Correspondence

Laparoscopic versus Open Appendectomy

N Engl J Med 1995; 333:881-882September 28, 1995

Article

To the Editor:

Advocates of laparoscopic appendectomy contend that it is superior to open appendectomy because there is less morbidity, a shorter hospital stay, and faster convalescence.1,2 We collected data on 277 appendectomies (175 open and 102 laparoscopic) performed in three hospitals in Nashville, Tennessee, during 1991 and 1992. To ensure similar clinical characteristics in the groups studied, we assessed 230 patients (143 who underwent open appendectomy and 87 who underwent laparoscopic appendectomy) with similar preoperative health (categories I and II of the classification system of the American Society of Anesthesiology [ASA]) and appendiceal disease (i.e., a normal appendix, acute appendicitis, or appendicitis with rupture).

Although the patients were evenly divided according to sex, surgeons performed laparoscopic appendectomy more frequently in female patients than in male patients. Forty-five percent of the female patients had laparoscopic appendectomy, as compared with 29 percent of the male patients (P<0.01). Older patients were more likely to have open appendectomy than younger ones (P<0.05). Among the laparoscopic appendectomies, 15.7 percent had to be converted to open appendectomies. Few high-risk patients had laparoscopy. (Only 3.2 percent of the patients who had laparoscopy were in ASA category III, whereas 11 percent of those undergoing open appendectomy were in categories III and IV.) Twenty-eight percent of the patients undergoing laparoscopic appendectomy had normal appendixes, as compared with 15 percent of the patients undergoing open appendectomy. As to whether there was a selection bias, surgeons appeared to prefer open to laparoscopic appendectomy in sicker patients. There was no difference in rates of complications between the two procedures.

General linear-model statistics were used to compare the durations of surgery, lengths of stay, and hospital charges among the 230 patients in ASA categories I and II. The mean duration of laparoscopic appendectomy was greater than that of open appendectomy (75 vs. 46 minutes, P<0.001). The hospital stay was 1 day longer on average for open than for laparoscopic appendectomy (3.63 vs. 2.57 days), although both mean stays were shorter than the 1991 U.S. average of 4.3 days.3

Laparoscopic appendectomy was significantly more expensive than open appendectomy after adjustment for differences in the severity of disease. Figure 1Figure 1Mean Hospital Charges for Open and Laparoscopic Appendectomy, According to Age Group and Severity of Disease. shows mean charges for different categories of age and disease.

In summary, surgeons preferred open to laparoscopic appendectomy in sicker patients, a circumstance that could bias comparisons between the procedures. When similar groups of patients were compared, we found that laparoscopic appendectomy takes more time and, despite a shorter hospital stay, costs more than open appendectomy, with no discernible difference in clinical results.

Robert W. Ikard, M.D.
Charles F. Federspiel, Ph.D.
Vanderbilt University School of Medicine, Nashville, TN 37232

3 References

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   Attwood SE, Hill AD, Murphy PG, Thornton J, Stephens RB. A prospective randomized trial of laparoscopic versus open appendectomy. Surgery 1992;112:497-501
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   Fritts LL, Orlando OR III. Laparoscopic appendectomy -- a safety and cost analysis. Arch Surg 1993;128:521-525
   Web of Science | Medline

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   Schneidman DS, Rogers CM, eds. Socio-economic factbook for surgery 1994. Chicago: American College of Surgeons, 1994.
   

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