Appendectomy in the pre- and postlaparoscopic eras

The role of laparoscopic appendectomy remains controversial since many auth ors have suggested that overall morbidity is primarily a function of the de gree of appendicitis rather than the operative approach. We have reviewed o ur appendectomy experience to determine the advantages and/or disadvantages of the laparoscopic technique in cases of acute appendicitis, and furtherm ore to ascertain whether the extent of disease should affect the surgical a pproach used. Data were accumulated for all 1158 patients who underwent app endectomy at a single institution during the following three time periods t hat span the pre- and postlaparoscopic eras: period I (1987 to 1990), perio d II (1991 to 1993), and period III (1994 to 1997). Cases were categorized with regard to pathologic findings and operative approach (i.e., open or la paroscopic appendectomy). The percentage of appendectomies performed laparo scopically increased with time (0%, 27%, and 79% for periods I, II, and III , respectively). Overall, the total operating room time was slightly shorte r for laparoscopic compared to open appendectomy (99 vs. 102 minutes; P <0. 05). Operating room times for open appendectomy remained unchanged, but the times for laparoscopic appendectomy decreased from period II to period III (119 to 94 minutes; P <0.001). In cases of gangrenous/perforated appendici tis, the times for laparoscopic appendectomy were significantly shorter tha n those for open appendectomy (98/115 vs. 120/125 minutes; P <0.001 for bot h). Overall, the hospital stay was shorter for patients undergoing laparosc opic appendectomy (1.63 vs. 4.21 days; P <0.001), and the difference was ma intained in all three time periods. The differences in length of hospital s tay for laparoscopic vs. open appendectomy were most dramatic in gangrenous /perforated cases (1.8/3.0 vs. 4.0/9.0 days; P <0.001), whereas there was o nly a slight difference in cases of simple appendicitis, for example, 1.6 v s. 2.1 days (laparoscopic vs. open appendectomy, period III). There was a s ignificant decrease in the percentage of perforated cases in which surgical treatment had been delayed (>8 hours) (21%, 5%, and 5%) over the three tim e periods, but the rate of "negative" appendectomies was similar (10%, 8%, and 8%). The complication rates following laparoscopic and open appendectom ies during period II were 5.4% and 7.5%, respectively (P >0.05). Laparoscop ic appendectomy results in a marked decrease in the length of hospital stay and similar postoperative morbidity compared to open appendectomy. In case s of gangrenous or perforated appendicitis, laparoscopic appendectomy appea rs to be especially worthwhile in regard to both operating room time and ho spital stay.