliable alternative due to less postoperative pain and improved aesthetics. How to proceed in case of an inconspicuous appendix during a procedure planned as an appendectomy remains controversial despite existing study results. But the main question still is: operate or not operate an acute appendicitis, in the meaning of an attempt of a conservative antibiotic therapy. Therefore, we have done a literature survey on the performance of appendectomies and their technical details as well as the management of the intraoperative finding of an inconspicuous appendix in order to write down - under the light of the latest evidence - a position paper.
After Semm performed the first LA in 1980 , this
new technique was picked up at the beginning only
slowly, with an increase in its use mainly after the 2005.
Meanwhile, there are a number of meta-analyses,
prospective randomized trials, and Cochrane analyses
comparing LA, OA, and different details concerning the
operative procedure itself. However it remains unclear
how far and if the recommendations reported are being
adapted in clinical practice [2-5]. In a Sauerlands Cochrane
analysis  (LE 1), the rate of wound infections, the first
postoperative day pain, hospital stay, postoperative return
to solid food, first postoperative bowel movement,
surgery-related aesthetics, and return to normal activity
were significantly better after LA as compared to OA.
On the other side, the rates of intraabdominal abscesses,
procedural time, and the costs of LA and its overall
hospital-related costs were significantly higher, although
the costs after discharge from the hospital were
significantly lower for LA. The costs related to the surgical
procedure itself greatly depend on the surgeons choice
for type of trocar and the technique for control of the
mesoappendix and the appendix stump. In a paper by
Chu , these three factors alone affect costs to vary
between $81 and $873. Despite the partly marginal
advantages and a limited clinical relevance, Sauerland
et al. recommended the laparoscopic technique.
Especially young, female, obese, and working patients
seem to profit from this technique. A further Cochrane
review by Guitan  (LE 1) has confirmed the
recommendation of LA especially for fertile women due to a
higher diagnostic value when compared to OA and a
lower rate of resection of inconspicuous appendices,
although the rate of adverse events has not been
reduced. All the advantages of LA versus OA has also
been confirmed also by a recent meta-analysis of 25
studies including 2,220 LAs and 2,474 OA, especially
concerned less postoperative complications and pain,
an earlier return to food intake, a shorter hospital stay,
and an earlier return to work and normal activity.
Another interesting point reported in this analysis is
that hospital-related costs were not differ significantly
between the two procedures, although the LA surgical
time was significantly longer  (LE I).
The European Association for Endoscopic Surgery
recommends LA in their evidence-based guidelines for
the treatment of suspected acute appendicitis due to a
significantly lower rate of wound infections and quicker
postoperative recovery . The Society of American
Gastrointestinal and Endoscopic Surgeons, too,
recommends LA in different patient collectives . Two
further Italians guidelines [12,13] on the same topic
recommend the laparoscopic approach in both
uncomplicated as complicated appendicitis, but above all in
both these guidelines has been stressed the idea of
laparoscopy as a final diagnostic and formal therapeutic
act (LE I). It is also well pointed out the idea that, has
previously reported in the EAES guidelines , the
converted cases have similar outcome when compared
to primarily open cases (LE II). Besides fertile women,
groups at major risk of complications, such as elderly
and obese patients, would benefit most from a
laparoscopic approach [14-24] (LE III). It is interesting to
notice that about this two groups of patients - elderly
and obese have beer recently published two papers
were the National Surgical Quality Improvement Program
database has been used. In the one by Mason et al. ,
13330 obese patients (body mass index 30) who
underwent an appendectomy (78% LA, 22% OA) during the
period 20052009, have been identified and their
shortterm outcomes has been analysed, using the American
College of Surgeons National Surgical Quality
Improvement Program database. The Conclusions of the
Authors is that the analysis of the NSQIP database
showed that the LA is superior to the OA in obese
patients and that a considerably greater risk of
complications is associated with the open technique; most of
the morbidity is due to wound-related issues that
become more prevalent in the open approach with
increasing obesity. In addition, length of stay (LOS) and
operative times were considerably lower in patients
approached laparoscopically, potentially reducing
hospital costs. Nevertheless, despite the added benefits of
laparoscopy in patients with complicated appendicitis,
use of the laparoscope was low in this group of obese
patients. Moazzez et all , still using the American
College of Surgeons National Surgical Quality
Improvement Program (ACS/NSQIP) databases for years 2005
2009, has identified 3,674 patients (age over 65 years)
who underwent an appendectomy for appendicitis, of
whom 72% with LA. The Authors conclusions is that,
through aggregate and matched cohort analysis of
elderly patients who underwent an OA or LA for
appendicitis, this last one was associated with less minor and
overall morbidity and lower superficial Surgical Site
Infection and a shorter LOS.
Regarding appendiceal stump closure, a meta-analysis
compared staplers versus the endoloop technique for LA
. A significant advantage for stapler appendectomy
was found for wound infections and postoperative ileus
(LE I), but this meta-analysis has not confirmed the
significantly lowered rate of intraabdominal abscesses and
readmissions that were reported elsewhere in the
literature  (LE IV) One bias to take in consideration when
reading a large case series published on the subject is
that the use of stapler devices was mainly used for
extensive inflammation, i.e., in cases with a higher risk
of infection  (LE IV).
Two novel ways of the abdominal access route, the
single-port/incision laparoscopic appendectomy (SPILA)
technique and NOTES (natural orifice transluminal
surgery), have emerged in recent years. The German Society
for General and Visceral Surgery (DGAV) started the
national NOTES registry for NOTES procedures (including
appendectomies) in February 2008 . The SPILA is
supposed to avoid visible scars by introducing all
instruments through a single port at the umbilicus. Although
the results reported in the Literature seem to be positive
(the incidence of complications with SPILA remains low
and operating times between new and traditional
approaches are comparable), articles retrieved varied in
quality, generally representing low-level evidence, at high risk
of intrinsic bias. The literature fails also to formally
document cosmetic results using questionnaires or visual
assessment scales, thus preventing assessment of this
outcomes. Adequately randomized trials are required to
assess the real effectiveness of the SPILA  (LE I).
The same difficulties occur with the NA: This
approach nowadays is admitted only in strictly controlled
and experimental protocols .
Needlescopy might be applied only in selected and not
complicated cases due to its higher rate of conversions
and prolonged OT time  (LE I).
Another very important point is the management of
the intraoperative finding of an inconspicuous appendix
during an operation for suspected appendicitis. In the
absence of an intraabdominal pathological finding explaining
the symptoms, the appendectomy en principe is
recommended due to the high rate of histologically found
appendicitis - so called endoappendicites - despite a
macroscopically normal appearance in up to 26% of
cases  (LE V). Considering also that morbidity of
appendectomy does not significantly exceed that of the
explorative laparoscopy .
Operate or not operate an acute appendicitis? Thats the
(main) question, someone could say. Although there are
some evidence in literature of the role of an attempt with
a conservative antibiotic therapy in case of a suspicious of
an acute appendicitis (when perforation and peritonitis is
not suspected) in selected patients, the problem is how to
select them. Although Antibiotic therapy is associated
with up to 70% success rate and a trend toward decreased
risk of complications without prolonging hospital stay,
however, no conclusion is possible to write down
according to the available literature due to its low methodological
quality  (LE II). While waiting for the results of some
prospective trial on this topic, actually there are no doubts
to agree with what Ansaloni and coll. have written in their
paper Conservative antibiotic therapy for AA should
continue to be considered within the limitations imposed
by its inherent advantages and disadvantages; surgery
remains the gold standard for treating AA despite the
clinical challenges involved.  (LE III).
In a frame time of economic problems all around the
world, it is a must to take a position according the cost
of LA. It is hard to state anything that could apply
everywhere, first because obviously the direct cost (operating
room occupancy longer?; instruments etc.) of a LA is
more than that of an OA and second because LA can be
performed using a myriad of techniques, the cost of each
method varies (range from US $81 to US $873).
Concerning the first point (LA versus OA), although it could
sound philosophy, the indirect cost of the LA (less pain,
less morbidity, less length of hospital stay, faster return
to daily activity and so on) are surely less of the OA
ones. About the second we do agree with Chu and coll:
surgeons should review the cost implications of their
practice and to find ways to provide the most costeffective
care without jeopardizing clinical outcome .
FA drafted the manuscript. FA, LA, FC, LAV, DP reviewed the draft and made
corrections and revisions. All authors read and approved the final manuscript.
1. Semm K : Endoscopic appendectomy . Endoscopy 1983 , 15 ( 2 ): 59 - 64 .
2. Bulian DR , Knuth J , Sauerwald A , Strhlein MA , Lefering R , Ansorg J , Heiss MM : Appendectomy in Germany-an analysis of a nationwide survey 2011/2012 . Int J Colorectal Dis 2013 , 28 ( 1 ): 127 - 138 .
3. Saia M , Buja A , Baldovin T , Callegaro G , Sandon P , Mantoan D , Baldo V : Trend, variability, and outcome of open vs. laparoscopic appendectomy based on a large administrative database . Surg Endosc 2012 , 26 ( 8 ): 2353 - 2359 .
4. Ingraham AM , Cohen ME , Bilimoria KY , Pritts TA , Ko CY , Esposito TJ : Comparison of outcomes after laparoscopic versus open appendectomy for acute appendicitis at 222 ACS NSQIP hospitals . Surgery 2010 , 148 ( 4 ): 625 - 635 .
5. Brugger L , Rosella L , Candinas D , Guller U : Improving outcomes after laparoscopic appendectomy: a population-based, 12-year trend analysis of 7446 patients . Ann Surg 2011 , 253 ( 2 ): 309 - 313 .
6. Sauerland S , Jaschinski T , Neugebauer EA : Laparoscopic versus open surgery for suspected appendicitis . Cochrane Database Syst Rev 2010 , 10 : CD001546 .
7. Chu T , Chandhoke RA , Smith PC , Schwaitzberg SD : The impact of surgeon choice on the cost of performing laparoscopic appendectomy . Surg Endosc 2011 , 25 ( 4 ): 1187 - 1191 .
8. Gaitan HG , Reveiz L , Farquhar C : Laparoscopy for the management of acute lower abdominal pain in women of childbearing age . Cochrane Database Syst Rev 2011 , 1 : CD007683 .
9. Wei B , Qi CL , Chen TF , Zheng ZH , Huang JL , Hu BG , Wei HB : Laparoscopic versus open appendectomy for acute appendicitis: a metaanalysis . Surg Endosc 2011 , 25 ( 4 ): 1199 - 1208 .
10. Sauerland S , Agresta F , Bergamaschi R , Borzellino G , Budzynski A , Champault G , Fingerhut A , Isla A , Johansson M , Lundorff P , Navez B , Saad S , Neugebauer EA : Laparoscopy for abdominal emergencies: evidencebased guidelines of the European Association for Endoscopic Surgery . Surg Endosc 2006 , 20 ( 1 ): 14 - 29 .
11. Korndorffer JR Jr, Fellinger E , Reed W: ( 2010 ) SAGES guideline for laparoscopic appendectomy . Surg Endosc 2010 , 24 ( 4 ): 757 - 761 .
12. Agresta F , Ansaloni L , Baiocchi GL , Bergamini C , Campanile FC , Carlucci M , Cocorullo G , Corradi A , Franzato B , Lupo M , Mandal V , Mirabella A , Pernazza G , Piccoli M , Staudacher C , Vettoretto N , Zago M , Lettieri E , Levati A , Pietrini D , Scaglione M , De Masi S , De Placido G , Francucci M , Rasi M , Fingerhut A , Urans S , Garattini S : Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Societ Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Societ Italiana di Chirurgia (SIC), Societ Italiana di Chirurgia d'Urgenza e del Trauma (SICUT), Societ Italiana di Chirurgia nell'Ospedalit Privata (SICOP), and the European Association for Endoscopic Surgery (EAES) . Surg Endosc 2012 , 26 ( 8 ): 2134 - 2164 .
13. Vettoretto N , Gobbi S , Corradi A , Belli F , Piccolo D , Pernazza G , Mannino L , Italian Association of Hospital Surgeons (Associazione dei Chirurghi Ospedalieri Italiani): Consensus conference on laparoscopic appendectomy: development of guidelines . Colorectal Dis 2011 , 13 ( 7 ): 748 - 754 .
14. Harrell AG , Lincourt AE , Novitsky YW , Rosen MJ , Kuwada TS , Kercher KW , Sing RF , Heniford BT : Advantages of laparoscopic appendectomy in the elderly . Am Surg 2006 , 72 ( 6 ): 474 - 480 .
15. Kim MJ , Fleming FJ , Gunzler DD , Messing S , Salloum RM , Monson JR : Laparoscopic appendectomy is safe and efficacious for the elderly: an analysis using the National Surgical Quality Improvement Project database . Surg Endosc 2011 , 25 ( 6 ): 1802 - 1807 .
16. Kirshtein B , Perry ZH , Mizrahi S , Lantsberg L : Value of laparoscopic appendectomy in the elderly patient . World J Surg 2009 , 33 ( 5 ): 918 - 922 .
17. Wang YC , Yang HR , Chung PK , Jeng LB , Chen RJ : Laparoscopic appendectomy in the elderly . Surg Endosc 2006 , 20 ( 6 ): 887 - 889 .
18. Baek HN , Jung YH , Hwang YH : Laparoscopic versus open appendectomy for appendicitis in elderly patients . J Korean Soc Coloproctol 2011 , 27 ( 5 ): 241 - 245 .
19. Wu SC , Wang YC , Fu CY , Chen RJ , Huang HC , Huang JC , Lu CW , Hsieh CH , Lin CY : Laparoscopic appendectomy provides better outcomes than open appendectomy in elderly patients . Am Surg 2011 , 77 ( 4 ): 466 - 470 .
20. Towfigh S , Chen F , Katkhouda N , Kelso R , Sohn H , Berne TV , Mason RJ : Obesity should not influence the management of appendicitis . Surg Endosc 2008 , 22 : 2601 - 2605 .
21. Corneille MG , Steigelman MB , Myers JG , Jundt J , Dent DL , Lopez PP , Cohn SM , Stewart RM : Laparoscopic appendectomy is superior to open appendectomy in obese patients . Am J Surg 2007 , 194 : 877 - 880 .
22. Masoomi H , Nguyen NT , Dolich MO , Wikholm L , Naderi N , Mills S , Stamos MJ : Comparison of laparoscopic versus open appendectomy for acute nonperforated and perforated appendicitis in the obese population . Am J Surg 2011 , 202 : 733 - 738 .
23. Varela JE , Hinojosa MW , Nguyen NT : Laparoscopy should be the approach of choice for acute appendicitis in the morbidlyobese . Am J Surg 2008 , 196 : 218 - 222 .
24. Clarke T , Katkhouda N , Mason RJ , Cheng BC , Olasky J , Sohn HJ , Moazzez A , Algra J , Chaghouri E , Berne TV : Laparoscopic versus open appendectomy for the obese patient: a subset analysis from a prospective, randomized, double-blind study . Surg Endosc 2011 , 25 : 1276 - 1280 .
25. Mason RJ , Moazzez A , Moroney JR , Katkhouda N : Laparoscopic vs open appendectomy in obese patients: outcomes using the American College of Surgeons National Surgical Quality Improvement Program database . J Am Coll Surg 2012 , 215 ( 1 ): 88 - 99 .
26. Moazzez A , Mason RJ , Katkhouda N : Thirty-day outcomes of laparoscopic versus open appendectomy in elderly using ACS/NSQIP database . Surg Endosc 2013 , 27 ( 4 ): 1061 - 1071 .
27. Kazemier G , In't Hof KH, Saad S , Bonjer HJ , Sauerland S : ( 2006 ) Securing the appendiceal stump in laparoscopic appendectomy: evidence for routine stapling? Surg Endosc 2006 , 20 ( 9 ): 1473 - 1476 .
28. Sahm M , Kube R , Schmidt S , Ritter C , Pross M , Lippert H: ( 2011 ) Current analysis of endoloops in appendiceal stump closure . Surg Endosc 2011 , 25 ( 1 ): 124 - 129 .
29. Lehmann KS , Ritz JP , Wibmer A , Gellert K , Zornig C , Burghardt J , Busing M , Runkel N , Kohlhaw K , Albrecht R , Kirchner TG , Arlt G , Mall JW , Butters M , Bulian DR , Bretschneider J , Holmer C , Buhr HJ : The German registry for natural orifice translumenal endoscopic surgery: report of the first 551 patients . Ann Surg 2010 , 252 ( 2 ): 263 - 270 .
30. Rehman H , Mathews T , Ahmed I : A review of minimally invasive singleport/incision laparoscopic appendectomy . J Laparoendosc Adv Surg Tech A 2012 , 22 ( 7 ): 641 - 646 .
31. Sajid MS , Khan MA , Cheek E , Baig MK : Needlescopic versus laparoscopic appendectomy: a systematic review . Can J Surg 2009 , 52 : 129 - 134 .
32. Phillips AW , Jones AE , Sargen K : Should the macroscopically normal appendix be removed during laparoscopy for acute right iliac fossa pain when no other explanatory pathology is found? Surg Laparosc Endosc Percutan Tech 2009 , 19 ( 5 ): 392 - 394 .
33. Varadhan KK , Neal KR , Lobo DN : Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials . BMJ 2012 , 5 : 344 .
34. Ansaloni L , Catena F , Coccolini F , Ercolani G , Gazzotti F , Pasqualini E , Pinna AD : Surgery versus conservative antibiotic treatment in acute appendicitis: a systematic review and meta-analysis of randomized controlled trials . Dig Surg 2011 , 28 ( 3 ): 210 - 221 .