Once the diagnosis of appendicitis is made, the surgeon must decide whether to perform an open (OA) or laparoscopic (LA) appendectomy. Numerous randomized controlled trials have compared these two methods for treat appendicitis, sometimes with conflicting results. Meta-analyses and systematic reviews have combined these studies to address the controversy (See table below). These meta-analyses have similar findings, which can be summarized in appendicitis surgery as follows:
(1) OA can be performed more quickly;
(2) LA patients have less postoperative pain and reduced narcotic requirements;
(3) there is a trend toward reduced length of stay with LA;
(4) LA patients have fewer wound infections;
(5) OA patients develop fewer intra-abdominal abscesses;
(6) LA patients return to work more quickly;
(7) operating room and hospital costs are less with OA; and
(8) societal costs may be less with LA.
Based on the data available, one cannot convincingly recommend either OA or LA over the other. Each method has its advantages and disadvantages that should be considered when deciding how to perform appendectomy.
One situation in which laparoscopic appendectomy may be advisable is when the diagnosis of appendicitis is in doubt. This can be particularly useful in women of childbearing age, in whom obstetric and gynecological pathology may also be likely. In this population, a normal appendix can be found in more than 40% of patients with suspected appendicitis. Laparoscopy can thus be both diagnostic and therapeutic, and a laparotomy can be avoided if gynecologic pathology is found. The ovaries, fallopian tubes, and uterus can be examined for nonappendiceal causes of abdominal pain, including ovarian cyst or torsion, endometriosis, or pelvic inflammatory disease. Laparoscopy makes this evaluation considerably easier and less morbid for the patient. In one study, when a normal appendix was discovered, gynecological pathology was found in 73% of women explored laparoscopically, but only 17% of women who had an open appendectomy. Although diagnostic accuracy will likely improve in young women with more widespread use of CT scans, this population will continue to provide diagnostic dilemmas that may be aided by laparoscopy.