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Laparoscopic Assisted Appendectomy - Comparative Study

Andrei B., Ionescu S., Nicoara D., Filip G., Gurita Adriana 
Bucharest, Romania

 

Abstract 

Objectives: The paper presents the results of a comparative study between laparoscopic-assisted appendectomy (LAA) and open appendectomy (OA) in the treatment of acute uncomplicated appendicitis in paediatric patients.

Material and methods: The results of 110 LAA and 120 OA, in patients with a preoperative diagnosis of acute uncomplicated appendicitis are compared. LAA was performed using a 10mm trocar inserted in the umbilicus, following an open procedure; through it a telescope with operative channel was inserted. After exteriorization of the appendix through the umbilical incision, appendectomy with inversion of the stump was performed outside the abdomen.

Results: Conversion was performed in 5 cases (4,5%), from LAA group. An additional 5mm trocar was introduced in 10 cases (9,1%). The conversions were for gangrenous perforated appendicitis in 2 cases (1,8%) and for intense peritiphlitis in 3 cases (2,7%). An additional trocar was introduced in 8 cases (7,3%) for mobilization of fixed appendix, and in 2 cases (1,8%) for the treatment of associated cystic pathology. There were no intra or postoperative complications. Cosmetic results were very satisfying. In OA group, enlargement of the incision was necessary in 13 cases (10,8%): ectopic appendix in 11 cases (9,2%) and gangrenous perforated appendicitis in 2 cases (1,7%). There were 2 cases (1,7%) of wound infections.

Conclusions: LAA is a viable technique alternative for treatment of acute uncomplicated appendicitis in paediatric patients. Laparoscopic inspection of the whole peritoneal space, reduced parietal trauma, very good cosmetic results, together with a decreased rate of complications, imposed LAA as an excellent method of treatment, especially in ectopic appendix, obese patients and in cases of diagnosis doubts.

 

Correspondence 

Andrei Bogdan; Pediatric Surgery Department, “M.S. Curie“ Children Hospital,

bd. Constantin Brancoveanu 20, sector 4, Bucharest.

e-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Introduction

Though acute appendicitis is the most frequent surgical emergency in paediatric patients, its treatment is still, nowadays, subject of controversial concerning viable operative technique. A new approach in acute uncomplicated appendicitis in children is laparoscopic assisted appendectomy (LAA), which tries to combine advantages from both laparoscopic and open surgery, proving itself a viable alternative in most cases. Our work tries to evaluate indicators for LAA and compares results from OA and LAA in acute uncomplicated appendicitis in children.

Material and Methods

There were 230 patients with a operative diagnosis of acute uncomplicated appendicitis from January 2002 to December 2005, 110 of them by means of LAA, the other 120 with OA. The preoperative diagnosis was established by clinical, laboratory and ultrasonographic evaluation. Preoperatively suspected complicated acute appendicitis were excluded from this study (i.e. palpable mass, located or generalized peritonitis). In the OA group there were 68 males and 52 females (mean age: 11,2 yrs), as compared to 62 females and 48 (mean age: 13,4 yrs) in the LAA group. Surveillance parameters were: the need of antibiotics and analgesics, the mean hospital stay, the time needed to return to normal daily activities, the satisfaction of the patients. We record postoperative complication like persistent fever, wound infections, endoabdominal abscess, hemorrhagic complication. Patients were scheduled for a clinical exam days 7 and 30 after surgery in order to evaluate results.

LAA Technique

The surgeon stands on the left side of the patient with an assistant on his right side, the video monitor is on the right side of the patient, next to his legs. A 10 mm umbilical trocar is inserted by the open technique to produce an 8 – 12 mm Hg pneumoperitoneum. A 10 mm telescope with a 5 mm operative channel is introduced transumbilically, and visual inspection of the entire abdominal cavity is then performed. An atraumatic grasper is introduced through the operative channel of the telescope to identify and grasp appendix near the tip (aprox. 0,5 mm). The mobility of the caecum, and appendix is carefully checked, the canula extracted and pneumoperitoneum deflected, prior to exteriorise the appendix through the umbilical wound. The appendectomy is performed outside the abdomen; the stump is inverted with a purse grasper and the caecum is replaced in the abdomen. A final video control (after restoring the pneumoperitoneum) is mandatory, then the pneumoperitoneum is deflated and the umbilical wound is sutured. If the appendix can’t be exposed and mobilized, an additional 5 mm trocar is introduced (suprapubic or in the left iliac fossa) for the second operative instrument. The successful mobilization of the appendix is followed by the same steps described above. If the acute appendicitis proves intraoperatively to be complicated (peritonitis, plastrona), conversion to either OA or LAA is mandatory, depending on the aspect of the lesion and the experience of the surgeon.

Results

LAA was successfully performed in 95,5% (105) cases, the other 4,5% (5) cases needed conversion to OA 1,8% (2) because of acute perforated appendicitis, extensive peritiflitis (2,7% - 3 cases). Using an additional 5 mm operative channel inserted in the suprapubic region or the left iliac fossa according to the preferences does not represent, in our opinion, a failure of this technique. The need for an additional channel appeared in 10 cases (9,1%) as follows: 8 cases – to better mobilise appendices with strong adhesions – which imposed the use of a monopolar hook; 2 cases – to treat an associated internal genital pathology (e.g. simultaneously solving of a cyst of the right broad ligamentum or of a left salpigneal hyalite).

In all, but 5 cases (4,5%), the inversion of the stump was possible. The other cases underwent double ligature of the appendix fosse. There were no wound infective complications, neither of other nature. In the OA group, wound enlargement was necessary in 13 cases (10,8%), in 11 cases (9,2%) this manoeuvre was imposed by ectopic appendicitis with adherent bridal, in the other 2 cases (1,7%) by acute perforated appendicitis. Wound infection occurred in 2 cases, both of them in the wound enlargement groups. None intraperitoneal septic or other nature complications were observed. Inversion of the stump was performed in 116 cases (96%). The mean operative tine was of 30 min in LAA group and of 35 min in the OA group. The difference was of no significance, this parameter taking little place in our concerns. The hospital stay of 2-5 days (mean 2,9) in the LAA group and 3-5 days in the OA makes no significant difference. The time necessary to return to normal daily activity was of 6-9 days (mean 7 days) in LAA group and 7-11 days (mean 9 days) in the OA group. This time was particularly longer in patients who suffered a wound enlargement or wound complications. The need of antibiotics was the same for both groups, with less analgesics use in LAA group.

Cosmetic results, as appreciated clinically 30 days after operation and satisfaction of the patients in regard of this aspect were excellent in the LAA group. In the OA group there were 19 cases with unsatisfactory cosmetic results (15,8%)(those patients with wound enlargement and obese patients).

Discussions

LAA tries to combine in an ideal compromise advantages from both OA and LA techniques. Its indications are confined to acute uncomplicated appendicitis; therefore, a prospective correct evaluation and diagnosis (by means of clinical, laboratory and ultrasonographic findings) are mandatory. Suspicions of peritonitis (either generalised or localised), palpations of abdominal masses are reasonable contraindications for this technique. Since preoperative estimates of the appendix position or the extension of the processes are not always possible, an additional operative channel may prove necessary (especially in case of strong adhesions) to help mobilising the organ. Bridal sectioning may be associated with sectioning of the short retracted mesoappendix with a monopolar hook or with caecoparietal decollation in case of a fixed caecum. The intraoperative finding of internal genital organs pathology in girls (e.g. ovarian cysts) can be solved by inserting a new trocar for the second operative instrument.

Localised or generalised peritonitis misdiagnosed preoperatively, extensive strong adhesions impose conversion either to LA or OA, according to the particular case and the experience of the surgeon. If LA is preferred, the through exploration of the abdominal cavity is the first step of this technique too. If OA is to be performed the patent benefits from the laparoscopic examination of the peritoneal cavity. Anatomic condition in children favours LAA: distances between the caecum and umbilicus are shorter; mesoorgans are more extendible, peritiflitis lesser extend then in adults, making caecum exteriorisation possible in more than 90% of cases. The appendectomy is therefore possible outside the abdomen, through the umbilical hole. Inversion of the stump is quicker and easier than by laparoscopic technique. The mean time, hospital stay and the time needed to return to normal daily activities are reduced, even if not statistically significant. The advantage of the laparoscopic evaluation of the abdominal cavity is worth mentioning again. Nevertheless cosmetic results are better after LAA compared to OA, which, together with the quicker recovery, contribute to diminish the negative psychological impact of the surgical intervention.

Conclusions

LAA is a viable alternative technique for the treatment of acute uncomplicated appendicitis in children, consisting in an almost ideal compromise the advantages of LA and those of OA. Maximal benefits are obtained especially in cases with ectopic appendices, obese patients, when anexial cyst or in pattern uncertain preoperatory diagnosis technique. The learning curve of this has very good indices.

 

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