Laparoscopic appendectomy. Initial experience in a teaching program.

From February 1990 to December 1991, 16 laparoscopic procedures were performed for right lower quadrant pain. There were nine men and seven women, aged 16 to 47 years (mean, 27.2 years). All procedures were performed by surgical chief residents with prior experience in laparoscopic cholecystectomy, first-assisted by an attending surgeon. The appendix was visualized and a definitive diagnosis was made in all patients. One patient with acute salpingitis underwent diagnostic laparoscopy only; two patients underwent laparotomy (perforated appendicitis, perforated diverticulitis). A fourth patient had an acute torsion of an ovarian cyst managed laparoscopically. Laparoscopic appendectomy was successfully performed in 12 patients (acute appendicitis, 9; fibrosis or chronic inflammation, 2; normal appendix, 1). Mean operative time for laparoscopic appendectomy was 95.7 minutes, and mean postoperative stay was 2.5 days. The authors conclude that operative time, diagnostic accuracy, and complication rates for laparoscopic appendectomy are acceptable. Within the context of a training program, laparoscopic appendectomy provides an opportunity for surgical residents to expand laparoscopic skills.     

Stump appendicitis after laparoscopic appendectomy: case report

Stump appendicitis is a rare delayed complication of appendectomy. The delay in diagnosis is usually because of a prior history of appendectomy. We report a case of stump appendicitis diagnosed pre-operatively with a computerized tomography (CT) scan after laparoscopic appendectomy. An 18-year-old male presented with a one-week history of lower abdominal pain, nausea and vomiting. He had a history of laparoscopic appendectomy for acute appendicitis. Physical examination revealed tenderness and guarding in the lower abdomen. CT scan showed free pelvic fluid with a tubular structure of about 2.5 cm in length and 0.78 cm in diameter located posterior to the ileo-cecal junction. Laparoscopic exploration confirmed the findings. A residual appendiceal stump was found and dissected from the adhesion and removed. Histopathology showed a residual appendix with transmural neutrophilic infiltration associated with multifocal hemorrhagic necrosis. The postoperative period was uneventful. The diagnosis of stump appendicitis can be challenging. CT scan has proven to be a useful tool for the diagnosis of this rare condition.     

Stump appendicitis after laparoscopic appendectomy; laparoscopic management and literature review

IntroductionAppendectomy is one of the most common surgical procedures performed worldwide There are different etiologies for acute appendicitis such as obstruction of the appendiceal lumen by fecalith, lymphoid hyperplasia, or neoplasm.Laparoscopic appendectomy has become the treatment of choice for both complicated and uncomplicated appendicitis; common postoperative complications include wound infection, bleeding, intraabdominal abscess.Stump appendicitis is defined as the interval repeated inflammation of remaining residual appendiceal tissue after an appendectomy.Presentation of case38-Year-old female patient with a history of laparoscopic appendectomy performed in 2016 for acute uncomplicated appendicitis.She arrived to the emergency room due to abdominal pain 7 out of 10, located in the periumbilical region, later with migration to the right lower quadrant, abdominal CT scan evidenced the presence of a cecal and pericecal inflammatory process as well as the base and residual proximal portion of the cecal appendix laparoscopic stump appendectomy was performed.DiscussionStump appendicitis (SA) is defined as the inflammation of the remnant of the cecal appendix after an appendectomy, whether due to impaction of a fecalith or secondary to an ischemic process, the probability of developing SA is estimated to be about 1/50,000 cases throughout life.The most frequently used treatment is exploratory laparotomy to complete the previous appendectomy; however, there are 5 reported cases of stump appendicitis, where surgical resolution was performed through laparoscopic surgery.ConclusionsIt is important to keep this entity in mind when evaluating a patient with acute abdomen with previous history of appendectomy, since the delay in diagnosis and treatment increases morbidity and mortality; laparoscopic stump appendectomy has been shown to be a safe treatment (Agha et al., 2020 [14]).¹     

Offene vs. laparoskopische Appendektomie

This article discusses the question of whether open or laparoscopic appendectomy is preferable in today's clinical routine. The article is based on data from randomized studies, evaluation of meta-analyses, and data from nonrandomized, multicentric studies evaluating the treatment of appendicitis in routine clinical practice. According to the data analysis, open appendectomy (OA) offers advantages with regard to a significantly shorter operative time and lower hospital costs. Laparoscopic appendectomy (LA) is characterized by a significantly decreased rate of failed septic wound healing and faster recovery. Both procedures can be performed with the same degree of safety and comparable outcome for acute appendicitis. Laparoscopic appendectomy offers significant advantages for establishing a precise diagnosis in young fertile women and overweight patients suffering from lower abdominal pain. The currently available data do not provide precise guidelines for the treatment of perforating appendicitis. However, we found significant evidence indicating an increased rate of postoperative intra-abdominal abscess after laparoscopic appendectomy. Thus, a laparoscopic approach cannot be regarded as a standard technique in advanced appendicitis.     

Laparoscopic appendectomy by ultrasonically activated scalpel in acute appendicitis: preliminary report

BACKGROUND AND PURPOSE: Laparoscopic appendectomy (LA) is increasingly being used in treating acute appendicitis. New instruments such as the ultrasonically activated scalpel (UAS) have been introduced for most laparoscopic procedures. We evaluated the use of UAS in the performance of LA, as the potential of this instrument in this type of surgery remains to be defined. PATIENTS AND METHODS: Three patients with acute right lower abdominal pain were managed by the laparoscopic approach. Once the diagnosis of acute appendicitis was established, laparoscopic appendectomy was performed with the UAS. RESULTS: The mean operative time was 42.3 minutes (range 32-49 minutes). There were no complications related to the treatment with UAS of either the vascular pedicle or the appendicecal stump. No electrosurgical coagulation, clips, loops, or endostapler was used in any patient. CONCLUSIONS: Total LA performed with UAS is feasible. Use of the UAS may make dissection and resection of the appendix easier, helping to reduce the mean operative time.     

Laparoscopic appendicectomy: an 8-year clinical experience

BACKGROUND: For more than a century, open appendectomy through a laparotomy has been the golden standard for the surgical removal of the appendix. Nowadays, many surgeons question the utility of laparoscopic surgery to perform appendectomies because it is commonly stated that the appendix can be removed through a small surgical incision carrying a minimal surgical trauma to the patient. Although open appendectomy is really safe, on the other hand it carries a considerable risk of postoperative complications, is associated with postoperative pain and affects patient s normal activity. Laparoscopic appendectomy was first described in 1983 and, in many studies, it is described to be better than open standard technique for the treatment of appendiceal diseases. The aim of the present study is the retrospective analysis of laparoscopic appendectomies performed in a 8-year period. METHODS: The authors report on 129 patients who underwent laparoscopic appendectomy. RESULTS: Conversion rate was 0.7 %, while the laparoscopic procedure was completed in 96 female and 32 male patients. The position of the appendix was behind the cecum in 37 cases, associate diseases were found in 15 cases. Mean operative time was 51 minutes; kind of laparoscopic instrumentation affected the operation time. Histologically there were 71 (55.5 %) focal appendicitis, 22 (17.1 %) suppurative appendicitis, 11 (8.6 %) gangrenous appendicitis, 18 (14.1 %) chronic appendicitis showing signs of previous suppurative episodes and 6 (4.7 %) normal appendix. There were neither in-hospital morbidity nor mortality. Follow-up showed reduced postoperative pain, short hospital stay, fast return to complete social activity. CONCLUSIONS: The authors conclude that laparoscopic technique can be considered a safe and effective procedure for the removal of the appendix as it has the advantage of allowing faster postoperative recovery; moreover the author recommend a wider and routinely use for appendectomy.     

Macroscopic assessment of the appendix at diagnostic laparoscopyis reliable

Background: Healthy-looking appendixes are often removed at laparoscopy for suspected appendicitis. This practice may have adverse secondary effects. Methods: We reviewed the literature for the years 1978 to 1998 to analyze the negative appendectomy rates, complication rates, the accuracy of laparoscopic appendix assessment, and the incidence of false negative diagnosis of appendicitis at surgical and gynecological laparoscopy. Results: The respective negative appendectomy rates were 22% and 15% in studies that compared laparoscopic with open appendectomy. The appendix was left in situ in 37% of 4,281 surgical diagnostic laparoscopies. There were instances of missed appendicitis among the 3,367 gynecological diagnostic laparoscopies performed on women for lower abdominal pain, and there were 188 appendectomies in this group. Studies comparing the macroscopic appearance of the appendix at operation with microscopic findings from the excised specimen had a false negative error rate of 3%. Conclusions: Contrary to general opinion, there is no substantial evidence to support the assumption that the macroscopic diagnosis of appendicitis is unreliable. High rates of conflicting diagnoses of excision specimens suggest that endoappendicitis has little clinical significance. At present, negative appendectomy rates are considerably higher for laparoscopic appendectomy than for the open approach. The role of diagnostic laparoscopy in suspected appendicitis should be reconsidered. It may be useful in particular subgroups of patients, but it is no substitute for good clinical judgment. Furthermore, it is not always necessary to perform an incidental appendectomy. Received: 7 September 1999/Accepted: 21 October 1999/Online publication: 30 May 2000     

腹腔镜治疗阑尾炎497例

目的:总结腹腔镜阑尾切除术在治疗阑尾炎中的效果。方法:回顾分析经腹腔镜行阑尾切除术497例的临床资料,并与同期剖腹治疗阑尾炎进行比较。结果:497例中63例无法满意处理残端或盲肠壁内阑尾、腹膜外位阑尾而中转开腹。11例腹腔脓肿,9例皮下气肿,6例术后肩背部疼痛,余者无粪瘘、肠粘连、切口感染、阑尾残株炎等术后并发症。结论:经腹腔镜治疗阑尾炎为首选治疗方式。经腹腔镜切除阑尾可取代传统的开腹阑尾切除术。     

Laparoscopic appendectomy in pediatric patients: experience of 2300 operations

The experience of 2300 laparoscopic appendectomies in children aged between 7 days and 14 years is presented. Uncomplicated forms of acute appendicitis were observed in 1611 patients (70.1%). Complicated forms were observed in 689 (29.9%) patients: general peritonitis in 196, local peritonitis--in 334, periappendicular abscess--in 122 and friable infiltrate--in 37 patients. Laparoscopic appendectomy according to F. G?tz modified and adapted by us to children's age was used for all variants of the appendix location, including atypical. Optimal surgical approaches for children of early age and children over 3 years were developed. All laparoscopic interventions were completed endosurgically. Only in 15 (0.65%) patients the transition to open surgical operation was carried out on a diagnostic phase of the laparoscopic appendectomy for contraindications (solid infiltration, general peritonitis with multiple abscesses, intestine paresis with need of decompression). On comparative estimation of the laparoscopic and traditional appendectomies the indisputable advantages of the endoscopic technique are proved: more smooth course of the postoperative period, reduction of complications' number, reduction of hospital stay. Laparoscopic appendectomy is the most effective technique for the treatment of acute appendicitis complicated forms. Mean operative time was 65 min (range 42-120 min). Total amount of the postoperative complications in this group decreased almost 3 times. Frequency of such serious intraabdominal complications as acute commissural ileus decreased 3.5 times, infiltrates and abscesses of the abdominal cavity--2 times. Suppuration of the anterior abdominal wall was extremely rare. Mean hospital stay reduced almost 2 times. Intraoperative complications and lethality was not observed.     

Diagnostic laparoscopy through the right lower abdominal incision following open appendectomy

Background: Diagnostic laparoscopy through the right lower abdominal incision following open appendectomy for suspected acute appendicitis may help in making the correct diagnosis in the absence of pathology of the appendix. Methods: Fourteen patients with a clinical diagnosis of acute appendicitis underwent diagnostic laparoscopy through the right lower quadrant incision after open appendectomy to exclude further pathology in the case of a noninflamed appendix. Results: In 10 of the 14 patients, laparoscopy helped to correct the diagnosis. In two patients, the etiology of the acute right lower abdominal pain remained unclear. In two others, histological examination showed acute appendicitis despite a normal macroscopic appearance. Conclusions: Diagnostic laparoscopy through the right lower quadrant incision may help to correct the diagnosis in patients who are operated on for clinically acute appendicitis but in whom no acute appendicitis or other pathological findings are seen. Received: 10 September 1997/Accepted: 15 April 1998     

Laparoscopic resection of perforated Meckel's diverticulum in a patient with clinical symptoms of acute appendicitis

We report the laparoscopic resection of a perforated Meckel's diverticulum (MD) found in a 14-year-old boy who presented with abdominal pain and nausea. There was rebound tenderness in the right lower quadrant of the abdomen, which appeared suspicious for acute appendicitis. The patient was referred to the operating room, and laparoscopic appendectomy was performed. With the appendix showing no macroscopic signs of inflammation, laparoscopy was continued and a perforated MD was identified 50 cm proximal to the ileocecal valve. The findings included pus and localized peritonitis between the ileal loops adjacent to the perforation site. The diverticulum was longitudinally resected with an Endo-Gia stapler. The histopathologic workup confirmed the diagnosis of a perforated MD. The patient completely recovered and was discharged 8 days after the procedures. At this writing, he is completely asymptomatic 6 months later. We conclude from our observation that laparoscopic resection of a perforated MD can be performed safely even when localized peritonitis is present. Inspection of the small intestine should be performed to exclude a symptomatic or perforated MD when the appendix does not show any signs of acute appendicitis.     

Incidental laparoscopic appendectomy for acute right lower quadrant abdominal pain

Background: Removing the normal appendix when operating for suspected acute appendicitis is the standard of care. The use of laparoscopy should not alter this practice. Methods: Retrospective review of 72 patients found to have grossly normal appendices while undergoing laparoscopy for suspected appendicitis. Twenty-eight patients underwent diagnostic laparoscopy (DL) alone while 44 patients underwent diagnostic laparoscopy with incidental laparoscopic appendectomy (ILA). Results: There was no difference in length of hospitalization (DL = 44 h, ILA = 43 h, p= 0.49) or morbidity (DL = 11%, ILA = 5%, p= 0.37). One patient required appendectomy 11 days after diagnostic laparoscopy for recurrent acute right lower quadrant abdominal pain. Five percent of resected appendices (2/44) demonstrated acute inflammation upon pathologic review. Conclusions: Laparoscopic removal of the normal appendix produces no added morbidity or increase in length of hospitalization as compared to diagnostic laparoscopy. It demonstrates cost effectiveness by preventing missed and future appendicitis. Incidental laparoscopic appendectomy is the preferred treatment option. Received 3 April 1997/Accepted: 3 July 1997     

腹腔镜阑尾切除术1261例报告

目的 :总结腹腔镜阑尾切除术的经验。方法 :回顾分析行腹腔镜阑尾切除术 12 6 1例的临床资料。结果 :12 6 1例中 ,12 4 9例在腹腔镜下完成阑尾切除术 ,2例行阑尾周围脓肿引流术 ,10例为阑尾根部穿孔或腹膜后阑尾中转剖腹手术。 1例术后出血而再手术 ,戳孔感染 4例 ,无因肠瘘、肠粘连、肠梗阻而再手术者。结论 :腹腔镜阑尾切除术要正确处理系膜并将阑尾移出腹腔 ,可降低切口感染、肠粘连、肠梗阻的发生率 ,此术式尤其适用于肥胖 ,小儿及化脓坏疽性阑尾炎患者     

Mobile Cecum: An Incidental Finding

To hypothesize that mobile cecum is a rare etiological factor and cecopexy is the choice of treatment in patients with recurrent right lower abdominal pain. Prospective study was conducted in the department of general surgery, SSG Hospital, Baroda, from January 2008 to December 2009. Patients with recurrent right lower abdominal pain were planned for appendectomy. In those patients with intraoperative findings suggestive of macroscopically normal appendix while cecum found to be mobile and no other gross abnormality, appendectomy was performed with cecopexy, fixing cecum to lateral abdominal wall with polypropylene 3-0 suture in interrupted manner. Histopathological examination was confirmed in all the cases. A total of 110 patients complaining of recurrent right lower abdominal pain, with clinical and radiological findings suggestive of appendicitis, were planned for appendectomy. Of 110 patients, 20 were found to have macroscopically normal appearing appendix and of those 20 patients, 8 had cecum unattached to the lateral peritoneal wall. The rest of 90 patients had grossly inflamed appendix in which 10 patients had cecum unattached to the lateral peritoneal wall. Appendectomy and cecopexy were performed in all the patients. On histological examination of the excised appendices, of those 20 with macroscopically normal appearance, 11 had features suggestive of chronic appendicitis and remaining 9 patients were found to have normal histology. While the other 90 with grossly inflamed appendix showed pathological changes of acute inflammation. A total of 64 patients of 110 were followed up till date with no recurrence of abdominal pain. A mobile cecum should be considered a cause of recurrent right lower abdominal pain, and cecopexy is easy to perform and good treatment of choice for a mobile cecum.     

A Comparison of Laparoscopic and Open Appendectomy

Background and Objectives:

To compare laparoscopic appendectomy with traditional open appendectomy.

Methods:

Seventy-one patients requiring operative intervention for suspected acute appendicitis were prospectively compared. Thirty-seven patients underwent laparoscopic appendectomy, and 34 had open appendectomy through a right lower quadrant incision. Length of surgery, postoperative morbidity and length of postoperative stay (LOS) were recorded. Both groups were similar with regard to age, gender, height, weight, fever, leukocytosis, and incidence of normal vs. gangrenous or perforated appendix.

Results:

Mean LOS was significantly shorter for patients with acute suppurative appendicitis who underwent laparoscopic appendectomy (2.5 days vs. 4.0 days, p<0.01). Mean LOS was no different when patients classified as having gangrenous or perforated appendicitis were included in the analysis (3.7 days vs. 4.1 days, P=0.11). The laparoscopy group had significantly longer surgery times (72 min vs. 58 min, p<0.001). There was no significant difference in the incidence of postoperative morbidity.

Conclusions:

Laparoscopic appendectomy reduces LOS as compared with the traditional open technique in patients with acute suppurative appendicitis. The longer operative time for the laparoscopic approach in our study is likely related to the learning curve associated with the procedure and did not increase morbidity.     

阑尾穿孔腹腔镜阑尾切除术41例临床分析

目的：总结腹腔镜阑尾切除术治疗阑尾穿孔并腹膜炎的效果。方法：分析41例患者阑尾穿孔并腹膜炎行腹腔镜手术的临床资料,并随机选择常规开腹手术40例为对照组,比较两组的手术时间、术后切口感染、腹腔残余感染及肠粘连等并发症的发生率。结果：腹腔镜组手术时间45～95min,平均61min,几乎无出血,术后穿刺口感染1例,肠间积液1例,无近期肠粘连等并发症。对照组40例手术时间50～110min,平均58min,腹腔残余感染8例,切口感染7例,近期肠粘连4例。结论：腹腔镜阑尾切除术是阑尾穿孔并腹膜炎的首选治疗方式,具有开腹手术无法比拟的优点,可明显降低切口感染、腹腔残余感染及肠粘连等并发症。取出阑尾时尽量不与穿刺口接触及术毕彻底冲洗腹腔是避免以上并发症的关键。     

Laparoscopic appendectomy in a patient with acute myelogenous leukemia with neutropenia

The management of acute myelogenous leukemia is often complicated by infections due to neutropenia, but the appendix is not a common site of infection in adult patients with acute myelogenous leukemia. The diagnosis of acute appendicitis may be delayed or even missed because of the lack of characteristic signs and symptoms associated with acute appendicitis in neutropenic patients. Moreover, urgent surgery may lead to high postoperative complications and mortality rates in these patients. The case presented here is of a 33-year-old Hispanic man with acute myelogenous leukemia who developed severe diffuse acute abdominal pain with positive signs of rebound tenderness, fever, and hypotension ten days after receiving reinduction chemotherapy. The patient was at his nadir, with a white blood cell count of 0.2 x 10(9)/L, platelet count of 20 x 10(9)/L, and hemoglobin of 7 g/dL. A computed tomography scan of the abdomen was suspicious for acute appendicitis. The patient underwent a laparoscopic appendectomy that revealed gangrenous appendicitis. No perioperative complications occurred. The patient was discharged on postoperative day 7 and his chemotherapy was continued as scheduled. Laparoscopic appendectomy may be considered a primary approach in neutropenic patients because it can be associated with less postoperative infection, hemorrhagic complications, and a lower mortality rate.     

Laparoscopic appendectomy for acute and recurrent appendicitis: retrospective analysis of a single-group 5-year experience

BACKGROUND AND PURPOSE: Twenty years after the first report of laparoscopic appendectomy (LA), its role in the treatment of appendicitis is still under debate. We report herein a retrospective analysis of our cases of LA in the last 5 years, during which we adopted a policy of an almost uniform laparoscopic approach on a rather selected population composed mainly of women with acute or recurrent lower quadrant abdominal pain. PATIENTS AND METHODS: Laparoscopic appendectomy was performed on 33 male and 98 female patients. The mean age at operation was 25.7+/-11.4 years (range 11-59 years). Acute appendicitis with localized or diffuse peritonitis was present in 34 cases. In the remaining 97 patients, the operation was performed for acute or recurring symptoms of lower quadrant abdominal pain. RESULTS: There were no conversions to open surgery. The operating time was 45+/-17 minutes (range 30-110 minutes). The pathology examination of the removed appendices showed acute appendicitis in 34 cases and chronic inflammation in the remaining 97 patients. In one case, histology revealed a coexisting mucinous carcinoid that extended to the perivisceral fat, and a completion right hemicolectomy was performed. Complications were minor in most cases. Reoperation for deep abdominal abscess or hematoma was required in three cases. The mean hospital stay was 2.59+/-1.58 days (range 24 hours-11 days). CONCLUSION: In our hands, LA has proven to be safe and effective. The laparoscopic operation has significant advantages in terms of lower invasiveness and better diagnostic capability. It is especially useful in women of child-bearing age, in whom it may be considered the procedure of choice.     

Laparoscopic appendectomy using a clip applier

Summary The diagnostic worth and therapeutic value of laparoscopic surgery are known for ovarian cysts and ectopic pregnancies. Diagnosis of appendicitis is difficult, and laparoscopy is useful in these cases. The present study was done to assess the feasibility, efficacy, and advantages of a new laparoscopic appendectomy technique. Between August 1,1989, and July 31,1990, patients exhibiting right pelvic pain associated with fever were divided into three groups according to the pre-operative diagnosis: appendicitis, pelvic inflammatory disease (PID), and diagnostic doubt between appendicitis and PID. An intra-peritoneal appendectomy was performed if the diagnosis was not PID. Via three suprasymphyseal trocars, the appendix was exposed and the mesoappendix was coagulated. The appendix stump was closed using a clip applier (Ethnor T1300). In all, 20 patients underwent laparoscopic appendectomies. The mean duration of the procedure was 36.5 min; in no case was laparotomy necessary. There were no post-operative complications, and digestive transit returned on the 2nd day post-surgery. Both patients and nurses appreciated the technique. The subjects experienced comfortable post-operative periods and gained aesthetic advantages. The operative procedure could be completed on each attempt. We conclude that this technique is sure, quick, and easily reproducible in young patients presenting with right pelvic pain associated with fever.     

腹腔镜阑尾切除术残端包埋技巧及临床应用

目的探讨腹腔镜阑尾切除术（LA）残端包埋技巧及临床应用。方法自2008年1月至2011年2月,行LA86例,采取四针正向浆肌层缝合包埋阑尾残端。结果 86例LA均顺利完成阑尾残端包埋,手术时间22～70min,平均36min,术后住院时间2～5d,平均2.8d,无并发症发生。随访71例,随访时间3～12个月,无腹痛症状及其他并发症发生。结论腹腔镜下四针正向缝合包埋阑尾残端,符合缝合习惯,操作简单,安全可行,容易在临床开展应用。