The Case for Laparoscopic Appendicectomy 2018

The Case for

LAPAROSCOPIC

APPENDICECTOMY

2018

Dr. Mohamad Al-Gailani FRCS

Consultant Surgeon

Al Hammadi Hospital, Suwaidi

Riyadh, KSA

THE CASE FOR

LAPAROSCOPIC

APPENDICECTOMY

2018

Dr. Mohamad Al-Gailani FRCS

Consultant Surgeon

Al Hammadi Hospital, Suwaidi

Riyadh, KSA

ACUTE APPENDICITIS

One of the most common causes of the Acute

Abdomen

One of the most frequent indications for

emergency abdominal surgical procedure

worldwide

Occurs most frequently in the second and third

decades of life

The incidence is approximately 233/100,000

population and is highest in the 10 to 19-year-old

age group

Male to Female ratio 1.4:1

Lifetime incidence 8.6 %

The Case For Laparoscopic Appendicectomy 2018 DR. Mohamad Al-Gailani FRCS Al Hammadi Hospital, Suwaidi, Riyadh, KSA

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Advantages of the Laparoscopic

Approach 1

A lower rate of wound infections

(Odds Ratio [OR] 0.43, 95% CI

0.34-0.54)

Less pain on postoperative day 1 by

the VAS pain score (8 mm, CI 5-11

mm)

Shorter duration for return of

bowel function


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Advantages of the Laparoscopic

Approach 2

Shorter duration of Hospital Stay

(1.1 days, CI 0.7-1.5 days)

Fewer Complications (13 % v 22 %)

Less chance of Incisional Hernia

Lower Mortality Rate (0.4 % v 2.1

%)


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Special Indications for the

Laparoscopic Approach

1. An Uncertain Diagnosis since it permits

inspection of the whole peritoneal cavity

2. Women of Childbearing Age in whom

laparoscopy may reveal other causes of

pelvic pathology

3. Obese patients since exposure of the right

lower quadrant during open appendectomy

may require larger morbidity-prone

incisions


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1.An Uncertain

Diagnosis

Initial Laparoscopy through a small

incision permits inspection of the whole

peritoneal cavity and is good as a general

laparotomy without the big incision!

The appendix, pelvic organs, gall bladder

and the presence or absence of pus or free

fluid may be visualized.

Any need to proceed to open laparotomy

could be planned then through an

appropriate incision.


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2.Women of Child

Bearing Age

Improved visualization of the

entire abdomen

Improves the diagnostic accuracy

and can identify the definitive

pathology more often than the open

approach

Potential less adhesions and so less

chance of potential future fertility

concerns


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3.Obesity

Laparoscopic Appendectomy is safe and

effective in obese patients and may be

the preferred approach

The Laparoscopic approach may convey

some advantages over the open approach

in access to the appendix, visualization,

and decrease in wound complications.

In the morbidly obese longer trocars and

instruments may be needed.


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Disadvantages of the Laparoscopic

Approach

A learning curve is

required

Potential injury during

port insertion

Higher costs of equipment


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Complications of Appendicectomy

in General

Average morbidity near 10%

Adynamic Ileus secondary to

severe sepsis

Surgical Site Infection (SSI)

Dehiscence (open)

Incisional hernia

Pelvic or abdominal abscess

Caecal fistulas


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Remove an Apparently

Normal Appendix at Laparoscopy?

Should you remove a

macroscopically apparently

Normal Appendix at

Laparoscopy?


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Remove an Apparently

Normal Appendix at Laparoscopy?

YES

Macroscopically normal appendixes may have

abnormal histopathology

19% - 40% rate of pathologically abnormal

appendix in the setting of no visual abnormalities

The risk of leaving a potentially abnormal

appendix must be weighed against the risk of

appendicectomy in each individual scenario

Cases of postoperative symptoms requiring

reoperation for appendicectomy have been

described in patients whose normal appendix was

left in place at the time of the original procedure.


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Need for Interval (Elective)

Appendectomy? 1

Following successful treatment

of an appendicular mass,

should you plan later for an

Interval or Elective

Appendicectomy?


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To prevent recurrence of appendicitis

To exclude neoplasms (such as carcinoid,

adenocarcinoma, mucinous cystadenoma, and

cystadenocarcinomas) especially in older adults

who have higher incidences of appendiceal

neoplasm

Older patients should also have a colonoscopy or

barium enema to rule out caecal pathology

The need for interval appendectomy is debated

with some studies suggesting that interval

appendectomy is unnecessary?


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Appendectomy? 2


Appendectomy?YES!

Retrospective review of 1012 patients treated non-

operatively for acute appendicitis

864 patients did not undergo an interval appendectomy

Of those (4.5 percent) required an appendectomy at a

median follow-up of four years

A malignant disease was detected in 1.2 %

Recurrent Appendicitis developed in 7.4 %

Interval Appendectomy for most adult patients is

Recommended

Colonoscopy should be considered prior to

Appendectomy in patients over 50 who have not had a

recent colonoscopy

*UptoDate


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SUMMARY

Diagnostic ability of laparoscopy especially in

female patients

Decreased postoperative pain

Earlier discharge

A shorter time to return to usual activities

Lower incidence of wound infections or

dehiscence

Training opportunity for laparoscopic skills

Better aesthetic result

Disadvantages: cost!


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CONCLUSION

1. Laparoscopic Appendectomy

Should be the Standard Approach

for patients with Appendicitis or

Suspected Appendicitis.

2. Consider removing a

Macroscopically Normal

Appendix

3. Consider Interval

Appendicectomy for most adult

patients


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REFERENCES

UptoDate

Society of American

Gastrointestinal and

Endoscopic Surgeons (SAGES)


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Health & Medicine

The Case for Laparoscopic Appendicectomy 2018