Nguyen D B, Silen W, Hodin R A
Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02215, USA.
J Gastrointest Surg. 1999 Jan-Feb;3(1):67-73. doi: 10.1016/s1091-255x(99)80011-0.
The role of laparoscopic appendectomy remains controversial since many authors have suggested that overall morbidity is primarily a function of the degree of appendicitis rather than the operative approach. We have reviewed our appendectomy experience to determine the advantages and/or disadvantages of the laparoscopic technique in cases of acute appendicitis, and furthermore to ascertain whether the extent of disease should affect the surgical approach used. Data were accumulated for all 1158 patients who underwent appendectomy at a single institution during the following three time periods that span the pre- and postlaparoscopic eras: period I (1987 to 1990), period II (1991 to 1993), and period III (1994 to 1997). Cases were categorized with regard to pathologic findings and operative approach (i.e., open or laparoscopic appendectomy). The percentage of appendectomies performed laparoscopically increased with time (0%, 27%, and 79% for periods I, II, and III, respectively). Overall, the total operating room time was slightly shorter for laparoscopic compared to open appendectomy (99 vs. 102 minutes; P<0.05). Operating room times for open appendectomy remained unchanged, but the times for laparoscopic appendectomy decreased from period II to period III (119 to 94 minutes; P<0.001). In cases of gangrenous/perforated appendicitis, the times for laparoscopic appendectomy were significantly shorter than those for open appendectomy (98/115 vs. 120/125 minutes; P<0.001 for both). Overall, the hospital stay was shorter for patients undergoing laparoscopic appendectomy (1.63 vs. 4.21 days; P<0.001), and the difference was maintained in all three time periods. The differences in length of hospital stay for lap-aroscopic vs. open appendectomy were most dramatic in gangrenous/perforated cases (1.8/3.0 vs. 4.0/9.0 days; P<0.001), whereas there was only a slight difference in cases of simple appendicitis, for example, 1.6 vs. 2.1 days (laparoscopic vs. open appendectomy, period III). There was a significant decrease in the percentage of perforated cases in which surgical treatment had been delayed (>8 hours) (21%, 5%, and 5%) over the three time periods, but the rate of "negative" appendectomies was similar (10%, 8%, and 8%). The complication rates following laparoscopic and open appendectomies during period II were 5.4% and 7.5%, respectively (P>0.05). Laparoscopic appendectomy results in a marked decrease in the length of hospital stay and similar postoperative morbidity compared to open appendectomy. In cases of gangrenous or perforated appendicitis, laparoscopic appendectomy appears to be especially worthwhile in regard to both operating room time and hospital stay.
腹腔镜阑尾切除术的作用仍存在争议，因为许多作者认为总体发病率主要取决于阑尾炎的程度，而非手术方式。我们回顾了我们的阑尾切除经验，以确定腹腔镜技术在急性阑尾炎病例中的优缺点，此外还确定疾病的程度是否应影响所采用的手术方式。收集了在跨越腹腔镜手术前后三个时间段内于单一机构接受阑尾切除术的所有1158例患者的数据：第一阶段（1987年至1990年）、第二阶段（1991年至1993年）和第三阶段（1994年至1997年）。根据病理结果和手术方式（即开放式或腹腔镜阑尾切除术）对病例进行分类。腹腔镜阑尾切除术的实施比例随时间增加（第一、二、三阶段分别为0%、27%和79%）。总体而言，与开放式阑尾切除术相比，腹腔镜阑尾切除术的总手术室时间略短（99分钟对102分钟；P<0.05）。开放式阑尾切除术的手术室时间保持不变，但腹腔镜阑尾切除术的时间从第二阶段到第三阶段有所减少（119分钟至94分钟；P<0.001）。在坏疽性/穿孔性阑尾炎病例中，腹腔镜阑尾切除术的时间明显短于开放式阑尾切除术（98/115分钟对120/125分钟；两者P<均0.001）。总体而言，接受腹腔镜阑尾切除术的患者住院时间较短（1.63天对4.21天；P<0.001），且在所有三个时间段内均保持这一差异。在坏疽性/穿孔性病例中，腹腔镜与开放式阑尾切除术的住院时间差异最为显著（1.8/3.0天对4.0/9.0天；P<0.001），而在单纯性阑尾炎病例中差异较小，例如，第三阶段为1.6天对2.1天（腹腔镜与开放式阑尾切除术）。在三个时间段内，手术治疗延迟（>8小时）的穿孔病例百分比显著下降（21%、5%和5%），但“阴性”阑尾切除术的发生率相似（10%、8%和8%）。第二阶段腹腔镜和开放式阑尾切除术后的并发症发生率分别为5.4%和7.5%（P>0.05）。与开放式阑尾切除术相比，腹腔镜阑尾切除术可显著缩短住院时间且术后发病率相似。在坏疽性或穿孔性阑尾炎病例中，就手术室时间和住院时间而言，腹腔镜阑尾切除术似乎特别值得采用。
