Page 24 - World Journal of Laparoscopic Surgery

RK Mishra et al

the risk of the early postoperative complications of pneumonia Laparoscopic Appendectomy in
and embolism. Complicated Appendicitis
A prospective randomized multi centre study was performed
to compare the outcome of laparoscopic and open Due to the risk of intra-abdominal abscess formation there is a
strong controversy among surgeons regarding the use of the
appendicectomy in patients with suspected acute appendicitis laparoscopic procedure in complicated appendicitis (gangrenous
by Hellberg A et al. Patients having laparoscopic appendec- or perforated).
tomy recovered more quickly than their open counterpart, but There are several reports which state that if gangrene or
interestingly there was no significant difference in sick leave perforation is found at the time of laparoscopic appendectomy
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than after laparoscopic operation. An insignificant reduction than the procedure should be converted. Frazee and Bohannon
in sick leave after laparoscopic appendectomy may be due to published a retrospective analysis of 15 patients with
unawareness of general practitioners about recovery time gangrenous appendicitis and 19 patients with perforated
difference between both the procedures, or patient expectation appendicitis who underwent laparoscopic appendectomy. They
in terms of time off work.
found a 7% rate of postoperative intra-abdominal abscess in
the gangrenous group and a 26% rate of postoperative intra-
Laparoscopic Appendectomy and Wound Infection
abdominal abscess in the perforated group. 15
The risk of wound infection is less in laparoscopic appendec- A prospective randomized study by Bonnani et al. found
tomy compared to the open procedure. A meta-analysis of that among adult patients, 2 of 66 (3.03%) patients undergoing
randomized controlled trials has been reported with outcomes open appendectomy for complicated (gangrenous or perforated)
of 2877 patients included in 28 trials. Overall complication rates appendicitis developed postoperative pelvic abscesses. Three
were comparable, but wound infections were definitely reduced of 11 patients (27%), developed postoperative pelvic abscesses
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after laparoscopy (2.3% to 6.1%). Rohr et al reported higher following laparoscopic appendectomy for complicated
wound infection rates after laparoscopic appendectomy, but appendicitis, and 1 patient developed a postoperative hepatic
most of the literature supports the view that wound infection is abscess. 9

less common after a laparoscopic procedure. It should be Tang et al found a postoperative intra-abdominal abscess
cautioned that the definition of wound infection varies between rate of 11% for perforated appendicitis treated laparoscopically
studies. compared with a rate of 3% treated by the open method. 47
In contrast, there is a group of laparoscopic surgeons, who
Laparoscopic Appendectomy and are now gaining confidence in handling complicated cases of
Intra-abdominal Abscess appendicitis. Johnson, after a retrospective trial of 112 patients,
advocates that most cases of acute appendicitis with suspected
Some studies have shown a significantly increased incidence perforation could be managed laparoscopically. There is a large
of postoperative intra-abdominal abscess with perforated group of surgeons who believe that laparoscopic appendectomy
appendicitis after laparoscopic appendectomy. 9,11,27,45,15,47 is safe in all form of appendicitis, even in perforated
More reports show that there is no increased incidence of 8,23,24,40,66,67
intra-abdominal abscess formation after laparoscopic appendicitis. Some believe that even if the patient
presents with fresh lower abdominal early peritonitis or even if
appendectomy. Barkhausen S et al conducted one trial, in which there is chance of fresh abscess formation, laparoscopic
930 patients were analyzed retrospectively. Conventional appendectomy is not only justifiable but also even recommended
appendectomy was performed in 330 patients; laparoscopic in as the procedure of choice. In generalized peritonitis
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554 others. The analysis shows that the incidence of intra- laparoscopic is not advocated.
abdominal abscess formation rate was same in both groups. 8
In Los Angeles, 2497 appendectomies were reviewed
retrospectively. Indications for these procedures included acute Operating Time and Laparoscopic Appendectomy
appendicitis 57%, gangrenous appendicitis 12%, and perforated In almost all the literature the operating time of laparoscopic
appendicitis in 31%. There was no difference in the rate of intra- appendectomy was found to be more than that of open
abdominal abscess formation between the groups undergoing appendectomy. The difference in mean operating time ranged
open and laparoscopic appendectomies for acute and from 8.3 to 29 minute. The operating time of laparoscopic
gangrenous appendicitis. For perforated appendicitis, however, appendectomy also depends on the experience of the surgeon
there was significantly higher rate of abscess formation and the competence of their team. 10
following laparoscopic appendectomy compared to open In considering operating time, the exact identification of the
appendectomy (9.0% vs 2.6%, P = 0.015%). 69 timing of the start of the procedure and its conclusion vary. In

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