Sauerland S, Lefering R, Neugebauer E A M
Biochemical & Experimental Division, Medical Faculty, University of Cologne, Ostmerheimer Str. 200, Cologne, Germany, 51109.
Cochrane Database Syst Rev. 2004 Oct 18(4):CD001546. doi: 10.1002/14651858.CD001546.pub2.
Laparoscopic surgery for acute appendicitis has been proposed to have advantages over conventional surgery.
To compare the diagnostic and therapeutic effects of laparoscopic and conventional 'open' surgery.
We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, SciSearch, the congress proceedings of endoscopic surgical societies.
We included randomized clinical trials comparing laparoscopic (LA) versus open appendectomy (OA) in adults or children. Studies comparing immediate OA versus diagnostic laparoscopy (followed by LA or OA if necessary) were separately identified.
Two reviewers independently assessed trial quality. Missing information or data was requested from the authors. We used odds ratios (OR), relative risks (RR), and 95% confidence intervals (CI) for analysis.
We included 54 studies, of which 45 compared LA (with or without diagnostic laparoscopy) vs. OA in adults. Wound infections were less likely after LA than after OA (OR 0.45; CI 0.35 to 0.58), but the incidence of intraabdominal abscesses was increased (OR 2.48; CI 1.45 to 4.21). The duration of surgery was 12 minutes (CI 7 to 16) longer for LA. Pain on day 1 after surgery was reduced after LA by 9 mm (CI 5 to 13 mm) on a 100 mm visual analogue scale. Hospital stay was shortened by 1.1 day (CI 0.6 to 1.5). Return to normal activity, work, and sport occurred earlier after LA than after OA. While the operation costs of LA were significantly higher, the costs outside hospital were reduced. Five studies on children were included, but the result do not seem to be much different when compared to adults. Diagnostic laparoscopy reduced the risk of a negative appendectomy, but this effect was stronger in fertile women (RR 0.20; CI 0.11 to 0.34) as compared to unselected adults (RR 0.37; CI 0.13 to 1.01).
REVIEWERS' CONCLUSIONS: In those clinical settings where surgical expertise and equipment are available and affordable, diagnostic laparoscopy and LA (either in combination or separately) seem to have various advantages over OA. Some of the clinical effects of LA, however, are small and of limited clinical relevance. In spite of the mediocre quality of the available research data, we would generally recommend to use laparoscopy and LA in patients with suspected appendicitis unless laparoscopy itself is contraindicated or not feasible. Especially young female, obese, and employed patients seem to benefit from LA.
有人提出腹腔镜手术治疗急性阑尾炎比传统手术具有优势。
比较腹腔镜手术与传统“开放”手术的诊断和治疗效果。
我们检索了Cochrane对照试验中心注册库、MEDLINE、EMBASE、SciSearch以及内镜外科学会的会议论文集。
我们纳入了比较成人或儿童腹腔镜阑尾切除术（LA）与开放阑尾切除术（OA）的随机临床试验。分别识别比较即刻OA与诊断性腹腔镜检查（必要时随后行LA或OA）的研究。
两名评价员独立评估试验质量。向作者索要缺失的信息或数据。我们使用比值比（OR）、相对危险度（RR）和95%置信区间（CI）进行分析。
我们纳入了54项研究，其中45项比较了成人LA（有或无诊断性腹腔镜检查）与OA。LA术后伤口感染的可能性低于OA（OR 0.45；CI 0.35至0.58），但腹腔内脓肿的发生率增加（OR 2.48；CI 1.45至4.21）。LA的手术时间长12分钟（CI 7至16）。在100mm视觉模拟量表上，LA术后第1天的疼痛减轻了9mm（CI 5至13mm）。住院时间缩短了1.1天（CI 0.6至1.5）。LA术后比OA术后更早恢复正常活动、工作和运动。虽然LA的手术费用显著更高，但院外费用降低。纳入了5项关于儿童的研究，但与成人相比结果似乎没有太大差异。诊断性腹腔镜检查降低了阴性阑尾切除术的风险，但与未选择的成人相比，这种效果在育龄妇女中更强（RR 0.20；CI 0.11至0.34）（RR 0.37；CI 0.13至).
在具备手术专业知识和设备且费用可承受的临床环境中，诊断性腹腔镜检查和LA（联合或单独使用）似乎比OA有多种优势。然而，LA的一些临床效果较小且临床相关性有限。尽管现有研究数据质量一般，但我们通常建议对疑似阑尾炎患者使用腹腔镜检查和LA，除非腹腔镜检查本身存在禁忌或不可行。尤其是年轻女性、肥胖和有工作的患者似乎从LA中获益。
