Page 79 - World Journal of Laparoscopic Surgeons

Md Sumon Rahman
Mortality and Morbidity position, excess IAA and extra-abdominal fat, ventilation
problem with pneumoperitoneum, which contribute to
Acute appendicitis is the most commonly diagnosed
cause of acute abdomen and managed surgically by LA higher perioperative complications. According to SAGES
around the world. But in case of complicated appendicitis, guideline, LA is safe and effective in obese patients (level II,
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the outcome varies according to the presentation, age, and grade II). Laparoscopy with longer trocars and instru-
other associated comorbidities. Mortality and morbidity ments has some additional advantages like better expo-
issue is a high concern in laparoscopic management of sure of anatomy, proper visualization, and lower wound
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perforated appendicitis. It has been claimed by some complications. Varela et al documented less overall
authors that in-hospital mortality was significantly lower complications, less hospital stays, and comparable or even
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with LA compared with OA. Moreover, it is reported lower treatment cost with LA than OA in over 906 morbid
that overall complication rate was reduced by LA vs OA obesity patients. Table 1 depicts the results of two different
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(17.43 vs 26.68%, p ≤ 0.0001). Other studies also docu- studies over obese patients with perforated appendicitis.
mented consistently lower postoperative morbidities for DISCUSSION
perforated appendicitis with LA than OA (12.8–39.5% for
LA and 26–37% for OA). 6,10,17 Most of the studies have reported the positive outcomes
of LA than OA in terms of shorter hospital stays, lower
Outcome in Elderly and Obese Patients infection rate, lower IAA, and comparable treatment
cost in perforated appendicitis (Table 2). Conversion rate
In elderly and obese patients, the presentation of appen-
dicitis is not commonly typical and becomes complicated and postoperative IAA remain two significant issues of
easily due to diagnostic delay and other associated debate for LA in perforated appendicitis management.
comorbidities. In the elderly, appendix might become Table 1: Population-based studies for obese patients with
gangrenous at the tip and perforated due to atherosclerotic perforated appendicitis
changes in blood vessels and 50% higher perforation rate is Study Varela et al 42 Masoomi et al 13
also documented in geriatric than younger population. 37,38 Study period 2002–2007 2006–2008
Creation of pneumoperitoneum in elderly patients might Patient number LA: 238 LA: 6769
be hazardous for cardiopulmonary activities proportion- OA: 441 OA: 7110
ately with the duration of operation time in perforated Definition of obesity BMI ≥ 40 kg/m 2 BMI ≥ 30 kg/m 2
appendicitis. So many surgeons discourage laparoscopy Length of hospital stay LA: 5 LA: 4.4
in complicated appendicitis in elderly population. Though OA: 7 a OA: 6.5
few studies reported better outcome in terms of shorter Mortality LA: 0% LA: 0% a
OA: 0%
OA: 0.50%
hospital stay and less infection with LA than OA with Overall complication rate LA: 18% LA: 22.34%
comparable operation time, 8,33,39,40 the benefit of minimal OA: 27% a OA: 34.65% a
access surgery in elderly patient needs more study. Mean cost, USD LA: 12300 LA: 36483
There are some mechanical problems with laparoscopic OA: 16600 OA: 43901 a
approach in obese population that include difficult port a p < 0.01 vs perforated appendicitis (OA); BMI: Body mass index

Table 2: Summary of various study results
Study Patient population Patient number LOS, days Wound infection IAA Treatment cost, USD
Tuggle et al 18 Adult LA: 2060 LA: 3.97 a LA: 2.56% LA: 6.74%
OA: 730 OA: 5.13 OA: 8.05% OA: 3.69%
Tiwari et al 29 Adult LA: 5212 LA: 4.34 a LA: 12125 a
OA: 5323 OA: 7.31 OA: 17594
Masoomi et al 13 Adult LA: 69810 LA: 4.0 a LA: 0.58% LA: 1.65% LA: 32487 a
OA: 68344 OA: 6.0 OA: 2.09% OA: 3.57% OA: 38503
Oyetunji et al 45 <18 years LA: 21254 LA: 5.06 a LA: 4.9% LA: 27951 a
OA: 51533 OA: 5.60 OA: 3.8% OA: 24965
Jen et al 46 <18 years LA: 9246 LA: 5.2 a LA: 5.5%
OA: 21347 OA: 5.5 OA: 6.4%
Mohamed et al 47 Adult LA: 42 LA: 5.3 a LA: 8.3%
OA: 32 OA: 7.2 OA: 24.4%
Gerg et al 4 All age group LA: 49 LA: 3.0 a LA: 8.2% LA: 8.2%
OA: 61 OA: 6.0 OA: 24.6% OA: 22.9%
a p < 0.01 vs perforated appendicitis (OA) group, LOS: length of stay, LA: Laparoscopic appendicectomy, IAA: Intra-abdominal abscess
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