Page 22 - World Journal of Laparoscopic Surgery

RK Mishra et al

Diagnosis of Acute Appendicitis and monitor, but after the advent of the three chip camera the
Laparoscopic Appendectomy sensitivity of laparoscopic diagnosis of appendix is 92%. 53
The diagnosis of acute appendicitis is mainly clinical. Several
methods have been suggested to diminish the diagnostic error Laparoscopic Appendectomy Women vs Men
that occurs if diagnosis is based solely on the clinical picture of Most surgeons agree on the use of laparoscopy when a patient
suspected appendicitis. The symptoms of appendicitis can is a young female with vague lower abdominal pain and its
initially be difficult to differentiate from gastroenteritis. Early progress to appendectomy. There are innumerable reports
symptoms may include vague bloating, indigestion and mild showing that laparoscopy improves diagnosis and reduces
pain which generally is perceived as being in the area of the unnecessary appendectomies in fertile women. 29,30,41,50,63,65,70
umbilicus. The diagnostic problem of suspected appendicitis is not
As the infection worsens, the pain becomes more prominent
in the right lower quadrant. There is usually nausea, vomiting limited to fertile women. It is also a problem of premenopausal
women. One study was done in Dublin on 100 premenopausal
and loss of appetite. The pain is generally constant and women who were admitted with abdominal pain. After final
progressive. There may be diarrhea, fever, and chills. These assessment, patients were placed in following diagnostic
symptoms progress over several hours to several days. categories; gynecological (30%); renal (9%); acute appendicitis
However, many patients may not report the sequence of (23%); nonspecific abdominal pain (29%) and miscellaneous
symptoms outlined above. Therefore, an accurate diagnosis of (9%).
appendicitis can often be challenging. Many other conditions The mean duration of hospital stay for patient with non
can mimic appendicitis such as gastroenteritis, kidney stones, specific abdominal pain was 67 days and one third of these
urinary infections, ulcerative colitis and Crohn’s disease. In patients, underwent appendectomy for normal appendix. 75
women, problems such as ovarian cysts and pelvic infections Abdominal pain in premenopausal women is often
can mimic appendicitis. In fact appendicitis is a disease which psychosomatic and the laparoscopic intervention may be
can mimic most of the causes of abdominal pain as well as some considered in these women with nonspecific pain abdomen to
chest pathology. prevent removal of a normal appendix.
Despite new X-ray techniques, CT scans and ultrasounds,
Even though laparoscopic appendectomy has been claimed
the diagnosis of appendicitis can be challenging. So far the to reduce postoperative pain, length of hospitalization,
most accurate non-invasive method of diagnosis is analgesic doses and surgery associated complication, many
ultrasonography but this is not totally reliable. The history and surgeons do not advocate this procedure on men because they
physical examination will generally lead to the correct diagnosis. do not find any superiority of laparoscopy over the open
According to one prospective non-randomized study procedure. 20,28,31,36 Cox et al conducted a prospective rando-
laparoscopy may prevent unnecessary appendectomy in 24% mized comparison of open versus laparoscopic appendectomy
of patients. Laparoscopy reveals a misdiagnosis rate of 8% in exclusively in men and they reported that laparoscopic
males and 41% in females of reproductive age group. 54,55 appendectomy in men has significant advantages in terms of
Laparoscopic appendectomy gives a better evaluation of the more rapid recovery. 60
peritoneal cavity than that obtained by the standard gridiron
exposure. The procedure allows rapid and thorough inspection Appendectomy in Pediatric Patients
of the para-colic gutters and the pelvic cavity that is not possible
with the open gridiron approach. The laparoscopic approach Although laparoscopic appendectomy is gaining popularity,
for patient with suspected appendicitis improves the diagnostic open appendectomy has remained popular with surgeons caring
accuracy and is therefore recommended. 70 for children. The reasons for this include the increased skill
There is also debate on whether a normal looking appendix level necessary for pediatric laparoscopic procedures, concerns
be removed at the time of laparoscopy or not? The major criticism over increased operating times and costs, and fears that the
against leaving the appendix in place is that mucosal laparoscopic approach to appendicitis is somehow associated
inflammation might be overlooked because only serosa can be with an increased complication rate.
inspected. Walker, et al reported that 3.2% of the intraoperatively There is a group of surgeons who are advocating
normal appearing appendices demonstrated acute inflammation laparoscopic appendectomy in all cases of appendicitis in
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after pathological examination. Mucosal inflammation pediatric patients. In one prospective nonrandomized trial
obviously can never be determined if the appendix is left in 500 appendectomies were studied, 362 children underwent open
place. The majority of surgeons state that normal looking procedure and 138 underwent laparoscopic appendectomy.
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appendix should not be removed. Previously there was doubt There was no mortality in either group. Major complications
on the color reliability of the image of inflamed appendix on the were 3% in open group but no major complications were seen in

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