Laparoscopic versus open appendectomy: Time to decide

Although widely practiced, laparoscopic appendectomy (LA) has not met with universal approval. Several controlled trials have been conducted, some in favor, others not. The goal of this review was to ascertain (1) if laparosc opy was capable of improving the diagnostic and therapeutic difficulties en countered during open appendectomy (OA) and (2) if the introduction of lapa roscopy in the overall management of acute appendicitis has changed anythin g in practice. Analysis and criticism of 17 controlled studies (nearly 1800 patients) on laparoscopic appendectomy and 2 randomized studies dealing wi th diagnostic laparoscopy are reported. Because of the questionable quality of randomized controlled trials (number of patients, exclusions, withdrawa ls, blinding, intention-to-treat analysis), publication biases, local pract ice variations (hospital stay, rate of enrollment), results regarding analg esia requirements, return to activity and work, duration of hospital stay, outcome, follow-up, and antibiotic prophylaxis the studies must be interpre ted with caution. The real world of appendicitis probably differs greatly f rom the atmosphere under which controlled trials comparing LA and OA have b een performed. Statistical significance is contrary to the clinical signifi cance of the results. Consistently longer operating times [the difference r anging from 8 minutes (NS) to 29 minutes (p < 0.0001)], a minimal reduction in hospital stay [0.1 day (NS) to 2.1 days (p < 0.007)], and, somewhat mor e controversial, an earlier return to normal activity were reported for LA. Data on analgesic requirements were confusing, but wound complications wer e more frequent after OA [pooled odds ratio for 10 studies: 2.6 (95% CI 1.3 -5.2)]. Unsolved problems include national behavioral problems, age and exp erience of operating surgeons (LA or OA), and emergency conditions (availab ility of staff, instruments). Results of cost analysis vary according to th e standpoint of disease, the patient, the surgeon, the treatment center, in dustry, and society. Three questions remain: Because of the competition of LA versus OA, OA has improved greatly. Can it be improved any more? Is ther e a place or need for further randomized controlled trials? Should we not c onclude once and for all that LA is out?.