Laparoscopic Articles from Laparoscopy Hospital

DR ANOLUE FREDRICK Bsc(Hons) , MB, chB ,FWACS
CONSULTANT OBSTETRICIAN AND GYNAECOLOGIST
IMO STATE UNIVERSITY TEACHING HOSPITAL ORLU IMO STATE NIGERIA

ABSTRACT

The role of diagnostic laparoscopy in the evaluation of female patients with suspected appendicitis is not in doubt. Opinion is however divided on the use of routine or selective diagnostic laparoscopy in the evaluation of these patients. A literature search using springelink , pubmed, and hirewire press of scientific articles and studies on the role of routine or diagnostic laparoscopy in female patients with suspected appendicitis was done. The negative appendectomy rate described as the presence of macroscopically normal appendix varied from 1.3% to 50% in the selective group and 5% to 26% in the routine group. Predominant non appendix pathologies were mainly gynecological .It was concluded that selective diagnostic laparoscopy after thorough clinical evaluation in consultation with Gynecologists is more cost effective with less morbidity.

INTRODUCTION

Appendectomy remain one of the most common abdominal operations in children and young adults (1).The clinical diagnosis of acute appendicitis based on symptoms, physical examination and serological test is relatively inadequate in women especially in the reproductive age group (2).Several reports (3, 4) have found the diagnostic accuracy of ultrasound and computed tomography (ct) to be of limited value in the pre operative evaluation of patients with suspected appendicitis. In female patients this diagnosis is further made difficult by the different pathological and physiological changes of the female reproductive organs .The incidence of wrong diagnosis as evidenced by negative appendectomy is therefore high especially in female patients .Rates of 15% to 50 % has been quoted in large prospective studies (5,6) for female patients. It has been widely accepted that diagnostic laparoscopy is reliable in assessing the appendix and has reduced the numbers of unnecessary appendicectomy in women (7,8). In addition it has been useful in the diagnosis of alternative pathology when it exists (9). There is however no concensus on whether diagnostic laparoscopy should be applied selectively or routinely in the diagnosis of suspected appendicitis in female patients.

The aim of this study is to review the literature for the practice of selective and routine diagnostic laparoscopy in women with suspected appendicitis. The negative appendectomy rate and its implication for practice guideline will be discussed.

METERIALS AND METHOD

This study was a literature review .Electronic search was made in the following websites for scientific journals

•  Springer link

•  Highwire press

•  Pubmed

The following headings were used for the search

•  Diagnostic laparoscopy

•  Laparoscopic appendectomy

The following selection criteria was adopted

•  All articles reporting routine and /or selective diagnostic laparoscopy in cases of suspected appendicitis, clinically diagnosed appendicitis or right lower quadrant pain.

•  “Routine” for the purposes of the review is when at least 75% of the appendectomies were preceded by a diagnostic laparoscopy.

•  The articles involving females alone were selected. Where an article involves men and women, the female subset is analysed only.

•  All ages of female were choosen; premenarchal, reproductive years and postmenopausal.

•  Articles involving less than 20 patients were not reviewed.

MEASUREMENTS AND MAIN RESULT

Rate of negative appendectomy: Negative appendectomy is defined as a surgical specimen of an appendix with normal histopathological features.

RESULT

The negative appendectomy rates reported in various studies when the policy of selective diagnostic laparoscopy was practiced ranged from 1.3% to 44% (10, 11, and 12). The rates when routine diagnostic laparoscopy was used ranged from 5% to 26 %( 11, 12, 13, 14, and 15).

A large retrospective study comparing selective versus routine policy noted a 32% negative appendectomy rate compared to 5% which was statistically significant (11).In this study no mention of removal of the normal looking appendix was made. There was also no follow up of the patients to evaluate possible morbidity for those reported to have negative appendix. The four other prospective studies of routine diagnostic laparoscopy noted rates of 14%,26%, 4% and 7%(12,13,14,15).However in the study with a negative appendectomy rate of 26% the authors had a practice of removal of normal looking appendix unless any other pathology was found. They recorded no increased morbidity with this approach. In the study with a negative appendectomy rate of 14%, the surgeons left the appendix and followed up their patients for 16 months. They were symptom free. The study also had an increased NAR of 44% in the selective laparoscopy group.

Most of the non appendix pathology was mainly gynaecological as expected (12, 13).They included ovarian cysts, ruptured follicles, pelvic inflammatory disease, fibroid degeneration and endometriosis.

Table 1 summarises the negative appendectomy rate and the practice of removal of normal looking appendix in the literatures reviewed.Table 2 summarises the various gynaecological pathology encountered during the study.

TABLE 1

NEGATIVE APPENDECTOMY RATE(NAR),PRACTICE OF REMOVAL OF NORMAL LOOKING APPENDIX(PMA),PERCENTAGE OF HISTOLOGICAL ABNORMALITY IN NORMAL LOOKING APPENDIX(PAA).

TABLE 2

Common Gynaecological Conditions Encountered at Laparoscopy

Ovary:

•  Ruptured ovarian follicle

•  Torsion of the ovary

Fallopian tube:

•  Ectopic pregnancy

•  Acute salpingit is

•  Pyosalpinx

Uterus:

•  Endometritis

•  Degenerating fibroids

•  Adenomyosis

Endometriosis involving various reproductive organs

DISCUSSION

The operations of acute appendicitis still remain one of the most common surgery in the developed and developing world (16). Despite more than 100years Experience ,accurate diagnosis still evades the surgeons and avoiding perforation and subsequent complication must be weighed against removal of a normal appendix –a negative appen dectomy .The issue of negative appendectomy is particularly relevant in female patients whose pelvis houses the internal reproductive organs with its regular physiological cyclical changes and pathology .These changes in many instances mimic the presentation of appendicitis and has been responsible for the high negative appendectomy in female patients (5,6).

The advent of laparoscopy in the last decade has brought the hope that the technology will greatly reduce the high negative appendectomy rates with or without the application of other emerging modalities like ultrasonagraphy and computed tomography. The results has however been variable albeit disappointing(3,4,17,18).This has resulted in variable application of laparoscopy routinely or selectively in dealing with suspected cases of appendicitis. The European Association of Endoscopic Surgeons (EAES) guidelines has emphasized the value of routine laparoscopy as a diagnostic tool in young women(19).There are also other large and small studies recommending routine laparoscopy in women(11,12,13,14)

Most surgeons agree that a negative appendectomy is a surgical specimen of the appendix devoid of any pathology (inflammation, malignancy etc).It is not the presence of a normal looking appendix during diagnostic laparoscopy. Reducing the population of patients with negative appendectomy and improving diagnosis has been in the mind set of Surgeons advocating for routine diagnostic laparoscopy. These surgeons will almost likely leave a normal looking appendix with or without an associated pathology. This practice will keep the negative appendectomy rate low but at what cost? Tzovaras et al (13) has demonstrated that with a policy of routine diagnostic laparoscopy and removal of the normal looking appendix, the rate of negative appendectomy remained high at 26%.The reduction of negative appendectomy will therefore be at a cost of incomplete analysis of possibly diseased appendix. Reports have emphasised the incompleteness of macroscopic examination of the appendix in the presence of symptoms. Prolonged relief of symptoms of the female patients in the presence of normal looking appendix has been well documented (13, 20, 21, 22).

The cost associated with “unnecessary” removal of the appendix for which routine diagnostic laparoscopy seeks to reduce may as well be cancelled by the cost of recurrencies, readmission and treatment. Reports of acute appendicitis days after leaving macroscopically normal looking appendix has been documented(22).Significant histopathological changes in normal looking appendix has also been documented(20,21) There is also the cost of routine use of laparoscopy as well as morbidity associated with an invasive procedure often requiring anesthesia.

A negative appendectomy rate of 1.3% one of the lowest in literature was achieved through a careful application of clinical examination, ultrasound when necessary and complete gynaecological evaluation of the patients (23). Most reviews that computed the incidental findings noted the preponderance of gynaecological pathology (12,13).The Gynaecologist should be involved early in equivocal cases of appendicitis. A study which suggested that Gynaecological examination did not improve the high negative appendectomy rate did not randomize the allotment of patients and could be biased (24).Pitfalls in diagnosis can not be completely eliminated even with the application of a routine invasive procedure like laparoscopy.

There is a fear that the current recommendation of routine diagnostic laparoscopy and subsequent laparoscopic appendectomy may be fuelled by the desire by surgeons to perform laparoscopic appendectomy. Selective diagnostic laparoscopic evaluation of the female patient suspected to have appendicitis should be the standard of care after a gynaecological consult has not resolved the diagnosis.Negative appendectomy should be seen in the light of relief of symptoms and avoidance of future diagnostic dilemma.

CONCLUSION

Selective diagnostic laparoscopy after thorough clinical evaluation, investigations and consultation with a Gynaecologist should be the standard of care in unresolved suspected appendicitis. It is cost effective and has no added morbidity.

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