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PubMed1995

Laparoscopic appendectomy: a review of 95 consecutive suspected cases of appendicitis.

OBJECTIVE: To assess the feasibility and efficacy of laparoscopic appendectomy. DESIGN: A review of a case series. SETTING: A single teaching and referral centre in Vancouver. PATIENTS: Ninety-five consecutive patients referred to the Division of General Surgery with suspected appendicitis requiring surgical intervention. The patients ranged in age from 15 to 85 years. INTERVENTIONS: Laparoscopic appendectomy or open appendectomy. MAIN OUTCOME MEASURES: Feasibility of laparoscopic appendectomy, duration of operation, intraoperative and postoperative complications and duration of postoperative hospital stay. RESULTS: Of the 95 patients, 9 had contraindications to laparoscopic appendectomy and underwent an open operation. Of the 86 patients who underwent laparoscopy, the diagnosis of appendicitis was confirmed in 69 (80%). Following this, 61 (88%) patients underwent laparoscopic appendectomy, and in 8 the procedure was converted to open appendectomy because of periappendiceal abscess or an immobile or perforated appendix. The mean duration of operation was 78.5 minutes. There were no intraoperative complications. The mean duration of postoperative hospital stay was 2.8 days. Postoperative complications consisted of ileus in two patients and diarrhea in two patients. There were no wound infections. CONCLUSIONS: Laparoscopic appendectomy can be performed safely, with minimal complications on most patients with appendicitis; hospital stay is reduced. Laparoscopy allows accurate diagnosis.

Adolescent↗
PubMed1997

Appendectomy. Improving care through quality improvement.

OBJECTIVE: To evaluate the practice of appendectomy in Department of Defense hospitals worldwide in a large-scale quality improvement initiative. DESIGN: Case series study. POPULATION AND SETTING: A total of 4950 consecutive nonincidental appendectomies performed in 147 Department of Defense hospitals worldwide during a 12-month period ending January 31, 1993. RESULTS: The mean age was 25.5 years, with 64% males and 36% females. The patients were assigned a diagnosis of normal appendix (negative appendectomy) in 632 cases (12.8%), acute appendicitis in 3286 cases (66.4%), and perforative appendicitis in 1032 cases (20.9%). The influence of inpatient and outpatient delays on perforation and negative appendectomy rates were studied. In at least 52% of all patients ultimately assigned a diagnosis of perforative appendicitis, the perforation occurred before the first outpatient contact with the health care system, and in at least 68% of all patients ultimately assigned the diagnosis of perforative appendicitis, the perforation occurred before surgical evaluation and admission. Neither outpatient delay in diagnosis nor inpatient delay in diagnosis and treatment was associated with a significant change in the rate of negative appendectomy. CONCLUSIONS: Perforation rates are determined predominantly by patient- and primary care-related factors over which surgeons have little control. Negative appendectomies are predominantly related to the wide overlap in presenting signs and symptoms between appendicitis and the diseases that most often mimic it but do not require operative intervention. Whereas studies of this type are useful for identifying potential problems at the health care system level, the relatively small number of appendectomies performed by each surgeon precludes analysis at the practitioner level.

Adolescent↗
PubMed1998

Incidental appendectomy--yes or no? A retrospective case study and review of the literature.

OBJECTIVE: A retrospective review of appendectomies performed at the University of Kansas Medical Center between January 1, 1989, and January 1, 1994, was conducted. In addition, the literature evaluating effectiveness of incidental appendectomy in preventing future operation and morbidity from appendicitis was reviewed. The results of the two reviews were analyzed to formulate guidelines for the appropriateness of performing incidental appendectomy in association with other operative procedures. METHOD: A retrospective review of results of appendectomies performed in 460 patients at the University of Kansas Medical Center with analysis of operative findings, pathology of the removed appendix and operative complications was performed. These results were compared with those of a systematic review of the literature utilizing a Medline search relating to the subject of incidental appendix removal. RESULTS: Two hundred sixty-one incidental appendectomies were performed in this study of 460 patients (60%). The procedure was most commonly performed with total abdominal hysterectomy (56%), followed by oophorectomy (15%) and exploratory laparotomy (11%). Morbidity was minimal at all ages. Microscopic pathology was found in 25% of the cases. CONCLUSION: The data from the current survey and literature review support incidental removal of the appendix in the young patient (< 35 years old). In patients 35-50 years old the literature is controversial, and the patient's clinical condition and judgment of the operating surgeon should determine whether incidental appendectomy should be performed. However, routine incidental appendectomy cannot be justified in patients greater than age 50.

Adult↗
PubMed1998

[Simplified appendectomy without stump embedding. Experiences of 20 years conventional and 5 years laparoscopic application].

Since 1975, the Department of Surgery in the Grevenbroich Community Hospital (Germany) has applied a simplified technique of open appendectomy. The inhouse modified procedure without stump embedding has been performed in 3,448 cases to date. The same approach has been used in 1,463 laparoscopic appendectomies since 1991. In the laparoscopic procedure the stump is ligated solely with Roeder's loop. None of the 4,911 patients who have undergone either open or laparoscopic appendectomy have developed stump inadequacy or stercoral fistulae. According to the special literature, the complication rate after appendectomies without stump embedding is lower than that after standard procedures. In retrospect, laparoscopic appendectomy with simple ligation has confirmed the results achieved with simple ligation in open appendectomies. The technique should therefore become more common practice in open appendectomies, as well.

Appendectomy↗
PubMed1996

Laparoscopic versus open appendectomy: prospective randomized trial.

A prospective randomized trial comparing laparoscopic appendectomy with open appendectomy in patients with a diagnosis of acute appendicitis was conducted between October 1992 and April 1994. Of the 158 patients randomized, 7 patients were excluded because of protocol violations (conversion to laparotomy in 4, appendix not removed in 3). The 151 patients randomized to either a laparoscopic (n = 79) or an open appendectomy (n = 72) showed no difference in sex, age, American Society of Anesthesiology (ASA) rating, or previous abdominal surgery. The histologic classification of normal, catarrhal, inflamed, suppurative, and gangrenous appendicitis was not different between the two groups. Conversion from laparoscopic to open appendectomy was necessary in seven patients (9%) who had advanced forms of appendiceal inflammation. When compared to open appendectomy the laparoscopic group had a longer median operating time (63 minutes versus 40 minutes), fewer wound infections (2% versus 11%), less requirement for narcotic analgesia, and an earlier return to normal activity (median 7 days versus 14 days). There was no difference in morbidity, and both groups had a median time to discharge of 3 days. Laparoscopic appendectomy is as safe as open appendectomy; and despite the longer operating time, the advantages such as fewer wound infections and earlier return to normal activity make it a worthwhile alternative for patients with a clinical diagnosis of acute appendicitis.

Adolescent↗
PubMed2002

The surgeon on call is a strong factor determining the use of a laparoscopic approach for appendectomy.

BACKGROUND: Laparoscopic and open approaches are commonly used for appendectomy. No previous studies have specifically examined which factors determine whether a laparoscopic or open approach is used for appendectomy. METHODS: We conducted a retrospective chart review of 140 patients who underwent a laparoscopic (n = 60) or open (n = 80) appendectomy between January 2000 and April 2001 at our hospital. Medical records were reviewed, and the data were analyzed using chi-square analysis, the Wilcoxon rank-sum test, and multivariate logistic regression. We studied patient age, gender, type of surgeon on call, leukocyte count, pathology, and the use of diagnostic imaging to determine whether there was any association with the use of a laparoscopic approach. RESULTS: The type of surgeon on call was strongly correlated with a laparoscopic approach. Of the 61 appendectomies performed by laparoscopic surgeons (those who use laparoscopy for operations other than appendectomies and cholecystectomies), 55 (90%) were laparoscopic and 6 (10%) were open. Of the 79 appendectomies performed by nonlaparoscopic surgeons, 5 (6%) were laparoscopic and 74 (94%) were open (multivariate odds ratio, 136; 95% confidence interval, 39-475; p < 0.001). CONCLUSIONS: The surgeon on call when a patient is admitted is an important factor determining whether a patient will receive a laparoscopic or open appendectomy.

Acute Disease↗
PubMed2003

Laparoscopic versus open appendectomy: a prospective comparative study of 227 patients.

BACKGROUND: Although laparoscopic appendectomy is widely practiced in developed countries, still there are many questions regarding the advantages and disadvantages of this approach in the treatment of acute appendicitis. Several controlled trials have been conducted, some in favor of laparoscopic appendectomy others not. The aim of this study was to evaluate laparoscopic appendectomy in comparison with open appendectomy, with special emphasis on postoperative septic complications. METHODS: For this study, 227 consecutive patients (159 males and 68 females) with a diagnosis of suspected appendicitis between 1995 and 1999 were assigned either to laparoscopic appendectomy (n = 108) or open appendectomy (n = 119). The patients were assigned according to insurance company approval and patient preference. There were no exclusion criteria and no age limits in this study. RESULTS: Wound infection was significantly higher in the open group (incidence, 7.6%) than in the laparoscopic group (incidence, 0%; p <0.003). Intraabdominal infections were equal in both groups. Hospital stay was significantly shorter in the laparoscopic group (p <0.046), but operative time was little longer than in the open group (p <0.002). Conversion to open surgery was necessary in one case. CONCLUSIONS: Laparoscopic appendectomy is as safe and effective as the open procedure. It significantly reduces the rate of postoperative wound infection. However, it is still acceptable to perform the open procedure, especially in hospitals without a large amount of laparoscopic experience.

Abdominal Abscess↗
PubMed2004

Preoperative and postoperative levels of interleukin-6 in patients with acute appendicitis: comparison between open and laparoscopic appendectomy.

BACKGROUND: Cytokine interleukin-6 (IL-6) is an early marker of systemic inflammatory response and tissue damage. This study aimed to evaluate the levels of IL-6 after open and laparoscopic appendectomy to compare the degree of surgical stress associated with these procedures. METHODS: The levels of IL-6 were measured pre- and postoperatively in the plasma of 37 consecutive patients with a diagnosis of acute appendicitis. After preoperative randomization, 22 patients underwent open appendectomy, and 15 patients underwent laparoscopic appendectomy. RESULTS: The preoperative concentrations of IL-6 were 7.2 +/- 5.6 pg/ml in the open appendectomy group, as compared with 12.1 +/- 9.7 pg/ml in the laparoscopic appendectomy group (p < 0.05). The postoperative levels were 16.9 +/- 15.7 and 23.2 +/- 19.4 pg/ml, respectively. The mean postoperative to preoperative ratio of IL-6 was slightly higher for open (2.7 +/- 2.4) than for laparoscopic (2.3 +/- 1.6) appendectomy, but the difference did not reach statistical significance. CONCLUSION: The operative stress in open as compared with laparoscopic appendectomy is not reflected by circulating levels of IL-6.

Acute Disease↗
PubMed2006

Videolaparoscopic appendectomy: the current outlook.

BACKGROUND: Mini-invasive techniques have revolutionized surgery, but the superiority of laparoscopic access for appendectomy is widely debated. The authors analyze their monocentric experience with 1,347 laparoscopic appendectomies. METHODS: Between October 1991 and December 2002, all the patients with an indication for appendectomy underwent surgery (301 emergency and 1,046 interval appendectomies) using the laparoscopic approach. RESULTS: For 1,248 patients, appendectomy was performed laparoscopically, whereas for 99 patients (7.3%), it was converted to an open procedure because of technical reasons (90 patients, 6.7%) or intraoperative complications (9 patients, 0.6%). For 59 patients (4.4%), the appendectomy was associated with another procedure. Histology showed "acute" alterations in 261 of the 301 emergency surgeries and in 148 of the 1,046 elective operations. Postoperative complications arose in 37 patients (2.7%), with 5 patients (0.3%) requiring invasive treatment. The mean postoperative stay was 30 h. CONCLUSIONS: Laparoscopic appendectomy offers unquestionable advantages, but it is not yet considered the "gold standard" for appendiceal pathology. Many centers reserve it for selected patients (e.g., obese patients and women suspected of having other pathologies). No randomized trials or metaanalyses have definitively proved its superiority.

Adolescent↗
PubMed2000

Laparoscopic interval appendectomy for periappendicular abscess.

BACKGROUND: Laparoscopic appendectomy was first described in the early 1980s and is currently widely used for the treatment of acute appendicitis. The application of laparoscopic techniques to interval appendectomy and the value of this procedure as compared to open elective interval appendectomy remains uncertain. Therefore, we set out to assess the usefulness of interval laparoscopic appendectomy following periappendicular abscess. METHODS: This study analyzes the data for 10 patients who underwent interval laparoscopic appendectomy 8-10 weeks following documented periappendicular abscess in the period between January 1996 and June 1998. RESULTS: Laparoscopic appendectomy was completed successfully in all 10 patients. Nine patients were discharged 1 day after the operation; one patient was discharged on the evening of the operative day. There were no complications and no wound infections. CONCLUSION: We conclude that the laparoscopic approach is the preferable treatment for interval appendectomy. It is associated with minimal or no morbidity and a very short hospital stay.

Abdominal Abscess↗
PubMed1983

Safety of incidental appendectomy.

Reports in the surgical literature are conflicting as to whether appendectomy "in passing" during laparotomy for trauma or for some other disease state does or does not significantly increase patient morbidity or mortality. A chart survey of all appendectomies (342 for acute appendicitis and 146 as incidental procedures) performed on the trauma service of Grady Memorial Hospital over a 40 month period appeared to indicate that the wound infection rate (6.8 percent) was the same as that for acute simple or suppurative appendicitis (6.7 percent), whereas the intraabdominal sepsis rate (17.5 percent) paralleled that for more advanced gangrenous or perforative appendicitis (18.6 percent). Since the validity of a retrospective review is always open to question, a prospective, randomized trial was carried out only on patients with a negative abdominal exploration for trauma over a 22 month interval at the same trauma service. An odd second from the last digit hospital number dictated appendectomy, provided the appendix was readily accessible; an even digit in the same locus dictated retention of the appendix. In no patient did intraperitoneal sepsis develop, regardless of the procedure chosen. Wound infection rates were 1.8 percent for appendectomy (1 of 56), if local anatomic considerations precluded an easy appendectomy (0 of 45), and 3.6 percent for the control subjects without appendectomy (3 of 83). There were no deaths. These data cast considerable doubt on the reliability of retrospective reviews and support the generally accepted dictum that incidental appendectomy, especially in the trauma patient, can be a relatively innocuous procedure.

Abdominal Injuries↗
PubMed2007

Effect of subspecialty training on outcome after pediatric appendectomy.

BACKGROUND/PURPOSE: There have been few studies documenting the effect of subspecialty training on outcomes after appendectomy in children. Some studies have suggested a better outcome in patients managed by pediatric surgeons as compared with general surgeons. METHODS: We studied the effect of subspecialty training on clinical outcome and negative appendectomy rate after pediatric appendectomy. Children less than 19 years in Ontario who underwent appendectomy were identified. Outcomes were compared between pediatric and general surgeons. Subanalyses were conducted for the age groups 0 to 5, 6 to 12, and 13 to 18 years. RESULTS: Over 8 years, 24,019 children underwent appendectomy with a preoperative diagnosis of appendicitis. Of these, 21,027 had appendicitis. General surgeons performed 81.2% of the operations. Negative appendectomy rates were 8.3% and 13.4% (P < .0001) in the pediatric and general surgeon groups, respectively. Children operated on by pediatric surgeons were younger (10.5 +/- 3.6 vs 12.8 +/- 3.8; P < .05), more likely to be perforated (36.6% vs 32.0%; P < .0001), and had a longer postoperative stay (3.8 vs 3.0 days; P < .0001). There was no difference between groups with respect to wound infection or readmission rate when age and perforation status were accounted for. CONCLUSIONS: Pediatric surgeons performed significantly fewer negative appendectomies than general surgeons. Although pediatric surgeons kept their patients longer in the hospital, their patients' wound infection and readmission rates were not different from that of the patients of general surgeons.

Adolescent↗
PubMed2000

Incidental appendectomy during radical cystectomy: an interdepartmental survey and review of the literature.

OBJECTIVES: To survey and review the incidence of appendectomy performed during radical cystectomy and urinary diversion. We were interested in the reasons behind the decision and if continent diversions have changed the policy. METHODS: We performed a selective survey among urologists in academic centers throughout the United States regarding their practice of incidental appendectomy during radical cystectomy. We also reviewed the literature regarding the rationale for incidental appendectomy in general and during radical cystectomy in particular. RESULTS: Among the 13 departments and 26 urologists replying to the survey, 9 (69%) departments and 20 (77%) individual clinicians are not performing routine incidental appendectomy. In 2 departments, it is considered a matter of choice, and, in 4 (31%) departments, appendectomy is performed routinely. Many believe that the low risk of subsequent appendicitis does not justify the procedure and that the appendix may be useful for future reconstruction. A review of the literature suggests that incidental appendectomy during radical cystectomy is not necessary. CONCLUSIONS: Incidental appendectomy during radical cystectomy is not necessary and is no longer being performed in many academic centers. The risk of subsequent appendicitis is extremely low. The decision may depend on the form of urinary diversion planned.

Academic Medical Centers↗
PubMed1997

Appendectomy and the risk of developing ulcerative colitis or Crohn's disease: results of a large case-control study. South Limburg Inflammatory Bowel Disease Study Group.

BACKGROUND & AIMS: Appendectomy has been pointed out as a protective factor for ulcerative colitis (UC). The aim of this study was to elucidate the role of appendectomy in inflammatory bowel disease (IBD). METHODS: Prevalent as well as incident cases with IBD were studied separately using a pairwise age- and sex-matched case-control study design. RESULTS: In 232 prevalent UC cases, the risk of developing UC was significantly lower after previous appendectomy (odds ratio [OR], 0.36; 95% confidence interval [CI], 0.15-0.80); subgroup analysis found a protective effect only in pancolitis (OR, 0.2; 95% CI, 0.02-0.7). In 208 patients with Crohn's disease (CD), the OR was not significantly increased but a positive association with appendectomy was observed in ileocecal disease. A significant larger proportion of appendectomies was performed close to the time of diagnosis. Smoking was not a confounding factor. No statistically significant associations were observed in incident IBD patients. Prevalent and incident patients taken together resulted in ORs of 0.44 (95% CI, 0.24-0.78) in UC and 1.65 (95% CI, 0.96-2.91) in CD. CONCLUSIONS: An overall protective role of appendectomy for UC was observed. The observations in CD suggest that appendectomy in some cases was a result of still undiagnosed CD.

Adolescent↗
PubMed1983

[Histopathological findings in incidental appendectomies during gynecologic laparotomies and their significance for the patient].

Incidental appendectomy is a more and more frequent part of gynaecological laparotomies. Doubts about the increased post-operative morbidity and mortality have been shown to be unfounded in numerous series. Opinions on contra-indications to incidental appendectomy are divided. German language authors do not do incidental appendectomies with Caesarean Sections, operations for Ectopic pregnancies, Tubo-Ovarian Abscess and Inoperable Carcinoma. In the English speaking literature an increasing number of authors show that even under these circumstances the appendectomy is without danger. Incidental appendectomy is indicated because of the high incidence of abnormal findings at microscopic examination and because the appendix may be a potential hazard for some groups of patients especially pregnant women and elderly women. An increased mortality can be attributed to the potential site of the disease in the appendix. The possible long term complications of incidental appendectomy by adhesions or bowel obstruction are lower than the potential risk of morbidity or mortality with the appendix in situ. In our series microscopic examination of one hundred and thirteen incidentally removed appendices showed abnormal findings in 82.9% of the cases. The appendices were removed in a series of 267 gynaecological laparotomies. In 17% of the cases the findings were important for the patient. An increased post-operative morbidity or mortality was not found in our series. The hospital stay was not prolonged over that of a comparitive group. The risk of a left behind appendix was calculated from a study of the literature both as to morbidity and mortality and compared to the possible short term and long term morbidity from an incidental appendectomy.

Abdomen↗
PubMed2002

Appendectomy in adulthood and the risk of inflammatory bowel diseases.

BACKGROUND: There is controversy as to whether appendectomy protects against the development of ulcerative colitis, but the possible impact of appendectomies performed in adulthood has not been systematically investigated. METHODS: We conducted a large case-control study based on inpatient records from Veterans Affairs hospitals in the United States for the period 1969-96. We identified 6,172 male patients with ulcerative colitis (age range 19-101 years, mean 57.4 years) and 4,498 male patients with Crohn disease (age range 18-99 years, mean 52.9 years). Each of these case patients was individually age- and race-matched to five other male veterans without recorded history of inflammatory bowel disease. We compared records of prior appendectomies in adulthood for the matched case-control sets using conditional logistic regression. RESULTS: Overall, both ulcerative colitis (odds ratio (OR) = 1.6, 95% confidence interval (CI): 1.3-2.1) and Crohn disease (OR = 2.5, 95% CI: 2.0-3.3) were significantly and positively associated with history of appendectomy in adulthood. However, risks were not increased at intervals of 15 years or more between appendectomy and inflammatory bowel disease (ulcerative colitis: OR = 0.9, 95% CI: 0.4-2.1; Crohn disease: OR = 1.2. 95% CI: 0.5-2.5). CONCLUSIONS: The elevated risk of inflammatory bowel disease, notably Crohn disease, after appendectomy probably reflects differential diagnostic difficulties in patients with abdominal pain. Appendectomy carried out during adulthood seems not to confer protection against ulcerative colitis.

Adolescent↗
PubMed2001

The use of computed tomography for the diagnosis of acute appendicitis in children does not influence the overall rate of negative appendectomy or perforation.

BACKGROUND: Computed tomography (CT) has been used more frequently to diagnose acute appendicitis in children. The purpose of this study was to determine whether the use of CT has any influence on negative appendectomy or perforation rates. METHODS: Review of a prospective database of children having appendectomy for suspected acute appendicitis. Negative appendectomy and perforation rates were determined by correlation with final pathology reports. RESULTS: Eighty-five consecutive patients underwent appendectomy for the suspicion of acute appendicitis. The overall negative appendectomy rate was 17.6%, being 19.4% in females and 16.6% in males (p = 0.75). The overall accuracy, sensitivity and positive predictive value of CT were 75%, 91%, and 81%, respectively. Patients that had CT did not have a significantly lower rate of negative appendectomy (17.9% vs. 19.3%, p > 0.99) or perforation (26% vs. 17%; p = 0.53). CONCLUSIONS: The use of CT for the diagnosis of appendicitis in children does not change the negative appendectomy rate. Results of studies performed in adults may not be extrapolated to the evaluation of children with suspected acute appendicitis.

Adolescent↗
PubMed2006

Laparoscopic appendectomy in children with perforated appendicitis.

PURPOSE: There is persistent controversy regarding the optimal surgical therapy for children with appendicitis. We have recently adopted laparoscopic appendectomy in lieu of the open technique for children with perforated appendicitis. We hypothesized that laparoscopic appendectomy would be as effective as open appendectomy in preventing postoperative complications. MATERIALS AND METHODS: We reviewed the medical records of children admitted to our hospital over a 5-year period with the diagnosis of perforated appendicitis. Patients were divided into two groups based on the operative approach: laparoscopic vs. open appendectomy. Demographic data, duration of presenting symptoms, initial white blood cell (WBC) count, length of stay, and complications were abstracted. Data were compared using appropriate statistical analyses. RESULTS: There was no difference between the laparoscopic (n = 43) and open (n = 77) groups with respect to gender, duration of presenting symptoms, initial WBC, or length of stay. However, patients in the laparoscopic group had a significantly lower complication rate than those in the open group (6/43 vs. 23/77, P = 0.05). Infectious complications were no different between groups. Patients in the laparoscopic group tended to be older than patients in the open group (10.6 +/- 3.3 years vs. 8.5 +/- 4.1 years, P = 0.003). CONCLUSION: Laparoscopic appendectomy for children with perforated appendicitis has the same infectious complication rate and a lower overall complication rate than open appendectomy. A prospective study with standardized postoperative care would be needed to determine whether laparoscopic appendectomy for children with perforated appendicitis is the treatment of choice, but until then it remains an attractive alternative.

Appendectomy↗