A three year experience in
Laparoscopic Appendectomy
Sharon W.1
1Dr. Wormi Sharon, Assistant Professor, Department of General Surgery,
Jawaharlal Nehru Institute of Medical Sciences, Porompat, Imphal, India
Corresponding Author:
Dr. Wormi Sharon, Email: wormi2008@gmail.com
Abstract
Background:
Acute appendicitis is one of the most common causes of acute abdomen.
It may occur from the time of infancy to old age, but the peak age of
incidence is in the second and third decades of life. The lifetime risk
of appendicitis is approximately 7-8%. Today in developed countries,
about 8% of the population is treated for acute appendicitis in the
course of their lifetime. The outcome can be very serious at both
extremes of life and there is a life time risk of developing acute
appendicitis in about 5-8%. The aim of this study was to evaluate the
clinical results of laparoscopic appendectomy (LA) for the treatment of
acute appendicitis. Material
and Methods: A retrospectiveanalysis fallpatients who
underwent laparoscopic appendectomy diagnosed with acute appendicitis
overa3-yearperiodwasreviewed. Data were retrieved from our departmental
data base and analyzed using descriptive statistics. Most of the
patients were diagnosed to have appendicitis by ultrasound or have
ruled out other cause of right lower abdominal pain especially in
females. Results:
Out of the 226 patients who underwent laparoscopic appendectomy,
138(61.1%) were females and the remaining 88(38.9%) were males. Most of
them are in the age group of 21-40years. 171 (75.7%) patients were
discharged within 48 hours. Conclusion:
Laparoscopic appendectomy is as safe and effective as conventional
surgery, has a higher diagnostic yield, causes less trauma, and offers
a more rapid postoperative recovery. Such features make laparoscopy a
challenging alternative to laparotomy in premenopausal women referred
for urgent abdominal or pelvic surgery, or both.
Keywords-
Acute appendicitis, Laparoscopic Appendectomy (LA), Open Appendectomy
(OA)
Manuscript Received:
20th January 2018,
Reviewed: 28th January 2018
Author Corrected:
4th February 2018,
Accepted for Publication: 9th February 2018
Introduction
Appendicitis is one of the most common acute abdomen conditions
requiring surgery, with a lifetime incidence of 6-8%.Appendectomy has
long been the gold standard of treatment due to its efficacy and low
mortality. Laparoscopic appendectomy (LA), initially described by Semm
in 1983 has increasingly gained favor in the past decade in management
of selected cases of acute appendicitis [1]. The benefit of LA as a
minimal access surgery include less post-operative pain, shorter
hospital stay, early return to work and better cosmesis [2,3]. These
benefits have made this approach attractive. Despite all these
benefits, LA has not been wildly accepted as a standard of care for
management of all cases. This is due to dispute regarding its advantage
compared with open surgery.
Perforated appendicitis may be seen in 20-30% of patients with acute
appendici¬tis [4]. Perforation is associated with a high risk
of postoperative complications, including wound infection and
intra-abdominal abscess. Laparoscopic appendectomy (LA) has become a
common intervention worldwide in recent years. The use of laparoscopic
appendectomy for complicated appendicitis is controversial, especially
with regard to the rate of postoperative infectious complications
including wound infec¬tion and abscess formation in abdominal
cavi¬ty [5, 6]. Laparoscopy has emerged as the standard
surgical approach to a wide host of diseases of the upper abdomen, but
its role in the management algorithm of lower abdominal emergencies
awaits definite clarification.This is especially true for suspected
appendicitis, a disease of huge epidemiological impact and several
diagnostic challenges [7, 8].
The purpose of this study is to evaluate the outcome of laparoscopic
appendectomy for the treatment of acute appendicitis
Material
and Method
A retrospective analysis of patients who had undergone laparoscopic
appendectomy for acute appendicitis between 1stJanuary 2013 and
31stDecember 2016 has been performed. This data is taken only from one
surgical unit (unit 4) in the department of General Surgery, JNIMS,
Imphal. Only the data of those patients who have undergone laparoscopic
appendectomy were taken.
The diagnosis of acute appendicitis was established with physical
examination, laboratory tests and ultrasound examination or has ruled
out other cause of right lower abdominal pain especially in females.
All the procedure was performed by Laparoscopic surgeon.
The operation is performed under general anesthesia. The bladder is
usually emptied by asking the patient tourinate immediately prior to
the procedure. The techniques were similar to those described in the
laparoscopic literature. LA was usually performed with the patients in
a Trendelenburg position rotated right side up and a three-trocar
technique at the umbilical, suprapubic, and right lower quadrant
positions. The surgeons altered trocar placement at their discretion.
Using a 30”videolaparoscope the mesoappendix was segmentally
ligated or thermo coagulated to the base, the appendix was doubly
ligated with 1-0 vicryl, and the stump was not buried. An end pouch was
used to retrieve the specimen more frequently.
All the patients received pre-operative antibiotic continued post
operatively as indicated.
Statistical Methods-
Descriptive and inferential statistical analysis has been carried out
in the present study. Results on continuous measurements are presented
on Mean SD (Min-Max) and results on categorical measurements are
presented in Number (%). Significance is assessed at 5 % level of
significance. The following assumptions on data is made, Assumptions:
1.Dependent variables should be normally distributed, 2.Samples drawn
from the population should be random, Cases of the samples should be
independent
Chi-square/ Fisher Exact test has been used to find the significance of
study parameters on categorical scale between two or more groups,
Non-parametric setting for Qualitative data analysis.
Significant figures
+ Suggestive significance (P value: 0.05<P<0.10)
* Moderately significant (P value: 0.01<P 0.05)
** Strongly significant(P value: P0.01)
Statistical software:
The Statistical software namely SPSS 18.0, and R environment ver.3.2.2
were used for the analysis of the data and Microsoft word and Excel
have been used to generate graphs, tables etc.
Results
A total of 226 patients underwent Laparoscopic Appendectomy.Most of the
patients are in the age group of 21-40 years (42.5%) followed by
41-60(29.2%) years age group.
Table-1: Age distribution
of patients studied
|
Age
in years
|
No.
of patients
|
%
|
|
1-20
|
38
|
16.8
|
|
21-40
|
96
|
42.5
|
|
41-60
|
66
|
29.2
|
|
61-80
|
23
|
10.2
|
|
>80
|
3
|
1.3
|
|
Total
|
226
|
100.0
|
Mean ± SD: 38.61±17.32
Table-2: Gender
distribution of patients studied
|
Gender
|
No.
of patients
|
%
|
|
Female
|
138
|
61.1
|
|
Male
|
88
|
38.9
|
|
Total
|
226
|
100.0
|
In this study, Female patients were found to be more compared to males.
Table-3: Hospital Stay
|
No.
of days in hospital
|
No.
of patients
|
%
|
|
1-2
|
171
|
75.7
|
|
3-4
|
15
|
6.6
|
|
5-6
|
36
|
15.9
|
|
7
or more
|
4
|
1.8
|
|
Total
|
226
|
100.0
|
Majority of the patients got discharged within 48 hours.
Table-4: Drain
distribution of patients studied
|
Drain
|
No.
of patients
|
%
|
|
No
|
194
|
85.8
|
|
Yes
|
32
|
14.2
|
|
Total
|
226
|
100.0
|
26 patients, 32 patients had drain (table 4).
Table-5: No. of days in
hospital distribution of patients studied in relation to Drain
|
No.
of days in hospital
|
Drain
|
Total
|
|
No
|
Yes
|
|
1-2
|
171(88.1%)
|
0(0%)
|
171(75.7%)
|
|
3-4
|
11(5.7%)
|
4(12.5%)
|
15(6.6%)
|
|
5-6
|
9(4.6%)
|
27(84.4%)
|
36(15.9%)
|
|
7
or more
|
3(1.5%)
|
1(3.1%)
|
4(1.8%)
|
|
Total
|
194(100%)
|
32(100%)
|
226(100%)
|
The decision to put drain was taken during the time of surgery. Also
the duration of their stay in hospital goes up for the patients with
drain as shown in table 5.
Discussion
The open appendectomythrough right grid iron incision was introduced by
Mc Burney (Mc Burney 1894) and thistechnique enjoyed decades of
un-opposed reputation and widespread use globally becauseof its proven
safety and efficacy.The introduction of laparoscopy has brought a
majorchange in the field of surgery. The laparoscopic appendectomy is
gradually gainingpopularity over the past 10-15 years by way of proving
improved diagnostic outcome anddecreased rate of wound problems. It was
way back in 1983 when a first laparoscopicsurgery for acute
appendicitis was performed by a German GynaecologistSemm (Semm K1983)
[1]. LA has all the potential benefits of other minimal access
procedures; many studies having demonstrated lower complication rates,
shorter hospitalization, and more rapid recovery and return to normal
activity[3].
Laparoscopy has gained widespread acceptance in common surgical
practice as a diagnostic and therapeutictool [9].
Suspected appendicitis is still a diagnostic challenge to the general
surgeon. To plan the appropriate procedure or to avoid an unnecessary
laparotomy, a correct diagnosis is crucial because of the various
diseases that may be responsible for the same symptoms. Noninvasive
diagnostic procedures are expensive and not always conclusive
[10].Laparoscopy is the only minimally invasive technique that allows
concurrently an appropriate diagnosis and treatment and the best
abdominal approach. It is generally believed that minimally invasive
surgeries result in less post-operative pain, fewer complication rates
and shorter recovery periods in comparison to open procedures [11].
Initially with the introduction of laparoscopy in surgery, reports on
the use of laparoscopy for appendicitis focused only on its efficacy as
a diagnostic tool. The advantage of LA over open procedure was
supported by several studies [12, 13]. For instance, a meta-analysis
has shown that LA results in earlier resumption of normal activity,
less post-operative complications and longer operative time [14].
Nowzaradan et al., that laparoscopic appendectomy resulted in less
post-operative pain, shorter hospitalization and earlier returns to
normal activities [15]. In many studies, LA has been attributed with a
relatively low incidence of complications compared with OA [16].
In this study too, there were no major complications at post-operative
period, only those patients with drain stays for a longer period in
Hospital. Drain was place intraoperatively in view of intra-operative
finding like perforated appendix, gangrenous or with fluid/abscess
collection.
A particular problem with laparoscopic appendectomy is the differing
experience of surgeons performing this operating procedure. Several
studies proved that appendectomy is an ideal operation for the
introduction of general surgery trainees in laparoscopic surgery [16,
17]. Things might be more difficult in complicated cases. But, as
surgical expertise increases with the number of operations, a surgeon
who routinely performs appendectomy laparoscopically will more likely
be able to handle complicated appendectomies in the same manner.
The diagnostic accuracy of laparoscopy is very high, 89% to 100% rate
reported in the international literature [8, 9]. The high diagnostic
yield of laparoscopy is even greater if we consider all the concomitant
diseases we found in patients without histology proven appendicitis. In
agreement with other authors, we always remove the appendix, even when
it appears macroscopically normal [18].
Debate still exists about the cost comparisons between laparoscopic and
open appendectomy. Most surgeons have the opinion that laparoscopic
appendectomy is cost effective. It may be more expensive for the
hospital but it offers diagnostic accuracy, offerscost saving to
society as a result of faster returns to work [19].
Conclusion
Laparoscopic appendectomy is as safe and effective as conventional
surgery, has a higher diagnostic yield, causes less trauma, and offers
a more rapid postoperative recovery. Such features make laparoscopy a
challenging alternative to laparotomy in premenopausal women referred
for urgent abdominal or pelvic surgery, or both.
Sparing unnecessary laparotomies, reduces postoperative pain, increases
prompt recovery of gastrointestinal functions, shorten hospitalization,
helps contain healthcare costs, and increases cosmesis. On these
grounds, we advocate wider adoption of laparoscopy and are confident it
will become more important in common surgical practice.
Funding:
Nil, Conflict of
interest: None initiated.
Permission from IRB:
Yes
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How to cite this article?
Sharon W. A three year experience in Laparoscopic Appendectomy.
Surgical Update:Int J surg Orthopedics.2018;4(1):01-05. doi:10.
17511/ijoso.2018.i1.01.