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Laparoscopy for the management of acute lower abdominal pain in women of childbearing age

  1. Hernando G Gaitán1,*,
  2. Ludovic Reveiz2,
  3. Cindy Farquhar3,
  4. Vanessa M Elias4

Editorial Group: Cochrane Menstrual Disorders and Subfertility Group

Published Online: 22 MAY 2014

Assessed as up-to-date: 22 OCT 2013

DOI: 10.1002/14651858.CD007683.pub3


How to Cite

Gaitán HG, Reveiz L, Farquhar C, Elias VM. Laparoscopy for the management of acute lower abdominal pain in women of childbearing age. Cochrane Database of Systematic Reviews 2014, Issue 5. Art. No.: CD007683. DOI: 10.1002/14651858.CD007683.pub3.

Author Information

  1. 1

    National University of Colombia, Department of Obstetrics & Gynecology and Clinical Research Institute, Faculty of Medicine, Bogota, Colombia

  2. 2

    Free time independent Cochrane reviewer, Potomac, USA

  3. 3

    University of Auckland, Department of Obstetrics and Gynaecology, Auckland, New Zealand

  4. 4

    Ecole des Hautes Etudes en Santé Publique, Paris, France

*Hernando G Gaitán, Department of Obstetrics & Gynecology and Clinical Research Institute, Faculty of Medicine, National University of Colombia, Carrera 30 No. 45-03, Bogota, Colombia. hggaitand@unal.edu.co. hernando.gaitan@gmail.com.

Publication History

  1. Publication Status: Stable (no update expected for reasons given in 'What's new')
  2. Published Online: 22 MAY 2014

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Summary of findings    [Explanations]

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

 
Summary of findings for the main comparison. Laparoscopy compared with open appendicectomy

Laparoscopy compared with open appendicectomy for acute lower abdominal pain in women of childbearing age

Patient or population: women of childbearing age with acute lower abdominal pain

Settings: hospital

Intervention: laparoscopy

Comparison: open appendicectomy

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No. of participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

Open appendicectomyLaparoscopy

Diagnosis before dischargeRisk populationOR 4.10 (2.50 to 6.71)561 (7)⊕⊕⊕⊝
moderate
Most studies had methodological limitations1

719 per 1000913 per 1000

(865 to 945)

Any adverse eventsRisk populationOR 0.46 (0.19 to 1.10)563 (7)⊕⊕⊝⊝
low
Most studies had methodological limitations2

54 per 100026 per 1000

(11 to 59)

Total length of in-patient stay (days)Mean ranged across control groups from 2.30 to 4.9Mean ranged across intervention groups from 2.16 to 4.0Mean difference -0.07 (-0.63 to 0.49)455 (6)⊕⊕⊝⊝
low
Most studies had methodological limitations3

Normal appendix removed356 per 100067 per 1000 (37 to 117)OR 0.13 (0.07 to 0.24)475 (7)⊕⊕⊕⊝
moderate
Most studies had methodological limitations4

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; OR: Odds ratio.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1Diagnosis before discharge: Six of seven studies had unclear risk of selection and attrition bias and high risk of detection and performance bias.
2Any adverse events: Six of seven studies had unclear risk of selection and attrition bias and high risk of detection and performance bias. Imprecision was noted.
3Five studies had unclear risk of selection and attrition bias and high risk of detection and performance bias. Inconsistency and imprecision were noted.
4Six of seven studies had unclear risk of selection and attrition bias and high risk of detection and performance bias.

 Summary of findings 2 Laparoscopy compared with 'wait and see' strategy

 

Background

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Description of the condition

Acute lower abdominal pain is commonly seen among patients attending hospital emergency departments (CDC 2003). Acute lower abdominal pain frequently presents as non-specific abdominal pain (NSAP), defined as pain of less than seven days' duration for which no immediate cause can be found after initial testing has been performed, or pain located on the right iliac fossa. For NSAP, there is no clear indication for surgery (Poulin 2000; Sanders 2006). It has been reported that of all patients with acute abdominal pain, 35% to 43% have NSAP (Irvin 1989; Strömberg 2007). The prevalence is higher in premenopausal women (Decadt 1999). Reaching a diagnosis is particularly challenging in premenopausal women, as the physiological changes associated with ovulation and menstruation can overlap with the symptoms of more serious conditions such as torsion of the ovary, pelvic inflammatory disease, ectopic pregnancy and appendicitis (Whitworth 1988). Such conditions are less likely in postmenopausal women; therefore misdiagnosis is not as common for these women. The incidence of a misdiagnosis could be as high as 26% to 45% in premenopausal women (Beyan 2003; Borgstein 1997; Laine 1997; Sanders 2006; Tzovaras 2007).

The traditional approach to the treatment of suspected appendicitis has been open appendicectomy. With this approach, the incidence of removal of a normal appendix is between 10% and 30% (Althoubaity 2006; Bijnen 2003; Flum 2002). The removal of a normal appendix is associated with substantial complications and costs. Bijnen et al. found that among study participants who underwent a negative appendicectomy for suspected appendicitis, complications occurred in 6%, reoperation was performed in 2% and mean extra hospital costs were EUR 2712 (Bijnen 2003). Another study, performed in the United States, estimated that 261,134 study participants underwent non-incidental appendicectomy in 1997, of which 15.3% were negative for appendicitis. The trial authors reported that women had a higher rate of removal of a normal appendix. In addition, participants with a normal appendix removed had a significantly longer length of stay and a higher total charge for the admission, as well as higher rates of case fatality and infectious complications (Flum 2002). In the past, women with NSAP have been managed by taking a 'wait and see' approach or, alternatively, by performing open appendicectomy, especially when pain was located on the right iliac fossa. However, with the advent of laparoscopy has come the change to a less invasive diagnostic strategy in patients with acute abdominal pain.

 

Description of the intervention

This review considered three strategies for the management of acute lower abdominal pain: the wait and see approach, open appendicectomy and laparoscopy.

The so-called wait and see approach for establishing the cause of NSAP involves close clinical observation and repeated laboratory and diagnostic imaging tests and sometimes laparotomy.

Open appendicectomy involves a surgical incision performed under general anaesthesia, using a right iliac fossa approach, and removal of the appendix, regardless of the presence or absence of pathology.

Laparoscopy is the direct visual examination of the abdominal and pelvic cavities. A minimal incision (1 cm) is made in the abdominal wall to allow a special port with a laparoscope to pass through. The lens is fitted with a video camera and zoom, a light source and a high-flow insufflator (for introduction of carbon dioxide gas), which allows the performance of surgical procedures when necessary.    

 

How the intervention might work

Diagnostic laparoscopy could provide both a more accurate diagnosis and reduced risks of complications related to delayed diagnosis (Golash 2005; Ou 2000; Salky 1998). Other possible benefits include improved quality of life, less associated pain and reduced length of hospital stay (Golash 2005). Management of conditions that cause acute lower abdominal pain could be enhanced.  

It has been estimated that an open appendicectomy strategy can establish the cause of acute lower abdominal pain in 45% of patients (Borgstein 1997), and a wait and see strategy with imaging in 84% (Sala 2007). Laparoscopy is associated with accurate diagnosis in 50% to 95% of patients (Moberg 1998; Sellors 1991; Spirtos 1987). This wide variation could be explained by gender, the accepted period of observation and the location of the pain.

However, laparoscopy is a costly technique that is associated with risks of complications such as bladder and bowel injury and wound infection; the need for anaesthesia (Golash 2005; Navez 1995); and the possibility that a final diagnosis still may not be made (Moberg 1998). One study using laparoscopic examination reported that histopathological examination of the appendix revealed no acute inflammation of the appendix in 24.9% of operated cases (Koch 2002).  

The harms of taking the wait and see approach or using the open appendicectomy strategy include increased likelihood of complications such as peritonitis, haemorrhage or infertility associated with a late diagnosis, as well as increased length of in-patient hospital stay and increased costs. In some cases, a laparotomy (a major surgical procedure involving a large incision (> 10 cm) through the abdominal wall to gain access to the abdominal cavity) might be performed unnecessarily.

 

Why it is important to do this review

Computed tomographic scanning, ultrasonography and laparoscopy have been advocated to improve accuracy in the diagnosis of appendicitis. It has been suggested that laparoscopy compared with the conventional strategy could lower the rate of diagnostic error in the management of acute abdominal pain. No definitive evidence has shown the comparative benefits and risks of these different strategies. The benefit of using laparoscopy over open surgery in the management of acute appendicitis in pregnant women remains a subject of controversy despite the publication of a number of randomised controlled trials (RCTs).

The intent of this review is to provide a unique evaluation of diagnostic strategies with regard to the management of acute lower abdominal pain in premenopausal women. The scope of the review does not include an evaluation of the diagnostic accuracy of either method in terms of their comparative effectiveness.

The scope of this intervention review reflects the description by Roper 1988, whereby we seek to technically assess and evaluate the appropriate use of an intervention in a given situation. The review sets out to compare both diagnostic strategies in terms of effectiveness, safety, costs and patient preferences.

Another Cochrane review compared the diagnostic and therapeutic effects of laparoscopic and conventional open surgery in all patients with symptoms and signs of acute appendicitis (Sauerland 2010). The review authors concluded that laparoscopy can serve as a diagnostic and therapeutic tool in patients with suspected appendicitis. The diagnostic effects were analysed separately for young women, and a large reduction in unnecessary appendicectomies and improved diagnostic efficacy were reported (Sauerland 2010). Although some of those findings overlap with the findings of our review, we decided to present a detailed description of the diagnostic effectiveness of laparoscopy in women of childbearing age compared with a wait and see strategy. 

 

Objectives

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

To evaluate the effectiveness and harms of laparoscopy for the management of acute lower abdominal pain in women of childbearing age.

 

Methods

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Criteria for considering studies for this review

 

Types of studies

 
Inclusion criteria

All published and unpublished RCTs comparing diagnostic laparoscopy with open appendicectomy or a wait and see strategy.

No limitation on language or publication status was applied. Open randomised clinical trials were included. RCTs that included women as part of the sample were included. Quasi-RCTs were not included.

 

Types of participants

 
Inclusion criteria

RCTs that included premenopausal women who presented with acute lower abdominal pain, non-specific abdominal pain, right-sided pain or suspected appendicitis were included. Studies in which participants had a clear diagnosis of appendicitis were excluded.

Non-specific abdominal pain is defined as pain of less than seven days’ duration for which no immediate cause can be found after initial tests have been performed. Non-specific abdominal pain does not clearly require surgical intervention (Poulin 2000; Sanders 2006).

Changes were made to the published protocol to include women with suspected appendicitis, and studies where at least 75% of the participants were women of premenopausal age.

 

Types of interventions

Trials were included if they evaluated the management of premenopausal women with non-specific acute pain or suspected appendicitis using:

  • laparoscopy compared with open appendicectomy; or
  • laparoscopy compared with a wait and see strategy.

Laparoscopy is defined as a surgical procedure in which a laparoscope is used through the abdominal wall with the aim of visualising the pelvic and abdominal cavities to diagnose an underlying cause of pain. Typically, this procedure is performed within the first 72 hours of an in-patient stay.

Open appendicectomy is performed when a right iliac fossa incision is made and the appendix is excised after the muscular and peritoneal layers are opened.

A wait and see strategy is defined as close clinical observation combined with the use of laboratory tests or diagnostic imaging. It does not include laparoscopy, but it could include laparotomy.

Changes made to the published protocol included that the conventional strategy was replaced by 'wait and see' or by open appendicectomy.

 

Types of outcome measures

Outcomes measured were related to the effectiveness and safety of each strategy used in the management of non-specific acute abdominal pain or suspected appendicitis in premenopausal women.

 

Primary outcomes

  • Number of specific diagnoses before discharge: number of cases in which a specific diagnosis was reached before discharge, for each strategy studied. 
  • Adverse events (AEs): any events that, in the opinion of the investigator, may adversely affect the rights, welfare or safety of participants in the study as a result of the application of a management method. Complications could be reported in the short term or over the long term. Although removal of a normal appendix is an AE, it was reported separately in the results section, as each participant could be counted only once within each study.

 

Secondary outcomes

  • Total length of in-patient stay.
  • Mean operating time.
  • Return to normal activities.
  • Quality of life.
  • Mortality.
  • Cost-effectiveness, taking into account direct medical costs from the point of view of third-party payers or institutions.

 

Search methods for identification of studies

We followed the Menstrual Disorders and Subfertility Group methodology.

 

Electronic searches

All reports that described RCTs of laparoscopy and acute abdominal pain were sought using the following strategy.

The Menstrual Disorders and Subfertility Group (MDSG) Specialised Register was searched by the Group’s trials search co-ordinator using the following terms: "laparoscopic" or "laparoscopic excision" or "laparoscopic imaging" or "laparoscopic dye" or "laparoscopic imaging" or "laparoscopic procedure" or "laparoscopic surgery" or "laparoscopic techniques" or "laparoscopy" or Title CONTAINS "laparoscopic" or "laparoscopic excision" or "laparoscopic imaging" or "laparoscopic dye" or "laparoscopic imaging" or "laparoscopic procedure" or "laparoscopic surgery" or "laparoscopic techniques" or "laparoscopy" AND the terms  "acute" or "abdominal pain" or "pelvic pain" or "Pain-abdominal" or "pain-pelvic" or "ectopic pregnancy" or "pelvic inflammatory disease" or "Ovarian Cysts" or "ovarian cyst" or "acute" or Title CONTAINS "acute" or "abdominal pain" or "pelvic pain" or "Pain-abdominal" or "pain-pelvic" or "ectopic pregnancy" or "pelvic inflammatory disease" or "Ovarian Cysts" or "ovarian cyst" or "acute", in the titles, abstracts and keywords.

This register also contains unpublished trial abstracts, which were found by handsearching of 20 relevant journals and conference proceedings.

The search was updated from January 2010 to October 2013 in the Cochrane MDSG Specialised Register, MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL) and PsycoINFO using the Ovid platform.

A previous search was carried out in the following databases using the Ovid platform.

  • MEDLINE (1980 to April 2010) (Appendix 1).
  • EMBASE (1980 to April 2010) (Appendix 2).
  • CINAHL (1980 to April 2010) (Appendix 3).
  • CENTRAL (1998  to October 2013) (Appendix 4); PsycINFO (1980 to October 2013) (Appendix 5); and the Cochrane MDSG Specialised Register (Appendix 6).
  • LILACS (Appendix 7) and SciELO for studies reported in Portuguese and Spanish (February 2013).

Both indexed and free text terms were used. The RCT filter from the MDSG was used.

We also searched the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/en/) search portal (last search May 2013) using the following search strategy: (Laparoscopic OR laparoscopy) AND women AND (abdominal OR pelvic OR appendicitis OR abdomen) AND pain.

 

Searching other resources

  • Citation lists from reviewed articles and other relevant publications were searched. 
  • No restrictions, such as language, were applied. 
  • Other strategies for locating studies included personal communication with manufacturers, experts and specialists working in the field and screening of conference proceedings. 

 

Data collection and analysis

Data were analysed using Review Manager software (RevMan 5).  

 

Selection of studies

Two review authors (from Gaitán H, Reveiz L, Elias VM) independently screened the titles and abstracts of trials identified by the search for inclusion based on the selection criteria outlined above. One review author is a content and methodology expert, and the other is a methodology expert. 

The full text of an article was retrieved if there was any doubt as to whether the article should be excluded. Gaitán H obtained copies of the studies selected for inclusion and sent them to Reveiz L. Both review authors then independently assessed whether the studies met the inclusion criteria. If disagreement between the two review authors arose, a third review author (Farquhar C) reviewed the information to decide on inclusion or exclusion of a trial.

Further information was sought from the study authors when papers contained insufficient information to allow a decision regarding eligibility for inclusion in the review.

 

Data extraction and management

Data from studies that met the inclusion criteria were independently extracted by two review authors (Gaitán H, Reveiz L) using a data extraction form. Discrepancies were resolved by discussion.

Data that were extracted included the following.

  • Inclusion and exclusion criteria, clearly defined.
  • Baseline information on participants for comparable intervention and control groups at entry (eligibility criteria, age of women, duration of pain, temperature, white blood cell count, abdominal surgery history).
  • Location of the study.
  • Trial design.
  • Power calculation performed.
  • Method used to generate random allocation.
  • Methods used to maintain allocation concealment.
  • Types of interventions provided: type of diagnostic laparoscopic method (video laparoscopy) and type of conventional diagnostic strategy, such as use of laboratory tests, and accepted time of observation.
  • Other interventions in the groups under evaluation.
  • Numbers of women enrolled, randomly assigned, excluded after randomisation and analysed.
  • Outcomes stated in methods versus outcomes reported in results.
  • Use of any method of blinding of researchers to the intervention for evaluation of outcomes.
  • How outcomes such as time of hospitalisation before diagnosis, definitive diagnosis, adverse events, recurrent episodes of pain, length of in-patient stay and cost-effectiveness were defined.
  • Differences between groups for outcome assessment in terms of methods used to obtain the definitive diagnosis.
  • Time of follow-up of participants to measure outcomes: evolution in terms of recurrent or chronic abdominal pain.   
  • How adverse event reports were validated.
  • Numbers of participants lost to follow-up in the two groups.
  • Use of intention-to-treat analysis.
  • Funding sources reported.
  • Ethical issues: use of signed informed consent; ethics approval.

 This information was collated and presented in the tables Characteristics of included studies and Characteristics of excluded studies

 

Assessment of risk of bias in included studies

Two review authors (Reveiz L, Gaitán H) independently assessed the risk of bias of each trial using a simple form and followed the domain-based evaluation as described in the Cochrane Handbook for Systematic Reviews of Interventions 5.1.0 (Higgins 2011). Review authors discussed discrepancies and achieved consensus on the final assessment.

We assessed the following domains as low, unclear or high risk of bias.

  • Generation of allocation sequence.
  • Allocation concealment.
  • Blinding (of participants, personnel and outcome assessors).
  • Incomplete outcome data.
  • Selective reporting.
  • Other sources.

Generation of allocation sequence (checking for possible selection bias)

We described for each included study the method used to generate the allocation sequence in sufficient detail to allow an assessment of whether it should produce comparable groups.

We assessed the method as:

  • low risk (any truly random process, e.g. random number table; computer random number generator); or
  • unclear risk (the trial was described as randomised, but the method used for allocation sequence generation was not described).   

Allocation concealment (checking for possible selection bias)

We described for each included study the methods used to conceal the allocation sequence in sufficient detail and to determine whether the intervention allocation could have been foreseen in advance of, or during, recruitment, or changed after assignment.

We assessed the methods as:

  • low risk (e.g. telephone or central randomisation; consecutively numbered sealed opaque envelopes);
  • high risk (open random allocation; unsealed or non-opaque envelopes, alternation; date of birth); or
  • unclear risk (trial was described as randomised, but the method used to conceal the allocation not described).

Blinding or masking (checking for possible performance and detection bias)

We described for each included study the methods used, if any, to blind study participants and personnel from knowledge of which intervention a participant received. We judged studies at low risk of bias if they were blinded, or if we judged that lack of blinding could not have affected the results. We assessed blinding separately for different outcomes or classes of outcomes.

We assessed blinding methods as:

  • low risk, high risk or unclear risk for participants;
  • low risk, high risk or unclear risk for personnel; or
  • low risk, high risk or unclear risk for outcome assessors.

Incomplete outcome data (checking for possible attrition bias through withdrawals, dropouts, protocol deviations)

We assessed methods on outcome data as:

  • low risk (any one of the following): no missing outcome data; reasons for missing outcome data unlikely to be related to true outcome (for survival data, censoring unlikely to be introducing bias); missing outcome data balanced in numbers across intervention groups, with similar reasons for missing data across groups; for dichotomous outcome data, the proportions of missing outcomes compared with observed event risk not enough to have a clinically relevant impact on the intervention effect estimate; for continuous outcome data, plausible effect size (difference in means or standardised difference in means) among missing outcomes not enough to have a clinically relevant impact on observed effect size; missing data imputed using appropriate methods;

  • high risk (any one of the following): reason for missing outcome data likely to be related to true outcome, with either imbalance in numbers or reasons for missing data across intervention groups; for dichotomous outcome data, the proportion of missing outcomes compared with observed event risk enough to induce clinically relevant bias in intervention effect estimate; for continuous outcome data, plausible effect size (difference in means or standardised difference in means) among missing outcomes enough to induce clinically relevant bias in observed effect size; ‘as-treated’ analysis done with substantial departure of the intervention received from that assigned at randomisation; potentially inappropriate application of simple imputation; or

  • unclear risk (any one of the following): insufficient reporting of attrition/exclusions to permit judgement of ‘low risk’ or ‘high risk’ (e.g. number randomly assigned not stated, no reasons provided for missing data); the study did not address this outcome.

Selective reporting bias (reporting bias due to selective outcome reporting)

We described for each included study how we investigated the possibility of selective outcome reporting bias and what we found.

We assessed reporting methods as:

  • low risk (any one of the following): The study protocol is available and all of the study’s prespecified (primary and secondary) outcomes of interest in the review have been reported in the prespecified way, or the study protocol is not available, but it is clear that published reports include all expected outcomes, including those that were prespecified (convincing text of this nature may be uncommon);

  • high risk (any one of the following): Not all of the study’s prespecified primary outcomes have been reported; one or more primary outcomes are reported using measurements, analysis methods or subsets of the data (e.g. subscales) that were not prespecified; one or more reported primary outcomes were not prespecified (unless clear justification for their reporting is provided, such as an unexpected adverse effect); one or more outcomes of interest in the review are reported incompletely so that they cannot be entered into a meta-analysis; the study report fails to include results for a key outcome that would be expected to have been reported for such a study; or

  • unclear risk: Information is insufficient to permit judgement of ‘low risk’ or ‘high risk’.

Free of other bias (bias due to problems not covered elsewhere in the table)

We described for each included study any important concerns that we have about other possible sources of bias (baseline imbalance, sponsorship bias, differential verification bias, partial verification bias and incorporation bias, bias of the presentation data, etc.).

  • Low risk of bias: The trial appears to be free of other components that could put it at risk of bias.
  • Unclear risk of bias: The trial may or may not be free of other components that could put it at risk of bias.
  • High risk of bias: Other factors in the trial could put it at risk of bias (e.g. no sample size calculation made, academic fraud, industry involvement, extreme baseline imbalance).

 

Measures of treatment effect

Dichotomous data were expressed as odds ratios (ORs) with 95% confidence intervals (CIs) and, when possible, were combined in a meta-analysis using RevMan 5 software. The OR has mathematically sound properties that are consistent with benefits or harms and work well in small samples with rare events.

For continuous outcome data, such as time of hospitalisation before diagnosis and total length of in-patient stay, results for each study were expressed as differences in means with 95% CIs and were combined for meta-analysis, when appropriate, using the mean difference (MD). If the standard deviation was not available, this was imputed using the technique described in the Cochrane Handbook for Systematic Reviews of Interventions (Section 7.7.3.3).

Primary analysis used the fixed-effect model, and sensitivity analysis (if required) used the random-effects model. We used the random-effects model if the I2 statistic was greater than 50% (Higgins 2011).

Cost-effectiveness and quality of life analyses were summarised in narrative form.

If no data were available for some outcomes, these were described within the review. This potentially indicated the need for further clinical trials in this area.

 

Unit of analysis issues

When different scales were used to report the same outcomes, and we were not able to convert them, we planned to use standardised mean difference (SMD). This was not necessary, as no outcome data were extracted that required this.

 

Dealing with missing data

The review authors contacted the lead authors of the trials for which data clarification was required. This contact was made by email.

 

Assessment of heterogeneity

Statistical analysis was performed in accordance with the guidelines developed by The Cochrane Collaboration (Higgins 2011). Assessment of heterogeneity was possible when two or more primary studies were identified for inclusion in a meta-analysis. Heterogeneity (variation) between results of different studies was evaluated by:

  • performing empirical evaluation through visual inspection of the overlap of CIs on the forest plot; poor overlap indicates heterogeneity;
  • using the Chi2 statistical test for heterogeneity (Higgins 2011);
  • using an I2 statistic, which evaluates variation between studies (Higgins 2011); if a value greater than 50% was found, substantial heterogeneity was assumed; or  
  • using a random-effects model or a fixed-effect model.

 

Assessment of reporting biases

Publication bias was to be assessed using a funnel plot if 10 or more studies were identified for either of the two comparisons. A gap on either side of the graph would have indicated that some trials had not been found, often as the result of difficulties in locating unpublished trials. No within-study reporting bias was assessed.

 

Data synthesis

The presence or absence of heterogeneity was considered before data from trials were pooled. When it was not appropriate to combine the data, primary studies were summarised in narrative form. Women with suspected appendicitis and women with NSAP were analysed separately.

 

Subgroup analysis and investigation of heterogeneity

Subgroup analysis was planned, if appropriate and possible, with consideration of the following.

  • Age: Data were not presented that allowed this.

If substantive heterogeneity was seen, the review authors first confirmed the data, then considered:

  • whether meta-analysis was warranted; and
  • whether a subgroup analysis should be completed.

The prespecified potential sources of heterogeneity were considered to explore possible explanations for variations in effects between trials and to guide interpretation of study findings, that is, location, method used to validate time to definitive diagnosis outcomes, location of pain and time of observation before intervention. We were aware of the limited value that interpretation of the causes of heterogeneity has after heterogeneity has been identified.

Protocol change: One of the planned subgroup analyses was changed to become one of the two comparisons.

 

Sensitivity analysis

A sensitivity analysis was planned to explore whether the results of any meta-analysis were sensitive to the inclusion or exclusion of RCTs with the following characteristics.

  • Unpublished studies, as these studies may not have been peer-reviewed and thus could be of lower quality (all studies were published manuscripts, and therefore this was not undertaken).
  • Studies with high risk of bias versus studies with low risk of bias.
  • Studies with no allocation concealment versus those with allocation concealment (this was not done, as most studies did not report on allocation concealment).
  • Studies in which men were included or women of postmenopausal age were included.
  • Studies that included participants who did not strictly meet the inclusion criteria (e.g. right-sided pain) (added as a protocol change).

 

Results

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Description of studies

 

Results of the search

This is an updated version of the original review, published in Issue 1, 2011, of The Cochrane Library (Gaitan 2011). A total of 2413 titles were reviewed (1010 new titles for this update). Of these, 74 were initially screened as RCTs (11 new titles for this update). Sixty-four studies were excluded for various reasons. Finally, we identified 12 studies that met the inclusion criteria. See Figure 1 for details of the screening and selection process.

 FigureFigure 1. Study flow diagram.

 

Included studies

At the time of last publication in 2011, 12 studies met the inclusion criteria and were included in the review. No new studies were identified for inclusion in this updated review.

The main characteristics of the included studies are detailed in the table Characteristics of included studies. All studies were published manuscripts. A total of 12 trials from 11 countries were identified: Denmark (Olsen 1993), Kuwait (Jadallah 1994), Finland (Laine 1997), France (Champault 1993), United Kingdom (Decadt 1999), Sweden (Larsson 2001), Colombia (Gaitan 2002), Italy (Morino 2006; Navarra 2002), Saudi Arabia (Al-Mulhim 2002), New Zealand (van Dalen 2003) and South Africa (Bruwer 2003).

Design: All included studies were randomised controlled trials

Settings: Ten studies were done in the Department of Surgery of a single hospital (Bruwer 2003; Champault 1993; Decadt 1999; Jadallah 1994; Laine 1997; Larsson 2001; Morino 2006; Navarra 2002; Olsen 1993; van Dalen 2003), one in the Department of Gynecology of a single hospital (Gaitan 2002) and one in a single hospital (Al-Mulhim 2002).

Participants: We included 1020 participants, of whom only 29 (2.8%) were men. The male participants were from just one study (Decadt 1999). Six studies included women with suspected diagnosis of appendicitis (Al-Mulhim 2002; Jadallah 1994; Larsson 2001; Navarra 2002; Olsen 1993; van Dalen 2003). One study (Laine 1997) included only participants with right-sided pain, and five studies included women having non-specific lower abdominal pain (Bruwer 2003; Champault 1993; Decadt 1999; Gaitan 2002; Morino 2006).

Interventions: Of the 12 included RCTs, eight compared laparoscopy with open appendicectomy (Al-Mulhim 2002; Bruwer 2003; Jadallah 1994; Laine 1997; Larsson 2001; Navarra 2002; Olsen 1993; van Dalen 2003), and four compared laparoscopy versus a wait and see approach (Champault 1993; Decadt 1999; Gaitan 2002; Morino 2006).

Outcomes: Although most studies reported at least one prespecified primary outcome of this review, differences in the reporting and definition of outcomes were noted. Specific diagnosis and adverse events were not reported in four RCTs (Al-Mulhim 2002; Bruwer 2003; Decadt 1999; Jadallah 1994). Total length of in-patient stay was not reported in six RCTs (Al-Mulhim 2002; Bruwer 2003; Decadt 1999; Gaitan 2002; Jadallah 1994; Larsson 2001). 

Length of follow-up: Participants were followed up until discharge from the institutions. Readmission was reported in one RCT (Bruwer 2003). Return to work (Bruwer 2003) and return to normal activities (Bruwer 2003; Laine 1997) were assessed in a few RCTs.

Ten trials were published in English, one in French (Champault 1993) and another in Italian (Navarra 2002).

Funding sources: One study described the source of funds (Gaitan 2002).

 

Excluded studies

A total of 63 studies were excluded (Excluded studies) for the following reasons: 32 included less than 75% women, and the authors did not provide additional data solely for women (including after written requests were made); five studies included only men, five included only children, 12 did not provide data about gender, five were excluded as they were considered to be non-randomised or non-controlled clinical trials and four studies were not included because only participants with a clear diagnosis of appendicitis were included (Excluded studies). The search of the ICTRP retrieved 1332 records, two of which were evaluated (ISRCTN42332281). One of them (NCT00908804) was completed and published but was finally excluded (Kouhia 2010) because only participants with confirmed appendicitis were inlcuded. None of the identified trials were eligible for the review.

 

Risk of bias in included studies

Overall the studies had a moderate risk of bias, mainly because allocation concealment or methods of sequence generation were not adequately reported. In addition, it was not clear whether follow-up was similar for the treatment groups. The index test was incorporated as a reference standard in the laparoscopy group, and the differential verification or partial verification bias may have occurred in most RCTs (Figure 2; Figure 3).

 FigureFigure 2. Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
 FigureFigure 3. Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

See the Characteristics of included studies for more information.

 

Allocation

Method of sequence generation: Four RCTs adequately reported the methods of generation of randomisation, attained by using a computer-generated randomisation list (Bruwer 2003; Gaitan 2002; Morino 2006) or a random table with random numbers (Champault 1993). The other RCTs did not report how randomisation was performed.

Allocation concealment: Two RCTs adequately reported how allocation concealment was maintained (Bruwer 2003; Gaitan 2002). In both RCTs, allocation concealment was ensured using sealed, opaque, sequentially numbered envelopes. The other RCTs did not report how allocation concealment was performed and were rated as having unclear risk of bias .

 

Blinding

Blinding: All studies were open RCTs, and no blinding of participants, clinicians or researchers was reported.

 

Incomplete outcome data

Incomplete outcome data: All of the included studies were judged as having unclear risk, mainly because It was not clear whether follow-up was similar in the two groups. Losses to follow-up were reported in only three RCTS (less than 5%) (Champault 1993; Larsson 2001; van Dalen 2003). We had to impute standard deviations for the total length of in-patient stay (Navarra 2002; Olsen 1993; van Dalen 2003) and mean operating time in three RCTs (Al-Mulhim 2002; Navarra 2002; van Dalen 2003). Adverse outcomes and complications frequently were not defined and were not reported in different ways.

 

Selective reporting

In addition, only two RCTs were considered to be free of selective reporting bias (Champault 1993; Jadallah 1994).

When differential verification of bias and partial verification bias were reported, most studies were judged as having unclear risk of bias; only one study (Gaitan 2002) had low risk of bias. Most studies had high risk of bias when rating Incorporation bias; however, three studies (Al-Mulhim 2002; Bruwer 2003; Navarra 2002) were judged as having unclear risk of bias.

 

Other potential sources of bias

In one study (Gaitan 2002), a definitive diagnosis was made by using the same reference standard for the comparison groups; all participants underwent the reference standard method.

 

Differential verification bias

When differential verification bias was assessed, most studies were judged as having unclear risk of bias; only one study (Gaitan 2002) had low risk of bias.

 

Partial verification bias

When partial verification bias was assessed, most studies were judged as having unclear risk of bias; only one study (Gaitan 2002) had low risk of bias.

 

Incorporation bias

When incorporation bias was assessed, almost all studies were judged as having unclear risk of bias; only one study (Gaitan 2002) had low risk of bias.

 

Effects of interventions

See:  Summary of findings for the main comparison Laparoscopy compared with open appendicectomy;  Summary of findings 2 Laparoscopy compared with 'wait and see' strategy

 
Comparison 1: laparoscopy compared with open appendicectomy

Specfic diagnosis before discharge: Meta-analysis of seven studies (Bruwer 2003; Jadallah 1994; Laine 1997; Larsson 2001; Navarra 2002; Olsen 1993; van Dalen 2003) found that laparoscopy was associated with a higher rate of diagnosis before discharge (seven RCTs, 561 participants; OR 4.10, 95% CI 2.50 to 6.71; I2 = 18%) (Figure 4).

 FigureFigure 4. Forest plot of comparison: 1 Laparoscopy versus open appendicectomy, outcome: 1.1 Final diagnosis.

Any adverse events: No evidence was found of a difference in the rate of any adverse event favouring laparoscopy (eight RCTs, 623 participants; OR 0.46, 95% CI 0.19 to 1.10; I2 = 0%) (Figure 5).

 FigureFigure 5. Forest plot of comparison: 1 Laparoscopy versus open appendicectomy, outcome: 1.2 Adverse events.

Total length of in-patient stay (days): No evidence was found of a significant mean difference in total length of in-patient stay (six RCTs, 455 participants; MD -0.07, 95% CI -0.63 to 0.49; I2 88%) (Figure 6) between groups; however, heterogeneity was high, and this result should be interpreted with caution. As standard deviations of total length of in-patient stay were available in only three studies (Bruwer 2003; Jadallah 1994; Laine 1997), we imputed data for the three other studies (Navarra 2002; Olsen 1993; van Dalen 2003). The study by Laine et al (Laine 1997) was the only RCT in which the total length of in-patient stay favoured open surgery.

 FigureFigure 6. Forest plot of comparison: 1 Laparoscopy versus open appendicectomy, outcome: 1.3 Total length of in-patient stay.

Mean operating time (minutes): Mean operating time was significantly lower in the open appendicectomy group (five RCTs, 355 participants; MD 14.55, 95% CI 3.62 to 25.48; I2 = 85%) (Figure 7); however, heterogeneity was high and this result should be interpreted with caution. Data were available in two studies (Bruwer 2003; Laine 1997), and we imputed data into three of the studies (Al-Mulhim 2002; Navarra 2002; van Dalen 2003).

 FigureFigure 7. Forest plot of comparison: 1 Laparoscopy versus open appendicectomy, outcome: 1.4 Mean operating time.

Return to normal activities: Mean number of days to return to normal activities was significantly lower in the laparoscopic group (three RCTs, 144 participants; MD -5.09, 95% CI -5.56 to -4.61; I2 = 0%) ( Analysis 1.5) (Al-Mulhim 2002; Bruwer 2003; Laine 1997).

Rate of normal appendix removed: Meta-analysis of seven studies revealed a significant difference favouring the laparoscopic procedure in the rate of normal appendix removed (seven RCTs, 475 participants; OR 0.13, 95% CI 0.07 to 0.24; I2 = 0%) (Figure 8;  Analysis 1.6) (Al-Mulhim 2002; Bruwer 2003; Jadallah 1994; Laine 1997; Larsson 2001; Olsen 1993; van Dalen 2003).

 FigureFigure 8. Forest plot of comparison: 1 Laparoscopy versus open appendicectomy, outcome: 1.7 Normal appendix removed.

Mortality: Only one RCT (Bruwer 2003) explicitly reported no deaths in either group ( Analysis 1.7).

 
Sensitivity analysis

Navarra 2002 included women older than childbearing age. A sensitivity analysis removing this study did not affect the significance of results for the above analyses.

Laine 1997 included women with right-sided pain only and therefore did not strictly meet the inclusion criteria for non-specific pain. A sensitivity analysis removing this study did not affect the significance of results for the above analyses, with the exception of adverse events, which were then found to be reduced by laparoscopic surgery (OR 0.36, 95% CI 0.13 to 0.95).

See also  Summary of findings for the main comparison.

 
Comparison 2: laparoscopy compared with 'wait and see' strategy

Specific diagnosis before discharge: Meta-analysis of four RCTs (Champault 1993; Decadt 1999; Gaitan 2002; Morino 2006) found a significant difference favouring laparoscopic diagnosis in the rate of diagnosis before discharge (four RCTs, 395 participants; OR 6.07, 95% CI 1.85 to 19.88; I2 = 79%) (Figure 9); however, heterogeneity was high, and findings should be interpreted with caution.

 FigureFigure 9. Forest plot of comparison: 2 Laparoscopy versus 'wait and see' approach, outcome: 2.1 Final diagnosis.

Any adverse events: No significant differences were found in the rates of adverse events (four RCTs, 399 participants; risk ratio (RR) 0.87, 95% CI 0.52 to 1.45; I2 = 0%) (Figure 10).

 FigureFigure 10. Forest plot of comparison: 2 Laparoscopy versus 'wait and see' approach, outcome: 2.2 Adverse events.

Total length of in-patient stay (days): A significant difference favouring the laparoscopic group was found in the mean difference of the total length of in-patient stay (two RCTs, 169 participants; MD -0.38, 95% CI -0.69 to -0.08; I2 = 49%) ( Analysis 2.3) (Champault 1993; Morino 2006).

Mean operating time: No significant difference was reported in the mean operating time ( Analysis 2.4) in one RCT (Morino 2006).

Rate of normal appendix removed: A significant difference in the rate of normal appendix removed favouring the 'wait and see' strategy group was found in one study only (Morino 2006) (OR 5.14, 95% CI 2.22 to 11.87) ( Analysis 2.5).

Mortality: No significant difference between groups ( Analysis 2.6) was reported in three RCTs (OR 1.03, 95% CI 0.06 to 16.93) (Decadt 1999; Gaitan 2002; Morino 2006).

Cost-effectiveness: Only one study (Gaitan 2002) provided data about the cost-effectiveness incremental ratio. Diagnostic laparoscopy was more cost-effective in four of the five possible scenarios.

Quality of life: One study (Decadt 1999) evaluated a well-being score at admission and six weeks later. This study showed greater improvement in the well-being score in the laparoscopy group.

 
Sensitivity analysis:

In the study by Decadt 1999, 24% of the sample were men. A sensitivity analysis removing this study did not affect the significance of the results for the above analyses.

Assessments of the quality of the body of evidence: See also  Summary of findings 2.

 

Discussion

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Summary of main results

Laparoscopy is superior to both open appendicectomy (OA) and a wait and see strategy in the management of women of childbearing age with acute lower abdominal pain, as an increased rate of specific diagnosis before discharge is accompanied by shorter hospital stays. No significant differences were found in the rates of adverse events favouring laparoscopic appendicectomy (LA) when compared with open appendicectomy or the wait and see strategy. The rate of removal of normal appendices was reduced with laparoscopy compared with open appendicectomy, but the rate was increased when laparoscopy was compared with a wait and see strategy.

 

Overall completeness and applicability of evidence

Although reasonable numbers of RCTs and participants were included in the two comparisons included in this review, the data are incomplete for a number of clinically important outcomes. For example, data on return to normal activities are available for only two trials in the comparison of laparoscopy versus open appendicectomy; in the comparison of laparoscopy versus a wait and see approach, no data at all are available on this outcome.

The applicability of evidence outside the research setting is reasonable, as all of these studies were conducted in clinical settings that are quite similar. The comparisons described in the review are commonly undertaken and are not difficult to apply. Less than 3% of participants were men. The 12 trials came from Colombia, Italy, Finland, Sweden, Denmark, France, UK, Saudi Arabia, Kuwait, United Kingdom, New Zealand and South Africa.

However, reporting bias is a matter of some concern. See the section below on potential biases.

 

Quality of the evidence

Overall the studies were of moderate quality (see  Summary of findings for the main comparison;  Summary of findings 2), mainly because allocation concealment or methods of sequence generation were not adequately reported and no blinding was reported. In addition, it was not clear whether follow-up was similar in the two treatment groups. The index test was incorporated as the reference standard in the laparoscopy group, and differential verification bias or partial verification bias may have occurred in most RCTs. Losses to follow-up were less than 5%. Studies that compare OA versus LA are reported to have problems, including the variable expertise of operating surgeons, unclear definitions of complications, reluctance to remove macroscopically normal appendices, difficulty with blinding for postoperative outcomes and, finally, statistical problems with the sample size related to the exploratory nature of the studies (Kapischke 2006).

Most studies had poor reporting of baseline conditions of participants and other measurement bias in both groups of included studies. This limited assessment of the risk of bias. Another limitation for continuous outcomes was the need to provide standard deviations in a number of RCTs.

 

Potential biases in the review process

Reporting bias is a possibility in this review, as 33 studies of OA versus LA were not included because less than 75% of included participants were women and the trial authors were unable to provide data for women only. This means that the data presented in this review represent only a subset of the women included in clinical trials. It is unfortunate that we were not able to collect data on more women from the studies identified, but as most of these studies were older than 15 years, this was not possible in spite of our efforts. However, in a Cochrane review of laparoscopy versus open surgery for suspected appendicitis, four studies of unselected adults reported that laparoscopy was associated with a similar reduction in the rate of 'no diagnosis' (Sauerland 2010). This Cochrane review also reported a similar reduction in the number of normal appendices removed (Sauerland 2010).

 

Agreements and disagreements with other studies or reviews

A systematic review of early laparoscopy (within 24 hours of admission) versus conventional approaches for patients with acute abdominal pain (Maggio 2008) reported findings similar to those of our review, with a reduced rate of negative diagnoses before discharge (OR 0.13, 95% CI 0.03 to 0.51). In both this systematic review and our own, significant heterogeneity for this outcome was evident. Our review did not report evidence of a difference in complications between groups (OR 0.31, 95% CI 0.02 to 4.15).

Maggio 2008 included men and women, and one study included all causes of abdominal pain (Schietroma 2007). Another failed to include one RCT (Gaitan 2002). All of the included studies had high risk of selection and measurement bias—a fact that might overvalue the effect.

Open appendicectomy versus laparoscopic appendicectomy has been summarised in a Cochrane review (Sauerland 2010) and in another systematic review (Bennett 2007). Sauerland 2010 evaluated diagnostic performance in a subgroup of fertile women and reported that diagnostic laparoscopy reduced the number of unnecessary appendicectomies (RR 0.20, 95% CI 0.11 to 0.34) and the number of participants without a final diagnosis (RR 0.27, 95% CI 0.17 to 0.44). However, the systematic review by Bennett 2007 included 17 studies and did not find evidence of a statistical difference in the final diagnosis between LA and OA (OR 0.82, 95% CI 0.58 to 1.15), although the review concludes that hospital stay was shorter and risk of adverse events was reduced.

Finally, the systematic review by Li 2010 (Li 2010) did not evaluate the diagnostic performance of the two strategies and did not report a subgroup analysis of women (Li 2010).

 

Authors' conclusions

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

 

Implications for practice

Laparoscopy should be the first strategy used in the management of women with acute lower abdominal pain as a specific diagnosis before discharge can be made with less time in hospital and earlier return to work.

 
Implications for research

More high-quality research is needed to determine the effectiveness of laparoscopy in specific cases (e.g. women with high body mass indices; when resources are scarce and access to the theatre is limited). Adverse events should also be investigated; several studies did not report AEs, and wide confidence intervals were presented in those that reported them (often regarded as a form of reporting bias).

 

Acknowledgements

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Cochrane Menstrual Disorders and Subfertility Group (MDSG) and Professor John Windsor, Department of Surgery, University of Auckland.

 

Data and analyses

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
Download statistical data

 
Comparison 1. Laparoscopy versus open appendicectomy

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Diagnosis before discharge7561Odds Ratio (M-H, Fixed, 95% CI)4.10 [2.50, 6.71]

 2 Any adverse events7563Odds Ratio (M-H, Fixed, 95% CI)0.46 [0.19, 1.10]

 3 Total length of in-patient stay6455Std. Mean Difference (IV, Random, 95% CI)-0.07 [-0.63, 0.49]

 4 Mean operating time4295Mean Difference (IV, Random, 95% CI)14.37 [1.89, 26.85]

 5 Return to normal activities (days)284Mean Difference (IV, Fixed, 95% CI)-5.08 [-5.56, -4.61]

 6 Normal appendix removed6415Odds Ratio (M-H, Fixed, 95% CI)0.13 [0.07, 0.24]

 7 Mortality1148Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 2. Laparoscopy versus 'wait and see' approach

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Diagnosis before discharge4395Odds Ratio (M-H, Random, 95% CI)6.07 [1.85, 19.88]

 2 Any adverse events4399Odds Ratio (M-H, Random, 95% CI)0.87 [0.45, 1.67]

 3 Total length of in-patient stay2169Std. Mean Difference (IV, Fixed, 95% CI)-0.38 [-0.69, -0.08]

 4 Mean operating time173Mean Difference (IV, Fixed, 95% CI)1.20 [-6.99, 9.39]

 5 Normal appendix removed1104Odds Ratio (M-H, Fixed, 95% CI)5.14 [2.22, 11.87]

 6 Mortality3334Odds Ratio (M-H, Fixed, 95% CI)1.03 [0.06, 16.93]

 

Appendices

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Appendix 1. MEDLINE search

1 exp Abdomen, Acute/ (7951)
2 (acute abdominal adj5 pain).tw. (2285)
3 (pain adj5 abdomen).tw. (1099)
4 (pelvic adj5 pain).tw. (5988)
5 exp Pelvic Pain/ (5837)
6 (abdomin$ adj5 pain).tw. (35301)
7 exp Abdominal Pain/ (23423)
8 exp Appendicitis/ (14349)
9 exp pelvic infection/ or exp pelvic inflammatory disease/ (9210)
10 pelvic inflammat$ disease.tw. (3409)
11 PID.tw. (2604)
12 exp pregnancy, ectopic/ or exp pregnancy, abdominal/ or exp pregnancy, tubal/ (12306)
13 append$.tw. (40271)
14 exp Ovarian Cysts/ (14351)
15 (Ovar$ adj5 Cyst$).tw. (8132)
16 or/1-15 (138947)
17 exp Laparoscopy/ (60772)
18 Laparoscop$.tw. (71334)
19 17 or 18 (80751)
20 exp diagnosis/ or exp "diagnostic techniques and procedures"/ or exp early diagnosis/ (5999808)
21 diagnos$.tw. (1467040)
22 (conventional or standard).tw. (738922)
23 (wait adj5 see).tw. (902)
24 (conservat$ or expectant).tw. (127271)
25 (clinical or observ$).tw. (3908721)
26 manage$.tw. (695438)
27 ultraso$.tw. (220084)
28 tomograph$.tw. (215687)
29 or/20-28 (9458331)
30 16 and 19 and 29 (10318)
31 randomized controlled trial.pt. (333009)
32 controlled clinical trial.pt. (84725)
33 randomized.ab. (248446)
34 placebo.ab. (138145)
35 cross-over studies/ (30040)
36 (crossover or cross-over or cross over).tw. (54199)
37 clinical trials as topic.sh. (161434)
38 randomly.ab. (182056)
39 trial.ti. (106887)
40 or/31-39 (816444)
41 humans.sh. (12444612)
42 40 and 41 (703668)
43 30 and 42 (790)
44 (2008$ or 2009$ or 2010$ or 2011$ or 2012$).ed. (4108570)
45 43 and 44 (224)

This search was updated in February and October 2013

 

Appendix 2. EMBASE search strategy

1 exp Abdomen, Acute/ (9462)
2 (acute abdominal adj5 pain).tw. (2858)
3 (pain adj5 abdomen).tw. (1521)
4 (pelvic adj5 pain).tw. (7983)
5 (abdomin$ adj5 pain).tw. (47290)
6 exp Abdominal Pain/ (72492)
7 exp Pelvis Pain Syndrome/ (8405)
8 or/1-7 (109636)
9 Laparoscopy/ (44967)
10 Laparoscop$.tw. (93316)
11 (earl$ adj5 laparoscop$).tw. (2074)
12 or/9-11 (104285)
13 8 and 12 (7697)
14 Controlled study/ or randomized controlled trial/ (3884819)
15 double blind procedure/ (109817)
16 single blind procedure/ (16128)
17 crossover procedure/ (34455)
18 drug comparison/ (81284)
19 placebo/ (201698)
20 random$.ti,ab,hw,tn,mf. (853728)
21 latin square.ti,ab,hw,tn,mf. (3282)
22 crossover.ti,ab,hw,tn,mf. (57206)
23 cross-over.ti,ab,hw,tn,mf. (19099)
24 placebo$.ti,ab,hw,tn,mf. (280621)
25 ((doubl$ or singl$ or tripl$ or trebl$) adj5 (blind$ or mask$)).ti,ab,hw,tn,mf. (186278)
26 (comparative adj5 trial$).ti,ab,hw,tn,mf. (65629)
27 (clinical adj5 trial$).ti,ab,hw,tn,mf. (1030107)
28 or/14-27 (4877370)
29 nonhuman/ (3877817)
30 animal/ not (human/ and animal/) (1332762)
31 or/29-30 (5196477)
32 28 not 31 (3030627)
33 13 and 32 (1289)
34 (2010$ or 2011$ or 2012$).em. (2701351)
35 33 and 34 (280)

This search was updated in February and October 2013

 

Appendix 3. CINAHL search strategy

1 exp Abdomen, Acute/
2 (acute abdominal adj5 pain).tw.
3 (pain adj5 abdomen).tw.
4 (pelvic adj5 pain).tw.
5 exp Pelvic Pain/
6 (abdomin$ adj5 pain).tw.
7 exp Abdominal Pain/
8 exp Appendicitis/
9 exp pelvic infection/ or exp pelvic inflammatory disease/
10 pelvic inflammat$ disease.tw.
11 PID.tw.
12 exp pregnancy, ectopic/ or exp pregnancy, abdominal/ or exp pregnancy, tubal/
13 append$.tw.
14 exp Ovarian Cysts/
15 (Ovar$ adj5 Cyst$).tw.
16 or/1-15
17 exp Laparoscopy/
18 Laparoscop$.tw.
19 17 or 18
20 exp diagnosis/ or exp "diagnostic techniques and procedures"/ or exp early diagnosis/
21 diagnos$.tw.
22 (conventional or standard).tw.
23 (wait adj5 see).tw.
24 (conservat$ or expectant).tw.
25 (clinical or observ$).tw.
26 manage$.tw.
27 ultraso$.tw.
28 tomograph$.tw.
29 or/20-28
30 16 and 19 and 29
31 exp clinical trials/
32 Clinical trial.pt.
33 (clinic$ adj trial$1).tw.
34 ((singl$ or doubl$ or trebl$ or tripl$) adj (blind$3 or mask$3)).tw.
35 Randomi?ed control$ trial$.tw.
36 Random assignment/
37 Random$ allocat$.tw.
38 Placebo$.tw.
39 Placebos/
40 Quantitative studies/
41 Allocat$ random$.tw.
42 or/31-41
43 30 and 42
44 from 43 keep 1-45

 

Appendix 4. CENTRAL search strategy

1 exp Abdomen, Acute/ (37)
2 (acute abdominal adj5 pain).tw. (50)
3 (pain adj5 abdomen).tw. (42)
4 (pelvic adj5 pain).tw. (451)
5 exp Pelvic Pain/ (510)
6 (abdomin$ adj5 pain).tw. (2203)
7 exp Abdominal Pain/ (781)
8 exp Appendicitis/ (299)
9 exp pelvic infection/ or exp pelvic inflammatory disease/ (399)
10 pelvic inflammat$ disease.tw. (218)
11 PID.tw. (209)
12 exp pregnancy, ectopic/ or exp pregnancy, abdominal/ or exp pregnancy, tubal/ (123)
13 append$.tw. (1030)
14 exp Ovarian Cysts/ (732)
15 (Ovar$ adj5 Cyst$).tw. (158)
16 or/1-15 (5931)
17 exp Laparoscopy/ (3056)
18 Laparoscop$.tw. (4742)
19 17 or 18 (4912)
20 exp diagnosis/ or exp "diagnostic techniques and procedures"/ or exp early diagnosis/ (200845)
21 diagnos$.tw. (30344)
22 (conventional or standard).tw. (53697)
23 (wait adj5 see).tw. (62)
24 (conservat$ or expectant).tw. (3404)
25 (clinical or observ$).tw. (210273)
26 manage$.tw. (28619)
27 ultraso$.tw. (9253)
28 tomograph$.tw. (5013)
29 or/20-28 (366147)
30 16 and 19 and 29 (552)
31 limit 30 to yr="2008 -Current" (124)

This search was updated in February and October 2013

 

Appendix 5. PsycINFO search strategy

1 exp Abdomen/ (441)
2 (acute abdominal adj5 pain).tw. (19)
3 (pain adj5 abdomen).tw. (46)
4 (pelvic adj5 pain).tw. (395)
5 append$.tw. (21917)
6 pelvic inflammat$ disease.tw. (59)
7 (Ovar$ adj5 Cyst$).tw. (24)
8 or/1-7 (22857)
9 Laparoscop$.tw. (229)
10 8 and 9 (27)
11 random.tw. (35688)
12 control.tw. (277569)
13 double-blind.tw. (16130)
14 clinical trials/ (6181)
15 placebo/ (3239)
16 exp Treatment/ (521145)
17 or/11-16 (790334)
18 10 and 17 (15)

This search was updated in February and October 2013

 

Appendix 6. MDSG Specialised Register search strategy

Keywords CONTAINS "laparoscopic" or "laparoscopic excision" or "laparoscopic imaging" or "laparoscopic dye" or "laparoscopic imaging" or "laparoscopic procedure" or "laparoscopic surgery" or "laparoscopic techniques" or "laparoscopy" or Title CONTAINS "laparoscopic" or "laparoscopic excision" or "laparoscopic imaging" or "laparoscopic dye" or "laparoscopic imaging" or "laparoscopic procedure" or "laparoscopic surgery" or "laparoscopic techniques" or "laparoscopy"

 AND

 Keywords CONTAINS "acute" or "abdominal pain" or "pelvic pain" or "Pain-abdominal" or "pain-pelvic" or "ectopic pregnancy" or "pelvic inflammatory disease" or "Ovarian Cysts" or "ovarian cyst" or "acute" Title CONTAINS "acute" or "abdominal pain" or "pelvic pain" or "Pain-abdominal" or "pain-pelvic" or "ectopic pregnancy" or "pelvic inflammatory disease" or "Ovarian Cysts" or "ovarian cyst" or "acute"

 

Appendix 7. LILACS search strategy

Keywords conmtains ( abdominal pain) OR (acute abdominal pain) OR (pelvic pain) OR (acute pelvic pain) OR (pelvic inflammatory disease ) OR (ovarian cyst ) OR (appendicitis ) OR (appendicitis ) OR (non-specific abdominal pain ) OR (lower abdominal pain ) AND (laparoscopy ) OR (diagnostic laparoscopy ) OR (videolaparoscopy ) OR laparotomy OR (clinical diagnosis ) OR (appendectomy ) OR (open appendectomy ) OR (laparoscopic appendectomy ) AND ( clinical trial) OR (randomized clinical trial) OR (controlled clinical trial)

Terms In spanish: dolor abdominal OR dolor abdominal agudo OR dolor pélvico OR dolor pélvico agudo OR apendicitis OR quiste de ovario OR enfermedad pélvica inflamatoria OR dolor abdominal no especifico AND laparoscopia OR laparoscopia diagnostica OR, laparotomía OR apendicectomia OR apendicetomia abierta, apendicectomia laparoscopica OR diagnostico clinico OR diagnostico convencional AND expermiento clinico OR experimento clinico aleatorizado OR experimento clinico controlado o experimental

 

What's new

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Last assessed as up-to-date: 22 October 2013.


DateEventDescription

11 June 2014Review declared as stableIt is unlikely that there will be any new studies for inclusion in this review, and accordingly this is now a stable review.



 

History

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Protocol first published: Issue 2, 2009
Review first published: Issue 1, 2011


DateEventDescription

22 October 2013New search has been performedThe search was updated and summary of findings tables were included in this version. No new studies were identified

9 October 2013New citation required but conclusions have not changedNo new studies were identified for inclusion in this updated review

26 February 2010AmendedTitle change was made with approval of the editorial office from "Early laparoscopy versus clinical observation for the management of nonspecific acute abdominal pain in women of childbearing age" to " Laparoscopy for management of lower acute abdominal pain in women of childbearing age" as this reflected the clinical intervention better. Other protocol changes were made and are mentioned in the methods section. Some editing of the background also occurred.



 

Contributions of authors

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

HGG: participated in conceiving of and designing the study, drafting the review and commenting on it critically for intellectual content and providing final approval of the document to be updated.

LR: participated in drafting the review and commenting on it critically for intellectual content and providing final approval of the document to be updated.

CF: participated in conceiving of and designing the study, drafting the review and commenting on it critically for intellectual content and providing final approval of the document to be updated.

VME: participated in preparing this update of the review, evaluating all titles and abstracts that were found, assessing the full text of studies and reviewing the manuscript.

 

Declarations of interest

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

One of the review authors (Gaitán H) was a principal investigator in an included study (Gaitan 2002). This study was financed by the Colombian Institute for Development of Science and Technology Colciencias (http://zulia.colciencias.gov.co:8098/protocol/index.jsp) (Grant No: 075-97).

 

Sources of support

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Internal sources

  • Cochrane Menstrual Disorders and Subfertility Group (MDSG), Not specified.

 

External sources

  • Universidad Nacional de Colombia, Not specified.

 

Differences between protocol and review

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

At full review stage in 2011 the primary outcome was changed from the number of definitive diagnoses (the number of cases in which a final diagnosis was reached for each strategy studied) to the number of specific diagnoses made before discharge. One secondary outcome was removed from those in the published protocol: time from admission to diagnosis. Three secondary outcomes were added: mean operating time, return to normal activities, and normal appendix removed.

Changes made to the published protocol also included replacement of the conventional strategy by 'wait and see' or by open appendicectomy and inclusion of women with suspected appendicitis.

At the 2014 update of this review the secondary outcome 'normal appendix removed' was moved to be included in the primary outcome 'adverse events', and the included studies now specify inclusion of trials where at least 75% of the participants were women of premenopausal age.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. AbstractRésumé scientifique
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to ongoing studies
  23. Additional references
Al-Mulhim 2002 {published data only}
  • Al-Mulhim AS, Al-Mulhim FM, Al-Suwaiygh AA, Al-Masaud NA. Laparoscopic versus open appendectomy in females with a clinical diagnosis of appendicitis. Saudi Medical Journal 2002;23(11):1339-42. [PUBMED: 12506292]
Bruwer 2003 {published data only}
  • Bruwer F, Coetzer M, Warren BL. Laparoscopic versus open surgical exploration in premenopausal women with suspected acute appendicitis. South African Journal of Surgery. Suid-Afrikaanse Tydskrif vir Chirurgie 2003;41(4):82-5. [PUBMED: 14768141]
Champault 1993 {published data only}
  • Champault G, Rizk N, Lauroy J, Olivares P, Belhassen A, Boutelier P. Right iliac fossa pain in women. Conventional diagnostic approach versus primary laparoscopy. A controlled study (65 cases) [Douleurs iliaques droites de la femme. Approche diagnostique conventionnelle versus laparoscopie pre,iere. Etude controlee (65 cas)]. Annales de Chirugie 1993;47(4):316-9.
Decadt 1999 {published data only}
Gaitan 2002 {published data only}
  • Gaitán H, Angel E, Sánchez J, Gómez I, Sánchez L, Agudelo C. Laparoscopic diagnosis of acute lower abdominal pain in women of reproductive age. International Journal of Gynaecology and Obstetrics 2002;76(2):149-58.
Jadallah 1994 {published data only}
  • Jadallah FA, Abdul-Ghani AA, Tibblin S. Diagnostic laparoscopy reduces unnecessary appendicectomy in fertile women. The European Journal of Surgery = Acta Chirurgica 1994;160(1):41-5. [PUBMED: 8186313]
Laine 1997 {published data only}
Larsson 2001 {published data only}
  • Larsson PG, Henriksson G, Olsson M, Boris J, Ströberg P, Tronstad SE, et al. Laparoscopy reduces unnecessary appendicectomies and improves diagnosis in fertile women. A randomized study. Surgical Endoscopy 2001;15(2):200-2.
Morino 2006 {published data only}
  • Morino M, Pellegrino L, Castagna E, Farinella E, Mao P. Acute nonspecific abdominal pain: a randomized, controlled trial comparing early laparoscopy versus clinical observation. Annals of Surgery 2006;244(6):881-6.
Navarra 2002 {published data only}
  • Navarra G, Ascanelli S Turini A, Carcoforo P, Tonini G, Pozza E. Laparoscopic appendectomy versus open appendectomy in suspected acute appendicitis in female patients [Appendicectomia laparoscopica versus appendicectomia aperta nel sospetto di appendicite acuta in pazienti di sesso femminile]. Annali Italiani di Chirurgia 2002;73:59-64.
Olsen 1993 {published data only}
van Dalen 2003 {published data only}
  • Van Dalen R, Bagshaw PF, Dobbs BR, Robertson GM, Lynch AC, Frizelle FA. The utility of laparoscopy in the diagnosis of acute appendicitis in women of reproductive age. Surgical Endoscopy 2003;17(8):1311-3.

References to studies excluded from this review

  1. Top of page
  2. AbstractRésumé scientifique
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to ongoing studies
  23. Additional references
Attwood 1992 {published data only}
  • Attwood SE, Hill AD, Murphy PG, Thornton J, Stephens RB. A prospective randomized trial of laparoscopic versus open appendectomy. Surgery 1992;112(3):497-501. [PUBMED: 1387739]
Bauwens 1998 {published data only}
  • Bauwens K, Schwenk W, Bohm B, Hasart O, Neudecker J, Muller JM. Recovery and duration of work disability after laparoscopic and conventional appendectomy. A prospective randomized study [Rekonvaleszenz und Arbeitsunfahigkeitsdauer nach laparoskopischer und konventioneller Appendektomie. Eine prospektiv-randomisierte Studie.]. Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen 1998;69(5):541-5. [PUBMED: 9653559]
Cho 2011 {published data only}
  • Cho MS, Min BS, Hong YK, Lee WJ. Single-site versus conventional laparoscopic appendectomy: comparison of short-term operative outcomes.. Surgical Endoscopy 2011;25(1):36-40.
Clarke 2011 {published data only}
  • Clarke T, Katkhouda N, Mason RJ, Cheng BC, Olasky J, Sohn HJ, et al. Laparoscopic versus open appendectomy for the obese patient: a subset analysis from a prospective, randomized, double-blind study. Surgical Endoscopy 2011;25(4):1276-80.
Cox 1996 {published data only}
  • Cox MR, McCall JL, Toouli J, Padbury RT, Wilson TG, Wattchow DA, et al. Prospective randomized comparison of open versus laparoscopic appendectomy in men. World Journal of Surgery 1996;20(3):263-6. [PUBMED: 8661828]
de Wilde 1991 {published data only}
  • de Wilde RL. Goodbye to late bowel obstruction after appendicectomy. Lancet 1991; Vol. 338, issue 8773:1012. [PUBMED: 1681313]
Eichen 1994 {published data only}
  • Eichen R, Heuser H, Nitschke B. Laparoscopic or conventional appendectomy: a prospective study. Langenbecks Archiv fur Chirurgie. Supplement. Kongressband 1994;111:223-5.
Frazee 1994 {published data only}
  • Frazee RC, Roberts JW, Symmonds RE, Snyder SK, Hendricks JC, Smith RW, et al. A prospective randomized trial comparing open versus laparoscopic appendectomy. Annals of Surgery 1994;219(6):725-8; discussion 728-31. [PUBMED: 8203983]
Goudar 2011 {published data only}
  • Goudar BV, Telkar S, Lamani YP, Shirbir SH, Shailesh ME. Laparoscopic versus open appendectomy: a comparison of primary outcome studies from Southern India. Journal of Clinical and Diagnostic Research 2011;5(8):1606-9.
Hansen 1996 {published data only}
  • Hansen JB, Smithers BM, Schache D, Wall DR, Miller BJ, Menzies BL. Laparoscopic versus open appendectomy: prospective randomized trial. World Journal of Surgery 1996;20(1):17-20; discussion 21. [PUBMED: 8588406]
Hart 1996 {published data only}
  • Hart R, Rajgopal C, Plewes A, Sweeney J, Davies W, Gray D, et al. Laparoscopic versus open appendectomy: a prospective randomized trial of 81 patients. Canadian Journal of Surgery. Journal Canadien de Chirurgie 1996;39(6):457-62. [PUBMED: 8956810]
Hebebrand 1994 {published data only}
  • Hebebrand D, Troidl H, Spangenberger W, Neugebauer E, Schwalm T, Gunther MW. Laparoscopic or classical appendectomy? A prospective randomized study [Laparoskopische oder klassische Appendektomie? Eine prospektiv randomisierte Studie.]. Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen 1994;65(2):112-20. [PUBMED: 8162812]
Heikkinen 1998 {published data only}
Hellberg 1999 {published data only}
  • Hellberg A, Rudberg C, Kullman E, Enochsson L, Fenyo G, Graffner H, et al. Prospective randomized multicentre study of laparoscopic versus open appendicectomy. The British Journal of Surgery 1999;86(1):48-53. [PUBMED: 10027359]
Helmy 2001 {published data only}
  • Helmy MA. A comparative study between laparoscopic versus open appendicectomy in men. Journal of the Egyptian Society of Parasitology 2001;31(2):555-62. [PUBMED: 11478454]
Henle 1996 {published data only}
  • Henle KP, Beller S, Rechner J, Zerz A, Szinicz G, Klingler A. Laparoscopic versus conventional appendectomy: a prospective randomized study [Laparoskopische versus konventionelle Appendektomie: eine prospektive, randomisierte Studie.]. Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen 1996;67(5):526-30; discussion 522. [PUBMED: 8777883]
Huang 2001 {published data only}
  • Huang MT, Wei PL, Wu CC, Lai IR, Chen RJ, Lee WJ. Needlescopic, laparoscopic, and open appendectomy: a comparative study. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques 2001;11(5):306-12. [PUBMED: 11668227]
Ignacio 2004 {published data only}
  • Ignacio RC, Burke R, Spencer D, Bissell C, Dorsainvil C, Lucha PA. Laparoscopic versus open appendectomy: what is the real difference? Results of a prospective randomized double-blinded trial. Surgical Endoscopy 2004;18(2):334-7. [PUBMED: 14691696]
Kald 1999 {published data only}
  • Kald A, Kullman E, Anderberg B, Wiren M, Carlsson P, Ringqvist I, et al. Cost-minimisation analysis of laparoscopic and open appendicectomy. The European Journal of Surgery = Acta Chirurgica 1999;165(6):579-82. [PUBMED: 10433143]
Kaplan 2009 {published data only}
  • Kaplan M, Salman B, Yilmaz TU, Oguz M. A quality of life comparison of laparoscopic and open approaches in acute appendicitis: a randomised prospective study. Acta Chirurgica Belgica 2009;109(3):356-63.
Karadayi 2003 {published data only}
  • Karadayi K, Turan M, Canbay E, Topcu O, Sen M. Laparoscopic versus open appendectomy: analysis of systemic acute-phase responses in a prospective randomized study. Chirurgische Gastroenterologie 2003;19:396-400.
Kargar 2011 {published data only}
  • Kargar S, Mirshamsi MH, Zare M, Arefanian S, Shadman Yazdi E, Aref A. Laparoscopic versus open appendectomy; which method to choose? A prospective randomized comparison. Acta Med Iran 2011;49(6):352-6.
Kazemier 1997 {published data only}
Khalil 2013 {published data only}
  • Khalil J, Muqim R, Rafique M, Khan M. Laparoscopic versus open appendectomy: a comparison of primary outcome measures. Saudi Journal of Gastroenterology 2011;17(4):236-40.
Koluh 2010 {published data only}
  • Koluh A, Delibegovic S, Hasukic S, Valjan V, Latic F. Laparoscopic appendectomy in the treatment of acute appendicitis. Medicinski Archive 2010;64(3):147-50.
Kouhia 2010 {published data only}
Kum 1993 {published data only}
Lavonius 2001 {published data only}
  • Lavonius MI, Liesjarvi S, Ovaska J, Pajulo O, Ristkari S, Alanen M. Laparoscopic versus open appendectomy in children: a prospective randomised study. European Journal of Pediatric Surgery = Zeitschrift fur Kinderchirurgie 2001;11(4):235-8. [PUBMED: 11558012]
Lejus 1996 {published data only}
  • Lejus C, Delile L, Plattner V, Baron M, Guillou S, Heloury Y, et al. Randomized, single-blinded trial of laparoscopic versus open appendectomy in children: effects on postoperative analgesia. Anesthesiology 1996;84(4):801-6. [PUBMED: 8638833]
Lintula 2004 {published data only}
  • Lintula H, Kokki H, Vanamo K, Valtonen H, Mattila M, Eskelinen M. The costs and effects of laparoscopic appendectomy in children. Archives of Pediatrics & Adolescent Medicine 2004;158(1):34-7. [PUBMED: 14706955]
Little 2002 {published data only}
  • Little DC, Custer MD, May BH, Blalock SE, Cooney DR. Laparoscopic appendectomy: an unnecessary and expensive procedure in children?. Journal of Pediatric Surgery 2002;37(3):310-7. [PUBMED: 11877640]
Long 2001 {published data only}
  • Long KH, Bannon MP, Zietlow SP, Helgeson ER, Harmsen WS, Smith CD, et al. A prospective randomized comparison of laparoscopic appendectomy with open appendectomy: clinical and economic analyses. Surgery 2001;129(4):390-400. [PUBMED: 11283528]
Macarulla 1997a {published data only}
  • Macarulla E, Vallet J, Abad JM, Hussein H, Fernandez E, Nieto B. Laparoscopic versus open appendectomy: a prospective randomized trial. Surgical Laparoscopy & Endoscopy 1997;7(4):335-9. [PUBMED: 9282768]
Martin 1995 {published data only}
  • Martin LC, Puente I, Sosa JL, Bassin A, Breslaw R, McKenney MG, et al. Open versus laparoscopic appendectomy. A prospective randomized comparison. Annals of Surgery 1995;222(3):256-61; discussion 261-2. [PUBMED: 7677456]
McAnena 1992 {published data only}
Meynaud-Kraemer 1999 {published data only}
  • Meynaud-Kraemer L, Colin C, Vergnon P, Barth X. Wound infection in open versus laparoscopic appendectomy. A meta-analysis. International Journal of Technology Assessment in Health Care 1999;15(2):380-91. [PUBMED: 10507196]
Minne 1997 {published data only}
  • Minne L, Varner D, Burnell A, Ratzer E, Clark J, Haun W. Laparoscopic vs open appendectomy. Prospective randomized study of outcomes. Archives of Surgery 1997;132(7):708-11; discussion 712. [PUBMED: 9230853]
Moirangthem 2008 {published data only}
  • Moirangthem GS, Arunkumar Ch, Marak AB, Lokendra K, Singh LD. A comparative study between laparoscopic versus open appendicectomy. Journal of Medical Society 2008;22(2):58-62.
Mutter 1996 {published data only}
  • Mutter D, Vix M, Bui A, Evrard S, Tassetti V, Breton JF, et al. Laparoscopy not recommended for routine appendectomy in men: results of a prospective randomized study. Surgery 1996;120(1):71-4. [PUBMED: 8693426]
Nordentoft 2000 {published data only}
  • Nordentoft T, Bringstrup FA, Bremmelgaard A, Stage JG. Effect of laparoscopy on bacteremia in acute appendicitis: a randomized controlled study. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques 2000;10(5):302-4. [PUBMED: 11083213]
Ortega 1995 {published data only}
  • Ortega AE, Hunter JG, Peters JH, Swanstrom LL, Schirmer B. A prospective, randomized comparison of laparoscopic appendectomy with open appendectomy. Laparoscopic Appendectomy Study Group. American Journal of Surgery 1995;169(2):208-12; discussion 212-3. [PUBMED: 7840381]
Ozmen 1999 {published data only}
  • Ozmen MM, Zulfikaroglu B, Tanik A, Kale IT. Laparoscopic versus open appendectomy: prospective randomized trial. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques 1999;9(3):187-9. [PUBMED: 10803997]
Pedersen 2001 {published data only}
Perner 1999 {published data only}
  • Perner A, Bugge K, Lyng KM, Schulze S, Kristensen PA, Bendtsen A. Changes in plasma potassium concentration during carbon dioxide pneumoperitoneum. British Journal of Anaesthesia 1999;82(1):137-9. [PUBMED: 10325852]
Reiertsen 1997 {published data only}
  • Reiertsen O, Larsen S, Trondsen E, Edwin B, Faerden AE, Rosseland AR. Randomized controlled trial with sequential design of laparoscopic versus conventional appendicectomy. The British Journal of Surgery 1997;84(6):842-7. [PUBMED: 9189105]
Schietroma 2007 {published data only}
  • Schietroma M, Cappelli S, Carlei F, Pescosolido A, Lygidakis NJ, Amicucci G. "Acute abdomen": early laparoscopy or active laparotomic-laparoscopic observation?. Hepatogastroenterology 2007;54:1137-41.
Schippers 1994 {published data only}
  • Schippers E, Pier A, May P, Schumpelick V. Laparoscopic vs open appendectomy—a comparison of postoperative pain and respiratory function [abstract]. Surgical Endoscopy 1994;8:561.
Settmacher 1995 {published data only}
  • Settmacher U, Manger T, Liebenthal C, Neuhaus K, Volk HD. Immunological modifications after open and laparoscopic surgery. Minimal Invasive Chirurgie 1995;4:95-102.
Sezeur 1997 {published data only}
  • Sezeur A, Bure-Rossier AM, Rio D, Savigny B, Tricot C, Martel P, et al. Does laparoscopy increase the bacteriological risk of appendectomy? Results of a randomized prospective study [La coelioscopie augmente-t-elle le risque bacteriologique de l'appendicectomie? Resultats d'une etude prospective randomisee.]. Annales de Chirurgie 1997;51(3):243-7. [PUBMED: 9297886]
Shirazi 2010 {published data only}
  • Shirazi B, Ali N, Shamim MS. Laparoscopic versus open appendectomy: a comparative study. Journal of Pakistan Medical Association 2010;60(11):901-4.
Stare 1998 {published data only}
  • Stare R, Kocman I, Povsic Cevra Z. Results of a prospective randomised study of laparoscopic appendectomy in community hospital [abstract]. Surgical Endoscopy 1998;12:573.
St Peter 2011 {published data only}
  • St Peter SD, Adibe OO, Juang D, Sharp SW, Garey CL, Laituri CA, et al. Single incision versus standard 3-port laparoscopic appendectomy: a prospective randomized trial. Annals of Surgery 2011;254(4):586-90.
Tate 1993 {published data only}
Tzovaras 2010 {published data only}
  • Tzovaras G, Baloyiannis I, Kouritas V, Symeonidis D, Spyridakis M, Poultsidi A, et al. Laparoscopic versus open appendectomy in men: a prospective randomized trial. Surgical Endoscopy 2010;24(12):2987-92.
Vallribera 2003 {published data only}
  • Vallribera Valls F, Sala Pedros J, Aguilar Teixedor F, Espin Bassany E. Influence of laparoscopic surgery on perception of quality of life after appendectomy [Influencia de la cirugia laparoscopica en la percepcion de la claidad de vida tras apendicectomia]. Cirugia Espanola 2003;73:88-94.
Wei 2010 {published data only}
  • Wei HB, Huang JL, Zheng ZH, Wei B, Zheng F, Qiu WS, et al. Laparoscopic versus open appendectomy: a prospective randomized comparison. Surgical Endoscopy 2010;24(2):266-9.
Williams 1996 {published data only}
  • Williams MD, Collins JN, Wright TF, Fenoglio ME. Laparoscopic versus open appendectomy. Southern Medical Journal 1996;89(7):668-74. [PUBMED: 8685751]
Witten 1998 {published data only}
  • Birth M, Witten I, Gadzepko E, Weiser HF. Laparoscopic vs open appendectomy for acute appendicitis: a prospective randomized trial [abstract]. The British Journal of Surgery 1998;85 Suppl 2:39.
Yeung 1997 {published data only}
  • Yeung CK, Yip KF, Lee KH, Lau WY. The role of minimally invasive surgery in the management of acute appendicitis in children: a prospective randomized trial of laparoscopic vs conventional appendectomy [abstract]. Asian Journal of Surgery 1997;20 Suppl:55.
Zaninotto 1995 {published data only}
  • Zaninotto G, Rossi M, Anselmino M, Costantini M, Pianalto S, Baldan N, et al. Laparoscopic versus conventional surgery for suspected appendicitis in women. Surgical Endoscopy 1995;9(3):337-40.
Zhang 1998 {published data only}
  • Zhang WF, Xu CX, Liu YH, Huang GJ. A randomized control study on the appendectomy of 103 cases with laparoscope or mini-incision. Modern Journal of Physicians 1998;3:8-9.

References to ongoing studies

  1. Top of page
  2. AbstractRésumé scientifique
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to ongoing studies
  23. Additional references
ISRCTN42332281 {published data only}
  • Sant'Orsola-Malpighi University Hospital Bologna (sponsor). Multicentre randomised, double-blind, controlled trial of laparoscopic versus open surgery for suspected appendicitis in adults. ISRCTN identifier: ISRCTN42332281 2005; Vol. http://isrctn.org/ISRCTN42332281.

Additional references

  1. Top of page
  2. AbstractRésumé scientifique
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to ongoing studies
  23. Additional references
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Beyan 2003
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Bijnen 2003
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Poulin 2000
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Salky 1998
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