Authors: Srinivasa Reddy, Darshana Tote, Anup Zade, Kesav Sudabattula, Tushar Dahmiwal, Akansha Hatewar, Dushyant Bawiskar
Categories: Public Health, appendectomy, appendicitis, laparoscopic appendectomy, open surgical repair, robotic-assisted surgery, Medical Education, General Surgery
Source: Cureus
Doi: 10.7759/cureus.63488
Appendectomy ranks among the most common surgical procedures. Laparoscopic appendectomy has become increasingly popular among certain surgeons. Even laparoscopic appendectomy is considered the gold standard; many surgical subspecialties have adopted robotic surgery in the past 10 years. The robotic system is recognized for enhancing stability, visualization, precision, and spatial flexibility. Surgeons can operate with enhanced dexterity, reduced tremors, three-dimensional visualization, up to 10 times magnification, and control over four arms thanks to improved ergonomics that allow them to sit at a customizable console. The purpose of this study is to evaluate and compare the overall effects, such as intraoperative time, postoperative recovery, feasibility for surgeons, and cost-effectiveness, of robotic-assisted appendectomy and laparoscopic appendectomy through the available literature. It was found that both robotic and laparoscopic surgeries work well for appendectomy, but in some studies, it was found that robotic surgery comes with the perks of shorter hospital stays and quicker recovery, even though it is more expensive, and in some studies, no differences were observed in patient recovery postoperatively. Laparoscopic surgery is still a highly effective and commonly used method, with proven advantages over open appendectomy, despite taking longer for the procedure. We need more studies to fully understand the advantages and disadvantages of robotic surgery, especially when it comes to cost-effectiveness and wider health outcomes.
Keywords: open surgical repair, appendicitis, laparoscopic appendectomy, robotic-assisted surgery, appendectomy
With a lifetime incidence of 7%-9%, acute appendicitis is a common cause of acute surgical abdominal pain. Consequently, appendectomy ranks among the most common surgical procedures [1]. The first description of the open approach to appendectomy came from McBurney [2]. Because of its good efficacy and safety, it has evolved into the preferred standard treatment for acute appendicitis and has remained mostly unchanged for the past 100 years. Subsequently, when Semm performed the first laparoscopic appendectomy (LA) in 1983, the procedure gradually gained popularity. Nonetheless, there is still debate in the literature regarding the best way to remove the inflamed appendix. LA has become increasingly popular among certain surgeons, while some surgeons are still doubtful that it will replace the more straightforward open appendectomy (OA) [3]. Nevertheless, LA is considered the gold standard for treating appendicitis owing to its advantages over OA, including a lower risk of wound infections, less pain after surgery, and a shorter hospital stay [4]. There have been a few prospective randomized controlled trials comparing LA and OA, taking into account research that has been published in English. While some research found that LA was superior to OA in terms of wound healing, more rapid recovery, and earlier diet resumption, other research found none of these advantages, and some even supported traditional appendectomy [5,6].
The field of minimally invasive surgery (MIS) has advanced significantly in more than a century since gynaecologist Dimitri Ott used a head mirror and a speculum to examine a woman's peritoneal cavity through a culdoscopic opening in 1901 [7,8]. In 1985, nearly 85 years later, Erich Mühe carried out Germany's first laparoscopic cholecystectomy [9]. The creation of remote robotic telesurgery, which was initially used in combat and is now used in many surgical specialties, marked a further advancement in medical technology [10]. It has been demonstrated over time that this development results in, at the very least, technical outcomes that are on par with or even better than those obtained from similar laparoscopic procedures [11-13]. The robotic platform presents a significant difference in the operative experience for surgeons. Surgeons can operate with enhanced dexterity, reduced tremors, 3D visualization, up to 10 times magnification, and control over four arms thanks to improved ergonomics that allow them to sit at a customizable console. These features make MIS easier for non-laparoscopy operators to understand [14,15].
Almost all surgical subspecialties have adopted robotic surgery as a routine procedure in the past 10 years, as its use has increased in several surgical specialties [16,17]. As surgeons gain proficiency with the robot, they can employ fewer instruments in more creative ways, which reduces the need for instrument exchanges and lowers operating room time and expense [18]. In laparoscopic procedures, the robotic system is recognized for enhancing stability, visualization, precision, and spatial flexibility [19].
It has been demonstrated that minimally invasive procedures are not only more patient-friendly in terms of a shorter recovery period and less pain but also the approach that patients prefer, leading to increased satisfaction [20]. It has been demonstrated to lower the possibility of transmission of communicable diseases to surgeons and other staff by enabling them to work remotely from both the patient and one another [21,22]. The main purpose of this study is to evaluate and compare the effects of robotic-assisted appendectomy and LA through the available literature. This study attempts to determine the benefits, drawbacks, and possible ramifications of each surgical technique in the treatment of appendicitis by reviewing the contents of existing literature.
Methodology
A search was conducted for articles published between September 1995 and October 2023 on electronic databases (PubMed, Google Scholar) using the search terms "Robotic-assisted appendectomy" and "Laparoscopic appendectomy" in the abstract or title. During the search, the study design criteria, publication type, and language limitations were applied. The inclusion criteria for the study included non-randomized controlled trials (non-RCTs), RCTs, and studies that looked at the effects of laparoscopic and robotic-assisted appendectomy published in English in peer-reviewed journals. Studies unrelated to the investigation or published in non-peer-reviewed journals were eliminated. RCTs, experimental studies, literature reviews, and other study designs were all utilized. Following a preliminary investigation, 680 articles were found in the search database; we then eliminated 394 articles that were duplicates. A total of 269 studies were excluded due to their irrelevance to the topic. After reviewing the full text of 17 articles, we excluded seven studies due to their failure to meet the inclusion criteria. Finally, 10 articles were included in the final review. Figure 1 shows a summary of the selected publications based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
Figure 1 PRISMA flowchartPRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses
Robotic-assisted appendectomy
Surgical Outcomes and Recovery
There have been studies evaluating RA and highlighting its advantages and disadvantages. According to Becker et al., RA takes longer surgical time compared to LA, but the postoperative stay was shorter for the patients treated with RA. Rifai et al. also found that recovery time after RA was noticeably shorter, even though the actual surgical time for both laparoscopic and robotic methods was the same. This implies that RA may have a positive effect on recovery time [23,24].
Safety and Efficacy
Akl et al. performed RA appendectomy as a combined procedure with other gynaecological conditions. The authors concluded that RA could be done safely and effectively without interrupting the total time of other gynaecological procedures and without the requirement to switch to regular laparoscopy. Therefore, it appears that RA can be smoothly integrated into more complex surgeries without compromising safety. According to Yi et al., using the "Micro Hand S" robot system for RA was also beneficial. They did not encounter any technical issues or complications during surgery, and the patients were recovering well at a three-month follow-up [25,26].
Cost Considerations
A study by Quilici et al. took a close look at the costs associated with RA surgeries. Their findings revealed that the average direct and total costs per case for RA appendectomies were significantly higher than those for LA. Compared to LAs, which cost 7709, the few robotically assisted appendectomies had an average direct cost per case of 13,210. They pointed out that the increased costs may not necessarily lead to better clinical care outcomes for gastrointestinal surgeries [27].
Specific Case Studies
Another study by Kelkar et al. showcased the successful completion of emergency robotic-assisted surgeries in four cases, with minimal blood loss during the surgery and reasonable surgical durations ranging from 80 to 135 minutes. Additionally, Orcutt et al. discussed the use of robotic-assisted surgery for treating patients with appendiceal mucoceles. They suggested that it provides safety and effectiveness comparable to traditional laparoscopy, along with added benefits for specific conditions [28,29]. The study by Becker et al. revealed that RA witnessed a shorter postoperative stay (0.7 days vs. 1.3 days, p < 0.01) but a longer median operation time (71.0 minutes vs. 46.0 minutes, p < 0.01). Overall, both robotic and laparoscopic surgeries work well for appendectomy, but robotic surgery comes with the benefits of shorter hospital stays and quicker recovery, even though it is more expensive. Laparoscopic surgery is still a highly effective and commonly used method, with proven advantages over OA, despite taking longer time for the procedure. We need more studies to fully understand the advantages and disadvantages of robotic surgery, especially regarding cost-effectiveness and broader health outcomes.
Laparoscopic appendectomy
Many studies have evaluated the effects of LA compared to OA and other methods. According to Biondi et al., LA comes with some clear advantages over OA, such as shorter hospital stays, less need for analgesics after surgery, quicker return to daily living activities, and a lower risk of wound infection. However, it is worth noting that these benefits do come with slightly higher costs. In a study by Khalil et al., it was found that although LA resulted in less pain after surgery, the procedure itself took longer compared to OA in LA, the surgery took 48.26 ± 12.82 minutes, while in OA, it took 31.36 ± 11.43 minutes (p < 0.001). They concluded that while the main results for LA and OA were similar, the advantages of less pain following surgery were somewhat offset by the longer surgical recovery time for LA. Similarly, Martin et al. found that there were not any significant differences in the time it took to go back to work or normal activities between LA and OA, even though LA did take longer to perform [30-32]. Table 1 includes a summary of the studies included in the review.
Discussion
The comparative analysis of RA and LA has revealed notable distinctions in the effectiveness of each approach, recovery period, and financial impact. First, RA implies several one-of-a-kind postoperative benefits since multiple sources point to a shorter period of hospitalization and time of recovery in comparison to LA surgeries. While this factor may improve patients’ postoperative results and diminish the extent of follow-up care, on the one hand, on the other, RA surgeries take longer duration and cause significantly higher expenditures. This factor calls the appropriateness of RA treatment into question since it does not consistently deliver better clinical results than LA.
LA, on the other hand, has been proven to be a reliable and efficient form of surgery. Although its operative times are longer than open repair but still shorter than RA, it leads to short hospital stays, decreased postoperative need for analgesics, and an earlier return to normal despite slightly rising direct costs. The increasing preference for this method of appendectomy has implied these benefits over OA. Robotic surgery has many benefits, but it also has many disadvantages, such as limited availability and the requirement for additional specialized surgical robotic training. Furthermore, one of the primary drawbacks of robotic surgery is still its high cost in comparison to laparoscopic or open surgery. Specialized training is necessary for robotic surgery, and compared to other surgical techniques, the cost of purchasing, using, and maintaining a surgical robotic system is much higher [27]. LA may remain a reliable, cost-effective, and clinically beneficial option [33,34]. The limitation of this review is the number of studies selected for RA and the availability of randomized trials for RA for appendectomy. Still, many available studies were included, but future studies are needed to further evaluate the effect of robotic-assisted surgeries in such cases.
Both RA and LA have their advantages and disadvantages in managing appendicitis. RA offers a shorter postoperative recovery but takes longer to perform and is costly. LA is a well-established, cost-effective procedure that is successfully used by all surgeons. RA is suitable for acute, complex cases, but more studies are needed to compare procedural times and address costs. Further research is necessary to improve the cost-effectiveness of RA and determine its role in appendectomies.
Open AI ChatGPT was used for paraphrasing some sentences.