Page 26 - World Journal of Laparoscopic Surgery

RK Mishra et al

• Those with lowered cardiopulmonary reserve of laparoscopy, others not. The goal of this review was to
— With regard to the consequences of the pneumo- ascertain that if the laparoscopic appendectomy is superior to
peritoneum and a longer operative time. conventional, and if so what are the benefits and how it could it
be instituted more widely. There is also diversity in the quality
COST EFFECTIVENESS OF of the randomized controlled trials. The main variable in these
LAPAROSCOPIC APPENDECTOMY trials are following parameters:
• Number of patients in trial
Debate still exists about the cost comparison between • Withdrawal of cases
laparoscopic and open surgery. Most surgeons have the • Exclusion of cases
opinion that laparoscopic appendectomy is cost effective. It • Blinding
may be more expensive for the hospital but it offers diagnostic • Intention to treat analysis
accuracy, and among employed patients, offers cost savings to • Publication biases
society as a result of faster return to work. 2,14,18,64 • Local practice variation
Heikkinen TJ, et al reported a randomized study for cost
effectiveness of laparoscopic appendectomy, the hospital cost • • Prophylaxis antibiotic used
Follow-up failure.
for laparoscopic appendectomy was higher, but it offers Without proper attention to the detail of all the parameters
significant cost savings from the rapid convalescence. Return it is very difficult to draw a conclusion. It has been found among
to normal life and work was faster in the laparoscopic group the surgeons that; there is a hidden competition between
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(14 versus 26.5 days). The Hospital costs of laparoscopic laparoscopic surgeons and the surgeons who are still doing
appendectomy were higher but the total costs were lower, such conventional surgery, and this competition influences the result
that a saving of $1481 was realized by laparoscopic of study. One should always think of laparoscopic surgery and
appendectomy. 2
open as being complimentary to each other.
A successful outcome requires greater skills from the
LAPAROSCOPIC APPENDECTOMY AND operator. The result of many comparative studies have shown
SURGICAL EXPERIENCE
that outcome of laparoscopic appendectomy was influenced
The outcome of any laparoscopic procedure greatly depends by the experience and technique of the operator. Minimal access
on the experience of the surgeon. In a study of two groups, surgery requires different skills and technological knowledge.
conducted at Los Angeles, general surgical services operated With a clear diagnosis of complicated appendicitis, the skill
on 413 patients, and 232 cases underwent the same procedure and experience of the surgeon should be considered for the
by trained specialized laparoscopic surgeons. selection of operating method. Surgeons should perform the
procedure with which they are more comfortable.
General surgical 285 acute 61 gangrenous 67 perforated
services
RELATIVE RISK FACTORS OF
Laparoscopic 126 acute 46 gangrenous 60 perforated LAPAROSCOPIC APPENDECTOMY
surgeons Missed Diagnosis

10 abscesses occurred postoperatively (2.4%) in the group There is report also of Mucinous cystadenoma of the cecum
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of patients whose operation was done by general surgical missed at laparoscopic appendectomy. Less than 1% of all
services, and only one case of intra-abdominal abscess (0.025%) patients with suspected acute appendicitis are found to have
were reported in the group of patients whose operation were an associated malignant process. During conventional
performed by a standardized laparoscopic method, using skilled appendectomy through a laparotomy incision, the caecum and
dissection, careful use of retrieval bag, proper ligation of stump the appendix are easily palpated, and an obvious mass can be
and thorough peritoneal toilet). This study may be taken to detected and properly managed at the time of appendectomy.
indicate that complications such as intra-abdominal abscess The inability to palpate any mass is an inherent problem of
following laparoscopic appendectomy for perforated laparoscopic surgery.
appendices can be reduced significantly by training.
Bleeding
DISCUSSION From the mesoappendix, omental vessels or retroperitoneum.
Laparoscopic appendectomy has gained lot of attention around Bleeding is usually recognized intraoperatively via adequate
the world. However, the role of laparoscopy for appendectomy, exposure, lighting, and suction. It is recognized postoperatively
one of the commonest indications, remains controversial. by tachycardia, hypotension, decreased urine output, anemia,
Several controlled trials have been conducted, some are in favor or other evidence of hemorrhagic shock.

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