DOI: 10.1097/SLA.0b013e31820347a2

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PMID: 21057305

Issn Print: 0003-4932

Publication Date: 2010/12/01


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Laparoscopic Appendectomy: Trading Superficial Infections for Intraabdominal Infections?

Kenneth W. Sharp

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The benefits of laparoscopic appendectomy over open appendectomy (ie, fewer incisional infections, shorter hospital stays, better cosmetic appearance, fewer incisional hernias, less postoperative pain, and faster return to work or school) are frequently acknowledged. So why is there any dispute over the superiority of laparoscopic appendectomy over the open approach? The result of a metaanalysis1 published in 2007 shows a lower risk of wound infection and prolonged postoperative ileus in patients undergoing laparoscopic appendectomy, but a significantly increased risk for the development of intraabdominal abscess (odds ratio of 2.26). This is different from the conclusion of several smaller retrospective analyses of open versus laparoscopic appendectomies that showed no difference in rates of postoperative intraabdominal infection between the two techniques.2–4 Thus the analysis of a very large National Surgical Quality Improvement Program (NSQIP) database comparing laparoscopic versus open appendectomy in this issue of Annals of Surgery performed by Fleming et al is both appropriate and important.5 Is it true that laparoscopic appendectomy trades fewer incisional problems for a much more serious complication: intraabdominal infection?
The authors report on a huge number of appendectomies in the NSQIP database: 39,950 appendectomies over a 3-year period. There were 9375 open appendectomies (23%)—the rest were attempted laparoscopically, with 576 of those converted to open (1.9% of the laparoscopic cases were converted to an open procedure; the reason for conversion could not be determined with NSQIP data). They carefully analyzed the outcomes of incisional infection versus organ space infection (OSI) in these cases and concluded that the overall risk of an incisional infection was lower in the laparoscopy group (OR = 0.37) but the risk of OSI was significantly increased in the laparoscopy group (OR = 1.44). As they dove further into subset analysis, it was found that low-risk patients were only minimally at increased risk for OSI (0.3 vs 0.4%, open vs laparoscopic approach), but the likelihood of OSI in high-risk patients was 8.9% vs 12.3% in the open and laparoscopic groups, respectively. High-risk patients with identifiable preoperative risk factors were male, were smokers, had a higher preoperative white blood cell count, and had preoperative systemic inflammatory response syndrome. Operative factors identifying high-risk patients were wound classes III and IV and total operative time of 60 minutes or more. I found the analysis of those patients undergoing conversion of a laparoscopic procedure to an open procedure interesting; those patients had more wound infections than patients having a totally laparoscopic procedure, but when risk adjusted, they had no increased risk of OSI.
What do we take away from this? Should we abandon laparoscopic appendectomy for patients with high-preoperative-risk factors for developing an intraabdominal infection?
Should we immediately convert a laparoscopic appendectomy to an open procedure if we encounter gangrenous or perforated appendicitis? We all should agree that it is not prudent to trade the lower incidence of an incisional infection for the much more serious and costly occurrence of an intraabdominal infection (this study demonstrated that the laparoscopic approach was highly associated with a lower rate of incisional infection even after adjusting for the high-risk factors; OR = 0.37). The authors give examples of risk-related decision making in several common clinical scenarios—an 18-year-old man with suspected appendicitis, a 23-year-old woman, and a 77-year-old man—and calculate the risk of OSI with variable preoperative risk factors showing the rates of OSI with increasing high factors that may lead the reader to reassess a preoperative recommendation for a laparoscopic appendectomy in a high-risk patient. The authors are unable to draw clear-cut decision-making lines for us but are able to make us think twice about our recommendations for operative approaches in appendicitis.

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