Abstracts
1998 Digestive Disease Week

#3586

APPENDECTOMY IN THE PRE AND POST LAPAROSCOPIC ERAS. DB Nguyen, W Silen, and RA Hodin. Dept of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.

The role of laparoscopic appendectomy remains controversial since many authors have suggested that overall morbidity is more a function of the degree of appendicitis, rather than the operative approach. We have reviewed our appendectomy experience in order to determine whether there is any benefit to the laparoscopic technique in cases of acute appendicitis. METHODS: Data were accumulated for all 1170 patients who underwent appendectomy at a single institution during three time periods which span the pre- and post-laparoscopic eras, I ('87-'90), II ('91-'93), and III ('94-97). Cases were categorized according to pathologic findings and in regard to operative approach, open (OA) or laparoscopic (LA). RESULTS: The percentage of cases performed laparoscopically increased with time (0, 23, and 79 for periods I, II, and II). Overall, the total operating room time was no different between LA and OA (99 vs 102 min). Operating room times for OA remained unchanged, but the times for LA decreased from period II to III (140 to 90 min, p<0.001). In perforated/gangrenous cases, the times for LA were significantly shorter than for OA (115/98 vs 125/120 min, p<0.001 for both). Overall, hospital stay was less in LA patients (1.63 vs 4.21 days, p<0.001), and the difference was maintained in all three time periods. The differences in length of stay for LA vs OA were most dramatic in perforated/gangrenous cases (3.0/1.8 vs 9.0/4.0 days, p<0.001), whereas there was only a slight difference in cases of simple appendicitis, e.g., 1.6 vs 2.1 days (LA vs OA, period III). The rate of "negative" appendectomies was similar over the three time periods (8%, 6%, and 6%), but there was a significant decrease in the percent of perforated cases with in-hospital (> 8 hr) delay (21%, 5%, and 5%). CONCLUSIONS: LA results in a marked decrease in hospital stay compared to OA. In cases of perforated or gangrenous appendicitis, LA appears to be especially worthwhile in regard to both operating room time and hospital stay.

#3587

LAPAROSCOPIC VS. OPEN INGUINAL HERNIORRAPHY, A RANDOMIZED CONTROLLED TRIAL. JS Barkun, MJ Wexler, M Fernandez, JL Meakins. McGill University, Montreal, Canada.

Over a 28 month period, 124 patients with a unilateral inguinal hernia were recruited into a randomized controlled trial comparing open (OH) to laparoscopic inguinal herniorraphy (LH). The primary endpoint was duration of convalescence. There was no difference in baseline parameters across groups with respect to: Age, Sex, Body mass index, American Society of Anaesthetists score, Employment status, incidence of symptoms, hernia type, or quality of life scores ((QOL), using two validated instruments). Sixty five patients underwent OH and 59 LH. Before operation, LH patients anticipated a significant shorter duration of convalescence than OH (14.2 ± 9.6 days vs. 18.4 ± 10.8 days p=0.027). The mean duration of operating room time utilization was 73.5 ± 26.2 min for OH and 88.8 ± 34 min for LH (p=0.007). Only 39% of OH patients and all LH patients underwent general anesthesia. Eighty one percent of LH repairs were performed using a trans-abdominal properitoneal technique, whereas 50% of OH patients had a tension-free repair. The median duration of hospital stay was one day in both groups. The total does of morphine equivalents required was 41.4 ± 33 mg in OH and 27.9 ± 34.7mg in LH (p=0.0035). The duration of time till return to work (for employed patients) and return to full activities (for unemployed or retired patients) was 11.4 ± 7.7 days in OH and 9.8 ± 7.4 days in LH (NS). This result was confirmed by survival analysis of the percentage of activities which could be performed at the time of post-operative follow-up interviews. There was a significant greater proportion of LH patients willing to undergo the same procedure (95% Odds ratio = 2.9-17.6, p<0.001). There was no difference however in QOL or morbidity between groups. After a median follow-up of 3 years one OH and three LH patients exhibited an asymptomatic recurrent hernia.

Conclusions: Although no difference in convalescence or QOL could be demonstrated across groups, LH patients reported significant benefits in post-OP pain and procedural satisfaction.

(Funded in part by Ethicon Canada)

Copyright 1996 - 1998, SSAT, Inc. Revised 29 June 1998.