Comparison of laparoscopic-assisted appendectomy with intracorporal laparoscopic appendectomy and open appendectomy.

BACKGROUND: A laparoscopic appendectomy is associated with less postoperative pain and a shorter postoperative stay than the open technique. However, the open technique is faster and less expensive than the completely laparoscopic method. A laparoscopic-assisted appendectomy has the advantages of both the laparoscopic and open techniques.
METHODS: A retrospective study involving 83 patients was performed comparing the three different techniques. The comparison studied operating time, surgical expense, and postoperative stay.
RESULTS: The completely laparoscopic method was performed on 24 patients with an average surgical time of 88.9 minutes, average charges of $604, and average postoperative stay of 2.6 days. The open technique was performed on 26 patients with a surgical time of 77.1 minutes, charges of $42, and a postoperative stay of 2.4 days. The laparoscopic-assisted technique was performed on 33 patients with a surgical time of 70.3 minutes, charges of $208, and a postoperative stay of 1.8 days.
CONCLUSION: The laparoscopic-assisted method of appendix removal can be performed as efficiently as the open technique but at <67% of the cost of the complete laparoscopic method. The postoperative stay is shorter for the laparoscopic-assisted technique than for the open technique. Thus, the laparoscopic-assisted technique is a cost-effective method for removing the appendix.

INTRODUCTION

Acute appendicitis is the most common condition leading to emergency abdominal surgery in young adults. Traditionally, the treatment for appendicitis has been a right lower quadrant incision with removal of the appendix as described by Charles McBurney in 1889 and 1894.[1,2] However, within the past decade, the introduction of laparoscopy has changed this approach. The laparoscopic appendectomy has allowed surgeons to diagnose and also treat appendicitis at the same time.[3-5] The advantages of laparoscopic appendectomy include less postoperative pain and faster return to work and normal activity.[6-14] The disadvantages of the laparoscopic procedure are longer operating time [5,7,8,10,15-18] and greater cost.[19-23] A technique to reduce operating room time and cost is a combination of the laparoscopic and open technique called the laparoscopic-assisted technique.[24-26] This technique allows surgeons to use the advantages of the laparoscopic method including visual diagnosis, less postoperative pain, and quicker return to work. The laparoscopic-assisted appendectomy requires less operating room time and is less costly than the traditional intracorporeal laparoscopic treatment. In essence, it offers the advantages of both the laparoscopic and the open techniques.

To evaluate the laparoscopic-assisted technique, we performed a retrospective evaluation of three surgical approaches for removing the appendix. The three methods included the traditional open McBurney approach (OA), the intracorporal laparoscopic method (LA), and a laparoscopic-assisted method (LAA). The study was conducted at a community hospital and specifically evaluated the surgical time, operating room cost, and postoperative hospital stay.

METHODS

We conducted a retrospective study of three different methods for removing the appendix. The first method is the traditional open method involving a muscle splitting technique through a McBurney incision. The second method is an intracorporal laparoscopic technique using three trocars and an endostapler at the base of the appendix. The third method is the laparoscopic-assisted technique involving insufflation of the abdomen through an infraumbilical port.

In the laparoscopic-assisted procedure, the abdomen is inspected and the appendix is visualized. A 10-mm port is placed through the abdomen over the location of the appendix. A Babcock grasper is used to clamp the appendix that is then pulled within the trocar port; the air in the abdomen is removed, thus allowing the appendix to be pulled through the incision into the operating field. The mesoappendix is dissected and vessels are ligated as in the traditional open technique. The appendiceal stump is then ligated. Once the appendix is removed, the cecum and appendiceal stump are placed within the abdomen; the abdomen is again insufflated to check for hemostasis and to irrigate the abdominal cavity. The trocars are removed and the fascia and peritoneum are closed.

To evaluate each technique, one general surgeon was chosen for each of the three techniques with which he or she was comfortable. The study group consisted of 83 patients selected over a two and one-half year period. The laparoscopic technique (LA) involved 24 patients, the open technique (OA) 26 patients, and the laparoscopic-assisted technique (LAA) 33 patients.

Each technique was evaluated for operative time, operation cost (including surgical supply charges), and postoperative length of stay.

The results were statistically evaluated using ANOVA with the Sheffe's posthoc method for analysis of surgery time. These data meet requirements using the test for homogeneity of variance. Significant differences were found between the open and laparoscopic group (P < .05) and between the open and laparoscopic-assisted group (P <.05).

RESULTS

Eighty-three appendectomies were performed in 46 males and 37 females. breaks out the demographic information by procedure group.

shows the surgical time for each group. The LAA technique was 22.4 minutes shorter than the LA and 6.8 minutes shorter than the OA. A statistically significant difference occurred between the LAA technique and the LA technique and between the OA and the LA techniques. However, no significant difference was discovered between the OA and LAA techniques.

The surgical charges for each technique are depicted in . The mean charge for each group includes surgical supplies only and excludes the cost for the operating room and surgeon's fee. The LAA was approximately $400 less expensive than the LA but was $165 more expensive than the OA. The LA was $560 more expensive than the OA. A statistically significant difference occurred among all three techniques.

The postoperative lengths of stay (LOS) are depicted in . A difference in postoperative length of stay did occur between the LAA and the OA. However, these results were not significantly different.

DISCUSSION

The introduction of laparoscopic surgery has had a great impact in many areas of general surgery. The greatest influence has been in gallbladder surgery. The laparo-scopic cholecystectomy was quickly adopted with the benefits of shorter operating time, less postoperative pain, and shorter hospital stays when compared with the traditional open technique. Laparoscopic appendectomy has not been accepted by surgeons as quickly because of the longer operating time and greater cost of the laparoscopic technique when compared with the open technique. However, patients suffer less postoperative pain and have shorter hospital stays with the laparoscopic technique when compared with the open technique. Thus, in an era of cost-conscious medicine, the choice of technique must be weighed carefully.

An additional advantage of laparoscopy is its use as a diagnostic tool. Diagnostic tests for suspected appendicitis including ultrasound, CT scan, and laboratory tests can be a significant expense. The introduction of laparoscopic surgery has allowed for a more accurate and less expensive method of diagnosis than was previously possible, but it carries with it the risks of a surgical procedure and anesthesia.

Because LA requires longer surgical time and is more expensive than the open technique, we evaluated a combination of the laparoscopic and open technique called the laparoscopic-assisted (LAA) technique. Our results indicate that LAA can be performed in approximately 18 minutes less operative time than the LA and in the same amount of surgical time as an open technique. We have shown in our study that a variation of the laparoscopic technique, the laparoscopic-assisted technique, can be performed in the same amount of operative time as the open technique

When evaluating laparoscopic techniques compared with open techniques, a noticeable difference has been shown in charges. The results of our study indicate that the LAA technique is significantly less costly than a completely laparoscopic technique. The LAA technique reduces the cost of the laparoscopic technique by reducing operating time and use of surgical supplies. The LAA at $200 is approximately $400 or 67% less expensive than the completely laparoscopic method at $600. Charges for the LAA can be even further reduced with the use of reusable trocars and Babcocks, which were not used in this study. The open technique remains less expensive than either the LAA or the LA. The difference in charges between the LAA and the open technique was approximately $150 whereas a difference of $560 occurred between the completely laparoscopic and the open technique.

A final area of comparison involves the postoperative length of stay. Patients undergoing the LA method have been shown in many studies[7,12–14,16,17 ,27–30] to have a shorter postoperative hospital stay than patients undergoing an open appendectomy. Patients undergoing the LAA technique appear to have the similar advantage of reduced postoperative recovery stay as OA patients (1.7 days vs. 2.4 days). But in our study, the difference in postoperative recovery time among all three groups did not show a statistically significant difference.

Finally, the laparoscopic-assisted technique has an advantage over the open technique in that it can be utilized as a diagnostic tool. The laparoscopic-assisted method is initially used to visualize the appendix, and thus diagnose appendicitis. If the cause of the abdominal pain is not appendicitis, the abdomen can be further explored laparoscopically to assess for another cause of abdominal pain without the use of any radiologic tests. If during an open appendectomy, the appendix appears normal, the abdominal exploration is more difficult to perform and, therefore, it is more difficult to determine the cause of the abdominal pain. In fact, the operation may even require a larger incision prolonging the operating time. In atypical presentation of appendicitis, diagnostic radiologic studies such as ultrasound and CT scan have a relatively high degree of accuracy, but not as great as direct visualization with the laparoscope.

CONCLUSION

The laparoscopic-assisted technique for appendectomy incorporates the advantages of both the laparoscopic technique and the open technique. The LAA technique has the advantage of a laparoscopic exploration, diagnosis, and treatment that is unavailable through an open technique. In addition, The LAA technique provides a laparoscopic method that can be performed in the same amount of operating time as an open technique. The LAA can be performed at 67% of the cost of a completely laparoscopic method thus making the surgical expense of a laparoscopic-assisted procedure close to the surgical cost of an open procedure. The LAA appears to have a shorter postoperative hospital stay when compared with the open technique. The laparoscopic-assisted technique has all the advantages of the laparoscopic method (diagnosis/exploration and reduced hospital stay) at less expense than the completely laparoscopic technique. The LAA technique also has the advantage of the open technique in that it has shorter operating time. Our study has shown that LAA is a cost-effective technique for removing the appendix.

Table 1.

Demographics by Appendectomy Procedure Group (Total n = 83)

	Laparoscopic (n=24)	Laparoscopic-assisted (n=33)	Open Appendectomy (n=26)
Age				ANOVA, P value
mean ± sd	36.3 ± 18.2	23.2 ± 15.2		37.5 ± 16.9
F=6.95, P = .002
Gender				Chi Square
Males	11 (45.8)	18 (54.5)	17 (65.4)	1.95, P = .378
Females	13 (54.2)	15 (45.5)	9 (34.6)

Table 2.

Analysis of Length of Stay, Surgery Time, and Operating Charges by Procedure Group

	Laparoscopic (n=24)	Laparoscopic-Assisted (n=33)	Open Appendectomy (n=26)	Kruskal-Wallis P value
LOS from Surgery
mean ± sd	2.6 ± 2.3	1.7 ± 1.0	2.4 ± 1.8	P = .403
median (IQ range)	2 (1-3)	2 (1-2)	2 (1-4)
Surgery Time (min)
mean ± sd	88.9 ± 24.0	70.3 ± 17.4	77.1 ± 21.0	*F = 5.67
median (IQ range)	85.0 (72.3-111.5)	69.0 (58.0-82.0)	73.0 (60.0-93.8)	P = .005
Operating Charges
mean ± sd	604.8 ± 206.5	207.9 ± 44.2	42.2 ± 19.5	P < .001
median (IQ range)	587.9 (452.1-775.5)	200.5 (189.8-222.0)	34.2 (29.4-59.1)

Significant differences occurred between the open and laparoscopic group (P < .05) and between the open and laparoscopic-assisted group (P < .05).