Laparoscopic Articles from Laparoscopy Hospital

Dr. Riadhi Yulianto
Tasikmalaya, Jabar
INDONESIA

(To be s ubmitted as a part of a requirement of DMAS course at Laparoscopy Hospital, New Delhi, India)

Background

The inquiry of whether there are benefits of laparoscopic appendicectomy (LA) in perforated appendicitis remain to be answered. The purpose of this study is to review literatures to find the role of the LA in perforated appendicitis. Many trials confirm some advantages of LA over open appendicectomy (OA) in acute appencitis, however, the significance of LA in perforated appendicitis is still much debated. Thus, the answer as to whether there are benefits of LA over OA in perforated appendicitis remains to be solved.

Methods

Articles of relevant studies are searched from the Internet using Google, Yahoo, HighWire Press, SpringerLink, PubMed etc, available at Laparoscopy Hospital, New Delhi.

Results

Many studies concerning both laparoscopic and open appendicectomy seem to be contradictorily. In fact, the average rate of abdominal abscesses, negative appendicectomies, and hospital stays are very similar according to a recent review of many retrospective studies. Laparoscopy has some advantages though, including decreasing postoperative pain, shorter time to return to usual activities, lower incidence of wound infections or dehiscence as well as cosmetic.

Conclusion

This review shows that laparoscopic appendicectomy is a safe and effective approach for perforated appendicitis. It results in shorter hospital stay and reduces wound infection complications than does the open approach. The advantage of laparoscopic appendicectomy for perforated appendicitis also is supported by the similar lengths of hospital stay and return to regular activity intervals between the laparoscopic groups in many studies. Laparoscopic appendicectomy also leads to a significant reduction of pain as well as of early postoperative complications in perforated appendicitis and therefore should be considered as the procedure of choice.

Keyword

laparoscopic appendicectomy, perforated appendicitis

Etiology

The etiology of appendicitis is obstruction of the lumen of the appendix followed by infection. In 60% of patients, obstruction is caused by hyperplasia of the submucosal follicles. A fecalith or fecal stasis causes luminal obstruction 35% of the time and is usually observed in adults. Obstruction may also be caused by foreign bodies (4%) and tumors (1%). Following obstruction, an increase in mucus production occurs, and cause an increased pressure. With increased pressure and stasis from obstruction, bacterial overgrowth developed. The mucus then turns into pus that leads a further increase in luminal pressure. This will distend the appendix and cause a visceral pain, typically located in the epigastric or periumbilical region. Since the luminal pressure continues to increase, lymphatic obstruction occurs, leading to an edematous appendix. This stage is identified as acute or focal appendicitis. The overlying parietal peritoneum becomes irritated, and the pain now localizes to the right lower quadrant (RLQ). This series of events results in the classic migrating abdominal pain described in patients with appendicitis.

Further increase in pressure leads to venous obstruction, edema and ischemia of the appendix. At this stage, bacterial invasion of the wall of the appendix occurs and is known as acute suppurative appendicitis. Finally, with continued pressure increases, venous thrombosis and arterial compromise occur, gangrene and perforation will develop. If the body successfully walls off the perforation, the pain may actually subside. However, symptoms do not fully resolve. Patients may still have underlying right lower quadrant pain, decreased appetite, change in bowel habits (eg, diarrhea, constipation), or intermittent low-grade fever. If the perforation is not effectively walled off, then diffuse peritonitis will take place.

Clinical Signs

The classic presentation of a patient with appendicitis includes a history of initial periumbilical or epigastric abdominal pain migrating to the RLQ. The pain is continuing in onset and gradually worsens. Anorexia, nausea, and vomiting are typically associated with the disease. Early on, the patient has a low-grade fever whereas in the patient with higher fevers is associated with a perforated appendix. On physical examination, we can find that movement of the patient worsens the pain. Local tenderness to palpation can be frequently observed. Tenderness on the right side during rectal examination may be found, whereas pelvic and testicular examination findings are normal. Other signs (eg, Rovsing, psoas, obturator) are undependable and typically occur late in the disease process. Nevertheless, only 55% of patients with appendicitis come with classic history and physical findings since the early signs and symptoms are primarily reliant upon the location of the tip of the appendix, which is greatly variable.

Therapy

Although many controversies exist over the non operative management of acute appendicitis, appendicectomy remains the only curative treatment of appendicitis. The first report of an appendicectomy came from Amyan, a surgeon of the English army. Amyan performed an appendicectomy in 1735 without anesthesia to remove a perforated appendix. Reginald H. Fitz, of Harvard who urged early surgical intervention, first described appendicitis in 1886. At the end of the 19th century, the English surgeon H. Hancock successfully performed the first appendicectomy in a patient with acute appendicitis and several years later the American C. McBurney brought out a series of reports that became the foundation of the subsequent diagnostic and therapeutic management of acute appendicitis in the present day.

Surgical Management

Appendicitis is the second most common cause of acute abdominal pain and thousands of open appendectomies (OA) have been undertaken and the mortality and morbidity have gradually decreased in the last few decades as a result of a more effective antibiotics, early diagnosis, and improvements in anesthesiology and surgical techniques. Prior to the advent of laparoscopy, appendectomies were conducted as an open technique with excellent outcomes. While other laparoscopic procedures such as cholecystectomy have shown a benefit over the open technique, the benefit of laparoscopic appendectomy especially in perforated appendicitis has not been demonstrated clearly. There have been many prospective randomized controlled trials in the comparing laparoscopic appendectomy with open appendectomy. (1–10)

Since 1987, many surgeons have begun to treat appendicitis laparoscopically and this procedure has now rapidly developed and conducted all around the world. Although laparoscopic appendectomy was performed since 21 years ago, the dispute between open and laparoscopic appendicectomy for perforated appendicitis remains active. Inspite the brief recovery time and generally good results the laparoscopic approach for perforated appencitis remains to be argued. Many studies concerning both laparoscopic and open appendicectomy seem to be contradictorily. In fact, the average rate of abdominal abscesses, negative appendicectomies, and hospital stays are very similar according to a recent review of many retrospective studies. Laparoscopy has some advantages though, including decreasing postoperative pain, a shorter time to return to usual activities, lower incidence of wound infections or dehiscence as well as cosmetic. (11-13)

Diagnosis of perforated appendicitis can be reasonably easy when there is unambiguous peritonitis with high fever or marked leukocytosis, while patients who have perforated but do not demonstrate these symptoms may not be diagnosed until surgery. Laparoscopic appendectomy is an acceptable alternative to OA or most patients and carries a special benefit for patients in whom the diagnosis is not easy to make. In a prospective randomized trial comparing OA to LA, Martin et al. observed that cases of perforated appendicitis that were operated laparoscopically enjoyed a significant decrease in hospital costs, resulting from a much shorter stay. (19)

Perforated appendicitis, on the other hands, is associated with an increased rate of postoperative abdominal and wound infections. The surgical management of perforated appendicitis generally requires longer operating time, longer incision and produces more surgical stress to the patients, compared with that for acute appendicitis. Moreover, the fact that surgical wound is exposed to contaminated fluid will result in an increased rate of wound infections. Hence, it is plausible that LA could represent clinically relevant advantages over OA in patients with perforated appendicitis, since LA is associated with less wound surface area exposed to contamination and potentially facilitates direct visualization during peritoneal lavage. However, whereas several studies have challenged the role of laparoscopy in perforated appendicitis, the results are controversial and the value of LA is not fully explained. (11–18) Several retrospective studies show that with perforated appendicitis have shown that the risks of intra-abdominal abscess and fistula formation are statistically similar between laparoscopic and open groups. It has also been recommended that the laparoscopic technique can result in a more complete and effective for the peritoneal cavity cleansing. This idea is back up by studies showing fewer wound infections with the laparoscopic approach. LA may also be advantageous in terms of optimizing exposure and thus minimising the risk of retraction- associated tissue disruption.

From the above mentioned studies we can find the fact that no statistically significant difference was found in the rate of infectious complications, including the development of an intra abdominal abscess or superficial wound infection. (20) Even numerous result of clinical studies on laparoscopic appendicectomy for perforated appendicitis have been controversial but no prospective randomized trial has shown a significant increase in the rate of intra abdominal abscess after laparoscopic appendicectomy for perforated appendicitis. However, in order for the surgery to be successful, the proper technique of laparoscopic appendicectomy should be emphasized that the surgeon must take great care to remove the complete appendix with a safe closure of the appendiceal stump. The surgeon should ensure the safe removal of the appendix while minimizing contact with visceral abdominal fascial surfaces in an endobag. If there is a collection of pus in the abdominal cavity, a thorough irrigation of should be performed with total aspiration of the lavage fluid. Several studies finds that the use of the endo-GIA stapler is the safest technique for stump closure and may avoid complications from the spillage of stool and breakdown of the appendiceal stump. (10,17) Another way is a closure of appendiceal stump by endoloop and the use of a simple intracorporeal Vicryl tie on the appendiceal stump. Wound protection may be achieved by removing the specimen through one of the trocars or by using an endobag or surgical glove, thus minimizing contact with visceral or fascial surfaces and reducing intra abdominal contamination.

It has also been suggested that the laparoscopic technique can result in a more complete and effective lavage of the peritoneal cavity. We hypothesize that during laparoscopic appendicectomy for perforated appendicitis, there is generalized intraabdominal contamination, which is reduced significantly by meticulous and targeted irrigation of the abdominal cavity. This reason is supported by studies demonstrating fewer wound infections with the laparoscopic approach. With this mind the European Association for Endoscopic Surgery and other interventional techniques stated the laparoscopic approach can be applied to cases of complicated appendicitis if the proper expertise is available. This reflects the surveillance that surgeons with less laparoscopic experience have a higher rate of conversion to on open procedure. The following is the study of WULLSTEIN et al (20) comparing LA vs OA which shows that in terms of complication, the difference of LA vs OA in perforated appendicitis is not significant whereas the benefit of LA vs OA has been scientifically proven.

Conclusion

Since the introduction of LA for the treatment of appendicitis more than 20 years ago, there has been no consensus on its advantages or disadvantages in comparison with OA. The above studies showed that LA is a safe and effective approach for perforated appendicitis. It resulted in shorter hospital stay and reduced wound infection complications than did the open approach. The advantage of LA for complicated appendicitis also is supported by the similar lengths of hospital stay and return to regular activity intervals between the laparoscopic groups. Equally important, the rates of postoperative complications are the same between the two groups. To sum up, we are in the favor of applying LA over OA in the case of perforated appendicitis, nevertheless, further studies are needed to confirm the role of laparoscopic appendicectomy in the management of perforated appendicitis.

References

•  Hansen JB, Smithers BM, Schache D, et al. Laparoscopic versus open appendectomy: prospective randomized trial. World J Surg 1996;20:17–21.

•  Chung RS, Rowland DY, Li P, et al. A meta-analysis of randomized controlled trials of laparoscopic versus conventional appendectomy. Am J Surg 1999;177:250–256.

•  Garbutt JM, Soper NJ, Shannon WD, et al. Meta-analysis of randomized controlled trials comparing laparoscopic and open appendectomy. Surg Laparosc Endosc 1999;9:17–26.

•  Golub R, Siddiqui F, Pohl D. Laparoscopic versus open appendectomy: a metaanalysis. J Am Coll Surg 1998; 186:545–553.

•  Temple LK, Litwin DE, McLeod RS. A meta-analysis of laparoscopic versus open appendectomy in patients suspected of having acute appendicitis. Can J Surg 1999; 42:377–383.

•  Sauerland S, Lefering R, Holthausen U, et al. Laparoscopic vs conventional appendectomy: a meta-analysis of randomized controlled trials. Langenbecks Arch Surg 1998; 383:289–295.

•  Milewczyk M, Michalik M, Ciesielski M. A prospective, randomized, unicenter study comparing laparoscopic and open treatments of acute appendicitis. Surg Endosc 2003; 17:1023–1028.

•  Apelgren KN, Molnar RG, Kisala JM. Laparoscopic is not better than open appendectomy. Am Surg 1995;61:240–243.

•  Mutter D, Vix M, Bui A, et al. Laparoscopy not recommended for routine appendectomy in men: results of a prospective randomized study. Surgery 1996;120:71–74.

•  Katkhouda N, Mason RJ, Towfigh S, et al. Laparoscopic versus open appendectomy: a prospective randomized double-blind study. Ann Surg 2005;242:439–450.

•  Frazee RC, Bohannon WT. Laparoscopic appendectomy for complicated appendicitis. Arch Surg 1996;131:509–513.

•  Johnson AB, Peetz ME. Laparoscopic appendectomy is an acceptable alternative for the treatment of perforated appendicitis. Surg Endosc 1998;12:940–943.

•  Khalili TM, Hiatt JR, Savar A, et al. Perforated appendicitis is not a contraindication to laparoscopy. Am Surg 1999; 65:965–967.

•  Guller U, Hervey S, Purves H, et al. Laparoscopic versus open appendectomy: outcomes comparison based on a large administrative database. Ann Surg 2004; 239:43–52.

•  Bonanni F, Reed J, Hartzell G, et al. Laparoscopic versus conventional appendectomy. J Am Coll Surg 1994; 179:273–278.

•  Klingler A, Henle KP, Beller S, et al. Laparoscopic appendectomy dose not change the incidence of postoperative infectious complications. Am J Surg 1998;175:232–235.

•  Piskun G, Kozik D, Rajpal S, et al. Comparison of laparoscopic, open, and converted appendectomy for perforated appendicitis. Surg Endosc 2001;15:660–662.

•  So JB, Chiong EC, Chiong E, et al. Laparoscopic appendectomy for perforated appendicitis. World J Surg 2002;26:1485–1488.

•  Martin LC, Puente I, Sosa J, Bassin A, Breslaw R, McKenney MG, Ginzberg E, Sleeman D (1995) Open versus laparscopic appendectomy: a prospective randomized comparison. Ann Surg 222: 256–262.

•  Wullstein, C.,Barkhausen, S ,Gross JE, Laparoscopy In Complicated Appendicitis, Dis Colon Rectum, November 2001.