Obesity and appendicitis: Laparoscopy versus open technique

Abstract

Objective: The clinical results of obese patients who have undergone open or laparoscopic appendectomy, whether one technique is superior to the other is still not clearly known.In our study, we compared the clinical results of obese patients operated with laparoscopic or open technique for acute appendicitis.

Material and Methods: We performed retrospective analyses of patients operated for acute appendicitis between the dates of July 2016 and July 2019 at Istinye University Faculty of Medicine Bahcesehir Liv Training and Research Hospital and Liv Hospital Ankara. Of the 241 patients whose height and weight information was accessible, 57 had a body mass index of 30 kg/m2 or higher. Eighteen of these patients underwent open surgery while the other 39 underwent laparoscopic surgery. The primary result criterion was complication ratio. Secondary criteria were operation time and length of hospital stay.

Results: Upon comparison of laparoscopic and open techniques in terms of intraoperative-postoperative complications (p= 0.01), operation time (p= 0.02) statistically significant differences were found between the groups. However the mean length of hospital stay (p= 0.181) was similar in both groups.

Conclusion: In obese appendicitis patients, the laparoscopic technique proved to be superior to the open technique in criteria such as perioperative-postoperative complications, operation time, and etc. Length of hospital stay was determined to be similar between the groups.

Keywords: Appendicitis, obesity, body mass index, laparoscopic appendectomy, open appendectomy

Introduction

Laparoscopic techniques have been more and more preferred to open surgical techniques due to reasons such as less post-operative pain, faster return to daily life and activities, and cosmetic advantages (1,2). Laparoscopic appendectomy (LA) was first described in 1983 (3). Lesser risk of intraoperative complication, fever surgical site infections and shortened hospital stays stand out in obese patient groups operated with laparoscopic techniques (4,5). Medical literature related to appendectomy also shows superiority of laparoscopy especially in terms of wound site infections, postoperative recuperation period and out-of-hospital costs. That said, the literature also shows a correlation between laparoscopy and certain situations such as increased ratio of intra-abdominal abscess and increased hospital costs (6). In obese patients, due to the abdominal wall being thicker, difficulty may be encountered in revealing the surgical field, performing surgical techniques and wound related situations. Laparoscopy overcomes these issues and creates the belief that laparoscopy is better than open appendectomy (OA) for appendicitis. While some research shows that LA is a safe and efficient treatment method for both acute and perforated appendicitis, some others show that the open technique is superior (7-9). That said, when the data is limited to the obese population, the discussion whether there is a difference remains. Our objective is to determine whether there is a difference between OA and LA for patients grouped according to their body mass indexes (BMI).

Material and Methods

We retrospectively examined the patients who underwent an operation for acute appendicitis at our institutions between the dates of July 2016 and July 2019.

Patient Selection

We separated patients with clinical appendicitis diagnosis into two groups, LA and OA. We followed up on the patients during their hospital stay and for 2 weeks after their discharge at the out-patient clinic. All patients were 16 or above (Figure 1).

Figure 1. Body mass index (BMI) of 23% of the 241 patients was at or above 30 kg/m². In 18 of these patients (31.5%) open appendectomy (OA) was performed, and laparoscopic appendectomy (LA) was perfor- med on the other 39 (69.5%).

Data

We examined the demographic data (age, sex), preoperative data [white blood cell (WBC), diagnosis], operation details (operation type, duration) and post-operative period (complications, length of hospital stay) of the patients.

Subgroup Analysis

We divided the patients into 3 subgroups according to their BMI’s: BMI of lower than 25 kg/m2, BMI between 25-30 kg/m2 (overweight) and BMI of 30 kg/m2 or above (obese).

Result Criteria

The primary criterion was complication ratio. Secondary criteria were operation time and length of hospital stay.

Statistical Methodology

We used SPSS 17. version. Data ranges were presented with median and percantages values. To compare the ratios of statistical significance, we used Mann-Whitney U test. Values with a p value of less than 0.05 were deemed statistically significant.

Ethics committee approval was received for this study from the Ethics Committee of Istinye University (No. 2019/1951) and Liv Hospital Ankara ( No. 2019/006).

Results

Both groups were similar in age (OA= 33, LA= 31, p= 0771), sex (OA= 61% male, LA= 52% male, p= 0.724) and presented with clinical appendicitis (confirmed with pathology p= 0.165) (Table 1). A statistically significant difference in favor of the laparoscopic group was observed in the ratio of complications between the open and laparoscopic groups categorized according to their BMIs (p= 0.01) (Table 2). No mortality occurred over the course of this study. Upon comparison of the laparoscopy group to the open technique group, operation time of the laparoscopy group was observed to be shorter (p= 0.02). No statistically significant difference was observed in the length of hospital stay of the groups (p= 0.181) (Table 3).

Table 1. Demographics and pathologies of the obese patients grouped according to types of operation

Table 2. Complications according to types of operation

Table 3. Results

Discussion

Comparison discussions between OA and LA continues with numerous papers. There are some meta-analyses that go over this subject in the literature. In a meta-analysis dated 2004 where 54 studies were analyzed, LA was shown to result in distinctly fewer wound infections, less pain and shorter hospital stay; however a correlation was shown between it and higher cost with an increased risk of prolonged operation time and intra-abdominal infections. The conclusion was that LA is the better option for patient groups consisting of working population, young women and obese people (6). In another meta-analysis, similarly, LA procedure was reported to result in a higher probability of intra-abdominal abscess while also being superior in terms of wound infections and length of hospital stay. The analysis recommended to avoid LA in perforated and gangrenous appendicitis cases (10). In a double-blind, prospective, randomized study dated 2005 comparing LA and OA, no superiority of one procedure to the other was observed other than a better quality of life at the 2nd week after operation for the LA group (1). As for our study, we performed analyses to demonstrate whether the two procedures created different results among the patients grouped up according to their BMIs. Our study demonstrated that the laparoscopic approach was more advantageous for obese patients in terms of complications and operation time. Previous studies conducted regarding obese patient groups have not been as comprehensive as the ones conducted among the general population (11-14). In another retrospective study, length of hospital stay and wound recuperation period were shown to be superior for obese patients that underwent laparoscopic appendectomy than their counterparts who underwent operations where the open technique was used (15). Varela et al. have also reached similar conclusions such as lower complication rates and costs for morbidly obese people. Many studies that reach the opposite conclusion have also been published. Ricca et al. have found LA to result in significantly longer operation time and higher costs (12,16). Towfigh et al. have found no significant difference between the laparoscopic and open approaches in terms of length of hospital stay or complication ratio (17). The reason for the varying results may also be the experiences of the teams studying obese patients. Operation times and wound side infection ratios may potentially be affected, and when it comes to discharging a patient, the initiative of clinical discretion may also affect the length of hospital stay. Factoring in the variables tied to the operating surgeon, the surgical techniques also need to be standardized. Appendectomy is generally a short-lasting operation that is performed with a small incision (4-6 cm). Some studies show that the McBurney incision is superior to the median line incision in terms of pain, complications and wound site healing (18). When compared to other open techniques, OA results in less operation site pain and shorter hospital stays for pain management (19,20). In addition, in the literature, a higher rate of trocar site hernia is reported in appendectomies performed with a single port compared to LAs (21). The parameter that affects the length of hospital stay of appendectomy patients is the severity of the infection encountered during the operation. Post-operative antibiotherapy of the patients with ruptured or gangrenous appendicitis may also prolong hospital stay. The risk of complications caused by prolonged operation times of obese patients such as atrial fibrillation, pulmonary embolism, deep vein thrombosis (DVT) and rhabdomyolysis are not disregarded (22-26). In patients with a BMI of over 40 kg/m2, while the risk of atrial fibrillation may increase by 50%, the risk of DVT or pulmonary embolism may increase by up to 3 times. In many studies, laparoscopy and obesity have been shown as independent factors for prolonged operation times (27-29). However, in our study, we recorded significantly shorter operation times in obese patients who underwent LA. We also observed the superiority of LA over OA in terms of complication frequency.

Limitations of the Study

One of the limitations of this study may have been ensuring that the operations would be performed by surgeons with high experience of operating on obese people. It must not be overlooked that the operation time, post-operative follow-up and treatment processes and even the decisions given regarding the patients’ discharge may be affected by the said experience. In addition, 44 obese appendicitis patients were a rather small sample size for observation.

Conclusion

According to our data, technically, we recommend LA to obese patients, however, we are of the opinion that it should be shaped according to clinical conditions and the discretion and experience of the surgeon.

Cite this article as: Özozan ÖV, Güldoğan CE, Gündoğdu E, Özmen MM. Obesity and appendicitis: laparoscopy versus open technique. Turk J Surg 2020; 36 (1): 105-109.

Ethics committee approval was received for this study from the Ethics Committee of Istinye University (No. 2019/1951) and Liv Hospital Ankara ( No. 2019/006).

Not required in this study.

Externally peer-reviewed.

Concept - Ö.V.Ö., C.E.G.; Design - Ö.V.Ö., C.E.G.; Supervision - M.M.Ö.; Data Collection and/or Processing - Ö.V.Ö., C.E.G., E.G.; Analysis and/or Interpretation - Ö.V.Ö., E.G.; Literature Review - C.E.G.; Writing Manuscript - Ö.V.Ö.; Critical Reviews - M.M.Ö.

The authors have no conflicts of interest to declare.

The authors declared that this study has received no financial support.

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