Laparoscopic versus open surgery for suspected appendicitis

Stefan Sauerland; Rolf Lefering; Edmund AM Neugebauer

doi:10.1002/14651858.CD001546.pub2

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Analysis 1.1

Comparison 1 Laparoscopic versus conventional appendectomy in adults, Outcome 1 Wound infections.

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Analysis 1.2

Comparison 1 Laparoscopic versus conventional appendectomy in adults, Outcome 2 Intraabdominal abscesses.

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Analysis 1.3

Comparison 1 Laparoscopic versus conventional appendectomy in adults, Outcome 3 Operation time (minutes).

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Analysis 1.4

Comparison 1 Laparoscopic versus conventional appendectomy in adults, Outcome 4 Anaesthesia time (minutes).

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Analysis 1.5

Comparison 1 Laparoscopic versus conventional appendectomy in adults, Outcome 5 Pain intensity on day 1 (cm VAS).

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Analysis 1.6

Comparison 1 Laparoscopic versus conventional appendectomy in adults, Outcome 6 Length of hospital stay.

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Analysis 1.7

Comparison 1 Laparoscopic versus conventional appendectomy in adults, Outcome 7 Time until reintroduction of liquid diet (days).

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Analysis 1.8

Comparison 1 Laparoscopic versus conventional appendectomy in adults, Outcome 8 Time until reintroduction of solid diet (days).

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Analysis 1.9

Comparison 1 Laparoscopic versus conventional appendectomy in adults, Outcome 9 Time until first stool (days).

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Analysis 1.10

Comparison 1 Laparoscopic versus conventional appendectomy in adults, Outcome 10 Time until return to normal activity (days).

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Analysis 1.11

Comparison 1 Laparoscopic versus conventional appendectomy in adults, Outcome 11 Time until return to work (days).

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Analysis 1.12

Comparison 1 Laparoscopic versus conventional appendectomy in adults, Outcome 12 Time until return to sport (days).

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Analysis 1.13

Comparison 1 Laparoscopic versus conventional appendectomy in adults, Outcome 13 Cosmesis (cm VAS).

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Analysis 1.14

Comparison 1 Laparoscopic versus conventional appendectomy in adults, Outcome 14 Costs of the operation.

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Analysis 1.15

Comparison 1 Laparoscopic versus conventional appendectomy in adults, Outcome 15 Costs within hospital stay (incl. the operation).

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Analysis 1.16

Comparison 1 Laparoscopic versus conventional appendectomy in adults, Outcome 16 Costs outside hospital.

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Analysis 2.1

Comparison 2 Laparoscopic versus conventional appendectomy in children, Outcome 1 Wound infections (rate).

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Analysis 2.2

Comparison 2 Laparoscopic versus conventional appendectomy in children, Outcome 2 Intraabdominal abscesses (rate).

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Analysis 2.3

Comparison 2 Laparoscopic versus conventional appendectomy in children, Outcome 3 Operation time (minutes).

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Analysis 2.4

Comparison 2 Laparoscopic versus conventional appendectomy in children, Outcome 4 Anaesthesia time (minutes).

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Analysis 2.5

Comparison 2 Laparoscopic versus conventional appendectomy in children, Outcome 5 Pain intensity on day 1 (cm VAS).

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Analysis 2.6

Comparison 2 Laparoscopic versus conventional appendectomy in children, Outcome 6 Length of hospital stay (days).

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Analysis 2.10

Comparison 2 Laparoscopic versus conventional appendectomy in children, Outcome 10 Time until mobilisation (days).

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Analysis 2.11

Comparison 2 Laparoscopic versus conventional appendectomy in children, Outcome 11 Time until return to normal activity (days).

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Analysis 2.12

Comparison 2 Laparoscopic versus conventional appendectomy in children, Outcome 12 Time until return to sport (days).

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Analysis 2.14

Comparison 2 Laparoscopic versus conventional appendectomy in children, Outcome 14 Costs of the operation.

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Analysis 2.15

Comparison 2 Laparoscopic versus conventional appendectomy in children, Outcome 15 Costs within hospital stay (incl. the operation).

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Analysis 3.1

Comparison 3 Diagnostic laparoscopy (and open or laparoscopic appendectomy if necessary) versus immediate open appendectomy, Outcome 1 Negative appendectomy (rate).

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Analysis 3.2

Comparison 3 Diagnostic laparoscopy (and open or laparoscopic appendectomy if necessary) versus immediate open appendectomy, Outcome 2 Patients with diagnosis not established.

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Analysis 4.1

Comparison 4 Diagnostic laparoscopy (and open appendectomy if necessary) versus immediate open appendectomy, Outcome 1 Wound infections.

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Analysis 4.2

Comparison 4 Diagnostic laparoscopy (and open appendectomy if necessary) versus immediate open appendectomy, Outcome 2 Intraabdominal abscesses.

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Analysis 4.3

Comparison 4 Diagnostic laparoscopy (and open appendectomy if necessary) versus immediate open appendectomy, Outcome 3 Operation time (minutes).

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Analysis 4.6

Comparison 4 Diagnostic laparoscopy (and open appendectomy if necessary) versus immediate open appendectomy, Outcome 6 Length of hospital stay (days).

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Comparison 1. Laparoscopic versus conventional appendectomy in adults

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Wound infections Show forest plot	40	4904	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.45 [0.35, 0.58]

2 Intraabdominal abscesses Show forest plot	40	4953	Peto Odds Ratio (Peto, Fixed, 95% CI)	2.48 [1.45, 4.21]

3 Operation time (minutes) Show forest plot	41		Mean Difference (IV, Random, 95% CI)	Subtotals only

3.1 Studies reporting mean data	32	3085	Mean Difference (IV, Random, 95% CI)	11.47 [6.90, 16.04]
3.2 Studies reporting median data	11	1937	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
4 Anaesthesia time (minutes) Show forest plot	3		Mean Difference (IV, Random, 95% CI)	Subtotals only

4.2 Studies reporting mean data	1	40	Mean Difference (IV, Random, 95% CI)	6.0 [‐4.86, 16.86]
4.3 Studies reporting median data	2	160	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
5 Pain intensity on day 1 (cm VAS) Show forest plot	13		Mean Difference (IV, Random, 95% CI)	Subtotals only

5.1 Studies reporting mean data	13	1808	Mean Difference (IV, Random, 95% CI)	‐0.87 [‐1.26, ‐0.47]
5.2 Studies reporting median data	0	0	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
6 Length of hospital stay Show forest plot	38		Mean Difference (IV, Random, 95% CI)	Subtotals only

6.1 Studies reporting mean data	26	2900	Mean Difference (IV, Random, 95% CI)	‐1.05 [‐1.49, ‐0.62]
6.2 Studies reporting median data	12	1988	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
7 Time until reintroduction of liquid diet (days) Show forest plot	5		Mean Difference (IV, Random, 95% CI)	Subtotals only

7.1 Studies reporting means	4	600	Mean Difference (IV, Random, 95% CI)	‐0.50 [‐0.87, ‐0.13]
7.2 Studies reporting medians	1	60	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
8 Time until reintroduction of solid diet (days) Show forest plot	11		Mean Difference (IV, Random, 95% CI)	Subtotals only

8.1 Studies reporting means	8	1070	Mean Difference (IV, Random, 95% CI)	‐0.22 [‐0.40, ‐0.04]
8.2 Studies reporting medians	3	220	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
9 Time until first stool (days) Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Subtotals only

9.1 Studies reporting means	2	97	Mean Difference (IV, Random, 95% CI)	‐0.31 [‐0.60, ‐0.02]
9.2 Studies reporting medians	0	0	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
10 Time until return to normal activity (days) Show forest plot	20		Mean Difference (IV, Random, 95% CI)	Subtotals only

10.1 Studies reporting means	11	1126	Mean Difference (IV, Random, 95% CI)	‐5.86 [‐8.11, ‐3.61]
10.2 Studies reporting medians	9	1733	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
11 Time until return to work (days) Show forest plot	12		Mean Difference (IV, Random, 95% CI)	Subtotals only

11.1 Studies reporting means	5	522	Mean Difference (IV, Random, 95% CI)	0.00 [‐1.97, 1.98]
11.2 Studies reporting medians	7	1303	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
12 Time until return to sport (days) Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Subtotals only

12.1 Studies reporting means	0	0	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
12.2 Studies reporting medians	2	223	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
13 Cosmesis (cm VAS) Show forest plot	2	623	Mean Difference (IV, Fixed, 95% CI)	‐1.0 [‐1.68, ‐0.32]

13.1 Studies reporting means	1	40	Mean Difference (IV, Fixed, 95% CI)	‐1.0 [‐1.68, ‐0.32]
13.2 Studies reporting medians	1	583	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
14 Costs of the operation Show forest plot	4		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

14.1 Studies reporting mean data	1	37	Std. Mean Difference (IV, Random, 95% CI)	4.55 [3.27, 5.82]
14.2 Studies reporting median data	3	189	Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
15 Costs within hospital stay (incl. the operation) Show forest plot	7		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

15.1 Studies reporting mean data	3	404	Std. Mean Difference (IV, Random, 95% CI)	0.20 [‐0.29, 0.68]
15.2 Studies reporting median data	4	339	Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
16 Costs outside hospital Show forest plot	3		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

16.1 Studies reporting mean data	1	198	Std. Mean Difference (IV, Random, 95% CI)	‐0.35 [‐0.63, ‐0.07]
16.2 Studies reporting median data	2	96	Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 1. Laparoscopic versus conventional appendectomy in adults

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Comparison 2. Laparoscopic versus conventional appendectomy in children

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Wound infections (rate) Show forest plot	5	462	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.20 [0.08, 0.54]

2 Intraabdominal abscesses (rate) Show forest plot	5	462	Peto Odds Ratio (Peto, Fixed, 95% CI)	1.97 [0.20, 19.13]

3 Operation time (minutes) Show forest plot	5		Mean Difference (IV, Random, 95% CI)	Subtotals only

3.1 Studies reporting mean data	3	193	Mean Difference (IV, Random, 95% CI)	11.09 [6.30, 15.88]
3.2 Studies reporting median data	2	269	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
4 Anaesthesia time (minutes) Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Subtotals only

4.1 Studies reporting mean data	2	150	Mean Difference (IV, Random, 95% CI)	14.26 [5.78, 22.74]
4.2 Studies reporting median data	0	0	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
5 Pain intensity on day 1 (cm VAS) Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Subtotals only

5.1 Studies reporting mean data	1	61	Mean Difference (IV, Random, 95% CI)	‐0.8 [‐1.65, 0.05]
5.2 Studies reporting median data	1	63	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
6 Length of hospital stay (days) Show forest plot	3	176	Mean Difference (IV, Fixed, 95% CI)	‐0.61 [1.00, ‐0.23]

6.1 Studies reporting mean data	3	176	Mean Difference (IV, Fixed, 95% CI)	‐0.61 [1.00, ‐0.23]
6.2 Studies reporting median data	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Time until reintroduction of liquid diet (days)	0		Mean Difference (IV, Random, 95% CI)	Subtotals only
8 Time until reintroduction of solid diet (days)	0		Mean Difference (IV, Random, 95% CI)	Subtotals only
9 Time until first stool (days)	0		Mean Difference (IV, Random, 95% CI)	Subtotals only
10 Time until mobilisation (days) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

10.1 Studies reporting mean data	0	0	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
10.2 Studies reporting median data	1	58	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
11 Time until return to normal activity (days) Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Subtotals only

11.1 Studies reporting mean data	0	0	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
11.2 Studies reporting median data	2	157	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
12 Time until return to sport (days) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

12.1 Studies reporting mean data	0	0	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
12.2 Studies reporting median data	1	87	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
13 Cosmesis (cm VAS)	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
14 Costs of the operation Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

14.1 Studies reporting mean data	0	0	Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
14.2 Studies reporting median data	1	88	Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
15 Costs within hospital stay (incl. the operation) Show forest plot	2		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

15.1 Studies reporting mean data	1	87	Std. Mean Difference (IV, Random, 95% CI)	0.10 [‐0.32, 0.53]
15.2 Studies reporting median data	1	88	Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
16 Costs outside hospital	0		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

Comparison 2. Laparoscopic versus conventional appendectomy in children

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Comparison 3. Diagnostic laparoscopy (and open or laparoscopic appendectomy if necessary) versus immediate open appendectomy

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Negative appendectomy (rate) Show forest plot	14		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

1.1 Negative appendectomy rate in unselected adults	8	1327	Risk Ratio (M‐H, Random, 95% CI)	0.37 [0.13, 1.01]
1.2 Negative appendectomy rate in fertile women	6	415	Risk Ratio (M‐H, Random, 95% CI)	0.20 [0.11, 0.34]
2 Patients with diagnosis not established Show forest plot	10		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

2.1 Patients with diagnosis not established in unselected adults	4	973	Risk Ratio (M‐H, Random, 95% CI)	0.43 [0.17, 1.08]
2.2 Patients with diagnosis not established in fertile women	6	500	Risk Ratio (M‐H, Random, 95% CI)	0.27 [0.17, 0.44]

Comparison 3. Diagnostic laparoscopy (and open or laparoscopic appendectomy if necessary) versus immediate open appendectomy

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Comparison 4. Diagnostic laparoscopy (and open appendectomy if necessary) versus immediate open appendectomy

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Wound infections Show forest plot	3	223	Peto Odds Ratio (Peto, Fixed, 95% CI)	7.54 [0.47, 122.28]

2 Intraabdominal abscesses Show forest plot	3	223	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.14 [0.01, 2.16]

3 Operation time (minutes) Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Subtotals only

3.1 Studies reporting mean data	2	163	Mean Difference (IV, Random, 95% CI)	‐2.62 [‐15.62, 10.38]
3.2 Studies reporting median data	0	0	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
4 Anaesthesia time (minutes)	0		Mean Difference (IV, Random, 95% CI)	Subtotals only
5 Pain intensity on day 1 (cm VAS)	0		Mean Difference (IV, Random, 95% CI)	Subtotals only
6 Length of hospital stay (days) Show forest plot	4		Mean Difference (IV, Random, 95% CI)	Subtotals only

6.1 Studies reporting mean data	4	273	Mean Difference (IV, Random, 95% CI)	‐0.16 [‐1.03, 0.71]
6.2 Studies reporting median data	0	0	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 4. Diagnostic laparoscopy (and open appendectomy if necessary) versus immediate open appendectomy

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