Thirteen studies (n=658) were included: 2 RCTs (n=161), 4 prospective non-randomised studies (n=228) and 7 retrospective controlled observational studies (n =264).
One of the RCTs used an adequate method of randomisation; the other did not report the methods used. In only one of the RCTs was the outcome assessor blinded to the treatment group; the outcome assessment was not blind in the other studies. Only four of the studies assessed the baseline comparability of the treatment groups.
The rates of conversion to open repair ranged from 0 to 29.1%. Reasons for conversion were given. The most common reasons were difficulty in identifying the perforation site, large perforation and technical problems.
The results for duration of the operation were mixed. Five studies found significantly longer operating times using laparoscopic versus open surgery, while another five showed no significant difference between the methods.
All 3 studies reporting post-operative pain scores found that laparoscopic repair significantly reduced pain scores compared with open repair. Eight of the 10 studies reporting analgesic consumption found that laparoscopic repair significantly reduced analgesic requirement in comparison with open repair; 2 studies found no difference between the treatments.
In terms of post-operative complications, laparoscopic repair did not significantly reduce overall chest infection analgesia compared with open repair (10 studies; OR 0.79, 95% CI: 0.38, 1.62, P=0.51); no significant statistical heterogeneity was found (P=0.14). Compared with open repair, laparoscopic repair significantly reduced the wound infection rate (6 studies; OR 0.39, 95% CI: 0.16, 0.94, P=0.036), but did not significantly increase leakage (7 studies; OR 1.49, 95% CI: 0.53, 4.24, P=0.45); no significant statistical heterogeneity was found (P=0.50 and P=0.87, respectively). There was no statistically significant difference between open and laparoscopic repair for intra-abdominal collection (7 studies; OR 1.99, 95% CI: 0.79, 5.02, P=0.15); no significant statistical heterogeneity was found (P=0.84). Studies suggested that laparoscopic repair reduced prolonged ileus in comparison with open repair, but the result was not statistically significant (5 studies; OR 0.62, 95% CI: 0.20, 1.92, P=0.41); no significant statistical heterogeneity was found (P=0.97).
Laparoscopic repair significantly increased reoperation compared with open repair (overall rate 3.7% versus 1.9% with open). The OR (8 studies) was 2.52 (95% CI: 1.02, 6.20, P=0.045); no significant statistical heterogeneity was found (P=0.69).
Laparoscopic repair was associated with lower mortality than open repair (4.8% versus 10.2% with open), but the result was not statistically significant. The OR (11 studies) was 0.63 (95% CI: 0.34, 1.15, P=0.13); no significant statistical heterogeneity was found (P=0.86).
All 13 studies showed that hospital stay was either shorter or equal with laparoscopic surgery versus open repair; the difference reached statistical significance in 3 studies.
Five of the 6 studies reporting time to resume normal diet found similar results for both treatments; one study found in favour of laparoscopic repair. One study found that time to return to work was significantly shorter after laparoscopic repair. One study found that time to return to normal activities was significantly shorter after laparoscopic repair (10 versus 26 days with open repair).