A prospective randomized comparison of laparoscopic appendectomy with open appendectomy: Clinical and economic analyses

Background. Previous randomized studies of laparoscopic appendectomy produced conflicting recommendations, and the adequacy of sample sizes is generally unknown. We compared clinical and economic outcomes after laparoscopic and open appendectomy in a sample of predetermined statistical power. Methods. A pre-study power analysis suggested that 200 randomized patients would yield 80% power to show a mean decrease of 1.3 days' hospitalization. One hundred ninety-eight patients with a preoperative diagnosis of acute appendicitis were randomized prospectively to laparoscopic or open appendectomy. Economic analysis included billed charges, total costs, direct costs, and indirect costs associated with treatment. Results. Laparoscopic appendectomy took longer to perform than open appendectomy (median, 107 vs 91 minutes; P < .01) and was associated with fewer days to return to a general diet (mean, 1.6 versus 2.3 days; P < .01), a shorter duration of parenteral analgesia (mean, 1.6 versus 2.2 days; P < .01), fewer morphine-equivalent milligrams of parenteral narcotic (median, 14 mg versus 34 mg; P = .001), a shorter postoperative hospital stay (mean, 2.6 versus 3.4 days; P < .01), and earlier return to full activity (median, 14 versus 21 days; P < .02). However, operative morbidity and time to return to work were comparable. Billed charges and direct costs were not significantly different in the 2 groups ($7711 versus $7146 and $5357 versus $4945, respectively), but total costs (including indirect costs) of laparoscopic appendectomy were, on average, nearly $2400 less, given the shorter length of stay and abbreviated recuperative period ($11,577 versus $13,965). Subgroup analyses suggested the benefit of a laparoscopic approach for uncomplicated appendicitis and for patients with active lifestyles. Conclusions. While laparoscopic appendectomy is associated with statistically significant but clinically questionable advantages over open appendectomy, a laparoscopic approach is relatively less expensive. The estimated difference in total costs of treatment (direct and indirect costs) was at least $2000 in more than 60% of the bootstrapped iterations. The economic significance and implications favoring a laparoscopic approach cannot be ignored.