Two-Year Experiences of 500 Appendectomies in Lahore General Hospital, Lahore

Introduction Acute appendicitis is a leading cause of abdominal conditions in emergency departments. Evidence from research studies has indicated the efficacies of surgical procedures involving appendectomies. However, in Pakistan, there is a paucity of information regarding the epidemiology, clinical presentations, and surgical management of acute appendicitis. Objective This paper aims to report the epidemiologic data and findings of surgical management of acute appendicitis in Lahore General Hospital (LGH). The data was based on our two-year experiences of appendectomies in the hospital. Materials and methodology Data were collected retrospectively. The patients underwent appendectomies performed by the team of surgeons of Surgical Unit 1 of LGH in the Accident and Emergency (A&E) Department from July 2019 to October 2021. Results The total number of patients was 506, and the mean age was 26.8. Males (67.29%) and young adults aged 18-34 years were at higher risk of appendicitis. Compared to other surgical procedures performed, open appendectomy and laparoscopic appendectomy operative times were significantly shorter. Histopathology of all the cases showed acute inflammation of the appendix. Discussion Similar to findings from other research studies, the operative time of open appendectomies was shorter (70.6 minutes) in the hospital than the operative time of laparoscopic appendectomies (77 minutes). However, the overall operative times were longer than the operative times reported in some other research studies. Also, contrary to other research findings, open appendectomy (1.22 days) was associated with a longer length of hospital stay than laparoscopic appendectomy (≈1 day). Simple acute appendicitis was the most predominant operation findings (289, 57.1%). Conclusion Compared to other hospitals, the shorter hospital stays/recovery time indicated the high surgical skill of performing open and laparoscopic appendectomies in Lahore General Hospital, Lahore, Pakistan.


Introduction
Appendicitis is one of the most predominant causes of acute abdominal cases, and it is responsible for 7%-10% of the total emergency clinical conditions [1]. Acute appendicitis is one of the leading causes of lower abdominal pains that cause patient emergency department visits. Furthermore, it is the most diagnosed abdominal condition in hospitalized patients with acute abdominal cases [2]. Evidence from research studies has indicated geographical differences in the incidence rates of acute appendicitis. In the United States, the reported incidence rate was 9%; in Europe, it was 8%; in Africa, it was 2% [3]. Notable differences can be observed in the presentation of acute appendicitis, its severity, and surgical management according to countries and their economic condition [4]. Perforation rates, for example, range from 16% to 40%, with younger patients (40%-57%) and older patients (55%-70%) being more affected [5]. Also, the incidence rates of acute abdominal pain vary between males and females [6]. 1 2 1 1 1 1 Morbidity and mortality are significantly increased with perforated acute appendicitis compared with nonperforated appendicitis. Furthermore, evidence from research studies indicated higher risks of mortality with gangrenous acute appendicitis [7]. However, reports from research studies have indicated the efficacy of the surgical intervention, via appendectomies, in mitigating the high morbidity and mortality rates associated with perforated appendicitis [8]. Addiss et al. (1990) reported that over 300,000 appendectomies are performed yearly in the United States [9]. However, in Pakistan, there is a paucity of published information regarding the epidemiology, clinical presentations, and surgical management of acute appendicitis. Hence, this paper aims to report our two-year experiences in performing appendectomies as surgeons in Lahore General Hospital (LGH), Lahore, Pakistan.

Materials And Methods
This retrospective cross-sectional study was carried out over a 27-month period from July 2019 to October 2021, and patients were surgically managed in the Accident and Emergency (A&E) Department of Lahore General Hospital. Patients with the clinical diagnosis of acute appendicitis were included, and patients whose appendectomy was conducted by other surgical departments of LGH were excluded. Patient records and surgery notes were used to compile the data. The patients in the study ranged in age from 15 to 68 years old.
A detailed history of the start of discomfort, radiation, anorexia, vomiting, and fever was taken. A complete description of menstrual history was noted in females of childbearing age (14-44 years) to rule out pelvic inflammatory illness. To rule out ureteric colic, all male patients with right iliac fossa discomfort and a history of burning sensation during micturation and/or hematuria were examined. A general survey was conducted, with a focus on measuring pulse, temperature, and blood pressure. McBurney's point, psoas test, obturator test, cough sign, pain on straight leg raise, localized stiffness of the right iliac fossa, and rebound tenderness were all part of the abdominal examination. Every patient has to undergo a rectal examination.
To look for symptoms of sepsis, other systems were checked. After provisionally diagnosing the patient with appendicitis, additional tests to confirm the diagnosis included a total count to check for leucocytosis; a biochemical examination to check for blood sugar, urea, and creatinine; an upright X-ray abdomen; and ultrasound. For all patients with appendicitis, a final decision on operational intervention was taken.
Open explorations and laparoscopic appendectomies were used to perform appendectomies. Due to advanced illness levels, several patients from the laparoscopic method were switched to open exploration when needed.
Open appendectomy was performed through a Lanz or gridiron incision. Some patients needed lower midline laparotomy as per requirement. For laparoscopic appendectomy, three ports (umbilical (10 mm), suprapubic (5 mm), and left iliac fossa (10 mm)) were performed. The appendicular artery was dissected and divided between hemostatic energy devices. The appendix was secured at the base with three loop ligatures, divided between the two distal ligatures, and removed through the 10-mm umbilical port.
If there were technical difficulties or an advanced stage of infection, such as four quadrant pus, the laparoscopy was modified to an open appendicectomy or lower midline laparotomy. Histopathological evaluation of the resected appendix was performed.
In patients with uncomplicated appendicitis, intravenous fluids (IVFs) were maintained for six hours following surgery, and a regular diet was resumed after that. IVF was maintained in severe instances (patients with perforation and peritonitis) until the normal intestinal function was restored (return of bowel sounds and passage of flatus). For simple instances, antibiotic prophylaxis consisted of a single dose of a third-generation cephalosporin. Meronem was administered preoperatively with metronidazole at induction and again after 12 hours in difficult patients.
Analgesics were administered in the form of ketorolac injections for a period of 24 hours. Additional analgesics were prescribed depending on the patients' pain perception.
The operating time and the length of hospital stay were recorded, as in comparable series. The patients were encouraged to return to their regular activities and work as soon as they felt ready. Normal activity was defined as the patient's return to normal household and social activities of his or her choosing.
For one month, the patients were followed up on weekly basis, but none of the patients required readmission. The Statistical Package for the Social Sciences (SPSS) version 24 for Windows was used to statistically evaluate the data obtained.

Procedures performed
Five surgical approaches were opted for managing acute appendicitis, depending upon the operative findings, during the period.   Table 2). The correlation between the surgical procedure performed and operative time was positive (0.63). Statistical analysis of the effect of surgical operation on the operative time indicated that the operative time was significantly dependent on the type of surgical procedures performed (p ≤ 0.001).

Procedures performed Mean duration of operation (minutes)
Open appendectomy 70.60 Laparoscopic appendectomy 77.04 Laparoscopy converted to midline laparotomy and appendectomy 139.41 Open appendectomy converted to midline laparotomy 146.75 Lower midline laparotomy 139.09  Table 3). The correlation between the surgical procedure performed and the duration of hospital stay after the surgical procedure was positively strong (0.75) and statistically significant (p ≤ 0.001) ( Table 3). Statistical analysis of the effect of surgical operation on hospital stay indicated that the duration of hospital stays was significantly dependent on the type of surgical procedures performed (p ≤ 0.001).

Procedures performed Mean duration of hospital stay (days)
Open appendectomy 1.22 Laparoscopic appendectomy 1.09 Laparoscopy converted to midline laparotomy and appendectomy 4.65 Open appendectomy converted to midline laparotomy 4.60 Lower midline laparotomy 5.45

Operation Findings by Age Group
The young adults, aged 18-34 years, showed the highest number of all the operation findings, while the operation findings were most minimal in the older adults, 65 years and older. In all age groups, except the older adults (65 years and older), acute appendicitis is the most frequently observed surgical finding ( Table  5). The t-test indicated that there were statistically significant differences in the surgical operation findings between the age groups (p ≤ 0.001). The correlation between the age and operation findings was positive, but it was weak (0.084).

Operation Findings Versus Hospital Stay
The duration of hospital stay for patients with acute appendicitis was 1.13 days, with acute gangrenous appendicitis was 1.28 days, with appendicular mass was 1.11 days, with appendicitis with minimal pus formation was 1.15 days, with appendicitis with four quadrant pus was 4.71 days, with perforated appendix with localized pus formation was 1.52 days, and perforated appendix with four quadrant pus formation was 4.80 days ( Table 7). Statistical analysis indicated that the duration of hospital stays was significantly dependent on the type of operation findings (p ≤ 0.001). Histopathology of all the specimens turned out to be acute inflammation of the appendix.
Regarding the duration of performing the surgical procedures (operative time), open appendectomy and laparoscopic appendectomy were significantly faster to perform (p ≤ 0.001) than other surgical procedures. Statistical analyses showed that the operative time and hospital stay were significantly dependent on the type of surgical procedures (p ≤ 0.001). The mean duration of performing open appendectomies was shorter (70.6 minutes) than the mean duration for performing laparoscopic appendectomies (77 minutes) ( Table 2).
Research studies that compared the operative time between the surgical procedures reported the same findings that the duration of open appendectomies was shorter than that of laparoscopic appendectomy [13][14][15]. Shimoda et al. (2018) noted that the longer operative time in laparoscopic appendectomy was due to the associated complications and largely dependent on the surgeon's skill and experience [16]. Compared to findings from other research studies, the operative time for the two procedures was longer.
The results of this research study showed that open appendectomy resulted in longer hospital stays (1.22 days) than laparoscopic appendectomy (approximately 1 day) (  [15]. The shorter hospital stay compared to other research findings might be attributed to the better surgeons' skills and experiences in performing an open appendectomy and laparoscopic appendectomy in Lahore General Hospital, Lahore. Acute appendicitis was the most predominant operation findings, which is more than half (289, 57.1%) of the findings ( Table 4). Many research studies have similarly reported the high incidence and prevalence rates of acute appendicitis in patients with acute abdominal conditions [1,2]. The operation findings vary by age group. The numbers of all the operation findings were significant in young adults aged between 18 and 34 years than other age groups (p ≤ 0.001) ( Table 5). This can be attributed to dietary habits. Evidence from research studies has indicated the relationship between the risk of acute appendicitis and dietary habits [17][18][19]. However, there was no correlation between the operation findings and the age groups, indicating that the operation findings could not be attributed to aging but could be attributed to the age group factor. Appendicitis with four quadrant pus, perforated appendix with localized pus formation, and a perforated appendix with four quadrant pus formation was associated with significantly longer operative time than other operation findings ( Table 6). Appendicitis with four quadrant pus and a perforated appendix with four quadrant pus formation resulted in significantly longer hospital stays ( Table 7). The majority of the patients (243, 48%) had their appendix located in the pelvic region ( Table 8).

Limitations
This is a single-center study and personal experience of appendectomy performed by surgeons of Surgical Unit 1 of Lahore General Hospital.