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Efficiency of Laparoscopic Appendicectomy in Perforated Appendicitis
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Operative Steps and Procedure Analysis experience. In converted cases, the benefit of LA in
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complicated appendicitis would be underestimated.
Multiport technique is most commonly performed for
appendicectomy. Single-port LA is a more less-invasive Basically, conversion rate varies depending on the evalu-
procedure. But conversion rate from single port to ation of anatomy, condition of the pathology, and the
multiport was higher (25% need additional trocars) in surgical skills also.
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complicated appendicitis. Although Muensterer et al Postoperative Complication Analysis
still considered single-port approach is applicable for
children with complicated appendicitis, so far multiport Infection
technique is a more effective approach to deal with per- A lot of studies documented less wound infection in LA
forated appendicitis. than OA, both in adults 8,10-14,17,18 and children in com-
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Safe and effective closure of appendiceal stump plicated appendicitis. Several studies documented the
could play a vital role for the outcomes of perforated infection rate for LA as 0 to 15% and OA as 2 to 48%.
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appendicitis management. Various methods including Practically, we used to retrieve the infected appendix
titanium endoclips, absorbable endoloops knot, nonme- with endobag to avoid port-site contamination. It has
tallic hemlocks, or staplers have been used for securing been suggested to handle the appendix during LA with
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appendiceal stumps during LA. A study by Beldi et al an atraumatic grasper and every attempt to avoid the
reported that stapler usage is safer to overcome IAA for- rupture of appendix. But the development of IAA for-
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mation compared with endoloops. But endoloops are 6 to mation during postoperative period is not uncommon in
12 times cheaper than stapling devices and convenient to perforated appendicitis because it would increase treat-
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use by most of the surgeons. Sahm et al reported that ment cost due to prolonged antibiotic usages, prolonged
there was no significant difference after using staplers hospital stays, and may even require readmission. To
or endoloops in perforated appendicitis for developing overcome such complications, LA could play a big role
IAA (4.2 vs 3.5%, p = 0.870), but only a few cases required compared with OA. 13,30,31 Masoomi et al reported the
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staplers. Operating surgeon is the best judge for choosing reduced rate of IAA in LA vs OA (1.65 vs 3.57%, p < 0.01).
the stump ligation device. But, some recent reports suggested the incidences of IAA
Surgical toileting is one of the must do steps in the were still significant in LA for perforated appendicitis. 18,32
presence of generalized peritonitis either in open or
laparoscopic approach. But the efficacy of lavage remains Postoperative Analgesia
controversial. The peritoneal lavage is effective before
wound closure to reduce wound contamination in perfo- Pain is a subjective issue. As the multiple small incisions
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rated appendicitis or appendicular abscess, and it is also are more immune than a single large incision, multiple
suggested by European guideline that through lavage small-port incisions could effectively lower the need for
(with 6–8 L normal saline) we can effectively lower the postoperative analgesics. Some studies also documented
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rate of IAA in perforated appendicitis. In contrast, the on adults that LA causes less pain in perforated appendi-
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lavage itself might spread the infection. Whenever a study citis compared with OA. But the children may show
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documents a higher IAA rate with peritoneal irrigation no difference.
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in perforated appendicitis, the role of lavage remains
controversial. Abdominal drains are commonly used Treatment Cost
either in laparoscopy or open approach to evacuate the After diagnosis and surgery, the treatment cost varies,
residual abdominal collection and prevent concurrent especially due to postoperative complications, including
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IAA in routine or emergency surgery. Sleem et al infection, sepsis, intensive care support, prolonged anti-
documented that pelvic drain could not reduce the rate biotics, analgesics, increased hospital stay, etc. Uncom-
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of IAA after LA or OA. Allemann et al reported overall plicated appendicitis managed by LA reported reduced
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less complication without drains vs with drain (7.7 vs hospital stay and treatment cost as well as in perforated
18.5%, p = 0.01) with shorter hospital stay (4.2 vs 7.3 days, appendicitis irrespective of patient’s age. 11,17,35,36 From
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p = 0.0001). Pessaux et al documented higher infection the nationwide inpatient sample data of 573,244 adults,
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rate related to abdominal drains after LA. Masoomi et al have concluded the length of hospital
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Conversion from LA to OA could negatively impact stay in LA vs OA (4.0 vs 6.0 days, p ≤ 0.01). Tiwari et al
the outcome due to longer operation time, excess use of also reported reduced medical cost in LA than OA. Treat-
anesthetic agents, and overall more stress to the surgeon ment cost largely varies from institutional practices by
and patient. The conversion rates have been reported using disposable laparoscopic instruments, expensive
from LA to OA as 0 to 47% 11,17 correlating with surgeon’s electrosurgical devices and stapling devices, etc.
World Journal of Laparoscopic Surgery, January-April 2018;11(1):38-42 39