Ortega A E, Hunter J G, Peters J H, Swanstrom L L, Schirmer B
Department of Surgery, University of Southern California, Los Angeles.
Am J Surg. 1995 Feb;169(2):208-12; discussion 212-3. doi: 10.1016/s0002-9610(99)80138-x.
While the advantages of laparoscopic cholecystectomy are clear, the benefits of laparoscopic appendectomy (LA) are more subtle. We conducted a randomized clinical trial to evaluate whether LA is deserving of more widespread clinical application than it has yet received.
Two hundred fifty-three patients with a preoperative diagnosis of acute appendicitis were randomized into three groups. LA with an endoscopic linear stapler (LAS) (U.S. Surgical Corp., Norwalk, Connecticut) was performed on 78 patients, LA with catgut ligatures (LAL) on 89, and open appendectomy (OA) on 86. LA was performed with a three-trocar technique. OA was accomplished through a right lower-quadrant transverse incision. Data with normal distributions were analyzed by analysis of variance. Nonparametric data were analyzed with either the Kruskal-Wallis H test or Fisher's exact test.
The mean operative times for the procedures were 66 +/- 24 minutes (LAS), 68 +/- 25 minutes (LAL), and 58 +/- 27 minutes (OA). The relative brevity of OA compared to LAS and LAL was statistically significant (P < 0.01). Conversion to open procedures was approximately as frequent in the LAS group (n = 5) and the LAL (n = 6). One OA, 2 LAS, and 11 LAL patients experienced vomiting postoperatively (P < 0.05). Two intra-abdominal abscesses occurred in LAS, 4 in LAL, and 0 in OA patients (P = NS). Wound infections were more common following OA (n = 11) than LAL (n = 4) or LAS (n = 0) (P < 0.05, < 0.001). The mean length of postoperative hospital stay was 2.16 +/- 3.2 days (LAS), 2.98 +/- 2.7 days (LAL), and 2.83 +/- 1.6 (OA) (P < 0.05 OA versus LAS). The number of days patients required pain medications overall was not different between groups, but a subgroup analysis of 134 patients who rated their postoperative pain on a visual analogue scale revealed a significantly lower mean level among patients undergoing LA (LAS and LAL) versus OA (P < 0.001). Patients undergoing LA resumed regular activities sooner than those undergoing OA (9 +/- 9 days versus 14 +/- 11 days, P < 0.001). Rates of readmission to the hospital were similar for all procedures.
Laparoscopic appendectomy appears to have distinct advantages over open appendectomy. The laparoscopic procedures produced less pain and allowed more rapid return to full activities, and LAS required shorter hospital stays. The only disadvantages to the laparoscopic approach were slightly increased operative time for both procedures, and increased emesis following LAL.
虽然腹腔镜胆囊切除术的优势显而易见，但腹腔镜阑尾切除术（LA）的益处却更为微妙。我们进行了一项随机临床试验，以评估LA是否值得比目前更广泛地应用于临床。
253例术前诊断为急性阑尾炎的患者被随机分为三组。78例患者接受使用内镜直线切割吻合器（LAS）（美国外科公司，康涅狄格州诺沃克）的LA，89例接受肠线结扎的LA（LAL），86例接受开腹阑尾切除术（OA）。LA采用三孔技术进行。OA通过右下腹横切口完成。对正态分布的数据采用方差分析进行分析。非参数数据采用Kruskal-Wallis H检验或Fisher精确检验进行分析。
各手术方式的平均手术时间分别为66±24分钟（LAS）、68±25分钟（LAL）和58±27分钟（OA）。与LAS和LAL相比，OA相对较短的手术时间具有统计学意义（P<0.01）。LAS组（n=5）和LAL组（n=6）中转开腹手术的频率相近。1例OA患者、2例LAS患者和11例LAL患者术后出现呕吐（P<0.05）。LAS组有2例患者发生腹腔内脓肿，LAL组有4例，OA组无（P=无显著性差异）。OA术后伤口感染（n=11）比LAL（n=4）或LAS（n=0）更常见（P<0.05，<0.001）。术后平均住院时间分别为2.16±3.2天（LAS）、2.98±2.7天（LAL）和2.83±1.6天（OA）（OA与LAS相比，P<0.05）。各组患者总体所需止痛药的天数无差异，但对134例采用视觉模拟评分法评估术后疼痛的患者进行亚组分析显示，LA（LAS和LAL）患者的平均疼痛水平明显低于OA患者（P<0.001）。接受LA的患者比接受OA的患者更早恢复正常活动（9±9天对14±11天，P<0.001）。所有手术方式的再入院率相似。
腹腔镜阑尾切除术似乎比开腹阑尾切除术具有明显优势。腹腔镜手术产生的疼痛较轻，能更快恢复正常活动，且LAS所需住院时间较短。腹腔镜手术的唯一缺点是两种手术方式的手术时间略有增加，以及LAL术后呕吐增加。
