Laparoscopic versus open appendectomy: a retrospective cohort study assessing outcomes and cost-effectiveness
Biondi et al. World Journal of Emergency Surgery
Laparoscopic versus open appendectomy: a retrospective cohort study assessing outcomes and cost-effectiveness
Antonio Biondi 0 1
Carla Di Stefano 1 3
Francesco Ferrara 1 3
Angelo Bellia 1 3
Marco Vacante 1 2
Luigi Piazza 1 3
0 Department of Surgery, Vittorio Emanuele Hospital, University of Catania , Via Plebiscito, 628, 95124 Catania , Italy
1 CT, Computed tomography; DM, Diabetes mellitus; LA , Laparoscopic appendectomy; OA, Open appendectomy; POD, Postoperative day; WBC, White blood cell
2 Department of Medical and Pediatric Sciences, University of Catania , 95125 Catania , Italy
3 General and Emergency Surgery Department, Garibaldi Hospital , 95100 Catania , Italy
Background: Appendectomy is the most common surgical procedure performed in emergency surgery. Because of lack of consensus about the most appropriate technique, appendectomy is still being performed by both open (OA) and laparoscopic (LA) methods. In this retrospective analysis, we aimed to compare the laparoscopic approach and the conventional technique in the treatment of acute appendicitis. Methods: Retrospectively collected data from 593 consecutive patients with acute appendicitis were studied. These comprised 310 patients who underwent conventional appendectomy and 283 patients treated laparoscopically. The two groups were compared for operative time, length of hospital stay, postoperative pain, complication rate, return to normal activity and cost. Results: Laparoscopic appendectomy was associated with a shorter hospital stay (2.7 ± 2.5 days in LA and 1.4 ± 0.6 days in OA), with a less need for analgesia and with a faster return to daily activities (11.5 ± 3.1 days in LA and 16.1 ± 3.3 in OA). Operative time was significantly shorter in the open group (31.36 ± 11.13 min in OA and 54.9 ± 14.2 in LA). Total number of complications was less in the LA group with a significantly lower incidence of wound infection (1.4 % vs 10.6 %, P <0.001). The total cost of treatment was higher by 150 € in the laparoscopic group. Conclusion: The laparoscopic approach is a safe and efficient operative procedure in appendectomy and it provides clinically beneficial advantages over open method (including shorter hospital stay, decreased need for postoperative analgesia, early food tolerance, earlier return to work, lower rate of wound infection) against only marginally higher hospital costs. Trial registration: NCT02867072 Registered 10 August 2016. Retrospectively registered.
Open appendectomy; Laparoscopic appendectomy; Hospital cost; Appendicitis
Appendicitis is the most common cause of surgical
abdomen in all age groups [
]. Approximately 7–10 % of
the general population develops acute appendicitis with
the maximal incidence being in the second and third
decades of life . Open appendectomy has been the gold
standard for treating patients with acute appendicitis for
more than a century, but the efficiency and superiority
of laparoscopic approach compared to the open
technique is the subject of much debate nowadays [
There is evidence that minimal surgical trauma through
laparoscopic approach resulted in significant shorter
hospital stay, less postoperative pain, faster return to
daily activities in several settings related with
gastrointestinal surgery [
]. However, several retrospective
], several randomized trials [
] comparing laparoscopic with
open appendectomy have provided conflicting results.
Some of these studies have demonstrated better clinical
outcomes with the laparoscopic approach [
15–17, 20, 23
while other studies have shown marginal or no
clinical benefits [
18, 19, 24–26
] and higher surgical costs
4, 19, 24, 25
]. Bearing in mind that laparoscopic
appendectomy, unlike other laparoscopic procedures ,
has not been found superior to open surgery for acute
appendicitis, we designed the present study to determine
any possible benefits of the laparoscopic approach. The
aim of this study was to compare the clinical outcomes
(hospital stay, operating time, postoperative
complications, analgesia requirement, time to oral intake and to
resume normal activity) and the hospital costs between
open appendectomy and laparoscopic appendectomy.
A retrospective observational study of patients admitted
to a single institution (Department of Emergency Surgery,
Garibaldi Hospital-Catania) between January 2004 and
July 2011 with the diagnosis of appendicitis was
conducted. Pregnant women and patients with severe medical
disease (hemodynamic instability, chronic medical or
psychiatric illness, cirrhosis, coagulation disorders) requiring
intensive care were excluded. The decision about the type
of the operation was made according to the preference
and experience of the surgical team on duty. We analyzed
593 patient that met the inclusion criteria and their
clinical data and hospital costs. The patients were divided into
two groups: open appendectomy (OA) group and
laparoscopic appendectomy (LA) group. The collected clinical
data included demographic data, co-morbidities, initial
laboratory findings, operation time, intraoperative findings
(acute, gangrenous or perforated appendix), time to soft
diet, postoperative hospital stay, amount of analgesics and
postoperative complications. We analyzed data on cost
separately. The diagnosis was made clinically with history
(right iliac fossa or periumbilical pain, nausea/vomiting),
physical examination (tenderness or guarding in right iliac
fossa). In patients where a clinical diagnosis could not be
established, imaging studies such as abdominal ultrasound
or CT were performed. Both groups of patients were given
a prophylactic dose of third-generation cephalosporin and
metronidazole at induction of the general anesthesia as
part of the protocol. OA was performed through standard
McBurney incision. After the incision, peritoneum was
accessed and opened to deliver the appendix, which was
removed in the usual manner. A standard 3-port
technique was used for laparoscopic group.
Pneumoperitoneum was produced by a continuous pressure of
12–14 mmHg of carbon dioxide via a Verres canula,
positioned in infraumbilical site. The patient was placed in a
Trendelenburg position, with a slight rotation to the left.
The abdominal cavity was inspected in order to exclude
other intrabdominal or pelvic pathology. After the
mesoappendix was divided with bipolar forceps, the base
of the appendix was secured with two legating loops,
followed by dissection distal to the second loop. Then, the
distal appendicular stump was closed to avoid the risk of
enteric or purulent spillage. The specimen was placed in
an endobag and was retrieved through a 10-mm
infraumbilical port. All specimens were sent for histopathology.
The patients were not given oral feed until they were fully
recovered from anesthesia and had their bowel sounds
returned when clear fluids were started. Soft diet was
introduced when the patients tolerated the liquid diet and
had passed flatus. Patients were discharged once they were
able to take regular diet, afebrile, and had good pain
control. The operative time (minutes) for both the procedures
was counted from the skin incision to the last skin stitch
applied. The length of hospital stay was determined as the
number of nights spent at the hospital postoperatively.
Wound infection was defined as redness or purulent or
seropurulent discharge from the incision site. Seroma was
defined as localized swelling without redness with ooze of
clear fluid. Paralytic ileus was defined as failure of bowel
sounds to return within 12 h postoperatively. The study
protocol was received and approved by the Institutional
Review Board and the Ethics Committee of Garibaldi
Hospital. Waiver of informed consent from patients was
approved because of the observational nature of the study.
This study uses compliance with STROBE criteria, a
checklist which has been developed to strengthen
reporting standards in epidemiological research [
Categorical data were presented as frequencies and
percentage and compared by the Chi-square test. Parametric
and nonparametric continuous data were presented as
mean and standard deviation and evaluated by the
Student’s t test and Mann–Whitney U test respectively.
Comparisons between the two groups were made on an
intention-to-treat basis. Thus, patients in the
laparoscopicassisted group converted to the open procedure were not
excluded from the analysis. The sample size for our study
was calculated based on an analysis of sample sizes
required for each of the parameters (operative time, length of
hospital stay, postoperative pain, complication rate, return
to normal activity and cost) for an α = 0.05 and a power of
90 %. A P-value of 0.05 was considered as significant. All
calculations were performed by using the SPSS software
package version 17.0 (SPSS Inc., Chicago, IL).
Out of 593 patients with acute appendicitis, 310 patients
underwent open appendectomy and 283 patients
underwent laparoscopic appendectomy. Demographic data
and preoperative clinical feature between OA group and
LA group are showed in Table 1. There were no
significant differences with respect to age and associated
comorbidities. On the contrary, the difference in gender
and in the white blood cell count at presentation was
statistically significant. Out of the total 310 open
procedures, 214 (69 %) were performed for uncomplicated
appendicitis and 96 (31 %) for complicated disease
including appendiceal perforation with local or widespread
peritonitis. In the laparoscopic group, 241 (85 %)
procedures involved uncomplicated disease and 42 (15 %)
complicated appendicitis. Noteworthy, we did not
observe differences between groups for all the grades of
appendicitis (Table 2). In our study, the mean ± standard
deviation (SD) operative time of 54.9 ± 14.7 min for the
LA group was longer than the mean operative time of
31.36 ± 11.43 min for open appendectomy (P <0.0001).
The laparoscopic group required fewer doses of
parenteral and oral analgesics in the operative and
postoperative periods compared with the open appendectomy
(P <0.0001). Bowel movements in the first postoperative
day were observed in 93 % patients subjected to
laparoscopic appendectomy and 69 % in the open group
(P <0.001). As a result, 85 % patients in the laparoscopic
group and 62 % in the open group were able to
tolerate a liquid diet within the first 24 postoperative
hours (P <0.001). Hospital stay was significantly shorter in
the laparoscopic group with a mean ± SD of 1.4 ± 0.6 days
compared with 2.7 ± 2.5 of the open appendectomy group
(P = 0.015). A highly significant difference existed between
the 2 groups in time taken to return to routine daily
activities, which was less in the laparoscopic group with a
mean 11.5 ± 3.1 days compared with mean 16.1 ± 3.3 days
in the open appendectomy group (Table 3). We observed
a greater overall incidence of complications in open
surgery than in laparoscopic surgery. A total of 29
Data are number (%) or mean ± standard deviation values, as indicated.
WBC White blood cell, CAD Coronary artery disease, COPD Chronic obstructive
pulmonary disease, DM Diabetes mellitus
complications occurred in the laparoscopic group, while
55 complications occurred in the open appendectomy
group, as summarized in Table 4. We did not observe a
significant difference between groups in vomiting,
paralytic ileus, intrabdominal abscesses and hemoperitoneum.
Differences in wound infection and wound dehiscence
were significant (P <0.001) (Table 4). Analysis of hospital
costs are presented in Table 5. As regards laparoscopy, it
is well known that the longer operative and
anaesthesiological time are more expensive than the cost of the open
approach (that uses reusable instruments and few and
cheaper equipment). However, the shorter hospital stay
(mean 1.4 ± 0.6 days) in the laparoscopic group kept low
the ward cost in comparison to the open group. So, the
total hospital cost for each patient of the LA group was
only 150 € higher compared to patients in the OA group.
Acute appendicitis is the most common intra-abdominal
condition requiring emergency surgery [
possibility of appendicitis must be considered in any patient
presenting with an acute abdomen, and a certain
preoperative diagnosis is still a challenge [
more than 20 years have elapsed since the introduction
of laparoscopic appendectomy (performed in 1983 by
Semm, a gynaecologist), open appendectomy is still the
Data are number (%) or mean ± standard deviation values, as indicated.
POD postoperative day
conventional technique. Some authors consider
emergency laparoscopy as a promising tool for the treatment
of abdominal emergencies able to decrease costs and
invasiveness and maximize outcomes and patients’ comfort
]. Several studies [
4, 10, 13, 16, 18, 32–34
shown that laparoscopic appendectomy is safe and
results in a faster return to normal activities with fewer
wound complications. These findings have been
challenged by other authors who observed no significant
difference in the outcome between the two procedures,
and moreover noted higher costs with laparoscopic
3, 19, 20, 33, 35
]. Anyway, a recent
systematic review of meta-analyses of randomised controlled
trials comparing laparoscopic versus open
appendectomy concluded that both procedures are safe and
effective for the treatment of acute appendicitis . Total
operative time in our series was significantly longer in
the laparoscopic group than in open group (P <0.0001).
Generally, the lack of experience of surgeons in the
laparoscopic approach may contribute to a longer duration
of the operation. By contrast, in the present study the
learning curve effect was minimal as the surgeons
performing the procedures were highly experienced in
laparoscopic procedures, including laparoscopic bariatric
surgery and colectomy surgery. So, in our series the
longer operation time in laparoscopic appendectomy may
be due to additional steps like setup of instruments,
insufflation, making ports under vision and a phase of
diagnostic laparoscopy. Length of hospital stay
represents a critical factor that directly influences the
economy and the well-being of the patient. We found that
hospital stay was significantly shorter in laparoscopic
group (P = 0.015) with a concomitant earlier bowel
movements in patient managed laparoscopically, leading
to earlier feeding and discharge from hospital. Our
findings are in agreement with several studies that
demonstrated a significantly short hospital stay for the
laparoscopic approach [
8, 22, 32, 33, 37
]. In our Surgery
Department, post-operative pain is assessed both
subjectively via a visual analogue scale and objectively by
the tabulation of analgesic use. In the present study, to
prevent that the perception of pain may have been
influenced by the patient’s enthusiasm for a novel technique,
we used only the number of analgesics doses (oral and
parenteral) required by individual patient to compare the
2 groups. In this series, parenteral and oral analgesic
requirements were less in the laparoscopic group
[parenteral 1 (mean); oral 1.86 (mean)] than in the open group
[parenteral 1.5 (mean); oral 2 (mean)] and we found a
statistically significant difference (P <0.001) in agreement
with many other studies [
15, 38, 39
] that reported less
pain in the laparoscopic group. Several studies showed no
difference between open and laparoscopic appendectomy
with respect to early return to activity and performance of
daily activities. However, this issue is still debated because
of the different definitions and classifications of “activity”
in such studies [
]. In this study we used the
return to work as an endpoint with a mean time of
11.5 ± 3.1 days in the laparoscopic group and 16.1 ± 3.3 in
the open group (P <0.001). Our results are in agreement
with a study by Hellberg et al. [
] and other randomized
clinical trials and meta-analysis.[
] The mortality rate
was nil in our study. The low mortality rates reported in
previous research (0.05 % and 0.3 % rate in laparoscopic
and open groups ) indicated that appendectomy,
especially in absence of complicated disease, is a safe
procedure regardless of the technique used [
]. In the present
study, the overall complication rates were 24.5 % and
6.7 % for open and laparoscopic appendectomy
respectively, with a rate of wound infection and dehiscence
significantly higher in the open group (P <0.001). Wound
infection is more common in complicated appendicitis
and may not represent a serious complication per se but
has a strong impact for convalescence time and quality of
life of patients. In our study no statistically difference was
observed in the intraoperative findings between the two
groups (Table 2), so the lower rate of wound infection in
laparoscopic group may be due to placement of the
detached appendix into an endobag before its removal from
the abdominal cavity, reducing contact with the fascial
surfaces and minimizing contamination. Conversely,
intra-abdominal abscess is a serious and life-threatening
complication. We observed intra-abdominal abscess
formation in 4 patients in laparoscopic group (4.1 %) and in
1 patient in the open group (0.32 %). These findings are
consistent with other studies that showed an increased
risk of intra-abdominal abscess after laparoscopic
appendectomy compared with open surgery [
hypotheses have been suggested to find possible
explanations: mechanical spread of bacteria in the peritoneal
cavity promoted by carbon dioxide insufflation, especially
in case of ruptured appendix [
learning curve , the meticulous irrigation, instead of
simple suctioning, of the infected area in severe
peritonitis, that leads to contamination of the entire abdominal
cavity, which is difficult to aspirate latter [
]. However, in
our study this finding was not statistically significant
(P = 0.147). The management of intrabdominal abscesses
included percutaneous drainage as first-line therapy, and
surgical procedures. Antibiotics were given before and
after percutaneous drainage or surgery. Other observed
postoperative complications included vomiting, paralytic
ileus and hemoperitoneum (Table 4). The higher cost of
laparoscopic instruments (1245 € in our Department)
compared to the conventional technique (50 € in our
Department) represents an obstacle to its greater use.
However, because of the shorter hospital stay, the total cost
for laparoscopic appendectomy (operating room + ward
costs) was only 155 € higher than open appendectomy. In
addition, Moore and al. demonstrated an economic benefit
of laparoscopic appendectomy from a social perspective,
since earlier return to daily activities is crucial, especially
for patients who are young and lead a productive life [
Limitations of our study included the lack of evaluation of
laparoscopic surgery in obese patients, as we did not
collect data on body mass index (BMI). Moreover the
follow up period was only limited to two weeks after
Our results showed the advantages of the laparoscopic
approach over open appendectomy including shorter
hospital stay, decreased need for postoperative analgesia,
early food tolerance, earlier return to work, lower rate of
wound infection, against only marginally higher hospital
costs. Furthermore we found a considerable preference
(during the collection of consent) of patients and a high
satisfaction after the surgery in the laparoscopic group.
Although the incidence of intra-abdominal abscess
formation was higher after laparoscopic appendectomy,
greater experience and improvements in our technique
may have eradicated this catastrophic complication.
Provided that surgical experience and equipment are
available, laparoscopy could be considered safe and equally
efficient compared to open technique and should be
undertaken as the initial procedure of choice for most
case of suspected appendicitis. However, since there is
no consensus to the best approach, both procedures
(open and laparoscopic appendectomy) are still being
practiced actively deferring the choice to the preference of
surgeon and patients. In the future, laparoscopic
appendectomy could represent the standard treatment for
patients with appendicitis and undiagnosed abdominal pain.
Availability of data and materials
Data will not be shared in the open access version of the paper. Please
contact the corresponding author to receive information on the dataset
supporting the conclusions of this article.
LP, CDS, FF, and Angelo Bellia: conceived and designed the study, collected
data and data interpretation. MV and Antonio Biondi: revised critically the
paper. All authors wrote, read and approved the final manuscript.
None. This manuscript has not been published previously and is not under
consideration for publication elsewhere.
Consent for publication
Ethics approval and consent to participate
The study was approved by the ethics committee of Garibaldi Hospital,
Catania. Waiver of informed consent from patients was approved because of
the observational nature of the study.
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