Clinical Outcomes of Laparoscopic Versus Open Appendectomy for Acute Appendicitis in a Resource-limited Setting
Mohanned Omer Abass1, Yassir Altahir Abdullah2, Elssayed Osman Elssayed1, Abdelrahman Babekir Mhammed1, and Mohamed Saeed Alfaki3
1Department of Surgery, Faculty of Medicine, Shendi University, Shendi, Sudan
2Faculty of Medicine, Shendi University, Shendi, Sudan
3Quality Department, King Abd-ul-Aziz Specialty Hospital, Taif, Saudi Arabia
Correspondence to: Dr. Mohanned Omer Abass; email: firstname.lastname@example.org
Received: 28 Jan 2021; Revised: 15 Jul 2021; Accepted: 20 Jul 2021; Available online: 2 Aug 2021
Background: Acute appendicitis is the most common cause of the acute abdomen; thus, appendectomy is part of most daily emergency surgical duties. It is conducted through either open or laparoscopic approach. Methods: A prospective hospital-based study compared the clinical outcomes of open versus laparoscopic appendectomy for patients with acute appendicitis in El-Mek Nimir University Hospital, Sudan. Results: A total of 550 cases of acute appendicitis were studied, of which 328 (59.6%) underwent open appendectomy surgery and 222 (39.4%) underwent laparoscopic appendectomy. The majority of the study’s population was female. Laparoscopic appendectomy generally involved a longer operation time than open appendectomy (mean duration, 42.4±12.5 vs. 29±16 minutes), lesser incidence of severe pain postoperatively (3% vs. 11%; p=0.000), shorter hospital stay (i.e., <24 hours; 96% vs.77%; p=0.000), and a higher rate of patient return to normal activities within 1 week (92% vs.15%; p=0.000). Differences in the occurrence of bleeding, wound infection, or intra-abdominal septic collection were not statistically significant. Conclusion: Both open and laparoscopic appendectomy procedures are safe for the management of acute appendicitis; however, laparoscopic appendectomy is associated with fewer complications and a faster recovery.
Keywords: acute appendicitis, open appendectomy, laparoscopic appendectomy, complications.
Ann Afr Surg. 2021 ; 18(4): 225-229
Conflicts of Interest: None
© 2021 Author. This work is licensed under the Creative Commons Attribution 4.0 International License
Acute appendicitis is the most common surgical emergency, with an approximate lifetime risk of 7% and a peak incidence between the ages of 10 and 30 years (1,2); hence, appendectomy is the most prevalent emergency procedure and is a daily practice within surgical duties worldwide (3,4). McBurney is credited for consolidating the surgical technique of classical open appendectomy at the end of the 19th century when there was no significant changes to the technique (5). In recent decades, minimal access surgery has emerged as a novel operative option and has revolutionized the surgical field (6). Laparoscopic appendectomy was first described in 1983 by Kurt Semm, and since then, its use has continued to increase (7). It has now largely replaced open surgery. It can be employed for simple or complicated presentations of acute appendicitis (8-10).
Surgery in a resource-limited setting is challenging yet important because it provides help to those who are unable to receive treatment at their localities, raising the values of health equity. The provision of advanced medical care, such as laparoscopic surgery, is far more challenging for multiple reasons, including the cost and beliefs of the rural community. The present study aimed to reflect on the current practice in the management of acute appendicitis by comparing the clinical outcomes of open and laparoscopic approaches employed in a resource-limited setting.
Materials and Methods
The study was conducted in El-Mek Nimir University Hospital, Shendi University, Shendi, Sudan, located 172 km north of Khartoum on the eastern bank of the River Nile. The hospital, built in 2002, serves both the people of Shendi and the nearby city of Almatama. Both locations are mostly rural. The hospital has a capacity of approximately 250 beds, and most major specialist treatments are available. Patients for whom specialist treatment is not available are referred to the capital (Khartoum). The surgical department is run by four general surgeons, one urologist, one orthopedic surgeon, and one anesthetist. The surgical wards comprise 60 beds with 4 high-dependency unit beds—there is no ventilator or other intensive care unit equipment available. Laparoscopy was introduced in the Surgery Department in 2018 and has since been gaining popularity.
The current study included all patients who presented with acute appendicitis and underwent an appendectomy at El-Mek Nimir University Hospital between January 2019 and January 2020. Patients who presented with right lower quadrant pain underwent detailed clinical evaluation (history and examination) in conjunction with laboratory tests and imaging studies to ensure a clear diagnosis of acute appendicitis. Patients in whom a diagnosis other than acute appendicitis was discovered intra-operatively and those who presented with a perforated appendix (generalized peritonitis) or appendicular abscess were excluded from the study. After discussing their condition and need for appendectomy with a medical professional, patients chose between open or laparoscopic appendectomy following an explanation of the two procedures. Consent regarding the procedure and their participation in the study was obtained from patients or guardian. Ethical approval was obtained from the Committee of El-Mek Nimir University Hospital (approval no. 09.01.2019).
Surgical procedures were performed by surgical residents and interns, with some contribution from the general surgery specialist in the case of open appendectomy. Laparoscopic appendectomies were performed by either general surgeons or surgical residents. Open appendectomies were performed through a Lanz's incision of approximately 3–4 cm, centered at the McBurney's point. Laparoscopic appendectomies were performed using three ports: a 10-mm port in the umbilicus, a 5-mm port in the left lower quadrant, and a 5-mm port in the suprapubic skin crease.
Operative time from skin incision to closure was measured in minutes, namely the exact time required by the surgeon to complete the procedure. Post-operatively, patients received standardized intravenous antibiotics (usually cephalosporine and metronidazole) as required. Post-operative pain was assessed after the patients had fully recovered from anesthesia using a modified verbal rating scale to categorize patients in one of three categories: no or mild pain, moderate pain, or severe pain. The standard post-operative analgesia included non-steroidal anti-inflammatory drug (NSAID) in the form of diclofenac sodium, paracetamol (if NSAID was contraindicated), and opiates in the form of pethidine. Patients received no analgesia for no or mild pain, NSAID/paracetamol for moderate pain, and opiates for severe pain. Complications, namely bleeding, wound infection, and intra-abdominal septic collection, were recorded as either occurred or did not occur. Post-operative hospital stay was measured in days. The time required by the patient to return to normal activities was measured in weeks since it was expected that patients would provide an approximate rather than exact figure.
The study focused on the immediate post-operative outcome since most of the morbidities were expected to occur early following appendectomy with few long-term complications. The operative cost of open appendectomy in our setting was 2500 SDG, whereas that of laparoscopic appendectomy was 3500 SDG. The total costs of both procedures were not studied.
Data were collected using a predesigned questionnaire and then plotted onto an Excel sheet, coded, and transferred to SPSS version 24 (IBM Corp., Armonk, NY, USA). A descriptive analysis was conducted along with a chi-square test for categorical variables. The results were considered statistically significant at p<0.05. Data are presented as frequencies and percentages or mean±standard deviation.
Of the 550 cases of acute appendicitis, 328 (59.6%) underwent open appendectomy, whereas 222 (39.4%) underwent laparoscopic appendectomy. The mean age of patients was 20.5±10.4years (range, 5–72 years) in the open appendectomy group and 22.7±11.5years (range, 4–70 years) in