Author(s): Rodney J Mason 1 , Ashley J Mason 2
appendectomy; appendicitis; laparoscopic appendectomy; obesity; postoperative outcomes
The USA and the rest of the world are suffering from an obesity epidemic [1,2] . Consequently, the proportion of obese to normal weight individuals is on the rise, and as a result surgeons must increasingly perform both emergent and elective nonbariatric surgeries on overweight people. It is therefore important for surgeons to use surgical techniques that will optimize outcomes of nonbariatric procedures in heavier patients. In this editorial, we focus specifically on obese patients who present with appendicitis and consider the role of open or laparoscopic appendectomy in the management of this subset of patients based on our analysis from the National Surgical Quality Improvement Program (NSQIP) database  . Currently, approximately 30% of patients with appendicitis in NSQIP hospitals are obese.
In the early days of laparoscopy, gynecologists considered obesity to be a contraindication to the technique  . There were difficulties associated with abdominal entry, insufflations of the obese abdominal wall, ventilation when positioning the patient in Trendelenburg and visualization secondary to increased intra-abdominal fat. General surgeons shared this sentiment at the time  and also considered obesity to be a contraindication. Interestingly, even today, 98% of Canadian surgeons believe that obesity increases operative time for colonic procedures  .
The first laparoscopic appendectomy was performed by Semm in 1981, and today laparoscopic appendectomy is almost universally favored over the traditional open muscle splitting incision  . Initially, many surgeons were reluctant to perform a laparoscopic appendectomy in obese patients, presumably due to a misperception that a laparoscopic appendectomy is more expensive, takes longer to perform or is more difficult to perform in obese patients. Even today, data show that surgeons are reluctant to perform a laparoscopic appendectomy in obese patients with complicated appendicitis. For example, in our analysis, 40% of patients with complicated appendicitis had an open appendectomy compared with 17% with uncomplicated appendicitis  . The latest Cochrane review suggests using laparoscopic appendectomy in obese patients  ; however, there are no randomized trials specifically looking at obese patients despite the fact that there are approximately 70 published randomized trials comparing open appendectomy to laparoscopic appendectomy. While a randomized trial specifically on obese patients would be informative, it would take time and would likely only be conducted at a single center or, at best, only a few hospitals. Our recent study, in which we created a matched cohort of patients from the large NSQIP database  , provides a potentially superior alternative to a randomized controlled trial. Here we discuss the results of that study as strong evidence for the superiority of the laparoscopic approach to appendectomy in...