Page 17 - World Journal of Laparoscopic Surgery

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Laparoscopic Appendectomy: Is it the Gold Standard Approach for Management of Acute Appendicitis?
Exclusion criteria: Patients­unfit­for­general­anesthesia,­ ReSuLTS
children below 10 years, pregnancy (second and third In­this­study,­all­patients­were­planned­to­go­for­LA.­
trimester), chronic medical diseases, such as cirrhosis, The demographic data (age, gender), comorbidities and
coagulation disorders and previous laparotomy for bowel clinical presentation of the patients were included in
obstruction. Table 2.
Preoperative workup in the form of complete history In the present study, out of total 573 patients, appen­
taking, complete clinical examination, laboratory (com­ diceal pathology was found in 504 patients (87.9%). No patho­
plete blood picture and urine analysis), and radiological logy was observed in the appendix after histopathological
examination includes abdominal ultrasonography for examination in 38 (6.7%) patients. Non appendiceal patho­
all patients and CT abdomen was done for some patients logy was found in 31 patients (5.4%). Conversion to open
with­unproved­diagnosis.­Modified­Alvarado­scoring­ procedure was done in 11 (1.9%) patients. The causes of
system (Table 1) was used as a guide in diagnosing all conversion­were:­right­hemicolectomy­in­five­patients,­
7
patients. Written fully informed consent was given by small intestinal resection (minilaparotomy for Mickle’s
all patients. diverticulitis in four patients and appendicular mass
Technique of the procedure: A 10 mm trocar was placed in two patients (in one case the appendix was ampu­
just above the umbilicus for the camera and 2 additional tated from the cecum during dissection and the stump
working 5 mm trocars were inserted, one suprapubic cannot­be­identified­and­the­other­case­due­to­suspected­
and the site of the other trocar depends on the patho­ cecal injury but on open procedure it was negative). The
logy­detected­and­abdominal­configuration­of­the­patient­ mean operative time in this study was 42 ± 17.54 minutes
mostly left iliac fossa (sometimes this trocar was replaced (Table 3).
by 10 mm depending on the size of the appendix as it is Wound infection had occurred in 16 patients (2.8%).
the extraction port). The patient was placed in a Tren­ One patient developed postoperative intra­abdominal
delenburg position, with right side slightly up (a slight abscess (IAA), she was from the start appendicular
rotation to the left). The abdominal cavity was thoroughly abscess and the drain was removed after 4 days but she
inspected in order to exclude other intra­abdominal or
pelvic pathology. The mesoappendix was transected by Table 1: Modified Alvarado score (Ganesh Babu et al, 2012)
diathermy after applying titanium hemoclip early in Score
this study but later on, blood vessel sealing device was Symptoms Migratory right iliac fossa pain 1
used (ligasure 5 mm). The bases of the appendix were anorexia 1
ligated with two endo­loops constructed with a Roeder’s Nausea and or vomiting 1
knot on a no­1 vicryl thread. The specimen was directly Signs Tenderness in right iliac fossa 2
extracted or placed in an endo­bag and then extracted. Rebound tenderness 1
All specimens were sent for histopathology. Drain was Elevated temperature 1
inserted in patients with pus in the peritoneal cavity or Extra signs; cough test, Rovsing sign 1
with abscess formation. Laboratory Leukocytosis 2
Total score
10
Prior to the surgery, all the patients received a Interpretation: Score 1 to 4: Acute appendicitis very unlikely;
standard regimen of intravenous antibiotics (1.5 gm of Score 5 to 7: Acute appendicitis probable; Score 8 to 10: acute
cefuroxime). Further antibiotic regimen was determined Appendicitis definitive
according­to­the­operative­findings. Table 2: Demographic data, clinical presentation and
The parameters examined in this study included: comorbidities of the patients
operation time (from skin incision to wound closure), Age Range 12-65 years
conversion­to­open­procedure,­intraoperative­findings­ Mean ± SD 23 ± 11.65 years
and length of hospital stay. Complications included Sex Male 151
wound infections, intra­abdominal abscess, as well as Female 422 Total = 573
30 day readmission for complications. Clinical Alvarado score 466
The discharge criteria included: afebrile patient with presentation ≥ 8 Total = 573
Alvarado score 107
audible bowel sounds and were able to tolerate a liquid 5­7
diet. Comorbidities DM 34
Statistical analysis was performed using SPSS statis­ HCV 25
tical­software,­version­12.0­(SPSS­Inc,­Chicago,­IL).­The­ Pulmonary 18 Total = 77
data were expressed as mean and standard deviation. disease

World Journal of Laparoscopic Surgery, September-December 2014;7(3):116-120 117