Laparoscopic versus open surgery for suspected appendicitis

Background The removal of the acute appendix is one of the most frequently performed surgical procedures. Open surgery associated with therapeutic efficacy has been the treatment of choice for acute appendicitis. However, in consequence of the evolution of endoscopic surgery, the operation can also be performed with minimally invasive surgery. Due to smaller incisions, the laparoscopic approach may be associated with reduced postoperative pain, reduced wound infection rate, and shorter time until return to normal activity. This is an update of the review published in 2010. Objectives To compare the effects of laparoscopic appendectomy (LA) and open appendectomy (OA) with regard to benefits and harms. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE and Embase (9 February 2018). We identified proposed and ongoing studies from World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov and EU Clinical Trials Register (9 February 2018). We handsearched reference lists of identified studies and the congress proceedings of endoscopic surgical societies. Selection criteria We included randomised controlled trials (RCTs) comparing LA versus OA in adults or children. Data collection and analysis Two review authors independently selected studies, assessed the risk of bias, and extracted data. We performed the meta‐analyses using Review Manager 5. We calculated the Peto odds ratio (OR) for very rare outcomes, and the mean difference (MD) for continuous outcomes (or standardised mean differences (SMD) if researchers used different scales such as quality of life) with 95% confidence intervals (CI). We used GRADE to rate the quality of the evidence. Main results We identified 85 studies involving 9765 participants. Seventy‐five trials included 8520 adults and 10 trials included 1245 children. Most studies had risk of bias issues, with attrition bias being the largest source across studies due to incomplete outcome data. In adults, pain intensity on day one was reduced by 0.75 cm on a 10 cm VAS after LA (MD ‐0.75, 95% CI ‐1.04 to ‐0.45; 20 RCTs; 2421 participants; low‐quality evidence). Wound infections were less likely after LA (Peto OR 0.42, 95% CI 0.35 to 0.51; 63 RCTs; 7612 participants; moderate‐quality evidence), but the incidence of intra‐abdominal abscesses was increased following LA (Peto OR 1.65, 95% CI 1.12 to 2.43; 53 RCTs; 6677 participants; moderate‐qualit