Laparoscopic Appendectomy Technique Is Not Necessarily Better

A new study has found that the danger of deep abdominal infections following appendix removal was markedly less when an open surgical approach was used.

Researchers from the University of Rochester Medical Center (URMC; NY, USA) conducted a multivariate analysis of 39,950 appendectomy cases, of which 77% were performed laparoscopically; the cases were retrieved from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database between 2005 to 2008. Patient factors, operative variables, and the primary outcomes of incisional infections and organ space infections (OSIs) were recorded. Factors associated with surgical infections were identified using logistic regression models, and were then used to calculate probabilities of OSI in clinical vignettes demonstrating varying levels of infectious risk.

The results showed that laparoscopy was associated with a lower risk of incisional infection, but with an increased risk of OSI after adjustment for confounding factors. For a low-risk patient, probability of OSI was calculated to be 0.3% open surgery, compared to 0.4% for laparoscopic appendectomy; in a high-risk patient, probabilities were estimated at 8.9% and 12.3%, respectively. Among the factors identified that might predispose some patients to being at higher risk for a serious infection were a high white blood-cell count; being male; diabetes; age; and smoking. The study was published in the December 2010 issue of Annals of Surgery.

"We think it comes down to balance. It's not just about how much a procedure exposes the body to potential infection - it's also about how easily that procedure allows you to mitigate infection risk,” said lead author John Monson, MD, chief of the division of colorectal surgery at URMC. "Consider the open approach. Admittedly, there's more chance of exposure to microbes; the wound is wide open. But there's also more opportunity to sterilize, since you can meticulously clean the operating space before closing it.”

"I think the data is pretty clear: for a select cohort of folks needing their appendix removed, we would be wise to consider an open procedure,” added Dr. Monson. "This is what good medicine is about - tailoring our approach based on the patient. It's about being willing to adapt.”

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