European Journal of Cardiovascular Medicine

Complicated appendicitis, encompassing perforated, gangrenous, or abscess-forming appendicitis, remains a significant cause of morbidity worldwide [1]. Although appendectomy is the definitive treatment, the optimal surgical approach for complicated cases is still debated [2]. The choice between laparoscopic appendectomy (LA) and open appendectomy (OA) is influenced by patient presentation, surgical expertise, and institutional resources [3].

The laparoscopic approach, introduced in the late 20th century, has gained widespread popularity due to its minimally invasive nature, associated with reduced postoperative pain, shorter hospital stay, and quicker return to normal activities [4]. However, in complicated appendicitis, concerns remain regarding the risk of intra-abdominal abscess formation due to pneumoperitoneum and potential spillage of infected material [5]. In contrast, OA, the traditional technique, is still favored in some settings for its perceived simplicity, faster operative time, and ease of handling complex inflammatory pathology [6].

Multiple studies have reported conflicting outcomes when comparing LA and OA in complicated appendicitis [7]. Some evidence suggests that LA may reduce wound infection rates, whereas others highlight no significant difference in major postoperative complications [8]. Moreover, variations in operative time, return to normal activity, and healthcare costs remain points of contention [9].

Given these uncertainties, the choice of surgical method often depends on surgeon preference and institutional capabilities rather than standardized evidence-based protocols [10]. This variability underscores the need for further comparative studies to clarify the relative merits and risks of each approach, particularly in complicated cases where patient morbidity can be substantial.

This prospective comparative cohort study was undertaken to evaluate and compare clinical outcomes of LA and OA in complicated appendicitis, focusing on operative time, complication rates, hospital stay, postoperative pain, and recovery period. By analyzing these outcomes in a controlled setting, the study aims to provide robust data that can inform surgical decision-making and optimize patient care pathways.

Study Design and Setting: This was a prospective comparative cohort study conducted in the Department of General Surgery, Gulbarga Institute of Medical Sciences, Kalaburagi, from January 2024 to December 2024.

Participants:
Patients aged 18–65 years diagnosed intraoperatively with complicated appendicitis (perforated, gangrenous, or with localized abscess) were eligible. Exclusion criteria included generalized peritonitis requiring extensive resection, severe cardiopulmonary comorbidity precluding laparoscopy, pregnancy, and inability to consent.

Grouping:
Patients were assigned to either LA (n = 60) or OA (n = 60) based on attending surgeon’s expertise and patient suitability.

Surgical Techniques:

• Laparoscopic Appendectomy: Standard three-port technique under general anesthesia, careful peritoneal lavage, and endobag retrieval of specimen.
• Open Appendectomy: Right lower quadrant incision, appendectomy with standard closure and drainage as required.

Outcome Measures:

Primary outcomes:

1. Operative time (minutes)
2. Length of postoperative hospital stay (days)
3. Postoperative complications (surgical site infection, intra-abdominal abscess)

Secondary outcomes:

1. Return to normal activity (days)
2. Postoperative pain scores using Visual Analogue Scale (VAS) on day 1
3. Readmission within 30 days

Data Collection: Patient demographics, intraoperative details, and postoperative course were recorded prospectively in a standardized proforma. Complications were defined according to CDC criteria.

Statistical Analysis: Continuous variables were expressed as mean ± standard deviation and compared using independent t-test or Mann–Whitney U test, as appropriate. Categorical variables were analyzed with chi-square or Fisher’s exact test. A p-value < 0.05 was considered statistically significant. Analyses were performed using SPSS v26.0 (IBM Corp., USA).

• Ethical Considerations: The study protocol was approved by the Institutional Ethics Committee. Informed consent was obtained from all participants.

Table 1. Demographic characteristics

Table 2. Primary outcomes

Table 3. Secondary outcomes

Figure 1: Bar chart comparing mean hospital stay between groups (LA shorter than OA).

In this prospective cohort study, notable differences were observed between laparoscopic appendectomy (LA) and open appendectomy (OA) in patients with complicated appendicitis. The mean operative time for LA was 74.2 ± 15.6 minutes, which was significantly longer than OA at 66.5 ± 13.8 minutes (p = 0.002). This difference suggests that the laparoscopic approach requires additional operative duration, likely due to the technical demands of minimally invasive surgery in an inflamed operative field.

Despite this increased operative time, LA demonstrated a substantial advantage in postoperative recovery parameters. The mean hospital stay was significantly shorter for LA (4.3 ± 1.2 days) compared to OA (6.1 ± 1.8 days, p < 0.001). This reduction of approximately 1.8 days has direct implications for bed utilization and healthcare costs.

Postoperative complications showed a favorable trend for LA. The incidence of surgical site infection (SSI) was significantly lower in the LA group (6.7%) compared to OA (20.0%, p = 0.03). However, the rate of intra-abdominal abscess formation did not differ significantly (LA: 5.0% vs OA: 8.3%, p = 0.47), indicating that both approaches had comparable outcomes for this complication.

Functional recovery was also faster following LA. Patients returned to normal activity after a mean of 8.2 ± 2.4 days versus 12.6 ± 3.1 days for OA (p < 0.001), representing a nearly 35% reduction in convalescence time. Pain assessment on the first postoperative day using the Visual Analogue Scale (VAS) revealed significantly lower scores in the LA group (3.2 ± 1.1) compared to OA (5.1 ± 1.4, p < 0.001).

Readmission rates were low in both groups (LA: 3.3%, OA: 5.0%, p = 0.65), with no statistically significant difference, suggesting similar safety profiles in terms of unplanned returns to hospital.

Overall, the findings indicate that LA offers distinct postoperative advantages despite longer operative times, particularly in terms of reduced wound infection rates, shorter hospital stay, faster functional recovery, and better early pain control.

Complicated appendicitis presents a challenging surgical scenario due to the increased risk of contamination, postoperative infection, and prolonged recovery (Bhangu et al. [11]). The present prospective comparative study sought to clarify whether laparoscopic appendectomy (LA) offers measurable advantages over open appendectomy (OA) in such cases, particularly in terms of perioperative and short-term outcomes.

The need for this research was based on persistent uncertainty in the literature. Sartelli et al. [2], in a large multicenter observational study, reported that the choice of surgical approach for complicated appendicitis varies widely across institutions, with no universally accepted protocol. Our findings indicate that LA, while associated with a longer operative time (74.2 ± 15.6 minutes vs 66.5 ± 13.8 minutes, p = 0.002), yielded superior postoperative outcomes, echoing trends reported in earlier comparative analyses.

In our study, the mean hospital stay was significantly shorter with LA (4.3 ± 1.2 days) than OA (6.1 ± 1.8 days, p < 0.001). Park et al. [13] similarly observed a mean stay of 4.5 days for LA compared with 6.3 days for OA in complicated cases, attributing this to reduced wound complications and earlier mobilization. The incidence of surgical site infection in our LA group (6.7%) was markedly lower than OA (20.0%, p = 0.03). Katsuno et al. [14] reported a comparable reduction, with infection rates of 8% in LA and 22% in OA, suggesting a consistent benefit of smaller incisions and minimal tissue handling.

Rates of intra-abdominal abscess in our cohort (LA: 5.0%, OA: 8.3%, p = 0.47) were not significantly different. This aligns with Khalil et al. [5], who found no statistically significant difference (LA: 4.9%, OA: 6.8%) when meticulous peritoneal lavage was performed. The faster return to normal activity in our LA patients (8.2 ± 2.4 days vs 12.6 ± 3.1 days, p < 0.001) parallels the findings of Li et al. [7], who documented a mean recovery time difference of 3.8 days favoring LA.

Pain control outcomes in our study, with lower day-1 VAS scores for LA (3.2 ± 1.1) compared to OA (5.1 ± 1.4, p < 0.001), were in agreement with Frazee et al. [15], who reported reduced analgesic requirements and improved early comfort with LA. Although our LA group had longer operative times, similar to observations by Long et al. [16], this was offset by the postoperative benefits.

Limitations of our work include the non-randomized design and limited follow-up of 30 days, which may not capture late complications. Future randomized trials with extended follow-up and cost analyses, as suggested by Di Saverio et al. [10], could provide stronger evidence for practice guidelines.

In this prospective comparative study, laparoscopic appendectomy demonstrated significant benefits over open appendectomy in complicated appendicitis. While the laparoscopic approach required a longer operative time, it was associated with shorter hospital stay, reduced surgical site infection rates, faster return to normal activity, and lower early postoperative pain scores. Rates of intra-abdominal abscess and readmission were comparable between the two methods, indicating similar safety profiles. These results suggest that laparoscopic appendectomy is a safe and effective alternative for complicated appendicitis in appropriately selected patients and, when performed by experienced surgeons, may improve short-term postoperative outcomes and optimize healthcare resource utilization.

Acknowledgement

The authors gratefully acknowledge the surgical, anesthetic, and nursing teams of the Department of General Surgery, Gulbarga Institute of Medical Sciences, Kalaburagi, From January 2024 to December 2024. for their contributions to patient care and data collection. We also thank the hospital’s medical records department for facilitating access to operative and postoperative data.

Conflict of Interest

The authors declare no conflict of interest related to this study.

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