Page 25 - World Journal of Laparoscopic Surgery

Laparoscopic versus Open Appendectomy for the Treatment of Acute Appendicitis

general the time should be calculated from the insertion of first Cirrhosis
trocar to the end of skin suturing. Cox, et al defined operating The immunity of the cirrhotic patient is compromised and there
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time as the time from incision to wound closure. Tate et al is more chance of wound infection with the open procedure.
calculated the time as use of anesthesia to the administration of Patients with cirrhosis have shown a faster recovery when
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a reversal agent. Generally all laparoscopic procedures are treated by laparoscopic procedure, for acute appendicitis. 48
more time consuming for the following reasons. These patients were benefited by this less traumatic method of
• Inherent nature of slow manoeuvre of laparoscopic surgery.
techniques
• Time taken by careful slow insufflation Sickle Cell Disease
• Routine diagnostic laparoscopy before starting any
laparoscopic procedure. There is also a report that laparoscopic appendectomy has clear
A meta-analysis of randomized controlled trial has been benefit over open inpatients with sickle disease. Patients with
reported with outcomes for 2877 patients. The mean operating acute appendicitis will certainly require surgery that may be
time was 16 minutes longer for laparoscopic appendectomy. associated with high morbidity and mortality as a result of
A prospective randomized trial comparing laparoscopic perioperative and postoperative complications, mainly vaso-
appendectomy with open appendectomy was conducted in 158 occlusive crises (VOC). The introduction of minimally access
patients by Hansen et al. They reported that despite of longer surgery is believed to be associated with minimal risks to the
operating time, (63 versus 40 minutes) the advantages of patients due to its numerous advantages over conventional
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laparoscopy (such as fewer wound infection and earlier return methods. The morbidity associated with surgery in sickle cell
to normal activity) make it a worthwhile alternative for patients patients can be further reduced by the use of preoperative
with a clinical diagnosis of acute appendicitis. 61,60 exchange transfusion and adequate maintenance of hydration
Kazemier et al in their report of a randomized clinical trial of in the patient with sickle cell disease.
201 patients found that laparoscopic appendectomy is superior
to open surgery regarding postoperative pain and postoperative
complications, recovery time and financial. 66 LAPAROSCOPY AND IMMUNITY
All surgery and anesthesia can cause depression of cell-
Long-term Complications and mediated immunity in the postoperative period, including
Laparoscopic Appendectomy reduction in the number of circulating lymphocytes, impairment
Adhesion formation is now one of the most common causes of of natural killer cell cytotoxicity, depression of T cell proliferation,
intestinal obstruction. The role of adhesion in the development and diminished neutrophil function. Animal and clinical studies
of chronic abdominal pain, although less certain, cannot be have shown that laparoscopic surgery impairs a patient’s
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ignored. Reduced adhesion formation is a substantive long immune state less than open surgery. Cell-mediated immunity
term advantage of laparoscopic appendectomy. is less impaired after laparoscopic operation than after open.
A study reported an adhesion rate of 80% after open Interleukin 6 levels were less in a study on newborn infants
appendectomy compared to 10% after laparoscopic appendec- undergoing laparoscopic procedures when compared to open. 55
tomy, when patients were laparoscoped three months after
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surgery. It has been shown that the tissue trauma of the incision LAPAROSCOPY AND RISK OF ANESTHESIA
increases the total inflammatory response, thereby inhibiting The general anesthesia and the pneumoperitoneum required as
fibrinolysis and promoting fibroblast migration and collagen part of the laparoscopic procedure does increase risk in certain
formation. patient groups. Most surgeons would not recommend
These results strongly suggest that laparoscopic surgical
techniques lead to fewer intra-abdominal adhesions by reducing laparoscopic appendicectomy in;
•
Patients with cardiac diseases and COPD
tissue trauma, which in turn reduces circulating inflammatory — Should not be considered a good candidate for laparos-
mediators. 56
copic appendectomy.
• In patients who have had previous lower abdominal surgery
LAPAROSCOPIC APPENDECTOMY IN — Laparoscopic appendectomy may also be more difficult.
SOME DISEASED CONDITIONS
• The elderly
There are some diseases where laparoscopic appendectomy — May also be at increased risk for complications with
has found clear benefit over open appendectomy. general anesthesia combined with pneumoperitoneum.

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