Surg Endosc (2017) 31:199–205
DOI 10.1007/s00464-016-4957-z
Comparison of clinical outcome of laparoscopic versus open
appendectomy for complicated appendicitis
P. Horvath1 • J. Lange1 • R. Bachmann1 • F. Struller1 • A. Königsrainer1
M. Zdichavsky1
Received: 2 February 2016 / Accepted: 18 April 2016 / Published online: 18 May 2016
Ó Springer Science+Business Media New York 2016
Abstract
Background Laparoscopic appendectomy is now the
treatment of choice in uncomplicated appendicitis. To date
its importance in the treatment of complicated appendicitis
is not clearly defined.
Methods From January 2005 to June 2013 a total of 1762
patients underwent appendectomy for the suspected diag-
nosis of appendicitis at our institution. Of these patients
1516 suffered from complicated appendicitis and were
enrolled. In total 926 (61 %) underwent open appendectomy
(OA) and 590 (39 %) underwent laparoscopic appendec-
tomy (LA). The following parameters were retrospectively
analyzed: age, sex, operative times, histology, length of
hospital stay, 30-day morbidity focusing on occurrence of
surgical site infections, intraabdominal abscess formation,
postoperative ileus and appendiceal stump insufficiency,
conversion rate, use of endoloops and endostapler.
Results A statistically significant difference in operative
time was observed between the laparoscopic and the open
group (64.5 vs. 60 min; p = 0.002). Median length of
hospitalization was significantly shorter in the laparoscopic
group (p \ 0.000). Surgical site infections occurred
exclusively after OA (38 vs. 0 patients). Intraabdominal
abscess formation occurred statistically significantly more
often after LA (2 vs. 10 patients; p = 0.002). There were
no statistical significances concerning the occurrence of
postoperative ileus (p = 0.261) or appendiceal stump
insufficiencies (p = 0.076).
& P. Horvath
philipp.horvath@med.uni-tuebingen.de
1
Department of General, Visceral and Transplant Surgery,
Comprehensive Cancer Center, University of Tübingen,
Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany
and Other Interventional Techniques
•
Conclusions The laparoscopic approach for complicated
appendicitis is a safe and feasible procedure. Surgeons
should be aware of a potentially higher incidence of
intraabdominal abscess formation following LA. Use of
endobags , inversion of the appendiceal stump and care-
fully conducted local irrigation of the abdomen in a supine
position may reduce the incidence of abscess formation.
Keywords Complicated
Appendicitis
Laparoscopy

Intraabdominal abscess
Since its first description in the early 1980s laparoscopic
appendectomy (LA) has advanced to the treatment of choice
for uncomplicated appendicitis, with increasing numbers of
procedures performed per year [1]. Several studies have
demonstrated the superiority of LA compared to open
appendectomy (OA) in uncomplicated appendicitis [2–10].
Compared to OA many advantages of LA have been high-
lighted, such as reduced postoperative pain, better cosmetic
results and faster return to physical activity, thus increasing
the chance of early discharge. The importance of LA in the
therapy of complicated appendicitis (CA) is still not clearly
defined as reflected by controversial findings in the past lit-
erature [7, 11, 12]. However, more recent studies conveyed
the superiority of LA in complicated appendicitis [13–16].
Opponents of LA for complicated appendicitis state that in
the presence of abdominal wall perforation and abscess
formation the laparoscopic approach represents a relative
contraindication [12]. On the other hand, especially in
severely ill patients with perforated appendicitis, LA might
offer various clinical benefits, such as reducing the risk of
extensive laparotomy [13]. Our study aimed to present the
clinical outcome regarding postoperative morbidity in
patients with CA treated by either LA or OA.
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Materials and methods
From January 2005 to June 2013 1762 patients underwent
LA or OA for the suspected diagnosis of appendicitis and
were retrospectively considered for this study. In total 1516
patients with CA defined as a phlegmonous, necrotic or
gangrenous transformation of the appendix, perforation of
the appendiceal wall (macroscopic or microscopically
proven by histological report) and presence of abscess
formation were enrolled.
Prior to surgery all patients were subjected to clinical
examination, blood and urine screening and ultrasonography
of the abdomen. In selected patients with unclear symptoms
a priori, computed tomography (CT) scan was conducted to
ensure correct diagnosis. All patients diagnosed with com-
plicated appendicitis were scheduled for immediate opera-
tion. All operations were performed by a team of two
surgeons, one resident and one consultant who were expe-
rienced in the open as well as the laparoscopic approach.
Prior to surgery each patient was given intravenous single-
shot antibiotic treatment consisting of a third-generation
cephalosporine, and in cases of perforation, gangrene and/or
abscess formation metronidazole was added.
OA and LA were performed as a standardized procedure
as described in our previous publication [14]. In all cases of
LA an endobag was used to remove the specimen from the
abdominal cavity.
Surgical site infections (SSI), intraabdominal abscess
formation (IAA), postoperative ileus (PI) and appendiceal
stump insufficiency (ASI) were retrospectively assessed.
According to the classification from the Centers of Disease
Control and Prevention (CDC) SSI were divided into
superficial incisional and deep incisional SSI [19]. IAA was
defined as an intraabdominal fluid collection diagnosed
radiologically accompanied by elevated inflammation
markers and deterioration of the patient’s clinical condition.
PI was defined as the presence of nausea, vomiting, pro-
gressive abdominal pain and absence of bowel movement.
Definite diagnosis was sought radiologically. ASI was
defined as intraoperatively proven insufficiency of the
appendiceal stump with a pericecal fluid collection and/or
peritonitis. All complications were graded using the Cla-
vien–Dindo classification of surgical complications [15].
Statistics
SPSS ver. 12.0 (SPSS Inc. Chicago, IL, USA) was used for
statistical analysis. A p \ 0.05 was considered statistically
significant when using the Chi-square test and the T test.
The Chi-square test was used for nominal variables and the
T test for continuous variables.
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Surg Endosc (2017) 31:199–205
Results
From January 2005 to June 2013 926 patients underwent
OA and 590 patients LA for CA (Table 1; Fig. 1). In the
OA group 13 % and in the LA group 9 % of the patients
were categorized as perforated appendicitis. There were
significantly more male patients in the OA than in the LA
group (p \ 0.000). Median age in both groups was com-
parable (28.9 vs. 28 years).
The conversion rate in the LA group was 0.86 %
(n = 5/590 patients). In all cases impaired visualization of
the right lower quadrant was the reason for conversion.
For appendiceal stump closure in 84 % of the patients
Roeder knots and in 16 % of the patients a stapler device
was used in the LA group. In 53 % of the patients with
perforated appendicitis (Fig. 2) in the LA group a stapler
device was used. Usually the reason for stapler use was an
inflamed appendix base.
In 16 % of the patients in the OA and in 12 % of the
patients in the LA group a drain was inserted.
Median operative time in the OA group was 64.5 min
(range 16–239 min) and in the LA group 60 min (range
11–185 min) (p = 0.002). In the case of perforated
appendicitis operative time was extended to 77 min (range
32–234 min) in the OA group and to 76 min (range
28–310 min) in the LA group (p = 0.631).
Median hospital stay in the OA group was 4 days (range
1–44 days) and in the LA group 3 days (range 1–27 days)
(p \ 0.000).
Of the patients with phlegmonous appendicitis 5 and
2 % and of the patients with perforated appendicitis 13 and
11 % suffered from any kind of complication within the
first 30 postoperative days in the OA and the LA group,
respectively (Table 1; Fig. 3). SSI occurred exclusively in
the OA group. All 38 patients with SSI of the OA group
required bedside wound treatment. In 16 % of these
patients intravenous antibiotic treatment consisting of
ciprofloxacin and metronidazole was commenced for at
least 5 days. Furthermore, daily wound inspection and
change of wound dressing were conducted. SSI were
classified according to the Clavien–Dindo classification as
group I (no antibiotic treatment; n = 32/38; 84 %) or as
group II (antibiotic treatment; n = 32/38; 84 %). All four
patients requiring antibiotic treatment suffered from deep
incisional SSI according to CDC classification. The
remaining SSI were categorized as superficial incisional.
Two and ten patients developed postoperative IAA in
the OA and the LA group, respectively (p = 0.002). In the
OA group IAA was diagnosed on postoperative days 11
and 15. The first patient was primarily treated with a CT-
targeted drain, but without improvement in clinical status
so that re-operation was scheduled for resection of the right
Surg Endosc (2017) 31:199–205 201

Table 1 Clinicopathological
Characteristics OA (n = 926) LA (n = 590) p value
characteristics in complicated
appendicitis in the OA and the Age (year) 0.381
LA group (yr years, US
ultrasound, CT computed Median 28.9 28
tomography, min minutes, dy Range 15–88 16–91
days, SSI surgical site infection, Sex (n) \0.000
IAA intraabdominal abscess
Male 527 215
formation, PI postoperative
ileus, ASI appendiceal stump Female 399 375
insufficiency) Preoperative diagnostic
US 855 548 0.691
CT 187 88 0.009
US ? CT 100 59 0.622
Operative time (min)
Median 64.5 60 0.002
Range 16–239 11–310
Histology (n) 0.015
Phlegmonous 805 537
Perforated 121 37
Median hospital stay (dy) 4 3 \0.000
30-day morbidity n (%)
SSI 38 (4) 0 (0) \0.000
IAA 2 (0.2) 10 (1.7) 0.002
PI 5 (0.5) 1 (0.17) 0.263
ASI 0 (0) 2 (0.4) 0.076
Endo-GIA (n) Not applicable 95
Roeder knots (n) Not applicable 495
Operative time (min) Endo-GIA versus Roeder knots
Range Not applicable 63.5 vs. 53 \0.000
Median Not applicable (26–172) vs (11–185)
Conversion rate (n) 0 5 0.005
Drain insertion (n) 151 71 0.021

Fig. 1 Numbers of OA and LA 200

from 2005 to 2013
180

160

140

120
paents

100 OA
80 LA
60

40

20

0
2005 2006 2007 2008 2009 2010 2011 2012 Jan.-Jun.
2013

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Fig. 2 Laparoscopic view of perforated appendicitis (black arrow)
with abscess formation in the background (black star)
40
35
30
25
paents
20 OA
LA
15
10
5
0
SSI IAA PI ASI
Fig. 3 Comparison of OA and LA regarding incidence of SSI, IAA,
PI and ASI
hemicolon. The second patient underwent re-laparotomy
due to interenteric abscess formation with abdominal
lavage but without bowel resection.
In the LA group IAA was diagnosed on days 3, 4, 5, 7, 10,
10, 12, 17, 26 and 29 postoperatively. Of ten patients seven
were primarily treated with CT-targeted drain. In one of
these patients percutaneous drainage was not sufficient so
that a laparotomy was performed. The remaining three
patients required re-operation. The first patient was pri-
marily treated with intravenous antibiotics, but clinical
deterioration made re-laparoscopy and lavage and drainage
of the abdomen necessary. Ten days later fever, abdominal
pain and elevated inflammation markers called for laparo-
tomy and resection of the ileocecal region. The second
patient suffered from IAA and postoperative ileus, so that re-
laparoscopy, adhesiolysis and drainage were performed. In
the last patient re-laparoscopy and lavage of the abdomen
were performed on postoperative day 12. All patients
received intravenous antibiotic treatment with ciprofloxacin
and metronidazole. IAAs were classified according to the
Clavien–Dindo classification as groups IIIa (CT-targeted
drain) and IIIb (re-operation). Further clinicopathologic
characteristics are shown in Tables 2 and 3.
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Surg Endosc (2017) 31:199–205
Five patients in the OA group developed PI (acute
abdominal pain, nausea and vomiting, elevated markers of
inflammation) and needed re-operation (Clavien–Dindo
IIIb) between postoperative days 3 and 7. In none of the
patients was bowel resection necessary. In the LA group
one patient suffered from PI and re-laparoscopy became
necessary on postoperative day 3 (Clavien–Dindo IIIb).
Intraoperatively an abscess in the lesser pelvis was found.
Adhesiolysis and abscess evacuation were performed.
One patient in the OA group showed clinical signs of
lower gastrointestinal bleeding on postoperative day 7.
Coronary heart disease made postoperative anticoagulation
with acetylsalicylic acid and clopidogrel necessary.
Emergency colonoscopy showed acute bleeding on the
appendiceal stump, which was graded Clavien–Dindo IIIa.
Hemostasis was achieved endoscopically.
Two patients in the LA group suffered from ASI on
postoperative days 5 and 8. Initially, Roeder knots were
used in one patient and a stapler device in the other patient.
In both patients laparotomy and resection of the ileocecal
region in the first and of the right hemicolon in the second
patient were necessary (Clavien–Dindo IIIb).
Discussion
The first clinical reports of LA for uncomplicated appen-
dicitis were published in the 1980s, and today LA is still
the treatment of choice. Superiority of LA over OA has
been demonstrated in several studies [2–10]. The benefits
of LA are reduced operative trauma, less postoperative
pain, quicker return to physical activity and better cosmetic
results [13, 16]. These features constitute the main reasons
why the laparoscopic approach has been adopted as the
gold standard for many other surgical procedures. Never-
theless, the value of LA in the treatment of CA is still not
clearly defined, which may be due to controversial findings
in the earlier literature, associating LA with either a clear,
marginal or no clinical benefit over OA for CA.
The aim of this study was to evaluate the outcome of LA
in the treatment of CA in comparison with the open
approach. In agreement with other studies we were able to
demonstrate that LA is a feasible and safe procedure [15,
16]. At our institution LA was started in 2005, and
nowadays, the vast majority of appendicitis cases, either
uncomplicated or complicated, are operated on laparo-
scopically. Consistent with other studies [17–24] SSI
occurred more often in the OA group, reaching statistical
significance in our study population. The main reasons for
the significantly larger number of SSI in the OA group
might be the direct trauma to the wound and the fact that
during LA the specimen is removed using an endobag. In
order to perform the resection during OA the inflamed
Surg Endosc (2017) 31:199–205 203

Table 2 Clinical characteristics

Characteristics IAA in OA group (n = 2) IAA in LA group (n = 10) p value
of patients with IAA in the OA
and the LA group Age (year) 0.634
Median 41.5 56.6
Range 18–65 18–91
Sex (n) [1.000
Male 1 5
Female 1 5
Comorbidity (n)
Hypertension 1 2 0.454
Diabetes mellitus 0 1 0.640
Chronic renal failure 0 1 0.640
Pathological finding (n)
Phlegmonous 0 5 0.274
Perforated 2 5 0.601

Table 3 Intraoperative and complication-management characteristics of patients suffering from IAA in the OA and the LA group (POD
postoperative day)
Characteristics IAA in OA group (n = 2) IAA in LA group (n = 10) p value

Intraoperative characteristics (n)

Roeder knot Not applicable 7
Endo-GIA Not applicable 3
Operative time (min) 0.293
Median 108 72
Range 78–138 58–143
Drainage insertion 2 8 0.480
Surgeon: resident 0 1 0.640
Surgeon: consultant 2 9 0.640
Type of complication (n)
Pericecal abscess formation 2 6 0.784
Interenteric abscess formation 0 4 0.784
Time point of complication (n)
POD 0–3 0 1 0.640
POD 4–7 0 3 0.371
POD 8–11 1 2 0.371
POD 12–15 1 1 0.729
POD 16–22 0 1 0.640
POD 23–30 0 2 0.488
Interventions (n)
Percutaneous CT-guided drainage 1 6 0.793
Re-operation 2 5 (one patient had two operations) 0.601
Re-laparoscopy Not applicable 3
Laparotomy 2 2 0.171

appendix has to be luxated out of the abdomen, which may
contribute to contamination of the surrounding tissue.
Furthermore, the laparoscopic approach creates a far
smaller operative trauma than does OA. None of the
patients had to be re-operated due to SSI, but were man-
ageable with antibiotics and bedside wound treatment.
Regarding further postoperative complications this
study shows that patients undergoing LA for CA developed
IAA statistically significantly more often than did patients
undergoing an open procedure. These findings go along
with results of other studies [25–27]. In total ten patients in
our LA group postoperatively developed IAA. Histology

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revealed five phlegmonous and five perforated appendices.
In seven out of ten patients Roeder knots were used. In the
vast majority of patients abscesses were able to be evacu-
ated by inserting a CT-guided drain. In comparison, only
two patients in the OA group suffered from IAA. The first
aspect that might explain this phenomenon is the fact that
during OA the appendiceal stump is completely inverted,
which prevents further postoperative contamination of the
abdominal cavity. In our study Roeder knots were used in
the vast majority of cases, also in the presence of perfo-
rated appendicitis, without routinely conducted appen-
diceal stump inversion. The second aspect might be the
patient’s position during laparoscopy and irrigation of the
abdomen after removal of the specimen. Usually patients
undergoing LA are positioned in a trendelenburg position
in order to optimize visualization of the right lower quad-
rant. Irrigation of the abdomen conducted in this position
might facilitate the intraabdominal spread of contaminated
fluids, thus promoting intraabdominal (i.e., subhepatic and
interenteric) abscess formation. This is why a routinely
conducted appendiceal stump inversion during LA, the use
of endobags to further minimize contamination and the
cautious only local irrigation of the right lower quadrant
preferably in supine position should be given consideration
[25–27]. A large retrospective study from the Netherlands
evaluated the efficacy of endoloops versus endostapler in
terms of appendiceal stump closure [28]. Over 1000
patients were enrolled (571 treated with endostapler vs. 465
treated with endoloops) in that study, and the authors found
routine use of stapler devices to provide no clinical
advantages. More IAAs were seen in the endoloop group,
but did not reach statistical significance. This circumstance
might advocate a laparoscopically conducted appendiceal
stump inversion, mainly when endoloops are used.
Unlike Lim et al. [16] we found more PI in the OA than
in the LA group (5 vs. 1 patient). Only one patient suffering
from IAA also had PI. Lim et al. [16] found a higher
incidence of IAA combined with PI in the LA than in the
OA group. The reason for a higher incidence of PI in the
OA group might be that during LA visualization not only
of the right lower quadrant but also of the remaining
abdomen is better, so that already present adhesions and
small abscess formation can be detected. Following LA
only two patients developed appendiceal stump insuffi-
ciency. In the first case a stapler device and in the second
case Roeder knots were used.
In our study a significant difference in operative time
was found between the OA and the LA group (64.5 vs
60 min), respectively. Some studies reported a longer and
some a shorter operative time for LA than for OA [12, 20,
29]. These heterogeneous results might be explained by
different laparoscopic skill levels in the authors. What we
found in our study population is that in the presence of
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Surg Endosc (2017) 31:199–205
perforation the operative times were synchronously
extended in both groups (77 min for LA and 76 min for
OA).
Only five of 590 patients who were operated on
laparoscopically for CA were converted to an open pro-
cedure because of impaired visualization of the right lower
quadrant, all of whom showed no postoperative compli-
cations. Compared to other reports with conversion rates of
up to 13 % for LA in CA our conversion rate seems to be
quite low [30].
In conclusion, LA constitutes a safe and feasible pro-
cedure for the treatment of CA. In the case of CA, endo-
bags and endostapler should be used or the appendiceal
stump should be inverted after applying Roeder knots.
Furthermore, local irrigation in supine position should be
performed carefully in order to further minimize the
occurrence of IAA in LA.
Compliance with ethical standards
Disclosures Dr. Philipp Horvath, Dr. Jessica Lange, Dr. Robert
Bachmann, Dr. Florian Struller, Dr. Alfred Königsrainer and Dr. Marty
Zdichavsky have no conflicts of interest or financial ties to disclose.
References
1. Semm K (1983) Endoscopic appendectomy. Endoscopy 15:59–64
2. Frazee RC, Roberts JW, Symmonds RE, Snyder SK, Hendricks
JC, Smith RW, Custer MD 3rd, Harrison JB (1994) A prospective
randomized trial comparing open versus laparoscopic appendec-
tomy. Ann Surg 219:725–728
3. Katkhouda N, Mason RJ, Towfigh S, Gevorgyan A, Essani R
(2005) Laparoscopic versus open appendectomy: a prospective
randomized double-blind study. Ann Surg 242:439–448
4. Milewczyk M, Michalik M, Ciesielski M (2003) A prospective,
randomized, unicenter study comparing laparoscopic and open
treatments of acute appendicitis. Surg Endosc 17:1023–1028
5. Ortega AE, Hunter JG, Peter JH, Swanstrom LL, Schirmer B
(1995) A prospective, randomized comparison of laparoscopic
appendectomy with open appendectomy. Am J Surg 169:208–212
6. Towfigh S, Chen F, Mason R, Katkhouda N, Chan L, Berne T
(2006) Laparoscopic appendectomy significantly reduces length
of stay for perforated appendicitis. Surg Endosc 20:495–499
7. Guller U, Hervey S, Purves H, Muhlbaier LH, Peterson ED,
Eubanks S, Pietrobon R (2004) Laparoscopic versus open
appendectomy: outcomes comparison based on a large adminis-
trative database. Ann Surg 239:43–52
8. Nguyen NT, Zainabadi K, Mavandadi S, Paya M, Stevens CM,
Root J, Wilson SE (2004) Trends in utilization and outcomes of
laparoscopic versus open appendectomy. Am J Surg 188:813–820
9. Golub R, Siddiqui F, Pohl D (1998) Laparoscopic versus open
appendectomy: a metaanalysis. J Am Coll Surg 186:545–553
10. Kehagias I, Karamanakos SN, Panagiotopoulos S, Panagopoulos
K, Kalfarentzos F (2008) Laparoscopic versus open appendec-
tomy: which way to go? World J Gastroenterol 14:4909–4914
11. Martin LC, Puente I, Sosa JL, Bassin A, Breslaw R, McKenney
MG, Ginzburg E, Sleeman D (1995) Open versus laparoscopic
appendectomy. A prospective randomized comparison. Ann Surg
222:256–261
Surg Endosc (2017) 31:199–205
12. Bonanni F, Reed J 3rd, Hartzell G, Trostle D, Boorse R, Gittle-
man M, Cole A (1994) Laparoscopic versus conventional
appendectomy. J Am Coll Surg 179:273–278
13. Wullstein C, Barkhausen S, Gross E (2001) Results of laparo-
scopic versus conventional appendectomy in complicated
appendicitis. Dis Colon Rectum 44:1700–1705
14. Ingraham AM, Cohen ME, Bilimoria KY, Pritts TA, Ko CY,
Esposito TJ (2010) Comparison of outcomes after laparoscopic
versus open appendectomy for acute appendicitis at 222 ACS
NSQIP hospitals. Surgery 148:625–637
15. Sauerland S, Jaschinski T, Neugebauer EA (2010) Laparoscopic
versus open surgery for suspected appendicitis. Cochrane Data-
base Syst Rev 10:CD001546
16. Yeh CC, Wu SC, Liao CC, Su LT, Hsieh CH, Li TC (2011)
Laparoscopic appendectomy for acute appendicitis is more
favorable for patients with comorbidities, the elderly, and those
with complicated appendicitis: a nationwide population-based
study. Surg Endosc 25:2932–2942
17. Tiwari MM, Reynoso JF, Tsang AW, Oleynikov D (2011)
Comparison of outcomes of laparoscopic and open appendectomy
in management of uncomplicated and complicated appendicitis.
Ann Surg 254:927–932
18. Zdichavsky M, Gögele H, Blank G, Kraulich M, Meile T, von
Feilitzsch M, Wichmann D, Königsrainer A (2013) Histological
characterization of appendectomy specimens with intraoperative
appearance of vascular injection. Surg Endosc 27:849–853
19. Procedure-associated Module SSI: Surgical Site Infection (SSI)
Event: Available from: http://www.cdc.gov/nhsn/PDFs/pscMan
ual/9pscSSIcurrent.pdf
20. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D,
Schulick RD, de Santibañes E, Pekolj J, Slankamenac K, Bassi C,
Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M
(2009) The Clavien-Dindo classification of surgical complica-
tions: five-year experience. Ann Surg 250:187–196
205
21. Lim SGL, Ahn EJ, Kim SY, Chung IY, Park JM, Park SH, Choi
KW (2011) A clinical comparison of laparoscopic versus open
appendectomy for complicated appendicitis. J Korean Soc
Coloproctol 27:293–297
22. Fukami Y, Hasegawa H, Sakamoto E, Komatsu S, Hiromatsu T
(2007) Value of laparoscopic appendectomy in perforated
appendicitis. World J Surg 31:93–97
23. Katsuno G, Nagakari K, Yoshikawa S, Sugiyama K, Fukunaga M
(2009) Laparoscopic appendectomy for complicated appendicitis:
a comparison with open appendectomy. World J Surg 33:208–
214
24. Lin HF, Wu JM, Tseng LM, Chen KH, Huang SH, Lai IR (2006)
Laparoscopic versus open appendectomy for perforated appen-
dicitis. J Gastrointest Surg 10:906–910
25. Yau KK, Siu WT, Tang CN, Yang GP, Li MK (2007) Laparo-
scopic versus open appendectomy for complicated appendicitis.
J Am Coll Surg 205:60–65
26. So JB, Chiong EC, Chiong E, Cheah WK, Lomanto D, Goh P,
Kum CK (2002) Laparoscopic appendectomy for perforated
appendicitis. World J Surg 26:1485–1488
27. Tuggle KR, Ortega G, Bolorunduro OB, Oyetunji TA, Alexander
R, Turner PL, Chang DC, Cornwell EE 3rd, Fullum TM (2010)
Laparoscopic versus open appendectomy in complicated appen-
dicitis: a review of the NSQIP database. J Surg Res 163:225–228
28. Khiria LS, Ardhnari R, Mohan N, Kumar P, Nambiar R (2011)
Laparoscopic appendectomy for complicated appendicitis: is it
safe and justified? A retrospective analysis. Surg Laparosc
Endosc Percutan Tech 21:142–145
29. Garg CP, Vaidya BB, Chengalath MM (2009) Efficacy of
laparoscopy in complicated appendicitis. Int J Surg 7:250–252
30. Piskun G, Kozik D, Rajpal S, Shaftan G, Fogler R (2001)
Comparison of laparoscopic, open, and converted appendectomy
for perforated appendicitis. Surg Endosc 15:660–662
123
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