Open versus Laparoscopic Appendectomy: A Literature Review

Abstract

Appendectomy is the most common emergency abdominal surgery in the United States. Open appendectomy has been the standard procedure for decades, whereas laparoscopic appendectomy is a newer, less-invasive method of removing the appendix. This review intends to elucidate the similarities and differences between these two procedures as well as explore the advantages and disadvantages of each approach. Socioeconomic factors, associated costs, preoperative imaging, operative time and methods, length of hospital stay, recovery time, and complications associated with open and laparoscopic appendectomy are discussed. Overall, laparoscopic appendectomy has shorter hospital stays and recovery times, requires less analgesics, and results in better postoperative outcomes. Although such an analysis/comparison involves several perspectives, a review of the available literature suggests that laparoscopic appendectomy is the operation of choice in most cases.

Introduction

Acute appendicitis is the most common abdominal emergency in the United States, occurring at a rate of approximately 90–100 cases per 100,000 people [1,2]. Surgical removal of the appendix is the treatment of choice in the majority of patients, which makes appendectomy one of the most frequently performed surgical procedures with over 300,000 operations annually [3]. Currently, there are two primary surgical approaches—open appendectomy (OA) and laparoscopic appendectomy (LA). OA had been the gold standard treatment of acute appendicitis for over a century before the advent of laparoscopy [4]. Nevertheless, the utilization of LA has been progressively increasing since it was first described in 1983 by Kurt Semm as it has consistently demonstrated to be safe and effective in treating acute appendicitis across different demographics [5,6]. However, various studies have shown conflicting or equivocal results in terms of the clinical advantages LA offers over OA with simultaneously higher surgical costs [7]. Neither approach has yet been clearly defined as the standard of care, and there is ongoing debate regarding which operation is preferred for managing acute appendicitis [8,9,10]. Because both procedures are equally effective at treating appendicitis, it is ultimately up to the surgeon which surgical approach to undertake [11]. Despite the ability to successfully treat appendicitis in both approaches, clinical differences between the two must be evaluated in order to optimize patient outcomes. The goal of this literature review is to compare the clinical outcomes between OA and LA and to discuss various demographic factors that may influence the utility of either operation.

Discussions

Accurate diagnosis of appendicitis is vital prior to operative management in order to avoid unnecessary medical interventions and reduce hospital expenses [12]. A thorough history, physical examination, and laboratory studies can achieve a diagnostic accuracy of approximately 80%, which can lead to a significant number of appendectomies performed on patients with normal appendices [12]. Therefore, imaging is used to improve diagnostic accuracy and decrease the negative appendectomy rate. The negative appendectomy rate was as high as 20% before the widespread use of preoperative imaging but has decreased to 2.5% once appropriate use of imaging was incorporated into the assessment for suspected appendicitis [13]. Computed tomography (CT) has been shown to have the highest accuracy for diagnosing appendicitis compared to other available imaging modalities, with a sensitivity of 91-94% and specificity of 90-95%, and is the main diagnostic tool for appendicitis in most patients [14]. Special considerations must be made for individuals who have contraindications to receiving a CT scan with contrast, such as those who have an allergy to contrast media or are more vulnerable to ionizing radiation, and should be evaluated with alternative imaging modalities [12]. Magnetic resonance imaging (MRI) without contrast is preferred in patients who are radiosensitive, including pregnant women and pediatric patients [14]. Ultrasonography may offer an advantage over MRI specifically in pediatric patients who are slim [14].

Imaging is a critical component in the clinical evaluation of a patient with suspected appendicitis that is used to rule in or rule out disease based on specific parameters. In order to rule in appendicitis, the appendix must be at least six millimeters in diameter [12]. On CT scan, evidence of a thickened appendiceal wall supports the diagnosis of appendicitis, and the addition of contrast can show inflammation in neighboring organs and tissues [12]. CT imaging can be used to differentiate uncomplicated appendicitis from complicated appendicitis (perforated or gangrenous appendix) based on several key features, including periappendiceal abscess, extraluminal air, and extraluminal appendicolith [15]. These findings on imaging related to the severity of the appendicitis can help guide a surgeon in their clinical decision-making on whether to proceed with a laparoscopic appendectomy or an open appendectomy.

Socioeconomic Factors

Socioeconomic status has been shown to impact the utilization of laparoscopic appendectomy [16,17]. While there has been a steady increase in the rate of LA over the past few decades, non-white patients and those from lowincome regions continue to be more likely to undergo OA due to the high cost of installment, lack of qualified maintenance personnel, unreliable electricity, and shortage of consumable items [17,18]. Laparoscopy has been shown to be particularly advantageous for patients from low- and middle-income areas because it is useful in minimizing challenges secondary to poor sanitation, limited imaging methods, fewer hospital beds, higher rates of hemorrhage, and single income households [19]. Despite the potential benefits of LA, a frequent challenge of implementing laparoscopic procedures in lower-income regions is a lack of specialized equipment and trained personnel [19]. Alternative approaches to circumvent these barriers include practices such as mechanical insufflation with room air, syringe suction, innovative use of cheaper instruments, and reuse of disposable tools with proper sterilization [19]. The use of syringe suction aids in decreasing the incidence of postoperative infection, and the alternate use of instruments is beneficial in areas that do not have access to specialized laparoscopic equipment [19].

Figure 1. CT of early acute appendicitis [14].

Figure 1. CT of early acute appendicitis [14].

Figure 2. MRI of pediatric appendicitis [16].

Figure 2. MRI of pediatric appendicitis [16].

Patient outcomes are also affected by socioeconomic status. People with lower income are more likely to present with complicated appendicitis or to be readmitted, and they also have a higher incidence of appendicitis, acute appendicitis, and perforated appendicitis relative to higherincome individuals [20]. Research shows that in lowincome patients, the mean hospital stay is longer, the casefatality ratio is higher, and postoperative complications occur more frequently and prolong recovery time [20]. Complications are due to poor hygiene and sanitation and fewer available hospital beds for effective postoperative care [19]. Overall, LA demonstrates significant benefits in patients of lower socioeconomic status for the treatment of acute appendicitis [20].

Cost

The total cost of an appendectomy is based upon several factors, including costs associated with the operation, length of hospital stays, postoperative complications, and recovery time [7,21]. LA requires specialized laparoscopic equipment and additional steps when accessing the abdomen; therefore, the upfront cost of LA is higher than OA due to the increased cost of instrumentation and the anesthesia required for a longer operative time [7]. While the laparoscopic operation is more expensive, studies have found the total cost of LA to be less than or comparable to OA [5,7]. This is because OA is more often associated with additional expenses related to longer hospital stay, higher incidence of postoperative complications, and prolonged recovery time [5,7]. Haas et al. found the total treatment costs of LA to be 27.6% lower than OA since LA is associated with a shorter length of hospital stay, lower rate of 30-day readmission, and fewer postoperative complications [21]. Based on the overall costs associated with LA versus OA, LA is the more costeffective option despite the higher initial cost of equipment and anesthesia.

Operative Time

Laparoscopic appendectomy has significantly longer operative times compared to open appendectomy, which is attributable to various factors, including staff experience, surgical technique, and laparoscopic equipment setup [8]. Operative times are shortened during LA when surgeons work closely alongside surgical staff who are experienced with laparoscopic procedures [22]. An assistant’s skill in driving the laparoscope to provide optimal visualization of the surgical field affects the surgeon’s performance because it determines the ability to see the proper planes of dissection and control inadvertent bleeding [23]. In contrast, the surgeon is not completely reliant on the assistant to visualize the surgical field during open procedures, which can prevent unnecessary delays. Nursing staff experience is also critical as they are responsible for setting up the laparoscopic equipment prior to surgery and managing it throughout the procedure [22].

The technique of accessing the abdomen and extent of operating room setup required for LA versus OA further contributes to the difference in operative time [7]. Before the laparoscopic instruments can be inserted into the patient during a LA, the abdomen needs to be insufflated to create a working space, and port sites have to be established under direct visualization by the laparoscope [7]. A diagnostic laparoscopy is also performed at the beginning of the operation to establish orientation and for a general inspection [8]. Additionally, the operating room setup for LA is more extensive since it utilizes specialized instruments that are not required in OA, such as an endoscope camera system, multiple video monitors, and additional power sources for specific laparoscopic instruments [7,24]. Although prolonged operative duration is generally associated with an increased risk of complications [25], studies specifically looking at appendectomy have shown LA to have significantly fewer complications compared to OA [8,26]. Therefore, LA should be considered as a safe and viable operative option for acute appendicitis in cases where experience and equipment allow [8].

Postoperative Care

Postoperative management varies depending on the surgical approach as well as the severity of appendicitis [27]. During recovery, temperature, bowel function, and pain levels are assessed periodically [27]. Patients begin with a clear liquid diet to allow the bowel to regain normal function before transitioning to a regular soft diet during recovery from anesthesia [27]. The transition to a soft diet occurs once the patient is able to tolerate a liquid diet, has return of bowel sounds, and passes flatus [7]. Following LA, bowel movements occur within the first 24 hours postoperatively in 93% of patients compared to 69% of patients who undergo OA [7]. This results in 85% of LA patients tolerating a clear liquid diet within the same postoperative timeframe versus 62% of OA patients [7]. Bowel movements may be complicated if over-the-counter pain medication is insufficient during recovery, thus necessitating the use of narcotics for pain control, as opioid use can reduce gastric emptying and peristalsis in the gastrointestinal tract [28]. The difference in time to recover normal bowel function between LA and OA is because less intravenous and oral analgesics are required for patients who undergo LA [29].

After LA for uncomplicated appendicitis, patients can be discharged on the same day of surgery and most return home within 48 hours if they meet all the discharge criteria [30]. These criteria consist of stable vital signs, return to regular diet, ability to walk, and pain managed with oral analgesics [30]. Same-day discharge is safe for a majority of these patients as it has been shown there is no increased risk of readmission, complications, or unexpected hospital visits following LA [30]. Patients with complicated appendicitis are discharged once they can tolerate a regular diet, which is typically after five to seven days [27]. Careful assessment of bowel function before the diet transition is essential since 3-7% of patients with perforated appendicitis can develop complications, such as ileus, that may lead to a bowel obstruction [27].

Hospital Stay and Recovery Time

Despite the longer operative time of LA, it is usually associated with a significantly shorter hospital stay [7]. The time a patient spends in the hospital postoperatively is determined by when they have good pain control, are afebrile, and can tolerate a normal diet [7]. A systematic review found that the majority of literature reports a reduction of pain intensity following LA, with consumption of fewer analgesic drug doses and a shorter duration of analgesia [31]. Several other studies have found that LA is associated with a shorter hospital stay, earlier return of bowel sounds, and sooner ability to tolerate a liquid diet [7,32]. When considering the severity of appendicitis in each group, there is a significant reduction in the length of hospital stay in both complicated and uncomplicated appendicitis following LA in the adult population [22,31,33]. Despite variation in the absolute number of days spent in the hospital, the length of hospital stay is generally reduced by one day in both complicated and uncomplicated cases treated by LA compared to OA [9,31]. LA results in a return to normal activity 5 days earlier than OA and is associated with improved quality of life in the physical functioning and general health domains [31,34].

The available data is limited in terms of childhood outcomes following appendectomy. One study failed to find significant differences in pain on postoperative day one between LA and OA in children [35]. Similar to the adult population, LA in children was also associated with a significant decrease in hospital stay following both complicated and uncomplicated appendicitis [10,31,36,37]. A randomized trial did not find significant differences in the time to return to normal activity between LA and OA in pediatric patients [38].

Complications

Post-operative

The risks and benefits associated with LA and OA, including infection rates, postoperative pain, and recovery time, help guide the decision of which operation a patient should undergo. The cases of surgical wound infection are much lower in LA (0.6%) compared to OA (10%), whereas the incidence of intra-abdominal abscess increases nearly 3-fold following LA [9,31]. There is a significant reduction in the amount of postoperative pain medication required in LA since it uses smaller incisions and causes less trauma on the body [8]. In general, postoperative complications are fewer in LA than OA, and this trend is followed in both complicated and uncomplicated appendicitis [8,26,31].

Covid-19

Patients who are infected with the SARS-CoV2 virus can spread the virus during abdominal surgery through the electrocautery smoke and surgical field contamination [39]. The surgical field of OA becomes significantly more contaminated compared to LA because OA creates larger incisions and leaves a greater area for particles to exit the body [39]. There was greater contamination of critical areas during OA, such as the surgeon’s gloves, face shield, and surgical drapes [39]. As a result, it appears that LA offers an advantage over OA in minimizing the spread of infectious diseases.

Pediatrics

LA has been shown to be safe and effective in the pediatric population for the management of acute appendicitis [40]. Interval LA, in particular, resulted in significantly less intraoperative blood loss and fewer postoperative complications, such as surgical site infection, ileus, remnant abscess, and others [40].

Pregnancy

Historically, laparoscopic operations have been considered high risk for pregnant women. Improvements in perioperative care and laparoscopic technique have greatly decreased the risk for fetal loss; however, the incidence of fetal loss following LA remains significant compared to OA [41]. The risk of fetal loss with LA should not be ignored and should be made clear during informed consent with thorough discussion of the advantages and disadvantages associated with the operation [41]. Similarly, to the general adult population, pregnant women who undergo LA have lower rates of wound infection and shorter length of hospital stay [41].

As a preliminary conclusion, open appendectomy has been the standard treatment for acute appendicitis for over a century. While OA remains widely used around the world today, emerging research shows evidence that LA is the superior operation for managing appendicitis because it results in better patient outcomes. LA is associated with fewer complications, shorter hospital stays and recovery time, fewer doses of analgesics, and faster return to normal activity. However, clinical judgment must be used in cases of pregnancy or complicated appendicitis, such as gangrenous or perforated appendix, where OA may be necessary [42]. One must also consider where the surgery takes place as not all facilities have the same access to staff, funding, resources, or training to perform laparoscopic procedures. Nevertheless, every patient with acute appendicitis must be evaluated on an individual basis, and the context of each case ultimately dictates the course of action.

Although appendectomy has been the treatment of choice for acute appendicitis for over a century, recent clinical trials have demonstrated success in using nonoperative management with antibiotics to treat uncomplicated cases of appendicitis [43]. Antibiotics were shown to be noninferior to appendectomy, and the risk of serious adverse effects was comparable between the two treatment groups [44]. In children with acute uncomplicated appendicitis, nonoperative therapy with antibiotics is effective as the initial treatment in 97% of patients and can help spare children from urgent surgery [45]. Therefore, in addition to surgical management, the use of antibiotics should be considered as a potential treatment option for acute uncomplicated appendicitis. Longer-term clinical outcomes are recommended regarding the efficacy of various treatment options for managing acute appendicitis across different demographics, comorbidities, and severity of disease in order to reliably inform clinical practice and decision-making.

Conclusions

Laparoscopic appendectomy has shorter hospital stay and recovery times, requires less analgesics, results in fewer postoperative complications, and is cost-effective.

LA should be considered as the procedure of choice in most cases of acute appendicitis since it is safe and effective in managing both uncomplicated and complicated appendicitis across various patient populations.

Highlights

• ✓ Laparoscopic appendectomy results in better patient outcomes and is more cost-effective compared to open appendectomy.
• ✓ Overall, laparoscopic appendectomy has shorter hospital stay and recovery times, requires less analgesics, and results in fewer postoperative complications.

Compliance with ethical standards

Any aspect of the work covered in this manuscript has been conducted with the ethical approval of all relevant bodies and that such approvals are acknowledged within the manuscript.

Conflicts of Interest disclosure

There are no known conflicts of interest in the publication of this article. The manuscript was read and approved by all authors.