Beruflich Dokumente
Kultur Dokumente
DOI 10.1007/s00464-015-4453-x
REVIEW
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Table 2 Postoperative
Laparoscopic (n = 42) Open (n = 39) Odds (95 % CI) p
complications
SSI any 14 (33.3 %) 10 (25.6 %) 1.450 (0.5533.800) 0.476
Incisional 8 (19.0 %) 3 (7.7 %) 2.824 (0.69111.533) 0.197
Organ space 8 (19.0 %) 7 (17.9 %) 1.076 (0.3503.308) 1.000
Leakage 4 (9.5 %) 5 (12.8 %) 0.716 (0.1782.885) 0.732
Bowel obstruction 2 (4.8 %) 0 1.050 (0.9811.123) 0.494
SSI surgical site infection
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Operative time (min) 84.6 34.57 63.5 20.76 1.066 (1.0281.106) 0.001
Blood loss (g) 25.1 64.02 71.5 117.77 0.976 (0.9590.993) 0.005
Days to resumption of liquids 1.1 0.37 1.4 1.18 0.432 (0.1131.652) 0.220
Days to resumption of solids 4.1 2.80 4.6 4.80 0.920 (0.7201.176) 0.507
Days to walking 1.5 0.67 1.3 0.51 4.246 (1.16215.514) 0.029
Duration of drainage (days) 8.9 10.54 8.4 7.99 0.990 (0.8301.182) 0.914
Duration of intravenous antibiotics (days) 5.5 4.28 4.4 3.03 0.923 (0.8111.050) 0.221
Length of postoperative stay (days) 11.4 8.57 11.9 6.65 1.023 (0.8201.278) 0.838
Analgesic use (times) 8.0 8.08 6.5 7.82 1.050 (0.9291.188) 0.434
Pentazosine 0.8 1.39 0.5 1.07 1.144 (0.5992.185) 0.684
NSAID 7.2 7.57 6.0 7.82 1.051 (0.9281.190) 0.470
Appendiceal stump \0.001
Linear stapler 39 2
Ligation 2 37
None 1 0
Postoperative diagnosis 0.582
Peritonitis 22 16
Abscess 17 20
Uncomplicated appendicitis 3 3
Postoperative interventional radiology 4 5 0.716 (0.1782.885) 0.732
Unintentional reoperation 1 0 1.024 (0.9771.074) 1.000
Mortality 0 0
Values are mean SD
NSAID nonsteroidal anti-inflammatory drug
with surgery for uncomplicated appendicitis. The effec- previous retrospective studies. An explanation for the rel-
tiveness of the laparoscopic approach for CA has been atively higher (but not significant) rate of incisional SSI in
extensively studied [115]. However, the role of laparo- LA than in OA may be that the incidence of wound
scopy in CA is still undefined due to lack of high-level infection was effectively suppressed in the OA group to a
evidence (e.g., randomized controlled trials). The present level lower (7.7 %) than we expected compared with data
randomized controlled trial addressed the issue as to in previous reports [3, 18]. The wound protection system
whether LA for CA effectively reduces the incidence of applied in all cases in OA may have contributed to the
postoperative complications and improves various mea- inhibition of incisional SSI in that group [19, 20]. On the
sures of postoperative recovery in adults in comparison other hand, no protective device against contaminated fluid
with OA, following a recently published study [16] in or irrigation with saline could be applied to the small trocar
which safety of LA for OA was assessed. No significant wounds in LA, except for an endoscopic bag to extract the
between-group differences were found in the parameters resected specimen.
for surgical outcomes and postoperative recovery studied Distinguishing features of the laparoscopic approach
except for operative time, appendiceal stump closure, days over the conventional open approach include earlier
to walking, and blood loss. resumption of oral intake, quicker return to activity, and
Suppression of wound infection and reduction in the reduced pain, resulting in a shorter hospital stay [2, 18, 21].
hospital stay have been emphasized as major benefits of An interesting aspect of the present findings is that such
LA for CA [2, 4, 18]. Surprisingly, the rate of incisional measures of postoperative recovery in LA were compara-
SSI or length of hospital stay was not reduced in the LA ble to those in OA, and advantages of the laparoscopic
group in the present study. Disadvantages of OA may have approach related to postoperative pain, physical activity, or
been overestimated because of potential bias concerning bowel function were not observed. Early postoperative
disease severity, antibiotics, analgesics, or surgeons in benefits of the procedure may become negligible when
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Fig. 2 Changes in the white blood cell (WBC) count and C-reactive protein (CRP) level before and after surgery. Values are shown as
mean SD. LA laparoscopic appendectomy, OA open appendectomy
patients are exposed to the profound effects of continued for percutaneous cannulation, wherein laparoscopic
infection and inflammation elicited by contamination due appendectomy is also hampered by the severe disease state.
to the perforated disease itself. Patients in both groups were Laparoscopic drainage can optionally be used in such a
urged to walk as early as possible after surgery in accor- situation, which may contribute to avoiding conversion to
dance with the same postoperative program for recovery of laparotomy. One patient in the LA group successfully
physical activity. This could account for the smaller underwent laparoscopic drainage and interval appendec-
advantage of LA related to physical activity than we tomy. The laparoscopic approach may have the potential
expected. benefit of lessening a surgeons hesitation about not
It is plausible that LA for perforated appendicitis should removing the inflamed appendix at the same time.
result in a decreased incidence of IAA because the The decision of whether to use ligation or a stapling
abdominal cavity can be better visualized and a more device for appendiceal stump closure in perforated
thorough washout can be performed. However, a higher appendicitis remains controversial [3133]. In the majority
incidence of IAA formation following the use of laparo- of our LA group cases, an endolinear stapler was used for
scopy has been reported [5, 11, 15], which possibly has appendiceal stump closure because we thought that the
hampered LA being adopted as a standard procedure for stapler has the advantages of relatively easy handling and
CA. Our findings showed that the rates of organ/space SSI, of avoiding ligation of fragile and necrotic tissue in CA,
with or without stump leakage, were similar between the presumably resulting in a reduction in the incidence of
study groups, with a comparable incidence of reoperation leakage. However, ligation or suture of the stump was
and IVR. These results are consistent with recent retro- possible and successfully done in most of the OAs with
spective studies [1, 3, 7, 8, 10, 14], and, therefore, LA for similar disease severity. Interestingly, the rates of stump
CA is considered safe and feasible with improvements in leakage were comparable between the LA and OA groups
techniques and devices. Nonetheless, the roles of extensive in this study. Regarding cost, no significant difference in
irrigation and routine drainage to reduce risks of IAA that total hospital charges, including the laparoscopic devices,
were employed in this study remain debatable [2226]. was found between groups in this study.
An alternative treatment for CA is nonsurgical, includ- This study was performed in a single center with a rel-
ing intravenous antibiotics and selective percutaneous atively small sample size and has several limitations. Data
drainage, followed by interval appendectomy [2730]. on cosmesis or the incidence of incisional hernia were not
There are refractory cases without any safe access routes recorded in this study, which might have disclosed some
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beneficial effects of the laparoscopic approach [34, 35]. 8. Galli R, Banz V, Fenner H, Metzger J (2013) Laparoscopic
The possibility cannot be excluded that the administration approach in perforated appendicitis: increased incidence of sur-
gical site infection? Surg Endosc 27:29282933
of analgesics does not always truly reflect actual pain 9. Katsuno G, Nagakari K, Yoshikawa S, Sugiyama K, Fukunaga M
levels, as this may follow department policies or standards (2009) Laparoscopic appendectomy for complicated appendicitis:
rather than real demand. The use of a visual analogue scale a comparison with open appendectomy. World J Surg 33:208214
may be more appropriate to assess postoperative pain. It is 10. Khiria LS, Ardhnari R, Mohan N, Kumar P, Nambiar R (2011)
Laparoscopic appendicectomy for complicated appendicitis: is it
conceivable that the benefits of LA would become more safe and justified?: a retrospective analysis. Surg Laparosc
evident in more complicated cases [4] or that there would Endosc Percutan Tech 21:142145
be some differences between small and large infected 11. Lim SG, Ahn EJ, Kim SY, Chung IY, Park JM, Park SH, Choi
incisions in the severity of illness, such as inflammatory KW (2011) A clinical comparison of laparoscopic versus open
appendectomy for complicated appendicitis. J Korean Soc
response, pain, cost, and length of healing. A larger sample Coloproctol 27:293297
size would be needed to address these hypotheses by pre- 12. Malagon AM, Arteaga-Gonzalez I, Rodriguez-Ballester L (2009)
cise analysis of patients with comorbidities or postopera- Outcomes after laparoscopic treatment of complicated versus
tive complications. In addition, it should be noted that an uncomplicated acute appendicitis: a prospective, comparative
trial. J Laparoendosc Adv Surg Tech A 19:721725
appropriate comparison of medical costs and hospital stay 13. Park HC, Yang DH, Lee BH (2009) The laparoscopic approach
between LA and OA was difficult because of the unique for perforated appendicitis, including cases complicated by
and complex medical insurance system in Japan, which abscess formation. J Laparoendosc Adv Surg Tech A 19:727730
allows a relatively longer hospital stay for patients with 14. Thereaux J, Veyrie N, Corigliano N, Servajean S, Czernichow S,
Bouillot JL (2014) Is laparoscopy a safe approach for diffuse
sufficient oral intake and physical activity. appendicular peritonitis? Feasibility and determination of risk
In conclusion, the present findings suggested that LA for factors for post-operative intra-abdominal abscess. Surg Endosc
CA is safe and feasible, while a distinguishing benefit of 28:19081913
LA was not validated in this clinical trial. A further study 15. Yeom S, Kim MS, Park S, Son T, Jung YY, Lee SA, Chang YS,
Kim DH, Han JK (2014) Comparison of the outcomes of
would be needed to clarify the effectiveness of LA for CA. laparoscopic and open approaches in the treatment of periap-
pendiceal abscess diagnosed by radiologic investigation. J La-
Compliance with Ethical Standards paroendosc Adv Surg Tech A 24:762769
16. Thomson JE, Kruger D, Jann-Kruger C, Kiss A, Omoshoro-Jones
Disclosures Yoshiro Taguchi, Shunichiro Komatsu, Eiji Sakamoto, JA, Luvhengo T, Brand M (2015) Laparoscopic versus open
Shinji Norimizu, Yuji Shingu, and Hiroshi Hasegawa have no conflict surgery for complicated appendicitis: a randomized controlled
of interest. trial to prove safety. Surg Endosc 29:20272032
17. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG
(1992) CDC definitions of nosocomial surgical site infections,
1992: a modification of CDC definitions of surgical wound
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