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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Laparoscopic vs open appendectomy in older patients

E Southgate, N Vousden, A Karthikesalingam, SR Markar, S Black, and A Zaidi.

Review published: 2012.

Link to full article: [Journal publisher]

CRD summary

The authors concluded that laparoscopic appendectomy was associated with reduced postoperative mortality and morbidity compared with open appendectomy in older adults. The conclusions appear to reflect the evidence presented and the need for randomised trials in this population to confirm findings.

Authors' objectives

To compare laparoscopic with open appendectomy for older adults.


MEDLINE, EMBASE, The Cochrane Library and the Web of Science were searched up to September 2011; search terms were reported. Conference abstracts from seven British, European and American surgical societies and references from included studies were checked. The Current Controlled Trials register was also searched.

Study selection

Eligible studies (randomised or non-randomised) compared laparoscopic and open appendectomy in patients over 60 years.

Mean age ranged from 68.7 to 75.3 years for the laparoscopic group and 70 to 75.5 years in the open appendectomy group. The male to female ratio was similar for both groups. Primary outcomes were postoperative mortality (in hospital or after 30 days) and complications (within first month of surgery and directly related to surgery).

Studies were selected by two reviewers independently.

Assessment of study quality

No quality assessment was performed although studies were classified according to level of evidence using the Oxford Centre for Evidence Based Medicine tool.

Data extraction

Primary (postoperative mortality, postoperative complications) and secondary (operative time, length of hospital stay, postoperative wound infection, and intra-abdominal collection) outcome data were extracted from each study to calculate odds ratios for dichotomous outcomes and mean differences for continuous outcomes with 95% confidence intervals.

Authors did not state how many reviewers extracted the data.

Methods of synthesis

The studies were pooled using DerSimonian and Laird random-effects meta-analysis. Heterogeneity was assessed using Ι² and Q (p<.05 was statistically significant). Funnel plots and Egger's test were used to assess publication bias.

Subgroup analyses were conducted according to incidence of appendiceal perforation.

Results of the review

Six studies (five retrospective and one prospective) were included in the review of 15,852 patients (4,398 patients received laparoscopic and 11,454 open appendectomy).

Postoperative mortality was lower for laparoscopic compared to open appendectomy with low heterogeneity (OR 0.24; 95% CI 0.15 to 0.37; four studies; Ι²=0%). Postoperative complications were also lower in laparoscopic compared with open appendectomy (OR 0.61; 95% CI 0.50 to 0.73; six studies; Ι²=49%) with some heterogeneity but this was not considered statistically significant.

For the secondary outcomes, length of stay was less for the laparoscopic appendectomy group by approximately half a day (MD -0.51; 95% CI -0.64 to -0.37; four studies Ι²=18%). There were no statistically significant differences on any other secondary outcomes (operative time, intra-abdominal collection and postoperative wound infection).

There was no evidence to indicate publication bias. Subgroup analyses did not find evidence that outcomes differed according to incidence of appendiceal perforation.

Cost information

Cost data was only available from one study. Laparoscopic appendectomy procedure was reported to have been of higher cost, but no differences were found in total treatment costs in comparison with open appendectomy.

Authors' conclusions

Laparoscopic appendectomy was associated with reduced postoperative mortality and complications compared with open appendectomy in older adults. Randomised trials were needed to confirm this result.

CRD commentary

The review question and inclusion criteria were clear. The search included good coverage of electronic databases and attempts were made to identify unpublished studies. Although appropriate methods were used to minimise error and bias in study selection it was unclear if this was the case for data extraction. In addition, no quality assessment was conducted.

Pooling data from the studies appeared appropriate due to relatively low statistical heterogeneity in most analyses. Suitable methods were used to assess heterogeneity. No evidence of publication bias was identified, but there was probably insufficient numbers of studies to reliably investigate this. Although there were large reductions in relative risk of mortality for laparoscopic appendectomy this translates into a small reduction in absolute risk as deaths were rare for both interventions.

Although there were limitations with the review mainly concerning limited information provided on the included studies, the conclusions appear to reflect the evidence presented and the need for randomised trials in this population given the uncertainty associated with observational studies.

Implications of the review for practice and research

Practice: Authors did not state any implications for practice.

Research: Authors stated RCTs were needed to confirm the benefits of laparoscopic versus open appendectomy in older adults and should assess additional outcomes including postoperative pain, cosmesis and patient satisfaction. In addition, a cost-effectiveness analysis was required to assess the benefit of reduced length of hospital stay associated with laparoscopic appendectomy.


None stated.

Bibliographic details

Southgate E, Vousden N, Karthikesalingam A, Markar SR, Black S, Zaidi A. Laparoscopic vs open appendectomy in older patients. Archives of Surgery 2012; 147(6): 557-562. [PubMed: 22786544]

Indexing Status

Subject indexing assigned by NLM


Aged; Appendectomy /adverse effects /methods /mortality; Appendicitis /surgery; Hospital Mortality; Humans; Laparoscopy; Length of Stay; Postoperative Complications /epidemiology; Treatment Outcome



Database entry date


Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 22786544