Appendicitis undergoing appendectomy in our social setups.

Appendicitis is the most common emergency requiring surgical intervention in teens 8. The possibility of appendicitis must be considered in patients presenting with lower quadrant abdominal pain and high index of suspicion required in obese due to paucity of clinical signs 9, 10. Although more than 20 years have passed since the introduction of laparoscopic appendectomy (performed in 1983 by Semm, a gynecologist), open appendectomy is still the widely practiced procedure. Some authors consider emergency laparoscopy as a precise tool for the treatment of abdominal emergencies like appendicitis especially in females of reproductive age groups  11, 12. Several studies 13, 14, 15 reflect that laparoscopic appendectomy leads to faster restoration of normal activities with fewer wound Sequele. These findings have been contradicted by many researchers who showed no significant difference in the outcome between the two procedures, despite more cost with laparoscopic appendectomy.  Recent meta-analyses of randomized controlled trials comparing laparoscopic versus conventional appendectomy concluded that acute appendicitis can be dealt with with open and laparoscopic approach safely 16,17.

 Obesity is a prevalent medical condition in western societies and also affects a great percentage of people undergoing appendectomy in our social setups. A popular myth that laparoscopic appendectomy should be “Gold Standard” in obese patients stands on the presumption that the increased abdominal wall thickness is a technical challenge during open appendectomy limiting accurate hand movements and visibility. More dissection required which ends up with prolong recovery time. Recently, published papers have considered laparoscopic approach as a better option in obese. Our study  focused on the obese  patients and compared the open and laparoscopic techniques for appendectomy. Most of the patients in our series were having BMI more than 30 with a female preponderance in the age group of 20-30 years.

 Surgical time is considered as important predictor of the procedural outcome. Most studies mentioned a long surgery time with laparoscopic approach .The likely explanation of this finding may be learning curve of the surgeons spending more time than conventional appendectomy. The longer operation time in laparoscopic appendectomy may be due to additional steps like setup of instruments, insufflations, making ports under vision and a phase of diagnostic laparoscopy. By contrast, in our series the impact of learning curve was almost nil as all surgeons performed the procedure were senior consultants..  Clarke et al.,6 reported a markedly elevated value for the laparoscopic appendectomy group. Our observations are different to a previously published meta-analysis by Markar et al.18  who investigated surgical time based on data available in3,19and detected no significant difference between laparoscopic and open appendectomy in normal patients. But in our series in obese patients, this finding is different20  which demonstrated a significant decrease of surgical time in the laparoscopic appendectomy group (P <0.001). The short hospital stay observed for patients treated by laparoscopic approach is not clinically significant, but it has bearing on the bed availability and hospital finances .Nonetheless, faster return to the normal activities cannot be attributed to short hospital stay only, because this vary from person to person attitude and job nature. Masoomi et al.4 emphasized the advantage of laparoscopic appendectomy by reporting a lower intra-abdominal abscess formation rate in the laparoscopic appendectomy group. we observed the same that the residual abscess formation rate in obese was lower in LA  as compared to open appendectomies . These findings are contradictory with other studies that showed an increased risk of residual abscesses after laparoscopic appendectomy compared with open surgery 21,22. Several hypotheses have been postulated to find possible justifications: mechanical spread of bacteria in the peritoneal cavity promoted by carbon dioxide insufflations, especially in perforated appendix , inadequate learning curve 22, the extensive washouts, instead of simple suction of the infected area in case of perforation, that results in soiling of the entire abdominal cavity, which is difficult to manage subsequently. Prophylactic Antibiotics were given before in all cases and afterwards in case of peritoneal contamination. Similarly the wound sepsis was encountered more in open appendectomy group .Wound infection could cause financial burden on the patient as well as on hospital by prolonging the Hospital stay. Wound dehiscence is more common in open group especially in complicated appendicitis despite receiving same antibiotics in pre and postoperative phase. Second reason may be the use of endobag for retrieval of appendix in LA Group. According to Mason et al23 main advantage of laparoscopic surgery in obese patients with acute appendicitis is reduced wound related sequele. We compared the pain intensity in postoperative period with the help of visual analogue score and analgesia requirement on the charts to seek the difference. We  used Parenteral doses of NSAIDS in routine and Parenteral narcotics on need base to compare both the groups .In accordance to many studies 14,24 the Parenteral Narcotic analgesia requirement was less in LA group. .This effect is same in laparoscopic surgery performed in obese as well as in normal BMI patients but has significantly reduced (P<0.001) requirement as compare to conventional open appendectomy. Postoperative ileus was more prolonged in case of open appendectomy group due to more handling but this fact was insignificant statistically(p= 0.09 ) .Mainly the advantage of less ileus is not only due to laparoscopic approach but also due to less use of narcotic analgesia in postoperative phase.  The mortality rate was negligible in our series. In General appendectomy performed either through laparoscopic or open route is a safe procedure as revealed by many studies 25.     CONCLUSION Laparoscopic approach is advantageous compared to open appendectomy in terms of less postoperative pain, ileus, short hospital stay, less wound sepsis and operation time in obese patients, but a large prospective trial is necessary to prove the better surgical outcomes of laparoscopic appendectomy.