Ryan Dumas, MD, Madhu Subramanian, MD, Stephen Luk, MD, Michael W Cripps, MD. University of Texas Southwestern Medical Center at Dallas
Introduction: Over the past few decades, the definitive surgical management of acute appendicitis has shifted from open appendectomy (OA) to laparoscopic appendectomy (LA). This is mirrored by the reversal in number of open versus laparoscopic appendectomies performed by graduating surgical residents during this time. However, there is an ongoing discussion regarding use of LA because of potential increased rates of intra-abdominal abscesses as well as a push towards conservative management alone. A single Emergency General Surgery (EGS) service does approximately 400 appendectomies per year at a high-volume, safety-net hospital. We sought to identify current practice patterns, treatment strategies, and complications from the surgical management of appendicitis.
Methods: A retrospective review was performed of all appendectomies done by the emergency general surgery service at a large safety-net hospital from January 2012 to December 2014. Demographic data, operative approach, comorbidities and complications were collected and reviewed. Chi square analysis was done for proportion and nonparametric analyses were done where appropriate.
Results: 1,159 appendectomies were performed at our institution by 13 surgeons. There was a 2.7% conversion rate from laparoscopic to open (n=32) and 3.9% were initiated and completed as an open appendectomy (n=45). The remaining 93.4% (n=1,082) appendectomies were initiated and completed laparoscopically. Over these three years, there was no statistical decrease in the conversion rate from LA to OA, with the lowest rate occurring in 2014 at 1.9% (p=0.13). Approximately 10% of the cohort had perforated or gangrenous appendicitis and the incidence of intraabdominal abscess (IAA) was 2.6%. However, the incidence of IAA was 17.8% in those with perforation vs 0.95% in those without (p<0.001). The median [IQR] time in days to definitive diagnosis of IAA from initial operation was 7 [5,9]. Serious wound infection rates occurred in only 1.1% (n=13) of all patients. In the overall cohort, the incidence of appendiceal tumors was 1.1% (n=13), the majority (n=10) consisted of low grade appendiceal mucinous neoplasm. In this study, there were zero mortalities and the overall unplanned readmission to the hospital was low at 4.4% (n=50).
Conclusions: Laparoscopic appendectomy continues to be a safe and effective method for treating acute appendicitis. There is a very low conversion rate with no associated mortalities and minimal comorbidity. There is a small rate of incidental appendiceal tumors and the overall incidence of IAA is low, but the risk significantly increases in patients with perforated appendicitis.