ORIGINAL ARTICLE

Comparison of Outcomes of Laparoscopic and Open

Appendectomy in Management of Uncomplicated and
Complicated Appendicitis
Manish M. Tiwari, MD, PhD, MPH, Jason F. Reynoso, MD, Albert W. Tsang, MD, and
Dmitry Oleynikov, MD, FACS

Background: Several studies have demonstrated the superiority of the la-

paroscopic approach in uncomplicated and complicated appendicitis with
L aparoscopic surgery is a less morbid procedure that usually results
in an uneventful postoperative recovery for many surgical proce-
dures. The distinguishing features of a laparoscopic approach over
conflicting results. As a result the role of laparoscopy in the management of
conventional open approach include shorter hospital stay, quicker
appendicitis in general and complicated or perforated appendicitis, in partic-
return to activity, reduced pain, and better cosmesis. These poten-
ular, is still undefined.
tial patient benefits coupled with superior outcomes have facilitated
Methods: A retrospective, observational study design was used to ana-
the adoption of laparoscopic approach as the gold standard for sur-
lyze multicenter outcomes using the University HealthSystem Consortium
gical procedures such as cholecystectomy. However, the role of la-
database. A 3-year discharge data of all open appendectomy (OA) and laparo-
paroscopy in appendectomy has remained controversial with no clear
scopic appendectomy (LA) procedures from 2006 to 2008 in adult patients
consensus yet.
older than 18 years for complicated or uncomplicated appendicitis was ac-
Conventional gridiron incision approach has been compared
cessed using International Classification of Diseases, Ninth Revision codes.
to the minimally invasive approach in many scientific studies in-
Data on several surgical outcome measures such as observed mortality, overall
cluding prospective randomized studies,1–5 retrospective experience
patient morbidity, intensive care unit admission rate, 30-day readmission rate,
analysis,6–11 and meta-analysis.12–15 Study results have been hetero-
length of hospital stay, and hospital costs were collected from the University
geneous with laparoscopic appendectomy (LA) demonstrating better
HealthSystem Consortium database. Stratification by University HealthSys-
clinical outcomes in some studies,1,2,4,5,8,10,11,13,16 no clear benefit or
tem Consortium-specific severity of illness groups and disease diagnosis of
marginal benefit in others,2,18 and some finding higher surgical costs
complicated or perforated and uncomplicated appendicitis was performed.
with laparoscopic surgery.6,17,19 Because of these disparate findings
Results: A total of 40,337 appendectomy procedures performed during 2006
the formation of a clear consensus for superiority of either approach
to 2008 in adult patients were included in the study. Laparoscopic appendec-
in the management of appendicitis has not been developed.
tomy for uncomplicated appendicitis resulted in significantly better surgical
Appendectomy outcomes can differ considerably secondary to
outcomes. However, surprisingly, these outcomes resulted in comparable but
patient illness severity and diagnosis of either complicated (perfo-
not significantly reduced hospital costs (7825 ± 6,009 for LA vs 7841 ±
rated) or uncomplicated appendicitis.3,10 Despite conflicting results,
13,147 for OA; P > 0.05). Laparoscopic appendectomy for complicated or
several studies have demonstrated the superiority of the laparoscopic
perforated appendicitis showed lower mortality, reduced overall morbidity
approach in uncomplicated appendicitis.1,2,4,5,8,10,11,13,16 However, the
(17.43% for LA vs 26.68% for OA; P < 0.001), relatively less 30-day read-
clinical benefit of laparoscopy as either a diagnostic or therapeutic
mission rate, fewer intensive care unit admissions, significantly shorter length
modality in the management of complicated or perforated appendici-
of hospital stay (4.34 ± 4.84 days for LA vs 7.31 ± 9.43 for OA; P < 0.001),
tis is still undefined. It is quite possible that perforated appendicitis
and reduced hospital costs (12,125 ± 14,430 for LA vs 17,594 ± 28,065
may still be considered by some surgeons as a contraindication to
for OA; P < 0.001) compared with patients undergoing OA. On stratification
laparoscopic mediation. Surprisingly, in contrast to such considera-
for severity of illness in both complicated and uncomplicated appendicitis, la-
tion, laparoscopic surgery might offer clinical benefits in perforated
paroscopic appendectomy resulted in a greater or comparable clinical benefit
appendicitis. In fact, shorter convalescence and the avoidance of ex-
than open appendectomy. Comparable clinical benefit was observed in minor
tensive laparotomy would be an advantage particularly in severely
severity patients and moderate and major/extreme severity patients showed
ill perforated patients. An extensive comparative evaluation of open
vastly improved surgical outcomes with the laparoscopic approach.
appendectomy (OA) and LA approaches with subgroup analysis of
Conclusions: Laparoscopic appendectomy is superior or comparable to open
patient illness severity could help define the role of LA in higher-
appendectomy in terms of several surgical outcome measures for both uncom-
risk patients. The purpose of this study is to examine the role of
plicated and complicated appendicitis, across most illness severity groups.
laparoscopic surgery in the management of both complicated and
Thus, laparoscopic appendectomy may be the preferred technique, irrespec-
uncomplicated appendicitis in higher- and lower-risk patient groups.
tive of appendicitis diagnosis or disease severity.
(Ann Surg 2011;254:927–932) METHODS
Database Description
Several studies have been conducted with the University
HealthSystem Consortium (UHC) clinical database and the UHC
From the Department of Surgery, University of Nebraska Medical Center,
database has previously been described.11,20 In brief, the UHC is an
Omaha, NE. alliance of more than 100 medical centers and their affiliate hospitals.
Disclosure: The authors declare that they have nothing to disclose. UHC’s clinical database/resource manager provides risk-adjusted,
Reprints: Dmitry Oleynikov, MD, FACS, Department of Surgery, 985126 Nebraska patient-level data for performance improvement purposes. The UHC
Medical Center, Omaha, NE 68198. E-mail: doleynik@unmc.edu.
Copyright C 2011 by Lippincott Williams & Wilkins
database provides patient discharge data collected from member hos-
ISSN: 0003-4932/11/25406-0927 pitals. Specific aggregate-level patient information is available for
DOI: 10.1097/SLA.0b013e31822aa8ea patient characteristics such age, sex, and race. In addition, specific

Annals of Surgery r Volume 254, Number 6, December 2011 www.annalsofsurgery.com | 927

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Tiwari et al Annals of Surgery r Volume 254, Number 6, December 2011

discharge data for inpatient stay such as length of stay, intensive

TABLE 1. Demographic Characteristics of the Study
care unit (ICU) admission, readmission, morbidity, observed, and
Population
expected risk-adjusted inpatient mortality, patient diagnosis, and in-
patient procedures, and inpatient hospital costs are available. Logistic Variable Laparoscopic Procedure Open Procedure
and multiple regression models are used for risk-adjustment for out-
Total patients 25,981 14,356
comes such as length of stay, mortality, and hospital cost.
Sex, %
UHC clinical database provides an estimated cost of patient Male 52.9 59.9
care using a ratio of cost-to-charge (RCC) methodology. Specific costs Female 47.1 40.1
and revenues from the Centers for Medicare & Medicaid Services are Age group, %
used to calculate a ratio of cost-to-charge for each service. Detailed 18–30 years 41.7 37.1
patient charges are collected at the revenue code level and estimated 31–50 years 38.6 36.4
service center costs are then calculated by multiplying these charges 51–64 years 13.9 16.6
by the ratio of cost-to-charge. Summation of individual cost center ≥65 years 5.8 9.9
estimates reveals the total costs. Race, %
White 56.5 52.5
The severity of illness classification is based on the Interna-
African American 9.7 12.6
tional Classification of Diseases, Ninth Revision, Clinical Modifica- Hispanic 18.7 21.6
tion (ICD-9-CM) diagnosis and procedure codes. Severity of illness Other 15.1 13.3
is based on a total of 29 comorbid illnesses and risk adjustment mod- Severity of illness, %
els that take into account factors such as age, sex, race, admission Minor 65.5 50.4
status, admission source, socioeconomic status and sets of variables Moderate 30.8 39.0
for specific patient population. On the basis of these factors, the 4 Major/Extreme 3.7 10.6
illness severity categories developed by the UHC system are minor,
moderate, major, and extreme.
RESULTS
Study Design A total of 40,337 appendectomy procedures performed dur-
This study was conducted after approval from institutional re- ing 2006 to 2008 in adult patients were included in the study. Pa-
view board and UHC. A retrospective, observational study design tients undergoing appendectomy, either open or laparoscopic, were
was used to analyze multicenter outcomes using the UHC database. predominantly white, male, and aged between 18 and 50 years as
A 3-year discharge data of all open and laparoscopic appendectomy shown in Table 1. Performance of appendectomy procedure through
procedures from 2006 to 2008 in adult patients older than 18 years a laparoscopic approach (n = 25,981) was considerably higher
for complicated or uncomplicated appendicitis was accessed. For data than appendectomy procedures performed through an open approach
collection, UHC database was accessed electronically with diagnosis (n = 14,356). The study population showed significant sex, racial,
and procedural ICD-9 CM codes. The ICD-9-CM codes for laparo- and severity of illness differences between the laparoscopic and open
scopic (47.01) and open (47.09) appendectomy, acute appendicitis procedure groups. Compared to open appendectomy, a higher pro-
(540, 540.9), and perforated appendicitis (540.0, 540.01) were used. portion of female (47.1% in LA vs 40.1% in OA), whites (56.5%
in LA vs 52.5% in OA), and minor illness severity (65.5% in LA
vs 50.4% in OA) patients underwent laparoscopic appendectomy.
Main Outcome Measures Alternately, the open procedure was favored over the laparoscopic
Data on several surgical outcome measures such as observed procedure in male, African American, and Hispanic racial groups,
mortality, overall patient morbidity, ICU admission rate, 30-day read- and moderate and major/extreme illness severity groups. Finally, a
mission rate, length of hospital stay, and hospital costs were collected comparison between patient groups with complicated and uncompli-
from the UHC database. In addition, demographic characteristics of cated appendicitis showed that patients with uncomplicated appen-
the study population such as age, sex, and race distribution was gath- dicitis frequently underwent a laparoscopic procedure. In addition,
ered. Admission age was subdivided as age 18 to 30 years, 31 to 50 complicated appendicitis was associated with higher observed mor-
years, 51 to 64 years and 65 years or more. Racial groups included tality, overall morbidity, 30-day readmission, ICU admission, length
in the analysis were whites, African Americans, Hispanics, and other of stay, and hospital costs. Comparison of surgical outcomes with un-
group including Asians, Native Americans, and undetermined cate- complicated and complicated appendicitis is presented in Table 2 and
gories. Stratification by disease diagnosis of complicated or perfo- Table 3, respectively.
rated and uncomplicated appendicitis was performed by restricting Patients with uncomplicated appendicitis frequently under-
outcome measures by ICD-9 CM disease diagnosis codes. Stratifica- went a laparoscopic procedure (20,769 LA vs 9033 OA) and were
tion of outcome measures by UHC-specific severity of illness groups commonly of the minor illness severity (16,962 in LA vs 7065 in
was also accomplished. OA). Overall, laparoscopic appendectomy for uncomplicated appen-
dicitis resulted in significantly reduced observed mortality (0.07%
Data Analysis with LA vs 0.17% with OA; P = 0.03), less overall morbidity (4.20%
Prism 5.0 (GraphPad Software; San Diego, CA) and PC SAS in LA vs 6.91% in OA; P < 0.001), relatively fewer ICU admissions
version 9.2 (SAS Institute Inc.; Cary, NC) statistical software were (2.04% in LA vs 3.68 in OA; P < 0.001), significantly less 30-day
used for statistical analysis. Data on variables such as length of hos- readmission (1.86% for LA vs 2.97 for OA; P < 0.001) and a shorter
pital stay, and hospitals costs are expressed as mean ± standard length of stay (1.74 ± 2.33 days for LA vs 2.45 ± 4.10 days for
deviation (SD) and compared with an unpaired t test. Frequency OA; P < 0.001). However, surprisingly, these outcomes resulted in
percentage is used to express variables such as observed mortality, comparable but not significantly reduced hospital costs (7825 ±
overall morbidity, ICU admission and 30-day readmission. A χ 2 or 6009 for LA vs 7841 ± 13,147 for OA; P > 0.05).
the Fisher exact test was performed for comparison of these categor- Stratification by severity of illness in patients with uncompli-
ical variables between groups. Significance for the study was set at cated appendicitis showed that the laparoscopic procedure resulted in
P < 0.05. significantly reduced morbidity and length of stay across all severity

928 | www.annalsofsurgery.com 
C 2011 Lippincott Williams & Wilkins

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 254, Number 6, December 2011Laparoscopic Versus Open Appendectomy in Management of Appendicitis

TABLE 2. Comparison of Outcomes of Patients Undergoing Laparoscopic or

Open Appendectomy for Uncomplicated Acute Appendicitis
Variable Laparoscopic Procedure Open Procedure P
All Severity
Total number of patients (n) 20,769 9,033 ...
Observed mortality, % 0.07 0.17 0.032
Overall morbidity, % 4.20 6.91 <0.001
30-day readmission, % 1.86 2.97 <0.001
ICU cases, % 2.04 3.68 <0.001
LOS, Days, Mean ± SD 1.74 ± 2.33 2.45 ± 4.10 <0.001
Cost, USD, Mean ± SD 7,825 ± 6,009 7,841 ± 13,147 0.89
Minor severity
Total number of patients, n 16,962 7,065 ...
Observed mortality, % 0.00 0.00 ...
Overall morbidity, % 1.47 2.03 0.0023
30-day readmission, % 1.62 2.56 <0.001
ICU cases, % 1.20 1.07 0.44
LOS, Days, Mean ± SD 1.46 ± 0.9 1.73 ± 1.17 <0.001
Cost, USD, Mean ± SD 7,242 ± 3,289 5,924 ± 2,682 <0.001
Moderate severity
Total number of patients, n 3,306 1,539 ...
Observed mortality, % 0.03 0.00 0.49
Overall morbidity, % 12.83 17.32 <0.001
30-day readmission, % 2.82 3.51 0.22
ICU cases, % 3.05 5.78 <0.001
LOS, Days, Mean ± SD 2.30 ± 2.03 3.36 ± 2.89 <0.001
Cost, USD, Mean ± SD 8,756 ± 5,513 8,898 ± 7,288 0.45
Major/extreme severity
Total number of patients, n 501 429 ...
Observed mortality, % 2.59 3.50 0.45
Overall morbidity, % 39.96 50.72 <0.001
30-day readmission, % 3.89 7.99 0.011
ICU cases, % 23.72 38.68 <0.001
LOS, Days, Mean ± SD 7.21 ± 11.65 11.15 ± 14.64 <0.001
Cost, USD, Mean ± SD 20,546 ± 26,752 32,377 ± 48,805 <0.001

of illness categories. The 30-day readmission rate with laparoscopic
appendectomy was significantly less for minor (1.62% for LA vs
2.56% for OA; P < 0.001) and major/extreme severity groups (3.89%
for LA vs 7.99% for OA; P < 0.01) but only comparable to the open
group in the moderate illness severity category. The ICU admissions
in the laparoscopic group were comparable to the open group in the
minor severity patients (1.20% for LA vs 1.07% for OA; P > 0.05)
but significantly reduced in the other severity of illness subgroups.
Surprisingly, compared to open surgery patients, the hospital costs
for the laparoscopic group were significantly higher for the minor
severity patients (7242 ± 3289 for LA vs 5924 ± 2682 for OA;
P < 0.001), comparable in the moderate severity subgroup and sig-
nificantly reduced in the major/extreme severity patients (20,546 ±
26,752 for LA vs 32,377 ± 48,805 for OA; P < 0.001).
Overall, patients undergoing laparoscopic appendectomy for
complicated or perforated appendicitis showed lower mortality
(0.13% for LA vs 1.03% for OA; P < 0.001), reduced overall mor-
bidity (17.43% for LA vs 26.68% for OA; P < 0.001), relatively less
30-day readmission rate (5.04% for LA vs 5.93% for OA; P < 0.05),
fewer ICU admissions (5.82% for LA vs 15.60% for OA; P < 0.001),
significantly shorter length of hospital stay (4.34 ± 4.84 days for
LA vs 7.31 ± 9.43 for OA; P < 0.001), and reduced hospital costs
(12,125 ± 14,430 for LA vs 17,594 ± 28,065 for OA; P < 0.001)
compared to patients undergoing open appendectomy.
Upon stratification by severity of illness, patients with compli-
cated appendicitis undergoing laparoscopic surgery showed shorter
duration of hospitalization across all severity groups, compared with
open surgery patients. Observed mortality in these patients was
comparable between laparoscopic and open groups for minor and
moderate illness severity patients but significantly reduced for ma-
jor/extreme illness severity patients (1.49% for LA vs 4.87% for OA;
P < 0.001). Overall morbidity and 30-day readmission between la-
paroscopic and open groups showed a trend toward reduction in the
minor and major/extreme severity groups but were only significantly
reduced in the moderate illness severity patients. No significant dif-
ference in the ICU admission rates between laparoscopic and open
surgery was noted for the minor severity group (3.92% for LA vs
5.70% for OA; P > 0.05). However, ICU admission rates were sig-
nificantly fewer in the laparoscopic group compared with the open
group in moderate (2.93% for LA vs 6.27% for OA; P < 0.001) and
major/extreme illness severity patients (34.43% for LA vs 51.79%
for OA; P < 0.001). Hospital costs were significantly less with la-
paroscopic surgery for the moderate (10,427 ± 5219 for LA vs
11,536 ± 6836 for OA; P < 0.001) and major/extreme severity ill-
ness patients (28,589 ± 41,036 for LA vs 38,847 ± 53,295 for OA;
P < 0.001). However, no significant difference in costs for the mi-
nor severity category between laparoscopic and open surgery groups
was found (11,923 ± 6146 for LA vs 13,180 ± 6378 for OA;
P > 0.05).
DISCUSSION
Despite several clinical benefits and superior outcomes with
laparoscopic appendectomy,1,2,4,5,8,10,11,13,16 the optimal surgical ap-
proach for appendectomy is still debatable. Conflicting comparative


C 2011 Lippincott Williams & Wilkins www.annalsofsurgery.com | 929

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Tiwari et al Annals of Surgery r Volume 254, Number 6, December 2011

TABLE 3. Comparison of Outcomes of Patients Undergoing Laparoscopic

or Open Appendectomy for Complicated Acute Appendicitis
Variable Laparoscopic Procedure Open Procedure P
All severity
Total number of patients, n 5,212 5,323 ...
Observed mortality, % 0.13 1.03 <0.001
Overall morbidity, % 17.43 26.68 <0.001
30-day readmission, % 5.04 5.93 0.050
ICU cases, % 5.82 15.60 <0.001
LOS, Days, Mean ± SD 4.34 ± 4.84 7.31 ± 9.43 <0.001
Cost, USD, Mean ± SD 12,125 ± 14,430 17,594 ± 28,065 <0.001
Minor severity
Total number of patients, n 53 167 ...
Observed mortality, % 0.00 0.00 ...
Overall morbidity, % 20.75 28.14 0.37
30-day readmission, % 3.77 6.59 0.74
ICU cases, % 3.92 5.70 0.74
LOS, Days, Mean ± SD 3.87 ± 2.88 5.58 ± 2.72 <0.001
Cost, USD, Mean ± SD 11,923 ± 6,146 13,180 ± 6,378 0.21
Moderate severity
Total number of patients, n 4,690 4,067 ...
Observed mortality, % 0.00 0.05 0.22
Overall morbidity, % 13.25 17.78 <0.001
30-day readmission, % 5.01 6.01 0.047
ICU cases, % 2.93 6.27 <0.001
LOS, Days, Mean ± SD 3.72 ± 2.82 5.32 ± 3.84 <0.001
Cost, USD, Mean ± SD 10,427 ± 5,219 11,536 ± 6,836 <0.001
Major/extreme severity
Total number of patients, n 469 1,089 ...
Observed mortality, % 1.49 4.87 <0.001
Overall morbidity, % 59.78 60.21 0.89
30-day readmission, % 5.41 5.51 0.98
ICU cases, % 34.43 51.79 <0.001
LOS, Days, Mean ± SD 10.61 ± 11.69 15.01 ± 17.44 <0.001
Cost, USD, Mean ± SD 28,589 ± 41,036 38,847 ± 53,295 <0.001

study results1,2,4,5,8,10,11,13,16,17 and apparently higher costs in some
studies6,17,19 have made it difficult to come to a consensus regarding
the preferred approach in the management of appendicitis, in general,
and for complicated appendicitis, in particular. However, laparoscopic
appendectomy has increased from 17.4% of all appendectomies in
199710 and 31.8% during 1999 to 200311 to 64.4% in 2006 to 2008.
Surprisingly 29.4% of patients with uncomplicated appendicitis and
a minor severity of illness underwent open appendectomy.
This study examined the role of laparoscopic surgery in the
management of both complicated and uncomplicated appendicitis
in patients with varying illness severity. Results from this retro-
spective study showed comparable or better outcomes with laparo-
scopic appendectomy and endorse laparoscopic appendectomy as the
preferred technique, regardless of appendicitis diagnosis or illness
severity.
Similar to previous administrative database studies, female
and white patients were found to be more likely to have LA.11,12 Con-
versely African American and Hispanic patients were more likely to
have OA. This study is not designed to determine whether this dis-
parity is secondary to regional differences, patient characteristics, or
lack of access to health care. However, a recent Medicare database
study which controlled for patient characteristics and regional dif-
ferences determined race to be a factor in utilization of the newest
surgical technology.21 Racial disparity in health care continues to be
an important issue and further studies are needed to fully understand
this complex problem.
Consistent with published estimates the observed mortality
with either approach was negligible10,22–24 and seen primarily in
the major/extreme severity illness. In addition, the overall morbidity
risk was significantly lower with laparoscopic appendectomy sim-
ilar to previous studies that have shown overall morbidity in the
range of 5% to 18.5% with laparoscopic appendectomy and 8%
to 17% with open appendectomy.1,2,16,25 Specifically, the morbid-
ity rates with complicated appendicitis were higher than uncompli-
cated appendicitis but yet significantly lower with laparoscopic ap-
proach than open approach. The postoperative morbidity, including
intra-abdominal abscess and wound infections, for complicated ap-
pendicitis with laparoscopic appendectomy has been shown to be
consistently lower than open appendectomy and estimates vary from
12.8% to 39.5% for laparoscopic appendectomy and 26% to 37%
for open appendectomy.7,23,26,27 These lower mortality and morbid-
ity rates with the laparoscopic procedure indicate that laparoscopic
appendectomy is a safe and effective procedure.
In this study, the length of hospitalization with laparoscopic
appendectomy was 1.74 days and 2.45 days with open appendec-
tomy for uncomplicated appendicitis and 4.34 days with laparoscopic
appendectomy and 7.31 days with open appendectomy for compli-
cated appendicitis. Previous reports using a large national database
have reported similar but slightly higher length of stay, perhaps be-
cause of clubbing of complicated and uncomplicated appendicitis
diagnosis.10,20 The length of stay for the laparoscopic group was re-
duced by about 3 days in patients with perforated appendicitis whereas
for patients with uncomplicated appendicitis reduction was about 0.8
days when compared to the open group. In a prospective study, a sim-
ilar result with a greater reduction in length of stay of about 2 days
with laparoscopic procedure was observed in perforated appendicitis

930 | www.annalsofsurgery.com 
C 2011 Lippincott Williams & Wilkins

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 254, Number 6, December 2011Laparoscopic Versus Open Appendectomy in Management of Appendicitis
patients versus patients with uncomplicated appendicitis who showed
a reduction of 0.3 days.8
As might be expected, complicated appendicitis in either the
open or laparoscopic group showed worse outcomes.3,10 Over-
all, laparoscopic surgery resulted in significantly better outcomes
than open surgery in both uncomplicated and complicated appen-
dicitis in terms of observed mortality, overall morbidity, length
of hospitalization, ICU admissions, readmissions, and hospital
costs. Several reports before this investigation have shown better
surgical outcomes in complicated7–9,22,24,26–28 and uncomplicated
appendicitis1,2,4,5,8,10,11,13,16 with laparoscopic appendectomy. Sub-
group analysis based on severity of illness demonstrated that the
outcomes with laparoscopic surgery are comparable to open surgery
in the minor severity of illness patients but significantly better on
most outcome measures in the moderate and major/extreme sever-
ity patients. Such stratification by severity of illness has previously
never been reported. For both perforated and uncomplicated appen-
dicitis, patients with minor severity of illness showed only comparable
outcomes between the laparoscopic and open procedures whereas pa-
tients with moderate and major/extreme severity showed significantly
better outcomes with the laparoscopic approach. This trend toward
better outcomes with the laparoscopic procedure with higher severity
of illness has not been observed previously and suggests that laparo-
scopic procedure might be particularly better and of greater benefit
in these severely ill patients with multiple comorbidities. Thus, peri-
operative outcomes data from the UHC database suggest that laparo-
scopic surgery can be endorsed as the preferred technique in patients
with uncomplicated or complicated appendicitis across all severity of
illness categories.
In addition to better postoperative outcomes the hospital costs
for the laparoscopic group were comparable to the open group. This
is consistent with previous studies showing comparable3,11 or even
higher costs with laparoscopic appendectomy.6,17,19 The higher la-
paroscopic operative costs seem to be a function of longer operative
times possibly attributable to surgeon learning curve and the higher
costs of disposable laparoscopic instruments. These inherent addi-
tional laparoscopy costs may be offset, marginally or entirely, by a
reduction in the hospitalization costs due to reduced overall morbid-
ity perhaps requiring fewer ICU admissions, and a shorter length of
stay in the laparoscopic group. Although UHC database cost informa-
tion does not distinguish between operative and hospitalization costs,
failure to detect an appreciable reduction in hospital costs may have
been due to proportionately higher operative costs with laparoscopic
appendectomy.
In addition, overall costs in this study were a result of aggre-
gation of costs across all severity illness groups with a dispropor-
tionate representation of severity groups showing hospital costs with
laparoscopy that were significantly higher in minor, comparable in
moderate and significantly reduced in the major/extreme severity pa-
tients. Likelihood of serious postoperative morbidity, need for ICU
admission, and relative reduction in length of stay in these severity
groups that can drive hospitalization costs may explain this variation
in hospital costs across severity groups. However, using a decision
analytic model it has previously been reported that despite higher
costs with laparoscopic appendectomy there is a definite economic
benefit from a patient-centered social perspective with a shorter hos-
pitalization and quicker return to daily activities.29
The study has several limitations. The study design did not
allow us to perform multivariate analysis. Thus, most outcome mea-
sures may not account for some of the potential confounding factors
such as age, sex, and race. It is quite possible that the differences
in outcome measures between the laparoscopic surgery and open
surgery groups may have been due to the differences observed in
the study populations between the groups. Furthermore, the patient

C 2011 Lippincott Williams & Wilkins
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
population in the academic centers included in the UHC database may
not be representative of the general population. The database does not
identify conversion cases from laparoscopic to open procedure due to
the absence of a specific procedure code. However, previous studies
have suggested that the rate of conversion from laparoscopic to open
has been on the decline in recent years and may not be substantial.17
The overall postoperative morbidity does not differentiate between
serious and nonserious morbidity in patients. The database allows
capture of data from in-patient admissions only. It is possible that
patients with laparoscopic surgery may have higher complications or
mortality postdischarge than open surgery. However, such patients
may have been captured by a higher readmission rate. Because the
readmission rate for laparoscopic procedures was significantly lower
than open procedures, it can be concluded that such was not the
case in this group of patients. The database provided information
on immediate postoperative surgical outcomes. Other patient-centric
outcomes such as postoperative pain, quality of life, and return to
work, and clinically relevant long-term functional outcomes cannot
be analyzed by the database. Laparoscopic appendectomy has previ-
ously been shown to offer additional clinical benefits in terms of less
intraoperative blood loss, reduced pain with a diminished need for
analgesia, better cosmesis, faster return to activity and better quality
of life. Nevertheless, results from this study highlight the differences
in outcomes between the groups but not the cause of differences.
In summary, the study findings confirmed previous study re-
sults and clearly demonstrated superiority of laparoscopic appendec-
tomy over open appendectomy, regardless of diagnosis of complicated
or uncomplicated appendicitis and severity of illness. Laparoscopic
appendectomy showed comparable or clear benefit over open appen-
dectomy in terms of reduced mortality, morbidity, 30-day readmission
rate, ICU admissions, length of hospital stay, and hospital costs for
both uncomplicated and complicated appendicitis. Thus, laparoscopic
appendectomy was found to be safe, efficacious, and cost-effective
for complicated and uncomplicated appendicitis. Perioperative out-
comes data support the utilization of laparoscopic appendectomy,
irrespective of appendicitis diagnosis or disease severity.
ACKNOWLEDGMENTS
The authors thank Valerie K. Shostrom, MS, for assistance in
statistical analysis.
REFERENCES
1. Frazee RC, Roberts JW, Symmonds RE, et al. A prospective randomized trial
comparing open versus laparoscopic appendectomy. Ann Surg. 1994;219:725–
728; discussion 728–731.
2. Katkhouda N, Mason RJ, Towfigh S, et al. Laparoscopic versus open appendec-
tomy: A prospective randomized double-blind study. Ann Surg. 2005;242:439–
448; discussion 448–450.
3. Martin LC, Puente I, Sosa JL, et al. Open versus laparoscopic appendectomy. A
prospective randomized comparison. Ann Surg. 1995;222:256–261; discussion
261–262.
4. Milewczyk M, Michalik M, Ciesielski M. A prospective, randomized, unicenter
study comparing laparoscopic and open treatments of acute appendicitis. Surg
Endosc. 2003;17:1023–1028.
5. Ortega AE, Hunter JG, Peters JH, et al. A prospective, randomized comparison
of laparoscopic appendectomy with open appendectomy. Laparoscopic appen-
dectomy study group. Am J Surg. 1995;169:208–212; discussion 212–213.
6. Kurtz RJ, Heimann TM. Comparison of open and laparoscopic treatment of
acute appendicitis. Am J Surg. 2001;182:211–214.
7. Lin HF, Wu JM, Tseng LM, et al. Laparoscopic versus open appendectomy for
perforated appendicitis. J Gastrointest Surg. 2006;10:906–910.
8. Towfigh S, Chen F, Mason R, et al. Laparoscopic appendectomy significantly
reduces length of stay for perforated appendicitis. Surg Endosc. 2006;20:495–
459.
9. Ball CG, Kortbeek JB, Kirkpatrick AW, et al. Laparoscopic appendectomy for
complicated appendicitis: An evaluation of postoperative factors. Surg Endosc.
2004;18:969–973.
www.annalsofsurgery.com | 931
Tiwari et al
10. Guller U, Hervey S, Purves H, et al. Laparoscopic versus open appendectomy:
Outcomes comparison based on a large administrative database. Ann Surg.
2004;239:43–52.
11. Nguyen NT, Zainabadi K, Mavandadi S, et al. Trends in utilization and out-
comes of laparoscopic versus open appendectomy. Am J Surg. 2004;188:813–
820.
12. Chung RS, Rowland DY, Li P, et al. A meta-analysis of randomized con-
trolled trials of laparoscopic versus conventional appendectomy. Am J Surg.
1999;177:250–256.
13. Golub R, Siddiqui F, Pohl D. Laparoscopic versus open appendectomy: A
metaanalysis. J Am Coll Surg. 1998;186:545–553.
14. Sauerland S, Lefering R, Neugebauer EA. Laparoscopic versus open surgery
for suspected appendicitis. Cochrane Database Syst Rev. 2004;18:CD001546.
15. Temple LK, Litwin DE, McLeod RS. A meta-analysis of laparoscopic versus
open appendectomy in patients suspected of having acute appendicitis. Can J
Surg. 1999;42:377–383.
16. Kehagias I, Karamanakos SN, Panagiotopoulos S, et al. Laparoscopic versus
open appendectomy: Which way to go? World J Gastroenterol. 2008;14:4909–
4914.
17. Sporn E, Petroski GF, Mancini GJ, et al. Laparoscopic appendectomy–is it
worth the cost? Trend analysis in the US from 2000 to 2005. J Am Coll Surg.
2009;208:179.e2–185.e2.
18. Slim K, Pezet D, Chipponi J. Laparoscopic or open appendectomy? Critical
review of randomized, controlled trials. Dis Colon Rectum. 1998;41:398–403.
19. Merhoff AM, Merhoff GC, Franklin ME. Laparoscopic versus open appendec-
tomy. Am J Surg. 2000;179:375–378.
932 | www.annalsofsurgery.com
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 254, Number 6, December 2011
20. Varela JE, Wilson SE, Nguyen NT. Laparoscopic surgery significantly re-
duces surgical-site infections compared with open surgery. Surg Endosc.
2010;24:270–276.
21. Osborne NH, Mathur AK, Upchurch GR Jr., et al. Understanding the racial
disparity in the receipt of endovascular abdominal aortic aneurysm repair. Arch
Surg. 2010;145:1105–1108.
22. Kirshtein B, Bayme M, Domchik S, et al. Complicated appendicitis: Laparo-
scopic or conventional surgery? World J Surg. 2007;31:744–749.
23. Pokala N, Sadhasivam S, Kiran RP, et al. Complicated appendicitis–is the
laparoscopic approach appropriate? A comparative study with the open ap-
proach: Outcome in a community hospital setting. Am Surg. 2007;73:737–741;
discussion 741–772.
24. Yau KK, Siu WT, Tang CN, et al. Laparoscopic versus open appendectomy for
complicated appendicitis. J Am Coll Surg. 2007;205:60–65.
25. Yong JL, Law WL, Lo CY, et al. A comparative study of routine laparoscopic
versus open appendectomy. JSLS. 2006;10:188–192.
26. Katsuno G, Nagakari K, Yoshikawa S, et al. Laparoscopic appendectomy for
complicated appendicitis: A comparison with open appendectomy. World J
Surg. 2009;33:208–214.
27. So JB, Chiong EC, Chiong E, et al. Laparoscopic appendectomy for perforated
appendicitis. World J Surg. 2002;26:1485–1488.
28. Fukami Y, Hasegawa H, Sakamoto E, et al. Value of laparo-
scopic appendectomy in perforated appendicitis. World J Surg. 2007;31:
93–97.
29. Moore DE, Speroff T, Grogan E, et al. Cost perspectives of laparoscopic and
open appendectomy. Surg Endosc. 2005;19:374–378.

C 2011 Lippincott Williams & Wilkins