**3.1 Parameters examined in the literature**

To evaluate the benefits of the laparoscopic approach in suspected appendicitis the scientific community examines several parameters. Important issues in the study of laparoscopic appendectomy are: **intraoperative findings, conversion rate to open surgery, histological findings and negative appendectomy rate, duration of operation, intra- and postoperative complications (early and late), postoperative pain, time to bowel mobilization, time until intake of solid food, duration of hospital stay, time until return to normal activities, full activities and sports, reoperations, cosmesis, and costs.** All of these parameters are dealt with in the literature and most of them were measured in our published study (Konstantinidis et al., 2008). In our patients we did not investigate the costs or the cosmetic results.

#### **3.2 Diagnostic and therapeutic outcomes of laparoscopic appendectomy**

**Conversion rate** ranges in meta-analyses between 0% and 23% (Lippert et al, 2002; Sauerland et al., 2004) but there are studies which report conversion rates as high as 39% (Moberg et al., 1998). In everyday praxis conversion rate typically seems to range between 10 and 20%, while in centers of excellence it is lower than 2%. It is apparent that these fluctuations are related with differences in laparoscopic experience. In most studies the operator is a surgical trainee for about 80 to 95% of open appendectomies and for about 50 to 75% of laparoscopic procedures. In our study we had a conversion rate of 0,55% in the 908 patients, in whom an appendectomy was performed. The low conversion rate in our study can be explained by the fact that we are not a teaching hospital but a private center. The operating surgeon in most of our patients has been the director of the department (K.M.K). But also the other surgeons belonging to the team are specialised and very experienced with laparoscopy. A learning curve was apparent for the first 100 appendectomies, where we had a conversion rate of 9%, but these patients were not included in the trial. Conversion rate is reported to be increased in complicated appendicitis (Wullstein et al., 2001). The most common reason for conversion is reported to be dense adhesions due to inflammation, followed by localized perforation and diffuse peritonitis (Agresta et al., 2003; Liu et al., 2002). The presence of significant fat stranding associated with fluid accumulation, inflammatory mass or localized abscess in CT scan is also reported to significantly increase the possibility of conversion (Liu et al., 2002). In our patients the reasons for conversion were dense adhesions in two patients and excessive inflammation in 3 patients.

There were also some patients, who had to be converted because of other pathologies. In our experience these were pelvic hemoperitoneum, inflammatory pelvic disease, ovarian cyst torsion, ovarian mass, ruptured diverticulitis (of the sigmoid and of the cecum) and cecal volvulus. Finally, we performed laparoscopic assisted procedures in a number of patients with Meckelitis. **The necessity to convert patients due to another pathology emphasises the role of laparoscopy as a diagnostic tool.**

There is a strong heterogeneity in **operating time** reported in the literature. Mean operating times in meta-analyses of randomised trials range between 23,5 and 102,2 min (Sauerland et al., 2004). Apart from differences in laparoscopic experience, this can be attributed to the different definitions of operating time. Nevertheless, all meta-analyses agree that the duration of surgery is longer in laparoscopic appendectomy (Benett, 2007; Chung et al., 1999; Fingerhut et al, 1999; Garbutt et al., 1999; Golub et al, 1998; Sauerland et al., 2010;

To evaluate the benefits of the laparoscopic approach in suspected appendicitis the scientific community examines several parameters. Important issues in the study of laparoscopic appendectomy are: **intraoperative findings, conversion rate to open surgery, histological findings and negative appendectomy rate, duration of operation, intra- and postoperative complications (early and late), postoperative pain, time to bowel mobilization, time until intake of solid food, duration of hospital stay, time until return to normal activities, full activities and sports, reoperations, cosmesis, and costs.** All of these parameters are dealt with in the literature and most of them were measured in our published study (Konstantinidis et al., 2008). In our patients we did not investigate the costs or the cosmetic

**Conversion rate** ranges in meta-analyses between 0% and 23% (Lippert et al, 2002; Sauerland et al., 2004) but there are studies which report conversion rates as high as 39% (Moberg et al., 1998). In everyday praxis conversion rate typically seems to range between 10 and 20%, while in centers of excellence it is lower than 2%. It is apparent that these fluctuations are related with differences in laparoscopic experience. In most studies the operator is a surgical trainee for about 80 to 95% of open appendectomies and for about 50 to 75% of laparoscopic procedures. In our study we had a conversion rate of 0,55% in the 908 patients, in whom an appendectomy was performed. The low conversion rate in our study can be explained by the fact that we are not a teaching hospital but a private center. The operating surgeon in most of our patients has been the director of the department (K.M.K). But also the other surgeons belonging to the team are specialised and very experienced with laparoscopy. A learning curve was apparent for the first 100 appendectomies, where we had a conversion rate of 9%, but these patients were not included in the trial. Conversion rate is reported to be increased in complicated appendicitis (Wullstein et al., 2001). The most common reason for conversion is reported to be dense adhesions due to inflammation, followed by localized perforation and diffuse peritonitis (Agresta et al., 2003; Liu et al., 2002). The presence of significant fat stranding associated with fluid accumulation, inflammatory mass or localized abscess in CT scan is also reported to significantly increase the possibility of conversion (Liu et al., 2002). In our patients the reasons for conversion

**3. Results of laparoscopic appendectomy and discussion** 

**3.2 Diagnostic and therapeutic outcomes of laparoscopic appendectomy** 

were dense adhesions in two patients and excessive inflammation in 3 patients.

**the role of laparoscopy as a diagnostic tool.**

There were also some patients, who had to be converted because of other pathologies. In our experience these were pelvic hemoperitoneum, inflammatory pelvic disease, ovarian cyst torsion, ovarian mass, ruptured diverticulitis (of the sigmoid and of the cecum) and cecal volvulus. Finally, we performed laparoscopic assisted procedures in a number of patients with Meckelitis. **The necessity to convert patients due to another pathology emphasises** 

There is a strong heterogeneity in **operating time** reported in the literature. Mean operating times in meta-analyses of randomised trials range between 23,5 and 102,2 min (Sauerland et al., 2004). Apart from differences in laparoscopic experience, this can be attributed to the different definitions of operating time. Nevertheless, all meta-analyses agree that the duration of surgery is longer in laparoscopic appendectomy (Benett, 2007; Chung et al., 1999; Fingerhut et al, 1999; Garbutt et al., 1999; Golub et al, 1998; Sauerland et al., 2010;

**3.1 Parameters examined in the literature** 

results.

Temple et al, 1999). It is nonetheless remarkable that - as laparoscopy evolves - the results of meta-analyses performed by the same investigators show through the years a decreasing difference in operating time between the two approaches (Sauerland et al., 1998, 2002, 2004, 2010). Sauerland et al. report in their most recent meta-analysis that laparoscopic appendectomy is on the average 10 minutes longer than the open one (Sauerland et al., 2010). The median operating time in our study was 26 minutes, which compares favourably with most other studies (The time from cutting the skin at the umbilicus until putting the last skin suture was defined as operating time). We believe that the short operating time is due to the surgeon's expertise, and the training of the surgical team. We also believe that it has to do with the standardisation of the surgical technique.

It has been suggested, and seems logical, that surgical expertise has a great impact in conversion rate and operating time. The latter one as well as the lack of precision in manoeuvers by novices could affect complication rate and patients' outcome.

In our study we had an overall **complication rate** of 5,7%, consisting mostly of minor complications. At the beginning of our series we had to reoperate on a 28 year old female patient 3 days after surgery because of persisting abdominal pain. We performed a diagnostic laparoscopy. There were no findings. We attributed the pain to not properly washed instruments, with remainings of Cidex™ (Johnson& Johnson, Cincinatti, Ohio, USA) solution on them. We had no other reoperations or major complications except for one intraabdominal abscess outside our published series.

The average **wound infection rate** for laparoscopic appendectomy is reported to be 2,8% in the meta-analysis by Golub et al. (Golub, 1998) and 2,5% in a big prospective multi-centerstudy (Lippert et al., 2002). Wound infection rate is reduced by a half after laparoscopic appendectomy in the most recent meta-analysis (Sauerland et al., 2010) based on the study of more than 6000 cases. This is consistent with the findings of a large data base analysis of over 40.000 in the US (Guller, 2004). Wound infection rate in our study was measured separately and was 1,1%.

**Intraabdominal abscesses** are reported in the older meta-analyses to be equally frequent as in the open procedure (Chung et al., 1999; Garbutt et al., 1999; Temple et al.) or even increased, but without reaching statistical significance (Golub, 1998). In the most recent review **intra-abdominal abscesses** are reported to be nearly threefold after laparoscopic appendectomy(Sauerland et al., 2010), and moderate heterogeneity was detectable. There were no notable differences in the results of trials using staplers versus loop. The problem with studies reporting higher incidence of intraabdominal abscesses with laparoscopic appendectomy is that they lack standardization of the surgical technique, and also that they do not uniformly describe the different grades of disease. A recent prospective randomised study on 220 patients reports less intraabdominal abscesses with the laparoscopic approach (Wei et al., 2010). Also, a very recent review on 2.264 patients (Asarias et al., 2011) did not find a significant difference in intraabdominal abscesses between the open and the laparoscopic approach. On the other hand a multivariate analysis from the American College of Surgeons on almost 40.000 appendectomies (77% laparoscopic) found that laparoscopy was associated with an increased risk for intraabdominal abscesses in the high risk patients (12,3% vs. 8,9%) but not for the low risk patients (Fleming et al., 2010). We had no intraabdominal abscesses after laparoscopic appendectomy in our study (Konstantinidis et al., 2008). Our only experience with an intraabdominal abscess after laparoscopic appendectomy was in a 59 year old man, in whom we performed one of the first operations for a ruptured appendix in January 1993, and who was not included in our study, as

Laparoscopic Appendectomy 123

by the gynaecologist –which is consistent with the literature (Borgstein, 1997)- and/or had imaging studies performed. The laparoscopic approach gave us the opportunity to define these problems, as well as to deal with most of them without having to convert to an open procedure. So, even in therapeutic terms, laparoscopy offers the possibility to manage unexpected problems, while a classical Mc Burney incision has many constraints in this

It has been questioned if one should remove **a normal looking appendix**, if there are no other findings at laparoscopy, especially in fertile women. Investigators who chose not to remove normal looking appendices report good results and almost no or few readmissions both in the fertile women group and in all patients (Borgstein et al., 1997; Moberg et al., 1998; Teh et al, 2000; van Dalen et al., 2003). That is why many investigators suggest not to remove a normal looking appendix (van Brock, 2001; Morino, 2006). Their argument is that removing all appendices diminishes the diagnostic value of laparoscopy, as well as beeing accompanied by morbidity, mortality, and extra hospital costs (Benjamin et al, 2002; Binjen et al, 2003; Sauerland et al., 2003). However, the assertion that mortality of incidental appendectomy exceeds that of appendectomy for appendicitis (Benjamin, 2002) did not find general acceptance (Howie, 2003). Howie reports that the estimated avoidable mortality from missed appendicitis or negative appendectomy in Scotland was virtually identical at 1,13 and 1,07 patients per 10.000 admissions. Another argument against incidental appendectomy is that it may have several adverse effects on fertility. Concerning this, a large Swedish retrospective study on 10.000 women could not confirm negative effects of appendectomy on fertility (Anderson et al, 1999). On the other hand incidental appendectomy may increase morbidity, and diminishes the diagnostic value of laparoscopy. We chose to remove all appendices if there were no other findings. This has to do with the nature of our hospital. We are a private center, and cannot always afford to reexamine patients, or, even worse, re-operate on them. It also has to do with the facilities, the laparoscopic experience of our team and the absence of major complications or mortality up to this point. In our study eighteen patients (2%) proved to have histological findings of appendicitis without having macroscopic ones. We had a negative appendectomy rate of 11,6% in fertile women and 6,4% in the rest of the patients after histological examination. In 0,8% of all excised appendices the histological examination revealed a carcinoid tumor. Removing a macroscopically innocent appendix surely diminishes the diagnostic advantages of laparoscopy. On the other hand, the question whether or not to remove a macroscopically normal appendix cannot be easily answered. Published data show a discrepancy between the good clinical course of most patients in these series, were a macroscopically innocent appendix was not removed and the histological findings in the series were a normal appearing appendix was removed. It has been shown that a macroscopically normal appendix is not always normal (Chiarugi et al., 2001), though the literature is quite inhomogenous concerning the histological findings. It also has been shown that a histologically normal appendix is not always normal (Wang et al, 1996) . Some of these appendices in patients with acute pain in the right iliac fossa have an abnormal content of neuropeptides. This could explain the pain relief after removal of a histologically

normal appendix (Di Sebastiano, 1999; Wang et al, 1996).

It seems that some patients suffer crises of **endoappendicitis**, that subsides with conservative treatment. Endoappendicitis varies from 11to 26% and the reoperation rate for the patients whose appendix was left in situ is reported to be 6%(Navez and Therasse, 2003). So it might be that the great majority of these patients will not have any problems in the

direction.

mentioned before. This patient was readmitted, and reoperated laparoscopically. A large retrocecal abscess was drained without further problems in his postoperative course. We believe that surgical expertise, precise manoeuvers during the operation, technique standardisation, and irrigation with normal saline solution (5 ltrs., under presure) are very important in order to avoid intraabdominal abscesses.

Most meta-analyses agree that **postoperative pain** is reduced after laparoscopy compared to the open procedure (Chung, 1999, Chung et al., 1999; Garbutt et al., 1999; Golub et al., 1999, Sauerland et al., 2010). Our patients required a median number of 4 minor drugs and 2 narcotics until their discharge.

There is consistent evidence that laparoscopy leads to a shorter **hospital stay** than the open appendectomy (Garbutt, 1999, Liu et al., 2011, Sauerland et al., 2010), although there are great fluctuations. We assume that this has to do with different discharge policies. Also, return to normal activity, which was 7 days in our trial, seems to fluctuate very much between most investigators, but is reported to be quicker with the laparoscopic approach (Chung et al., 1999; Garbutt et al., 1999; Golub et al., 1998; Liu et al, 2010; Sauerland et al., 2010; Temple et al., 1999) as is return to full activity and sport (Sauerland et al., 2010). In our experience **recovery** as expressed through time until flatus (24 hours) and intake of solid food (48 hours), as well as time until discharge (30 hours) was very satisfactory.

There is no other pathology in surgery where as high percentages for **negative laparotomies** are tolerated as in suspected acute appendicitis. In the literature negative laparotomies in suspected acute appendicitis typically range between 20-30%, while the typical range for negative laparoscopies is 10-15% (Tate, 1996). Especially in the subgroup of fertile females authors report a negative laparotomy rate between 22-40% and a negative laparoscopy rate between 4-17% and (Sauerland et al., 2004). We assume that in experienced hands a negative laparoscopy is truly negative - at least concerning the macroscopic findings- whereas a negative laparotomy with a Mc Burney incision fails to diagnose the pathology in about half of the cases as can be confirmed by the numbers. The long-term clinical course of these patients with the missed pathology cannot always be concluded from the published literature (Vettoretto&Agresta, 2010).

The **superior visualization of the abdominal cavity** is undoubtedly the great advantage of laparoscopy and leads to a much higher diagnostic yield in comparison to the open procedure. In the most recent meta-analysis laparoscopy reduced the rate of negative appendectomies and the rate of un-established diagnoses, especially in fertile women (Sauerland et al., 2010). **Gynecological problems** are found more frequently in laparoscopy for suspected acute appendicitis than in laparotomy (Larsson, 2001). Hence, there is consensus about laparoscopy being an invaluable tool in the management algorithm of women in childbearing age (Agresta, 2003; Borgstein, 1997; Cox, 1995; Larsson, 2001; Sauerland et al., 2010; van Dalen, 2003). A recent Cochrane Review about the role of laparoscopy for the management of lower abdominal pain in women of childbearing age found in the laparoscopic group higher rates of specific diagnoses been made, lower rates of negative appendectomies and shorter hospital stays. Also, there was no evidence of an increase of adverse events with either of the two approaches (Gaitan et al., 2010). In our series laparoscopy alone could establish diagnosis in 89% of all patients, in 85,4% of fertile women and in 93,1% in all other patients except fertile women. We had to face other surgical problems than appendicitis in 11,5% of all patients. In the subgroup of fertile women we were confronted with other diagnoses in 20,4% of all patients. Most of these conditions were gynaecologic problems (19,2%), despite the fact that some of these patients were examined

mentioned before. This patient was readmitted, and reoperated laparoscopically. A large retrocecal abscess was drained without further problems in his postoperative course. We believe that surgical expertise, precise manoeuvers during the operation, technique standardisation, and irrigation with normal saline solution (5 ltrs., under presure) are very

Most meta-analyses agree that **postoperative pain** is reduced after laparoscopy compared to the open procedure (Chung, 1999, Chung et al., 1999; Garbutt et al., 1999; Golub et al., 1999, Sauerland et al., 2010). Our patients required a median number of 4 minor drugs and 2

There is consistent evidence that laparoscopy leads to a shorter **hospital stay** than the open appendectomy (Garbutt, 1999, Liu et al., 2011, Sauerland et al., 2010), although there are great fluctuations. We assume that this has to do with different discharge policies. Also, return to normal activity, which was 7 days in our trial, seems to fluctuate very much between most investigators, but is reported to be quicker with the laparoscopic approach (Chung et al., 1999; Garbutt et al., 1999; Golub et al., 1998; Liu et al, 2010; Sauerland et al., 2010; Temple et al., 1999) as is return to full activity and sport (Sauerland et al., 2010). In our experience **recovery** as expressed through time until flatus (24 hours) and intake of solid

There is no other pathology in surgery where as high percentages for **negative laparotomies** are tolerated as in suspected acute appendicitis. In the literature negative laparotomies in suspected acute appendicitis typically range between 20-30%, while the typical range for negative laparoscopies is 10-15% (Tate, 1996). Especially in the subgroup of fertile females authors report a negative laparotomy rate between 22-40% and a negative laparoscopy rate between 4-17% and (Sauerland et al., 2004). We assume that in experienced hands a negative laparoscopy is truly negative - at least concerning the macroscopic findings- whereas a negative laparotomy with a Mc Burney incision fails to diagnose the pathology in about half of the cases as can be confirmed by the numbers. The long-term clinical course of these patients with the missed pathology cannot always be concluded from the published

The **superior visualization of the abdominal cavity** is undoubtedly the great advantage of laparoscopy and leads to a much higher diagnostic yield in comparison to the open procedure. In the most recent meta-analysis laparoscopy reduced the rate of negative appendectomies and the rate of un-established diagnoses, especially in fertile women (Sauerland et al., 2010). **Gynecological problems** are found more frequently in laparoscopy for suspected acute appendicitis than in laparotomy (Larsson, 2001). Hence, there is consensus about laparoscopy being an invaluable tool in the management algorithm of women in childbearing age (Agresta, 2003; Borgstein, 1997; Cox, 1995; Larsson, 2001; Sauerland et al., 2010; van Dalen, 2003). A recent Cochrane Review about the role of laparoscopy for the management of lower abdominal pain in women of childbearing age found in the laparoscopic group higher rates of specific diagnoses been made, lower rates of negative appendectomies and shorter hospital stays. Also, there was no evidence of an increase of adverse events with either of the two approaches (Gaitan et al., 2010). In our series laparoscopy alone could establish diagnosis in 89% of all patients, in 85,4% of fertile women and in 93,1% in all other patients except fertile women. We had to face other surgical problems than appendicitis in 11,5% of all patients. In the subgroup of fertile women we were confronted with other diagnoses in 20,4% of all patients. Most of these conditions were gynaecologic problems (19,2%), despite the fact that some of these patients were examined

food (48 hours), as well as time until discharge (30 hours) was very satisfactory.

important in order to avoid intraabdominal abscesses.

narcotics until their discharge.

literature (Vettoretto&Agresta, 2010).

by the gynaecologist –which is consistent with the literature (Borgstein, 1997)- and/or had imaging studies performed. The laparoscopic approach gave us the opportunity to define these problems, as well as to deal with most of them without having to convert to an open procedure. So, even in therapeutic terms, laparoscopy offers the possibility to manage unexpected problems, while a classical Mc Burney incision has many constraints in this direction.

It has been questioned if one should remove **a normal looking appendix**, if there are no other findings at laparoscopy, especially in fertile women. Investigators who chose not to remove normal looking appendices report good results and almost no or few readmissions both in the fertile women group and in all patients (Borgstein et al., 1997; Moberg et al., 1998; Teh et al, 2000; van Dalen et al., 2003). That is why many investigators suggest not to remove a normal looking appendix (van Brock, 2001; Morino, 2006). Their argument is that removing all appendices diminishes the diagnostic value of laparoscopy, as well as beeing accompanied by morbidity, mortality, and extra hospital costs (Benjamin et al, 2002; Binjen et al, 2003; Sauerland et al., 2003). However, the assertion that mortality of incidental appendectomy exceeds that of appendectomy for appendicitis (Benjamin, 2002) did not find general acceptance (Howie, 2003). Howie reports that the estimated avoidable mortality from missed appendicitis or negative appendectomy in Scotland was virtually identical at 1,13 and 1,07 patients per 10.000 admissions. Another argument against incidental appendectomy is that it may have several adverse effects on fertility. Concerning this, a large Swedish retrospective study on 10.000 women could not confirm negative effects of appendectomy on fertility (Anderson et al, 1999). On the other hand incidental appendectomy may increase morbidity, and diminishes the diagnostic value of laparoscopy. We chose to remove all appendices if there were no other findings. This has to do with the nature of our hospital. We are a private center, and cannot always afford to reexamine patients, or, even worse, re-operate on them. It also has to do with the facilities, the laparoscopic experience of our team and the absence of major complications or mortality up to this point. In our study eighteen patients (2%) proved to have histological findings of appendicitis without having macroscopic ones. We had a negative appendectomy rate of 11,6% in fertile women and 6,4% in the rest of the patients after histological examination. In 0,8% of all excised appendices the histological examination revealed a carcinoid tumor.

Removing a macroscopically innocent appendix surely diminishes the diagnostic advantages of laparoscopy. On the other hand, the question whether or not to remove a macroscopically normal appendix cannot be easily answered. Published data show a discrepancy between the good clinical course of most patients in these series, were a macroscopically innocent appendix was not removed and the histological findings in the series were a normal appearing appendix was removed. It has been shown that a macroscopically normal appendix is not always normal (Chiarugi et al., 2001), though the literature is quite inhomogenous concerning the histological findings. It also has been shown that a histologically normal appendix is not always normal (Wang et al, 1996) . Some of these appendices in patients with acute pain in the right iliac fossa have an abnormal content of neuropeptides. This could explain the pain relief after removal of a histologically normal appendix (Di Sebastiano, 1999; Wang et al, 1996).

It seems that some patients suffer crises of **endoappendicitis**, that subsides with conservative treatment. Endoappendicitis varies from 11to 26% and the reoperation rate for the patients whose appendix was left in situ is reported to be 6%(Navez and Therasse, 2003). So it might be that the great majority of these patients will not have any problems in the

Laparoscopic Appendectomy 125

**Quality of life** is also reported to be better with the laparoscopic approach, both in the early

**Cost- effectiveness** is difficult to measure. From the institutional perspective laparoscopic appendectomy is reported to be less cost- effective than the open procedure, even if in the future the costs of the operation and the equipment (single- use vs. reusable; Endo-GIA vs. Roeder loops) may decrease whereas from the societal perspective the laparoscopic approach seems to be more cost- effective (Heikkinen et al., 1998; Macarulla et al., 1997; Sauerland, 2010) if lost productivity is taken into consideration (Moore et al., 2004). In middle- aged patients overall costs are reported to be lower with the laparoscopic procedure (Lagares- Garcia et al., 2003). In our patients we try to reduce costs by applying reusable instruments. We also prefer to use loops for the appendicular base instead of staplers and

It has been suggested that there may be fewer **adhesions** after laparoscopic appendectomy compared to the open procedure (De Wilde, 1991; Gutt, 2004). We had no patients with adhesion-related complications such as intestinal obstruction in our study. The incidence of late readmitions (>30 days) after appendectomy is of particular interest. In the literature there is increasing evidence that open appendectomy is related to late readmissions and, in some cases, reoperations for SBO but there is an inhomogeneity in the results of different studies (Anderson, 2001;Riber, 1997; Zbar, 1993). During a mean follow-up of 10 years the authors of a retrospective study on 3,230 patients report 2,94% late readmissions after open appendectomy. Almost half (45%) of readmissions were caused by nonspecific abdominal pain with no signs of small bowel obstruction. SBO was seen in 1,24% of patients and was surgically treated in 0,68%. Incisional hernias were seen in 0,4% of all appendectomies., as did patients with complicated appendicitis or negative appendectomy (Tingstend et al.,

Our follow-up lasted 4 weeks. From the 63 patients operated on for chronic symptoms 5(8%) continued to have abdominal pain one month after appendectomy. There were no readmitions or reoperations for adhesion related complications or incisional hernias. We can also report that no patient of this series was readmitted in our department with a late complication such as small bowel ileus or an incisional hernia. More prospective, randomized trials comparing the incidence of late complications with the laparoscopic and open approach for suspected appendicitis in an intention-to-treat basis are needed. We also

Laparoscopic appendectomy is reported to be a safe and suitable procedure for **surgical training** (Botha et al., 1995; Duff&Dixon, 2000; Scott-Conner et al., 1992). In our opinion it is in many cases an ideal operation for a surgical trainee starting his/her training in

Especially in the subgroup of fertile females authors report a negative laparotomy rate between 22-40% and a negative laparoscopy rate between 4-17% and (Sauerland et al., 2004). Females predominated among those readmitted (76%). Fertile females benefit from the laparoscopic approach at a level Ia evidence and there was no inconsistency between studies

think that late complications should be included in future cost-analyses.

(Sauerland, 2010; Vettoretto & Agresta, 2010; Gaitan, 2011).

and late period (Kaplan et al, 2009).

2004).

laparoscopy.

**4.1 Fertile females** 

**4. Special patient categories** 

can report excellent results and no complications.

future but for the individual patient the surgeon's decision to leave the appendix behind could mean a readmission, a peritonitis, a second operation, or the persistence of recurrent symptoms. So we think that the decision to remove the appendix has to be individualized and discussed with the patient prior to the operation. The experience of the laparoscopic team is very important in this context. We generally agree with the algorithm proposed by (Navez & Therasse, 2003) in the treatment of suspected acute appendicitis. The authors propose to remove a macroscopically normal appendix if one suspects an appendicitis clinically and there are no other findings. In cases of acute abdominal pain of uncertain origin and negative laparoscopy the authors propose to perform only a diagnostic laparoscopy and to avoid the terms of appendicitis or appendectomy. We also agree with the investigators that the appendix should be removed if chronic recurrent symptoms exist, and there are no other findings. We think there is enough evidence about this in the literature (Chandler et al., 2002; Mussak et al., 2002), especially in young females (Chicolm Mefire et al., 2011).

The debate on whether **complicated appendicitis** is a contraindication for the laparoscopic approach is still ongoing. Sauerland et al. reported in an earlier review (Sauerland et al., 2004) that laparoscopic approach for complicated appendicitis can probably lead to increased complications, though there is not yet enough evidence to support this. On the other hand many authors do not regard complicated appendicitis to be a contraindication for laparoscopic appendectomy. On the contrary, laparoscopic appendectomy in complicated appendicitis is reported to be safe (Ball et al., 2004; Kapischke et al., 2005; Pedersen et al., 2001; Stolzing et al., 2000; Wullstein et al., 2001) and reduce complication rate (Kapischke et al., 2005; Wullstein et al, 2001). Septic wound complications are reported to be less (Piskun et al., 2001; Stolzing et al., 2000). Intraabdominal abscesses are reported to be equally frequent (Asarias et al., 2011; Khalili et al., 1999; Wullstein et al., 2001) in the open and the laparoscopic approach. Also laparoscopic appendectomy in complicated appendicitis is supposed to lead to a shorter length of stay (Ball et al., 2004; Johnson et al., 1998; Kapischke et al., 2005; Towfigh et al., 2006) and reduced hospital costs (Johnson et al., 1998). The problem with some comparative studies is the existence of selection bias in patients undergoing laparoscopic or open appendectomy and also the fact that statistical analysis is not always done on an intention-to-treat-basis. Nevertheless Wullstein et al. in their study on 299 patients with complicated appendicitis report that laparoscopic appendectomy when compared with open appendectomy leads to a significant reduction of early postoperative complications by itself and in an intention-to-treat view (Wullstein et al., 2001). A recent systematic review with meta-analysis of 12 retrospective case-control studies found less surgical site infections in laparoscopic appendectomy for complicated appendicitis with no significant additional risk for intraabdominal abscesses (Makrides et al., 2010). More prospective, randomized trials focusing on this question are needed in the future. We did not study patients with complicated appendicitis separately in our series. Nevertheless we had to face a ruptured or gangrenous appendix in 14,1% and, in spite of that, had an overall wound infection rate of 1,1% and no intraabdominal abscesses. In our experience complicated appendicitis is not a contraindication for the laparoscopic approach. There is evidence supporting that **cosmesis** is superior with the laparoscopic approach (Pedersen et al., 2001), and is difficult to improve (Ruiz de Angulo et al., 2011). We think that this must be especially true in obese patients and complicated appendicitis, where normally bigger incisions are needed. Also, in case of other findings that need an extension of a Mc Burney incision or a new incision, laparoscopy is surely the best choice from the cosmetic point of view.

future but for the individual patient the surgeon's decision to leave the appendix behind could mean a readmission, a peritonitis, a second operation, or the persistence of recurrent symptoms. So we think that the decision to remove the appendix has to be individualized and discussed with the patient prior to the operation. The experience of the laparoscopic team is very important in this context. We generally agree with the algorithm proposed by (Navez & Therasse, 2003) in the treatment of suspected acute appendicitis. The authors propose to remove a macroscopically normal appendix if one suspects an appendicitis clinically and there are no other findings. In cases of acute abdominal pain of uncertain origin and negative laparoscopy the authors propose to perform only a diagnostic laparoscopy and to avoid the terms of appendicitis or appendectomy. We also agree with the investigators that the appendix should be removed if chronic recurrent symptoms exist, and there are no other findings. We think there is enough evidence about this in the literature (Chandler et al., 2002; Mussak et al., 2002), especially in young females (Chicolm

The debate on whether **complicated appendicitis** is a contraindication for the laparoscopic approach is still ongoing. Sauerland et al. reported in an earlier review (Sauerland et al., 2004) that laparoscopic approach for complicated appendicitis can probably lead to increased complications, though there is not yet enough evidence to support this. On the other hand many authors do not regard complicated appendicitis to be a contraindication for laparoscopic appendectomy. On the contrary, laparoscopic appendectomy in complicated appendicitis is reported to be safe (Ball et al., 2004; Kapischke et al., 2005; Pedersen et al., 2001; Stolzing et al., 2000; Wullstein et al., 2001) and reduce complication rate (Kapischke et al., 2005; Wullstein et al, 2001). Septic wound complications are reported to be less (Piskun et al., 2001; Stolzing et al., 2000). Intraabdominal abscesses are reported to be equally frequent (Asarias et al., 2011; Khalili et al., 1999; Wullstein et al., 2001) in the open and the laparoscopic approach. Also laparoscopic appendectomy in complicated appendicitis is supposed to lead to a shorter length of stay (Ball et al., 2004; Johnson et al., 1998; Kapischke et al., 2005; Towfigh et al., 2006) and reduced hospital costs (Johnson et al., 1998). The problem with some comparative studies is the existence of selection bias in patients undergoing laparoscopic or open appendectomy and also the fact that statistical analysis is not always done on an intention-to-treat-basis. Nevertheless Wullstein et al. in their study on 299 patients with complicated appendicitis report that laparoscopic appendectomy when compared with open appendectomy leads to a significant reduction of early postoperative complications by itself and in an intention-to-treat view (Wullstein et al., 2001). A recent systematic review with meta-analysis of 12 retrospective case-control studies found less surgical site infections in laparoscopic appendectomy for complicated appendicitis with no significant additional risk for intraabdominal abscesses (Makrides et al., 2010). More prospective, randomized trials focusing on this question are needed in the future. We did not study patients with complicated appendicitis separately in our series. Nevertheless we had to face a ruptured or gangrenous appendix in 14,1% and, in spite of that, had an overall wound infection rate of 1,1% and no intraabdominal abscesses. In our experience complicated appendicitis is not a contraindication for the laparoscopic approach. There is evidence supporting that **cosmesis** is superior with the laparoscopic approach (Pedersen et al., 2001), and is difficult to improve (Ruiz de Angulo et al., 2011). We think that this must be especially true in obese patients and complicated appendicitis, where normally bigger incisions are needed. Also, in case of other findings that need an extension of a Mc Burney incision or a new incision, laparoscopy is surely the best choice from the

Mefire et al., 2011).

cosmetic point of view.

**Quality of life** is also reported to be better with the laparoscopic approach, both in the early and late period (Kaplan et al, 2009).

**Cost- effectiveness** is difficult to measure. From the institutional perspective laparoscopic appendectomy is reported to be less cost- effective than the open procedure, even if in the future the costs of the operation and the equipment (single- use vs. reusable; Endo-GIA vs. Roeder loops) may decrease whereas from the societal perspective the laparoscopic approach seems to be more cost- effective (Heikkinen et al., 1998; Macarulla et al., 1997; Sauerland, 2010) if lost productivity is taken into consideration (Moore et al., 2004). In middle- aged patients overall costs are reported to be lower with the laparoscopic procedure (Lagares- Garcia et al., 2003). In our patients we try to reduce costs by applying reusable instruments. We also prefer to use loops for the appendicular base instead of staplers and can report excellent results and no complications.

It has been suggested that there may be fewer **adhesions** after laparoscopic appendectomy compared to the open procedure (De Wilde, 1991; Gutt, 2004). We had no patients with adhesion-related complications such as intestinal obstruction in our study. The incidence of late readmitions (>30 days) after appendectomy is of particular interest. In the literature there is increasing evidence that open appendectomy is related to late readmissions and, in some cases, reoperations for SBO but there is an inhomogeneity in the results of different studies (Anderson, 2001;Riber, 1997; Zbar, 1993). During a mean follow-up of 10 years the authors of a retrospective study on 3,230 patients report 2,94% late readmissions after open appendectomy. Almost half (45%) of readmissions were caused by nonspecific abdominal pain with no signs of small bowel obstruction. SBO was seen in 1,24% of patients and was surgically treated in 0,68%. Incisional hernias were seen in 0,4% of all appendectomies., as did patients with complicated appendicitis or negative appendectomy (Tingstend et al., 2004).

Our follow-up lasted 4 weeks. From the 63 patients operated on for chronic symptoms 5(8%) continued to have abdominal pain one month after appendectomy. There were no readmitions or reoperations for adhesion related complications or incisional hernias. We can also report that no patient of this series was readmitted in our department with a late complication such as small bowel ileus or an incisional hernia. More prospective, randomized trials comparing the incidence of late complications with the laparoscopic and open approach for suspected appendicitis in an intention-to-treat basis are needed. We also think that late complications should be included in future cost-analyses.

Laparoscopic appendectomy is reported to be a safe and suitable procedure for **surgical training** (Botha et al., 1995; Duff&Dixon, 2000; Scott-Conner et al., 1992). In our opinion it is in many cases an ideal operation for a surgical trainee starting his/her training in laparoscopy.
