Impact of previous abdominal surgery on laparoscopic appendectomy for acute appendicitis

Laparoscopic anatomical left hemihepatectomy guided by middle hepatic vein in the treatment of left hepatolithiasis with a history of upper abdominal surgery

BACKGROUND

This study aimed to investigate the safety and efficacy of laparoscopic anatomical left hemihepatectomy guided by the middle hepatic vein (MHV) for the treatment of patients with hepatolithiasis who had a history of upper abdominal surgery.

METHODS

Retrospective data analysis was performed on patients who underwent laparoscopic left hepatectomy for hepatolithiasis and with previous upper abdominal surgery at the Second Affiliated Hospital of Nanchang University from January 2018 to April 2022. According to the different surgical approaches, patients were divided into laparoscopic anatomical left hepatectomy guided by the MHV group (MHV-AH group) and laparoscopic traditional anatomical left hepatectomy not guided by the MHV group (non-MHV-AH group).

RESULTS

This study included 81 patients, with 37 and 44 patients in the MHV-AH and non-MHV-AH groups, respectively. There was no significant difference in the basic information between the two groups. Five cases were converted to laparotomy, and the remaining were successfully completed under laparoscopy. Compared to the non-MHV-AH group, the MHV-AH group had a slightly longer operation time (319.30 min vs 273.93 min, P = 0.032), lower bile leakage rate (5.4% vs 20.5%, P = 0.047), stone residual rate (2.7% vs 20.5%, P = 0.015), stone recurrence rate (5.4% vs 22.7%, P = 0.028), and cholangitis recurrence rate (2.7% vs 22.7%, P = 0.008).There were no significant differences in the results of other observation indices between the groups.

CONCLUSIONS

Laparoscopic anatomical left hepatectomy guided by the MHV is safe and effective in the treatment of left hepatolithiasis with a history of upper abdominal surgery. It does not increase intraoperative bleeding and reduces the risk of postoperative bile leakage, residual stones, stone recurrence, and cholangitis recurrence.

Conversion from Laparoscopic to Open Appendectomy: Trends, Risk Factors and Outcomes. A 15-Year Single-Center Analysis of 2193 Adult Patients

Background

Laparoscopic appendectomy (LA) has become the standard of care for the management of acute appendicitis in adult patients. Despite the increasing experience in laparoscopy, conversion to open surgery might still occur. We aimed to identify preoperative and intraoperative risk factors for conversion and determine surgical outcomes in this population.

Methods

We performed a retrospective analysis of a consecutive series of patients undergoing LA during the period 2006–2020. The cohort was divided into two groups: patients who underwent a fully laparoscopic appendectomy (FLA) and patients who were converted to open appendectomy (CA). Demographics, perioperative variables and postoperative outcomes were compared between both groups. Independent risk factors for conversion were determined by logistic regression analysis.

Results

A total of 2193 patients were included for analysis; 2141 (98%) underwent FLA and 52 (2%) CA. Conversion rates decreased significantly over time (p = 0.006). Patients with CA had significantly higher overall postoperative morbidity rates (FLA 14.9% vs. CA 48.0%, p < 0.0001) and longer mean length of hospital stay (FLA 1.7 vs. CA 5 days). In the multivariate analysis, obesity (p < 0.001), previous abdominal operations (p = 0.013), peritonitis (p = 0.003) and complicated appendicitis (p < 0.001) were independent risk factor for conversion.

Conclusions

Although conversion from laparoscopic to open appendectomy is infrequent and has decreased over time, it is associated with significantly higher postoperative morbidity. Patients with previous abdominal operations, obesity and complicated appendicitis should be thoroughly advised about the higher risk of conversion.

Hand-assisted Laparoscopic Repeat Hepatectomy for Secondary Liver Neoplasm

BACKGROUND

Hand-assisted laparoscopic surgery is a widely accepted alternative to an open approach. The use of this technique in repeat liver resection is limited due to technical difficulties caused by postsurgical adhesions. We aimed to assess the feasibility and safety of hand-assisted laparoscopic repeat hepatectomy (HALRH).

MATERIALS AND METHODS

This was a retrospective study of the medical files of patients who had undergone HALRH between 2010 and 2017 in 2 university-affiliated medical centers.

RESULTS

Sixteen patients with repeat hepatectomy were included with a median age of 67.5 years. The first liver resection was a traditional laparotomy for 9 patients and hand-assisted laparoscopic surgery for 7 patients. The conversion rate to open surgery was 6%. The median operative time, blood loss during surgery, and postoperative hospital stay were 166 minutes, 400 mL, and 7 days, respectively. R0 resections were achieved in 88% of patients. The median number of tumors and tumor size were 1 and of 25 mm, respectively. There were no mortalities or major complications postoperatively. For patients with colorectal liver metastases, the median follow-up and overall survival were 21 and 43 months, respectively.

CONCLUSION

The findings suggest HALRH to be safe and feasible. Future ERAS guidelines should evaluate this approach for liver surgery.

Laparoscopic common bile duct exploration with primary closure is beneficial for patients with previous upper abdominal surgery

BACKGROUND

Previous upper abdominal surgery (PUAS) is considered a contraindication to laparoscopic surgery. Whether LCBDE-PC is feasible and beneficial for patients with PUAS remains unclear. This study aimed to evaluate the feasibility and benefits of LCBDE-PC for patients with PUAS.

METHODS

From June 2011 to September 2019, 1167 patients who underwent laparoscopic procedures for choledocholithiasis were reviewed retrospectively. Perioperative outcomes were compared between patients with and without PUAS in un-matched and matched cohorts.

RESULTS

LCBDE-PC was performed successfully in 88.3% of patients with PUAS, and 92.5% of patients without PUAS (P > 0.05). Multivariate analysis showed that PUAS was not a risk factor that affected successful performance of LCBDE-PC. Although a higher rate of conversion to open surgery and longer operative time were observed in patients with PUAS, no significant differences were found between patients with and without PUAS in multivariate and propensity score analysis (P > 0.05). A predictive nomogram for LCBDE-PC failure was developed based on potential predictors from the least absolute shrinkage and selection operator (LASSO) regression model. Successful performance of LCBDE-PC was associated with operative time. A linear regression model for operative time showed impacted stone in the CBD and intraoperative laser use was the most important factor in determining the operative time.

CONCLUSION

LCBDE-PC is feasible and beneficial for patients with PUAS. However, patients with PUAS with a high possibility of LCBDE-PC failure from the nomogram and a longer operative time from the linear regression model should be cautious when undergoing LCBDE-PC.

Laparoscopic repeat liver resection

Recurrence of liver cancers inside the liver are often treated with liver resection (LR). However, increased risks of complications and conversion during operation were reported in laparoscopic repeat LR (LRLR). The indication is still controversial. One multi-institutional propensity score matching analysis of LRLR vs open repeat LR for hepatocellular carcinoma, two propensity score matching analyses for colorectal metastases, and two meta-analyses including hepatocellular carcinoma, intrahepatic cholangiocarcinoma, metastases, and other tumors have been reported to date. LRLR was reported with better to comparable short-term and similar long-term outcomes. Furthermore, the shorter operation time and the smaller amount of intraoperative bleeding for LRLR was reported for the patients who had undergone laparoscopic rather than open LR as an earlier procedure. The speculations are presented, that complete dissection of adhesion can be dodged and laparoscopic minor repeated LR can minimize the liver functional deterioration in cirrhotic patients. LRLR, as a powerful local therapy, could contribute to the long-term outcomes of those with deteriorated liver function. However, the procedure is now in its developing stage worldwide and further accumulation of experiences and evaluation are needed.

Acute appendicitis after liver transplantation: A single center experience and review of the literature

Backgrounds/Aims

Acute appendicitis is one of the most common emergent disease in the general population requiring surgical treatment. However, only a few cases of appendicitis after liver transplantation (LT) were reported. We described experiences of acute appendicitis after LT in single center.

Methods

From March 1988 to July 2019, we reviewed retrospectively all the patients who diagnosed with acute appendicitis after LT at the Seoul National University Hospital. We described and analyzed clinical outcomes of appendectomy after LT.

Results

A total of 12 patients out of 2,237 LT patients underwent appendectomy due to acute appendicitis. The mean age was 48±12 years. Nine patients (75%) underwent deceased donor liver transplantation (DDLT) and three patients (25%) underwent living donor liver transplantation (LDLT). The mean days from transplantation to the onset of acute appendicitis was 739 (range 57–4,496) days. Every patients underwent appropriate appendectomy within 1 days after visiting hospital. Leukocytosis was seen in three patients (25%). Seven patients (58%) underwent laparoscopic appendectomy and five patients (42%) underwent open appendectomy. The total operative time was 47.5 (range 25–135) minutes. The median postoperative hospitalization was 4 (range 2–11) days. There was no postoperative complications documented. There was no significant difference of clinical outcomes between laparoscopic appendectomy group and open appendectomy group.

Conclusions

Early surgical management achieved satisfactory postoperative results without graft dysfunction after LT. Laparoscopic appendectomy also could be applicable with safe and feasible outcomes even in post-LT recipients.

Conversion from laparoscopic to open appendectomy: decreased risk at dedicated children's hospitals

PURPOSE

The advent of laparoscopy has revolutionized surgical practice within the last 30 years. Conversion to open surgery, however, remains necessary at times, even for the most experienced laparoscopic surgeon.

METHODS

The kids' inpatient database was analyzed for 2006, 2009, and 2012 for patients who underwent laparoscopic appendectomy and conversion to open (CPT 470.1 and V64.41, respectively). Variables included in multivariable analysis were determined based on those variables found to have significance on univariate analysis.

RESULTS

A total of 104,865 patients, ages 0-17 years, underwent laparoscopic appendectomy during the three study periods. Of these, 2370 (2.2%) laparoscopic surgeries were converted to open appendectomy. Multivariable logistic regression showed significantly higher rates of conversion amongst patients with peritonitis (OR 6.7, p < 0.001) or abscess (OR 14.3, p < 0.001), obesity (OR 2.02, p < 0.001), age > 13 years (OR 1.53 for ages 13-15, OR 1.77 for ages 16-17, p < 0.001 for both), or cared for at rural hospitals (OR 1.55, p = 0.002). Rates of conversion decreased over time for children at adult hospitals and at urban hospitals, regardless of teaching status (p < 0.001 for both).

CONCLUSION

Risk factors for conversion from laparoscopic to open appendectomy included abscess, peritonitis, increased age, obesity, male gender, socioeconomic status and treatment at a non-pediatric-specific hospital, and the overall rate is decreasing over time.

Status and perspective of laparoscopic repeat liver resection

Liver resection (LR) is now actively applied to intrahepatic recurrence of liver metastases and hepatocellular carcinoma. Although indications of laparoscopic LR (LLR) have been expanded, there are increased risks of intraoperative complications and conversion in repeat LLR. Controversy still exists for the indication. There are 16 reports of small series to date. These studies generally reported that repeat LLR has better short-term outcomes than open (reduced bleedings, less or similar morbidity and shorter hospital stay) without compromising the long-term outcomes. The fact that complete adhesiolysis can be avoided in repeat LLR is also reported. In the comparison of previous procedures, it is reported that the operation time for repeat LLR was shorter for the patients previously treated with LLR than open. Furthermore, it is speculated that LLR for minor repeat LR of cirrhotic liver can be minimized the deterioration of liver function by LR. However, further experience and evaluation of anatomical resection or resections exposing major vessels as repeat LLR, especially after previous anatomical resection, are needed. There should be a chance to prolong the overall survival of the patients by using LLR as a powerful local therapy which can be applied repeatedly with minimal deterioration of liver function.

Minimally Invasive Treatment for Appendiceal Mass Formed After Acute Perforated Appendicitis

The optimal treatment for appendiceal mass formed after appendiceal rupture due to acute appendicitis is surrounded with controversy. The treatment strategy ranges from open surgery (emergency or interval appendectomy), laparoscopic appendectomy, and image-guided drainage, to conservative treatment with or without antibiotics. Nonsurgical treatment (including conservative and drainage treatment), followed by interval appendectomy to prevent recurrence, is the traditional management of these patients. The need for interval appendectomy after a successful conservative or/and image-guided drainage treatment, has recently been questioned as the risk of recurrence is relatively small. Several authors consider that even in cases involving only ambulatory follow-up observation, without interval surgery after conservative management, the recurrence rate and risks of missing underlying pathologies were not high. This article evaluates the minimally invasive treatment modalities in the management of appendiceal mass, risk of undetected serious disease, and the need for interval appendectomy to prevent recurrence.

Conversion-to-open in laparoscopic appendectomy: A cohort analysis of risk factors and outcomes

BACKGROUND

Identifying risk factors for conversion from laparoscopic to open appendectomy could select patients who may benefit from primary open appendectomy. We aimed to develop a predictive scoring model for conversion from laparoscopic to open based on pre-operative patient characteristics.

METHODS

A retrospective review of the State Inpatient Database (2007-2011) was performed using derivation (N = 71,617) and validation (N = 143,235) cohorts of adults ≥ 18 years with acute appendicitis treated by laparoscopic-only (LA), conversion from laparoscopic to open (CA), or primary open (OA) appendectomy. Pre-operative variables independently associated with CA were identified and reported as odds ratios (OR) with 95% confidence intervals (CI). A weighted integer-based scoring model to predict CA was designed based on pre-operative variable ORs, and complications between operative subgroups were compared.

RESULTS

Independent predictors of CA in the derivation cohort were age ≥40 (OR 1.67; CI 1.55-1.80), male sex (OR 1.25; CI 1.17-1.34), black race (OR 1.46; CI 1.28-1.66), diabetes (OR 1.47; CI 1.31-1.65), obesity (OR 1.56; CI 1.40-1.74), and acute appendicitis with abscess or peritonitis (OR 7.00; CI 6.51-7.53). In the validation cohort, the CA predictive scoring model had an optimal cutoff score of 4 (range 0-9). The risk of conversion-to-open was ≤5% for a score <4, compared to 10-25% for a score ≥4. On composite outcomes analysis controlling for all pre-operative variables, CA had a higher likelihood of infectious/inflammatory (OR 1.44; CI 1.31-1.58), hematologic (OR 1.31; CI 1.17-1.46), and renal (OR 1.22; CI 1.06-1.39) complications compared to OA. Additionally, CA had a higher likelihood of infectious/inflammatory, respiratory, cardiovascular, hematologic, and renal complications compared to LA.

CONCLUSIONS

CA patients have an unfavorable complication profile compared to OA. The predictors identified in this scoring model could help select for patients who may benefit from primary open appendectomy.

Identification of preoperative risk factors associated with the conversion of laparoscopic to open appendectomies

Our goals were to (1) identify risk factors associated with conversion from laparoscopic to open appendectomies and (2) establish criteria that predict the possibility of conversion to an open technique. We did a retrospective chart review of all patients who underwent laparoscopic appendectomies during a 5-year period (2004-2008). Preoperative risk factors, intraoperative findings, and postoperative complications were compared. We found that of 763 patients who had undergone laparoscopic appendectomy, 44 patients were converted to open technique (conversion rate of 5.8%). For these 44 patients, the male to female ratio was 2 to 1, and the men were older (45 versus 37 years of age, P < 0.001). Conversion rates decreased with time (8.7% in 2004 versus 3.5% in 2008). Past surgical history was insignificant. However, a duration of symptoms of >5 days as well as a white blood cell count >20,000 were found to have a direct correlation. Incidence of postoperative complications did not increase in converted patients. The conversion rate is highest in male patients above 45 years of age, with over 5 days' duration of symptoms, leukocytosis >20,000, and ruptured appendicitis on computed tomography scan. The presence of 3 to 4 of these risk factors should lower the threshold for consideration of conversion to open appendectomy.

Pure laparoscopic hepatectomy as repeat surgery and repeat hepatectomy

AIM: To assess clinical outcomes of laparoscopic hepatectomy (LH) in patients with a history of upper abdominal surgery and repeat hepatectomy.

METHODS: This study compared the perioperative courses of patients receiving LH at our institution that had or had not previously undergone upper abdominal surgery. Of the 80 patients who underwent LH, 22 had prior abdominal surgeries, including hepatectomy (n = 12), pancreatectomy (n = 3), cholecystectomy and common bile duct excision (n = 1), splenectomy (n = 1), total gastrectomy (n = 1), colectomy with the involvement of transverse colon (n = 3), and extended hysterectomy with extensive lymph-node dissection up to the upper abdomen (n = 1). Clinical indicators including operating time, blood loss, hospital stay, and morbidity were compared among the groups.

RESULTS: Eighteen of the 22 patients who had undergone previous surgery had severe adhesions in the area around the liver. However, there were no conversions to laparotomy in this group. In the 58 patients without a history of upper abdominal surgery, the median operative time was 301 min and blood loss was 150 mL. In patients with upper abdominal surgical history or repeat hepatectomy, the operative times were 351 and 301 min, and blood loss was 100 and 50 mL, respectively. The median postoperative stay was 17, 13 and 12 d for patients with no history of upper abdominal surgery, patients with a history, and patients with repeat hepatectomy, respectively. There were five cases with complications in the group with no surgical history, compared to only one case in the group with a prior history. There were no statistically significant differences in the perioperative results between the groups with and without upper abdominal surgical history, or with repeat hepatectomy.

CONCLUSION: LH is feasible and safe in patients with a history of upper abdominal surgery or repeat hepatectomy.

Short- and long-term results of open versus laparoscopic appendectomy

BACKGROUND

Clinical advantages of laparoscopic appendectomy have been shown in numerous trials and reviews. Most of these advantages are small and of limited clinical relevance, while laparoscopic operation costs are reported to be higher. The present study compares short- and long-term results of conventional appendectomy with or without diagnostic laparoscopy (OA), and laparoscopic appendectomy (LA).

METHODS

All adult patients who underwent appendectomy in our institution from 1995 to 2005 were included retrospectively. Patient data were retrieved from medical records, questionnaires sent by mail, and records of general practitioners. Primary outcome parameters were long-term complications, readmissions, and reinterventions (>30 days postoperatively). Secondary outcome parameters were short-term complications, readmissions, and reinterventions (≤30 days postoperatively).

RESULTS

A total of 755 patients were included, 545 of whom underwent OA, with the remaining 210 undergoing LA. In the long term there were few complications noted, and there were no significant differences in complications between the two groups. Within 30 days postoperatively, LA was associated with a significantly higher incidence of abdominal abscesses with consequent diagnostic investigations, interventions, and readmissions.

CONCLUSIONS

Although laparoscopic appendectomy is known to deliver clinical advantages, it is associated with a higher incidence of abdominal abscesses. Because the procedure is about to become the standard of care, future research must be directed at solving this issue. The expected lower incidence of incisional hernia and small bowel obstruction after laparoscopic appendectomy was not shown in the present study.

Laparoscopic liver resection in patients with a history of upper abdominal surgery

BACKGROUND

The liver is the organ where tumors most frequently metastasize. Hepatic recurrence after resection of hepatocellular carcinoma also occasionally occurs. With the increasing use of laparoscopic surgery for hepatic tumors, there may be a high probability that laparoscopic liver resection can be performed in patients with a surgical history. The purpose of this study was to assess the feasibility and clinical outcomes of laparoscopic liver resection in patients a history of upper abdominal surgery.

METHODS

Of 202 laparoscopic liver resections, 47 patients underwent laparoscopic liver resection after previous upper abdominal surgery between January 2004 and July 2009. Fifty-five previous surgeries were performed in the 47 patients. The previous types of surgical procedures included hepatobiliary and pancreatic (HPB) procedures (n=25) and non-HPB procedures (colorectal malignancies, subtotal gastrectomy, and splenectomy; n=22).

RESULTS

In patients with a history of surgery, the mean operative time for laparoscopic liver resection was 312.3 min and the mean blood loss was 481.0 ml. In 42 patients (89.4%), there were severe adhesions in the hepatoduodenal ligament and hilar areas. Transfusion was required in 7 patients (14.9%). There was one conversion to a laparotomy due to severe adhesions. Complications occurred in 11 patients (23.4%) and the mean hospital stay was 10.6 days. When we compare patients with and without a history of surgery, there were no differences in the above-mentioned perioperative results. However, among patients with a history of surgery, patients who underwent HPB procedures had longer operative times and higher postoperative morbidities than those who had not undergone HPB procedures.

CONCLUSION

Laparoscopic liver resection in patients with a history of upper abdominal surgery is feasible and safe.

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.

[Open appendectomy. When do we still need it?]

Acute appendicitis is the most common emergency visceral surgical procedure in Germany with 130,000 appendectomies. The question of which operational procedure should be used must therefore be discussed at regular intervals. In many centers of minimal invasive surgery, laparoscopic appendectomy (LA) is the standard procedure. Nearly 30 years after introduction of LA, it is believed that open appendectomy (OA) is needed only on rare occasions, but the actual percentage of OAs carried out in 2006 was 46% of all appendectomies. This high percentage documents that OA is still the standard procedure in many German hospitals. A review of the literature shows that there are still some situations in which OA is superior to LA. Infants younger than 5 years old have a more difficult basic requirement for LA due to the small abdominal cavity, therefore OA is the procedure of choice in most cases. During pregnancy OA has a lower risk for the fetus than LA. Cost analyses show that OA is less expensive for the hospital in material costs, whereas LA is the better economic choice due to an earlier return to work. In summary, there are only marginal differences between the two procedures since both offer a fast patient recovery. Advantages in favor of both LA and OA exist in subgroup analyses and the possible subgroups that can benefit from OA are discussed in this article.