Laparoscopic appendectomy for perforated appendicitis

Perforated appendicitis treated with laparoscopic appendicectomy or open appendicectomy: A meta-analysis

Aim

This analysis compared the impact of laparoscopic appendicectomy (LA) and open appendicectomy (OA) on treating adult perforated appendicitis (PA).

Methods

Articles relating to LA and OA in treating PA were retrieved from databases including PubMed, Cochrane Library and Embase since their founding to January 2022. These articles were independently filtered based on the inclusion and exclusion criteria by two investigators. The quality of these articles was assessed and article data were extracted. Dichotomous data were presented in the form of odd's ratio (OR), whereas continuous data were in the form of weighted mean difference (WMD). The included articles reported at least one of the following outcomes: intra-abdominal abscess (IAA), wound infection, operative time, hospital stay and complications.

Results

Three randomised control trials (198 LA cases vs. 205 OA cases) and 12 case - control trials (914 LA cases vs. 2192 OA cases) were included. This analysis revealed that although the IAA formation rate was similar in the LA and OA groups (OR: 1.28, 95% confidence interval [CI]: 0.87-1.88), the wound infection rate was lower in the LA group (OR: 0.38, 95% CI: 0.28-0.51). Furthermore, LA was associated with shorter hospital stay (WMD: -1.43 days, 95% CI: -2.33--0.52) and fewer complications than OA (OR: 0.40, 95% CI: 0.28-0.57).

Conclusion

LA has significant benefits in treating PA and is associated with better post-operative outcomes such as shorter hospital stay, lower incidence of wound infection and other complications. However, more studies with randomised and large-sample populations are still required to determine the clinical benefit of LA in treating PA.

Post-Operative Outcomes of Laparoscopic Appendectomy in Acute Complicated Appendicitis: A Single Center Study

BACKGROUND

Acute appendicitis (AA) is a surgical emergency because of inflammation in the appendix leading to swelling, whereas acute complicated appendicitis is characterized by a gangrenous or perforated appendix with or without periappendicular abscess, peritonitis, and an appendicular mass. The laparoscopic approach in complicated acute appendicitis is a viable alternative method but is not practiced in all cases because of technical difficulties and unpredictable complications. Thus, the present study aimed to evaluate the primary and secondary outcome predictors of laparoscopic appendectomy in complicated appendicitis.

METHODS

A single-center prospective observational study was carried out after the approval of the Institutional Ethics Committee (IEC). A total of 87 complicated acute appendicitis patients were included in the study. Clinico-demographic features such as age, gender, duration of surgery, post-operative pain, and hospital stay were monitored in different age groups of <20, 20-39, and >40 years, and the primary and secondary outcomes of laparoscopic surgery in acute complicated appendicitis were measured.

RESULT

Acute complicated appendicitis cases were observed mostly in people older than 42 years in the total study population. Laparoscopic appendectomy was conducted in all 87 acute complicated appendicitis patients, and the major surgical outcome predictors were monitored, such as mean operating time (87.9 minutes), post-operative pain (3.9 scores), and post-operative stay (6.7 days). Post-operative complications such as drain site infection (1.14%), enterocutaneous fistula (2%), and intra-abdominal abscess (7%) were observed.

CONCLUSION

Based on our observations, a laparoscopic appendectomy can be considered a viable alternative with an acceptable complication rate. Operative time varies from 84 to 94 minutes in different age groups and with the extent of the disease.

Machine learning prediction model for postoperative outcome after perforated appendicitis

Purpose

Appendectomy for acute appendicitis is one of the most common operative procedures worldwide in both children and adults. In particular, complicated (perforated) cases show high variability in individual outcomes. Here, we developed and validated a machine learning prediction model for postoperative outcome of perforated appendicitis.

Methods

Retrospective analyses of patients with clinically and histologically verified perforated appendicitis over 10 years were performed. Demographic and surgical baseline characteristics were used as competing predictors of single-patient outcomes along multiple dimensions via a random forest classifier with stratified subsampling. To assess whether complications could be predicted in new, individual cases, the ensuing models were evaluated using a replicated 10-fold cross-validation.

Results

A total of 163 patients were included in the study. Sixty-four patients underwent laparoscopic surgery, whereas ninety-nine patients got a primary open procedure. Interval from admission to appendectomy was 9 ± 12 h and duration of the surgery was 74 ± 38 min. Forty-three patients needed intensive care treatment. Overall mortality was 0.6 % and morbidity rate was 15%. Severe complications as assessed by Clavien-Dindo > 3 were predictable in new cases with an accuracy of 68%. Need for ICU stay (> 24 h) could be predicted with an accuracy of 88%, whereas prolonged hospitalization (greater than 7–15 days) was predicted by the model with an accuracy of 76%.

Conclusion

We demonstrate that complications following surgery, and in particular, health care system-related outcomes like intensive care treatment and extended hospitalization, may be well predicted at the individual level from demographic and surgical baseline characteristics through machine learning approaches.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-022-02456-1.

An evaluation of the choice of the treatment for the acute appendicitis an original research

Introduction:

Material and Methods:

Results:

Conclusion:

The management of appendicular abscesses in a Tunisian Tertiary Care Hospital

Background

This study aims to describe the epidemiological, clinical, and radiological features of appendicular abscesses, compare the different approaches, and assess the safety and utility of laparoscopy in its management.

Methods

This descriptive retrospective study was carried out over 3 years extending from January 2017 to December 2019, reporting 150 appendicular abscesses cases. Data were collected from the register of the general surgery department B of the Rabta hospital. Cases with appendicular abscess were included. Files concerning patients with early appendicitis, non-appendicular abscesses or generalized appendicular peritonitis were excluded. Data were analysed with Statistical Package for the Social Sciences (SPSS) software. In univariate analysis, we used the chi² test, the Fischer test, the Student t test. The factors retained by the univariate analysis were introduced into a logistic regression model. The significance level was set to 0.05.

Results

The mean age was 40.51 years. The gender ratio in patients with appendicular abscesses was M:F 1.94:1. Pain in the right iliac fossa associated with fever was the most common symptom (78% of cases). Clinical examination showed tenderness in the right iliac fossa in 38% of cases, rebound and guarding were found in 77 patients (51.3%), and a palpable mass was noted in 4 cases (4.2%). Imaging was done to confirm diagnosis; 46 patients underwent ultrasonogram and this confirmed the diagnosis in 26 patients (56%), while among the 71 patients who underwent CT abdomen confirmatory diagnosis was made in 65 patients (91.55%). An appendectomy was performed in 148 patients (98.6%) via laparoscopic approach in 94 patients, open Mac burney procedure in 32 cases (21.3%) and midline incision in 24 cases (16%). Two patients had an ileocecal resection. The appendix was most commonly located retrocecally (55.3%) in our cohort. The laparoscopic approach was performed in 94 patients (62.6%), and we had to convert in 44 patients due to dissection difficulties (46.8%). Among patients who underwent laparascopic approach 7 had developed peritonitis.. There were only 2 deaths. The mortality rate was 0,013%. The median duration of outpatient followup was 6 months (4–24 weeks) and was uneventful.

Conclusion

Appendicular abscess is a disease of young adults more common in men. Location of the appendix in our case series was mostly retroceacal. Laparoscopy was associated with good outcomes; peritonitis was uncommon and mortality was rare. The laparoscopic approach is a safe surgical technique for treating appendicular abscess and it can be considered as the routine approach for this condition In developing countries with limited technical resources, laparoscopy guarantees the absence of recurrence, reduces healthcare costs and decreases the risk of treating a severe disease conservatively.

Structured Training for Lap Appendectomy for Residents (STAR Trial)-A Randomized Pilot Study

OBJECTIVE

Laparoscopic appendectomy is a common operation that is frequently performed by junior surgical residents. We investigated the effect of a structured training program on the proficiency of junior residents in acquiring skills necessary in this operation.

DESIGN AND PARTICIPANTS

This is a randomized pilot trial. Between December 2014 and July 2018, twenty junior residents were recruited for this study. 11 were randomized to receive a structured training program of supervised, task-specific training. Each resident subsequently performed ten cases of laparoscopic appendectomy with their performance assessed for the last 5. The GOALS scale was used as the primary endpoint. Secondary endpoints were perioperative outcomes. The effect of intervention on these outcomes were evaluated assuming a linear mixed effect multi-level model. The study was single-blinded as the assessors did not know which group each resident belonged to.

RESULTS

There were no statistically significant differences in the total GOALS score or any of its individual domains. After adjusting for the number of operations done within the trial, the mean difference between the total GOALS score was 0.07 (95% CI -0.76 to 0.90, P=0.866). Blood loss, hospital stay and postoperative complication rates were similar. There was suggestion of a shorter operative time (effect estimate -9.03, 95% CI -19.56 to 1.50) in the intervention arm although statistical significance was not achieved. No avoidable adverse events due to this study were recorded.

CONCLUSION

Structured training program did not significantly improve surgical performance and outcomes in laparoscopic appendectomy in this pilot trial. Despite these findings, residents can still potentially mount their learning curves in laparoscopy earlier in a safe environment with such a program which is especially important in the era of minimally invasive surgery.

Variations and morphometric features of the vermiform appendix: A systematic review and meta-analysis of 114,080 subjects with clinical implications

Determining the true and indisputable data regarding the vermiform appendix (VA) morphology is of a great clinical interest. The aim of this study was to provide the best evidence-based anatomical overview of the variations in location and size of VA using a systematic and meta-analytical approach. A systematic review with meta-analysis was performed of studies reporting variants of the location and morphometric data regarding the VA. The MEDLINE/PubMed, ScienceDirect, EMBASE, BIOSIS, SciELO, and Web of Science databases were thoroughly searched throughout June 2018. The reported locations of the body of the VA were re-classified into a new, standardized classification system divided into nine categories. The AQUA tool was used to assess the quality of included studies. The research was conducted following PRISMA guidelines and registered at PROPSERO database. Our meta-analysis included 242 studies (n = 114,080). Overall, the VA was most commonly found in the retrocecal location (32.1%, 95%CI: 29.2-35.1), followed by the pelvic (28.5%, 95%CI: 26.7-30.4) and ileal (14.5%, 95%CI: 11.8-17.7) locations. Subjects without known appendiceal pathologies had significantly smaller VA outer diameters (5.84 mm, 95%CI: 5.68-5.99) than patients diagnosed with acute appendicitis (10.64 mm, 95%CI: 10.14-11.15). The overall pooled mean length of the VA was 80.29 mm (95%CI: 76.68-83.89). Significant differences were found in size of the VA between imaging modalities. The results obtained from this evidence-based anatomy study will improve the clinical understanding of the VA anatomy, which in turn will have major implications for clinical practice. Clin. Anat. 32:85-98, 2019. © 2019 Wiley Periodicals, Inc.

Comparison of Open Appendectomy and Laparoscopic Appendectomy in Perforated Appendicitis

Introduction Laparoscopic appendectomy for nonperforated appendicitis is associated with improved outcomes. This study compares laparoscopic appendectomy and open appendectomy in cases of a perforated appendix by assessing surgical site infection, mean operating time, and length of hospital stay. Materials and methods This study was a prospective randomized study conducted at the Department of Surgery, Holy Family Hospital, Rawalpindi, Pakistan, from January 2016 to January 2017, by randomly allotting the laparoscopic or the open appendectomy technique to 130 patients by the lottery method. Patients having a perforated appendix were included after they provided informed consent. Data were entered and analyzed using IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY, US). Results The frequency of wound site infection was significantly higher in open appendectomy (27.69%) than in the laparoscopic approach (10.77%; p=0.01). Mean hospital stay was slightly longer in the laparoscopic approach (4.38 ± 1.09 days) than in open appendectomy (4.18 ± 0.77 days; p=0.23). Mean operating time for laparoscopic appendectomy and open appendectomy was 46.98 ± 2.99 minutes and 53.02 ± 2.88 minutes, respectively (p<0.000). Conclusion Laparoscopic appendectomy was associated with fewer surgical site infections and shorter mean operating time than an open appendectomy.

Laparoscopic appendicectomy is superior to open surgery for complicated appendicitis

BACKGROUND

Over the last three decades, laparoscopic appendicectomy (LA) has become the routine treatment for uncomplicated acute appendicitis. The role of laparoscopic surgery for complicated appendicitis (gangrenous and/or perforated) remains controversial due to concerns of an increased incidence of post-operative intra-abdominal abscesses (IAA) in LA compared to open appendicectomy (OA). The aim of this study was to compare the outcomes of LA versus OA for complicated appendicitis.

METHODS

A systematic literature search following PRISMA guidelines was conducted using MEDLINE, EMBASE, PubMed and Cochrane Database for randomised controlled trials (RCT) and case-control studies (CCS) that compared LA with OA for complicated appendicitis.

RESULTS

Data from three RCT and 30 CCS on 6428 patients (OA 3,254, LA 3,174) were analysed. There was no significant difference in the rate of IAA (LA = 6.1% vs. OA = 4.6%; OR = 1.02, 95% CI = 0.71-1.47, p = 0.91). LA for complicated appendicitis has decreased overall post-operative morbidity (LA = 15.5% vs. OA = 22.7%; OR = 0.43, 95% CI: 0.31-0.59, p < 0.0001), wound infection, (LA = 4.7% vs. OA = 12.8%; OR = 0.26, 95% CI: 0.19-0.36, p < 0.001), respiratory complications (LA = 1.8% vs. OA = 6.4%; OR = 0.25, 95% CI: 0.13-0.49, p < 0.001), post-operative ileus/small bowel obstruction (LA = 3.1% vs. OA = 3.6%; OR = 0.65, 95% CI: 0.42-1.0, p = 0.048) and mortality rate (LA = 0% vs. OA = 0.4%; OR = 0.15, 95% CI: 0.04-0.61, p = 0.008). LA has a significantly shorter hospital stay (6.4 days vs. 8.9 days, p = 0.02) and earlier resumption of solid food (2.7 days vs. 3.7 days, p = 0.03).

CONCLUSION

These results clearly demonstrate that LA for complicated appendicitis has the same incidence of IAA but a significantly reduced morbidity, mortality and length of hospital stay compared with OA. The finding of complicated appendicitis at laparoscopy is not an indication for conversion to open surgery. LA should be the preferred treatment for patients with complicated appendicitis.

A clinical comparison of laparoscopic versus open appendectomy for the treatment of complicated appendicitis: historical cohort study

Background

Appendectomy is one of the most common operations. Laparoscopic appendectomy (LA) is considered first-line treatment, but the use of LA for treatment of complicated appendicitis remains controversial. Here, we performed a retrospective analysis to compare clinical outcomes between patients treated with LA and those who underwent open appendectomy (OA).

Methods

Data for 179 patients who underwent an operation for the treatment of complicated appendicitis at our hospital between 2011 and 2017 were retrospectively analyzed. The selection included 89 patients who underwent a conventional appendectomy and 90 patients who were treated laparoscopically. Outcome measures such as mean operative time, blood loss, time until oral intake duration of hospital stay, and postoperative complications were analyzed. Logistic regression analysis was performed to determine the concurrent effects of the examined factors on the rate of postoperative complications.

Results

The mean ages of patients in the OA and LA groups were 50.17 ± 22.77 and 50.13 ± 25.84 year. Mean operative times were longer in the LA group than OA (10.2.56 ± 44.4 versus 85.4 ± 43.11 min; p = 0.009). The duration of hospital stay was shorter for the LA group (9.61 ± 5.57 versus 12.19 ± 8.4; p = 0.016). There were no significant differences in return to consumption of oral intake between the LA and OA groups (2.03 ± 1.66 versus 2.48 ± 2.17; p = 0.123). Multivariable analysis found that the rate of postoperative complications was significantly reduced for the LA group, in comparison with the postoperative-complication rate of the OA group (16.7% versus 27%; odds ratio 0.376; 95% CI 0.153–0.923; p = 0.0327).

Conclusions

These results suggest that LA is a safe and efficient operative procedure that provides clinically beneficial advantages in comparison with OA. Thus, when possible, appendectomy for complicated appendicitis should be attempted using a laparoscopic approach.

Trial registration

Retrospectively registered.

Systematic Review and Meta-Analysis of Laparoscopic Versus Open Appendicectomy in Adults with Complicated Appendicitis: an Update of the Literature

AIMS

To review and compare the outcomes of laparoscopic (LA) versus open appendicectomy (OA) in complicated appendicitis in adult patients, eight years after the last literature review.

METHODS

The PRISMA guidelines were adhered to. Pre-defined inclusion and exclusion criteria were used to search the PubMed, Scopus and Cochrane databases and extract relevant data. Methodological and quality assessment was undertaken with outcome meta-analysis and subgroup analyses of methodological quality, type of study and year of study. Assessment of clinical and statistical heterogeneity and publication bias was conducted.

RESULTS

Three randomised control trials (RCTs) (154LA vs 155OA) and 23 case-control trials were included (2034LA vs 2096OA). Methodological quality was low to average but with low statistical heterogeneity. Risk of publication bias was low, and meta-regression indicated shorter length of hospital stay (LOS) in more recent studies, Q = 7.1, P = 0.007. In the combined analysis LA had significantly less surgical site infections [OR = 0.30 (0.22,0.40); p < 0.00001] with reduced time to oral intake [WMD = -0.98 (-1.09,-0.86); P < 0.00001] and LOS [WMD = -3.49(-3.70,-3.29); p < 0.00001]. There was no significant difference in intra-abdominal abscess rates [OR = 1.11(0.85,1.45); p = 0.43]. Operative time was longer during LA [WMD = 10.51 (5.14,15.87); p = 0.0001] but did not reach statistical significance (p = 0.13) in the RCT subgroup analysis.

CONCLUSIONS

LA appears to have significant benefits with improved morbidity compared to OA in complicated appendicitis (level of evidence II).

Is laparoscopic appendectomy feasible for complicated appendicitis ?A systematic review and meta-analysis

BACKGROUND

laparoscopic appendectomy(LA) has proved to be a safe alternative to open appendectomy(OA) in uncomplicated appendicitis; however, the feasibility of LA for complicated appendicitis(CA) has not been conclusively determined.

OBJECTIVES

To assess the feasibility and safety of LA for CA through a systematic review and meta-analysis.

METHODS

A literature search in PubMed, Embase, Cochrane Library, and web of Science was performed for eligible studies published from the inception of the databases to January 2016. All studies comparing LA and OA for CA were reviewed. After literature selection, data extraction and quality assessment were performed by two reviewers independently, and meta-analysis was conducted using Revman software, vision 5.2.

RESULTS

Two randomized controlled trials (RCTs) and 14 retrospective cohort studies(RCSs) were finally identified. Our meta-analysis showed that LA for CA could reduce the rate of surgical site infections (SSIs) (OR = 0.28; 95% CI: 0.25 to0.31, P < 0.00001), but LA did not increase the rate of postoperative intra-abdominal abscess(IAA) (OR = 0.79; 95% CI: 0.45 to 1.34, P = 0.40). The results showed that the operating time in the LA groups was much longer than that in the OA groups (WMD = 13.78, 95% CI: 8.99 to 18.57, P < 0.00001). However, the length of hospital stays in the LA groups were significantly shorter than those in the OA groups (WMD = -2.47, 95%CI: -3.75 to -1.19, P < 0.0002), and the time until oral intake(TTOI) was much earlier in the LA groups than in the OA groups (WMD = -0.88, 95% CI: -1.20 to -0.55, P < 0.00001). No significant difference was observed in the times of postoperative analgesia between the two groups(P > 0.05).

CONCLUSION

LA was feasible and safe for complicated appendicitis, and it not only could shorten the hospital stays and the time until oral intake, but it could also reduce the risk of surgical site infection.

Comparison of clinical outcome of laparoscopic versus open appendectomy for complicated appendicitis

BACKGROUND

Laparoscopic appendectomy is now the treatment of choice in uncomplicated appendicitis. To date its importance in the treatment of complicated appendicitis is not clearly defined.

METHODS

From January 2005 to June 2013 a total of 1762 patients underwent appendectomy for the suspected diagnosis of appendicitis at our institution. Of these patients 1516 suffered from complicated appendicitis and were enrolled. In total 926 (61 %) underwent open appendectomy (OA) and 590 (39 %) underwent laparoscopic appendectomy (LA). The following parameters were retrospectively analyzed: age, sex, operative times, histology, length of hospital stay, 30-day morbidity focusing on occurrence of surgical site infections, intraabdominal abscess formation, postoperative ileus and appendiceal stump insufficiency, conversion rate, use of endoloops and endostapler.

RESULTS

A statistically significant difference in operative time was observed between the laparoscopic and the open group (64.5 vs. 60 min; p = 0.002). Median length of hospitalization was significantly shorter in the laparoscopic group (p < 0.000). Surgical site infections occurred exclusively after OA (38 vs. 0 patients). Intraabdominal abscess formation occurred statistically significantly more often after LA (2 vs. 10 patients; p = 0.002). There were no statistical significances concerning the occurrence of postoperative ileus (p = 0.261) or appendiceal stump insufficiencies (p = 0.076).

CONCLUSIONS

The laparoscopic approach for complicated appendicitis is a safe and feasible procedure. Surgeons should be aware of a potentially higher incidence of intraabdominal abscess formation following LA. Use of endobags , inversion of the appendiceal stump and carefully conducted local irrigation of the abdomen in a supine position may reduce the incidence of abscess formation.

Laparoscopic versus open approach in the management of appendicitis complicated exclusively with peritonitis: a single center experience

BACKGROUND

Controversial evidence exists regarding the laparoscopic approach in patients with acute appendicitis complicated with peritonitis due to a higher rate of surgical complications. The aim of this study was to compare post-operatory outcomes in patients with acute appendicitis complicated exclusively with peritonitis approached by laparoscopy versus open surgery.

METHODS

Single center retrospective analysis of clinical records of patients with appendicitis complicated with peritonitis operated from January 2003 until October 2013. Demographic data, intra-operative variables, length of stay, surgical complications, mortality, readmissions and reoperations were retrieved.

RESULTS

227 patients were identified, 43% males, mean age 39±17 years (range: 12-85 years). Ninety-seven patients (43%) underwent laparoscopic appendectomy, 13 of them were converted to open surgery (13%). Ninety-four patients presented with diffuse peritonitis (41.4%). Laparoscopic appendectomy showed longer operative time but shorter hospital stay (p<0.05). There were no differences in post-operatory complications (intra-abdominal abscess, surgical site infection and prolonged ileus). Laparoscopic appendectomy was associated with lower odds for developing any surgical complication in the multivariate analysis (OR 0.301, p=0.036).

CONCLUSION

Both approaches showed no differences in complications in the management of appendicitis complicated exclusively with peritonitis. In our experience, laparoscopic appendectomy is a safe approach in cases of appendicitis complicated exclusively with peritonitis.

Laparoscopic treatment of perforated appendicitis

The use of laparoscopy has been established in improving perioperative and postoperative outcomes for patients with simple appendicitis. Laparoscopic appendectomy is associated with less wound pain, less wound infection, a shorter hospital stay, and faster overall recovery when compared to the open appendectomy for uncomplicated cases. In the past two decades, the use of laparoscopy for the treatment of perforated appendicitis to take the advantages of minimally invasiveness has increased. This article reviewed the prevalence, approaches, safety disclaimers, perioperative and postoperative outcomes of the laparoscopic appendectomy in the treatment of patients with perforated appendicitis. Special issues including the conversion, interval appendectomy, laparoscopic approach for elderly or obese patient are also discussed to define the role of laparoscopic treatment for patients with perforated appendicitis.

Do Postoperative Antibiotics Prevent Abscess Formation in Complicated Appendicitis?

Recent studies have shown that postoperative antibiotics in nonperforated appendicitis do not reduce infectious complications; however, there is no consensus on patients with complicated appendicitis. The aim of this study is to determine whether postoperative antibiotic administration in complicated appendicitis prevents intra-abdominal abscess formation. We conducted a retrospective chart review of all patients undergoing appendectomy from 2007 to 2012 at our institution. Patients with complicated appendicitis (perforated, gangrenous, or periappendiceal abscess) were identified and data collected including details of postoperative antibiotic administration and rates of postoperative abscess development. Of 444 charts reviewed, 52 patients were included. Forty-four patients received greater than 24 hours and eight patients received 24 hours or less of postoperative antibiotics. In those receiving greater than 24 hours of antibiotics, nine of 44 (20.5%) developed a postoperative abscess, and in those receiving 24 hours or less of antibiotics, two of eight (25.0%) developed a postoperative abscess ( P = 1.0000). There is no significant difference in postoperative abscess development among those with complicated appendicitis who received greater than 24 hours of postoperative antibiotics compared with those who did not. Postoperative antibiotics may not provide an appreciable clinical benefit for preventing intra-abdominal abscesses; however, larger sample sizes and prospective studies are needed to confirm these findings.

Lessons learned with laparoscopic management of complicated grades of acute appendicitis

Background

Laparoscopy has not been consolidated as the approach of first choice in the management of complicated appendicitis. Methodological flaws and absence of disease stratification criteria have been implicated in that less evidence. The objective is to study the safe and effectiveness of laparoscopy in the management of complicated appendicitis according to laparoscopic grading system.

Method

From January 2008 to January 2011, 154 consecutive patients who underwent a laparoscopic appendectomy for complicated appendicitis were evaluated in the prospective way. The patient’s age ranged from 12 to 75 years old (31.7 ± 13.3) and 58.3% were male. Complicated appendicitis refers to gangrenous and/or perforated appendix and were graded as 3A (segmental necrosis), 3B (base necrosis), 4A (abscess), 4B (regional peritonitis) and 5 (diffuse peritonitis). The outcomes including operative time, infection complication, operative complications and conversion rate were chosen to evaluate the procedure.

Results

The grade 3A was the most frequent with 50 (32.4%) patients. The mean operative time was 69.4 ± 26.3 minutes. The grade 4A showed the highest mean operative time (80.1 ± 26.7 minutes). The wound and intra-abdominal infection rates were 2.6 and 4.6%, respectively. The base necrosis was the most important factor associated with the conversion (5.2%). The grades 4A and 5 were associated with greater possibility of intra-abdominal collection. There were no operative complications.

Conclusion

The laparoscopic management of all complicated grades of acute appendicitis is safe and effective and should be the procedure of first choice. The laparoscopic grading system allows us to assess patients in the same disease stage.

Appendiceal stump closure by metal endoclip in the management of complicated acute appendicitis

Background

Closure of appendicular stump has been performed in different ways; however, the use of the metal endoclip in complicated grades of acute appendicitis, has not been evaluated yet in a prospective way.

Objective

To establish the effectiveness of appendiceal stump closure by metal endoclip for complicated appendicitis.

Method

From January 2009 to January 2011 were evaluated 131 consecutive patients who underwent a laparoscopic appendectomy for complicated acute appendicitis. From those, 118 underwent appendiceal stump closure by metal endoclip. The patient’s age ranged from 12 to 75 years old (31.7 ± 13.3) and 52.7% were male. Complicated appendicitis refers to gangrenous and/or perforated appendix, which may lead to abscess formation and degrees of peritonitis. The outcomes viability, operative time, infection complication, operative complications, and conversion rate were chosen to evaluate the procedure.

Results

The appendiceal stump closure by metal endoclip was used in 90% of cases. The presence of appendix base necrosis was the most important factor involved in failure of the procedure. Laparoscopic knot (1.5%), laparoscopic endo-suture (3.8%) and video assisted laparotomy (4.7%) were the alternatives used in difficult cases. The mean operative time was (67.54 ± 28.13 minutes). The wound and intra-abdominal infection rates were 2.54% and 5.08%, respectively. There were no operative complications and the conversion rate was 0.85%.

Conclusion

The appendiceal stump closure by metal endoclip, in complicated grades of acute appendicitis, is a safe and effective procedure. In patients with appendix base necrosis it should be avoided in favor of other alternatives.

Treatment options of inflammatory appendiceal masses in adults

At present, the treatment of choice for uncomplicated acute appendicitis in adults continues to be surgical. The inflammation in acute appendicitis may sometimes be enclosed by the patient’s own defense mechanisms, by the formation of an inflammatory phlegmon or a circumscribed abscess. The management of these patients is controversial. Immediate appendectomy may be technically demanding. The exploration often ends up in an ileocecal resection or a right-sided hemicolectomy. Recently, the conditions for conservative management of these patients have changed due to the development of computed tomography and ultrasound, which has improved the diagnosis of enclosed inflammation and made drainage of intra-abdominal abscesses easier. New efficient antibiotics have also given new opportunities for nonsurgical treatment of complicated appendicitis. The traditional management of these patients is nonsurgical treatment followed by interval appendectomy to prevent recurrence. The need for interval appendectomy after successful nonsurgical treatment has recently been questioned because the risk of recurrence is relatively small. After successful nonsurgical treatment of an appendiceal mass, the true diagnosis is uncertain in some cases and an underlying diagnosis of cancer or Crohn’s disease may be delayed. This report aims at reviewing the treatment options of patients with enclosed appendiceal inflammation, with emphasis on the success rate of nonsurgical treatment, the need for drainage of abscesses, the risk of undetected serious disease, and the need for interval appendectomy to prevent recurrence.

Risk factors of converting to laparotomy in laparoscopic appendectomy for acute appendicitis

Purpose

Laparoscopic appendectomy (LA) for acute appendicitis has several advantages over open appendectomy (OA). In cases of complicated appendicitis, LA is converted to OA at a constant rate, though converting appendectomy (CA) has several disadvantages. We retrospectively determined preoperative risk factors for failure of LA and subsequent conversion to OA.

Methods

Consecutive cases of preoperative computed tomography (CT) and attempted LA were retrieved from our hospital database and grouped by procedure (LA versus CA). Patients with negative appendectomies (n = 28), opened appendectomy (n = 210), delayed interval appendectomy (n = 3), or who were <14 years of age were excluded.

Results

Average patient age, preoperative C-reactive protein (CRP) level, and diffuse peritonitis were significantly different between the groups. CT inflammation and occurrence of complicated appendicitis were significantly higher in CA than LA. Conversion to OA was mostly because of dense adhesions, diffuse peritonitis, and difficulties in excision of the appendix due to perforation or severe inflammation from surgical point of view. Postoperative complications were significantly lower in LA than CA, although the rate of intraoperative abscess was not different.

Conclusion

Most patients with acute appendicitis can be successfully treated with LA. We identified the following significant risk factors of CA: CT inflammation grade 4 or 5; complicated appendicitis; higher preoperative CRP level; and diffuse peritonitis.

Laparoscopic appendectomy in complicated appendicitis: Is it safe?

BACKGROUND

Because of lack of good evidence supporting laparoscopic approach for complicated appendicitis, we carried out this study to evaluate efficacy of laparoscopic appendectomy (LA) in management of patients with complicated appendicitis.

MATERIALS AND METHODS

This study was carried out in Surgical Department, Minia University, Egypt involving 214 patients underwent appendectomy for complicated appendicitis over three years. 132 patients underwent LA and remaining 82 patients underwent OA. Parameters studied included operating time, return to oral feeding, postoperative pain, wound infection, intra-abdominal abscess, duration of abdominal drainage and hospital stay.

RESULTS

There were four conversions, two due to extensive cecal adhesions and two due to friable appendix. LA took longer time to perform (p = 0.0002) but with less use of analgesics (p < 0.0001), shorter hospital stay (p < 0.0001), shorter duration of abdominal drainage (p < 0.0001) and lower incidence of wound infection (p = 0.0005). Nine patients in LA and seven patients in OA group developed intra-abdominal abscess treated successfully with sonographic guided percutaneous drainage. Postoperative ileus was recorded in two patients in LA group and three patients in OA group, chest infection in one patient in OA group, hernia in one patient in LA and fecal fistula was present in one patient in OA. Overall complications were significantly lower in laparoscopy group and managed conservatively with no mortality in either group.

CONCLUSIONS

LA in complicated appendicitis is feasible and safe with lower incidence of complications than OA and should be the initial choice for all patients with complicated appendicitis.

Peritonitis from perforated peptic ulcer and immune response

BACKGROUND

Elevated intra-abdominal pressure during the laparoscopy may promote bacteremia, endotoxemia, and systemic inflammatory response. In patients with generalized peritonitis from perforated peptic ulcer (PPU), we sought to compare acute phase response, immunologic status, and bacterial translocation from laparoscopic and open approach.

STUDY DESIGN

From July 2005 to September 2011, 115 consecutive patients underwent peptic ulcer repair for PPU: 58 cases laparoscopic peptic ulcer repair (LR) and 57 cases open peptic ulcer repair (OR). Bacteremia, endotoxemia, white blood cells population, human leukocyte antigen-DR (HLA-DR), neutrophil-elastase, interleukin-1 and 6 (IL-1 and IL-6), and C-reactive protein (CRP) were investigated.

RESULTS

Patients characteristics and grade of peritoneal contamination were similar in the two groups. One hour after intervention, bacteremia was significantly higher in the "open" group than in the laparoscopic group (p < .001). A significantly higher concentration of systemic endotoxin was detected intraoperatively in the "open" group of patients in comparison to the laparoscopic group (p < .0001). Laparotomy caused a significant increase in neutrophil concentration, neutrophil-elastase, IL-1 and IL-6, CRP, and decrease of HLA-DR. We recorded six cases (10.3%) of intra-abdominal abscess in the "open" group and one (1.7%) in laparoscopic group (p < .001).

CONCLUSIONS

OR, in case of peritonitis after PPU, increased the incidence of bacteremia, endotoxemia, and systemic inflammation compared with LR. Early enhanced postoperative systemic inflammation may cause lower transient immunologic defense after laparotomy (decrease of HLA-DR), leading to enhanced sepsis in these patients.

Laparoscopic appendectomy for complicated acute appendicitis does not result in increased surgical complications

BACKGROUND/OBJECTIVES

Septic postoperative complications are debated in patients with complicated acute appendicitis treated with laparoscopic appendectomy (LA). The aim of this study was to investigate the results of LA in both complicated and uncomplicated cases of acute appendicitis.

METHODS

From January to December 2009, 94 patients with acute appendicitis underwent LA by the same surgeon using the three-port technique. Data were accumulated and compared between complicated and uncomplicated acute appendicitis.

RESULTS

Of the 94 patients (45 women and 49 men), 19 had complicated and 75 uncomplicated acute appendicitis. The group with complicated acute appendicitis, as compared to the uncomplicated group, was significantly older (55.7 ± 20.5 years vs. 41.0 ± 18.0 years), and had a significantly increased operation time (117.6 ± 45.5 minutes vs. 78.2 ± 39.4 minutes), longer length of hospital stay (9.0 ± 3.3 days vs. 5.2 ± 6.0 days) and higher conversion rate (21.1% vs. 2.7%). No increase in surgical complications was noted in patients with complicated acute appendicitis, as compared to those with uncomplicated acute appendicitis.

CONCLUSION

This study demonstrated no increase in surgical complications after LA in patients with complicated acute appendicitis when compared with those who had uncomplicated disease. Therefore, LA may be considered the first-choice treatment option for both uncomplicated and complicated acute appendicitis.

Peritonitis from Perforated Appendicitis: Stress Response after Laparoscopic or Open Treatment

Elevated intra-abdominal pressure during laparoscopy may promote systemic inflammatory response. In patients with generalized peritonitis from perforated appendicitis, we sought to compare acute phase response and immunologic status from laparoscopic and open approach. One hundred and forty-seven consecutive patients underwent appendectomy for perforated appendicitis (73 patients had laparoscopic appendectomy and 74 patients had open appendectomy. Bacteremia, endotoxemia, white blood cells, peripheral lymphocytes subpopulation, human leukocyte antigen-DR (HLA-DR), neutrophil-elastase, interleukin-1 and 6 (IL-1 and 6), and C-reactive protein were investigated. One hour after intervention, bacteremia was significantly higher in the open group compared with the laparoscopic group ( P < 0.05). A significantly higher concentration of systemic endotoxin was detected intraoperatively in the open group of patients in comparison with the laparoscopic group ( P < 0.05). Laparotomy caused a significant increase in neutrophil concentration, neutrophil-elastase, IL-1 and 6, and C-reactive protein and a decrease of HLA-DR. We recorded 6 cases (8.1%) of intra-abdominal abscess in the open group and one (1.3%) in the laparoscopic group ( P < 0.05). Open appendectomy, in case of peritonitis, increased the incidence of bacteremia, endotoxemia, and systemic inflammation compared with laparoscopic appendectomy. Early enhanced postoperative systemic inflammation may cause lower transient immunologic defense after laparotomy (decrease of HLA-DR), leading to enhanced sepsis in these patients.

Endoloop versus endostapler closure of the appendiceal stump in pediatric laparoscopic appendectomy

BACKGROUND

There is little information available to inform choice of technique for appendiceal stump control in pediatric laparoscopic appendectomy (LA). We compared complications (stump leak, intra-abdominal abscess formation [IAA], surgical site infection [SSI]) in children undergoing LA for perforated (PA) and nonperforated appendicitis (NPA) by technique of appendiceal stump control.

METHODS

All children who underwent LA for confirmed acute appendicitis between 2006 and 2009 were reviewed. Choice of stump control (endoloop [EL] or endostapler [ES]) was determined by surgeon preference. Interactions between stump closure techniques and other potential confounders (intra-abdominal drain, irrigation, different antibiotic regimens) were explored using a logistic regression model.

RESULTS

Of 242 patients undergoing LA, 57 (23.6%) had PA. In the PA group the appendiceal stump was closed with EL in 47 (82.5%) patients, while in the NPA group EL was used in 161 (87%) patients. Among PA patients, IAA was more common in the ES than the EL group (5 of 10 [50%] v. 6 of 47 [12.7%]). There was no significant difference in rates of SSI. Among NPA patients, there were no differences in rates of IAA or SSI. There were no stump leaks in either group. Logistic regression analysis confirmed the predictive effect of ES use on IAA formation in PA (adjusted odds ratio 7.09; 95% confidence interval 1.08-46.13; p = 0.042).

CONCLUSION

Our data suggest that in most cases of PA, the appendiceal stump can be safely controlled with EL. Within the PA group, the higher rates of IAA seen in ES patients may be attributable to the quality of the appendiceal stump rather than the technique of closure.

Comparison of outcomes of laparoscopic and open appendectomy in management of uncomplicated and complicated appendicitis

BACKGROUND

Several studies have demonstrated the superiority of the laparoscopic approach in uncomplicated and complicated appendicitis with conflicting results. As a result the role of laparoscopy in the management of appendicitis in general and complicated or perforated appendicitis, in particular, is still undefined.

METHODS

A retrospective, observational study design was used to analyze multicenter outcomes using the University HealthSystem Consortium database. A 3-year discharge data of all open appendectomy (OA) and laparoscopic appendectomy (LA) procedures from 2006 to 2008 in adult patients older than 18 years for complicated or uncomplicated appendicitis was accessed using International Classification of Diseases, Ninth Revision codes. Data on several surgical outcome measures such as observed mortality, overall patient morbidity, intensive care unit admission rate, 30-day readmission rate, length of hospital stay, and hospital costs were collected from the University HealthSystem Consortium database. Stratification by University HealthSystem Consortium-specific severity of illness groups and disease diagnosis of complicated or perforated and uncomplicated appendicitis was performed.

RESULTS

A total of 40,337 appendectomy procedures performed during 2006 to 2008 in adult patients were included in the study. Laparoscopic appendectomy for uncomplicated appendicitis resulted in significantly better surgical outcomes. However, surprisingly, these outcomes resulted in comparable but not significantly reduced hospital costs (7825 ± 6,009 for LA vs 7841 ± 13,147 for OA; P > 0.05). Laparoscopic appendectomy for complicated or perforated appendicitis showed lower mortality, reduced overall morbidity (17.43% for LA vs 26.68% for OA; P < 0.001), relatively less 30-day readmission rate, fewer intensive care unit admissions, significantly shorter length of hospital stay (4.34 ± 4.84 days for LA vs 7.31 ± 9.43 for OA; P < 0.001), and reduced hospital costs (12,125 ± 14,430 for LA vs 17,594 ± 28,065 for OA; P < 0.001) compared with patients undergoing OA. On stratification for severity of illness in both complicated and uncomplicated appendicitis, laparoscopic appendectomy resulted in a greater or comparable clinical benefit than open appendectomy. Comparable clinical benefit was observed in minor severity patients and moderate and major/extreme severity patients showed vastly improved surgical outcomes with the laparoscopic approach.

CONCLUSIONS

Laparoscopic appendectomy is superior or comparable to open appendectomy in terms of several surgical outcome measures for both uncomplicated and complicated appendicitis, across most illness severity groups. Thus, laparoscopic appendectomy may be the preferred technique, irrespective of appendicitis diagnosis or disease severity.

A Clinical Comparison of Laparoscopic versus Open Appendectomy for Complicated Appendicitis

Purpose

Although laparoscopic appendectomies (LAs) are performed universally, a controversy still exists whether the LA is an appropriate surgical approach to complicated appendicitis (CA). We retrospectively evaluated the outcomes of laparoscopic versus open appendectomies for CA.

Methods

We retrospectively analyzed 60 consecutive patients who were diagnosed as having CA from July 2009 to January 2011. Outcomes such as operative time, time to soft diet, length of hospital stay, and postoperative complications were analyzed.

Results

There were no statistically significant differences in operative time between the LA and the open appendectomy (OA) groups. Return to soft diet was faster in the LA group (2.1 ± 1.2 vs. 3.5 ± 1.5 days; P = 0.001). Length of hospital stay was shorter for the LA group (4.4 ± 2.3 vs. 5.8 ± 2.9 days; P = 0.045). The overall complication rates showed no statistically significant difference between the two groups. In cases involving a periappendiceal abscess, the LA had a significantly higher incidence of intra-abdominal abscess (IAA) and postoperative ileus (PI; P = 0.028).

Conclusion

The LA showed good results in terms of the time to soft diet, the length of hospital stay, and surgical site infection (SSI) whereas the overall complication rates were similar for the two groups. However, the LA was associated with significantly higher incidence of IAA and PI for the cases with a periappendiceal abscess. Therefore, when using a LA, the surgeon must take great care to minimize the incidence of IAA and PI if a periappendiceal abscess is present.

[Pediatric appendicitis : Open or laparoscopic appendicectomy in a specialized visceral surgical clinic?]

Following the first description of open appendicectomy using a lateral incision in the right lower abdomen by McBurney in 1894, this intervention was considered to be the standard method for treatment of appendicitis for nearly 100 years. In 1983 the gynecologist Semm presented a new option for the surgical therapy of appendicitis with the implementation of laparoscopic appendicectomy. Since then the indications for laparoscopic therapy have developed from young adults through elderly patients to children, pregnant women and finally to infants and newborns.

Laparoscopic versus open appendectomy in adults with complicated appendicitis: systematic review and meta-analysis

BACKGROUND

The goal of the present study was to critically review and identify the strength of available evidence in the literature on the use of laparoscopic appendectomy (LA) in complicated appendicitis (CA).

METHODS

The Cochrane Library and Controlled Trials Registry, MEDLINE (Ovid), PubMed, Web of knowledge, and SCOPUS databases were electronically searched, using the keywords "appendectomy," "laparoscopy," "appendicitis." "complicated appendicitis." "gangrenous appendicitis," "perforated appendicitis," with English language as a limit. Backward chaining was also employed. The NHS Public Health Resource Unit Critical Appraisal Skills Programme Tools were used for critical appraisal.

RESULTS

Twelve retrospective case-control studies were included in the review. Overall methodological quality was moderate to poor, with heterogeneity, absence of randomization and blinding, and presence of important methodological flaws. Meta-analysis showed that LA in CA has reduced surgical site infection (SSI) rates compared to open appendectomy (OA), odds ratio (OR) 0.23, 95% confidence intervals (CI): 0.14-0.37 (level 3a evidence), and no difference with regard to intra-abdominal abscess (IAA) complication rates OR: 1.02, 95% CI 0.56-1.86 (level 3a evidence).

CONCLUSIONS

When compared to OA, laparoscopic appendectomy is advantageous in CA with regard to SSIs, with no significant additional risk of IAA (level 3a evidence).

Laparoscopic appendectomies: experience of a surgical unit

Appendicitis is one of the most common causes of acute abdomen in adults and appendectomy is the most common emergency abdominal procedure. Laparoscopic appendectomy has gained popularity only in recent years and the optimal approach for the treatment of acute appendicitis is still under debate. This retrospective study aimed at examining the current indications for laparoscopic appendectomy. 1024 patients undergoing laparoscopic appendectomy between February 1992 and December 2007 were retrospectively reviewed. 39.9% of patients (n=408) underwent emergency surgery. In 616 cases (60.1%) conservative management was performed in vain and these patients underwent an elective operation. In the 36 patients with an intraoperative normal appendix, other pathological findings were laparoscopically detected and treated. Conversion to an open procedure was required for 13 (1.3%) cases. The mean operative time was 38 min and the average length of postoperative hospitalization was 2.5 days. The overall morbidity rate was 2.6%. Laparoscopic appendectomy should be considered a procedure of choice for the treatment of non-complicated appendicitis. We stress the possibility to laparoscopically treat even complicated appendicitis in the surgical setting with substantial experience in minimally invasive surgery.

Laparoscopic versus open appendectomy in complicated appendicitis: a review of the NSQIP database

BACKGROUND

Laparoscopic appendectomy (LA) has been an established treatment method for uncomplicated acute appendicitis. Controversy still exits regarding the superiority of either laparoscopic or open technique for the treatment of complicated appendicitis.

OBJECTIVE

To examine for benefits in postoperative morbidity comparing laparoscopic versus open appendectomy for complicated appendicitis.

METHODS

A retrospective analysis was performed using the American College of Surgeon's National Surgical Quality Improvement Project (ACS-NSQIP) dataset between 2005 and 2007. Inclusion criteria were patients undergoing either open or laparoscopic appendectomy, and had complicated appendicitis. Patients with negative appendectomies and age less than 18 y old were excluded. The primary outcome variable was postoperative complications. Multivariate analysis was performed adjusting for demographics and standard NSQIP comorbidities.

RESULTS

We identified 2,790 complicated appendicitis cases treated with laparoscopic or open appendectomy. The majority were male (56.6%), White (70.3%), and 39.1% were younger than 40 y of age. On unadjusted analyses, the mean length of stay was significantly shorter for LA cases (3.97 d) than OA cases (5.13 d) (P < 0.001). On multivariate analysis, superficial surgical site infection was 70% less likely to occur in LA (OR 0.304 P = 0.000), organ space infection was 2-fold more likely to occur in LA (OR 2.19 P = 0.003), and dehiscence was 78% less likely to occur in LA (OR 0.22 P = 0.015).

CONCLUSION

In cases of complicated appendicitis, laparoscopic appendectomy is superior in terms of superficial and deep wound infections; however, it is associated with an increased incidence of postoperative intra-abdominal abscess.

Laparoscopic appendectomy by residents: evaluating outcomes and learning curve

BACKGROUND

Laparoscopic appendectomy is being performed increasingly, worldwide. To the resident, it provides a valuable opportunity to master basic laparoscopic skills. Studies have shown that laparoscopic appendectomy performed by residents is safe. However, to date, there is no clear evidence for the minimum number of these operations required to achieving proficiency and safety. The aim of this study is to assess the outcome of laparoscopic appendectomies performed by surgical residents and to evaluate the effect of learning curve on patient outcome.

METHODS

All patients undergoing laparoscopic appendectomies performed by six residents during the study period were reviewed. Data on patient demographics,clinical and histological diagnosis, and outcome variables including operative duration, conversion to open surgery, complications, and length of stay were analyzed. We evaluated the effect of the learning curve by dividing patients into two groups: a first group consisting of the initial 20 patients and a second group consisting of the next 20 patients operated upon independently by each resident. Variables were analyzed to determine any difference between the two groups.

RESULTS

Three hundred six patients with the clinical diagnosis of acute appendicitis underwent laparoscopic appendectomy by residents. Mean operative time was 83.8 min. Of patients, 14.6% required conversion to open surgery. Mean length of hospitalization was 2.82 days. Operative duration and complication rate were significantly reduced with increasing experience of residents. The length of hospital stay and conversion rate to open surgery remained unchanged.

CONCLUSION

Operative duration and complications can be reduced with increasing experience of a resident.

The laparoscopic approach for perforated appendicitis, including cases complicated by abscess formation

BACKGROUND

Although the laparoscopic approach for perforated appendicitis is commonly performed, there is some controversy over its use because of postoperative complications. These may be associated with various types of disease entities, from gangrenous change to diffuse peritonitis with abscess formation. The aim of the present study was to evaluate the safety and benefits of the laparoscopic approach for perforated appendicitis, including cases complicated by abscess, compared to open.

MATERIALS AND METHODS

A total of 1747 patients underwent treatment for appendicitis over a period of 3 years. The diagnosis of perforated appendicitis was made by radiology, operative finding, and pathology. Of our five attending surgeons, three performed open surgery for perforated appendicitis, while two performed laparoscopy.

RESULTS

There were 474 patients (27%) with perforated appendicitis without abscess (156 underwent laparoscopy, 318 underwent open) and 113 patients (6.4%) with perforated appendicitis and abscess (44 underwent laparoscopy, 69 underwent open). The duration for resumption of diet and hospital stay was shorter in the laparoscopy group than in the open group. There were no significant differences in postoperative complications between patients who had no abscess with laparoscopy and those with open: 5 intra-abdominal abscesses and 10 wound infections versus 11 intra-abdominal abscesses and 25 wound infections (P = 0.88, 0.12), and between patients who had abscesses with laparoscopy and those with open: 4 intra-abdominal abscesses and 3 wound infections versus 6 intra-abdominal abscesses and 6 wound infections (P = 0.94, 0.72).

CONCLUSIONS

The laparoscopic approach may be a safe, effective treatment for perforated appendicitis, even in the presence of an abscess.

[Surgical techniques of appendectomy for acute appendicitis]

Over the last 20 years, the treatment of acute appendicitis has been transformed by the development of the laparoscopic approach. And yet the net value of this approach continues to be debated. Laparoscopic appendectomy is associated with a lower complication rate and a shorter period of disability in the general population. While operative costs are higher, the global cost of laparoscopic appendectomy is lower than for open appendectomy. There is a somewhat higher rate of abdominal abscess for the laparoscopic route. Laparoscopic appendectomy shows clear advantages in obese patients and in those with gangrenous or ruptured appendicitis. The laparoscopic approach is contra-indicated during pregnancy due to a higher incidence of miscarriage. Treatment of the appendiceal stump by ligature decreases the expense associated with the use of a surgical stapler. When Meckel's diverticulum is encountered during appendectomy, it should be removed in all pediatric patients; in adults, Meckel's diverticulectomy in adults should be performed only for clear-cut pathology. Surgeons continue to innovate and refine appendectomy techniques but many questions remain to be answered.

Complicated appendicitis in children: is laparoscopic appendectomy appropriate? A comparative study with the open appendectomy--our experience

PURPOSE

Good outcomes have been reported with laparoscopic appendectomy (LA) for uncomplicated appendicitis in children, but the use of laparoscopy for complicated appendicitis in children is more controversial. This is related to a higher incidence of postoperative abdominal and wound infections. The purpose of this trial was to retrospectively compare LA and open appendectomy (OA) for complicated appendicitis and evaluate the efficacy of LA in children with complicated appendicitis.

METHODS

The outcome of 128 patients with complicated appendicitis in children was retrospectively analyzed. There were 80 children in the LA group and 48 in the OA group. The appendectomies were performed by a single senior surgeon and his surgical trainees. There was no selection of cases for LA. Data collection included demographics, operative time, resumption of diet, infectious complications (wound infection and intraabdominal abscess), length of hospitalization, and duration of antibiotic use.

RESULTS

There were no cases of LA that required conversion to OA. The operative time for LA (88.5 +/- 28.8 minutes for LA vs 71.8 +/- 30.6 minutes for OA; t = 3.10; P = .002) was longer. Patients in the LA group returned to oral intake earlier (1.8 +/- 0.6 days for LA vs 2.8 +/- 0.8 days for OA; t = -8.04; P < .01) and had a shorter length of hospital stay (6.5 +/- 2.2 days for LA vs 7.8 +/- 2.9 days for OA; t = -2.87; P = .005). The incidence of wound infection (1/80 [1.3%] for LA vs 6/48 [12.5%] for OA; P < .05) and postoperative intraabdominal abscess (2/80 [2.5%] for LA vs 7/48 [14.6%] for OA; P < .05) in LA group was lower. No significant difference was found in the duration of antibiotic administration between the 2 groups (5.8 +/- 1.8 days for LA vs 6.3 +/- 2.3 days for OA; t = -1.37; P = .174). No mortality was observed in either group.

CONCLUSIONS

The minimally invasive laparoscopic technique is feasible, safe, and efficacious for children with complicated appendicitis. Laparoscopic appendectomy should be the initial procedure of choice for most cases of complicated appendicitis in children.

Laparoscopic versus open appendectomy: a prospective randomized comparison

BACKGROUND

Whether laparoscopy offers a benefit over open surgery in the management of acute appendicitis or not remains a subject of controversy despite the publication of numerous randomized studies. This study aimed to compare laparoscopic appendectomy (LA) with open appendectomy (OA) and to ascertain its therapeutic benefit.

METHODS

Adult patients older than 14 years presenting with signs and symptoms suggestive of acute appendicitis were randomized to undergo either LA or OA from January 2006 to December 2007. Comparisons were based on operating time, time until return to a general diet, time until return to normal activity and work, length of hospital stay, billed charges, and postoperative complications.

RESULTS

The study enrolled 220 patients: 108 to undergo OA and 112 to undergo LA. The groups were similar in terms of clinicopathologic characteristics. The operating time seemed to be shorter for the OA patients than for the LA patients, but the difference was not significant (LA, 30 +/- 15.2 min vs. OA, 28.7 +/- 16.3 min; p > 0.05). The hospital stay of 4.1 +/- 1.5 days for the LA group and 7.2 +/- 1.7 days for the OA group, and the difference was statistically significant (p < 0.05). Laparoscopic appendectomy remained associated with a shorter time until return to a general diet (LA, 20.2 +/- 12.4 h vs. OA, 36.5 +/- 10 h; p < 0.05), to normal activity (LA, 9.1 +/- 4.2 days vs. OA, 13.7 +/- 5.8 days; p < 0.05), and to work (LA, 21.2 +/- 3.5 days vs. OA, 27.7 +/- 4.9 days; p < 0.05). The billed charges appeared to be higher for LA (LA, 5,720.3 +/- 115.7 yuan vs. OA, 5,310 +/- 575.4 yuan), but this difference failed to be clinically important or statistically significant (p > 0.05). Wound infections were more common after OA (n = 14) than after LA (n = 0) (p < 0.05). Intraabdominal abscesses occurred for two patients in the LA group and nine patients in the OA group (p < 0.05). Postoperative ileus occurred with frequencies of 0% in the LA group and 7.4% in the OA group (p < 0.05). The rate for overall complications was significantly lower in the LA group.

CONCLUSION

Laparoscopic appendectomy is a useful tool in the treatment of acute appendicitis. Its advantages lie in its minimal invasiveness, its better cosmetic outcome, its lower rate of complications based on surgical expertise and state-of-the-art equipment. It can be recommended as an adoptable method for the routine patient with appendicitis.

Efficacy of laparoscopy in complicated appendicitis

BACKGROUND

Laparoscopic appendectomy has been widely practiced for uncomplicated appendicitis. The role of laparoscopy in management of complicated appendicitis remains undefined. We undertook this study to evaluate the efficacy of laparoscopic appendectomy in patients with complicated appendicitis.

METHOD

This study involved a total of 110 consecutive patients who had undergone appendectomy for perforated or gangrenous appendicitis between March 2004 and December 2008. Sixty-one patients underwent open appendectomy (OA) and remaining 49 patients underwent laparoscopic appendectomy (LA). Parameters studied were operative time, conversion rate, wound infections, intra-abdominal abscess and duration of pain and hospital stay.

RESULTS

There were two conversions due to extremely friable appendix. Laparoscopic appendectomy took longer to perform (98 min versus 79 min) but was associated with less analgesic use, shorter median hospital stay (LA- 3 days; OA- 6 days, p<0.05), and lower rate of wound infections (LA, 8.2%; OA, 24.6 %, p<0.05). Intra-abdominal abscess occurred in four patients (8.2%) in LA group and fourteen patients (22.9%) in OA group (p<0.05). More patients in OA group experienced prolonged ileus than LA group but the difference was statistically insignificant. All complications were managed conservatively and there was no mortality in either group.

CONCLUSIONS

Laparoscopic appendectomy for complicated appendicitis is feasible and safe. It is associated with less postoperative pain, lower incidence of infectious complications and reduced length of hospital stay when compared with patients who had open appendectomy.

[Laparoscopic or open appendectomy?]

Despite the fact that laparoscopic appendectomy was one of the first performed minimally invasive surgical procedures, the benefits and indications of its use are still controversial.

METHODS

Data of patients with the diagnosis of appendicitis operated either with laparoscopic (LA) or open (OA) appendectomy were collected and analyzed.

PATIENTS

This study involved 273 consecutive patients who had undergone appendectomy with the diagnosis of acute appendicitis at the Uzsoki Teaching Hospital, Department of Surgery between January 2005 and December 2007. 185 patients (68%) operated with the laparoscopic, 88 (32%) with the open technique, in the third year 89% of the cases underwent laparoscopic appendectomy.

RESULTS

The conversion rate was 27%, the reason of the conversion was the progression of the disease in 35 patients (70%) and technical in 15 cases (30%). The wound infection rate was 8% in the LA and 18% in the OA group ( p = 0.022). No significant difference was found in the reoperation rate and in the hospital readmission rate between the two groups. There was one insufficiency which was treated with conservative therapy. The hospital stay was significantly lower in the laparoscopic group ( p = 0.031).

CONCLUSIONS

This study demonstrated that laparoscopic appendectomy has significant advantages over open appendectomy. In our practice, laparoscopic appendectomy is the first choice of procedure in acute appendicitis.

[Complicated acute apendicitis. Open versus laparoscopic surgery]

INTRODUCTION

Although laparoscopy has become the standard approach in other procedures, this technique is not generally accepted for acute appendicitis, especially if it is complicated due reports on the increase in intra-abdominal abscesses.

OBJECTIVE

The purpose of this study was to evaluate the morbidity in a group of patients diagnosed with complicated apendicitis (gangrenous or perforated) who had undergone open or laparoscopic appendectomy.

MATERIAL AND METHOD

We prospectively studied 107 patients who had undergone appendectomy for complicated appendicitis over a two year period. Mean operation time, mean hospital stay and morbidity, such as wound infection and intra-abdominal abscess were evaluated.

RESULTS

In the group with gangrenous appendicitis morbidity was significantly lower in laparoscopic appendectomy group (p = 0.014). Wound infection was significantly higher in the open appendectomy group (p = 0.041), and there were no significant differences in intra-abdominal abscesses (p = 0.471). In the perforated appendicitis group overall morbidity (p = 0.046) and wound infection (p = 0.004) was significantly higher in the open appendectomy group. There were no significant differences in intra-abdominal abscesses (p = 0.612).

CONCLUSION

These results suggest that laparoscopic appendectomy for complicated appendicitis is a safe procedure that may prove to have significant clinical advantages over conventional surgery.

Efetividade e segurança da apendicectomia videoassistida em porta única transumbilical em adolescentes e adultos

OBJETIVO: Aplicar o método apendicectomia videoassistida em porta única transumbilical (AVATU) e avaliar a sua efetividade e a sua segurança. MÉTODO: A AVATU visa combinar os benefícios do acesso laparoscópico com a segurança e simplicidade da remoção do apêndice pela técnica convencional. Analisou-se, retrospectivamente, 300 adolescentes e adultos, com diagnóstico pressuposto de apendicite aguda, nos quais indicou-se a AVATU como abordagem inicial, entre junho de 2001 e junho de 2006. A exeqüibilidade do procedimento no tratamento da apendicite aguda em todos os seus estágios de evolução, tempo operatório e a necessidade de conversão para apendicectomia convencional ou laparoscópica, foram os parâmetros utilizados para avaliação da efetividade do método. A segurança foi avaliada pela incidência de complicações transoperatórias, pós-operatórias e mortalidade. RESULTADOS: Houve necessidade de conversão para a via convencional ou laparoscópica em 9% dos casos. As principais causas de conversão foram aderências inflamatórias locais densas e apendicite aguda nas suas formas mais avançadas. A incidência de complicações pós-operatórias foi de 6,6%, incluindo 1,3% de abscesso intra-abdominal e 2,0% de infecção de sítio cirúrgico. Não ocorreram óbitos. O resultado histopatológico confirmou 11,7% de apendicite em estágio avançado. CONCLUSÃO: A AVATU mostrou-se exeqüível, efetiva e segura. Os resultados deste estudo e os atrativos da técnica, podem avalizar a recomendação do método na abordagem inicial de pacientes adolescentes e adultos, com suspeita de apendicite aguda.

A self-approximating transluminal access technique for potential use in NOTES: an ex vivo porcine model (with video)

BACKGROUND

NOTES (natural orifice transluminal endoscopic surgery) is an area of active research in experimental endoscopy and has the potential to significantly advance the field of minimally invasive surgery. Several investigators have illustrated the need for a transluminal access technique that is safe, reliable, and reproducible. Currently used methods directly cut through the organ wall into the peritoneum; however, rare difficulty in closing the defect with negative outcomes have been described.

OBJECTIVE

To evaluate an alternative method for transluminal access.

DESIGN

An ex vivo, experimental endoscopy study.

SETTING

Penn State Hershey Medical Center, Animal Research Laboratories.

METHODS

By using ex vivo porcine esophagus, stomach, and colon, a submucosal tunnel was created as a means of physically separating the lumen from the peritoneum during transluminal access. Postprocedure leak testing was performed, and all procedures were video recorded.

RESULTS

Results of the self-approximating transluminal access technique (STAT) in porcine esophagus and stomach demonstrated the technical feasibility of this approach. The STAT was not felt to be feasible in the porcine colon.

LIMITATIONS

This investigation was a limited, ex vivo pilot study and will require further testing in an adequate number of live animals.

CONCLUSIONS

The STAT is technically feasible in porcine esophagus and stomach, and may have advantages over currently used techniques.

Complicated Appendicitis–Is the Laparoscopic Approach Appropriate? A Comparative Study with the Open Approach: Outcome in a Community Hospital Setting

Good outcome has been reported with the laparoscopic approach in uncomplicated appendicitis, but a higher incidence of postoperative intraabdominal abscesses has been reported after laparoscopic appendectomy in complicated appendicitis. This retrospective comparative study compares outcome after laparoscopic (LA) and open appendectomy (OA) in complicated appendicitis. All patients who had LA or OA for complicated appendicitis between January 2003 and February 2006 were included in the study. Data collection included demographics, operative time, estimated blood loss, length of stay (LOS), complications, readmission, and reoperative rates. The primary end points for analysis were postoperative intraabdominal abscess and complication rates and secondary end points were LOS and operative time. All data were analyzed on an intent-to-treat basis. Of 104 patients, 43 patients underwent LA and 61 had OA. The mean age (24.8 ± 16.5 versus 31.3 ± 18.9, P = 0.08) in the LA group was lower than the OA group because there was a significantly higher proportion of pediatric patients (34.8% versus 14.8%, P = 0.02) who had LA. There was no significant difference in gender (female/male, 14/29 versus 27/34, P = 0.3) or American Society of Anesthesiologists class distribution (American Society of Anesthesiologists 1/2/3/4/, 35/7/1/0 versus 45/12/3/1, P = 0.68) between the two groups. The operative time (100.5 ± 36.2 versus 81.5 ± 29.5 minutes, P = 0.03) was significantly longer and the estimated blood loss (21 mL versus 33 mL, P = 0.01) was lower in LA when compared with OA, but there was no significant difference in the number of patients with preoperative peritonitis versus abscesses (7/36 versus 13/48, P = 0.6) in both groups. There was no difference in the median LOS (6 [interquartile range 5–9] versus 6 [interquartile range 4–8], P = 0.7) in the two groups. The conversion rate in LA was 18.6% (n = 8). There was also no significant difference in the complication (17/43 [39.5%] versus 21/61 [34.4%], P = 0.54), reoperative (3/43 [7%] versus 0/61 [0%], P = 0.07), and 30-day readmission (5/41 [11.6%] versus 3/61 [4.9%], P = 0.23) rates between the two groups. The rate of postoperative intraabdominal abscesses was significantly higher in the LA group when compared with the OA group (6/43 [14%] versus 0/61 [0%], P = 0.04) and the wound infection (1/43 [2.3%] versus 5/61 [8.2%], P = 0.4) and pulmonary complication (0/43 [0%] versus 3/61 [4.9%], P = 0.26) rate was higher in the OA group. There was no mortality in the LA group, but there was one mortality in the OA group resulting from postoperative myocardial infarction. Laparoscopic appendectomy can be performed in patients with complicated appendicitis with a comparative operative time, LOS, and complication rates but results in a significantly higher intraabdominal abscess rate and lower wound infection rate when compared with OA.

Endoloop application as an alternative method for gastrotomy closure in experimental transgastric surgery

BACKGROUND

Experimental studies investigating transgastric endoscopic surgery report closure of the gastric wall incision with clips. The author of this report describes endoloop placement as an alternative, equally efficient, faster method for gastrotomy closure.

METHODS

Eight female pigs with a mean weight of 30 kg were used. Abdominal endoscopic exploration and transgastric operations including hepatic biopsies, bilateral tubal ligation, cholecystectomy, and closure of the gastrotomy were performed. The experiment was divided into two parts. The first part included five animals, which were killed immediately after the procedure. The second part included five animals, which were kept alive and killed 15 to 20 days later.

RESULTS

The first part of the experiment, performed for technical skills acquisition, involved transgastric abdominal exploration, liver biopsies, and bilateral tubal ligation, which were successful for all five animals. The gastric wall incision was closed by applying clips in four animals and endoloops in one animal. During the autopsy at the end of the experiment, the sites of intervention were examined macroscopically. In the second part of the experiment, gastrotomy closure with endoloop application was performed in two animals and with clip application in one animal. All three animals survived, gained weight, and demonstrated no signs of infection. They were killed 15 to 20 days after the procedure, and no signs of intraabdominal infection were found. Cultures from the peritoneal cavity were negative. At necropsy, macroscopic and microscopic examination confirmed complete healing of the gastrotomy.

CONCLUSIONS

Transgastric endoscopic surgery is technically feasible and effective. The application of endoloops for closure of the gastric opening is a fast, easy, and equally safe alternative to clip placement.