Review Article

Perforated appendicitis treated with laparoscopic

appendicectomy or open appendicectomy: A meta‑analysis
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Qianquan Gu1, Ye Hua2

1
Department of General Surgery, The First Affiliated Hospital of Chongqing Medical and Pharmaceutical College, Chongqing, China,
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2
Department of General Surgery, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, China

Abstract Aim: This analysis compared the impact of laparoscopic appendicectomy (LA) and open appendicectomy (OA)
on treating adult perforated appendicitis (PA).
Methods: Articles relating to LA and OA in treating PA were retrieved from databases including PubMed,
Cochrane Library and Embase since their founding to January 2022. These articles were independently
filtered based on the inclusion and exclusion criteria by two investigators. The quality of these articles
was assessed and article data were extracted. Dichotomous data were presented in the form of odd’s
ratio (OR), whereas continuous data were in the form of weighted mean difference (WMD). The included
articles reported at least one of the following outcomes: intra‑abdominal abscess (IAA), wound infection,
operative time, hospital stay and complications.
Results: Three randomised control trials (198 LA cases vs. 205 OA cases) and 12 case − control trials
(914 LA cases vs. 2192 OA cases) were included. This analysis revealed that although the IAA formation
rate was similar in the LA and OA groups (OR: 1.28, 95% confidence interval [CI]: 0.87–1.88), the wound
infection rate was lower in the LA group (OR: 0.38, 95% CI: 0.28–0.51). Furthermore, LA was associated
with shorter hospital stay (WMD: −1.43 days, 95% CI: −2.33–−0.52) and fewer complications than OA
(OR: 0.40, 95% CI: 0.28–0.57).
Conclusion: LA has significant benefits in treating PA and is associated with better post‑operative outcomes
such as shorter hospital stay, lower incidence of wound infection and other complications. However, more
studies with randomised and large‑sample populations are still required to determine the clinical benefit
of LA in treating PA.

Keywords: Abdominal abscess, laparoscopic appendectomy, open appendectomy, perforated appendicitis,

wound infection

Address for correspondence: Dr. Ye Hua, Department of General Surgery, Chongqing Emergency Medical Center, Chongqing University Central Hospital,
No. 1, Jiankang Road, Yuzhong, Chongqing 400014, China.
E‑mail: huaye23332022@163.com
Submitted: 01‑Jun‑2022, Revised: 09‑Mar‑2023, Accepted: 03‑Apr‑2023, Published: 29-May-2023

INTRODUCTION abdominal pain globally.[1] The disease has an extremely

rapid onset, and if not treated promptly, the inflamed
Acute appendicitis (AA) is often diagnosed in appendix will form perforated AA due to necrosis of
gastrointestinal surgery and is the common cause of acute
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DOI: How to cite this article: Gu Q, Hua Y. Perforated appendicitis treated with
10.4103/jmas.jmas_158_22 laparoscopic appendicectomy or open appendicectomy: A meta‑analysis.
J Min Access Surg 2023;19:348-54.

348 © 2023 Journal of Minimal Access Surgery | Published by Wolters Kluwer - Medknow
 Gu and Hua: Treatment of perforated appendicitis with different appendicectomy
appendiceal wall tissue, and perforation and abscesses
are more likely to develop, especially in patients with AA
with foecal stones.[2] The estimated range of perforated
AA incidence is 20%–30%, [3] which often presents
as appendiceal abscess or signs of diffuse peritonitis.
Non‑surgical treatment is often adopted in clinical for
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patients with appendiceal abscess, including antibiotics,
radio‑guided aspiration or catheter drainage, while surgical
treatment is used for patients who fail conservative
treatment.[4,5] Surgical treatment is mainly recommended
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for patients with appendix perforation, such as those with
localised or diffuse peritonitis.[6]
Surgical treatment refers to appendicectomy followed
by fluid resuscitation, analgesia and intravenous
antibiotics.[7] Open appendicectomy (OA) is a common
surgery method for perforated AA.[8] OA can effectively
avoid the recurrence of the disease by completely
removing the lesion, but it is characterised by a large
abdominal incision, large amount of intraoperative
blood loss and a high incidence of post‑operative
complications, leading to great physical trauma and a slow
post‑operative rehabilitation process.[7,9,10] Laparoscopic
appendicectomy (LA) is more and more frequently
applied in AA treatment due to the ongoing development
of minimally invasive surgeries.
As one of the minimally invasive surgeries, LA is
characterised by the reduction in overall post‑operative
morbidity and wound infection, shorter hospital stay, less
postoperative pain and earlier post‑operative recovery.[8,11]
As reported by Fukami et al.,[12] LA is associated with
less analgesic use, shorter hospital stay and lower wound
infection rate, indicating that LA has significant clinical
advantages in the treatment of perforated appendicitis (PA)
and is a safe and effective procedure. However, while
laparoscopic equipment is developing, intra‑abdominal
abscess (IAA) remains a common problem for general
surgeons after PA surgery. The application of LA in PA
treatment is still controversial. Relevant reports indicated
that this causes a high incidence of IAA and a high
operative time.[13,14] A systematic review and a meta‑analysis
compared the effects of LA and OA in complicated
appendicitis and revealed that LA lessens surgical site
infection but remarkably increases operative time, and the
two approaches do not differ in IAA incidence, overall
morbidity and mortality.[14,15] At present, the performance
of LA in treating PA has not been sufficiently studied. We
designed a meta‑analysis that included three randomised
controlled trials (RCTs) (198 LA cases vs. 205 OA cases)
and 12 case − control studies (CCS) (914 LA cases vs. 2192
OA cases) to assess whether surgical approach (LA/OA)
Journal of Minimal Access Surgery | Volume 19 | Issue 3 | July-September 2023
influenced operative time, hospital stay and the occurrence
of post‑operative IAAs and wound infections of PA with
the backdrop of widespread use of laparoscopic surgery.
METHODS
Types of research
RCTs and CCS are the two types of our research.
The included articles involved all studies comparing the
effect of LA and OA in treating adult PA. The studies
reported at least one outcome of interest: operative time,
hospital stay, IAA, wound infection and post‑operative
complications. Odds ratio (OR) analysis and 95%
confidence interval (CI) were set for pooling dichotomous
data; weighted mean difference (WMD) analysis and 95%
CI were applied for pooling continuous data, presenting as
mean difference or standardised mean difference.
Search and selection strategies
From PubMed, Cochrane Library and Embase databases,
articles about LA and OA for PA were systematically
retrieved with the searching keywords ‘laparoscopic
appendectomy’, ‘open appendectomy’ and ‘PA’. Articles
were limited to English publications, but there were no
restrictions on publication dates. Case reports or case series
lacking a control group for comparison were excluded from
this review. All articles that included potentially relevant
studies were independently reviewed and selected by two
investigators, and if the abstract failed to imply sufficient
information about the applicability, then the full article
was reviewed. After independently assessing the full text,
the criteria for inclusion and exclusion were determined
by discussion. The final articles were confirmed for the
meta‑analysis.
Data extraction and validity assessment
Methods of study, selection of participants and
confirmation of intervention characteristics and outcomes
were independently summarised by two investigators to
determine the main outcomes of this study, and these
data were prepared into a sheet. Extracted data included
general data from publications (authors, year of publication
and journal), characteristics of studies (study design and
sample size) and surgical outcomes (operative time, hospital
stay, IAA, wound infection, complications, etc.). All data
were cross‑checked independently by two investigators.
The risk of bias of RCTs was assessed according to the
methodological quality of the included trials recommended
by the Cochrane Handbook; the quality of CCS was
assessed according to the Newcastle − Ottawa Scale (NOS),
including studies at 6 scores minimum.
349
 Gu and Hua: Treatment of perforated appendicitis with different appendicectomy
Statistical analysis
Meta‑analysis was performed with Review Manager
version 5.4 (The Nordic Cochrane Centre, Copenhagen,
Denmark). For continuous data, the inverse variance method
was utilised to calculate the WMD and corresponding 95%
CI. For dichotomous data, ORs and corresponding 95%
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CIs were calculated based on the Mantel–Haenszel method.
The heterogeneity of effect size in the study was judged
using I2 quantitative analysis and was considered statistically
significant when P < 0.10 or I2 ≥50%. A random‑effect
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model was used in the presence of heterogeneity; otherwise,
a fixed‑effect model would be utilised. Although there were
only three RCT studies, there were 12 CCS articles. Thus,
the overall number of patients was still adequate to perform
the meta‑analysis.
RESULTS
Literature search results
Three hundred and eleven articles were initially searched.
According to the inclusion criteria, 265 articles that were
inconsistent with the topic of this study or duplicate articles
as implied by their titles and abstracts were excluded.
Amongst the remaining 46 articles, 26 articles that could
not be analysed (abstracts only, non‑comparative studies,
review articles and data that could not be extracted) were
also excluded. Then, the rest of 20 articles were subjected
to data extraction, and finally, 15 articles met the inclusion
criteria. The search and selection process is shown in
Figure 1.
Basic characteristics and quality assessment of the
included literature
RCTs were adopted in three articles[2,16,17] and CCS were
adopted in 12 articles. [12,18‑28] Amongst 403 patients
with RCTs, 198 underwent LA and 205 underwent OA.
Figure 1: Flow diagram of the literature search and study selection
350
Amongst 3182 patients with CCS, 914 underwent LA and
2192 underwent OA. For RCT articles, the risk of bias
was assessed by the Cochrane risk‑of‑bias tool and 3 of
them manifested low risk of bias with high quality. Twelve
retrospective CCS articles were evaluated by NOS scale,
and the included articles had high quality with over six
scores. Basic characteristics and quality assessment of the
included articles are exhibited in Table 1.
Meta‑analysis results
Operative time
Two‑RCT and four‑CCS articles reported operative
time in the LA and OA groups, respectively [Figure 2].
Combining RCTs and CCS analyses, the difference in
operative time between LA and OA was not remarkable
(WMD: 9.04 min, 95% CI: −6.57–24.66), with high
statistical heterogeneity (I2 = 97%, P < 0.00001). Subgroup
analyses of RCTs and CCS also revealed no remarkable
difference between the two groups (WMD: 10.38 min, 95%
CI: −22–42.76; WMD: 8.32 min, 95% CI: −8.08–24.71),
with high statistical heterogeneity (I2 = 99%, P < 0.00001;
I2 = 87%, P < 0.0001).
Hospital stay
Two‑RCT and six‑CCS articles listed hospital stay
in both LA and OA groups, respectively [Figure 3].
Combining RCTs and CCS analyses, the hospital stay
of the LA group was markedly shorter than the OA
group (WMD: −1.43 days, 95% CI: −2.33–−0.52), with
high statistical heterogeneity (I2 = 90%, P < 0.00001).
Nevertheless, the subgroup analysis of RCTs suggested
no remarkable difference between the two groups (WMD:
−0.83 days, 95% CI: −2.89‑1.22), with high statistical
heterogeneity (I2 = 97%, P < 0.00001). The subgroup
analysis of CCS suggested that hospital stay in the LA
group was remarkably higher than the OA group (WMD:
−1.68 days, 95% CI: −2.74–−0.62), with statistically
significant heterogeneity (I2 = 78%, P = 0.0003).
Intra‑abdominal abscess
Only one RCT documented IAA, indicating less
post‑operative IAA in the OA group (4.5%). In our
meta‑analysis, there was no remarkable difference in
post‑operative IAA between the two groups as revealed
by the combined analysis of RCT and CCS (OR: 1.28,
95% CI: 0.87–1.88), with low statistical heterogeneity
[I2 = 11%, P = 0.34, Figure 4].
Wound infection
Two RCTs revealed that the wound infection rate of the
surgical site was markedly lower in LA than in OA group
(OR: 0.30, 95% CI: 0.16–0.57), without heterogeneity
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 Gu and Hua: Treatment of perforated appendicitis with different appendicectomy

Table 1: Primary characteristics of the eligible studies in more detail

Authors Year Total Surgery methods Study (type) Outcomes NOS score
patients Open Laparoscopic
surgery surgery
Tang E 1996 597 529 28 Case‑controlled study IAA 6
Paik PS 1997 786 683 67 Case‑controlled study HS, IAA 7
Stöltzing H 2000 89 45 44 Case‑controlled study IAA, WI, mortality, IAB 8
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Piskun G 2001 42 24 18 Case‑controlled study OT, HS, IAA, WI 7

So JB 2002 231 146 85 Case‑controlled study OT, HS, IAA, WI, complications, reoperation 7
Kouwenhoven EA 2005 47 21 26 Case‑controlled study IAA, WI 6
Lin HF 2006 229 130 99 Case‑controlled study OT, HS, IAA, WI, IVAU, complications, 8
reoperation, EF, IAB
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Towfigh S 2006 85 66 19 Case‑controlled study HS 6

Fukami Y 2007 73 39 34 Case‑controlled study IAA, WI, EF 8
Sleem R 2009 247 59 188 Case‑controlled study Age, IAA, WI, IVAU 8
Park HC 2009 587 387 200 Case‑controlled study IAA, WI 7
Galli R 2013 169 63 106 Case‑controlled study Age, OT, HS, complications, reoperation, 7
mortality
Authors Year Total Surgery methods Study (type) Outcomes Cochrane
patients Open Laparoscopic Collaboration’s
surgery surgery tool
Schietroma M 2012 147 74 73 RCTs WI, complications Low risk
Nazir A 2019 130 65 65 RCTs Age, OT, HS, WI Low risk
Talha A 2020 126 66 60 RCTs Age, OT, HS, IAA Low risk
IAA: Intra‑abdominal abscess, HS: Hospital stay, WI: Wound infection, IAB: Intra‑abdominal bleeding, OT: Operative time, PI: Post‑operative ileus,
IVAU: Intra‑venous antibiotic usage, EF: Enterocutaneous fistula, NOS: Newcastle−Ottawa Scale, RCTs: Randomised controlled trials

Figure 2: Meta‑analysis of operative time between LA and OA groups. SD: Standard deviation, CI: Confidence interval, LA: Laparoscopic
appendicectomy, OA: Open appendicectomy

Figure 3: Meta‑analysis of hospital stay between LA and OA groups. SD: Standard deviation, CI: Confidence interval, LA: Laparoscopic
appendicectomy, OA: Open appendicectomy

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Figure 4: Meta‑analysis of IAA between LA and OA groups. IAA: Intra‑abdominal abscess, CI: Confidence interval, LA: Laparoscopic
appendicectomy, OA: Open appendicectomy

Figure 5: Meta‑analysis of wound infection between LA and OA groups. CI: Confidence interval, LA: Laparoscopic appendicectomy,
OA: Open appendicectomy

(I2 = 0%, P = 0.91). Eight CCS also suggested that LA could
lower the wound infection rate (OR: 0.40, 95% CI: 0.28–
0.57), with low statistical heterogeneity (I2 = 37%, P = 0.13).
The comprehensive analysis of all 10 studies implied that the
wound infection rate of LA group was remarkably lower than
OA group (OR: 0.38, 95% CI: 0.28–0.51), with low statistical
heterogeneity [I2 = 24%, P = 0.22, Figure 5].
Complications
The combined analysis of five studies suggested that the
incidence rate of complications in LA group was notably
less than OA group (OR: 0.40, 95% CI: 0.28–0.57), without
heterogeneity (I2 = 0%, P = 0.88). Subgroup analyses of
RCTs and CCS also revealed the statistical significance of
352
differences between the two groups (OR 0.26, 95% CI 0.10–
0.68; OR 0.43, 95% CI 0.30–0.63) without heterogeneity
[I2 = 0%, P = 0.58; I2 = 0%, P = 0.96, Figure 6].
DISCUSSION
Although the simplicity and effectivity of OA have made
it a gold standard for AA treatment, OA has disadvantages
such as wound infection and delayed recovery while treating
PA, and LA, as reported, can reduce the risk of infectious
complications in PA patients and speed up their recovery.[2,29,30]
At present, few studies reported LA in treating PA. We aimed
to assess whether LA/OA impacts on the operative time,
hospital stay and post‑operative complications of PA. Our
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Figure 6: Meta‑analysis of complications between LA and OA groups. CI: Confidence interval, LA: Laparoscopic appendicectomy, OA: Open
appendicectomy
study included 3 RCTs and 12 CCS and revealed remarkable
benefits of LA for PA treatment in comparison with OA.
Operative time and incidence of IAA were not notably
different in both groups, but the LA group had a shorter
hospital stay and markedly lower incidence of wound infection
and post‑operative complications than the OA group.
LA has gradually become a routine procedure but with
controversial efficacy and superiority. PA is known to be
associated with high post‑operative morbidity and mortality,
the most horrible of which is IAA with incidence as high
as 26%.[31,32] The high incidence of IAA makes LA unable
to be a standard procedure for PA.[13,33] As manifested by
a CRT, the incidence of IAA in PA patients was 11.6% in
the LA group and 4.5% in the OA group, with no notable
difference between the two groups.[2] These were similar to
our results, and the combined analysis of RCTs and CCS
exhibited no remarkable difference in the occurrence of
post‑operative IAA in both groups.
Another advantage of LA is the reduction of the incidence
of wound infection, which was also been revealed in both
cholecystectomy and colonic surgery.[34,35] The main reason
for this phenomenon is the prevention of contaminating
surgical wounds through laparoscopic ports and specimen
extraction bags.[36] Another reason may be that immunity is
preserved after LA in comparison with OA.[37,38] Markides
et al.[39] noted that LA in appendectomy could lower the
incidence of surgical site infection in comparison with
OA. Our study found that the subgroup analyses of RCTs
and CCS showed that the wound infection rate in the LA
group was significantly lower than that in the OA group.
In respect of hospital stay, patients in LA group were
discharged earlier than OA patients, which was consistent
with loads of publications. [15,25,28,40,41] The reason for
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this might be fewer infectious complications and faster
post‑operative recovery. Furthermore, we also found that
the incidence of other post‑operative complications in the
LA group was remarkably less than that in the OA group.
Recent work manifested that the operative time in OA is
notably higher over LA.[42] However, our meta‑analysis
found no remarkable difference in the operative time of
LA and OA. The difference in operative time tends to be
reduced with the progress in laparoscopic technique, such
as a haemostatic device that facilitates faster dissection.[43]
This study still has some limitations. Few publications
focus on the application of LA in treating PA, which led
to only 3 RCTs being included in our study. Previous CCS
documented few post‑operative conditions, which caused
the need for more randomised and large‑sample size studies
to determine the occurrence of intestinal obstruction,
incisional hernia and infection of different organs. In
addition, patients who received surgery after conservative
treatment failed were not discussed in this study, and
corresponding cases should be collected in the future to
analyse whether pre‑operative aspiration and drainage
affect the choice of surgical methods. Finally, the large
statistical heterogeneity in some results was speculated to be
impacted by the subjects and study designs to some extents.
On the above, our study manifested remarkable benefits
of LA for PA treatment and LA was associated with better
post‑operative outcomes such as shorter hospital stay, lower
incidence of wound infection and other complications.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
353
 Gu and Hua: Treatment of perforated appendicitis with different appendicectomy
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