ANNSURG-D-15-01088; Total nos of Pages: 1;
ANNSURG-D-15-01088
Letter to the Editor:
Laparoscopic Surgery or
Conservative Treatment
for Appendiceal Abscess in
Adults?
To the Editor:
W e read with great interest the random-
ized controlled trial by Mentula et al1
exploring the role of immediate laparoscopic
surgical intervention and comparing this
with conservative treatment for appendiceal
abscesses.
The paper is a welcome addition to the
acute care surgery literature, and further
reinforces the clear feasibility of laparo-
scopic surgery in potentially complex acute
surgical pathology. However, we are con-
cerned regarding the applicability of the
paper to the wider surgical community and
to the individual, rather than the average,
surgical patient.
The authors report on an enviable and
unique patient cohort; the patients are rela-
tively slim and have a very low rate of neo-
plastic disease underlying their appendiceal
abscesses. The low average body mass index
(and narrow interquartile range) makes the
laparoscopic procedure more attractive, is
likely to result in a reduced conversion rate,2
and is probably associated with improved
The authors report no conflicts of interest.
Copyright ß 2015 Wolters Kluwer Health, Inc. All
rights reserved.
ISSN: 0003-4932/14/26105-0821
DOI: 10.1097/SLA.0000000000001494
Annals of Surgery  Volume XX, Number X, Month 2015
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTER TO THE EDITOR
overall success. These points also apply to
low rate of neoplastic disease in this group
of patients.
Apart from patient characteristics, the
clinical environment and treatment system is
also important in determining an appropriate
management strategy. Laparoscopic appen-
dicectomy, particularly in complex pathol-
ogy, may be technically challenging. The
authors acknowledge that the majority of
patients in this study were operated on by
a single surgeon, and at a single center; this
single surgeon’s excellent skill and work-
place environment has determined this
study’s outcome.
To illustrate these concerns, let us
consider 2 hypothetical cases. First: an 88-
year-old patient with a 6 to 7 cm periappen-
diceal, a history of chronic obstructive pul-
monary disease and cardiac disease, with
multiple stents, presenting late at night,
and, the on-call surgeon is junior, with lim-
ited laparoscopic experience, and even less
experience in open surgery should a conver-
sion be required, with the risk that this sur-
geon will persist in the laparoscopic approach
for 2 to 3 hours, and struggle to perform the
highly challenging appendicectomy. Second:
a slim, 28-year-old patient with a 3 to 4 cm
periappendiceal abscess, fit for surgery and
anesthesia, presenting in the middle of the
day, and, with a skilled laparoscopic special-
ist in charge of the case and primary operator.
Notwithstanding the findings of the random-
ized controlled trial by Mentula et al,1 we
suspect most experienced surgeons will treat
the first case percutaneously, and the second
case surgically.
We will continue to advocate for a
clinical approach that is tailored to the indi-
vidual patient’s circumstance, and reflective of
the situational realities of each case. For either
treatment strategy, patient selection is key.
Dieter G. Weber, MBBS (Hons), FRACS
Trauma and General Surgeon
Royal Perth Hospital
The University of Western Australia
Perth, Australia
Salomone Di Saverio, MD, PhD, FACS
General, Emergency and Trauma Surgeon
Maggiore Hospital C.A. Pizzardi
AUSL Bologna
Bologna, Italy
Dieter.Weber@health.wa.gov.au
REFERENCES
1. Mentula P, Sammalkorpo J, Leppaniemi A. Lapa-
roscopic surgery or conservative treatment for
appendiceal abscess in adults? A randomized con-
trolled trial. Ann Surg. 2015;262:237–242.
2. Bhama AR, Charlton ME, Schmitt MB, et al.
Factors associated with conversion from laparo-
scopic to pen colectomy using the National Surgi-
cal Quality Improvement Program (NSQIP)
database. Colorectal Dis. 2015;17:257–264.
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