Br. J. Surg. 1992, Vol. 79, August. 818-820

0.J. McAnena, 0. Austin, P. R . O'Connell, W. P. Hederman, T. F. Gorey and J. Fitzpatrick Department of Surgery, The Mater Misericordiae Hospital, Dublin, Ireland Correspondence to: Mr 0 . J. McAnena, Surgical Unit, The Royal London Hospital, Whitechapel Road, London E l 166, UK

Laparoscopic versus open appendicectomy: a prospective eva Iuat ion A prospective evaluation of laparoscopic surgery f o r acute appendicitis over a 6-month period is reported. Sixty-jive patients with signs and symptoms of appendicitis necessitating surgery were assigned to open (n = 3 6 ) or laparoscopic (n = 29) appendicectomy. Thirty-seven patients were female (22 open) and 28 were male ( 1 4 open). The median age was 24 (range 14-64) years f o r open appendicectomy and 18 (range 14-60) years f o r the laparoscopic procedure. The mean postoperative stay f o r open operation was 4.8 (range 1-21) days and f o r the laparoscopic route 2-2 (range 1-11) days ( P < 0.05).Inflammation was conjirmed histologically in 72 per cent of the open cases and in 74 per cent of the Iaparoscopic cases ( P not signiJcant). The wound infection rate was 11 per cent (n = 4 ) f o r open and 4 per cent (n = 1 ) f o r laparoscopic appendicectomy ( P < 0.05).The median anaesthesia time was 52 (range 15-90) min f o r open appendicectomy and 48 (range 20- 120) min f o r laparoscopic surgery (P not signijkant). After open appendicectomy patients had a median of 5 (range 2-12) intramuscular injections of analgesia compared with a median of 1 (range 0-5) in the laparoscopic group ( P < 0.05). Two laparoscopic operations were converted to an open procedure. The results suggest that emergency laparoscopic appendicectoiny should be explored further as an alternative to open surgery for acute appendicitis.

The mortality rate following surgery for acute appendicitis has declined over the past 60 years to almost zero. Many surgeons question the utility of laparoscopic surgery for acute appendicitis as the appendix can often be removed through a small incision and the degree of trauma to the patient may be equivalent to that of a laparoscopic approach. However, even some patients with a non-inflamed appendix suffer wound infection, prolonged hospital stay and delay in returning to normal activity'. Laparoscopic removal of the appendix is commonly performed in continental Europe' but laparoscopy has more often been used to aid diagnosis of acute appendicitis'. Laparoscopic removal of an acutely inflamed appendix has considerable appeal in that the diagnosis of acute appendicitis can be verified, other pathologies for the cause of right iliac fossa pain can be identified and, if feasible, the appendix removed through a laparoscopic cannula, thus avoiding direct contact of contaminated contents with the abdominal wound. The present study was undertaken to test the feasibility of laparoscopic appendicectomy for acute appendicitis by comparing the outcome for patients undergoing laparoscopic or open surgery.

Patients and methods From January to June 1991, patients over 14 years of age with clinical signs of acute appendicitis were assigned to open or laparoscopic surgery. Formal randomization was precluded on occasions by instrument availability but not by the time ofday at which the operation was performed. Open appendicectomy was performed by a senior registrar or a surgical senior house officer under direct senior registrar supervision. Laparoscopic appendicectomy was performed by a senior registrar (0.J.McA.) with experience in laparoscopic cholecystectomy but no previous training in laparoscopic appendicectomy. All patients were given perioperative intravenous antibiotics in accordance with each consultant surgeon's usual practice. Antibiotics ~

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Presented to the Association of Surgeons of Great Britain and Ireland in Jersey, UK, in April 1992

818

were continued for 24 h after operation if the appendix was grossly inflamed or for a longer period if perforated or gangrenous. The open procedure was performed in a routine fashion through a gridiron incision in the right iliac fossa. The skin was closed with interrupted 3/0 nylon sutures. Laparoscopic appendicectomy was performed by a standard technique. After creation of pneumoperitoneum, a stab incision was made inferiorly at the umbilicus and a 10-mm cannula advanced into the abdominal cavity. A 5-mm cannula was inserted below the right costal margin and a blunt grasping forceps applied to the caecum, which was drawn towards the spleen. After tilting the table to displace small bowel from the pelvis the ovaries were examined. Any free fluid or pus was aspirated at this point. The diagnosis of appendicitis was confirmed and a second 5-mm cannula inserted in the lower left iliac fossa under direct vision, to identify and avoid the inferior epigastric vessels. Using a second grasping forceps through the left iliac fossa cannula, the appendix was grasped along its body and its mesentery clearly displayed. If there was an inflamed retrocaecal appendix, the caecum was retracted cephalad and to the left, and the appendix dissected off the posterior abdominal wall, usually without difficulty. When the mesentery of the appendix had been displayed, the peritoneum was divided and all vessels were coagulated. The appendix was stripped of as much of its mesentery as possible during the dissection: this facilitated its removal through the 10-mm cannula at the end of the operation. When the vessels had been dealt with, a pretied catgut ligature (Ethibinder; Ethicon, Edinburgh, U K ) was advanced through the right hypochondrial cannula. The appendix was lassoed and ligated at its base. A second Ethibinder was placed distally along the appendix to prevent spillage ofluminal contents after division of the appendix. Care was taken to divide the appendix about 4 mm from the ligature. Magnification on the screen may tempt the surgeon to divide the appendix too close to the caecum, which may cause diathermy injury. After division, the appendix was held by a forceps inserted through the right hypochondrial cannula. The 10-mm telescope was removed and replaced with a 5-mm telescope advanced through the left iliac fossa cannula. The appendix was then withdrawn into the 10-mm cannula, which was extracted with the appendix contained within it. The wounds were infiltrated with 0.5 per cent bupivacaine and closed. The outcome was assessed using the Mann-Whitney U test and z2 analysis as appropriate.

ooO7-1323/92/080818-03

0 1992 Butterworth-Heinemann

Ltd

Laparoscopic versus open appendicectomy: 0. J. McAnena et al. Table 1 Outcome of appendicitis

open and laparoscopic surgery for

Open ( n = 36) Median postoperative stay (days)* Median anaesthesia time (min)* Histological inflammation (n)t Wound infection (n)? Median doses of intramuscular analgesia* ~~~~~~

Laparoscopic ( n = 27)

acute

P

Laparoscopic versus open appendicectomy: a prospective evaluation.

A prospective evaluation of laparoscopic surgery for acute appendicitis over a 6-month period is reported. Sixty-five patients with signs and symptoms...
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