COMPARATIVE STUDY OF LAPAROSCOPIC APPENDECTOMY VERSUS OPEN APPENDECTOMY AT BIRAT MEDICAL COLLEGE TEACHING HOSPITAL

1* 2 3 4 Sanjaya Kumar Yadav , Sabin Shrestha , Sanjib Koirala , Ram Kumar Singh Received : 11 August, 2021 Accepted : 21 January, 2022 Published : 22 January, 2022 Yadav SK et al ISSN: 2542-2758 (Print) 2542-2804 (Online) 1611 Birat Journal of Health Sciences Vol.6/No.3/Issue 16/Sep.-Dec., 2021 Original Research Ar cle


INTRODUCTION
Appendici s is a commonly encountered surgical problem. The two modali es of appendectomy are evident. Laparoscopic appendectomy is a new technique than open appendectomy. Both laparoscopic appendectomy and open 1 appendectomy are prac sed in different surgical se ngs. The outcome of appendectomy ma ers whether it is an open appendectomy or laparoscopic appendectomy. The outcome in terms of dura on of surgery, length of hospital stay, pain, and wound infec on reported by various studies [2][3][4][5][6] in different se ngs was different. A study found the postopera ve pain and hospital stay were less in 2 laparoscopic appendectomy than open appendectomy. Another study found postopera ve pain score at different me was less in the laparoscopic appendectomy group than 3 the open appendectomy group. The outcome in terms of dura on of surgery, length of hospital stay, pain, wound infec on is not accessed in our centre. We found this as a research gap and conducted a study with an objec ve to find the outcome of laparoscopic appendectomy versus open appendectomy in terms of dura on of surgery, length of hospital stay, pain, and wound infec on at Birat Medical College Teaching Hospital.  7 and laparoscopic appendectomy groups respec vely. Sample size was calculated by using a formula for two independent samples for the con nuous outcome. By considering effect size (0.2), the sample size was; n=2 (Z*SDtotal/Effect Size) 2 where SD total and effect size = (Mean1-Mean2)/SDtotal. So, the total number of pa ents in each group was 24. Adjus ng the 10% nonresponse rate, the minimum sample size was 24/0.9=27, but we enrolled 30 pa ents in each group. The first pa ent was enrolled by the coin toss method and then each alterna ve pa ent was enrolled in each group a er taking informed consent. Postopera ve pain was assessed according to a visual analogue scale (VAS) from 0 (no pain) to 10 (worst pain imaginable). We assessed postopera ve pain at 6 hours, 12 hours and 24 hours. The local wound infec on was assessed on the 7th postopera ve day. Collected data were entered in Microso Excel and doubled checked and analyzed by sta s cal package for social sciences (SPSS 23). Anonymity and confiden ality data was maintained. Frequency, mean and standard devia on were used for univariate analysis. Independent sample t-test and chi-square test were used for bivariate analysis and sta s cal significance was set at 95% confidence interval and p-value less than 0.05.

RESULTS
We enrolled 30 pa ents in the open appendectomy group and 30 pa ents in the laparoscopic appendectomy group. The mean age of the open appendectomy group was 30±16.85 years and the laparoscopic appendectomy group was 33.47 ±13.29 years. The majority were female 32 (53.3%) ( Table 1).

Table 1: Baseline characteris c of par cipants (n=60)
Dura on of surgery ma ers for postopera ve outcomes. The mean dura on of surgery was more in the laparoscopic appendectomy group (43.67±6.94) than the open appendectomy group (35.83±12.11), which was found to be sta s cally significant (p=0.003) (table 2). Length of hospital stay is important in any surgical procedure for its quality outcome. Regarding the length of hospital stay, it was more in the open appendectomy group (3.93±1.26) than the laparoscopic appendectomy group (1.7±0.65), which was found to be sta s cally significant (p=0.001) (table 3). Postopera ve pain is an important parameter to assess for the quality of life of the pa ent. The postopera ve pain a er surgery varies as per procedure and me passes. At 6 hours, the postopera ve pain score was more in the open appendectomy group (5.07±0.79) than the laparoscopic appendectomy group (4.77±0.68), which was not sta s cally significant (p=012). At 12 hours, the postopera ve pain score was more in the open appendectomy group (3.13±0.82) than the laparoscopic appendectomy group (2.77±0.82), which was not sta s cally significant (p=0.09). At 24 hours, the post-opera ve pain score in both groups is similar and has no sta s cally significant difference was found (Table 4). Wound infec on is a major factor in the quality of surgical care. There was no sta s cally significant associa on between the open appendectomy and laparoscopic appendectomy in terms of wound infec on (p=0.053) (table 5). In terms of wound infec on, both procedures has no pros and cons.  studies in different se ngs was different. We found the mean age of the open appendectomy group was 30±16.85 years and the laparoscopic appendectomy group was 33.47 ±13.29 years. Almost similar mean age in 2 both groups was reported in another study. We found the majority were female 32 (53.3%) which was similar to the 2 study conducted in central Nepal. But in another study, [3][4] males had higher rates of appendici s than females. We found the mean dura on of surgery was more in the laparoscopic appendectomy group (43.67±6.94) than the open appendectomy group (35.83±12.11), which was found to be sta s cally significant (p=0.003). Similar findings were 7 reported by another study from India. Similar findings were reported by another study where the mean opera ve me in laparoscopic appendectomy was 61.52 minutes and in 10 open appendectomy 39.61 minutes (p<0.001). Here open appendectomy seems be er but we need to consider various factors to determine the outcome of surgery by a different procedure. But another study found similar 11 opera ng mes for both groups (p=0.855). A metaanalysis found the dura on of surgery was 10 minutes (CI 6 12 to 15) longer for laparoscopic appendectomy. Another study also reported similar findings where laparoscopic appendectomy opera ng me was significantly greater 13 than that of open appendectomy. In contrast to the above findings, the mean opera ve me was 55 minutes for the laparoscopic appendectomy group and 70 minutes for the 14 open appendectomy group (p<0.001). We found the length of hospital stay, was more in the open appendectomy group (3.93±1.26) than the laparoscopic appendectomy group (1.7±0.65), which was found to be sta s cally significant (p=0.001). Similar findings were reported from another study where hospital stay was less in 2 laparoscopic appendectomy. The length of hospital stay was significantly more in the open appendectomy group 7 than in the laparoscopic appendectomy group. Similar findings were reported from another study where the mean length of hospital stay in laparoscopic appendectomy was 10 2.69 days and in open appendectomy 4.03 days (p<0.001). In addi on, a significant difference was found between the 13 two modali es in terms of the length of hospital stay. Mean hospital stay was 5 days and 6 days for laparoscopic appendectomy and open appendectomy groups 14 respec vely (p<0.001). So, in almost all studies reported hospital stay is more in open appendectomy group than laparoscopic appendectomy group. We found the postopera ve pain score was more in the open appendectomy group (5.07±0.79) than the laparoscopic appendectomy group (4.77±0.68) at 6 hours, which was not sta s cally significant (p=012). At 12 hours, the post-opera ve pain score was more in the open appendectomy group (3.13±0.82) than the laparoscopic appendectomy group (2.77±0.82), which was not sta s cally significant (p=0.09). At 24 hours, the postopera ve pain score in both groups is similar and has no sta s cally significant difference. The postopera ve pain score at different mes was less in the laparoscopic Wound infec on determines the quality of surgical care during and a er surgery. In our study, we found no sta s cally significant associa on between open appendectomy and laparoscopic appendectomy in terms of wound infec on (p=0.053). But a significant wound infec on was reported in a study where open appendectomy has more would 7 complica ons than laparoscopic appendectomy. Wound infec ons were less likely a er the laparoscopic appendectomy group than a er the open appendectomy 1 3 group (OR 0.43; CI 0.34 to 0.54). Laparoscopic appendectomyfavor less wound infec on. A meta-analysis recommended that using laparoscopy appendectomy in pa ents with suspected appendici s unless laparoscopy itself is contraindicated or not feasible. Especially young female, obese, and employed pa ents seem to benefit from 1 2 a laparoscopic appendectomy. Another research suggested that laparoscopic appendectomy is more useful for trea ng acute appendici s, especially when perforated 13 appendici s is suspected. This type of research work will help the surgeons with ra onal thinking while following a type of surgical procedure. Evidence-based prac ce with ra onale thinking would help pa ents for be er compliance hence be er service u liza on. The cost of treatment also ma ers for the choice of surgical procedure. Choosing a surgical procedure might be not as easy as we think. We need to consider different medical, social, financial and cultural barriers.

CONCLUSION
In our Centre, despite having more dura on of surgery for laparoscopic appendectomy, the length of hospital stay is less. Postopera ve pain score at a different me and wound infec on have no difference in both groups of appendectomy.

RECOMMENDATIONS
As long hospital stay is a major contributor to pa ent sa sfac on, we recommend laparoscopic appendectomy as it has less length of hospital stay in comparison to open appendectomy. It would be be er to have a meta-analysis of such a comparison from studies conducted in Nepal. We will further recommend conduc ng this study with a large number of samples from different centre with considera on of all factors that might affect the outcome of surgical techniques. Opera onal research in terms of the new procedure and its further outcome needs to be raised. The local informa on regarding the outcome of different medical care and prac ces needs to be generated as much as possible.

LIMITATION OF THE STUDY
While deciding and recommending open appendectomy versus laparoscopic appendectomy, various factors need to be considered. The pa ent's surgical condi on, the skill of the doctor, availability of instruments, cost of surgery, willingness of the pa ent etc. are the other contributors.