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Our experience with selective laparoscopy through an open appendectomy incision in the management of suspected appendicitis
The American Journal of Surgery 194 (2007) 231–233
How I do it
Our experience with selective laparoscopy through an open appendectomy incision in the management of suspected appendicitis Subhasis K. Giri, M.B.B.S., D.M.R.D., M.S., D.N.B., F.R.C.S.I., F.R.C.S.E.D., M.Ch.*, Faisal M. Shaikh, M.B.B.S., A.F.R.C.S., Debasri Sil, M.B.B.S., John Drumm, F.R.C.S.I., F.R.C.S., M.Ch., Syed A. Naqvi, M.B.B.S., F.R.C.S.I. Department of Surgery, University Hospital, Dooradoyle, Limerick, Ireland Manuscript received June 29, 2006; revised manuscript October 11, 2006
Abstract Background: An accurate preoperative diagnosis of suspected appendicitis at times can be extremely difficult. We report our experience with a simple strategy of selective laparoscopy through an open appendectomy incision after finding a noninflamed appendix in the management of suspected appendicitis. Methods: Patients presenting with suspected appendicitis after regular office hours (6 PM to 8 AM weekdays and weekends) were recruited prospectively from January 2002 to December 2003. Laparoscopy through an open appendectomy incision was performed only when the appendix was found to be normal. Results: Twenty-five (18.5%) of 135 patients underwent laparoscopy through an open appendectomy incision because of a normal-looking appendix. Laparoscopy through an open appendectomy incision helped to identify additional intra-abdominal pathology in 13 (52%) of the 25 patients; thus improving the overall detection rate of underlying pathology from 81.5% (110 of 135) to 91.2% (123 of 135). Conclusions: Selective laparoscopy through an open appendectomy incision in patients with a noninflamed appendix is a simple technique that can identify potentially fatal pathology and also maintains a valuable training opportunity for young surgeons to perform open abdominal surgery. We recommend using this technique in the management of suspected appendicitis. © 2007 Published by Excerpta Medica Inc. Keywords: Suspected appendicitis; Open appendectomy; Laparoscopy
Acute abdominal pain and suspected appendicitis are the most common causes of emergency surgical admissions. An accurate preoperative diagnosis at times can be extremely difficult. The negative appendectomy rate in a large series ranged from 15% to 33% [1]. Although imaging modalities such as ultrasound (US) and computed tomography (CT) may help in the diagnosis, they are not always readily available to emergency clinicians, especially outside of regular office hours, and may in fact delay the diagnosis with high falsenegative rates for the diagnosis of acute appendicitis [1,2]. Open appendectomy is still the most common emergency surgery performed in most hospitals. McBurney’s surgery usually is well tolerated by most patients. Universal laparoscopy may be an option in suspected appendicitis, but
* Corresponding author. Tel.: ⫹35-3879227648; fax: ⫹35-314284090. E-mail address: [email protected] 0002-9610/07/$ – see front matter © 2007 Published by Excerpta Medica Inc. doi:10.1016/j.amjsurg.2006.10.030
issues such as higher cost and reduced exposure to open abdominal surgeries among surgical trainees have been the main concern in adopting the technique widely [3–5]. In this article we report our experience with a simple strategy of selective laparoscopy through an open appendectomy incision after finding a noninflamed appendix in the management of suspected appendicitis. Methods Patients presenting with acute abdominal pain and suspected appendicitis outside of regular office hours (6 PM to 8 AM and weekends) were recruited prospectively from January 2002 to December 2003. Our exclusion criteria were patients who underwent preoperative imaging studies such as US and CT scan. Preoperatively, all patients were evaluated by taking a full history and performing a physical examination. Patients received broad-spectrum antibiotic prophylaxis. All procedures were performed under general anesthesia.
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S.K. Giri et al. / The American Journal of Surgery 194 (2007) 231–233
and 3 months postoperatively in the outpatient clinic. Follow-up data consisted of details of the postdischarge course. Our primary outcome measures were the rate of detection of additional underlying pathology using this technique and any associated complications. Results A total of 135 patients underwent an emergency open appendectomy outside of regular office hours during the study period. None of these patients had preoperative imaging studies such as US or CT scan because of the high clinical suspicion of acute appendicitis and because of the restricted availability of imaging facilities in our hospital outside of regular office hours. The median patient age was 21 years. The male to female ratio was 1.4:1. Twenty-five (18.5%) of 135 patients underwent laparoscopy through an appendectomy incision because of a normal-looking appendix during the appendectomy. Laparoscopy through the appendectomy incision helped to identify intra-abdominal pathology in 13 (52%) of the 25 patients (Table 1). In the remaining 12 patients, histologic examination showed acute appendicitis in 2 (despite a normal macroscopic appearance), whereas in 10 patients (7.4%) the cause of the pain remained unclear. Thus, our technique not only improved the overall diagnosis of cause of pain from 81.5% (110 of 135) to 91.2% (123 of 135), but also identified some potentially fatal underlying pathology (Table 1). None of these patients developed any wound-related complications. One patient developed a urinary tract infection in the postoperative period that was treated successfully with oral antibiotics.
Fig. 1. (A) Lanz incision for an open appendectomy. (B) Laparoscopy using an inflatable balloon port through the Lanz incision.
Surgical technique All patients underwent an open appendectomy for suspected appendicitis through either a McBurney or Lanz incision (Fig. 1A). It was our standard practice to check the terminal ileum, the mesentery, and the right ovary during the appendectomy. Laparoscopy was performed through an appendectomy incision only when the appendix was found to be normal and no obvious pathology was detected in the local area. A purse-string suture-using 2/0 polydioxanone was placed at the peritoneal edge of the open appendectomy incision. The blunt 10-mm port with an inflatable balloon (Blunt Tip Trocar; Auto Suture, Norwalk, CT) was used to maintain the pneumoperitoneum (Fig. 1B). Then standard laparoscopy using a 0° telescope was performed to identify any underlying pathology. Appropriate intervention was taken after identification of pathology. The purse-string suture was tied to close the peritoneum and the grid-iron incision was closed in layers using 0 polyglactin. The skin was closed with subcuticular 4/0 polyglactin. Postoperative protocol Postoperatively, patients were assessed closely for any complications. Patients were evaluated further at 6 weeks
Comments Acute abdominal pain and suspected appendicitis often present as a diagnostic dilemma. In treating such patients the surgeon mostly makes the decision to perform an appendectomy by mainly relying on clinical features, rather than on laboratory and radiologic investigations. Open appendectomy has been the gold standard treatment for acute appendicitis. By virtue of its small incision, open appendectomy is already a type of minimal-access surgery, and is well tolerated, well accepted, and thus the benefits of routine laparoscopic appendectomy are likely to be small and difficult to prove. The potential advantages of the laparoscopic approach include reduced pain and hospital stay and a more rapid return to normal activities [6,7]. However, the validity of these points remains unconvincing to some surTable 1 Distribution of additional pathology detected by laparoscopy through an open appendectomy incision in patients with suspected appendicitis Additional pathology
No. of patients
Perforated anterior duodenal ulcer Twisted left ovarian cyst Ruptured left follicular ovarian cyst Ruptured right follicular ovarian cyst Hemorrhage in left follicular cyst Torsion of appendices epiploicae Sigmoid diverticulitis
2 2 3 1 1 1 3
S.K. Giri et al. / The American Journal of Surgery 194 (2007) 231–233
geons, and the efficacy and indications for emergency laparoscopic appendectomy still are debated [8,9]. When compared with the open procedure, laparoscopic appendectomy is relatively expensive, mainly because of its longer surgical time and costly disposable equipment [3]. Being one of the most common emergency surgical procedures, open appendectomy is traditionally a valuable training exercise for surgical trainees, giving them their initial chance to perform surgery independently. This is not only enjoyable but also fruitful in building their confidence in performing open surgery before learning to treat appendicitis laparoscopically [10]. It has been shown that this introductory opportunity may be lost if the laparoscopic procedure is chosen because in most centers laparoscopic procedures are more likely to be performed by more senior personnel than junior trainees. A recent study by McCormick et al [4] showed a 50% reduction in the number of appendectomies performed by surgical trainees after the introduction of laparoscopic techniques. Radiologic investigations such as US and CT scan may be used in addition to our strategy, but the main limitation is 24-hour availability. By adopting our technique of selective laparoscopy through an open appendectomy incision, trainees will have ample opportunity to perform an open appendectomy and at the same time can diagnose additional, potentially fatal, pathology. We diagnosed 13 further underlying pathology (some potentially fatal) in patients with a noninflamed appendix, thus improving the overall management outcome in these patients. Conclusions Selective laparoscopy through an open appendectomy incision in patients with a noninflamed appendix is a simple
233
technique that can identify potentially fatal pathology and also maintains a valuable training opportunity for young surgeons to perform open abdominal surgery. We recommend using this technique in the management of suspected appendicitis. References [1] Lee SL, Walsh AJ, Ho HS. Computed tomography and ultrasonography do not improve and may delay the diagnosis and treatment of acute appendicitis. Arch Surg 2001;136:556 – 62. [2] McDonald GP, Pendarvis DP, Wilmoth R, et al. Influence of preoperative computed tomography on patients undergoing appendectomy. Am Surg 2001;67:1017–21. [3] Cothren CC, Moore EE, Johnson JL, et al. Can we afford to do laparoscopic appendectomy in an academic hospital? Am J Surg 2005;190:950 – 4. [4] McCormick PH, Tanner WA, Keane FB, et al. Minimally invasive techniques in common surgical procedures: implications for training. Ir J Med Sci 2003;172:27–9. [5] McCahill LE, Pellegrini CA, Wiggins T, et al. A clinical outcome and cost analysis of laparoscopic versus open appendectomy. Am J Surg 1996;171:533–7. [6] Frazee RC, Roberts JW, Symmonds RE, et al. A prospective randomised trial comparing open versus laparoscopic appendectomy. Ann Surg 1994;219:725–31. [7] Hansen JB, Smithers BM, Schache D, et al. Laparoscopic versus open appendectomy: prospective randomised trial. World J Surg 1996;20:17–21. [8] Katkhouda N, Mason RJ, Towfigh S, et al. Laparoscopic versus open appendectomy: a prospective randomized double-blind study. Ann Surg 2005;242:439 – 48. [9] Ignacio RC, Burke R, Spencer D, et al. Laparoscopic versus open appendectomy: what is the real difference? Results of a prospective randomized double-blinded trial. Surg Endosc 2004;18:334 –7. [10] Carrasco-Prats M, Soria Aledo V, Lujan-Mompean JA, et al. Role of appendectomy in training for laparoscopic surgery. Surg Endosc 2003;17:111– 4.
How I do it
Our experience with selective laparoscopy through an open appendectomy incision in the management of suspected appendicitis Subhasis K. Giri, M.B.B.S., D.M.R.D., M.S., D.N.B., F.R.C.S.I., F.R.C.S.E.D., M.Ch.*, Faisal M. Shaikh, M.B.B.S., A.F.R.C.S., Debasri Sil, M.B.B.S., John Drumm, F.R.C.S.I., F.R.C.S., M.Ch., Syed A. Naqvi, M.B.B.S., F.R.C.S.I. Department of Surgery, University Hospital, Dooradoyle, Limerick, Ireland Manuscript received June 29, 2006; revised manuscript October 11, 2006
Abstract Background: An accurate preoperative diagnosis of suspected appendicitis at times can be extremely difficult. We report our experience with a simple strategy of selective laparoscopy through an open appendectomy incision after finding a noninflamed appendix in the management of suspected appendicitis. Methods: Patients presenting with suspected appendicitis after regular office hours (6 PM to 8 AM weekdays and weekends) were recruited prospectively from January 2002 to December 2003. Laparoscopy through an open appendectomy incision was performed only when the appendix was found to be normal. Results: Twenty-five (18.5%) of 135 patients underwent laparoscopy through an open appendectomy incision because of a normal-looking appendix. Laparoscopy through an open appendectomy incision helped to identify additional intra-abdominal pathology in 13 (52%) of the 25 patients; thus improving the overall detection rate of underlying pathology from 81.5% (110 of 135) to 91.2% (123 of 135). Conclusions: Selective laparoscopy through an open appendectomy incision in patients with a noninflamed appendix is a simple technique that can identify potentially fatal pathology and also maintains a valuable training opportunity for young surgeons to perform open abdominal surgery. We recommend using this technique in the management of suspected appendicitis. © 2007 Published by Excerpta Medica Inc. Keywords: Suspected appendicitis; Open appendectomy; Laparoscopy
Acute abdominal pain and suspected appendicitis are the most common causes of emergency surgical admissions. An accurate preoperative diagnosis at times can be extremely difficult. The negative appendectomy rate in a large series ranged from 15% to 33% [1]. Although imaging modalities such as ultrasound (US) and computed tomography (CT) may help in the diagnosis, they are not always readily available to emergency clinicians, especially outside of regular office hours, and may in fact delay the diagnosis with high falsenegative rates for the diagnosis of acute appendicitis [1,2]. Open appendectomy is still the most common emergency surgery performed in most hospitals. McBurney’s surgery usually is well tolerated by most patients. Universal laparoscopy may be an option in suspected appendicitis, but
* Corresponding author. Tel.: ⫹35-3879227648; fax: ⫹35-314284090. E-mail address: [email protected] 0002-9610/07/$ – see front matter © 2007 Published by Excerpta Medica Inc. doi:10.1016/j.amjsurg.2006.10.030
issues such as higher cost and reduced exposure to open abdominal surgeries among surgical trainees have been the main concern in adopting the technique widely [3–5]. In this article we report our experience with a simple strategy of selective laparoscopy through an open appendectomy incision after finding a noninflamed appendix in the management of suspected appendicitis. Methods Patients presenting with acute abdominal pain and suspected appendicitis outside of regular office hours (6 PM to 8 AM and weekends) were recruited prospectively from January 2002 to December 2003. Our exclusion criteria were patients who underwent preoperative imaging studies such as US and CT scan. Preoperatively, all patients were evaluated by taking a full history and performing a physical examination. Patients received broad-spectrum antibiotic prophylaxis. All procedures were performed under general anesthesia.
232
S.K. Giri et al. / The American Journal of Surgery 194 (2007) 231–233
and 3 months postoperatively in the outpatient clinic. Follow-up data consisted of details of the postdischarge course. Our primary outcome measures were the rate of detection of additional underlying pathology using this technique and any associated complications. Results A total of 135 patients underwent an emergency open appendectomy outside of regular office hours during the study period. None of these patients had preoperative imaging studies such as US or CT scan because of the high clinical suspicion of acute appendicitis and because of the restricted availability of imaging facilities in our hospital outside of regular office hours. The median patient age was 21 years. The male to female ratio was 1.4:1. Twenty-five (18.5%) of 135 patients underwent laparoscopy through an appendectomy incision because of a normal-looking appendix during the appendectomy. Laparoscopy through the appendectomy incision helped to identify intra-abdominal pathology in 13 (52%) of the 25 patients (Table 1). In the remaining 12 patients, histologic examination showed acute appendicitis in 2 (despite a normal macroscopic appearance), whereas in 10 patients (7.4%) the cause of the pain remained unclear. Thus, our technique not only improved the overall diagnosis of cause of pain from 81.5% (110 of 135) to 91.2% (123 of 135), but also identified some potentially fatal underlying pathology (Table 1). None of these patients developed any wound-related complications. One patient developed a urinary tract infection in the postoperative period that was treated successfully with oral antibiotics.
Fig. 1. (A) Lanz incision for an open appendectomy. (B) Laparoscopy using an inflatable balloon port through the Lanz incision.
Surgical technique All patients underwent an open appendectomy for suspected appendicitis through either a McBurney or Lanz incision (Fig. 1A). It was our standard practice to check the terminal ileum, the mesentery, and the right ovary during the appendectomy. Laparoscopy was performed through an appendectomy incision only when the appendix was found to be normal and no obvious pathology was detected in the local area. A purse-string suture-using 2/0 polydioxanone was placed at the peritoneal edge of the open appendectomy incision. The blunt 10-mm port with an inflatable balloon (Blunt Tip Trocar; Auto Suture, Norwalk, CT) was used to maintain the pneumoperitoneum (Fig. 1B). Then standard laparoscopy using a 0° telescope was performed to identify any underlying pathology. Appropriate intervention was taken after identification of pathology. The purse-string suture was tied to close the peritoneum and the grid-iron incision was closed in layers using 0 polyglactin. The skin was closed with subcuticular 4/0 polyglactin. Postoperative protocol Postoperatively, patients were assessed closely for any complications. Patients were evaluated further at 6 weeks
Comments Acute abdominal pain and suspected appendicitis often present as a diagnostic dilemma. In treating such patients the surgeon mostly makes the decision to perform an appendectomy by mainly relying on clinical features, rather than on laboratory and radiologic investigations. Open appendectomy has been the gold standard treatment for acute appendicitis. By virtue of its small incision, open appendectomy is already a type of minimal-access surgery, and is well tolerated, well accepted, and thus the benefits of routine laparoscopic appendectomy are likely to be small and difficult to prove. The potential advantages of the laparoscopic approach include reduced pain and hospital stay and a more rapid return to normal activities [6,7]. However, the validity of these points remains unconvincing to some surTable 1 Distribution of additional pathology detected by laparoscopy through an open appendectomy incision in patients with suspected appendicitis Additional pathology
No. of patients
Perforated anterior duodenal ulcer Twisted left ovarian cyst Ruptured left follicular ovarian cyst Ruptured right follicular ovarian cyst Hemorrhage in left follicular cyst Torsion of appendices epiploicae Sigmoid diverticulitis
2 2 3 1 1 1 3
S.K. Giri et al. / The American Journal of Surgery 194 (2007) 231–233
geons, and the efficacy and indications for emergency laparoscopic appendectomy still are debated [8,9]. When compared with the open procedure, laparoscopic appendectomy is relatively expensive, mainly because of its longer surgical time and costly disposable equipment [3]. Being one of the most common emergency surgical procedures, open appendectomy is traditionally a valuable training exercise for surgical trainees, giving them their initial chance to perform surgery independently. This is not only enjoyable but also fruitful in building their confidence in performing open surgery before learning to treat appendicitis laparoscopically [10]. It has been shown that this introductory opportunity may be lost if the laparoscopic procedure is chosen because in most centers laparoscopic procedures are more likely to be performed by more senior personnel than junior trainees. A recent study by McCormick et al [4] showed a 50% reduction in the number of appendectomies performed by surgical trainees after the introduction of laparoscopic techniques. Radiologic investigations such as US and CT scan may be used in addition to our strategy, but the main limitation is 24-hour availability. By adopting our technique of selective laparoscopy through an open appendectomy incision, trainees will have ample opportunity to perform an open appendectomy and at the same time can diagnose additional, potentially fatal, pathology. We diagnosed 13 further underlying pathology (some potentially fatal) in patients with a noninflamed appendix, thus improving the overall management outcome in these patients. Conclusions Selective laparoscopy through an open appendectomy incision in patients with a noninflamed appendix is a simple
233
technique that can identify potentially fatal pathology and also maintains a valuable training opportunity for young surgeons to perform open abdominal surgery. We recommend using this technique in the management of suspected appendicitis. References [1] Lee SL, Walsh AJ, Ho HS. Computed tomography and ultrasonography do not improve and may delay the diagnosis and treatment of acute appendicitis. Arch Surg 2001;136:556 – 62. [2] McDonald GP, Pendarvis DP, Wilmoth R, et al. Influence of preoperative computed tomography on patients undergoing appendectomy. Am Surg 2001;67:1017–21. [3] Cothren CC, Moore EE, Johnson JL, et al. Can we afford to do laparoscopic appendectomy in an academic hospital? Am J Surg 2005;190:950 – 4. [4] McCormick PH, Tanner WA, Keane FB, et al. Minimally invasive techniques in common surgical procedures: implications for training. Ir J Med Sci 2003;172:27–9. [5] McCahill LE, Pellegrini CA, Wiggins T, et al. A clinical outcome and cost analysis of laparoscopic versus open appendectomy. Am J Surg 1996;171:533–7. [6] Frazee RC, Roberts JW, Symmonds RE, et al. A prospective randomised trial comparing open versus laparoscopic appendectomy. Ann Surg 1994;219:725–31. [7] Hansen JB, Smithers BM, Schache D, et al. Laparoscopic versus open appendectomy: prospective randomised trial. World J Surg 1996;20:17–21. [8] Katkhouda N, Mason RJ, Towfigh S, et al. Laparoscopic versus open appendectomy: a prospective randomized double-blind study. Ann Surg 2005;242:439 – 48. [9] Ignacio RC, Burke R, Spencer D, et al. Laparoscopic versus open appendectomy: what is the real difference? Results of a prospective randomized double-blinded trial. Surg Endosc 2004;18:334 –7. [10] Carrasco-Prats M, Soria Aledo V, Lujan-Mompean JA, et al. Role of appendectomy in training for laparoscopic surgery. Surg Endosc 2003;17:111– 4.