LAPROSCOPIC APPENDECTOMY IN OBESE AN ATTRACTIVE OPTION Abstract Background Laparoscopic appendectomy is not yet unanimously considered the gold standard in the treatment of acute appendicitis because of its higher operative time and postoperative sequele as compared to open appendectomy However its role in overweight and obese patients should be revisited Objectives This study aimed to compare outcomes of laparoscopic and open appendectomy in obese patients in a Tertiary care hospital Methods This prospective study of 173 patients aged or 16 years BMI 30 who underwent standard laparoscopic appendectomy LA and open Appendectomy OA from January 2013 to December 2016 in tertiary care facility Patients age gender operative time OT postoperative pain return of bowel function intraabdominal abscesses wound sepsis and length of stay LOS were compared between two groups The test of significance used was the Chi square test for categorical variables and t test for quantitative variables Results Laparoscopic appendectomy was performed in 83 patients open appendectomy in 90 the mean operative time was less in the LA 52 min as compae to OA 67 min group The rate of intra abdominal abscess was more in OA 11 than LA group 3 Similarly the post operative ileus was less 12 in LA then Open appendectomy 20 Wound sepsis was observed more in OA 9 than LA 

2 The length of hospital stay was shorter in laparoscopic group 2 5 days than in open group 5 days the mortality rate was nil CONCLUSION Laparoscopic approach is advantageous compared to open appendectomy in terms of less postoperative pain ileus short hospital stay less wound sepsis and operation time in obese patients but a large prospective trial is necessary to prove the better surgical outcomes of laparoscopic appendectomy Key words Laparoscopic Appendectomy Open Appendectomy LAPROSCOPIC APPENDECTOMY IN OBESE AN ATTRACTIVE OPTION INTRODUCTION Appendectomy is one of the commonest surgical procedure Despite a growing body of literature comparing results of laparoscopic and open approaches data has revealed inconclusive and often contradictory According to a Cochrane review published by Sauerland et al 1 laparoscopy does not show relevant advantages compared to open appendectomy therefore indication should be limited to young women and obese patients Evidence supporting this theory was based on retrospective studies2 3 administrative databases studies4 5 and prospective trials with limited populations 6 7 therefore cannot be considered solid enough to set laparoscopy as the gold standard procedure for obese patients affected by acute appendicitis Since obesity represents a widespread condition in west and it s a prevailing problem in our society too so we planned this prospective study comparing open and laparoscopic appendectomy to present data regarding the issue in our set ups PATIENTS AND METHODS This Prospective observational study included173 patients above 16 years of age with BMI 30 or greater with a preoperative diagnosis of appendicitis who underwent laparoscopic and open appendectomy from January 2013 to December 2016

All patients selected by simple random sampling completed the study including post discharge follow up Patients with complicated appendicitis pregnant women and patients with severe medical disease chronic medical or psychiatric illness cirrhosis coagulation disorders etc requiring intensive care were excluded The variables analyzed included patients age gender operative time OT postoperative pain return of bowel function intraabdominal abscesses and length of stay LOS were compared between groups stratified by body mass index BMI and operative technique Both groups of patients were given a prophylactic dose of third generation cephalosporin and metronidazole at induction of the general anesthesia as part of the protocol OA was performed through standard McBurney incision A standard 3 port technique was used for laparoscopic group All specimens were sent for histopathology On return of bowel sounds and passage of flatus clear fluids were started Patients were discharged once they were able to take regular diet Temperature free and had good pain control The operative time minutes for both the procedures was determined from the skin incision to the last skin stitch applied The length of hospital stay was determined as the number of nights spent at the hospital postoperatively 

Wound infection was defined as redness or purulent or seropurulent discharge from the incision site Paralytic ileus was defined as failure of bowel sounds to return within 12 h postoperatively The intraabdominal abscesses were confirmed on ultrasound in both groups Pain intensity was measured by visual analogue score All patients were given NSAIDS in routine Narcotic analgesics were used on demand and frequency was measured The results were analyzed using the t Student test for quantitative variables and the Chi square test for categorical variables RESULTS 173 patients 98 women and 75 men were operated for acute appendicitis having BMI over 30 Ninety three patients n 93 underwent LA 2 requiring conversion to an OA eighty n 80 patients underwent an OA Demographic data between OA group and LA group are showed in Table 1 which showed a female preponderance There were no significant differences with respect to age and associated co morbidities DEMOGRAPHY Table No 1 Age Male 75 Female 98 16 20 15 24 20 30 29 31 30 40 13 17 40 18 26 POSTOPERATIVE CLINICAL DATA Table No 2 COMPLICATIONS LA OA P Value WOUND SEPSIS 2 9 0 022 OPERAATION TIME minutes 52 8 67 13 0 0001 HOSPITAL STAY 3 1 days 5 1 days 0 0001 RESIDUAL ABSCESS 3 11 0 019 ILEUS 12 20 0 09 Use of Parenteral Narcotic analgesia 29 53 0 0001

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