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PubMed2000

Syringe pressure irrigation of subdermic tissue after appendectomy to decrease the incidence of postoperative wound infection.

To evaluate syringe pressure irrigation of the surgical wound to decrease its infection after appendectomy, we designed a randomized control trial at the Emergency Department of Mexico City General Hospital, including 350 patients with acute abdomen suggestive of appendicitis, without any other infection clinically evident. The trial was randomized into 2 groups. Group I patients received prophylactic systemic antibiotics before surgery. Group II patients received the same prophylactic systemic antibiotics plus syringe pressure irrigation of the surgical wound with 300 ml of saline solution using a 20-ml syringe with 19-gauge intravenous (IV) catheter to measure the incidence of postoperative wound infection. In our results, 283 patients had appendicitis. Of these, 188 were uncomplicated (66.4%) and 95 (33.6%) were complicated. Of the complicated cases, 40 were assigned to group I, and of these, 29 (72. 5%) developed wound infection. In group II there were 55 patients and only 9 (16.3%) developed wound infection after syringe pressure irrigation [p = 0.000001; 95% confidence interval (CI) = 0.02-0.22]. We conclude that syringe pressure irrigation of the surgical wound after appendectomy contributes significantly to decrease the incidence of postoperative wound infection in complicated cases. It is a cheap, safe, and accessible method in any surgical room.

Adolescent↗
PubMed2004

Diagnostic laparoscopy with planned appendectomy: an integral step in the evaluation of unexplained right lower quadrant pain.

Recurrent right lower quadrant (RLQ) abdominal pain is often difficult to diagnose and treat. We reviewed our experience with diagnostic laparoscopy with planned appendectomy for children with unexplained RLQ pain. This procedure was performed when the cause of atypical RLQ pain could not be diagnosed by comprehensive medical and radiological evaluation. Outcome data was obtained at office visits and by telephone. From 1997 to 2000, 30 children (22 female) presented with unexplained RLQ pain. Ages ranged from 5 to 16 years (mean 11 years). Symptoms had been present from 6 days to 2 years (median 6 weeks). Gross and/or histological appendiceal abnormalities were found in 26 children (87%). Incidental findings included patent processus vaginalis in one and adnexal cysts in six. Two complications occurred: pelvic fluid collection and umbilical suture reaction. At initial follow-up, 29 patients (97%) were pain-free. Long-term follow-up was continued through 2002. At a median of 19 months (range 2-47 months), 25 of 28 patients (89%) reported no recurrence of their original pain. Our results confirm that the appendix is an important source of unexplained recurrent RLQ pain in children. Diagnostic laparoscopy with planned appendectomy is highly effective and should be considered an integral step in the management of these patients.

Abdominal Pain↗
PubMed2001

Port-exteriorization appendectomy (PEA): a preliminary report.

Between 1994 and 1999, 121 patients with the clinical diagnosis of acute appendicitis were operated upon at our institute, 70 by conventional appendectomy and 51 by laparoscopic procedures. There were no significant differences in the demographic data, but the percentage of complicated appendicitis operated upon laparoscopically (47%) was higher than in those operated upon conventionally (35.6%). In 13 children a new laparoscopy-assisted technique was used, which entails exteriorization of the inflamed appendix via a right-iliac-fossa port and a complete appendectomy outside the abdominal cavity. The new technique proved to be useful in all types of appendiceal pathology; there were shorter operative times and hospital stays and it avoids the drawbacks associated with operating in complicated appendicitis.

Adult↗
PubMed1998

Laparoscopic versus conventional appendectomy in children.

Over a period of 6 months, 48 children who underwent conventional appendectomy (CA) were compared to 34 children who had laparoscopic appendectomy (LA) for acute and recurrent subacute appendicitis. Their ages ranged from 4 to 12 years (mean 8). LA took significantly longer, 76 min, versus 50 min for CA. Less than 2 days' hospitalization was required in 95% of LA cases and 45% of CA cases. Time to return to normal activity averaged 7 days for LA and 12 days for CA (P < 0.001). Wound complications were fewer and the cosmetic appearance was most satisfactory in LA patients. LA is a safe operation that has the advantage of being exploratory, with shorter hospitalization time, early ambulation, and superior cosmetic results.

Acute Disease↗
PubMed1998

Laparoscopic appendectomy and duodenocolonic dissociation (LADD) procedure for malrotation.

The treatment of "asymptomatic" intestinal malrotation remains controversial, particularly beyond the neonatal period. Two cases illustrate the application of laparoscopy for correction of malrotation: one in an older child and another in an asymptomatic infant. Both patients recovered well and were discharged 2 days after surgery. Laparoscopic appendectomy and duodenocolonic dissociation allows excellent visualization of the duodenocolic and Ladd's bands and easily accommodates appendectomy. The availability of this minimal-access technique should encourage correction of malrotation in the asymptomatic patient.

Appendectomy↗
PubMed2002

Role of appendectomy in training for laparoscopic surgery.

BACKGROUND: This study aimed to evaluate a program of training in laparoscopic surgery based on clinical practice in the emergency room, in which laparoscopic appendectomy is the first technique that residents perform as surgeons. METHODS: A prospective nonrandomized study was conducted involving all the laparoscopies performed in emergencies with a diagnosis of acute abdomen, appendicular in origin, during the period between June 1991 and December 1997. RESULTS: There were no statistically significant differences between residents and assistants in terms of conversion rates (22/242 vs 15/158), mean hospital stay for each type of surgeon (5.2 days for residents and 5.1 days for assistants), and complications (12.8% for residents and 13.7% for assistants). Operating time, was significantly longer (p < 0.05) for residents (52.2 min) than for assistants (48 min). CONCLUSIONS: Apprenticeship in laparoscopic appendectomy can be accomplished with gradual clinical training and without the need for resort to animal experimentation laboratories.

Abdomen, Acute↗
PubMed2002

Early laparoscopic appendectomy for appendicular mass.

BACKGROUND: The surgical management of acute appendicitis presenting with appendicular mass remains controversial. The aim of this study was to evaluate the role of early laparoscopy and laparoscopic appendectomy (LA) in the management of appendicular mass. METHODS: During a 1-year period, 62 patients underwent LA for suspected appendicitis (n = 50), generalized peritonitis (n = 2), and an appendicular mass (n = 10). Another patient who presented with an appendicular mass was found at laparoscopy to have an ileo-ileal intussusception. RESULTS: All appendectomies were attempted and completed laparoscopically. Postoperative complications occurred in two patients; there were no deaths. None of the patients treated for an appendicular mass developed complications. There was no difference between the patients who underwent LA during the index admission for an appendicular mass and those who had surgery for non-mass-forming appendices with regard to the operative time (median [interquartile range]: 45 [36-60] vs 40 [25-50] min, p = 0.085) and postoperative hospital stay (median [interquartile range]: 2 [1-2] vs [1-2] days, p = 0.1). CONCLUSION: Early LA during the index admission of patients with an appendicular mass is feasible and safe, obviates the need for a second hospital admission, and avoids misdiagnoses.

Adolescent↗
PubMed2003

Successful laparoscopic Ladd's procedure and appendectomy for intestinal malrotation with appendicitis.

We successfully performed a laparoscopic Ladd's procedure and an appendectomy in a 15-year-old girl with intestinal malrotation and appendicitis. She had tenderness and rebound pain in the umbilicus and left lower abdominal quadrant. Blood analysis revealed a moderate inflammatory response. Enhanced computerized tomography (CT) scanning revealed a whirl-like pattern and a superior mesentric vein (SMV) rotation sign in the mesentry of the small intestine. A swollen appendix was seen just below the umbilicus. An upper gastrointestinal (GI) radiological series confirmed agenesis of Treitz's arch. The patient was diagnosed as having a nonrotation type of malformation accompanied by acute appendicitis. She underwent a laparoscopic Ladd's procedure, an appendectomy, peritoneal lavage, and drainage. The technique for this procedure and its effectiveness are briefly discussed.

Adolescent↗
PubMed2003

Needlescopic appendectomy.

BACKGROUND: In this paper, we compare our experience with the techniques of needlescopic appendectomy (NA) (2-mm instruments) for the treatment of acute appendicitis with the more conventional approach of a laparoscopic appendectomy (LA). METHODS: We did a retrospective review of patients who underwent NA for the diagnosis of acute appendicitis between August 1996 and January 2002. Variables including operative time, blood loss, postoperative time to discharge, intra- and postoperative complications were analyzed and compared to data from control patients who had undergone an LA for acute appendicitis. RESULTS: The NA group had a longer average operating time (54.5 +/- l3 vs. 42.5 +/- 12.6 min, p = 0.0001) and a longer postoperative hospital stay (2.1 +/- 1.4 vs. 1.3 +/- 1.1 days, p = 0.01). Blood loss was similar for the two groups. CONCLUSIONS: With the exception of superior cosmesis, NA appears to have little advantage over the better-established LA; moreover, it has some disadvantages. A clearer benefit of this procedure over LA, as well as improvements in instrumentation, needs to be shown before it can be widely accepted.

Adolescent↗
PubMed2004

Mini-laparoscopic appendectomy using a needle loop retractor offers optimal cosmetic results.

BACKGROUND: Do conventional laparoscopic appendectomy (LA) techniques provide truly satisfying results for patients and surgeons? We have devised a more advanced technique that improves cosmesis. METHODS: A 2-mm scope is inserted at the umbilicus, and a 12-mm working trocar is inserted through a suprapubic incision placed below the line of pubic hair. A needle loop retractor (NLR) is inserted to hold the appendix in the lower right abdomen. In this NLR, a stainless steel wire is placed within a needle having a diameter of 2 mm. From the suprapubic trocar, a bipolar coagulator is inserted to transect the appendiceal mesentery. A series of 30 patients underwent this procedure. RESULTS: There were no conversions to laparotomy and no intra- or postoperative complications. CONCLUSIONS: Laparoscopic appendectomy using a 2-mm scope, suprapubic trocar, and an NLR yields optimal cosmetic results. For surgeons, the NLR allows the appendix to be held more firmly than then a 5- or 2-mm grasping forceps is used.

Adult↗
PubMed2004

Outcome after intra- and extra-corporeal laparoscopic appendectomy techniques.

BACKGROUND: This study aimed to assess the outcome after intracorporeal (IC) and extracorporeal (EC) laparoscopic appendectomy technique in a single institution over a 5-year period. METHODS: Records of all children ( n = 60) who underwent laparoscopic appendectomy at the Royal Aberdeen Children's Hospital between February 1997 and March 2002 were retrieved and evaluated. Observations were made regarding operative technique, anesthetic time, intra- and postoperative complications, postoperative analgesic requirement, and postoperative hospital stay. RESULTS: There were 30 children in each group who had a similar demographic profile. The magnitude of appendicitis severity in both groups was similar. The mean anesthetic time was 67.8 min for the IC group and 50.7 min for the EC group (p = 0.001). There were no recorded intraoperative complications, although a single case in the EC group required conversion to open procedure. The postoperative analgesic requirement in both groups was similar. The mean postoperative stay was 2.1 days in the IC group and 2.5 days in the EC group. Two postoperative complications were noted in the IC group; one intraperitoneal collection and one postoperative chest infection. Four complications occurred in the EC group; one intraperitoneal collection and three minor port-site wound infections. CONCLUSIONS: The authors' experience shows the EC technique to be significantly quicker, although with a slightly increased complication rate. Either technique can be applied safely for acute appendicitis.

Adolescent↗
PubMed2006

Securing the appendiceal stump in laparoscopic appendectomy: evidence for routine stapling?

BACKGROUND: This metaanalysis aimed to compare endoscopic linear stapling and loop ligatures used to secure the base of the appendix. METHODS: Randomized controlled trials on appendix stump closure during laparoscopic appendectomy were systematically searched and critically appraised. The results in terms of complication rates, operating time, and hospital stay were pooled by standard metaanalytic techniques. RESULTS: Data on 427 patients from four studies were included. The operative time was 9 min longer when loops were used (p = 0.04). Superficial wound infections (odds ratio [OR], 0.21; 95% confidence interval (CI), 0.06-0.71; p = 0.01) and postoperative ileus (OR, 0.36; 95% CI, 0.14-0.89; p = 0.03) were significantly less frequent when the appendix stump was secured with staples instead of loops. Of 10 intraoperative ruptures of the appendix, 7 occurred in loop-treated patients (p = 0.46). Hospital stay and frequency of postoperative intraabdominal abscess also were comparable in loop-treated and staple-treated patients. CONCLUSIONS: The clinical evidence on stump closure methods in laparoscopic appendectomy favors the routine use of endoscopic staplers.

Appendectomy↗
PubMed2001

Laparoscopic vs open appendectomy in overweight patients.

BACKGROUND: Laparoscopic appendectomy (LA) has been associated with a faster recovery and less postoperative pain than the open technique. However, few data are available on the clinical outcome of LA in overweight patients. METHODS: A group of 106 patients with a body mass index (BMI) > 26.4, representing the upper quintile of 500 prospectively randomized patients, were included in the study. They were randomized to undergo either laparoscopic or open appendectomy (OA). Operating and anesthesia times, postoperative pain, complications, hospital stay, functional index (1 week postoperatively), sick leave, and time to full recovery were documented. RESULTS: In OA, the operating time for overweight patients was significantly longer than that for patients in the normal weight range (40 vs 35 min, p < 0.05). In LA, there was no difference in operating time between the normal and overweight patients. Overweight patients who underwent LA had longer operating and anesthesia times than their OA counterparts (55 vs 40 min, p < 0.001; and 125 vs 100 min, p < 0.001, respectively). Postoperative pain was significantly greater in overweight patients who underwent OA than in those treated with the laparoscopic technique. Postoperative pain was also significantly greater in overweight patients subjected to OA than in patients of normal weight after 4 weeks; the clinical significance may, however, be of less importance since the values are low (0.26 vs 0.09, p < 0.05). There were no significant differences between the two operating techniques in terms of complications. Hospital stay was longer for overweight patients than for normal-weight patients undergoing OA (3.0 vs 2.0, p < 0.01). The functional index did not differ between any group of patients. Sick leave was longer for overweight patients who underwent OA than for normal-weight patients treated with the same technique (17 vs 13 days, p < 0.01). In the laparoscopic group, however, there were no differences between the overweight and normal-weight patients. Time to full recovery was greater in overweight patients subjected to OA than in the overweight patients in the LA group (22 vs 15 days, p < 0.001). CONCLUSION: In this study, overweight patients who were submitted to LA had less postoperative pain and a faster postoperative recovery than overweight patients who had OA. LA also abolished some of the negative effects that overweight had on operating time, hospital stay, and sick leave with the open technique. However, anesthesia and operating times were significantly longer in LA for both overweight patients and those with a normal BMI.

Adolescent↗
PubMed1997

Laparoscopic vs open appendectomy. A randomized clinical trial.

BACKGROUND: A randomized clinical trial was performed to compare open appendectomy (OA) and laparoscopic appendectomy (LA). METHODS: 201 patients with similar characteristics of appendicitis were randomized to either OA or LA. Operative time and technique, reintroduction of diet, postoperative pain, use of analgesia, hospital stay, and complications were documented. RESULTS: 104 patients were allocated to the OA group and 97 to the LA group. Postoperative pain was significantly less in the LA group on the 1st (p < 0.001) and 2nd (p < 0.001) postoperative day, resulting in less use of analgesics on both days (p < 0.001). Restoration of diet was similar in both groups. Mean operative time was longer in the LA group: 61 vs 41 min (p < 0.001). Postoperative complications did not differ in either group, except for wound infections (six OA group vs zero LA group, p < 0.05). Mean hospital stay was similar in both groups. CONCLUSIONS: LA results in less postoperative pain and fewer wound infections. The laparoscopic procedure is technically more demanding to perform, resulting in longer operative time.

Acute Disease↗
PubMed1999

Umbilical one-puncture laparoscopic-assisted appendectomy in children.

To perform a laparoscopic appendectomy, three trocars are usually needed. In order to reduce abdominal wall trauma, we have adopted an umbilical one-puncture laparoscopic-assisted appendectomy (UOPLAA). We did a retrospective study of UOPLAA performed during last 2 years on 200 children aged from 5 to 18 years (median, 9 years). The patients were selected after clinical examination. No child with advanced generalized peritonitis or an abscess with a palpable mass was a candidate for this technique. UOPLAA was successful in 184 patients (92%). In 16 cases (8%), an additional trocar was required to manage perforated or retrocecal appendicitis. The mean operative time was 15 min, and the mean hospital stay was 2 days. There were no intraoperative complications. There were 10 (5%) postoperative complications (three parietal and seven intraabdominal). Four patients (2%) needed reoperation under general anesthesia. The UOPLAA is our preference in cases of acute nonperforated appendicitis because it is simple and fast, with good cosmetic results; but in 8% of our cases, an intraoperative difficulty (retrocecal location, abnormal adhesive band, peritonitis, etc.) arose that required the introduction of additional devices to ensure the safety of the laparoscopic procedure.

Acute Disease↗
PubMed1999

Diagnostic laparoscopy through the right lower abdominal incision following open appendectomy.

BACKGROUND: Diagnostic laparoscopy through the right lower abdominal incision following open appendectomy for suspected acute appendicitis may help in making the correct diagnosis in the absence of pathology of the appendix. METHODS: Fourteen patients with a clinical diagnosis of acute appendicitis underwent diagnostic laparoscopy through the right lower quadrant incision after open appendectomy to exclude further pathology in the case of a noninflamed appendix. RESULTS: In 10 of the 14 patients, laparoscopy helped to correct the diagnosis. In two patients, the etiology of the acute right lower abdominal pain remained unclear. In two others, histological examination showed acute appendicitis despite a normal macroscopic appearance. CONCLUSIONS: Diagnostic laparoscopy through the right lower quadrant incision may help to correct the diagnosis in patients who are operated on for clinically acute appendicitis but in whom no acute appendicitis or other pathological findings are seen.

Abdomen, Acute↗
PubMed2001

The management of appendiceal mass in children: is interval appendectomy necessary?

In this study we aimed to show that performing interval appendectomy is unnecessary in the management of appendiceal mass in children. Between 1990 and 1996, 866 patients were treated for appendicitis. Abdominal ultrasonography (USG) was performed in patients who were admitted with abdominal pain, vomiting, and fever accompanying a mass in the right lower quadrant. Seventeen patients (12 boys and 5 girls, with a mean age of 9.5 years) with a mass in the appendiceal lodge and no abscess formation were treated conservatively. Appendectomy was performed on any patients with perforated or unperforated appendicitis who had an appendiceal abscess with a mass in the right iliac fossa. Three-agent antibiotic therapy was administered for at least 1 week. These patients were discharged after a mean hospital time of 9.7 days if regression of the mass was seen ultrasonographically. They were followed up for 1-60 months by physical examination and USG, and 11 of the 17 also underwent barium enema. USG demonstrated disappearance of the mass and barium enema showed a normal appendix in 10 of the 11 patients. No recurrent appendicitis was detected during follow-up for 1-7 years. This study shows that appendiceal masses that are perforated, but localized with no fluid content revealed by USG, can be treated conservatively even if they are detected late.

Adolescent↗
PubMed2001

Laparoscopic appendectomy with the help of a wire snare.

This report describes the performance of a laparoscopic appendectomy (LA), a new technique using a "wire snare" without any specific complications. The snare consisted of an 18-gauge injection needle and folded fine wire, measuring 0.28 mm in diameter. LA was performed in 95 patients with acute appendicitis using a cheap and simple wire snare to catch the ligation thread of #0 silk. A good view of the appendix and mesoappendix was obtained in all cases by traction of the #0 silk. The operative time needed to perform LA using a wire snare for nongangrenous appendicitis in 77 cases overall, the first 10 cases, and the last 10 cases was 54+/-17, 64+/-5, and 33+/-4 min, respectively. Two of the 95 patients required conversion to an open appendectomy because of technical difficulties due to the formation of an inflammatory mass. There were no complications associated with insertion of the snare. The wire snare is an innovative technique and does not increase the costs significantly, and should help reduce the number of trocar sites and the operative time, while also making an LA easier to perform.

Adolescent↗