The Egyptian Journal of Hospital Medicine (October 2017) Vol.

69 (5), Page 2480-2485

Open Appendectomy versus Laparoscopic Appendectomy in Adults

Abdullah Eid Ayyadah Alahmadi 1, Ali Mohammed Fayez AlShehri2,
Fatemah Nasser Al Rebh3, Areej Mohammed Al-Amri1, Abdullah Mohammed ALdayri4,
Raid Naysh Alghamdi5, Qais Saad Alrashidi5, Abdullah Suliman Alwehibi6,
Ali Mohammed Ali Al-Mousa7, Abdulla Abduljaleel Alkhalifa7
1 Taibah University, 2 King Khalid University, 3 Umm Al_Qura University,
4 Majmaah University, 5 King Saud Bin Abdulaziz University for Health Sciences Riyadh,
6 Qassim University, 7 King Faisal University
Corresponding Author: Abdullah Eid Ayyadah Alahmadi - [email protected] – 0567790806

ABSTRACT
As of late, the occurrence of appendicitis has notably diminished. However, appendicitis stays one of the
more common surgical emergencies, and appendectomy stays the treatment of non-complicated appendicitis.
Acute appendicitis (AA), a typical intra-abdominal surgical pathology, obliges a comprehensive
understanding of its presentation, assessment, diagnosis, and overall operative administration. There are two
types of surgery to remove the appendix. The standard technique is an open appendectomy and laparoscopic
appendectomy. As with other laparoscopic surgical procedures, the literature defines decreased pain, earlier
resumption of diet, and decreased length of hospital stay for laparoscopic appendectomy versus the
equivalent open procedure. Nevertheless, this should be accurately considered in the light of the present
condition of the open procedure, which already causes minimal risk and is related with an extremely short
hospital stay and a low complication rate. Further disadvantages of laparoscopy incorporate increased cost
and longer operating times. We conducted this review using a comprehensive search of MEDLINE,
PubMed, EMBASE, Cochrane Database of Systematic Reviews, and Cochrane Central Register of
Controlled Trials from January 1, 1988, through July 28, 2017.
Keywords: Open appendectomy, Laparoscopic appendectomy, Appendicitis.

INTRODUCTION
Acute appendicitis (AA), a typical intra- Expanding evidence proposes that in numerous
abdominal surgical pathology, obliges a patients with uncomplicated acute AA, antibiotic
comprehensive understanding of its presentation, treatment might be as effective as surgical
assessment, diagnosis, and overall operative treatment [2, 3].
administration. There are two types of surgery to Concisely, the pathophysiology and progressive
remove the appendix. The standard technique is an timeline of AA are ascribed to the following:
open appendectomy and laparoscopic
appendectomy. Concisely, the pathophysiology and  Bacterial invasion
progressive timeline of AA are ascribed to luminal  Luminal obstruction causing distention
obstruction, causing distention, bacterial invasion,  Ineffective venous and lymphatic drainage
ineffective venous and lymphatic drainage, and  Perforation with associated leakage of contents into
lastly, perforation with related leakage of contents the peritoneal cavity. The operative method to deal
into the peritoneal cavity. with AA comprises of appendectomy (surgical
The presentation, assessment, and diagnosis expulsion of the vermiform appendix); be that as it
of AA are extremely inconsistent; many factors may, the decision between an open and a
attribute to these inconsistencies. The classic laparoscopic operation keeps on being argued in the
history consists of anorexia and periumbilical pain, medical literature [4, 5]. The right-lower-quadrant
after that nausea, vomiting, and right-lower- entry point of open appendectomy has persevered
quadrant pain, in addition to leucocytosis [1]. basically unaltered since it was spearheaded by
Physical examination and history ought to provide McBurney in the nineteenth century [6]. The
sufficient clinical information to diagnose AA, with utilization of laparoscopy in the surgical
the utilization of imaging modalities as adjuncts in administration of AA was first portrayed in 1983,
the valuation. and there is progressing pattern toward expanded
Treatment comprises of giving aggressive utilization of this approach [7]. Likewise with other
intravenous liquid resuscitation and antibiotics, laparoscopic surgical techniques, the literature
putting the patient on nil per os (NPO) status, depicts diminished pain, before resumption of
giving pain control, and getting a general surgical eating routine, and diminished length of hospital
counsel for authoritative operative administration. stay remain for laparoscopic appendectomy versus

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Received:1 / 9 /2017 DOI : 10.12816/0041698
Accepted: 10 /9 /2017
 Open Appendectomy versus Laparoscopic Appendectomy in Adults

the identical open system [8, 9]. However, this must performed operation specified for patients with AA.
be impartially considered in the light of the present Whether and when to implement a laparoscopic
condition of the open method, which as of now appendectomy as opposed to an open procedure
induces insignificant hazard and is related with an stays a relevant question. Open appendectomy
amazingly short healing center stay and a low brings marginal risk and has a tremendously short
intricacy rate. Extra disadvantages of laparoscopy length of hospital stay [10, 11].
incorporate expanded cost and longer operating
times. The World Society of Emergency Surgery (WSES)
published in 2016 guidelines for acute appendicitis
INDICATIONS that comprised the following recommendations
From the time when described by McBurney regarding laparoscopic appendectomy (Table 1) [12]:
[6]
, open appendectomy has been a firm and widely

Table 1: Recommendations regarding laparoscopic appendectomy

Laparoscopy is feasible and safe in adolescent male patients, still no clear advantages can be
validated in this population (level 2 evidence; grade B recommendation)
No main assistances have also been detected for laparoscopic appendectomy in youngsters, but it
decreases hospital stay and general morbidity (level 1 evidence; grade A recommendation)
Laparoscopy should not be considered as a first choice over open appendectomy in pregnant
patients (level 1 evidence; grade B recommendation)
Laparoscopy offers clear benefits and ought to be preferred in obese patients, older patients and
patients with comorbidities (level 2 evidence; grade B recommendation)
In knowledgeable hands, laparoscopy is more valuable and cost-effective than open surgery for
complicated appendicitis (evidence level 3; grade B recommendation)
Laparoscopic appendectomy ought to represent the first selection where laparoscopic equipment
and skills are available, in that it offers clear benefits in terms of less pain, lower frequency of
surgical-site infection (SSI), decreased length of stay, earlier return to work, and reduced overall
costs (level 1 evidence; grade A recommendation)

CONTRAINDICATIONS In a study comparing laparoscopic and open

There are no known contraindications for appendectomy for complicated appendicitis in adult
appendectomy in patients with suspected patients, Taguchi et al [6] found that the minimally
appendicitis, aside from an account of a patient invasive method was safe and practical in this
with a long history of side effects and indications of setting; however, it did not significantly decrease
a vast phlegmon. In the event that a periappendiceal complications. Li et al [14] found that laparoscopic
ulcer or phlegmon exists secondary to appendiceal appendectomy, as compared with open
perforation or rupture, a few clinicians can pick a appendectomy, was practical and effective in
moderate method with wide range antibiotics and paediatric patients giving an appendiceal abscess
percutaneous drainage followed by appendectomy and that it had useful clinical effects (e.g., in terms
later (interval appendectomy). Certain of postoperative recovery of gastrointestinal
contraindications occur for laparoscopic function) and a lesser rate of postoperative
appendectomy, comprising extensive adhesions, complications.
radiation or immunosuppressive treatment, severe
portal hypertension, and coagulopathies. Equipment & Preparation
Laparoscopic appendectomy is contraindicated in For open appendectomy, all equipment should
the first trimester of pregnancy. On the odd be present in the surgical arena and checked for
occasion, an appendiceal mucocele (i.e., a appropriate working capacity before the procedure
collection of mucus within the appendiceal lumen) starts. A standard laparotomy set with customary
might happen. Infrequently, patients might present clamps and retractors (Regnel, Roux, and
with a low-grade carcinoma of the appendix or the Richardson) are used, accompanied by proper
cecum. In these cases, the surgeon should prevent sutures and ties. All methods of laparoscopic
perforation throughout dissection, for the reason appendectomy require the standard laparoscopic
that it might cause seeding of the peritoneum with equipment and some helpful equipment (Table 2).
viable cells, leading to pseudomyxoma peritonei.

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 Abdullah Alahmadi et al.

Table 2: Required equipment for laparoscopic appendectomy

Standard laparoscopic Helpful equipment

Hook electrocautery Endoscopic ligatures (Endoloop; Ethicon,
Somerville, NJ)
Blunt graspers Laparoscopic clip applier
Trocars Endoscopic retrieval bag
Electrosurgical device (eg, electrocautery wand, Endocopic gastrointestinal anastomosis
Harmonic Scalpel [Ethicon, Somerville, NJ], (Endo-GIA) 45-mm stapler, white cartridge
Sonosurg [Olympus, Hamburg, Germany])
Laparoscope, 30º, 10 mm Laparoscope, 30º, 5 mm
Suction irrigator

Table 3: Patient Preparation for open Appendectomy vs. Laparoscopic Appendectomy

Open Appendectomy Laparoscopic Appendectomy

Anesthesia Open appendectomy can be performed with Because of the inherent surgical
various anesthetic techniques, technique and requirements, general
including general, regional, and local. anesthesia is the preferred method in
Routinely, general anesthesia is the first choice, performing a laparoscopic
especially in the pediatric population. Studies appendectomy. Administer
show that local anesthesia, with anesthetic preoperative antibiotics to cover gram-
infiltrated into the subcutaneous and deep tissue negative and anaerobic bacteria.
layers (including the peritoneum), and are a safe
and cost-effective practice [15, 16]. The operative
procedure must always start with the surgical
time-out. The importance of reviewing the patient
identification, surgical team, procedure to be
performed, and completion of all preoperative
requirements prior to proceeding cannot be
overstated. At this point, the patient is ready to be
prepared and draped in a sterile fashion.

Positioning Place the patient supine, and tuck his or her right Place the patient supine and tuck the
arm for the duration of the procedure. The left arm for initial peritoneal access. A
surgeon should stand on the patient's right, and single monitor is best positioned to the
the assistant surgeon should stand on the patient's right of the patient, along the line of
left. the right anterior superior iliac spine
(ASIS). Upon abdominal insufflation
and laparoscope insertion, steep
Trendelenburg positioning allows
proper placement of the last two
trocars. After all of the trocars have
been placed, placing the patient with
the left side down aids gravity in
relocating the small bowel away from
the appendiceal/cecal field of vision.

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 Open Appendectomy versus Laparoscopic Appendectomy in Adults

Open Appendectomy vs. Laparoscopic cauterized to prevent a future mucocele. The

Appendectomy Technique appendix might be inverted into the cecum with
the utilization of a purse-string suture or Z-stitch.
 Open Appendectomy Appendiceal stump inversion is not compulsory.
Before incision, the surgeon ought to The cecum is positioned back into the
wisely perform a physical examination of the abdomen, and the abdomen is irrigated. When
abdomen to detect any mass and to define the site indication of free perforation occurs, peritoneal
of the incision. Open appendectomy needs a lavage with some liters of warm saline is
transverse incision in the right lower quadrant suggested. After the lavage, the irrigation fluid
over the McBurney point (i.e., 2/3 of the way should be totally aspirated to diminish the
between the umbilicus and the anterior superior likelihood of spreading infection to other areas of
iliac spine [ASIS]). Vertical incisions (e.g., the the peritoneal cavity. The utilization of a drain is
Battle pararectal) are hardly performed due to the not usually necessary in patients with acute
trend for dehiscence and herniation. The appendicitis, but noticeable abscess with gross
abdominal wall fascia (i.e., Scarpa fascia) and the infection calls for drainage. Wound closure
essential muscular layers are abruptly dissevered initiates with closing of the peritoneum with a
or split in the direction of their fibers to take continuous suture. At that point, the fibers of the
access to the peritoneum. If essential (e.g., on muscular and fascial layers are re-approximated
account of concomitant pelvic pathologies), the and closed with a continuous or interrupted
incision can be stretched medially, with the absorbable suture. Lastly, the skin is closed with
surgeon dissevering some fibers of the oblique subcutaneous sutures or staples. In cases of
muscle and retracting the lateral part of the rectus perforated appendicitis, some surgeons leave the
abdominis. The peritoneum is opened wound open, letting for secondary closure or a
transversely and entered. The character of any late primary closure until postoperative day 4 or
peritoneal fluid ought to be prominent to support 5. Other surgeons favour immediate closure in
confirm the diagnosis, and the fluid ought to be these cases [17, 18]. According to a 2015 Cochrane
suctioned from the field. If the fluid is purulent, it review, it is unclear whether routine abdominal
ought to be collected and refined. Retractors are drainage is effective in preventing intraperitoneal
tenderly set into the peritoneum. The cecum is abscesses after open appendectomy for
recognized and medially withdrawn. It is then complicated appendicitis [19].
exteriorized by utilizing a soggy cloth wipe or
Babcock clasp, and the taeniae coli are taken after  Laparoscopic Appendectomy
to their joining. The meeting of the taeniae coli is The surgeon normally positions on the left
identified at the base of the index, underneath the of the patient, and the assistant stands on the
Bauhin valve (ie, the ileocecal valve), and the right. The anaesthesiologist and the anaesthesia
reference section is then seen. On the off chance equipment are placed at the patient's head, and
that the supplement is concealed, it can be the video monitor and the instrument table are
distinguished medially by withdrawing the cecum placed at the feet. Albeit a few varieties are
and horizontally by broadening the peritoneal conceivable, a standard approach is to put three
entry point. cannulae amid the system. Two of these have a
If the appendix appears normal, other settled position (ie, umbilical, suprapubic); the
reasons of the patient's condition ought to be position of the third, which is set in the privilege
sought, for example, ovarian pathology, Meckel periumbilical district, may fluctuate enormously,
diverticulum, and sigmoid disease. After contingent upon the patient's life systems. It
exteriorization of the informative supplement, the ought to be noticed that these are recommended
mesoappendix is held between clips, separated, port locales and that it is adequate to change port
and ligated. The reference section is clipped situation as indicated by the attributes of the
proximally around 5 mm over the cecum to patient, the sort of ports utilized, and the
maintain a strategic distance from sullying of the experience of the specialist. As indicated by the
peritoneal depression, and the cut is made over inclinations of the specialist, a short umbilical cut
the clasp by a surgical tool. Fecaliths inside the is made to permit position of a Hasson cannula or
lumen of the informative supplement might be Veress needle that is secured with two absorbable
identified. The supplement must be ligated to sutures. Pneumoperitoneum (10-14 mm Hg) is
keep draining and spillage from the lumen. The built up and kept up by insufflating carbon
residual mucosa of the appendix is softly dioxide. Through the entrance, a laparoscope is

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 Abdullah Alahmadi et al.

embedded to see the whole abdomen cavity. A port patient with perforated appendicitis. [24] The
12-mm trocar is embedded over the pubic authors determined that the single-port procedure
symphysis to permit the presentation of is a practical technique that, in addition to leaving
instruments (eg, incisors, forceps, or stapler). a nearly inconspicuous scar, has results similar
Another 5-mm trocar is put in the privilege with those of three-port appendectomy.
periumbilical area, as a rule between the privilege
costal edge and the umbilicus, to permit the CONCLUSION
addition of an atraumatic grasper to uncover the The benefits of the laparoscopic technique
supplement. over open appendectomy including shorter
The appendix is grabbed and withdrawn hospital stay, decreased need for postoperative
upward to expose the mesoappendix. The analgesia, early food tolerance, earlier return to
mesoappendix is separated with a dissector work, lower rate of wound infection, against only
inserted through the suprapubic trocar. At that marginally higher hospital costs. Provided that
point, a linear endostapler, endoclip, or suture surgical experience and equipment are available,
ligature is passed through the suprapubic cannula laparoscopy could be considered safe and equally
to ligate the mesoappendix. The mesoappendix is efficient compared to open technique and should
transected with scissors or electrocautery; to be undertaken as the initial procedure of choice
prevent perforation of the appendix and for most case of suspected appendicitis.
iatrogenic peritonitis, the tip of the appendix Nevertheless, since there is no agreement to the
ought to not be grabbed [20]. best technique, both procedures (open and
The appendix can at the moment be laparoscopic appendectomy) are still being
transacted with a linear endostapler, or practiced actively deferring the choice to the
consecutively, the base of the appendix might be preference of surgeon and patients.
suture-ligated in a comparable manner to that in In the future, laparoscopic appendectomy
an open procedure. The appendix is currently free could represent the standard treatment for
and might be removed through the umbilical or patients with appendicitis and undiagnosed
the suprapubic cannula in a laparoscopic pouch to abdominal pain.
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