Surgical workshop Br. J. Surg. 1992, Vol. 79, June, 574-575
Technique for la pa roscopic appendicectomy D. S. Byrne, G. Bell, J. J. Morriceand G. Orr Department of Surgery, lnverclyde Royal Hospital, Larkfield Road, Greenock PA16 OXN, UK Correspondence to: Mr G . Bell
Laparoscopic appendicectomy was introduced by Semm' in 1983. Several modifications of his technique have been described2-', all of which involve resection of the appendix within the peritoneal cavity and subsequent removal. This paper describes a technique for excising the appendix after delivering it laparoscopically through the abdominal wall, minimizing intra-abdominal dissection.
Surgical technique Between August 1990 and April 199 I , laparoscopic appendicectomy was performed in 31 patients (28 as an emergency and three as elective procedures). Patients under the age of I 5 years were not included. The technique was employed whenever possible, subject only to the availability of the surgeons and equipment. All patients received antibiotic prophylaxis with metronidazole, 1 g rectally 1 h before surgery or 500 mg intravenously at induction of anaesthesia. Peritoneal insufflation with carbon dioxide was produced by means of a Verres needle introduced infraumbilically. Insufflation was controlled by automatic regulation to a maximal intraperitoneal pressure of 15 mmHg. Once the pressure was achieved, a 10-mm disposable trocar and cannula (Auto Suture, Ascot, U K ) was introduced at the same site and a 10-mm Hopkins end-viewing laparoscope (Olympus Optical, Tokyo, Japan) inserted to inspect the peritoneal cavity and confirm the diagnosis. A second incision was made over McBurney's point and a 12-mm trocar and cannula introduced under direct vision at this site. The tip of the appendix was grasped with forceps and brought up into the lumen of this cannula. Gentle traction on the omentum was sometimes required to tease off inflammatory adhesions before this was achieved. Cannula and appendix were then withdrawn together, delivering the appendix on to the surface. It was manipulated through the wound until the pole of the caecum became visible. This manoeuvre was facilitated by evacuation of gas from the abdominal cavity allowing the anterior abdominal wall to fall back on to the caecum. The mesoappendix was ligated and divided and the appendix stapled using a TA30 stapler (Auto Suture) or ligated and excised. The stump was inspected and cauterized as necessary. The caecum was returned to the abdominal cavity, and the stump and surrounding area irrigated with tetracycline solution. The cannulae were withdrawn after evacuating the carbon dioxide from the abdomen. Tetracycline was instilled into the wounds which were closed with subcuticular absorbable sutures or skin staples. Where the appendix could not easily be delivered owing to peritoneal attachments or inflammatory adhesions, a third trocar and cannula (5 m m ) was introduced suprapubically in the midline or slightly to the left to avoid instrument crowding. Dissecting instruments and diathermy were then used to mobilize the appendix and caecum before proceeding. The appendix may be so oedematous or friable that it cannot be drawn into the lumen of the 12-mm cannula. The cannula can then be removed and the appendix and mesoappendix grasped close to the caecum with a Babcock's forceps introduced directly through the wound. The appendix can then be manipulated gently on to the surface. After discharge patients were reviewed at 7- 10 days and at monthly intervals until full recovery. All wounds were inspected at each visit.
introduced to allow dissection of the appendix from surrounding structures, and two retrocaecal appendices were freed by division of the lateral peritoneal reflection of the caecum. In six patients the operation was converted to open appendicectomy by extending the incision at McBurney's point. Technical difficulties in two patients were omental insufflation with the Verres needle, resulting in a restricted view, and abdominal wall adiposity. Disease-related difficulties included four patients with dense inflammatory adhesions or small bowel dilatation; these problems occurred in patients whose symptoms had been present for more than 72 h. The diagnosis of acute appendicitis was confirmed histologically in 23 patients. Acute salpingitis was diagnosed in one patient and the normal appendix removed. In four patients presenting acutely no definitive diagnosis was achieved and the appendix was histologically normal. In the three patients undergoing elective operation, histological evidence of previous appendicitis was found. The mean operating time was 62 (range 18-135) min. The median time to discharge was 2 (range 1-4)days and the median time to resumption of normal activity 14 (range 7-28) days. Two patients whose operations were converted to open appendicectomy experienced prolonged postoperative ileus which in one patient necessitated re-exploration and division of adhesions. The decision to abandon laparoscopic appendicectomy was made early owing to inability to locate the appendix behind dilated small bowel loops and densely adherent omentum. The postoperative problems were caused by the severe inflammation and intra-abdominal sepsis associated with the primary pathology and not by the initial laparoscopy. Four patients recovered uneventfully from open appendicect omy .
Discussion
The technique was successful in 25 patients, and in 14 only two cannulae were needed. In 11 patients an extra cannula was
In the original description of laparoscopic appendicectomy ', the mesoappendix and appendix were dissected, ligated and divided within the peritoneal cavity. The appendix was then withdrawn through a cannula, avoiding contact with the wound edges. Gotz et a!.' reported 388 patients undergoing laparoscopic appendicectomy by this method and claimed not to have any severe wound infection. The technique described in this paper involved contact between appendix and wound, but no infections of the latter were seen. One patient reported some erythema around the right iliac fossa wound which resolved spontaneously. The main advantage of this technique is that the vessels and appendix are divided under direct vision. The appendix stump was stapled in most cases but it can easily be ligated and invaginated. Invagination of the stump is probably unnecessary6. Operating time varied considerably and was influenced by the number of inflammatory adhesions and patient obesity. The most important factor was the experience of the operator. The decrease in mean operating time by one member of the surgical team was from 86 min for the first four patients to 28 min for patients 11 to 14. A similar but less pronounced learning curve was apparent for other, less experienced operators. The conversion rate to open appendicectomy (19 per cent) was similar to the early results of Gotz et a ! . ' ; they noted a reduction to 3 per cent with greater experience. Obesity presents a problem in that the distance through which the appendix and caecum are to be manipulated is increased by the thickness of the abdominal wall. By appropriate placement of the cannulae and more extensive intra-abdominal mobilization this can usually be overcome.
574
ooO7-1323/92/060574-02
Results
0 1992 Butterworth-Heinemann
Ltd
Surgical workshop
These patients may benefit most by avoiding what would otherwise be a relatively long incision. This therapeutic application adds to the diagnostic value of laparoscopy and may reduce the need for exploratory laparotomy in patients with lower abdominal peritonitis of uncertain aetiology.
References 1. 2.
Semm K. Endoscopicappendectomy. Endoscupy 1983; 15: 59-64. Gangal HT, Gangal MH. Laparoscopic appendicectomy. Endoscopy 1987; 19: 127-9.
3. 4.
5. 6.
Schreiber JH. Early experience with laparoscopic appendectomy in women. Surg Endosc 1987; 1: 211-16. Leahy PF. Technique of laparoscopic appendicectomy. Br J Surg 1989; 76: 616. Gotz F, Pier A, Bacher C. Modified laparoscopic appendectomy in surgery: a report on 388 operations. Sury Endosc 1990; 4 : 6-9. Engstrom L, Fenyo G . Appendicectorny: assessment of stump invagination. A prospective randomized trial. Br J Surg 1985; 72: 971 -2.
Paper accepted 30 December 1991
Announcement The International Association for the Surgery of Trauma and Surgical Intensive Care (IATSIC) was founded in Toronto in 1989 during International Surgical Week. It is an affiliated association of the International Surgical Society. The Society has become an immediate success and was responsible for five main sessions on trauma and intensive care at the Stockholm meeting last year. A British chapter has been formed with Professor Brian Rowlands (Belfast) as Chairman and Mr Alberic Fiennes (St George’s, London) as Secretary. Any surgeon interested in joining this new Association should contact the Secretary at the following address: Mr Alberic G. T. W. Fiennes, Senior Lecturer, Department of Surgery, St George’s Hospital Medical School, Jenner Wing, Cranmer Terrace, London SW17 ORE, UK.
Miles Irving
Br. J. Surg., Vol. 79, No. 6, June 1992
575
Technique for la pa roscopic appendicectomy D. S. Byrne, G. Bell, J. J. Morriceand G. Orr Department of Surgery, lnverclyde Royal Hospital, Larkfield Road, Greenock PA16 OXN, UK Correspondence to: Mr G . Bell
Laparoscopic appendicectomy was introduced by Semm' in 1983. Several modifications of his technique have been described2-', all of which involve resection of the appendix within the peritoneal cavity and subsequent removal. This paper describes a technique for excising the appendix after delivering it laparoscopically through the abdominal wall, minimizing intra-abdominal dissection.
Surgical technique Between August 1990 and April 199 I , laparoscopic appendicectomy was performed in 31 patients (28 as an emergency and three as elective procedures). Patients under the age of I 5 years were not included. The technique was employed whenever possible, subject only to the availability of the surgeons and equipment. All patients received antibiotic prophylaxis with metronidazole, 1 g rectally 1 h before surgery or 500 mg intravenously at induction of anaesthesia. Peritoneal insufflation with carbon dioxide was produced by means of a Verres needle introduced infraumbilically. Insufflation was controlled by automatic regulation to a maximal intraperitoneal pressure of 15 mmHg. Once the pressure was achieved, a 10-mm disposable trocar and cannula (Auto Suture, Ascot, U K ) was introduced at the same site and a 10-mm Hopkins end-viewing laparoscope (Olympus Optical, Tokyo, Japan) inserted to inspect the peritoneal cavity and confirm the diagnosis. A second incision was made over McBurney's point and a 12-mm trocar and cannula introduced under direct vision at this site. The tip of the appendix was grasped with forceps and brought up into the lumen of this cannula. Gentle traction on the omentum was sometimes required to tease off inflammatory adhesions before this was achieved. Cannula and appendix were then withdrawn together, delivering the appendix on to the surface. It was manipulated through the wound until the pole of the caecum became visible. This manoeuvre was facilitated by evacuation of gas from the abdominal cavity allowing the anterior abdominal wall to fall back on to the caecum. The mesoappendix was ligated and divided and the appendix stapled using a TA30 stapler (Auto Suture) or ligated and excised. The stump was inspected and cauterized as necessary. The caecum was returned to the abdominal cavity, and the stump and surrounding area irrigated with tetracycline solution. The cannulae were withdrawn after evacuating the carbon dioxide from the abdomen. Tetracycline was instilled into the wounds which were closed with subcuticular absorbable sutures or skin staples. Where the appendix could not easily be delivered owing to peritoneal attachments or inflammatory adhesions, a third trocar and cannula (5 m m ) was introduced suprapubically in the midline or slightly to the left to avoid instrument crowding. Dissecting instruments and diathermy were then used to mobilize the appendix and caecum before proceeding. The appendix may be so oedematous or friable that it cannot be drawn into the lumen of the 12-mm cannula. The cannula can then be removed and the appendix and mesoappendix grasped close to the caecum with a Babcock's forceps introduced directly through the wound. The appendix can then be manipulated gently on to the surface. After discharge patients were reviewed at 7- 10 days and at monthly intervals until full recovery. All wounds were inspected at each visit.
introduced to allow dissection of the appendix from surrounding structures, and two retrocaecal appendices were freed by division of the lateral peritoneal reflection of the caecum. In six patients the operation was converted to open appendicectomy by extending the incision at McBurney's point. Technical difficulties in two patients were omental insufflation with the Verres needle, resulting in a restricted view, and abdominal wall adiposity. Disease-related difficulties included four patients with dense inflammatory adhesions or small bowel dilatation; these problems occurred in patients whose symptoms had been present for more than 72 h. The diagnosis of acute appendicitis was confirmed histologically in 23 patients. Acute salpingitis was diagnosed in one patient and the normal appendix removed. In four patients presenting acutely no definitive diagnosis was achieved and the appendix was histologically normal. In the three patients undergoing elective operation, histological evidence of previous appendicitis was found. The mean operating time was 62 (range 18-135) min. The median time to discharge was 2 (range 1-4)days and the median time to resumption of normal activity 14 (range 7-28) days. Two patients whose operations were converted to open appendicectomy experienced prolonged postoperative ileus which in one patient necessitated re-exploration and division of adhesions. The decision to abandon laparoscopic appendicectomy was made early owing to inability to locate the appendix behind dilated small bowel loops and densely adherent omentum. The postoperative problems were caused by the severe inflammation and intra-abdominal sepsis associated with the primary pathology and not by the initial laparoscopy. Four patients recovered uneventfully from open appendicect omy .
Discussion
The technique was successful in 25 patients, and in 14 only two cannulae were needed. In 11 patients an extra cannula was
In the original description of laparoscopic appendicectomy ', the mesoappendix and appendix were dissected, ligated and divided within the peritoneal cavity. The appendix was then withdrawn through a cannula, avoiding contact with the wound edges. Gotz et a!.' reported 388 patients undergoing laparoscopic appendicectomy by this method and claimed not to have any severe wound infection. The technique described in this paper involved contact between appendix and wound, but no infections of the latter were seen. One patient reported some erythema around the right iliac fossa wound which resolved spontaneously. The main advantage of this technique is that the vessels and appendix are divided under direct vision. The appendix stump was stapled in most cases but it can easily be ligated and invaginated. Invagination of the stump is probably unnecessary6. Operating time varied considerably and was influenced by the number of inflammatory adhesions and patient obesity. The most important factor was the experience of the operator. The decrease in mean operating time by one member of the surgical team was from 86 min for the first four patients to 28 min for patients 11 to 14. A similar but less pronounced learning curve was apparent for other, less experienced operators. The conversion rate to open appendicectomy (19 per cent) was similar to the early results of Gotz et a ! . ' ; they noted a reduction to 3 per cent with greater experience. Obesity presents a problem in that the distance through which the appendix and caecum are to be manipulated is increased by the thickness of the abdominal wall. By appropriate placement of the cannulae and more extensive intra-abdominal mobilization this can usually be overcome.
574
ooO7-1323/92/060574-02
Results
0 1992 Butterworth-Heinemann
Ltd
Surgical workshop
These patients may benefit most by avoiding what would otherwise be a relatively long incision. This therapeutic application adds to the diagnostic value of laparoscopy and may reduce the need for exploratory laparotomy in patients with lower abdominal peritonitis of uncertain aetiology.
References 1. 2.
Semm K. Endoscopicappendectomy. Endoscupy 1983; 15: 59-64. Gangal HT, Gangal MH. Laparoscopic appendicectomy. Endoscopy 1987; 19: 127-9.
3. 4.
5. 6.
Schreiber JH. Early experience with laparoscopic appendectomy in women. Surg Endosc 1987; 1: 211-16. Leahy PF. Technique of laparoscopic appendicectomy. Br J Surg 1989; 76: 616. Gotz F, Pier A, Bacher C. Modified laparoscopic appendectomy in surgery: a report on 388 operations. Sury Endosc 1990; 4 : 6-9. Engstrom L, Fenyo G . Appendicectorny: assessment of stump invagination. A prospective randomized trial. Br J Surg 1985; 72: 971 -2.
Paper accepted 30 December 1991
Announcement The International Association for the Surgery of Trauma and Surgical Intensive Care (IATSIC) was founded in Toronto in 1989 during International Surgical Week. It is an affiliated association of the International Surgical Society. The Society has become an immediate success and was responsible for five main sessions on trauma and intensive care at the Stockholm meeting last year. A British chapter has been formed with Professor Brian Rowlands (Belfast) as Chairman and Mr Alberic Fiennes (St George’s, London) as Secretary. Any surgeon interested in joining this new Association should contact the Secretary at the following address: Mr Alberic G. T. W. Fiennes, Senior Lecturer, Department of Surgery, St George’s Hospital Medical School, Jenner Wing, Cranmer Terrace, London SW17 ORE, UK.
Miles Irving
Br. J. Surg., Vol. 79, No. 6, June 1992
575
