Short-term complications and long-term morbidity of laparoscopic and open appendicectomy in a national cohort

Background: Laparoscopic appendicectomy has been proposed as the standard for surgical treatment of acute appendicitis, based on controversial evidence. This study compared outcomes after open and laparoscopic appendicectomy in a national, population-based cohort. Methods: All patients who underwent open or intended laparoscopic appendicectomy in Sweden between 1992 and 2008 were identified from the Swedish National Patient Register. The outcomes were analysed according to intention to treat with multivariable adjustment for confounding factors and survival analytical techniques where appropriate. Results: A total of 169 896 patients underwent open (136 754) or intended laparoscopic (33 142) appendicectomy. The rate of intended laparoscopic appendicectomy increased from 3.8 per cent (425 of 11 175) in 1992 to 32.9 per cent (3066 of 9329) in 2008. Laparoscopy was used most frequently in middle-aged patients, women and patients with no co-morbidity. The rate of conversion from laparoscopy to open appendicectomy decreased from 75.3 per cent (320 of 425) in 1992 to 19.7 per cent (603 of 3066) in 2008. Conversion was more frequent in women and those with perforated appendicitis, and the rate increased with age and increasing co-morbidity. After adjustment for co-variables, compared with open appendicectomy, laparoscopy was associated with a shorter length of hospital stay (by 0.06 days), a lower frequency of negative appendicectomy (adjusted odds ratio (OR) 0.59; P < 0.001), wound infection (adjusted OR 0.54; P = 0.004) and wound rupture (adjusted OR 0.44; P = 0.010), but higher rates of intestinal injury (adjusted OR 1.32; P = 0.042), readmission (adjusted OR 1.10; P < 0.001), postoperative abdominal abscess (adjusted OR 1.58; P < 0.001) and urinary infection (adjusted OR 1.39; P = 0.020). Laparoscopy had a lower risk of postoperative small bowel obstruction during the first 2 years after surgery, but not thereafter. Conclusion: The outcomes of laparoscopic and open appendicectomy showed a complex and contrasting pattern and small differences of limited clinical importance. The choice of surgical method therefore depends on the local situation, the surgeon's experience and the patient's preference.