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Meta-Analysis
. 2014 May 22;2014(5):CD007683.
doi: 10.1002/14651858.CD007683.pub3.

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

Hernando G Gaitán  1 , Ludovic Reveiz, Cindy Farquhar, Vanessa M Elias
Affiliations
Meta-Analysis

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

Hernando G Gaitán et al. Cochrane Database Syst Rev. .

Abstract

Background: This is an updated version of the original review, published in Issue 1, 2011, of The Cochrane Library. Acute lower abdominal pain is common, and making a diagnosis is particularly challenging in premenopausal women, as ovulation and menstruation symptoms overlap with symptoms of appendicitis, early pregnancy complications and pelvic infection. A management strategy involving early laparoscopy could potentially provide a more accurate diagnosis, earlier treatment and reduced risk of complications.

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

Search methods: The Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, PsycINFO, LILACS and CINAHL were searched (October 2013). The International Clinical Trials Registry Platform (ICTRP) was also searched. No new studies were included in this updated version.

Selection criteria: Randomised controlled trials (RCTs) that included women of childbearing age who presented with acute lower abdominal pain, non-specific lower abdominal pain or suspected appendicitis were included. Trials were included if they evaluated laparoscopy with open appendicectomy, or laparoscopy with a wait and see strategy. Study selection was carried out by two review authors independently.

Data collection and analysis: Data from studies that met the inclusion criteria were independently extracted by two review authors and the risk of bias assessed. We used standard methodological procedures as expected by The Cochrane Collaboration. A summary of findings table was prepared using GRADE criteria.

Main results: A total of 12 studies including 1020 participants were incorporated into the review. These studies had low to 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 differential verification or partial verification bias may have occurred in most RCTs. Overall the quality of the evidence was low to moderate for most outcomes, as per the GRADE approach.Laparoscopy was compared with open appendicectomy in eight RCTs. Laparoscopy was associated with an increased rate of specific diagnoses (seven RCTs, 561 participants; odds ratio (OR) 4.10, 95% confidence interval (CI) 2.50 to 6.71; I(2) = 18%), but no evidence was found of reduced rates for any adverse events (eight RCTs, 623 participants; OR 0.46, 95% CI 0.19 to 1.10; I(2) = 0%). A meta-analysis of seven studies found a significant difference favouring the laparoscopic procedure in the rate of removal of normal appendix (seven RCTs, 475 participants; OR 0.13, 95% CI 0.07 to 0.24; I(2) = 0%).Laparoscopic diagnosis versus a 'wait and see' strategy was investigated in four RCTs. A significant difference favoured laparoscopy in terms of rate of specific diagnoses (four RCTs, 395 participants; OR 6.07, 95% CI 1.85 to 29.88; I(2) = 79%), but no evidence suggested a difference in rates of adverse events (OR 0.87, 95% CI 0.45 to 1.67; I(2) = 0%).

Authors' conclusions: We found that laparoscopy in women with acute lower abdominal pain, non-specific lower abdominal pain or suspected appendicitis led to a higher rate of specific diagnoses being made and a lower rate of removal of normal appendices compared with open appendicectomy only. Hospital stays were shorter. No evidence showed an increase in adverse events when any of these strategies were used.

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Conflict of interest statement

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).

Figures

1
1
Study flow diagram.
2
2
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
3
3
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
4
4
Forest plot of comparison: 1 Laparoscopy versus open appendicectomy, outcome: 1.1 Final diagnosis.
5
5
Forest plot of comparison: 1 Laparoscopy versus open appendicectomy, outcome: 1.2 Adverse events.
6
6
Forest plot of comparison: 1 Laparoscopy versus open appendicectomy, outcome: 1.3 Total length of in‐patient stay.
7
7
Forest plot of comparison: 1 Laparoscopy versus open appendicectomy, outcome: 1.4 Mean operating time.
8
8
Forest plot of comparison: 1 Laparoscopy versus open appendicectomy, outcome: 1.7 Normal appendix removed.
9
9
Forest plot of comparison: 2 Laparoscopy versus 'wait and see' approach, outcome: 2.1 Final diagnosis.
10
10
Forest plot of comparison: 2 Laparoscopy versus 'wait and see' approach, outcome: 2.2 Adverse events.
1.1
1.1. Analysis
Comparison 1 Laparoscopy versus open appendicectomy, Outcome 1 Diagnosis before discharge.
1.2
1.2. Analysis
Comparison 1 Laparoscopy versus open appendicectomy, Outcome 2 Any adverse events.
1.3
1.3. Analysis
Comparison 1 Laparoscopy versus open appendicectomy, Outcome 3 Total length of in‐patient stay.
1.4
1.4. Analysis
Comparison 1 Laparoscopy versus open appendicectomy, Outcome 4 Mean operating time.
1.5
1.5. Analysis
Comparison 1 Laparoscopy versus open appendicectomy, Outcome 5 Return to normal activities (days).
1.6
1.6. Analysis
Comparison 1 Laparoscopy versus open appendicectomy, Outcome 6 Normal appendix removed.
1.7
1.7. Analysis
Comparison 1 Laparoscopy versus open appendicectomy, Outcome 7 Mortality.
2.1
2.1. Analysis
Comparison 2 Laparoscopy versus 'wait and see' approach, Outcome 1 Diagnosis before discharge.
2.2
2.2. Analysis
Comparison 2 Laparoscopy versus 'wait and see' approach, Outcome 2 Any adverse events.
2.3
2.3. Analysis
Comparison 2 Laparoscopy versus 'wait and see' approach, Outcome 3 Total length of in‐patient stay.
2.4
2.4. Analysis
Comparison 2 Laparoscopy versus 'wait and see' approach, Outcome 4 Mean operating time.
2.5
2.5. Analysis
Comparison 2 Laparoscopy versus 'wait and see' approach, Outcome 5 Normal appendix removed.
2.6
2.6. Analysis
Comparison 2 Laparoscopy versus 'wait and see' approach, Outcome 6 Mortality.
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Stare 1998 {published data only}
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St Peter 2011 {published data only}
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Tzovaras 2010 {published data only}
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Vallribera 2003 {published data only}
    1. 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}
    1. 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. - PubMed
Williams 1996 {published data only}
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Witten 1998 {published data only}
    1. 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}
    1. 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}
    1. 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. - PubMed
Zhang 1998 {published data only}
    1. 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

ISRCTN42332281 {published data only}
    1. 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.

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