Laparoscopic or Open Appendectomy? An Aid to Guide a Novice Laparoscopic Surgeon (With Access to Basic Laparoscopic Instruments) for Apt Patient-Procedure Selection

BACKGROUND: Various intra-operative findings cannot be tackled suitably via laparoscopy by a novice laparoscopic surgeon, necessitating a conversion to open approach. These, if identified well in advance, can help the operating surgeon in proper selection of patient and procedure and its apt execution; thereby preventing avoidable conversion and its associated complications. OBJECTIVES: The primary outcome was to identify significant per-operative risk factors which necessitates conversion from laparoscopic to open approach. Secondarily, the post-operative course and outcomes comparing the two operative modalities were studied. METHODS: This prospective, single-center, observational study consisted of 50 adult patients diagnosed with acute or recurrent appendicitis in whom elective minimal access laparoscopic appendectomy was planned. Significant per-operative findings, conversion indications and rate, and post-op course was studied and statistical comparisons were done using Chi-squared test and Z test and p value was obtained. RESULT: Out of 50, 48 patients successfully underwent the planned laparoscopic appendectomy irrespective of the complicated nature of the appendicitis. 2 patients needed conversion to open approach; appendicular mass with dense adhesions to the right ovary with no plane for dissection in the first, and a hemorrhagic right ovarian cyst with torsion and imminent risk of hemorrhage in the second. Patients who underwent laparoscopic surgery had a smooth uncomplicated post-op course with significantly less post-op pain, shorter duration of hospital stay and faster return to work. CONCLUSIONS: Patients with significant per-operative finding needing conversion to open appendectomy have an unfavorable complication profile compared to primary laparoscopic approach. Therefore, the predictors of the same, if identified well in advance, can help in the selection of patients who may benefit from primary open appendectomy.