Aurt
NZ J Obsier Gynaecol 1990. 30: 3: 231
Laparoscopic-Guided Appendicectomy A Study of 100 Consecutive Cases David S. Browne' FRCOG, FRACOG'
Gold Coast Hospital, Queensland2 EDITORIAL COMMENT: We accepted thispaperforpublication because it shows readers that laparoscopic-guided appendicectomy is pmible. The author does not mention his operating time, a point raised by the reviewer, who stated that the operation often takes more than 60 minutes when performed laparoscopically. The need to restrict time spent in hospital is becoming increasingly important in public hospital practice as we follow the North American example and teach ourselves to maximize outpatient and short-stay surgery with minimization of postoperative morbidity. One might wonder why the most @fluent nations practise the worst medicine since surely painful parts should be rested, yet we are told that in some American centres discharge home the day after surgery is now happening even after vaginal hysterectomy! What are they trying to prove? Such is the trend imposed by our administrative masters that we consider that more data should be collected in such studies to assesspostoperative morbidity. Patients having laparoscopy and early discharge oftens state that the postdischarge days were unpleasant or even intolerable. Day cases ideally should be planned flexibly so that the patient may remain in hospital overnight i f she so wishes when questioned after the operation. Early discharge after operation is not an easy optionfor medical and nursing staffs - it requires careful postoperative assessment and follow-up; these women require intensive care and counselling during their shortened sojourn in hospital i f they are to remain healthy and happy customers. We wish to question one of the premises of thispaper, namely that chronic recurring lower abdominal pain is due to a pathological appendix. Most surgical literature accepts the existence of recurrent appendicitis, but the data in this paper does not substantiatethis diagnosis sincefollow-up was inadequate. The surgical literature on appendicectomy for recurring nonspecific lower abdominal pain shows that there is a very poor cure rate with follow-up of more than 12 months (Creed F. Life events and appendicectomy. Lancet 1981; 1381-1385). Our reviewer was also concerned with the diagnosis of mild chronic appendicitis based upon the finding of lymphocytes and plasma cellsfound in the submucosa - these findings are nonspecific and pathologists usually regard them as a normal finding rather than evidence of mild chronic appendicitis. This paper shows that laparoscopic appendicectomy can be performed with minimal morbidity and much shortened hospitalization.How much is new? - when the editor did his first locum in a small Mallee township in 1954 the cheerful inhabitants boasted that their local doctor, who he was relieving, had removed all their appendices via a tiny wound that required no stitch and could be covered by aflorin! - the main difference is that he had not used a laparoscope. AUTHOR'S REPLY TO EDITORIAL COMMENT It was an omission not to mention operating time. The procedure takes no more than 20 minutes, i.e. adds 5-10 minutes to the time of a diagnostic laparoscopy. Since the paper was written diathermy is not used to cut through with the miniMcBurney 's incision. A scalp1 is used and this gives better results with the scar. The paper by Creed is not applicable. His series of 125 cases was of patients with acute lower abdominal pain who had an appendicectomy performed, the indications were not mentioned, whereas my series concerns patients with chronic or recurring pain and strict criteria were adopted for removal of the appendix. 1. Consultant Gynaecologist.
A U S . AND N.Z. JOURNALOF OBSFETRlCS AND GYNAECOLOGY
232
Sporadic reports have appeared regarding laparoscopically-guided appendicectomy (1,2). The following is a description of 100 consecutive cases performed between January, 1987 and June, 1989. Gynaecologists are frequently confronted by the problem of chronic or recurring lower abdominal pain. It is my belief that in many women the pain is appendiceal in origin. This study was undertaken to evaluate the method and indications. METHOD
All patients were referred for investigation of lower abdominal pain. Many had had previous laparoscopy or treatment for pelvic inflammatory disease. All patients required laparoscopy, a n d appendicectomy was performed if the following strict criteria were met, whether the appendix look macroscopically normal or not: a. chronic or recurring lower abdominal pain, b nausea or anorexia, c. tenderness in the right iliac fossa, associated in many patients with tenderness of the right adnexa. Table 1 shows the age distribution of patients. TpMe 1 - Aee Distribution of Patients Age (years) Numbers 1-10 1 11-20 40 21-30 49 31-40 5 41-50 5 Totd 100
was tethered to the undersurface of the liver and had to be mobilized, before it could be removed. A lcm McBurney incision was made at the most appropriate site as determined with the laparoscope. A sharp No. 11 blade was used. The skin was stretched with the Iaparoscope, holding it firm with one's abdomen. This gave countertraction to the skin and with the light, one can be certain to avoid any vessels in the abdominal wall. With the skin still stretched, using the cutting diathermy set at No. 4 level, the incision was taken down to the peritoneum which was stretched by the laparoscope, until the laparoscope could be advanced through the incision created. The tip of the Harrison Clip was placed over the laparoscope, which was retracted back into the peritoneal cavity. This acted as a guide for the Harrison Clip. The tip of the appendix was grasped by the Harrison Clip and the grasping forceps released. The appendix was then pulled out. The gas was turned off and released from the peritoneal cavity. Some difficulty could be experienced if the mesentery was thick, and this is why it is important to have an adequate incision. The mensentery was progressively clamped and tied with 2/0 vicryl. The base of the appendix was doubly tied at the base with 2/0 vicryl and the appendix removed. The bowel then reentered the abdominal cavity and this was checked with the laparoscope, as it may need to be pulled back. The gas was released and the incisions closed with 410 Nylon. The rectus sheath was closed with 2/0 Vicryl on a cutting needle. RESULTS
AII patients were followed-up 6 weeks after surgery and again in September, 1989 giving a follow-up time of between 3 and 33 months.
Surgicai Technique All patients were prepared for laparoscopy in the usual way with the legs angled forward 45" and a diathermy plate attached. A pneumoperitoneum was created and the laparoscope inserted through an umbilical incision. A 5mm trocar and cannula was inserted suprapubically and a grasping instrument inserted. A thorough inspection of the pelvis and abdominal cavity was made, and any necessary pathology attended to. If it was decided to proceed with appendicectomy, the following technique was adopted. The appendix was grasped with the suprapubic grasping forceps just below the tip. In most cases the appendix was mobile, but if lightly tethered with adhesions, these were divided. The small amount of bleeding always ceased. In one patient the appendix
The majority of patients were discharged on the first postoperative day. There was more nausea and pain than with a simple laparoscopy, and so far no patient has been discharged on the same day. With experience patients were discharged sooner (Table 2). Table 2. Time of Discharge Posfoperntivdy in Total Series First 50 Day 1 65 28 (56%) Day 2 24 * 11 (22%) Day 3 8 8 (16%) Day 4 3 3 { 6%)
Days Second 50 37 (74%) 13 (26%)
-
-
Recuperation The vast majority of patients are ready to return to work or study within 3-4 days and definitely within one week. Complications Complications were minimal. There were 7 cases of superficial wound abscess which drained; these resolved within a few days with antibiotics and drainage.
DAVID S. BROWNE
One operation could not be completed laparoscopically since the appendix was tethered in a retrocaecal position and a formal appendicectomy was performed after laparotomy. In the early part of the study, there was one patient in whom the appendix was incompletely removed as it was tethered half-way and a subsequent formal appendicectomy was performed some months later. One patient had a persistent loss of peritoneal fluid through the McBurney incision; this was due to the use of catgut which has now been abandoned in favour of Vicryl. There were no cases of peritonitis or serious complication.
Parhology Mild chronic appendicitis was diagnosed when there were findings of lymphocytes and plasma cells in the submucosa. Normal appendix Mild chronic appendicitis Fibrous obliteration Lymphoid hyperplasia Acute appendicitis Carcinoid tumour Mucinous cvstadenoma
42 27 16 9 4 1 1
Number
100
FOllOw-Up All patients, where possible, were seen at 6 weeks and again in September, 1989, and consequently had from 3-33 months follow-up. Three patients were lost to follow-up at 6 weeks, and 17 to long-term followup, making 97% and 83% follow-up respectively. Table 4 shows the results at follow-up. Table 4. Results of follow-up Short-term
Long-term
83 3 14 100
69 17 14 100
None of the patients cured in the short term subsequently developed symptoms, so that it is reasonable to assume that using the criteria adopted, approximately 85% will be free of symptoms postoperatively. Other pathology included spastic colon, back problems, hernia, polycystic ovaries. An effort was made to link the results obtained with the pathological findings as shown in the accompanying table of short-term follow-up (table 5).
Tabk 5. Skort-termReslltr of Opcrrtion Related to Pathologhl Findings
Normal appendix Mild chronic appendicitis Fibrous obliteration Lymphoid hyperplasia Acute appendicitis Carcinoid tumour Mucinous cvstadenoma
Cured
Not Cured
Lost to follow-UD
Total
33 25
6 2
-
3
42 27
11
5
-
16
8
1
-
9
4
-
-
4
1
-
-
1
1
-
-
1
DISCUSSION
Tabk 3. Pathology
Cured Lost t o follow-up Not cured Total
233
If it is determined that appendicectomy is indicated, from the results of this paper, laparoscopic appendicectomy is the method of choice in the uncomplicated case. If difficulties are encountered, the McBurney incision can be enlarged and a formal appendicectomy performed after laparotomy . No significant complications were encountered and the majority of patients were discharged home on the first postoperative day with a return to normal activities within a few days. The indications for surgery could be disputed. Some deny the existence of the ‘grumbling appendix’, but there is no doubt that in 85% of patients in this series, the pain which had been present for months, or even years, ceased, never to return. The response was not dependent on the pathology present or even whether the appendix was histologically normal. In any event, it is not possible to determine the pathology present with a Iaparoscope, and in most cases the appendix with mild pathology looks macroscopically normal. The explanation must lie with the phleboliths which occurred in the majority of the above cases. It is postulated that these cause an appendiceal colic similar to renal or biliary colic, so that pain can occur in the absence of histological abnormality. Investigations such as blood counts are no value in diagnosis. The results of this study thus show that laparoscopic appendicectomy is a simple, safe, reliable and effective method of dealing with chronic appendiceal pain.
References 1. Laparoscopically Directed Appendicectomy. Fleming JS.
Aust NZ J Obstet Gynaecol 1985; 3: 238-240. 2. Laparoscopically Assisted Appendicectomies (letter). Wilson T. Med J Aust 1986; 145 (10): 55.
NZ J Obsier Gynaecol 1990. 30: 3: 231
Laparoscopic-Guided Appendicectomy A Study of 100 Consecutive Cases David S. Browne' FRCOG, FRACOG'
Gold Coast Hospital, Queensland2 EDITORIAL COMMENT: We accepted thispaperforpublication because it shows readers that laparoscopic-guided appendicectomy is pmible. The author does not mention his operating time, a point raised by the reviewer, who stated that the operation often takes more than 60 minutes when performed laparoscopically. The need to restrict time spent in hospital is becoming increasingly important in public hospital practice as we follow the North American example and teach ourselves to maximize outpatient and short-stay surgery with minimization of postoperative morbidity. One might wonder why the most @fluent nations practise the worst medicine since surely painful parts should be rested, yet we are told that in some American centres discharge home the day after surgery is now happening even after vaginal hysterectomy! What are they trying to prove? Such is the trend imposed by our administrative masters that we consider that more data should be collected in such studies to assesspostoperative morbidity. Patients having laparoscopy and early discharge oftens state that the postdischarge days were unpleasant or even intolerable. Day cases ideally should be planned flexibly so that the patient may remain in hospital overnight i f she so wishes when questioned after the operation. Early discharge after operation is not an easy optionfor medical and nursing staffs - it requires careful postoperative assessment and follow-up; these women require intensive care and counselling during their shortened sojourn in hospital i f they are to remain healthy and happy customers. We wish to question one of the premises of thispaper, namely that chronic recurring lower abdominal pain is due to a pathological appendix. Most surgical literature accepts the existence of recurrent appendicitis, but the data in this paper does not substantiatethis diagnosis sincefollow-up was inadequate. The surgical literature on appendicectomy for recurring nonspecific lower abdominal pain shows that there is a very poor cure rate with follow-up of more than 12 months (Creed F. Life events and appendicectomy. Lancet 1981; 1381-1385). Our reviewer was also concerned with the diagnosis of mild chronic appendicitis based upon the finding of lymphocytes and plasma cellsfound in the submucosa - these findings are nonspecific and pathologists usually regard them as a normal finding rather than evidence of mild chronic appendicitis. This paper shows that laparoscopic appendicectomy can be performed with minimal morbidity and much shortened hospitalization.How much is new? - when the editor did his first locum in a small Mallee township in 1954 the cheerful inhabitants boasted that their local doctor, who he was relieving, had removed all their appendices via a tiny wound that required no stitch and could be covered by aflorin! - the main difference is that he had not used a laparoscope. AUTHOR'S REPLY TO EDITORIAL COMMENT It was an omission not to mention operating time. The procedure takes no more than 20 minutes, i.e. adds 5-10 minutes to the time of a diagnostic laparoscopy. Since the paper was written diathermy is not used to cut through with the miniMcBurney 's incision. A scalp1 is used and this gives better results with the scar. The paper by Creed is not applicable. His series of 125 cases was of patients with acute lower abdominal pain who had an appendicectomy performed, the indications were not mentioned, whereas my series concerns patients with chronic or recurring pain and strict criteria were adopted for removal of the appendix. 1. Consultant Gynaecologist.
A U S . AND N.Z. JOURNALOF OBSFETRlCS AND GYNAECOLOGY
232
Sporadic reports have appeared regarding laparoscopically-guided appendicectomy (1,2). The following is a description of 100 consecutive cases performed between January, 1987 and June, 1989. Gynaecologists are frequently confronted by the problem of chronic or recurring lower abdominal pain. It is my belief that in many women the pain is appendiceal in origin. This study was undertaken to evaluate the method and indications. METHOD
All patients were referred for investigation of lower abdominal pain. Many had had previous laparoscopy or treatment for pelvic inflammatory disease. All patients required laparoscopy, a n d appendicectomy was performed if the following strict criteria were met, whether the appendix look macroscopically normal or not: a. chronic or recurring lower abdominal pain, b nausea or anorexia, c. tenderness in the right iliac fossa, associated in many patients with tenderness of the right adnexa. Table 1 shows the age distribution of patients. TpMe 1 - Aee Distribution of Patients Age (years) Numbers 1-10 1 11-20 40 21-30 49 31-40 5 41-50 5 Totd 100
was tethered to the undersurface of the liver and had to be mobilized, before it could be removed. A lcm McBurney incision was made at the most appropriate site as determined with the laparoscope. A sharp No. 11 blade was used. The skin was stretched with the Iaparoscope, holding it firm with one's abdomen. This gave countertraction to the skin and with the light, one can be certain to avoid any vessels in the abdominal wall. With the skin still stretched, using the cutting diathermy set at No. 4 level, the incision was taken down to the peritoneum which was stretched by the laparoscope, until the laparoscope could be advanced through the incision created. The tip of the Harrison Clip was placed over the laparoscope, which was retracted back into the peritoneal cavity. This acted as a guide for the Harrison Clip. The tip of the appendix was grasped by the Harrison Clip and the grasping forceps released. The appendix was then pulled out. The gas was turned off and released from the peritoneal cavity. Some difficulty could be experienced if the mesentery was thick, and this is why it is important to have an adequate incision. The mensentery was progressively clamped and tied with 2/0 vicryl. The base of the appendix was doubly tied at the base with 2/0 vicryl and the appendix removed. The bowel then reentered the abdominal cavity and this was checked with the laparoscope, as it may need to be pulled back. The gas was released and the incisions closed with 410 Nylon. The rectus sheath was closed with 2/0 Vicryl on a cutting needle. RESULTS
AII patients were followed-up 6 weeks after surgery and again in September, 1989 giving a follow-up time of between 3 and 33 months.
Surgicai Technique All patients were prepared for laparoscopy in the usual way with the legs angled forward 45" and a diathermy plate attached. A pneumoperitoneum was created and the laparoscope inserted through an umbilical incision. A 5mm trocar and cannula was inserted suprapubically and a grasping instrument inserted. A thorough inspection of the pelvis and abdominal cavity was made, and any necessary pathology attended to. If it was decided to proceed with appendicectomy, the following technique was adopted. The appendix was grasped with the suprapubic grasping forceps just below the tip. In most cases the appendix was mobile, but if lightly tethered with adhesions, these were divided. The small amount of bleeding always ceased. In one patient the appendix
The majority of patients were discharged on the first postoperative day. There was more nausea and pain than with a simple laparoscopy, and so far no patient has been discharged on the same day. With experience patients were discharged sooner (Table 2). Table 2. Time of Discharge Posfoperntivdy in Total Series First 50 Day 1 65 28 (56%) Day 2 24 * 11 (22%) Day 3 8 8 (16%) Day 4 3 3 { 6%)
Days Second 50 37 (74%) 13 (26%)
-
-
Recuperation The vast majority of patients are ready to return to work or study within 3-4 days and definitely within one week. Complications Complications were minimal. There were 7 cases of superficial wound abscess which drained; these resolved within a few days with antibiotics and drainage.
DAVID S. BROWNE
One operation could not be completed laparoscopically since the appendix was tethered in a retrocaecal position and a formal appendicectomy was performed after laparotomy. In the early part of the study, there was one patient in whom the appendix was incompletely removed as it was tethered half-way and a subsequent formal appendicectomy was performed some months later. One patient had a persistent loss of peritoneal fluid through the McBurney incision; this was due to the use of catgut which has now been abandoned in favour of Vicryl. There were no cases of peritonitis or serious complication.
Parhology Mild chronic appendicitis was diagnosed when there were findings of lymphocytes and plasma cells in the submucosa. Normal appendix Mild chronic appendicitis Fibrous obliteration Lymphoid hyperplasia Acute appendicitis Carcinoid tumour Mucinous cvstadenoma
42 27 16 9 4 1 1
Number
100
FOllOw-Up All patients, where possible, were seen at 6 weeks and again in September, 1989, and consequently had from 3-33 months follow-up. Three patients were lost to follow-up at 6 weeks, and 17 to long-term followup, making 97% and 83% follow-up respectively. Table 4 shows the results at follow-up. Table 4. Results of follow-up Short-term
Long-term
83 3 14 100
69 17 14 100
None of the patients cured in the short term subsequently developed symptoms, so that it is reasonable to assume that using the criteria adopted, approximately 85% will be free of symptoms postoperatively. Other pathology included spastic colon, back problems, hernia, polycystic ovaries. An effort was made to link the results obtained with the pathological findings as shown in the accompanying table of short-term follow-up (table 5).
Tabk 5. Skort-termReslltr of Opcrrtion Related to Pathologhl Findings
Normal appendix Mild chronic appendicitis Fibrous obliteration Lymphoid hyperplasia Acute appendicitis Carcinoid tumour Mucinous cvstadenoma
Cured
Not Cured
Lost to follow-UD
Total
33 25
6 2
-
3
42 27
11
5
-
16
8
1
-
9
4
-
-
4
1
-
-
1
1
-
-
1
DISCUSSION
Tabk 3. Pathology
Cured Lost t o follow-up Not cured Total
233
If it is determined that appendicectomy is indicated, from the results of this paper, laparoscopic appendicectomy is the method of choice in the uncomplicated case. If difficulties are encountered, the McBurney incision can be enlarged and a formal appendicectomy performed after laparotomy . No significant complications were encountered and the majority of patients were discharged home on the first postoperative day with a return to normal activities within a few days. The indications for surgery could be disputed. Some deny the existence of the ‘grumbling appendix’, but there is no doubt that in 85% of patients in this series, the pain which had been present for months, or even years, ceased, never to return. The response was not dependent on the pathology present or even whether the appendix was histologically normal. In any event, it is not possible to determine the pathology present with a Iaparoscope, and in most cases the appendix with mild pathology looks macroscopically normal. The explanation must lie with the phleboliths which occurred in the majority of the above cases. It is postulated that these cause an appendiceal colic similar to renal or biliary colic, so that pain can occur in the absence of histological abnormality. Investigations such as blood counts are no value in diagnosis. The results of this study thus show that laparoscopic appendicectomy is a simple, safe, reliable and effective method of dealing with chronic appendiceal pain.
References 1. Laparoscopically Directed Appendicectomy. Fleming JS.
Aust NZ J Obstet Gynaecol 1985; 3: 238-240. 2. Laparoscopically Assisted Appendicectomies (letter). Wilson T. Med J Aust 1986; 145 (10): 55.
