JOURNAL OF LAPAROENDOSCOPIC SURGERY Volume 1, Number 5, 1991 Mary Ann Liebert, Inc., Publishers
Laparoscopic Appendectomy for Acute Appendicitis: Indications and Current Use YOUNAN NOWZARADAN, M.D., F.A.C.S., JACK WESTMORELAND, M.D., CHARLES T. McCARVER, M.D., and RUDOLPH J. HARRIS, M.D.
ABSTRACT
Laparoscopic evaluation was performed in 43 consecutive patients with right lower abdominal pain and preoperative diagnosis of possible appendicitis. Patients with generalized peritonitis and evidence of perforation of the appendix were not considered for laparoscopy. Visualization was sufficient for making a diagnosis in 97.7 % of the cases. In 95 %, laparoscopic findings were compatible with the pathology report. Thirty-five patients underwent successful laparoscopic appendectomy with neither intraoperative nor postoperative complications. No further surgery was required; slightly elevated temperatures in 6 patients responded to treatment with antibiotics, and there were no wound infections. Laparoscopic appendectomy is minimally invasive and results in less postoperative pain and morbidity and fewer adhesions and other long-term sequelae than conventional laparotomy. It is associated with superior cosmetic results, a shorter hospital stay, and faster return to normal activities. This experience suggests that if there is no evidence that the appendix is perforated or that generalized peritonitis exists and if qualified physicians and adequate facilities are available, patients presenting with right lower quadrant abdominal pain and possible appendicitis are best evaluated and treated with laparoscopic technique.
INTRODUCTION than 70 years have elapsed since laparoscopy was introduced for diagnosis and treatment of intra-abdominal and pelvic disorders. Only recently, however, have advances in optics, video transmission, and high-resolution video monitoring opened the door to its use for a number of surgical procedures both diagnostic and therapeutic. Newly developed laparoscopic instruments with multiloaded automatic devices used in combination with laser technology are making it possible to perform an increasing variety of endoscopie procedures. Indeed, today, one can inspect the peritoneal cavity and pelvis much more thoroughly with the laparoscope than with a McBurney incision or a small laparotomy incision. Laparoscopy
More
Surgical Department,
Best Care Clinic, Houston, TX.
247
NOWZARADAN ET AL. is being used with increasing regularity for therapeutic measures such as cholecystectomy and is gaining attention as an alternative to conventional appendectomy. ' Laparoscopic appendectomy for a noninflamed appendix was first reported in Germany in 1983 by Semm. In 1985, Flemming2 reported from South Wales, and in 1986 Wilson3 reported from Sydney, Australia on laparoscopically directed or assisted appendectomy for treatment of acute appendicitis. In 1987, Schreiber4 from Germany reported laparoscopic appendectomy for treatment of acute appendicitis. Additional investigators have reported results of laparoscopic appendectomy.59 Although a large series suggesting routine use of laparoscopy for appendectomy has recently been reported from Germany,10 the absence of general agreement about the indications and efficacy of laparoscopic appendectomy has motivated us to report on our own
recent
experience.
MATERIALS AND METHODS Patient population
During an 18-month period between November 1989 and April 1991, laparoscopy was used in the care of patients who presented with acute right lower quadrant abdominal pain and were believed to have appendicitis. Patients with preoperative diagnosis of ruptured appendix or generalized peritonitis were not considered for laparoscopy. Laparoscopic surgery was performed by the same surgeon in two community hospitals. Of 43 patients, 28 (65%) were female and 15 (35%) were male. Their age range was 9 to 62 years. Eleven patients (26%) had previously undergone abdominal surgery. 43
Operative technique All patients were given intravenous antibiotics preoperatively, and all received general anesthetic administered by endotrachial intubation. The patients were placed in a supine position. Gastric decompression was accomplished with a nasogastric tube and the bladder was decompressed with an indwelling Foley catheter with its inflated balloon firmly pulled against the bladder neck. Video laparoscopy was used with two viewing monitors at the head of the operating table, one on each side, placed at 45 degree angles. The surgeon and the video camera operator stood on the patient's left and his assistant on the opposite side. A vertical incision of 1 cm was made in the infraumbilical skin. Blunt dissection was achieved with a hemostat, and the subcutaneous tissue was spread down to the abdominal fascia at the umbilica. A Kocher clamp was placed either on the fibrous attachment of the umbilica to the abdominal fascia or on the edge of the umbilical fascia. The abdominal fascia was elevated with a Kocher clamp, and a Veress needle was placed straight into the peritoneal cavity (Fig. 1). Proper positioning of the Veress needle in the peritoneal cavity was ensured by dioxide was established in a aspiration and saline drop test. A standard pneumoperitoneum with carbon ' ' '2 manner similar to the technique used for laparoscopic cholycystectomy. An automatic insufflator with preset pressure up to 15 mmHg was used. While the abdominal fascia was elevated with the Kocher clamp, an 11 mm trocar and sheath were inserted into the peritoneal cavity through the infraumbilical incision. The trocar was aimed straight and was placed next to the Kocher clamp (Fig. 2). The peritoneal cavity was visualized with a 10 mm, 30 degree panaview video scope. Under direct vision, while epigastric vessels were visualized and avoided, a second trocar with a 5-mm sheath was inserted in the right lower quadrant at the midclavicular line (Fig. 3). The patient was placed in the Trendelenburg position at 20 to 30 degrees with rotation to the left to facilitate visualization of the appendix. With an atraumatic intestinal clamp inserted through the right lower quadrant (RLQ) port, the cecum was manipulated until the entire appendix was inspected. In some cases., when adhesions of the cecum were present or the appendix was retrocecal, a third 5-mm trocar and sheath were placed in the right upper quadrant (RUQ) at the midclavicular line (Fig. 3). With an atraumatic clamp inserted through this port, the cecum was retracted cephalad. After inspection of the entire appendix, the small bowel was inspected for the presence of a Meckel's diverticulum. In female patients, the ovaries, fallopian tubes, and uterus were routinely inspected.
248
LAPAROSCOPIC APPENDECTOMY FOR ACUTE APPENDICITIS
FIG. 1.
Technique of insertion of Veress needle into the peritoneal cavity.
After completion of the diagnostic laparoscopy, if the appendix was to be removed, a fourth trocar and sheath were placed above the symphysis pubis. This port was used for the laparoscope and camera during the actual removal of the appendix. In children and small patients, we have used a 5-mm trocar with a 5-mm scope, and in larger patients we have used a 10-mm trocar with the same scope used for the diagnostic laparoscopy. The fourth trocar was always inserted under direct visualization while the bladder was pushed away with an RLQ clamp (Fig. 4). The suprapubic port was then used for the viewing scope and camera during the entire procedure, and the umbilical port was used for insertion of the main operating instruments such as those used for electrocautery, suction, and irrigation, the laser fiber endoclip applier (AutoSuture®, USSC), and the endoloop (Ethicon Inc., Somerville, NJ). On several occasions it was necessary to lyse adhesions using monopolar electrocautery or KTP laser energy. The tip of the appendix then was grasped with either a fallopian tube holder or an endoloop and pulled down with the RLQ clamp. Next, the mesoappendix was grasped and stretched with the RUQ clamp. Sometimes the anatomic position of the appendix was different and it was necessary to retract the appendix cephalad and the mesoappendix inferiorly (Fig. 5). With a monopolar electrocautery or KTP laser beam, the mesoappendix was divided as closely as possible to the appendix, step-by-step from the tip of the appendix toward its base (Fig. 6). Division of the mesoappendix close to the appendix made hemostasis easier and, at the completion of the procedure, facilitated removal of the appendix through the umbilical port. During division of the mesentery, any mesenteric vessels visualized, were doubly ligated with 9-mm titanium multiloaded automatic endoclips (Fig. 7). If bleeding from the divided mesentery occurred, hemostasis was established by using electrocautery, endoclips, or endoloops (Fig. 8) after complete division of the mesoappendix. We used three chromic endoloops on the cecal side of the appendix, placing each endoloop 2 to 3 mm apart. A fourth endoloop was used on the distal end of the appendix. The appendix was divided with KTP laser or 249
NOWZARADAN ET AL.
FIG. 2.
Technique of insertion of umbilical trocar into the peritoneal cavity.
scissors. Care was taken to provide a safe backstop for the laser energy (Fig. 9). In three patients with acute appendicitis, the distal end of the appendix was severely inflamed and was too friable to be grasped. In these patients, a retrograde appendectomy was carried out using a technique similar to that described recently by Schultz et al.13 The mesoappendix was opened at the base of the appendix and two Hulka clamps were placed at the base of the appendix 1 cm from the cecum. The appendix was divided between the two Hulka clamps (Fig. 10) thus avoiding spillage of appendix or cecal contents. We did not invert the appendiceal stump. Previous studies have shown no advantages of inversion over simple ligation and diversion.14 The divided appendix was removed through the umbilical sheath. In some patients an acutely inflamed appendix would not pass into the 11-mm sheath and it was necessary to enlarge the umbilical incision. After removal of the appendix, the peritoneal cavity was irrigated with an antibacterial solption. In two patients with severe right lower quadrant cellulitis, 10-mm Jackson Pratt drains were used and were removed the following
day.
All of the trocar sheaths were removed under direct visualization to ensure proper hemostasis. After removal of carbon dioxide from the peritoneal cavity, all abdominal wounds were irrigated with an antibacterial solution. The fascia was closed with 2-0 vicril suture. Subcutaneous tissue was closed with 4-0 vicril. The skin was closed with a steristrip. 250
LAPAROSCOPIC APPENDECTOMY FOR ACUTE APPENDICITIS
FIG. 3.
Sites of insertion of trocars in
diagnostic laparoscopy.
Upon completion of the procedure, the Foley catheter was removed. The nasogastric tube was removed as postoperative nausea, if any, had subsided and fluid intake was encouraged. Antibiotics were not given routinely, but used if the patient's temperature rose above 101°F or if an elevated white blood count persisted. Patients were discharged as soon as parenteral analgesic was no longer necessary. soon as
RESULTS
Laparoscopic evaluation Visualization of the entire appendix was possible in 39 of 43 patients (91%) and was sufficient for diagnosis in 42 (98%), even though 11 patients previously had undergone abdominal or pelvic surgery and had intra-abdominal adhesions. In only 1 patient, because of severe pelvic adhesions and endometriosis, were we unable to visualize the appendix. Laparoscopic diagnosis was histologically confirmed in 38 of the 39 who underwent a surgical procedure beyond the diagnostic laparoscopy. In 1 patient whose symptoms were of short duration, laparoscopic findings were thought to be unremarkable, but histological examination revealed early acute appendicitis. The results of laparoscopic evaluation and subsequent surgical procedures are shown in Table 1. Four patients who had normal appendices but were found to have PID (2 patients), mesenteric enteritis (1 patient), or enterocolitis (1 patient) had diagnostic laparoscopy only, and the appendix was not removed. 251
NOWZARADAN ET AL.
FIG. 4.
Technique of insertion of the suprapubic trocar.
FIG. 5.
The
appendix and mesentery is positioned so that it can be easily divided. 252
LAPAROSCOPIC APPENDECTOMY FOR ACUTE APPENDICITIS
FIG. 6.
Division of mesoappendix.
FIG. 7.
Hemostasis of mesoappendix with endoclip.
253
NOWZARADAN ET AL.
FIG. 8.
The
technique for the hemostasis of bleeding from the divided mesoappendix.
FIG. 9.
The
appendix is divided with KTP laser or scissors. 254
LAPAROSCOPIC APPENDECTOMY FOR ACUTE APPENDICITIS
FIG. 10.
Technique of retrograde appendectomy.
Laparoscopic appendectomy patients evaluated by laparoscopy, 31 had acute appendicitis; 28 of these underwent laparoscopic appendectomy, and 3 who had perforated appendices were converted to formal 1 aparotomy. Of 11 patients with normal appendices, 8 had incidental appendectomies, 7 by laparoscopy and 1, who had severe endometriosis, by an open procedure. Of the 43
Complications In the 43 patients who underwent diagnostic laparoscopy there were no intraoperative complications; there intra-abdominal injuries; and there was no intra-abdominal bleeding. There also were no postoperative complications related to diagnostic laparoscopy. In the 35 patients who had laparoscopic appendectomy, there were no intra-abdominal injuries, and intraoperative blood loss averaged less than 50 cc. In only one case did it exceed 100 cc. In a patient, who was obese, visualization of deep epigastric vessels was not possible, and insertion of the right lower quadrant (RLQ) 5-mm trocar and sheath was associated with significant bleeding around the trocar and sheath into the peritoneal cavity. It was then necessary to place a 12 French Foley catheter with 5 cc balloon into the port and into the peritoneal cavity. The port was then pulled out of the abdominal wall while the catheter's balloon was inflated with normal saline and pulled tightly against the abdominal wall. A hemostat clamp was placed were no
Table 1. Results of Laparoscopic Evaluation Evaluated by Laparoscopy No.
in
43 Patients
of Patients
Laparoscopic findings
Surgical procedure
28
Acute appendicitis Nonacute appendicitis Perforated appendix Severe endometriosis Normal appendix
Laparoscopic appendectomy Laparoscopic appendectomy Converted to open procedure Converted to open procedure Diagnostic laparoscopy only
7
3 1 4 Total 43
255
NOWZARADAN ET AL.
FIG. 11.
Technique of hemostasis for bleeding at the site of insertion of the trocar.
against the abdominal skin. The Foley catheter was cut 2 inches above the skin level and was left in place until the next morning when it was easily removed at the bed side (Fig. 11). No further bleeding or hematoma occurred. No further surgery was necessitated by postoperative complications; there were no readmissions for any complications. Despite our concerns in several cases about removal of a markedly inflamed and enlarged appendix directly through the umbilical incision, there were no postoperative wound infections. However, we made a point of irrigating the umbilical incision with antibacterial solution at the completion of the procedure. Lately, we have cut the finger from a large surgical glove and used it as a pouch to contain the inflamed appendix as it is removed from the peritoneal cavity. There were no incisional hernias. In 6 patients temperatures were elevated above 101 degrees, but responded to administration of intravenous antibiotics. DISCUSSION Patients with symptoms suggesting that the appendix is perforated are not appropriate candidates for laparoscopic treatment and should be treated with formal laparotomy. But for patients with right lower quadrant abdominal pain and possible appendicitis, the laparoscopic technique is an invaluable method for both diagnosis and therapy. In patients with borderline symptoms of appendicitis, a diagnostic laparoscopy (which can be performed in 30 minutes) offers a safe, early, and accurate (95%) diagnosis, and thus eliminates a long period of observation and empirical treatment. In the absence of appendiceal pathology, a laparoscopic diagnosis obviates the need for unnecessary laparotomy (20-30%)6 and thus eliminates complications of laparotomy and its sequelae. During laparo256
LAPAROSCOPIC APPENDECTOMY FOR ACUTE APPENDICITIS scopy, unless contraindications exist, incidental appendectomy should be considered. Incidental appendectomy not only eliminates the chance of missing an early stage appendicitis, but also removes future diagnostic dilemmas associated with abdominal pain, especially in female patients of child-bearing age. The value of the laparoscopic appendectomy may not be immediately obvious to those accustomed to the standard open procedure. However, for the physician who performs laparoscopy, experiences similar to our own will offer convincing evidence. Laparoscopic appendectomy is a minimally invasive technique; it results in less postoperative pain, and thus a shorter hospital stay and an earlier return to normal activities than conventional laparotomy. It is associated with less postoperative morbidity and superior cosmetic results. It has fewer long-term sequelae and results in fewer adhesions than a standard appendectomy. Using this technique, we have seen a 34-year-old plumber return to a normal work routine on the second day after laparoscopic appendectomy. A high school basketball player, 8 days after laparoscopic appendectomy, participated in athletic activities and performed normally. We believe that if there is no evidence that the appendix is perforated or that generalized peritonitis exists and if qualified physicians and adequate facilities are available, patients presenting with right lower quadrant abdominal pain and possible appendicitis are best treated with the laparoscopic techniques.
REFERENCES 1. SemmK:
Endoscopie appendectomy. Endoscopy 1983; 15:59-64. 2. Fleming JS: Laparoscopically directed appendicectomy. Aust NZ Obstet Gynaecol 1985; 25:238-240. 3. Wilson T: Laparoscopically-assisted appendicectomies. Med J Aust 1986; 145:551. 4. Schreiber JH: Early experience with laparoscopic appendectomy in women. Surg Endose 1987; 1:211-216. 5. Leahy PF: Technique of laparoscopic appendicectomy. Br J Surg 1989; 76:616. 6. Götz F, Pier A, Bacher C: Modified laparoscopic appendectomy in surgery: A report on 388 operations. Surg Endose 1990;4:6-9.
Laparoscopic appendectomy in pregnancy. Surg Endose 1990; 4:100-102. Gangal HT, Gangal MH: Laparoscopic appendectomy. Endoscopy 1987; 19:127-129. Reddick EJ, Saye WB: Laparoscopic appendectomy. In: Zucker KA, Bailey RW, and Reddick EJ (eds). Surgical Laparoscopy. St Louis: Quality Medical Publishing, Inc., 1991, pp. 227-239. Pier A, Götz F, Bacher C: Laparoscopic appendectomy in 625 cases: From innovation to routine. Surg Laparosc
7. Schreiber JH: 8. 9. 10.
Endose 1991; 1,8-13.
11. Meador JH, Nowzaradan Y, Matzelle W: 84:186-189.
12. Nowzaradan Y, Westmoreland JC: 1:71-76.
Laparoscopic cholecystectomy: Report of 82 cases.
Laparoscopic cholecystectomy:
13. Schultz LS, Pietrafitta JJ, Graber JN, Hickok DF: J Laparoendosc Surg 1991; 1:111-114. 14.
New indications.
South Med J 1991 ;
Surg Laparosc
Endose 1991;
Retrograde laparoscopic appendectomy: Report
of
a case.
Engstrom L, and Fenyö G: Appendicectomy: assessment of stump invagination versus simple ligation: a prospective, randomized trial. Br J Surg 1985; 27:971-972. Address
reprint requests
to:
Younan Nowzaradan, M.D., F.A.C.S. 4009 Bellaire Blvd., Suite K Houston, TX 77025
257
Laparoscopic Appendectomy for Acute Appendicitis: Indications and Current Use YOUNAN NOWZARADAN, M.D., F.A.C.S., JACK WESTMORELAND, M.D., CHARLES T. McCARVER, M.D., and RUDOLPH J. HARRIS, M.D.
ABSTRACT
Laparoscopic evaluation was performed in 43 consecutive patients with right lower abdominal pain and preoperative diagnosis of possible appendicitis. Patients with generalized peritonitis and evidence of perforation of the appendix were not considered for laparoscopy. Visualization was sufficient for making a diagnosis in 97.7 % of the cases. In 95 %, laparoscopic findings were compatible with the pathology report. Thirty-five patients underwent successful laparoscopic appendectomy with neither intraoperative nor postoperative complications. No further surgery was required; slightly elevated temperatures in 6 patients responded to treatment with antibiotics, and there were no wound infections. Laparoscopic appendectomy is minimally invasive and results in less postoperative pain and morbidity and fewer adhesions and other long-term sequelae than conventional laparotomy. It is associated with superior cosmetic results, a shorter hospital stay, and faster return to normal activities. This experience suggests that if there is no evidence that the appendix is perforated or that generalized peritonitis exists and if qualified physicians and adequate facilities are available, patients presenting with right lower quadrant abdominal pain and possible appendicitis are best evaluated and treated with laparoscopic technique.
INTRODUCTION than 70 years have elapsed since laparoscopy was introduced for diagnosis and treatment of intra-abdominal and pelvic disorders. Only recently, however, have advances in optics, video transmission, and high-resolution video monitoring opened the door to its use for a number of surgical procedures both diagnostic and therapeutic. Newly developed laparoscopic instruments with multiloaded automatic devices used in combination with laser technology are making it possible to perform an increasing variety of endoscopie procedures. Indeed, today, one can inspect the peritoneal cavity and pelvis much more thoroughly with the laparoscope than with a McBurney incision or a small laparotomy incision. Laparoscopy
More
Surgical Department,
Best Care Clinic, Houston, TX.
247
NOWZARADAN ET AL. is being used with increasing regularity for therapeutic measures such as cholecystectomy and is gaining attention as an alternative to conventional appendectomy. ' Laparoscopic appendectomy for a noninflamed appendix was first reported in Germany in 1983 by Semm. In 1985, Flemming2 reported from South Wales, and in 1986 Wilson3 reported from Sydney, Australia on laparoscopically directed or assisted appendectomy for treatment of acute appendicitis. In 1987, Schreiber4 from Germany reported laparoscopic appendectomy for treatment of acute appendicitis. Additional investigators have reported results of laparoscopic appendectomy.59 Although a large series suggesting routine use of laparoscopy for appendectomy has recently been reported from Germany,10 the absence of general agreement about the indications and efficacy of laparoscopic appendectomy has motivated us to report on our own
recent
experience.
MATERIALS AND METHODS Patient population
During an 18-month period between November 1989 and April 1991, laparoscopy was used in the care of patients who presented with acute right lower quadrant abdominal pain and were believed to have appendicitis. Patients with preoperative diagnosis of ruptured appendix or generalized peritonitis were not considered for laparoscopy. Laparoscopic surgery was performed by the same surgeon in two community hospitals. Of 43 patients, 28 (65%) were female and 15 (35%) were male. Their age range was 9 to 62 years. Eleven patients (26%) had previously undergone abdominal surgery. 43
Operative technique All patients were given intravenous antibiotics preoperatively, and all received general anesthetic administered by endotrachial intubation. The patients were placed in a supine position. Gastric decompression was accomplished with a nasogastric tube and the bladder was decompressed with an indwelling Foley catheter with its inflated balloon firmly pulled against the bladder neck. Video laparoscopy was used with two viewing monitors at the head of the operating table, one on each side, placed at 45 degree angles. The surgeon and the video camera operator stood on the patient's left and his assistant on the opposite side. A vertical incision of 1 cm was made in the infraumbilical skin. Blunt dissection was achieved with a hemostat, and the subcutaneous tissue was spread down to the abdominal fascia at the umbilica. A Kocher clamp was placed either on the fibrous attachment of the umbilica to the abdominal fascia or on the edge of the umbilical fascia. The abdominal fascia was elevated with a Kocher clamp, and a Veress needle was placed straight into the peritoneal cavity (Fig. 1). Proper positioning of the Veress needle in the peritoneal cavity was ensured by dioxide was established in a aspiration and saline drop test. A standard pneumoperitoneum with carbon ' ' '2 manner similar to the technique used for laparoscopic cholycystectomy. An automatic insufflator with preset pressure up to 15 mmHg was used. While the abdominal fascia was elevated with the Kocher clamp, an 11 mm trocar and sheath were inserted into the peritoneal cavity through the infraumbilical incision. The trocar was aimed straight and was placed next to the Kocher clamp (Fig. 2). The peritoneal cavity was visualized with a 10 mm, 30 degree panaview video scope. Under direct vision, while epigastric vessels were visualized and avoided, a second trocar with a 5-mm sheath was inserted in the right lower quadrant at the midclavicular line (Fig. 3). The patient was placed in the Trendelenburg position at 20 to 30 degrees with rotation to the left to facilitate visualization of the appendix. With an atraumatic intestinal clamp inserted through the right lower quadrant (RLQ) port, the cecum was manipulated until the entire appendix was inspected. In some cases., when adhesions of the cecum were present or the appendix was retrocecal, a third 5-mm trocar and sheath were placed in the right upper quadrant (RUQ) at the midclavicular line (Fig. 3). With an atraumatic clamp inserted through this port, the cecum was retracted cephalad. After inspection of the entire appendix, the small bowel was inspected for the presence of a Meckel's diverticulum. In female patients, the ovaries, fallopian tubes, and uterus were routinely inspected.
248
LAPAROSCOPIC APPENDECTOMY FOR ACUTE APPENDICITIS
FIG. 1.
Technique of insertion of Veress needle into the peritoneal cavity.
After completion of the diagnostic laparoscopy, if the appendix was to be removed, a fourth trocar and sheath were placed above the symphysis pubis. This port was used for the laparoscope and camera during the actual removal of the appendix. In children and small patients, we have used a 5-mm trocar with a 5-mm scope, and in larger patients we have used a 10-mm trocar with the same scope used for the diagnostic laparoscopy. The fourth trocar was always inserted under direct visualization while the bladder was pushed away with an RLQ clamp (Fig. 4). The suprapubic port was then used for the viewing scope and camera during the entire procedure, and the umbilical port was used for insertion of the main operating instruments such as those used for electrocautery, suction, and irrigation, the laser fiber endoclip applier (AutoSuture®, USSC), and the endoloop (Ethicon Inc., Somerville, NJ). On several occasions it was necessary to lyse adhesions using monopolar electrocautery or KTP laser energy. The tip of the appendix then was grasped with either a fallopian tube holder or an endoloop and pulled down with the RLQ clamp. Next, the mesoappendix was grasped and stretched with the RUQ clamp. Sometimes the anatomic position of the appendix was different and it was necessary to retract the appendix cephalad and the mesoappendix inferiorly (Fig. 5). With a monopolar electrocautery or KTP laser beam, the mesoappendix was divided as closely as possible to the appendix, step-by-step from the tip of the appendix toward its base (Fig. 6). Division of the mesoappendix close to the appendix made hemostasis easier and, at the completion of the procedure, facilitated removal of the appendix through the umbilical port. During division of the mesentery, any mesenteric vessels visualized, were doubly ligated with 9-mm titanium multiloaded automatic endoclips (Fig. 7). If bleeding from the divided mesentery occurred, hemostasis was established by using electrocautery, endoclips, or endoloops (Fig. 8) after complete division of the mesoappendix. We used three chromic endoloops on the cecal side of the appendix, placing each endoloop 2 to 3 mm apart. A fourth endoloop was used on the distal end of the appendix. The appendix was divided with KTP laser or 249
NOWZARADAN ET AL.
FIG. 2.
Technique of insertion of umbilical trocar into the peritoneal cavity.
scissors. Care was taken to provide a safe backstop for the laser energy (Fig. 9). In three patients with acute appendicitis, the distal end of the appendix was severely inflamed and was too friable to be grasped. In these patients, a retrograde appendectomy was carried out using a technique similar to that described recently by Schultz et al.13 The mesoappendix was opened at the base of the appendix and two Hulka clamps were placed at the base of the appendix 1 cm from the cecum. The appendix was divided between the two Hulka clamps (Fig. 10) thus avoiding spillage of appendix or cecal contents. We did not invert the appendiceal stump. Previous studies have shown no advantages of inversion over simple ligation and diversion.14 The divided appendix was removed through the umbilical sheath. In some patients an acutely inflamed appendix would not pass into the 11-mm sheath and it was necessary to enlarge the umbilical incision. After removal of the appendix, the peritoneal cavity was irrigated with an antibacterial solption. In two patients with severe right lower quadrant cellulitis, 10-mm Jackson Pratt drains were used and were removed the following
day.
All of the trocar sheaths were removed under direct visualization to ensure proper hemostasis. After removal of carbon dioxide from the peritoneal cavity, all abdominal wounds were irrigated with an antibacterial solution. The fascia was closed with 2-0 vicril suture. Subcutaneous tissue was closed with 4-0 vicril. The skin was closed with a steristrip. 250
LAPAROSCOPIC APPENDECTOMY FOR ACUTE APPENDICITIS
FIG. 3.
Sites of insertion of trocars in
diagnostic laparoscopy.
Upon completion of the procedure, the Foley catheter was removed. The nasogastric tube was removed as postoperative nausea, if any, had subsided and fluid intake was encouraged. Antibiotics were not given routinely, but used if the patient's temperature rose above 101°F or if an elevated white blood count persisted. Patients were discharged as soon as parenteral analgesic was no longer necessary. soon as
RESULTS
Laparoscopic evaluation Visualization of the entire appendix was possible in 39 of 43 patients (91%) and was sufficient for diagnosis in 42 (98%), even though 11 patients previously had undergone abdominal or pelvic surgery and had intra-abdominal adhesions. In only 1 patient, because of severe pelvic adhesions and endometriosis, were we unable to visualize the appendix. Laparoscopic diagnosis was histologically confirmed in 38 of the 39 who underwent a surgical procedure beyond the diagnostic laparoscopy. In 1 patient whose symptoms were of short duration, laparoscopic findings were thought to be unremarkable, but histological examination revealed early acute appendicitis. The results of laparoscopic evaluation and subsequent surgical procedures are shown in Table 1. Four patients who had normal appendices but were found to have PID (2 patients), mesenteric enteritis (1 patient), or enterocolitis (1 patient) had diagnostic laparoscopy only, and the appendix was not removed. 251
NOWZARADAN ET AL.
FIG. 4.
Technique of insertion of the suprapubic trocar.
FIG. 5.
The
appendix and mesentery is positioned so that it can be easily divided. 252
LAPAROSCOPIC APPENDECTOMY FOR ACUTE APPENDICITIS
FIG. 6.
Division of mesoappendix.
FIG. 7.
Hemostasis of mesoappendix with endoclip.
253
NOWZARADAN ET AL.
FIG. 8.
The
technique for the hemostasis of bleeding from the divided mesoappendix.
FIG. 9.
The
appendix is divided with KTP laser or scissors. 254
LAPAROSCOPIC APPENDECTOMY FOR ACUTE APPENDICITIS
FIG. 10.
Technique of retrograde appendectomy.
Laparoscopic appendectomy patients evaluated by laparoscopy, 31 had acute appendicitis; 28 of these underwent laparoscopic appendectomy, and 3 who had perforated appendices were converted to formal 1 aparotomy. Of 11 patients with normal appendices, 8 had incidental appendectomies, 7 by laparoscopy and 1, who had severe endometriosis, by an open procedure. Of the 43
Complications In the 43 patients who underwent diagnostic laparoscopy there were no intraoperative complications; there intra-abdominal injuries; and there was no intra-abdominal bleeding. There also were no postoperative complications related to diagnostic laparoscopy. In the 35 patients who had laparoscopic appendectomy, there were no intra-abdominal injuries, and intraoperative blood loss averaged less than 50 cc. In only one case did it exceed 100 cc. In a patient, who was obese, visualization of deep epigastric vessels was not possible, and insertion of the right lower quadrant (RLQ) 5-mm trocar and sheath was associated with significant bleeding around the trocar and sheath into the peritoneal cavity. It was then necessary to place a 12 French Foley catheter with 5 cc balloon into the port and into the peritoneal cavity. The port was then pulled out of the abdominal wall while the catheter's balloon was inflated with normal saline and pulled tightly against the abdominal wall. A hemostat clamp was placed were no
Table 1. Results of Laparoscopic Evaluation Evaluated by Laparoscopy No.
in
43 Patients
of Patients
Laparoscopic findings
Surgical procedure
28
Acute appendicitis Nonacute appendicitis Perforated appendix Severe endometriosis Normal appendix
Laparoscopic appendectomy Laparoscopic appendectomy Converted to open procedure Converted to open procedure Diagnostic laparoscopy only
7
3 1 4 Total 43
255
NOWZARADAN ET AL.
FIG. 11.
Technique of hemostasis for bleeding at the site of insertion of the trocar.
against the abdominal skin. The Foley catheter was cut 2 inches above the skin level and was left in place until the next morning when it was easily removed at the bed side (Fig. 11). No further bleeding or hematoma occurred. No further surgery was necessitated by postoperative complications; there were no readmissions for any complications. Despite our concerns in several cases about removal of a markedly inflamed and enlarged appendix directly through the umbilical incision, there were no postoperative wound infections. However, we made a point of irrigating the umbilical incision with antibacterial solution at the completion of the procedure. Lately, we have cut the finger from a large surgical glove and used it as a pouch to contain the inflamed appendix as it is removed from the peritoneal cavity. There were no incisional hernias. In 6 patients temperatures were elevated above 101 degrees, but responded to administration of intravenous antibiotics. DISCUSSION Patients with symptoms suggesting that the appendix is perforated are not appropriate candidates for laparoscopic treatment and should be treated with formal laparotomy. But for patients with right lower quadrant abdominal pain and possible appendicitis, the laparoscopic technique is an invaluable method for both diagnosis and therapy. In patients with borderline symptoms of appendicitis, a diagnostic laparoscopy (which can be performed in 30 minutes) offers a safe, early, and accurate (95%) diagnosis, and thus eliminates a long period of observation and empirical treatment. In the absence of appendiceal pathology, a laparoscopic diagnosis obviates the need for unnecessary laparotomy (20-30%)6 and thus eliminates complications of laparotomy and its sequelae. During laparo256
LAPAROSCOPIC APPENDECTOMY FOR ACUTE APPENDICITIS scopy, unless contraindications exist, incidental appendectomy should be considered. Incidental appendectomy not only eliminates the chance of missing an early stage appendicitis, but also removes future diagnostic dilemmas associated with abdominal pain, especially in female patients of child-bearing age. The value of the laparoscopic appendectomy may not be immediately obvious to those accustomed to the standard open procedure. However, for the physician who performs laparoscopy, experiences similar to our own will offer convincing evidence. Laparoscopic appendectomy is a minimally invasive technique; it results in less postoperative pain, and thus a shorter hospital stay and an earlier return to normal activities than conventional laparotomy. It is associated with less postoperative morbidity and superior cosmetic results. It has fewer long-term sequelae and results in fewer adhesions than a standard appendectomy. Using this technique, we have seen a 34-year-old plumber return to a normal work routine on the second day after laparoscopic appendectomy. A high school basketball player, 8 days after laparoscopic appendectomy, participated in athletic activities and performed normally. We believe that if there is no evidence that the appendix is perforated or that generalized peritonitis exists and if qualified physicians and adequate facilities are available, patients presenting with right lower quadrant abdominal pain and possible appendicitis are best treated with the laparoscopic techniques.
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reprint requests
to:
Younan Nowzaradan, M.D., F.A.C.S. 4009 Bellaire Blvd., Suite K Houston, TX 77025
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