Treating appendicitis by laparoscopic surgery may not be worth the cost

New research published in the February issue of the Journal of the American College of Surgeons suggests that a traditional, "open" appendectomy may be preferable to a less-invasive laparoscopic appendectomy for the majority of patients with acute appendicitis, contrary to recent trends.

Approximately 250,000 appendectomies are performed in the United States each year to treat appendicitis, an inflammation of the appendix that is considered a medical emergency. If treatment is delayed, the appendix can rupture, causing infection and even death.

For almost a century, open appendectomy was the standard treatment for appendicitis, until the 1980s when laparoscopic appendectomy first gained popularity. This transition was based on data that suggested the operation, in which an instrument called a laparoscope is inserted through small incisions in the abdomen, was associated with reduced pain, faster recovery and better cosmetic results.

"The results of this study challenge the current trend toward increased use of laparoscopic appendectomy," said Klaus Thaler, MD, FACS, department of surgery, University of Missouri, Kansas City. "Although laparoscopic surgery is associated with shorter hospital stays, it actually increases costs and may raise the risk of complications in the majority of appendectomy patients."

This retrospective study examined 235,473 patients who underwent open or laparoscopic appendectomy between 2000 and 2005. Length-of-stay, costs and complications were assessed by stratified analysis for uncomplicated (n=169,094) and complicated (n=66,379) appendicitis. Regression methods were used to adjust for covariates and to detect trends.

The study demonstrated that the odds of having any kind of complication were significantly higher in the laparoscopic group among patients with uncomplicated appendicitis (p<0.05, odds ratio = 1.07), and that there was no difference among patients with complicated appendicitis (p=0.74). The only complications reduced by using the laparoscopic approach were infections in the uncomplicated group, and infections and pulmonary complications in the complicated group.

The adjusted costs for laparoscopic appendectomy were 22 percent higher in uncomplicated appendicitis and 9 percent higher in patients with complicated appendicitis (p<0.001). The increased expense for laparoscopic appendectomy are likely related to higher operating room costs, including greater expense for operative instruments and longer operative times. According to the study, laparoscopic appendectomy did result in a reduced length of hospital stay for both the uncomplicated and complicated groups (p<0.001 and p<0.0001, respectively).