Predictors of early outcome after acute appendicitis: is delaying surgery for acute appendicitis an option? A retrospective study

PURPOSE

This study analysed the clinical and para-clinical criteria that may allow surgeons and emergency physicians to take a decision regarding the surgery of acute appendicitis.

METHODS

A retrospective analysis was conducted on 284 acute appendicitis patients who underwent surgery between January 2007 and December 2009 in our institution. The registered data were extracted from patient files and statistically analysed. These data included past medical history, clinical, laboratory and imaging data, duration of hospital stay and post-operative complications. Patient delay (time between the appearance of symptoms and patient arrival at the emergency department) and hospital delay (time between hospital arrival and operation) were correctly investigated. Statistical analysis was done by using SPSS software.

RESULTS

The patient delay is significantly increased in relation to the severity of appendicitis: 24 h (10.8-30.8 h) versus 37.4 h (36.8-38 h) (P < 0.05), unlike hospital delay, which remains constant (between simple and severe appendicitis): 7.5 h (5-14.8 h) versus 8 h (5-13 h). In severe appendicitis, the proportion of guarding, rebound tenderness, tachycardia (P < 0.05) and fever (P < 0.005) were significantly high, and leucocytosis (P < 0.05), C-reactive protein (CRP) (P < 0.001) and eosinopaenia [37.0 vs. 72.8 (P < 0.001)] were significantly different. Concerning computed tomography (CT) and echography, perforation, abscess formation (P < 0.05), phlegmon (P < 0.005) and peritonitis (P < 0.05) were significant signs of complicated cases. The length of hospital stay (P < 0.001) and duration of antibiotic therapy (P < 0.001) were statistically significant in cases of complicated appendicitis.

CONCLUSION

Patient delay is a determining factor for the grade of appendicitis. It has an influence on the complications, length of hospital stay and duration of antibiotic treatment, unlike hospital delay.

A laparoscopic approach to left diaphragmatic rupture after blunt trauma

Diaphragmatic rupture after blunt trauma is rare, but indicates a powerful external impact. Associated lesions are often life-threatening and require a rapid diagnosis and management. We report a case of a 24-year-old man, admitted to the emergency department after a serious car accident. He complained of a left sided thoraco-abdominal pain with breathing difficulties. Chest X-ray showed a left diaphragmatic elevation. Computed tomography demonstrated a left haemo-pneumothorax, herniation of the stomach in the chest and a haemoperitonium. Laparoscopically, herniated organs were re-integrated in the abdominal cavity ; the diaphragmatic tear was repaired by both direct suture and synthetic prosthesis. Closure of a small bowel perforation found during the laparoscopic exploration was also performed. We consider this therapeutic modality to be an excellent approach in the management of acute left side diaphragmatic rupture in haemodynamically stable patients. Firstly, it permits an inspection of the thoracic cavity through the diaphragmatic tear and secondly, an easy repair of damaged structures in the abdominal cavity.

Surgical technique and complications during laparoscopic repair of diaphragmatic hernias

Diaphragmatic hernias can present as retrocostoxiphoid hernias (RCXH) or diaphragmatic dome hernias. The RCXH include the Larrey hernia (LH), the Morgagni hernia (MH), and the Larrey-Morgagni hernia (LMH). These congenital hernias are usually asymptomatic, and the diagnosis is simplified by two exams: chest X-ray, and thoraco-abdominal computed tomography (CT) scan. The potential risk in this condition is small-bowel incarceration in the hernia defect and subsequent obstruction. We report two cases of LH and one case of LMH treated by laparoscopy between February 2004 and October 2005, with a review of the surgical techniques. Two different laparoscopic techniques were used: the tension-free technique, and resection of the hernia sac with closure of the defect and reinforcement by prosthesis. One patient presented a postoperative cardiac tamponade due to a clip-induced bleeding of an epicardial artery at the inferior surface of the heart. Treatment by laparoscopy is feasible, but a consensus regarding the best laparoscopic repair is needed.

Thoracoscopic and laparoscopic oesophagectomy improves the quality of extended lymphadenectomy

BACKGROUND

Oesophagectomy with extended lymphadenectomy carries considerable morbidity due to parietal trauma. It is also technically extremely demanding because the difficult access even through a large thoracotomy requires the use of long instruments to reach the deepest recess in the chest cavity. Since the first thoracoscopic oesophagectomy reported by Cuschieri et al. [1] in 1992, different minimally invasive approaches have been proposed [2-12]. The aim of this video is to show the accurate and relative ease of an entirely thoracoscopic and laparoscopic oesophagectomy with an extended lymph node dissection of mediastinum in prone position (thoracoscopically) and celiac trunk (laparoscopically).

METHODS

Oesophagectomy by thoracoscopy, laparoscopy and cervicotomy was proposed in a 63-year-old man with a lower third oesophageal cancer. General anaesthesia was performed with a double-lumen endotracheal tube and the patient was placed in prone position. Surgeons were positioned at the right side of the patient. Only three trocars were needed. A 10 mm 30-degree angled scope was inserted in the 7th intercostal space on the posterior axillary line and the remaining two 5 mm trocars were inserted in the 5th and 9th intercostal spaces on the posterior axillary line. Prone position allows an excellent visibility of the operative field even in an only partially deflated lung. In order to achieve a good exposure, transitory pneumothorax with CO2 (14 mmHg) was performed. The mediastinal pleura overlying the oesophagus was incised and the arch of azygos vein was isolated, ligated and divided. The oesophagus was circumferentially mobilized from the thoracic inlet down to oesophageal hiatus. Para oesophageal and subcarinal lymph nodes were dissected so as to remain in block with the surgical specimen. A 28 F chest tube was inserted in the 8th intercostal space on the anterior axillary line. In the second stage the patient was placed in supine position and pneumoperitoneum was established. Five trocars were placed along an ideal semicircular line, with the concavity facing the subcostal margin and a 30-degree angled laparoscope was used. The lesser omentum was widely opened up the right pillar of the hiatus. Mobilization of the greater curvature of the stomach was performed preserving the right gastroepiploic artery. A wide Kocher maneuver was performed. Celiac lymphadenectomy started with skeletonization of the hepatic artery until the root of left gastric artery was reached. This artery and the left gastric vein were dissected, clipped and sectioned. All fatty tissue and lymph nodes along hepatic artery, left gastric artery and celiac trunk were resected in block with the surgical specimen. Multiple applications of a linear endoscopic stapler were used to create the gastric tube. Finally the distal oesophagus was dissected, until the thoracoscopic dissection field was joined. In the third stage a left lateral cervicotomy was performed and the cervical oesophagus was dissected down to the thoracoscopic dissection plane. Oesophagus and stomach were delivered through the cervical incision and an oesophagogastric anastomosis was created by a linear stapler technique. Cervical and abdominal drainages were installed.

RESULTS

The total operative time was 271 minutes (thoracoscopy: 106 minutes, laparoscopy 120 minutes and cervicotomy 45 minutes) and blood loss was about 100 ml. Histological examination demonstrated a squamous cell carcinoma. Both margins of resection were free of tumour and 29 lymph nodes were retrieved. The final stage was IIA (pT3N0Mx).

CONCLUSIONS

Thoracoscopic and laparoscopic oesophagectomy with extended lymphadenectomy is technically feasible and safe. Thoracoscopic oesophagectomy in prone position improves the quality of dissection because: The oesophagus and aorto-pulmonary window are reached under excellent visibility, despite a partially deflated lung, which because of gravity will always remain out of harm's way. For the same reason small to moderate bleeding will not obscure the operative field. Dissection with the long endoscopic instruments is more accurate due to the support provided by the entrance site at the parietal level and the ergonomic position of surgeon. This article contains a supplementary video.

Laparoscopic left lateral hepatic lobectomy for metastatic colorectal tumor

BACKGROUND

The growth of experience in laparoscopic surgery, technological improvements in laparoscopic instruments, and the application of laparoscopy to oncology surgery are responsible for the new challenge of laparoscopic liver surgery. Several series of laparoscopic liver resections have been reported, and these series have shown the feasibility of resections. The first anatomical laparoscopic liver resection was a left lateral segmentectomy, reported in 1996 by Azagra et al. due to favorable anatomy of this hepatic segment for a totally laparoscopic approach.

METHODS

This video shows a left lateral hepatic lobectomy (bisegmentectomy 2-3) by a total laparoscopic approach in a 56-year-old woman who presented with a metastatic tumor from operated colorectal cancer. A CO(2) pneumoperitoneum was induced with a Veress needle and abdominal pressure was maintained at 12 mmHg. Five trocars were placed along an ideal semicircular line, with the concavity facing the right subcostal margin, and a 30 degrees angled laparoscope was used. A retraction of round ligament with suture was performed to obtain exposure of the inferior face of liver. The left hepatic pedicle was dissected in close vicinity with the portal branch. Segmental vascular structures and bile ducts of segments 3 and 2 were progressively and intraparenchymatously identified, clipped, and sectioned. A Pringle's maneuver was not necessary. The dissection line was demarcated on the liver with monopolar cautery, and liver parenchymal transection was obtained with an ultrasound scalpel (Ultracision, Ethicon Endosurgery). Finally, the left hepatic vein was sectioned with a linear vascular endostapler (Ethicon Endosurgery). Extraction of specimen was performed using a plastic bag through an enlarged trocar site.

RESULTS

The operative time was 110 min, and blood loss was zero. The postoperative period was uneventful, the length of hospital stay was 5 days, and the patient returned to normal activity 1 week postoperatively. The surgical margins of specimen were free of disease.

CONCLUSIONS

Laparoscopic left lateral lobectomy of the liver is feasible and safe in patients with isolated malignant disease of the left lateral segment. This approach reduces blood loss and postoperative hospital stay, and it has a better cosmetic result.

Thromboembolism prophylaxis and incidence of thromboembolic complications after laparoscopic surgery

The aim of this prospective study was to assess the clinical thrombo-embolic risk in laparoscopic digestive surgery.

METHODS

The study prospectively included 2384 patients, who underwent laparoscopic surgery between June 1992 and June 1997. All patients received peri-operative low molecular weight heparin (LMWH) thromboprophylaxis. This regimen was administered until the patient resumed normal ambulatory activity.

RESULTS

Eight cases (0.33%) of deep vein thrombosis (DVT) were observed, but no pulmonary embolism was noted. In 6 cases (5 cholecystectomies with reverse Trendelenburg position and 1 inguinal hernia repair), the pneumoperitoneum was more than 2 h, and in 2 cases (1 rectopexy and 1 sigmoid colectomy for diverticulitis), more than 3 h. In 6 out of the 8 cases, the diagnosis of DVT was established after cessation of LMWH delivery, after the patients were discharged home, and before post-operative day 10.

CONCLUSION

During laparoscopic surgery, long operations and reverse Trendelenburg position are potentiating factors to DVT. Heparin prophylaxis for laparoscopic procedures should continue at least until discharge, and continued prophylaxis after discharge should only be considered in individual patients at continued high risk. We also recommend using graduated compression stockings, maintaining a relatively low insufflation pressure, keeping use of the reverse Trendelenburg position to a minimum, and intermittently releasing the pneumoperitoneum in longer procedures.

Laparoscopic right posterior hepatic bisegmentectomy (Segments VII-VIII)

The role of laparoscopy in liver surgery is still a subject of debate. Up to now, isolated hepatic lesions requiring a segmental (or bisegmental) resection have been considered to be an indication for laparoscopic surgery only when they are located in the left lobe or in the right lower lobe, whereas an open approach by laparotomy or thoracotomy is still preferred for lesions of the upper right lobe. Here we report a case of a right posterior hepatic bisegmentectomy (segments VII-VIII) performed for a hepatic hemangioma that was carried out entirely laparoscopically. In our opinion, there is not an a priori contraindication to the laparoscopic resection of any hepatic benign lesion, wherever it is located in the liver parenchyma. Nevertheless, major hepatic resections still have to be performed by expert surgeons in specialized centers.

Quality of life 2 years after laparoscopic total fundoplication: a prospective study

This study was a prospective evaluation of the quality of life of 50 patients after laparoscopic total fundoplication surgery for gastroesophageal reflux disease. The quality of life of 50 consecutive patients who underwent laparoscopic total fundoplication was evaluated using the Gastrointestinal Quality of Life Index questionnaire, which included 36 items in five different areas: symptoms, physical well-being, psychologic well-being, social relationships, and effects of medical treatment. Twenty-seven men and 23 women with a mean age of 52.6 +/- 16 years (range, 31-68 years) with gastroesophageal reflux disease were treated by laparoscopic total fundoplication (Nissen-Rosetti) and were included in the study. The follow-up was at least 2 years after surgery. The quality of life was evaluated before the surgery and 1 month, 3 months, 6 months, 1 year, and 2 years after surgery with follow-up in 100% of the cases. A control group of 50 healthy volunteers representing an identical population to that of the patients operated on (with respect to age, sex, body mass index, profession, and smoking) anonymously completed the same questionnaire. The preoperative and postoperative Gastrointestinal Quality of Life Index questionnaire scores of patients who had laparoscopic total fundoplication were compared with the Gastrointestinal Quality of Life Index questionnaire scores of the control group. Before surgery, the Gastrointestinal Quality of Life Index questionnaire score (86.7 +/- 8.5) was much inferior to that of the control group (123.8 +/- 13.6) (P < 0.001). This score significantly improved 3 months after surgery and was comparable (not significant) to that of the healthy control population 3 months, 6 months, 1 year, and 2 years after surgery (119.3 +/- 7.8). Improvements were reported mainly with respect to gastrointestinal symptoms and physical well-being. Social relationships were not modified. The quality of life of patients after laparoscopic surgery for gastroesophageal reflux disease improved and was close to the level expected in a healthy individual.

Feasibility of robotic laparoscopic surgery: 146 cases

Theoretically, in laparoscopic surgery, a computer interface in command of a mechanical system (robot) allows the surgeon: (1) to recover a number a number of lost degrees of freedom, thanks to intraabdominal articulations; (2) to obtain better visual control of instrument manipulation, thanks to three-dimensional vision; (3) to modulate the amplitude of surgical motions by downscaling and stabilization; (4) to work at a distance from the patient. These advances improve the quality of surgical tasks in a perfect ergonomic position. The purpose of this paper is to evaluate the feasibility of utilizing a robot in laparoscopic surgery. The first robot-assisted procedure in humans was performed in March 1997 by our team. One hundred forty-six patients underwent robot-assisted laparoscopic surgery. Between March 1997 and February 2001 a nonconsecutive series was performed of 39 antireflux procedures, 48 cholecystectomies, 28 tubal reanastomoses, 10 gastroplasties for obesity, 3 inguinal hernias, 3 intrarectal procedures, 2 hysterectomies, 2 cardiac procedures, 2 prostactectomies, 2 arteriovenous fistulas, 1 lumbar sympathectomy, 1 appendectomy, 1 laryngeal exploration, 1 varicocele ligation, 1 endometriosis cure, 1 neosalpingostomy, 1 deferent canal. The robot (Da Vinci system, Intuitive Surgical, Mountain View, CA), consists of a console and a cart with three articulated robot arms. The surgeon sits in front of the console, manipulating joysticklike handles while observing the operative field through binoculars that provide a three-dimensional picture. This computer is capable of modulating these data by eliminating physiologic tremor and by downscaling the amplitude of motions by a factor 5 or 3 to one. This study has demonstrated the feasibility of several laparoscopic robotic procedures. There is no morbidity related to the system. Operating time and the hospital stay were within acceptable limits. The system seems most beneficial in intra-abdominal microsurgery or for manipulations in a very small space. Optimized ergonomics and increased mobility of the instrument tips are beneficial in many steps of abdominal surgical procedures.

[Quality of life one year after laparoscopic fundoplication is close to that of a control group: prospective study]

AIM OF THE STUDY

Prospective evaluation of the quality of life of patients after laparoscopic fundoplication for gastroesophageal reflux disease (GERD).

PATIENTS AND METHODS

The quality of life of 30 consecutive patients who underwent laparoscopic fundoplication was evaluated using the GIQLI (gastrointestinal quality of life index) questionnaire, which included 36 items in five different areas: digestive symptoms, physical condition, emotional reaction, social integration and medical treatment. Seventeen men and 13 women (mean age: 50.2 +/- 17 years (32-68) were included with a follow-up of at least 1 year and with complete data available. The quality of life was evaluated before surgery, and at 1 month, 3 months, 6 months and 1 year after surgery with a 100% follow-up. Thirty healthy volunteers representing an identical population (with respect to age, sex, BMI, profession, smoking, etc.) anonymously filled in the same questionnaire. The pre- and postoperative GIQLI scores of patients operated for GERD were compared with the GIQLI score of the control group.

RESULTS

Preoperatively, the GIQLI score (87 +/- 9.5) was much lower than that of the control group (123.4 +/- 13.6) (p < 0.001). This score significantly improved 3 months and 1 year after surgery and was comparable to that of the healthy population (115.3 +/- 9.6 vs 123.4 +/- 13.6 [ns]). Improvements were reported mainly with respect to digestive symptoms and physical condition. Social integration was slightly modified.

CONCLUSION

The quality of life of patients after laparoscopic antireflux surgery was greatly improved and was close to the level expected in an healthy population. However, the study demonstrated the possible presence of postoperative functional digestive disorders, although these symptoms were not considered as being uncomfortable, since the level of satisfaction was 96.6% (n = 29).

[Comparison of laparoscopic ultrasound and cholangiography during laparoscopic cholecystectomies. Results of a prospective study]

AIM

Prospective evaluation of the results of laparoscopic ultrasound and cholangiography to investigate choledocholithiasis and detect variations in biliary anatomy during laparoscopic cholecystectomies.

METHODS

The biliary trees of 600 patients who underwent laparoscopic cholecystectomy were routinely explored by laparoscopic ultrasound and cholangiography.

RESULTS

Laparoscopic ultrasound was performed in all 600 cases. Cholangiography was performed in 498 (83%). Laparoscopic ultrasound required less time than cholangiography: 10.2 minutes versus 17.9 minutes (P=0.0001). Common bile duct stones were detected intraoperatively in 40 cases (7%). Both methods were equally effective. The sensitivity of laparoscopic ultrasound was 80% and its specificity 99%. For cholangiography these values were 75% and 98% respectively. For laparoscopic ultrasound, false positives and false negatives were noted in the first 45 cases of individual trainees. Nevertheless, cholangiography showed 30 anatomical anomalies and laparoscopic ultrasound only 15.

CONCLUSION

Laparoscopic ultrasound can be performed rapidly and in all cases. Results are comparable to cholangiography in the detection of common duct stones. Individual training is necessary to optimize efficacy. Anatomical anomalies are often missed.

[Variations in intraperitoneal temperature during laparoscopic cholecystectomy]

STUDY AIM

The aim of this study was to measure thermal variation during laparoscopy in the vicinity of heat sources such as monopolar (MC), bipolar (BC) and ultrasound coagulation (USC) and to evaluate their possible negative consequences for the patient.

METHODS

This study included 67 patients who underwent laparoscopic cholecystectomy. The temperature measurements were taken with a sterile thermal probe introduced through a 5 mm trocar, coupled with a recording monitor reading variations between 20 degrees and 80 degrees C. The variation in temperature was measured as a function of the power applied to the electrodes (20 or 30 W) and in relation to the distance (1, 2, 3, 4, and 5 cm) from the electrodes.

RESULTS

The temperature varied by 3 degrees for BC, 29 degrees for MC and only 0.2 degree for USC when the distance increased for 1 to 5 cm. Depending on the power delivered, (20 or 30 W or 1 to 5 for USC), the variations were 1 degree for BC, 17 degrees for MC and there was still no variation for USC.

CONCLUSION

The use of bipolar coagulation and ultrasonic coagulation associated with minimal temperature variations is the option of choice for operating near structures such as the common bile duct or the gastrointestinal tract.

[Systematic peroperative cholangiography during laparoscopic cholecystectomy]

STUDY AIM

The aim of this study was to assess the feasibility of routine intra operative cholangiography during laparoscopic cholecystectomy (LC) and to evaluate its impact in the detection of common bile duct stones or iatrogenic bile duct injuries.

PATIENTS AND METHOD

From January 1991 to January 1999, 1,050 patients (mean age: 52.5 years) with symptomatic or complicated cholelithiasis were operated on laparoscopically. Intraoperative cholangiography was attempted in all patients before cholecystectomy, performed with an ureteral catheter (diameter: 5 F) introduced into the cystic duct under control of intensifier screen. In case of detection of common bile duct stones (CBDS) or bile duct injury, a surgical management was routinely attempted laparoscopically.

RESULTS

Cholangiography was successfully performed in 840 cases (82.4%). The mean duration of this examination was 15 min (7-45). The success rate was significantly higher in patients with uncomplicated cholelithiasis (90.4%), compared to patients with acute cholecystitis (61.9%) (p = 0.01). The failure rate decreased with experience, falling from 23% for the first 100 attempts to 1% for the last 100. CBDS were identified in 62 patients (7.4%) in 18% of those with acute cholecystitis and 4.6% of those with uncomplicated cholelithiasis. In 21 cases (33%), there were no predictive factors to suggest CBDS. There were 8 false positive (0.9%). Among the 6 cases of bile duct injury observed in this series (0.57%), four patients had an intraoperative cholangiography and the injury was diagnosed peroperatively in two patients and immediately repaired. There was no postoperative death in this series.

CONCLUSIONS

Routine intraoperative cholangiography appears to be the best method for the detection of common bile duct stones and improves prognosis of bile duct injuries when they are immediately detected and peroperatively repaired.

Intraperitoneal thermal variations during laparoscopic surgery

BACKGROUND

The aim of this study was to measure thermal variations during laparoscopy in the vicinity of heat sources such as monopolar (MC) and bipolar coagulation (BC) and to evaluate their possible negative consequences for the patient.

METHODS

This study included 43 patients who underwent laparoscopic cholecystectomy. The temperature measurements were taken with a sterile thermal probe (Mallinkrot Medical) introduced through a 5-mm trocar coupled with a recording monitor reading variations between 20 and 80 degreesC. The variation in temperature was measured as a function of the power applied to the electrodes (20 or 30 W) and in relation to the distance (1, 2, 3, 4, and 5 cm) from the electrodes.

RESULTS

The temperature varied by 3 degrees for BC and 29 degrees for MC when the distance increased from 1 to 5 cm. With respect to the power delivered, 20 or 30 W, the variations were 1 degrees for BC and 17 degrees for MC.

CONCLUSIONS

The minimal temperature variations associated with the use of BC makes it the option of choice for operating near structures such as the common bile duct or the gastrointestinal tract.