Ever since the first use of the laparoscope in the early 1900s [1], innovative laparoscopic techniques and devices have been continuously developed. Lataparoscopic surgery is a minimally invasive surgical technique of choice for the diagnosis and treatment of diseases in the abdominal organs and is being increasingly used, especially in emergency settings. Laparoscopic emergency surgery (LES) offers several advantages over the traditional treatment approach of open abdominal emergency surgery (OES) in this scenario [2].

However, despite the benefits of LES, it is not always the first choice in emergency settings because of several clinical limitations. Due to the various limitations associated with the use of LES, it has been difficult to evaluate the available data on domestic and global states in LES. Also, there has been no nationwide study or survey that has compared the clinical use, benefits, and complications of LES versus OES in Korea. Therefore, we examined the recent state of LES across multiple centers in Korea and further compared this data with the global state based on published reports.

The data of 2,122 patients who had undergone emergency surgery between 2014 and 2019 in three hospitals in Korea were collected from their medical records and retrospectively analyzed.

The inclusion criterion was any patient who had undergone emergency abdominal surgery immediately after admission to the emergency department without admission to the ward. The exclusion criteria were as follows: age of <18 years; patients from the outpatient department, obstetrics and gynecology department, urology department, or vascular department; patients who had received in-hospital emergency or transplant surgery.

The data regarding the clinical characteristics of patients, sex, age, surgical method used, and organs operated on were collected, collated, and analyzed from their medical records.

Since the surgeries were being performed in the emergency setting, the clinical status of the patient at the time of the surgery would have been evaluated. Especially, sepsis and shock are important and representative factors that reflect a patient’s general status. Shock was defined as the use of an inotropic or vasopressor drug for the elevation of blood pressure. Sepsis was defined according to the Third International Consensus Definitions for Sepsis and Septic Shock [3].

The operation time slots were divided into daytime and non-daytime. Daytime surgery was defined as surgery performed during regular working hours (9 AM to 6 PM) and on regular working days (Monday to Friday, except holidays). Operated organs were analyzed and were further categorized into the laparoscopic and open surgery groups.

Statistical analysis

The demographic and clinical characteristics of the patients were analyzed using descriptive statistics. The age group and surgery type were compared and analyzed using the linear-by-linear association in a two-by-K crossover analysis. The shock, sepsis, and operation time slot were compared and analyzed using the Pearson chi-square test in a two-by-two crossover analysis. The Charlson comorbidity index (CCI) and the emergency surgery acuity score (ESAS) were compared and analyzed using the Student t-test in independent samples t-test. All tests were two-sided, and significance was set at p < 0.05. The IBM SPSS version 12.0 (IBM Corp.) was used for all the analysis.

Of the patients, 1,232 were male (58.1%) and 890 were female (41.9%); 1,280 were in the OES group (60.3%) and 842 were in the LES group (39.7%). The mean age of the patients was 59.2 years. The most common age group for all patients overall and for OES was above 70 years, whereas that for LES was 50 to 59 years. In OES and LES, the distribution of sex and age group were significantly different.

The most commonly operated organ in all the patients as well as OES was the small bowel (25.8%), whereas that for LES was the appendix (Table 1).

In appendectomy and cholecystectomy, 493 (93.7%) and 133 88.0%) were in the LES group. In small bowel surgery, gastric surgery, and large bowel surgery, 491 (89.4%), 185 (92.0%), and 364 (79.1%) were in the OES group (Table 2).

The overall statistical significance result between operated organ and variables are summarized in Table 3. In the statistical analysis, the CCI, ESAS, shock, sepsis, and operation time slot demonstrated significant differences between LES and OES groups (Table 3).

The LES rate comparison between our study and references according to operated organ are summarized in Table 4.

In our study, the choice of LES decreased when limiting factors, such as the CCI, ESAS, shock, and sepsis were poor. These limiting factors were demonstrated in different results according to operated organ in our study (Table 2). Also, in the World Society of Emergency Surgery (WSES) survey, the limiting factor according to operated organ is different [2].

Due to the various limiting factors associated with the use of LES, it has been difficult to evaluate the available data on domestic and global states in LES. Among the Korean data, disease-specific LES rates in Korea have been inferred indirectly from several studies [4-8]. Data on the overall rate in LES are not available from Korea, though some LES-related survey results have been published [9,10].

Emergency appendectomy and cholecystectomy were the most common emergency laparoscopic surgeries performed. Laparoscopic appendectomy was the most frequent, with a laparoscopic surgery rate of 93.7% in the present study (Table 3). In the United States, the laparoscopic appendectomy rate was approximately 93% to 95% (Table 4) [9]. Sex, age, and sepsis were not significant factors that decided LES in appendectomy. These demonstrated that surgeons did not consider sex, age, and sepsis when deciding between LES and OES in appendectomy.

The laparoscopic surgery rate of cholecystectomy was 88.0% in the present study (Table 3); in the United States, this rate was approximately 95% (Table 4) [9]. The sex, age, and sepsis were significant factors when deciding to perform LES or OES in cholecystectomy. However, in the WSES survey, the shock condition is only an important patient-related limiting factor in appendectomy and cholecystectomy [2]. Based on the LES rate of appendectomy and cholecystectomy in Korea, this result is similar to that of these surgeries in the United States and appears to suggest that the use of laparoscopic techniques for appendectomy and cholecystectomy is the standard of care despite various limiting factors [9].

However, unlike the ease of performing LES for appendectomy and cholecystectomy, it is difficult to perform LES for esophageal perforation, necrosectomy for acute pancreatitis, strangulated ventral hernia, bowel perforation, adhesiolysis, and sigmoid resection [2].

Most emergency abdominal surgeries involve small bowel pathologies. The main pathologies of small bowel disease are obstruction, perforation, and bleeding where the open approach is the most accepted method. Laparoscopic surgery for small bowel obstruction could lead to complications due to the increase in the risk of iatrogenic bowel injury because of the difficulty in manipulating the distended bowel in the narrow working space available in the laparoscopic technique [6].

In the analysis of literature, the laparoscopic approach for small bowel pathologies is a suitable option for select cases that include small bowel obstruction with single-band adhesion, absence of perforation, diffuse peritonitis, and advanced abdominal distension and in patients with fewer comorbidities [6,11]. However, prospective randomized trials comparing LES and OES in the treatment of small bowel emergencies have not been published. Therefore, the decision to perform LES or OES depends on the patient’s condition and the surgeon’s preference [6]. The rate of small bowel LES was low at 10.6% in the present study and that in literature was approximately 6% to 10% (Table 4) [9,10].

Most gastric surgery cases involve peptic ulcer perforations wherein approximately 50% of anterior wall perforations are <5 mm in size [12]. Although perforations of <5 mm in the anterior wall are suitable for laparoscopic repair, the laparoscopic repair rate for peptic ulcer perforation is low. According to the WSES guidelines for perforated and bleeding peptic ulcer, a laparoscopic approach in perforated peptic ulcers is recommended in ‘stable” patients, while an open approach should be performed in the absence of laparoscopic skills and equipment as well in “unstable” patients [13].

The gastric LES rate was 8.0% in the present study and approximately 14% to 30% in the literature (Table 4) [9,10,14]. A recent meta-analysis has reported significant advantages of laparoscopic repair in terms of postoperative pain and wound infection. However, no significant differences in the overall postoperative mortality, suture leakage, postoperative abscesses, and reoperation rates in stable patients were observed between laparoscopic and open surgery [13,15]. In higher-risk patients, laparoscopic perforated peptic ulcer surgery may lead to conversion and mortality [16,17]. LES involving the small bowel and stomach can be more invasive and technically challenging for general and emergency general surgeons [9].

The colorectal LES rate was 20.9% in the present study and approximately 6% to 12% in the literature (Table 4) [10,18,19]. Also, laparoscopic colorectal surgery in an elective setting has many benefits compared to open surgery such as safety, reduced pain, less postoperative morbidity, less frequent intensive care unit admissions, shorter length of hospital stay, and lower costs, as well as improved quality of life [18]. Despite these benefits, fewer surgeons perform LES in colorectal disease. This is probably due to the increased complexity of the patient’s presentation, advanced or complicated disease, as well as the experience of the surgeon, on call during evening and night-time hours [18]. Also, colorectal LES covers various and distinct disease entities such as inflammatory bowel disease, diverticulitis, bleeding, colon cancer, rectal cancer, and procedures such as right hemicolectomy, transverse colectomy, left hemicolectomy, and the Hartmann procedure [19,20].

In LES of small bowel, stomach, and larger bowel, these groups have some similarities in that the OES rate is higher than the LES rate, and operation is more complex than appendectomy and cholecystectomy [2]. More patients with the same emergent disease have higher CCI, ESAS, sepsis, and shock ratio (Fig. 1–4). Therefore, systemic severity according to disease is an important limiting factor that decides between LES and OES in our study and WSES survey [2].

We thought that the variability in the healthcare infrastructure and patient-related factors between countries may result in differing trends in LES usage across the world. However, the active use of laparoscopic surgery in emergency settings is not always the right approach. In several studies, LES is attempted only in selected cases to ensure patient safety [21,22]. Published literature indicates that the use of LES has increased because of increased laparoscopic experience during training, improved surgical outcomes, and evolving efforts in research and laparoscopic sub-specializations of the acute care surgery department [9].

We believe that ideally, as surgeons become more comfortable with laparoscopic techniques, and gain relevant experience in postoperative critical care, they will be able to tackle the other factors limiting the use of this technique. Also, as hospitals become better equipped to support the technology, it is reasonable to hypothesize that the use of LES will increase in practice and will find a representation in global literature [19].

Our study has several limitations. First, this study was retrospective in nature, which led to selection bias regarding the inclusion and exclusion criteria. However, paradoxically, our study demonstrates surgeon’s decision-making selection bias based on various limiting factors in an emergency state. Second, another limitation in any LES study is the surgeon’s preference evaluation. Practically, the surgeon’s experience, confidence, mood, fatigue, and patient selection still remain important biases in the use of LES [2,9]. Third, heterogeneity in the social and base characteristics of the hospitals, including region, backup populations in the city, city size, and the availability of dedicated emergency surgeons and so on, may exist. Also, this study does not precisely represent the general data of the Korean population. Fourth, the postoperative outcomes including mortality, morbidity, or curability of the primary disease were not investigated. Fifth, the conversion rate was not investigated. Sixth, detailed various surgery types according to operated organ were not investigated. Seventh, the degree of emergency or exigency related to each enrolled patient was not investigated, although the decision to perform surgery was made in the emergency room. Eighth, traumatic, and pediatric abdominal emergencies were not investigated. Ninth, recent LES and OES data in 2020 to 2022, coronavirus disesase 2019-pandemic were not investigated because of the unordinary medical environment.

However, these limitations are likely outweighed by the large number of enrolled patients and the multicenter cohort. These limitations are relatively minor, and the results of this study could be representative of the state of LES in Korea.

In conclusion, although data from the three hospitals in our study does not represent the general Korean data and there are some limitations, compared to the LES data from other countries, the general LES state was similar in appendectomies, cholecystectomies, and small bowel surgeries. However, in gastric and colorectal surgeries, the LES state was different from those of other countries. This study demonstrated the utilization status of LES and OES and statistically significant limiting factors that should be considered when choosing between LES and OES in appendectomy, cholecystectomy, small bowel surgery, gastric surgery, and large bowel surgery. Further studies are required to analyze these differences. Also, the various limiting factors with respect to LES and specifically LES in ward patient emergencies need to be studied.

Ethical statements

This study was approved by the Institutional Review Boards of Yeungnam University Medical Center (No. 2022-06-033), Samsung Medical Center (No. 2022-08-110), and Asan Medical Center (No. 2022-1031). The requirement for informed consent was waived owing to the retrospective nature of the study. Medical records and clinical information were anonymized prior to the analysis.

Authors’ contributions

Conceptualization, Funding acquisition: JMB

Data curation: JMB, CYJ, KY, HJL, YTJ, SKH, SY

Formal analysis: JMB, MJK, SKH, HJL, KY, SY, EYK

Investigation: JMB, CYJ, KY, HJL

Methodology: JMB, SKH

Project administration: JMB, KY, HJL

Visualization: JMB, YTJ, EYK

Writing–original draft: JMB

Writing–review & editing: All authors

All authors read and approved the final manuscript.

Conflict of interest

All authors have no conflicts of interest to declare.

Funding/support

This work was supported by a grant from the Chunma Medical Research Foundation, Korea, 2022.

Data availability

Data sharing is not applicable to this article, as no datasets were generated or analyzed during the current study.

Patient’ demographics and clinical characteristics between the OES and LES groups

Patient’ demographics and clinical characteristics OES and LES group in operated organ

The overall statistical significance result between operated organ and variables

LES rate comparison between our study and references according to operated organ