Outcomes After Laparoscopic Treatment of Complicated Versus Uncomplicated Acute Appendicitis: A Prospective,Comparative Trial

Abstract

Background:

Laparoscopic treatment of simple acute appendicitis (AA) is a safe procedure; however, there are doubts about its safety in cases of complicated AA. The aim of this study was to determine the differences in results of laparoscopic treatment between cases of complicated versus simple AA.

Materials and Methods:

We prospectively included all patients treated for suspected AA by two surgeons of our service between May 2002 and May 2007. Of 221 patients, 20 were excluded from the study because the laparoscopic approach was not posible; 116 of 201 had uncomplicated AA, 57 complicated AA, 12 gynecologic ethiology, 11 negative appendectomy, and 5 other causes; patients without acute appendicitis were also excluded from the study. In all cases, laparoscopy was the first treatment option. The following variables were considered: mean surgical time, reconversions, emergency readmissions, emergency reinterventions or invasive procedures, mean postoperative hospital stay, and postoperative complications (i.e., infectious or noninfectious).

Results:

Our results showed statistically significantly worse results, in terms of surgical time, postoperative stay, reconversions, and infectious complications, for patients with complicated versus uncomplicated AA; however, no differences were observed regarding noninfectious complications, emergency readmissions, and emergency reinterventions or invasive procedures.

Conclusions:

We consider that laparoscopic treatment of complicated AA may be safely used, despite worse results than in cases of simple AA, since the differences in numbers of severe postoperative complications requiring emergency readmission, reintervention, or invasive procedures were not statistically significant.

Introduction

Since its introduction in 1983,¹ laparoscopic treatment of acute appendicitis (AA) has been controversial, especially in cases of complicated AA, owing to the publication of studies^2–5 showing a high incidence of infectious complications (e.g., intra-abdominal abcesses). In these cases, open surgery has been proposed as a safer option, while the laparoscopic approach has been considered a safe procedure in uncomplicated AA. However, more recent publications have shown that laparoscopic treatment is a valid option even in evolved cases, with complication rates that are similar or lower than those of open surgery.^6–9 The percentage of infectious complications secondary to laparoscopic appendectomy in complicated AA varies widely in the literature, from 1⁹ to 28%,¹⁰ and doubts, therefore, remain about the safety of this procedure. In both open and laparoscopic apendicectomy, it is accepted that the greater the degree of evolution of AA, the worse the short-term results and the higher the rate of infectious complications. However, few published reports¹¹ have addressed to what extent the degree of evolution of AA affects the results of laparoscopic appendectomy and what variables are most affected on comparing treated cases of uncomplicated versus complicated AA. This was the aim of the present study.

Materials and Methods

We prospectively included all patients >14 years of age treated for suspected AA by two surgeons of our service between May 2002 and May 2007. Data from interventions were retrospectively analyzed. Two hundred twenty-one patients with suspected AA were treated. In all cases, laparoscopic intervention was the first treatment option, which was used in 201 cases. In the remaining 20 cases, open surgery was performed for reasons including nonavailability of the laparoscopic device, nonfamiliarity of the available nursing staff with the procedure, or the procedure was counterindicated by the anesthetist; these patients were excluded from the study.

During the 5-year study period, variations in surgical technique were introduced. The pneumoperitonium was always performed with a Veress needle at the umbilicus. Until 2004, appendectomies were performed with three ports: an 11-mm umbilical, a 5-mm suprapubic, and a 12-mm port inserted in the right hypochondrium (RH). After 2004, the 12-mm RH port was changed to the left iliac fossa (LIF), and the RH port was only used when the appendectomy was technically difficult or when a subhepatic cecal appendix was found; in these cases, a fourth 5-mm port was used. In most cases (191 of 201), three ports were used. In 7 cases, a fourth RH port was necessary due to the technical difficulty of the appendectomy; in 2 cases, only two ports were used, since the cause of pain was clearly identified as being due to ovarian follicule rupture, and the appendectomy was not performed; and in the remaining case, only one trocar was inserted, revealing diffuse peritonitis, which motivated early conversion to open surgery. Transection of the appendix base was always performed by using an endostapler with blue cartridges, while the mesoappendix was transected by using different methods (e.g., white cartridge endostapler, monopolar electrocautery, vessel sealer, clips, or ultrasonic scalpel), depending mainly on the thickness and inflammation of the mesoappendix.

When the mesoappendix was thin and easily transectable, clips, monopolar electrocautery, or white cartridges were used; when enlarged, an ultrasonic scalpel or vessel sealer was used. Transection of the mesoappendix was always performed as near to the appendix as possible so that the appendix could be extracted via the 12-mm port. If this was not possible, a specimen bag was used. On occasions, it was necessary to widen the port site.

After reviewing the last 20 cm of the terminal ileum, the intra-abdominal cavity was irrigated thoroughly (right-lower quadrant, pelvis, and around the terminal ileum) with normal saline until the surgeon considered that no purulent material remained, then fluids were suctioned, leaving as little liquid in the cavity as possible. Port-site closure was only performed if it had been widened to remove the appendix. Before appendectomy, no blood cultures or intra-abdominal fluid cultures were done by routine. Antibiotic treatment consisted of 1 preoperative and 3 postoperative doses of amoxicillin/clavulanic acid. If the patient presented fever after intervention, blood cultures were extracted and antiobiotic treatment was continued until the patient remained afebrile during 48 hours.

Different variables were recorded, including: mean surgical time, reconversions, emergency readmissions and emergency reinterventions and invasive procedures, mean postoperative hospital stay, and postoperative complications (i.e., infectious or noninfectious). The data were analyzed to determine to what extent these variables were affected by the degree of evolution of the AA. Operative findings were classified according to the opinion of the operating surgeon and subsequently confirmed by pathologic study, and there were no differences between the operative classification and the final pathologic diagnosis. Cases of catarrhal or phlegmonous appendicitis were considered as simple or uncomplicated (UCAA), while the following cases were considered as complicated (CAA): gangrenous appendix, perforated appendix, appendicular mass palpable in the abdomen after anethetization, or those with diffuse peritonitis. If the cause of pain was not evident, it was considered as negative appendectomy (NEG). If the cause was gynecologic, it was classified as such (GYN). Cases not classifiable as one of the above were considered as other (OTHER). Patients of the GYN, NEG, and OTHER groups were also excluded from the study.

Statistical analysis

Statistical analysis was carried out by using SPSS 15.0 (SPSS, Inc., Chicago, IL). The Student's t-test was used to compare independent variables, and a P-value of <0.05 was considered as significant.

Results

The study included 69 women (40%) and 104 men (60%) (mean age, 34 ± 14 years), 77% of whom had American Society of Anesthesiologists classification 1 (ASA 1), 16% ASA 2, and 7% ASA 3. With regard to operative findings, 67% were classified as UCAA and 33% as CAA. Table 1 shows the demographic and clinical characteristics of the CAA and UCAA groups. Comparing each group, we found no significant differences, except for age, which was higher in the UCAA group. With regard to the short-term results of laparoscopic treatment of AA, the degree of evolution of AA clearly influenced them, as shown in Table 2.

Table 1.

Demographic and Clinical Characteristics of Groups

Characteristic	UCAA	CAA	P-value
N (%)	116 (67)	57 (33)
Mean age (years)	33 ± 14	38 ± 15	0.04
Male, n (%)	66 (57)	38 (67)	0.25
Previous abdominal surgery, n (%)	11 (9)	6 (11)	0.79
ASA 3, n (%)	7 (6)	5 (9)	0.53

ASA 3, American Society of Anesthesiologists classification 3; UCAA, uncomplicated acute appendicitis; CAA, complicated acute appendicitis.

Table 2.

Short-Term Results According to Groups

	UCAA	CAA	P-value
Mean surgical time (minutes)	54.6 ± 19.5	71.8 ± 24	<0.01
% reconversions (n/total)	0.8 (1/116)	17.5 (10/57)	<0.01
Mean postoperative stay (nights)	3.1 ± 1.8	5.9 ± 3.7	<0.01
% total complications (n/total)	10.3 (12/116)	28.07 (16/57)	0.003
% emergency readmissions (n/total)	5.1 (6/116)	0 (0/57)	0.08
% emergency reinterventions or invasive procedures (n/total)	1.7 (2/116)	7 (4/57)	0.07

UCAA, uncomplicated acute appendicitis; CAA, complicated acute appendicitis.

Surgical time

Mean surgical time for all procedures was 60.3 ± 22.6 minutes. Mean surgical time for the UCAA and CAA groups is shown in Table 2 and was clearly longer in the CAA than in the UCAA group. The difference between each group was statistically significant (P < 0.01).

Intraoperative complications and reconversions

No serious intraoperative complications were recorded in our series. There were no incidences in 154 cases (89%). Reconversion to open surgery was necessary in 11 patients (6%), and all conversions were due to technical difficulties. Finally, in 8 patients (5%), intraoperative bleeding occurred after withdrawal of the trocar situated at LIF: This was controlled in 7 cases by monopolar coagulation or transmural sticthes, and 1 patient left the operating room with a Foley catheter capping and compressing the port site, which was removed 48 hours later without evidence of renewed bleeding. Table 2 shows how reconversion percentages varied with operative findings. Reconversion was required in only 1 of 116 UCAA patients (<1%), as opposed to 10 of 57 CAA patients (17.54%), where most reconversions were recorded (10/11). The difference in reconversions between the CAA and UCAA groups was statistically significant (P < 0.01).

Postoperative stay

Mean postoperative stay was 4 ± 2.9 nights. In the CAA group, it was 5.9 ± 3.7 nights, significantly higher than the 3.1 ± 1.8 nights of the UCAA group (P < 0.01) (Table 2).

Postoperative complications

No mortality was recorded. As shown in Table 2, morbidity in the CAA group was relatively high (16/57; 28.07%), whereas in the UCAA group it was substantially lower (12/116; 10.3%); this difference was statistically significant (P = 0.003). Complications are shown in Table 3. The most frequent was prolonged fever without evidence of intra-abdominal fluid collection (n = 14), which required delaying discharge or readmission. All these cases were satisfactorily treated with antibiotics. There were only 5 cases of intra-abdominal abscess, 3 of which required percutaneous drainage, while the other 2 cases resolved with antibiotic therapy. The 2 cases of surgical wound infection occurred in reconversions to open surgery; this complication was not observed in any cases where the intervention was entirely laparoscopic. The 2 cases of port-site hernia ocurred in the CAA group, but they were not related to infectious complications of the wound. One patient presented a large hematoma in one of the port sites and needed a blood transfusion.

Table 3.

Comparison of Postoperative Complications Between UCAA and CAA Groups

	UCAA	CAA	P-value
% uncomplicated patients (n/total)	89.6 (104/116)	71.9 (41/57)	0.003
% total complications (n/total)	10.3 (12/116)	28.07 (16/57)	0.003
% infectious complications (n/total)	9.48 (11/116)	22.81 (13/57)	0.017
% noninfectious complications (n/total)	0.86 (1/116)	5.26 (3/57)	0.07
% intra-abdominal abscess (n/total)	1.72 (2/116)	5.26 (3/57)	0.2
% fever without fluid collection (n/total)	5.17 (6/116)	14.04 (8/57)	0.04
% surgical wound infection (n/total)	0 (0/116)	3.5 (2/57)	0.2
% infected intra-abdominal hematoma	1.72 (2/116)	0 (0/57)	0.3
% surgical wound hematoma (n/total)	0.86 (1/116)	0 (0/57)	0.8
% port-site hernia (n/total)	0	1.75 (2/57)	0.15
% other complications (n/total)	0.86 (1/116)	1.75 (1/57)	0.6
% invasive treatment for infectious complications (n/total)	1.72 (2/116)	3.51 (2/57)	0.5
% prolonged antibiotic therapy (n/total)	9.48 (11/116)	17.54 (10/57)	0.13

UCAA, uncomplicated acute appendicitis; CAA, complicated acute appendicitis.

The main cause of morbidity in this series was complications of an infectious nature (24/27), including: intra-abdominal abscess, persistent fever without intra-abdominal fluid collection, surgical wound infection, or infected intra-abdominal hematoma. A breakdown of complications comparing the CAA and UCAA groups (Table 3) showed a significant difference in infectious complications: CAA 22.81% versus UCAA 9.48% (P = 0.017), but no significant difference was found in noninfectious complications (P = 0.07). In those patients with infectious complications, there were no differences between these two groups regarding intra-abdominal abscess (P = 0.2), but the CAA group showed a higher percentage of persistent fever without intra-abdominal fluid collection, and the difference was slightly statistically significant (P = 0.04). Despite the higher frequency of infectious complications in the CAA than the UCAA group, these did not appear to be more severe, since no significant differences were observed between the two groups (Table 3) in the number of patients requiring emergency invasive treatment (i.e., percutaneous drainage or reintervention; P = 0.5) or in those only requiring prolonged antibiotic therapy (P = 0.13).

Readmissions and reinterventions

Data on readmissions and reinterventions are shown in Tables 4 and 5. Three patients required emergency reintervention and another 3 required percutaneous drainage of intra-abdominal abscesses. The reinterventions included 1 patient whose first appendectomy was incomplete and was readmitted with a new episode of acute appendicitis, 1 patient with an incarcerated port-site hernia, and the third reintervention was the laparoscopic extraction of an abdominal drainage tube that ruptured during the extraction maneuver. The total percentage of emergency reinterventions or invasive procedures was 3.4%. Six patients were readmitted, 1 whose first appendectomy was incomplete and required reintervention and 5 patients with fever. Of these 5, 3 patients had persistent fever without intra-abdominal fluid collection, 1 had an intra-abdominal abscess, and the other presented with an infected intra-abdominal hematoma; all resolved with conservative treatment. The total percentage of readmissions was 2.98%. No significant differences between the CAA and UCAA groups were found for readmissions and reinterventions (Table 2).

Table 4.

Emergency Reinterventions/Invasive Procedures

Procedure/cause	UCAA	CAA
Complete appendectomy/first appendectomy incomplete	1	0
Hernioplasty/port-site hernia	0	1
Laparoscopic drainage removal/drainage tube rupture on extraction	0	1
Percutaneous drainage/infected intra-abdominal collection	1	2
Emergency reinterventions/invasive rocedures (total)	2/116	4/57

UCAA, uncomplicated acute appendicitis; CAA, complicated acute appendicitis.

Table 5.

Emergency Readmissions

Emergency readmissions/cause	UCAA	CAA
Acute appendicitis first/appendectomy incomplete	1	0
Fever/infected intra-abdominal hematoma	1	0
Fever/intra-abdominal abscess	1	0
Fever/fever without intra-abdominal abscess (3 cases)	3	0
Total emergency readmisions (total)	6/116	0/57

UCAA, uncomplicated acute appendicitis; CAA, complicated acute appendicitis.

Discussion

The analysis of findings from this series shows that laparoscopic appendectomy for the treatment of acute appendicitis yielded significantly worse results for the group of patients with complicated, as compared with the uncomplicated acute appendicitis group, considering the variables of mean surgical time, reconversion, mean postoperative stay, and percentage of total and infectious postoperative complications. However, no significant differences were observed between the two groups regarding noninfectious complications, emergency reinterventions or invasive procedures, and emergency readmissions, which were not affected by the degree of evolution of acute appendicitis.

Surgical intervention time was clearly affected, being significantly longer in the CAA group, where mesoappendix enlargement and a tendency to bleeding was frequently found; hemostasis in this group required careful, time-consuming management. In addition, the number of inflammatory adherences was higher, requiring greater dissection, which slowed the procedure time. However, we consider a mean time of 71 minutes for laparoscopic treatment of CAA (complicated cases) is not a sufficient reason to reject the technique—it may still be considered a fairly short intervention. In the cases of uncomplicated appendicitis with less tissue inflammation, mean surgical time was only 54 minutes.

Although our total percentage of reconversions (6%) is similar to that reported by other prestigious teams,¹² there was a great difference in reconversions between complicated and uncomplicated cases (0.89 versus 17.54%), with most (10/11) occurring in the CAA group. We believe this may be due to the fact that in the first years of the study, the mesoappendix was always transected by using an endostapler, which required greater dissection, since a vessel sealer was not employed. This variable may also be greatly influenced by the learning curve. Laparoscopic appendectomy in cases of UCAA is a simple procedure and may be safely performed by surgeons with little experience of laparoscopy; however, in cases of CAA, the procedure may be complex and require more skills, which may be reflected in the high number of reconversions recorded at the beginning of the study.

Mean postoperative stay was significantly higher in the CAA group, as compared with the other groups (Table 2), due to a higher frequency of infectious complications observed in the CAA patients. Overall postoperative morbidity of 16% was also similar to that reported by other well-known groups.¹² Differentiated by groups, morbidity was clearly higher in the CAA, compared to the UCAA, group. This difference was entirely based on persistent postoperative fever in the CAA group, since no significant differences were found in the number of intra-abdominal abscesses or noninfectious complications in this study. Previous studies have reported greater risk of intra-abdominal abscessses in CAA patients,¹¹ which was not found in our series.

The most frequent complication in our CAA group was postoperative fever without intra-abdominal fluid collection, which cannot be considered severe, given that 100% of these cases resolved with prolonged antibiotic therapy. However, it did contribute to increasing the mean postoperative hospital stay and was also the cause of some readmissions. Despite its frequency and consequences in our series, this complication after laparoscopic appendectomy is rarely reported in the literature. Perhaps, postoperative fever without intra-abdominal abscess can be minimized by thorough irrigation of the surgical site and maximum efforts to remove liquid or remains of blood from the abdominal cavity. As for readmissions and reinterventions, we found no significant differences between the CAA and UCAA groups. As stated, this is attributable to the fact that most of the observed postoperative complications were not severe.

In summary, the major conclusions of this study were that laparoscopic treatment of evolved versus uncomplicated acute appendicitis showed worse short-term results in terms of surgical time, postoperative stay, reconversions, and infectious complications, but no difference was observed regarding noninfectious complications, readmissions, and reinterventions or invasive procedures. The high rate of reconversion may be reduced by the use of advanced hemostatic instruments. No significant differences in intra-abdominal abscesses were observed between the UCAA and CAA groups. Despite these worse results, we consider that lapaoroscopic appendectomy remains a safe procedure in cases of CAA, without severe complications, with acceptable surgical time and postoperative stay. The most frequent complication in our CAA group was persistent postoperative fever without intra-abdominal abscess, which resolved in all cases with antibiotic therapy.

Footnotes

Disclosure Statement

No competing financial interests exist.

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