versus open appendectomy in 222 hospitals participating in the American College of Surgeons National

Surgical Quality Improvement Program (ACS NSQIP) was conducted by Ingraham and colleagues.73 The

analysis of 30-day outcomes following laparoscopic and open appendectomy showed overall morbidity,

serious morbidity, surgical site infection, and serious morbidity or mortality to be higher in patients

undergoing open appendectomy, although these complications were generally low in both groups. A

Cochrane review of 67 trials comparing laparoscopic and open appendectomy was updated in 2010.74 Of

these studies, the vast majority (56) were conducted in adults. Outcomes assessed by the included trials

most frequently included operating time, complication rates, hospital stay, pain, and return to normal

activity.

6 Although a variety of complications were evaluated, due to inconsistencies in the definition and

reporting of these complications, the authors only examined two specific complications in their analysis:

wound infection and intra-abdominal abscess. Following laparoscopic appendectomy, wound infections

were approximately one-half as likely when compared to open appendectomy (OR 0.43; 95% CI: 0.34 to

0.54). Conversely, laparoscopic appendectomy was associated with a nearly threefold increase in the

likelihood of intra-abdominal abscess when compared to an open technique (OR 1.77; 95% CI: 1.14 to

2.76). Operative time was 10 minutes longer for laparoscopic appendectomy (95% CI: 6 to 15), but this

difference has been decreasing in recently published trials. Laparoscopic appendectomy was also

associated with lower postoperative pain, shorter hospital stay (1.1 days), and faster return to normal

activity (5 days), although these results are highly heterogeneous and further study is warranted.

Hospital and operational costs are higher with laparoscopic appendectomy, but again, these results are

strongly heterogeneous. The authors concluded that laparoscopic appendectomy confers many benefits

over open appendectomy, and should be strongly considered as the preferred approach where surgical

expertise is appropriate and equipment is available and affordable.

The question of whether or not appendectomy should be performed via an open or laparoscopic

technique has been inherently difficult to answer because both approaches offer similar advantages,

namely, a small incision, low incidence of complications, a short hospital stay, and rapid return to

normal activity. Newer studies would favor laparoscopic approaches but the answer is still not

definitive. Ultimately the surgical approach remains up to the surgeon. Well-trained surgeons should be

facile in both approaches should the need arise.

Single-Incision (Single-Port) Laparoscopic (SILS) Appendectomy

In the evolving era of “scarless surgery,” SILS has been utilized for appendectomy. A single-incision

laparoscopic-assisted appendectomy for acute appendicitis was first reported in adult patients in 1992.75

Soon thereafter, this surgical approach began to be reported in children, with the first reports utilizing a

single umbilical incision with a laparoscopic-assisted appendectomy, in which the appendectomy was

performed after exteriorization through the umbilical incision.76 Since then, several techniques under

the auspices of SILS have been utilized including natural orifice transluminal endoscopic surgery and

many variations of single-incision techniques.77–80 The touted advantages of the SILS approach to

appendectomy are similar to general laparoscopy compared to open operations, including less pain,

faster recovery, and better cosmesis. However, critics countered these with concerns about increased

costs, longer operation times, and higher complication rates.81

In adult studies comparing SILS with conventional three-port laparoscopic appendectomy, advantages

in cosmetic outcomes were at the cost of longer operation times and substantial early postoperative

pain.82 SILS is even more popular in children without significant data that show a benefit. Oltmann and

colleagues

83 reported that SILS with appendectomy is feasible and safe in the pediatric population.

Although operating times were longer than the conventional three-port laparoscopic appendectomy, the

authors suggested these should improve with better instrumentation and experience. St. Peter and

colleagues

84 reported on the only randomized control trial comparing SILS-assisted appendectomy to

conventional three-port laparoscopic appendectomy in 160 children with nonperforated acute

appendicitis. Utilizing an extracorporeal appendectomy, there was a nonsignificant difference in wound

infection rates of 3.3% for SILS patients compared to 1.7% for conventional laparoscopy. Although there

was a statistically significant difference in operative time between the two approaches, the SILS

technique was only 5.4 minutes longer (29.8 ± 11.6 vs. 35.2 ± 14.5 minutes). The investigators

suggested that the difference was not clinically relevant and both techniques had comparable outcomes.

Operative Approach in Complicated Appendicitis

Clinical evidence that supports the laparoscopic approach for complicated (perforated or intra1898

abdominal abscess) appendicitis remains controversial. The concern over greater incidence of intraabdominal abscess following the laparoscopic approach was reported in some studies

85–87 but not

supported by others.88,89 Due to the increased morbidity associated with complicated disease, some

surgeons have opted for an initial nonoperative approach.70,84,90 Using nonoperative treatment for

complicated appendicitis followed by interval appendectomy obviates the need to manage the

inflammatory environment in the acute stage. Such a strategy has been shown to be successful in

treating most of the cases of complicated appendicitis with shorter hospitalization, lower charges, and

lower morbidity.91,92

Outpatient Appendectomy

Traditionally, patients are hospitalized for 24 hours after laparoscopic appendectomy. As we move

toward laparoscopic appendectomy becoming a new standard, the question has arisen if this surgery can

be done as an outpatient operation. Although this strategy has been advanced in many elective

abdominal procedures – laparoscopic cholecystectomy,93 gastric bypass,94 and incisional hernia repair,95

for example – surgeons remain hesitant to discharge patients on the day of emergency surgery,

particularly one with an infectious etiology. As recently as 2004, the average length of stay for

laparoscopic appendectomy was 2.06 days.96

Most protocols in the literature describe discharge after a set of criteria has been reached. Utilizing

these protocols it has been shown that discharge can occur as soon as 171 minutes after completion of

the surgery.97 This is true regardless of the time of day the surgery was completed. In the largest

published adult series, 55% of the patients were discharged between the hours of 6 PM and 6 AM.97 Other

studies confirm that a protocol for outpatient appendectomy can be successful for early same day

discharge.98,99 In a study of 179 children 158 were targeted for same day discharge. Twenty-one

patients were excluded due to findings of perforated or gangrenous appendicitis. One hundred and

twenty six (80%) were discharged the same day as surgery with exceptions being made for social issues

(too late at night or families unwilling to leave).100

The studies to date, have been unable to show a difference in morbidity in the groups when

comparing immediate discharge to patients who are admitted.96,97,99,101 In the largest of the studies on

the topic postoperative complications occurred in 2.4% of outpatients and 11.7% per cent of inpatients

(P = 0.16). Complications included superficial wound infections, urinary retention, urinary tract

infection, intra-abdominal bleeding, pneumonia, and infected hematoma. Based upon the data, the

authors concluded that outpatient laparoscopic appendectomy can be performed safely in selected

patients.98

7 Certainly from an economic standpoint, an argument could be made for this transition to outpatient

surgery for uncomplicated appendicitis. Length of stay following laparoscopic appendectomy for

uncomplicated appendicitis ranges from 1.6 days to 2.1 days.102 If an outpatient protocol were applied

universally, it could result in annual healthcare savings of $920 million. Even a more conservative

estimate done in Canada comparing outpatient appendectomies to same day discharges showed a cost

saving of $323 Canadian dollars per patient.99

APPENDICEAL NEOPLASMS

8, 9 Approximately 1% of all appendectomy specimens will contain a neoplasm.103 The most common

tumors are carcinoid, benign mucoceles, and mucinous carcinoma. Rare tumors of the appendix include

adenoma, adenocarcinoid, lymphoma, and GI stromal tumors. Appendiceal cancer is a rare disease, yet

its incidence in the reported literature varies depending on the histologic types included in the

classification of appendiceal malignancies. Historic evidence suggests that appendiceal primaries are

diagnosed in approximately 1% of all appendectomy specimens.103–105 In a SEER database retrospective

analysis that excluded low-grade carcinoid tumors, the annual age-adjusted incidence of appendiceal

primaries was 0.12 cases per 1,000,000 of population. Appendiceal adenocarcinoma represented 66.5%

of these patients.106 Extrapolating from the SEER data, the annual incidence of the appendiceal

adenocarcinoma in the country should be around 300 to 400 cases, although estimates up to 2,000 cases

annually in the United States have been made. This incidence approximates the estimate that the

appendix represents approximately 1% of the mucosal surface of the colon, with 137,000 cases of

colorectal carcinoma in the United States encountered annually.107 The rate of appendiceal neoplasms

seems to be increasing.

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