Asian Journal of Surgery (2012) 35, 113e116

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journal homepage: www.e-asianjournalsurgery.com

ORIGINAL ARTICLE

Laparoscopic appendectomy for complicated acute

appendicitis does not result in increased surgical
complications
Yueh-Ming Lin a, Ching-Hua Hsieh b, Chia-I Cheng a, Boon-Lee Tan c,*,y,
Hang-Tsung Liu b,*,y
a
Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine,
Kaohsiung, Taiwan
b
Department of Trauma and Emergency Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University
College of Medicine, Kaohsiung, Taiwan
c
Department of Surgery, Putra Medical Centre, Alor Setar, Kedah, Malaysia

Received 17 May 2011; received in revised form 14 September 2011; accepted 1 December 2011
Available online 29 May 2012

KEYWORDS
complicated acute
appendicitis;
laparoscopic
appendectomy;
surgical
complications

Summary Background/Objectives: Septic postoperative complications are debated in

patients with complicated acute appendicitis treated with laparoscopic appendectomy (LA).
The aim of this study was to investigate the results of LA in both complicated and uncomplicated cases of acute appendicitis.
Methods: From January to December 2009, 94 patients with acute appendicitis underwent LA
by the same surgeon using the three-port technique. Data were accumulated and compared
between complicated and uncomplicated acute appendicitis.
Results: Of the 94 patients (45 women and 49 men), 19 had complicated and 75 uncomplicated
acute appendicitis. The group with complicated acute appendicitis, as compared to the
uncomplicated group, was significantly older (55.7  20.5 years vs. 41.0  18.0 years), and
had a significantly increased operation time (117.6  45.5 minutes vs. 78.2  39.4 minutes),
longer length of hospital stay (9.0  3.3 days vs. 5.2  6.0 days) and higher conversion rate
(21.1% vs. 2.7%). No increase in surgical complications was noted in patients with complicated
acute appendicitis, as compared to those with uncomplicated acute appendicitis.
Conclusion: This study demonstrated no increase in surgical complications after LA in patients
with complicated acute appendicitis when compared with those who had uncomplicated

* Corresponding authors. Department of Trauma and Emergency Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung
University College of Medicine, 123 Dapi Road, Niaosong District, Kaohsiung City 833, Taiwan, ROC.
E-mail addresses: fwlchen@yahoo.com.tw (B.-L. Tan), alcohol@adm.cgmh.org.tw (H.-T. Liu).
y
These authors contributed equally to this work.
1015-9584/$36 Copyright 2012, Asian Surgical Association. Published by Elsevier Taiwan LLC. All rights reserved.
doi:10.1016/j.asjsur.2012.04.014

114

Y.-M. Lin et al.

disease. Therefore, LA may be considered the first-choice treatment option for both uncomplicated and complicated acute appendicitis.
Copyright 2012, Asian Surgical Association. Published by Elsevier Taiwan LLC. All rights
reserved.

1. Introduction
Laparoscopic appendectomy (LA) has been an increasingly
used surgical procedure for acute appendicitis since its introduction in 1983.1 Although not yet established as the standard
method for treatment of acute appendicitis, it provides better
diagnostic accuracy, reduced use of analgesics, shorter
hospital stay, earlier return to daily activities, and a lower rate
of wound infection in comparison to open appendectomy
(OA).2e7 Some investigations have also revealed that elderly
patients, morbidly obese patients, and fertile women can take
advantage of LA to treat acute appendicitis.8e11 In addition,
LA is cosmetically beneficial, can aid in the development of
a surgeons laparoscopic skills, and is cost-effective.12
However, there is a debated issue regarding septic postoperative complications (e.g., intra-abdominal abscess)
following LA, especially in cases with complicated
appendicitis.13e16 Although some studies have concluded that
LA is a safe and effective treatment for complicated acute
appendicitis,17e20 undesirable short-term results including
prolonged operation time and postoperative stay, increased
rate of conversion, and greater complications due to infection
have been reported when compared to uncomplicated
appendicitis. Thus, some surgeons are hesitant to perform LA
in those patients in whom they suspect complicated appendicitis. Therefore, the aim of this study was to investigate the
feasibility of LA in cases of complicated acute appendicitis.

2. Patients and methods

Data were collected and recorded from 94 patients who had
consecutively undergone treatment for acute appendicitis by
a single senior surgeon (TBL) in our hospital from January to
December 2009. The diagnosis of acute appendicitis was made
by preoperative clinical presentation. Complicated acute
appendicitis was defined by the presence of a ruptured
gangrenous appendix with or without pus formation. Laparoscopy was performed with the three-port approach (two
10 mm, one 5 mm) using Hassons technique with monopolar
dissectors and forceps. The mesoappendix was divided using
electrocautery or clips. Pre-tied suture loops or laparoscopic
free ties were used for stump closure. The appendix was
extracted within the trocar via the umbilical 10-mm port
without using a plastic bag. Gangrenous and ruptured appendices were irrigated with normal saline (at least 2000 mL), and
a silastic drain was used for ruptured appendices. If the
patients anatomy impeded the laparoscopic procedure,
conversion to open appendectomy was performed through
a low midline incision, following the conventional approach.
Patient follow-up occurred at least once in the outpatient
clinic after discharge. Data collected included demographic
records, white blood cell (WBC) count, operation time, length

of hospitalization, pathology report, and complications.

These parameters were compared between complicated and
uncomplicated cases of acute appendicitis. The c2 and t test
were used; a p value < 0.05 was considered significant.

3. Results
The study included 45 women (47.9%) and 49 (52.1%) men
(mean age: 44.0  19.3 years) who were preoperatively
diagnosed with acute appendicitis. Of the 94 patients, 19
(20.2%) had complicated acute appendicitis, and 75 (79.8%)
uncomplicated acute appendicitis. All patients underwent
routine laparoscopic surgery, but six (6.38%) of the patients
required conversion to open appendectomy after laparoscopy, due to anatomical difficulties encountered during LA.
With regard to the pathology reports, 19 (20.2%) of the
patients had ruptured acute appendicitis, and 51 (54.3%)
had simple acute appendicitis. Thus, the accuracy of
diagnosis based on pathology reports was 74.5% (70/94). In
this study, only 14 patients received preoperative
computed tomography (CT). Among them, acute appendicitis was confirmed by pathologist in 13 patients.
A comparison of complicated and uncomplicated cases of
acute appendicitis initially treated by LA is given in Table 1.
Both groups were comparable regarding sex, duration of
symptoms, WBC count, and surgical complications. In
contrast, the complicated acute appendicitis group had
significantly longer operation times and length of hospital
stay, a higher conversion rate, and was significantly older.
The mean operation time for LA for ruptured acute appendicitis was 118 minutes and 78 minutes for simple acute
appendicitis. The mean length of hospital stay after LA for
ruptured acute appendicitis was 9 days and 5 days for simple
acute appendicitis. One patient received converted open
appendectomy (COA) for uncomplicated acute appendicitis
and had a length of stay of 53 days due to postoperative intraabdominal abscess superimposed on poor compliance with
sugar control of pre-existing diabetes mellitus.
Notably, none of the patients with complicated acute
appendicitis had surgical complications, but six (8.0%)
patients with uncomplicated acute appendicitis sustained
surgical complications (4 intra-abdominal abscesses, 1
wound infection, and 1 liver abscess). This paradoxical result
may be attributed to the higher conversion rate (21.1%, or 4/
19) in patients with complicated acute appendicitis than in
those with simple acute appendicitis (2.7%, or 2/75).
Comparisons between patient who underwent LA versus
COA are summarized in Table 2. The COA group had a significantly longer duration of symptoms and operation times and
had more patients with complicated acute appendicitis, who
were significantly older. In fact, 66.7% (four out of six) of the
patients in the COA group had complicated acute appendicitis. There was no significant difference in sex, WBC count,

Laparoscopic appendectomy for complicated acute appendicitis

115

Table 1 Comparison between complicated and uncomplicated acute appendicitis initially treated by laparoscopic
appendectomy.
Factor

Complicated, (range), n Z 19

Uncomplicated, (range), n Z 75

p value

Age (yr)
Sex (M:F)
Duration of symptoms (d)
WBC (103/L)
Operation time (min)
Length of hospital stay (d)
Surgical complications
Conversion rate

55.7  20.5 (20-84)

12:7
2.4  1.3 (1e5)
13.9  4.0 (7.0e25.3)
117.6  45.5 (60e225)
9.0  3.3 (4e13)
0
4 / 19 (21.1%)

41.0  18.0 (12e83)

37:38
1.9  1.1 (1e7)
13. 6  4.3 (13.6e25.6)
78.8  39.4 (25e195)
5.2  6.0 (1e53)
6
2 / 75 (2.7%)

0.003*
0.281
0.096
0.726
0.000*
0.009*
0.203
0.003*

*Statistically significant.

and length of hospital stay between the two groups.

Regarding surgical complications, there were three of 88
(3.4%) patients with an intra-abdominal abscess, and one
(1.1%) with a wound infection, and one (1.1%) with liver
abscess in the LA group. In the COA group, one of six (16.7%)
patients suffered from intra-abdominal abscess. However,
overall, there was no significant difference in the rate of
surgical complications between the two groups. All complications resulting from infection were successfully treated
with administration of intravenous antibiotics.

4. Discussion
Although septic postoperative complications following LA for
acute appendicitis still pose a problem, in the present study,
there was no significant increase in the rate of surgical
complications in patients with complicated versus uncomplicated acute appendicitis. Indeed, there were no surgical
complications in patients with complicated acute appendicitis, but six (8.0%) of the 75 patients with uncomplicated
acute appendicitis sustained surgical complications. We
believe that these paradoxical results were due to the higher
conversion rate in patients with complicated acute appendicitis, which prevented further surgical complications.
Although some authors have argued that aggressive manipulation of the infected appendix and increased use of irrigation
fluid may increase the risk of contamination of the peritoneal
cavity during LA,21 we found that irrigation of the gangrenous

Table 2

and ruptured appendices with normal saline during LA did not

result in an increased rate of intra-abdominal abscess
formation. This observation was consistent with a study
demonstrating that peritoneal lavage with 3 L 0.9% saline
during LA for perforated appendicitis does not lead to
increased postoperative intra-abdominal abscess formation.22 Therefore, we suggest that irrigation with copious
amounts of solution during LA is feasible, even in cases of
complicated acute appendicitis, which may contribute to
a more favorable surgical outcome. In addition, copious
peritoneal lavage may also be helpful for uncomplicated
acute appendicitis, particularly when iatrogenic rupture of
appendix happens during the operation.
Significantly longer operation times and a prolonged
hospital stay are major concerns when dealing with complicated acute appendicitis treated by LA, because skillful and
meticulous laparoscopic techniques are required to address
the inflammatory changes related to adherence. Of note,
there were only 14 patients who received preoperative CT in
this study. Among these, acute appendicitis was confirmed by
a pathologist in 13 patients. With associated CT, the accurate
diagnosis of acute appendicitis is higher and it may help us to
evaluate the relevant anatomical structure, particularly in
those who sustain suspected complicated acute appendicitis.
Therefore, implementation of CT may help us to determine
which patients can be managed successfully by LA, thus
decreasing the conversion rate in those who have complicated acute appendicitis. However, the correlation of
CT findings with complicated or uncomplicated acute

Comparison between LA and COA in acute appendicitis.

Factor

LA (range), n Z 88

COA (range), n Z 6

p value

Age (yr)
Sex (M:F)
Duration of symptoms (d)
WBC (103/L)
Operation time (min)
Length of hospital stay (d)
Complicated acute appendicitis
Surgical complication
Intra-abdominal abscess
Wound infection
Liver abscess

42.31  18.80 (12e84)

46:42
1.97  1.11 (1e7)
13.74  4.10 (1.5e25.6)
82.14  39.84 (25e225)
5.19  2.70 (1e13)
15/88 (17.0%)
5/88
3/88 (3.4%)
1/88 (1.1%)
1/88 (1.1%)

68.00  7.616 (54e75)

3:3
3.0  1.27 (2e5)
12.13  5.61 (7.0e22.3)
145.00  51.67 (90e210)
17.50  17.76 (6e53)
4/6 (66.7%)
1/6
1/6 (16.7%)
0/6 (0%)
0/6 (0%)

0.000*
0.914
0.003*
0.367
0.000*
0.151
0.003*
0.287
0.120
0.793
0.793

*Statistically significant. COA Z converted open appendectomy; LA Z laparoscopic appendectomy.

116
appendicitis or to surgical procedure was beyond the scope of
the present study. In the present study, the mean operation
time for complicated and simple acute appendicitis by LA was
118 minutes and 78 minutes, respectively. If conversion was
required, the mean operation time increased to 145 minutes.
In addition, the mean length of hospital stay after LA for
ruptured acute appendicitis was 9 days and 5 days for simple
acute appendicitis. If conversion was required, the mean
length of hospital stay increased to 18 days, although this
increase was not significant, due to high variation in COA
patients. Although a longer operation time and prolonged
hospital stay were expected following treatment of complicated acute appendicitis by LA, a comparison of the results
between the traditional open method and LA for complicated
acute appendicitis was beyond the scope of the study design.
In the present study, the overall conversion rate was
6.38%, which was comparable to the rate in other
studies19,20; the conversion rate for complicated and
uncomplicated acute appendicitis groups was 21.1% and
2.7%, respectively. A higher conversion rate was noted in
nearly 20% of the patients with complicated acute appendicitis; however, no significant increase in the rate of
surgical complications was noted. A surgeons experience
has been shown to correlate with the rate of conversion to
open procedures.20 In the present study, all procedures (LA
and COA) were performed by the same senior surgeon, thus
making the comparison more meaningful.
The benefits of treating complicated acute appendicitis
with LA include wide inspection of the peritoneal cavity,
debridement, irrigation, and lavage under direct visualization, avoidance of large abdominal incisions, and fewer
pulmonary complications.23 Another benefit of LA is that
diagnostic laparoscopy can be performed before the actual
open appendectomy in doubtful cases.24 It is undecided
whether LA has an immunological advantage in cases of
complicated appendicitis; however, our WBC count data did
not reveal any significant difference between the subgroups,
which is consistent with other reports that indicate no
differences in inflammatory parameters after LA for nonperforated appendicitis.25 Therefore, in accordance with
other studies that have proposed the feasibility of LA for
treating complicated acute appendicitis, we propose that LA
should be considered as the first intervention, not only for
uncomplicated but also for complicated acute appendicitis.
Our study demonstrated that using LA to treat complicated acute appendicitis was not associated with additional
surgical complications when compared with those who had
uncomplicated acute appendicitis. Therefore, it seems
feasible to use LA as the first-choice treatment for both
uncomplicated and complicated acute appendicitis.

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