Key messages

• Laparoscopic appendectomy might reduce the length of hospital stay and might reduce the risk of wound infection compared to open appendectomy. 
• Laparoscopic appendectomy probably increases the duration of surgery, but the relevance of this increase is not clear.
• It is not clear if there are differences in the risk of intra-abdominal abscess between open or laparoscopic appendectomy in complicated appendicitis, because the certainty of the evidence is very low.

What is the evidence.
See evidence matrix in Epistemonikos later

We identified six systematic reviews [4],[5],[6],[7],[8],[9], including 55 primary studies overall, of which four were randomized trials [10],[11],[12],[13]. This table, and the summary in general, is based on the latter, since the inclusion of the observational studies did not increase the certainty of the evidence or added additional information.

What types of patients were included*

A total of 857 patients were included in the trials, of which 466 presented complicated appendicitis. Their age ranged from 2 to 85 years. 

Two trials only included adults [12],[13], one only included children between 2 and 20 years [10] and one implicitly included children, but did not analyze them separately [11].

Male:female ratio was 1.3:1. 

All trials included patients with complicated appendicitis, which was defined as the presence of intestinal perforation. Only one trial included patients with and without perforation, but presented data separately [10].

What types of interventions were included*

Only one trial used 2-handed, 4-trocar technique [12], while the rest used conventional 3-trocar technique.

All trials compared against open appendectomy, whether by classic incision (McBurney) or infraumbilical.

All trials used an antibiotics scheme pre- and post-surgery. There was no information regarding the level of training of surgeons performing the interventions. 

What types of outcomes
were measured

The outcomes measured can be classified into two groups:

1. Technique

• Duration of surgery 
• Length of hospital stay.
• Post-surgical analgesia.
• Time to oral intake.

2. Post-surgical complications

• Mortality.
• Total complications.
• Wound infection.
• Intra-abdominal abscess.
• Intestinal obstruction.

Patients were monitored for 14-30 days after surgery.

To whom this evidence does and does not apply

• The conclusion of this article apply to patients of any age with complicated appendicitis. 
• It does not apply to pregnant women with complicated appendicitis, given complications and consequences to the mother and fetus are different from those in the general population. Furthermore, the technique may vary substantially keeping into consideration the gravid uterus that protrudes to the abdominal cavity. 
• This summary considers obese patients as part of the population studied, and not as a subpopulation. However, the conclusions must be applied carefully, since the laparoscopic technique may be more difficult in these cases.

• The outcomes selected are the ones considered critical for decision-making, based on the opinion of the authors of this article. In general, it agrees with those presented in the systematic reviews and main clinical guidelines.

• The intervention shows some benefit, but the relevance is difficult to establish. There is uncertainty regarding the main undesirable effects, in particular the risk of intra-abdominal abscess, which makes it difficult to balance the risk and benefits of laparoscopic appendectomy.

• The intervention probably saves some resources secondary to the cost of hospitalization. However, the uncertainty about the risk of complications makes it hard to ponder the benefits against the costs.
• It would be reasonable to make a formal economic evaluation in the settings where the implementation of this intervention is being considered.

• There might be variability in the decision-making with the evidence presented. Clinicians who value most the length of hospital stay and the associated costs might choose laparoscopic appendectomy. On the other hand, those who give more importance to the complications may prefer an open appendectomy. 

Differences between this summary and other sources

• The systematic reviews identified differ in their conclusions. Some conclude laparoscopic appendectomy is superior [4],[6],[7],[8], while the rest agree with this summary, stating there are risks and benefits [5],[9]. The main differences between this summary and the systematic reviews is they have a narrower coverage of the literature (none of the systematic reviews included all four randomized trials), give more relevance to non-randomized studies and they do not consider the certainty of the evidence to formulate their conclusions.

• There is a high probability that the evidence will change in the future due to the existing uncertainty. 
• We did not find ongoing trials evaluating laparoscopy for the treatment of complicated appendicitis in the International Clinical Trials Registry Platform of the World Health Organization.