1c A Clinical Outcome and Cost Analysis of Laparoscopic versus Open Appendectomy Laurence E. McCahill, MD, Carlos A. Pellegrini, MD, Thomas Wiggins, BS, W. Scott Helton, MD, Seattle, Washington BACKGROUND: Benefits of laparoscopic appen- dectomy are controversial, and the results of re- cent clinical studies have contradictory conclu- sions. We performed a cost analysis comparing laparoscopic and open appendectomies to as- sess potential efficacy of the laparoscopic ap- proach. METHODS: All patients operated on for suspected acute appendicitis at the University of Washing- ton Medical Center (UWMC) from January 1, 1991 through January 1,1995 were analyzed. Potential benefits of the laparoscopic approach were ex- amined in five major categories: hospital length of stay, total hospital charges, operative time, op- erating room charges, and postoperative compli- cations. Patients were stratified according to the presence or absence of perforation for outcome analysis. RESULTS: There were 163 appendectomies per- formed in 82 men and 81 women. Twenty-seven (17%) patients had laparoscopic evaluation, of which 21 underwent attempted laparoscopic ap- pendectomy. Among nonperforated patients, la- paroscopic appendectomy did not reduce hospi- tal stay compared with open appendectomy, but did lead to greater hospital charges ($7760 vs $5064; P < 0.001). Operating times were longer in the laparoscopic group (104 vs 74 minutes; P < 0.001) compared with open appendectomies. Op- erating room charges for laparoscopic appendec- tomies exceeded charges for the open approach ($4740 vs $1870; P < 0.001). Complication rates were similar (laparoscopic, 19% vs open, 16%; NS). The false diagnostic rate for women was four times greater than for men among patients undergoing open appendectomy (31% vs 8%; P < 0.01). Patients with perforation undergoing a midline incision had a longer hospital stay (9.5 vs 5.9; P < 0.02) than patients operated on through a right lower quadrant incision. CONCLUSIONS; In our analysis, laparoscopic ap- pendectomy, while safe, was more expensive and From the Department of Surgery, University of Washington Med- ical Center, Seattle, Washington. Request for reprints should be addressed to W. Scott Helton, MD, Department of Surgery, University of Washington Medical Center, 1959 N.E. Pacific Avenue, Seattle, Washington 98195. Presented at the 82nd Annual Meeting of the North Pacific Sur- gical Association, Victoria, British Columbia, November 9-l 1, 1995. was not associated with better clinical outcome compared with open appendectomy patients. Am J surg. 1996;171:533-537. A ppendecromy through a right lower quadrant inci- sion has been the traditional approach to treat pa- tients with suspected appendicitis since Fitz’s orig- inal description of appendiceal inflammation in 1886.’ In 1983, Semm introduced the use of laparoscopic techniques for appendectomy.2 More recent advances in videoendo- scopic surgery comhmed with attempts to decmase health care costs have led surgeons to consider laparoscopic ap- pendectomy as an alternative approach for the treatment of acute appendicitis. However, the acceptance of laparop scopic appendectomy has heen slow, due to the recognized effectiveness and rapid recovery associated with the stan- dard open technique. The potential for laparoscopic appendectomy to improve patient outcomes and reduce health care spen(ding led to several randomized trials where open and laparoscopic ap- pendectomy were compared. ‘-lo Early randomized trials comparing open and laparoscopic appendectotny demon- strated that the lapatoscopic approach was safe and could shorten hospital stay.3*h,sSince the incidence of acute ap- pendicitis in the United States is high, even small reduc, tions in hospital stay could potentially reduce r-he number of dollars spent on the treatment of acute appendicitis. Re- cent trials, however, have not convincingly demonstrated an improved clinical outcome, decreased length of hospital stay, or reduced costs for laparoscopic appendectomy.5’9 l2 The uncertain benefit and cost savings of laparoscopic ap- pendectomy led us to analyze our own experience with this approach. We hypothesized that patients undergoing lapa- roscopic appendectomy would have a shorter hospital stay, less morbidity, and reduced overall costs than patients un- dergoing an open appendectomy. To that end, we compared costs and clinical outcomes of patients with suspected ap- pendicitis operated on by open and laparoscopic ap- proaches. We also analyzed the safety, efficiency, and mor- bidity of both open and laparoscopic appendectomy. PATIENTS AND METHODS The medical records and hospital hills of all patients operated on for suspected acute appendicitis during the 4-year period from January 1991 through December 1994 were analyzed. Patients undergoing incidental or interval appendectomies were excluded. Cases converted from laparoscopic to open procedures were included in the laparoscopic group for purposes of outcome and cost anal- ysis. Cases involving diagnostic laparoscopy prior to a planned open approach were excluded from analysis. 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