DR. LAWRENCE J. TARASUK DO, General/Trauma Surgeon, D.MAS

Project to be submitted towards completion of Diploma in Minimal Access Surgery

Abstract:

Appendicitis today is still overwhelmingly treated by employing an open procedure. Although some surgeons do opt to perform a laparoscopic procedure. Laparoscopic appendectomy has gained universal acceptance and is generally considered a safe and cost effective treatment option. Laparoscopic appendectomy has been gaining popularity since it was first outlined as a “new” procedure in 1983. The laparoscopic approach is considered a “safe” procedure but every surgery has complications. This paper will discuss prior studies that shed light on the benefits and risks of both procedures in regards to post operative pain and complications, operative and recovery time, hospital length of stay, outcomes in patients with co morbid conditions and cost effectiveness. This paper will also study the use of endoscopic staplers vs. endoloop application at the appendix base and vascular pedicle.

Keywords:

Appendectomy, Acute appendicitis, Laparoscopic appendectomy, Open appendectomy, Laparoscopic vs. Open appendectomy, Endoloop, Endostapler.

Introduction:

Appendicitis is the most common cause of acute abdominal pain that requires surgical treatment in developed countries. It affects millions of patient’s world wide. The diagnosis of acute appendicitis is difficult and may be missed by the most experienced surgeon. Early diagnosis and treatment is paramount to decrease the morbidity and mortality secondary to perforation. McBurney first described the clinical sequence of peri-umbilical abdominal pain radiating to the right lower quadrant in 1889. According to the recent literature, laparoscopic appendectomy is a mainstream option for the treatment of acute appendicitis. Each patient is unique in their presentation and medical history, therefore indications and contraindications will exist. It is important for the surgeon to view the patient as a whole and decide accordingly to the use of a laparoscopic procedure over an open one. One of the most important considerations today is patient comfort. Improved surgical training and advanced technology gives the surgeon as well as the patient options as to which mode in which the appendix is to be removed. This paper will discuss the recent literature pertaining to advances in the field of laparoscopic appendix removal and treatment guidelines.

Aims:

The aim of this review article was to evaluate and assess the past, present and future role of laparoscopic removal of the appendix for the treatment of acute appendicitis. The following parameters were evaluated in the laparoscopic treatment of acute appendicitis.

1. Operative time
2. Postoperative pain and discomfort
3. Intraoperative and postoperative complications
4. Hospital length of stay
5. Financial considerations
6. Use of the endoloop vs. endostapler in children
7. Role of laparoscopy in complicated appendicectomy

Materials and Methods:

A literature search was performed using Highwire Press, Google, PubMed, and Springer Link. Selected papers were screened for other related reports and references.

Content:

Operative time in laparoscopic appendectomy

The overall consensus reported in the recent literature suggests that the operative time associated with the laparoscopic appendectomy is longer than that of open appendectomy. Some of the reasons for this increase in time is due to the experience level of the surgeon, routine diagnostic laparoscopy before starting dissection, incorrect trocar placement, waiting for adequate pneumoperitoneum, retrocecal appendix, severe inflammation and delivery of the specimen. The longer operative time in the laparoscopic mode which is defined as the time from the insertion of the first trocar to the end of skin suturing averaged from 8.3-29 minutes respectively.[1]

A meta-analysis of a randomized controlled study of 2,877 patients demonstrated that the mean operative time was 16 minutes longer for laparoscopic appendectomy compared to open appendectomy. Despite longer operative times, laparoscopic appendectomy offers fewer wound infections and an earlier return to normal activity which makes it an attractive alternative to an open procedure.[1]

Postoperative Pain and discomfort

In a study of 100 patients treated over a 3 year period who were subjected to laparoscopic appendectomy for the treatment of acute appendicitis were evaluated for postoperative results and complications. This group was compared with 100 patients diagnosed with acute appendicitis who were treated with the open technique performed by the same surgeon during the same 3 years. The results of this study favor the laparoscopic approach because of vast exposure of the appendix regardless of its position. In the event of encountering a normal appendix on laparoscopy, an additional advantage is being able to visualize the entire abdomen to search for other pathology. This can not be performed via an open procedure.[2]

Most recent literature has suggested that laparoscopic procedures are associated with less postoperative pain compared to open procedures. It is also suggested that postoperative analgesics are administered in lower doses and with less frequency as compared to patients who have undergone an open procedure. Patients treated laparoscopically exhibited earlier postoperative food intake and earlier ambulation which in turn resulted in fewer complications such as pneumonia, atelectasis, and DVT. Therefore it can be concluded that laparoscopic appendectomy is associated with less postoperative pain, shorter hospital stays, an earlier return to work and daily activities and fewer postoperative complications.

Intraoperative and postoperative complications

Some studies suggest that the incidence of postoperative intra-abdominal abcess is higher after laparoscopic appendectomy compared to the open alternative for perforated appendicitis. Krisher et al. demonstrated that in 170 patients with perforated appendicitis, the incidence of postoperative abscess after laparoscopic appendectomy was 24% vs 4.2% after open appendectomy. Postoperative abscess in all acute, gangrenous, and perforated appendicitis after laparoscopic appendectomy was 6.4% vs. 3.0% after open appendectomy which is not statistically significant.[3]

There are many reports that do not conclude that there is an increased incidence of intra-abdominal abscess after laparoscopic appendectomy compared to the open procedure. Barkhausen S et al conducted a trial in which 930 patients were retrospectively analyzed. Open appendectomy was performed in 330 patients, 554 patients underwent a laparoscopic approach. The results of this study revealed that the incidence of intra-abdominal abscess formation was equal in both patient populations.[1]

The were less reported incidence of wound infections in patients that underwent a laparoscopic intervention compared to open procedures. There is also less risk of adhesion formation in the laparoscopic population compared to open. This is thought to be due to reduced trauma to the tissues. The incidence of thermal injury to the bowel is a rare complication that can be successfully avoided by only using a bipolar current. There have also been reported cases of stump appendicitis. This is due to the appendix not being ligated close enough to the base. Infection could be caused by a retained fecolith. The surgeon should be diligent to remove the fecolith if present. Herniation of bowel through the trocar sites is a rare complication that can be avoided by properly closing the site.

Hospital length of stay

In a 2006 study conducted at the University of Southern California, 272 adults underwent appendectomy at a large county hospital and were enrolled in a prospective clinical pathway that detailed their hospital course from the time of diagnosis to discharge. Data included patient demographics, time elapse from diagnosis to surgery, surgical technique (laparoscopic vs. open), operative diagnosis (acute vs perforated) and postoperative hospital length of stay. This study concluded that the patients who underwent a laparoscopic appendectomy had a significantly shorter hospital length of stay (1.6 days) than those patients who had an open procedure.[4]

This decrease in hospital length of stay was significantly shorter for those patients who were found to have a ruptured appendix compared to patients who had an intact appendicitis. (2 days). This study showed laparoscopy to have a significant effect on postoperative hospital length of stay in all patients with acute appendicitis. This was more pronounced in patients with ruptured appendicitis. Therefore, laparoscopic appendectomy should be considered as the treatment of choice for all patients with non-complicated acute appendicitis.

Financial considerations

The question still exists. Is a laparoscopic appendectomy cost effective? The consensus from the majority of surgeons is ‘yes’. Hospital costs may be more, but along with that comes better diagnostic accuracy and a accelerated return to work which in turn results in less lost work days , hence more money in the economy.

In 2004, Lintula H et al reported in a prospective clinincal trial which compared the costs of laparoscopic appendectomy with those of open appendectomy. The cost surplus of the laparoscopic procedure was higher than the open procedure but these increased operative expenses were offset by a shorter hospital stay and earlier return to work. [5]

The use of the endoloop vs. endostapler

Two techniques are used for performing a laparoscopic appendectomy. One involves dividing the mesoappemdix with the use of a harmonic scalpel and ligating the appendix with an endoloop. A second technique entails the use of an endostapler to divide the mesoappendix and appendix. Lukish J et al in Archives of Surgery 2007 advocates the use of the endostapler. His study showed that the endostapler is a cost effective technique that provides an outcome benefit in children who require laparoscopic appendectomy. In this paper, 5 children who underwent laparoscopic appendectomy from January 2002-March 2004 were studied. Age, diagnosis, length of hospital stay, surgical time, complications and instrumentation costs were compared between the endoloop and endostapler groups. This study concluded that there was no significant difference in outcome in the children who underwent laparoscopic appendectomy with the use of an endoloop or an endostapler. Overall this study endorses the endostapler because of it’s cost effectiveness secondary to decreased operative time.[6]

The technique of employing an endostapler device in performing a laparoscopic appendectomy decreased operative time from an average of 30 minutes to a minimum of 5 minutes. No immediate or late complicatons were reported. The endostapler is a safe, easy and rapid method of removing the appendix laparoscopically.[7]

Discussion:

The laparoscopic removal of the appendix for the treatment of acute appendicitis is gaining popularity worldwide. Although many surgeons still employ the “open appendectomy”, laparoscopy is catching on. There have been many clinical trials that study the safety and efficacy of laparoscopic appendectomy; some are favorable while others are not. The objective of this review was to determine if laparoscopic appendectomy was in fact a better, cost effective procedure when compared to its “open” counterpart.

In order for laparoscopic surgery to flourish, surgeons must acquire the necessary skills. The results and outcomes of these studies are highly dependent on the level of experience and surgical skill of the participating surgeons. The difference in surgical skill and knowledge that is required to successfully perform laparoscopic surgery is paramount when compared to conventional surgery. These variables must be considered when deciding on the surgical mode.

Conclusion:

In a patient afflicted with acute appendicitis, it is imperative to remove the appendix before perforation ensues. Open surgery is widely practiced to attain this goal but laparoscopic appendectomy is increasing in popularity. The first laparoscopic appendectomy was performed in 1980 by a German gynecologist with the surgical community expressing reservations. These reservations still exist today.

Although many surgeons still have apprehensions about performing laparoscopic appendectomy, several studies suggest that the laparoscopic approach has several advantages over the conventional open procedure. These advantages include decreased postoperative pain and discomfort, decreased hospital length of stay with an earlier return to work and normal daily activities. Better cosmesis is also a strong patient motivator in favor of the laparoscopic mode of treatment. These advantages are responsible for growing popularity and enthusiasm favoring laparoscopic appendectomy over the open procedure. The majority of cases of acute appendicitis can be managed laparoscopically. Improved laparoscopic training and education has channeled this procedure into mainstream medicine, which in turn will only add to its growing popularity and acceptance in the medical and surgical community.

References:

1. R.K Mishra, G.B. Hanna, A. Cuschieri. Laparoscopic versus open appendectomy for the treatment of acute appendicitis. Surgical skills unit: Department Of Surgery and Molecular Oncology, Ninewells hospital and medical school, University Of Dundee.
2. Nowzaradan Y, Barnes JP, Westmoreland J, Hojabri M. Laparoscopic appendectomy, treatment of choice for suspected appendicitis. Surgery Laparoscopy Endoscopy 1993 Oct. 3(5): 411-6.
3. Stacey L. Krisher, MD; Allen Browne MD; Albert Dibbins MD; Nancy Tkacz, PNP; Micheal Curci MD, Intra-abdominal abcess following laparoscopic appendectomy for perforated appendicitis. Arch Surg 2001; 136: 438-441.
4. Towfigh S, Chen F, Mason R, Katkhouda N, Chan L, Berne T. Laparoscopic appendectomy significantly reduces length of stay for perforated appendicitis. Surg Endosc. 2006 March. 20(3): 495-9.
5. Lintula, Kokki, Vanamo, Valtonen, Mattia, Eskelinea. The cost and effects of laparoscopic appendectomy in children. Arch Pediatrics Adolescent Medicine 2004: 158: 34-37
6. Lukish J MD, Powell D MD, Morrow S MD, Cruess D pHD, Gouzzetta P MD. Laparoscopic Appendectomy in children: Use of endoloop vs. endostapler. Arch Surg 2007; 142: 58-61.
7. Daniel JF MD, Gurley LD MD, Kurtz BR MD, Chambers JF MD. The use of automatic stapling device for laparoscopic appendectomy. Obstetrics and Gynecology 1991; 78: 721-723.