Securing the appendiceal stump in laparoscopic appendectomy: evidence for routine stapling?

Laparoscopic-assisted single-port appendectomy in children: it is a safe and cost-effective alternative to conventional laparoscopic techniques?

Aim. Laparoscopic-assisted single-port appendectomy (SPA), although combining the advantages of open and conventional laparoscopic surgery, is still not widely used in childhood. The aim of this study was to evaluate the safety and the cost effectiveness of SPA in children. Methods. After institutional review board approval, we retrospectively evaluated 262 children who underwent SPA. The appendix was dissected outside the abdominal cavity as in open surgery. For stump closure, we used two 3/0 vicryl RB-1 sutures. Results. We identified 146 boys (55.7%) and 116 girls (44.3%). Median age at operation was 11.4 years (range, 1.1–15.9). Closure of the appendiceal stump using two sutures (cost: USD 15) was successful in all patients. Neither a stapler (cost: USD 276) nor endoloops (cost: USD 89) were used. During a follow-up of up to 69 months (range, 30–69), six obese children (2.3%, body mass index >95th percentile) developed an intra-abdominal abscess after perforated appendicitis. No insufficiency of the appendiceal stump was observed by ultrasound. Five of them were treated successfully by antibiotics, one child required drainage. Conclusion. The SPA technique with conventional extracorporal closure of the appendiceal stump is safe and cost effective. In our unit, SPA is the standard procedure for appendectomy in children.

Analysis of endoloops and endostaples for closing the appendiceal stump during laparoscopic appendectomy

PURPOSE

An inadequate closure of the appendiceal stump can lead to intra-abdominal surgical site infections. The aim of this study was to assess the efficiency of different closure techniques by focusing on the intraoperative and postoperative complications versus cost.

METHODS

From June 2011 to June 2013, 333 patients from two different hospitals undergoing laparoscopic appendectomy were included in this study. The patients were divided into two groups based on the technique used for appendiceal stump closure: there were 104 patients in the stapler group and 229 in the loop group.

RESULTS

Among the 333 patients who underwent laparoscopic appendectomy, there were two (0.6%) intraoperative complications and 22 (6.6%) postoperative complications. There were no significant differences between the groups with respect to the intraoperative and postoperative complications. The length of the operation was 7 min shorter when the endoloop was used (p = 0.014). The mean costs of the operation were significantly lower when the loop was used (<euro> 554.93) compared to the stapler (<euro> 900.70) (p = 0.000).

CONCLUSIONS

There is no clinical evidence supporting the routine use of endoscopic staplers. The appendiceal stump can be secured safely with the use of endoloops in the majority of patients. Surgeons have to be more selective when choosing how to perform closure, and an endostapler should be used only in cases where it is clinically indicated.

A systematic review of systematic reviews and panoramic meta-analysis: staples versus sutures for surgical procedures

Objective

To systematically evaluate the evidence across surgical specialties as to whether staples or sutures better improve patient and provider level outcomes.

Design

A systematic review of systematic reviews and panoramic meta-analysis of pooled estimates.

Results

Eleven systematic reviews, including 13,661 observations, met the inclusion criteria. In orthopaedic surgery sutures were found to be preferable, and for appendicial stump sutures were protective against both surgical site infection and post surgical complications. However, staples were protective against leak in ilecolic anastomosis. For all other surgery types the evidence was inconclusive with wider confidence intervals including the possibly of preferential outcomes for surgical site infection or post surgical complication for either staples or sutures. Whilst reviews showed substantial variation in mean differences in operating time (I² 94%) there was clear evidence of a reduction in average operating time across all surgery types. Few reviews reported on length of stay, but the three reviews that did (I² 0%, including 950 observations) showed a non significant reduction in length of stay, but showed evidence of publication bias (P-value for Egger test 0.05).

Conclusions

Evidence across surgical specialties indicates that wound closure with staples reduces the mean operating time. Despite including several thousand observations, no clear evidence of superiority emerged for either staples or sutures with respect to surgical site infection, post surgical complications, or length of stay.

Endostapler or endoloops for securing the appendiceal stump in laparoscopic appendectomy: a retrospective cohort study

BACKGROUND

Laparoscopic appendectomy is the treatment of choice for appendicitis provided sufficient laparoscopic expertise is available. The endostapler possibly provides an easier and safer closure of the appendiceal stump, but at greater expense. This study aimed to compare two strategies for closure of the appendiceal stump in a large retrospective cohort of patients.

METHODS

This study reviewed patients who underwent laparoscopic appendectomy for acute appendicitis in three academic hospitals and two regional hospitals in The Netherlands during the period 1 January 2007 to 30 June 2011. The endostapler was routinely used in two hospitals and selectively used in the remaining three hospitals. Both strategies were compared for complications according to the Clavien-Dindo classification.

RESULTS

A total of 1,036 patients were analyzed according to the strategy followed. The 571 patients in the first group were routinely treated with the endostapler. For the 465 patients in the second group, the intentional method of stump closure was with endoloops. The endostapler was used when indicated for 69 of these patients. The patient characteristics did not differ between the two groups. The groups also did not differ significantly in number of intra- and postoperative complications. In both groups, 4.3 % of the patients had complications classified as grade 3 or higher. There were no significant differences in the prevalence of intraabdominal abscesses (3.2 % vs. 4.3) or wound infections (0.4 and 1.5 %). In a multivariate analysis, the chosen strategy for stump closure was not a significant predictor for postoperative complications.

CONCLUSION

Routine use of the endostapler showed no clinical advantages over the use of endoloops with selective endostapler closure. The latter strategy is preferable because it is more cost effective.

Appendectomy in Germany-an analysis of a nationwide survey 2011/2012

INTRODUCTION

Although appendectomies are frequently performed and new procedural techniques have emerged, no nationwide analysis exists after the cessation of the German quality control in 2004.

METHODS

One thousand eight hundred seventy surgical hospitals in Germany were asked to answer questions anonymously concerning the size of the department, applied procedural techniques, various technical details, as well as the approach to the intraoperative finding of an inconspicuous appendix.

RESULTS

We received 643 questionnaires (34.4 %) for evaluation. Almost all hospitals (95.5 %) offer laparoscopic appendectomy (LA), 15.4 % offer single-port (SPA), and 2.2 % (hybrid-) NOTES technique (NA). LA is the standard procedure in 85.2 % of male and in 89.1 % for female patients. In an open procedure (OA), the appendix and mesoappendix are mostly ligated (93.8 and 91.5 %). A Veress needle and open access are employed equally for LA. In 66.6 % of LA, the appendix is divided using an Endo-GIA, the mesoappendix in 45.5 % with bipolar coagulation. Almost half of the hospitals routinely flush the site in OA and LA. In open surgery with an inconspicuous appendix but a pathological finding elsewhere in the abdomen, it is resected "en principe" in 64.7 % and in the absence of any pathological finding in 91.2 %. For laparoscopic procedures, the numbers are 54.8 and 88.4 %.

CONCLUSIONS

Most German hospitals perform appendectomies laparoscopically regardless of patients' gender. Usage of an Endo-GIA is widely established. SPA has not gained much acceptance, nor is NA widely used yet. In the absence of any pathological findings in particular, the macroscopically inconspicuous appendix results in an appendectomy "en principe" in most German hospitals.

The usefulness and safety of Hem-o-lok clips for the closure of appendicular stump during laparoscopic appendectomy

PURPOSE

The purpose of this study was to investigate the safety and usefulness of the Hem-o-lok clip for the closure of appendicular stumps and limitations of the Hem-o-lok clip.

METHODS

From May 2010 to August 2011, 105 consecutive patients underwent laparoscopic appendectomies by three surgeons. XL size Hem-o-lok clips were used for the closure of appendicular stumps by one surgeon. The remaining surgeons used double endoloop ligatures. Prospectively collected data from patients who underwent laparoscopic appendectomy due to acute appendicitis were retrospectively reviewed.

RESULTS

A total of 105 laparoscopic appendectomies were performed. The endoloop group consisted of 66 patients (mean age, 34.6 years; range, 16 to 82 years), while the Hem-o-lok group consisted of 39 patients (mean age, 43.5 years; range, 11 to 88 years). In three cases, the Hem-o-lok clip was not used due to enlargement and severe inflammation of the appendix base. No specific intraoperative or postoperative complications were observed in either group.

CONCLUSION

The use of Hem-o-lok clips for the closure of appendicular stumps in laparoscopic appendectomy is a feasible, safe, fast and cost-effective procedure in patients with a mildly to moderately inflamed appendix base of less than 10 mm in diameter.

Analysis of intracorporeal knotting with invaginating suture versus endoloops in appendiceal stump closure

Introduction

Laparoscopic appendectomy is a well-described surgical technique and has gained wide clinical acceptance. Laparoscopic appendectomy offers fewer wound infections, faster recovery and an earlier return to work in comparison to open surgery. However, concerns still exist regarding the appendiceal stump closure.

Aim

The aim of this study was to compare the overall incidence and specific intraoperative and postoperative complications after application of intracorporeal knotting with invaginating suture versus endoloops for stump closure in laparoscopic appendectomy.

Material and methods

One hundred fifty two consecutive patients according to the following inclusion criteria were included in the study: 1. Laparoscopic appendectomy was performed during the study period; 2. Acute phlegmonous or gangrenous appendicitis without perforation was diagnosed during operation. Exclusion criteria - patients with acute perforated appendicitis and local or diffuse peritonitis. Data was grouped according to the appendiceal stump closure technique, with either endoloops – 112 patients (73.7 percent) or intracorporeal knotting with invaginating suture – 40 patients (26.3 per cent). The primary outcome measure was the rate of intraabdominal surgical-site infection, defined as post-operative intra-abdominal abscess. Secondary outcome variables were intraoperative and postoperative complications, duration of operation, hospital stay.

Results

There were no significant differences between the two groups in overall intraoperative and postoperative complications rate and in hospital stay. The median duration of operation was significantly shorter when the endoloop was used. The use of intracorporeal knotting with invaginating suture instead of endoloop to close the appendiceal stump decreased the total cost of laparoscopic appendectomy.

Conclusions

According our study results, intracorporeal knotting with invaginating suture appendiceal stump closure technique is acceptable laparoscopic procedure, which intraoperative and postoperative results do not differ from endoloops technique. The total cost of this procedure is 80 € cheaper then endoloops technique.

The "BASE-FIRST" technique in laparoscopic appendectomy

BACKGROUND:

Appendicitis is the most common cause of acute abdomen, and appendectomy is the most frequent surgical procedure performed in the world. In recent times, laparoscopic appendectomy has been gaining increasing consensus, although comparison with traditional open surgery is still debated. Recent reports seem to agree in recognizing laparoscopy as the favourable approach in cases of non-complicated appendicitis, in women and in obese patients. The use of a linear stapler to close the appendiceal stump also seems to guarantee a dramatic decrease of complications and this observation could be the rationale for considering the laparoscopic approach to also be safe in complicated appendicitis. In these cases, dissection of the mesoappendix and isolation of the viscum could be very difficult and could cause complications. By proposing this technique using a laparoscopic approach, we try to permit a simple and safe section of the appendix leaving the detachment from vessels and from the neighbourhood to a second moment.

MATERIALS AND METHODS:

We report our initial experience including the first 50 cases and proposing our personal technique of laparoscopic appendectomy.

RESULTS AND CONCLUSION:

We recorded only one intraoperative haemorrhage, one bladder perforation due to trocar insertion and no conversion. Our goal is to standardize and simplify the laparoscopic approach in order to give any surgeon, even non-expert ones, a simple way to remove the viscum especially in complicated pictures.

Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Società Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Società Italiana di Chirurgia (SIC), Società Italiana di Chirurgia d'Urgenza e del Trauma (SICUT), Società Italiana di Chirurgia nell'Ospedalità Privata (SICOP), and the European Association for Endoscopic Surgery (EAES)

BACKGROUND

In January 2010, the SICE (Italian Society of Endoscopic Surgery), under the auspices of the EAES, decided to revisit the clinical recommendations for the role of laparoscopy in abdominal emergencies in adults, with the primary intent being to update the 2006 EAES indications and supplement the existing guidelines on specific diseases.

METHODS

Other Italian surgical societies were invited into the Consensus to form a panel of 12 expert surgeons. In order to get a multidisciplinary panel, other stakeholders involved in abdominal emergencies were invited along with a patient's association. In November 2010, the panel met in Rome to discuss each chapter according to the Delphi method, producing key statements with a grade of recommendations followed by commentary to explain the rationale and the level of evidence behind the statements. Thereafter, the statements were presented to the Annual Congress of the EAES in June 2011.

RESULTS

A thorough literature review was necessary to assess whether the recommendations issued in 2006 are still current. In many cases new studies allowed us to better clarify some issues (such as for diverticulitis, small bowel obstruction, pancreatitis, hernias, trauma), to confirm the key role of laparoscopy (such as for cholecystitis, gynecological disorders, nonspecific abdominal pain, appendicitis), but occasionally previous strong recommendations have to be challenged after review of recent research (such as for perforated peptic ulcer).

CONCLUSIONS

Every surgeon has to develop his or her own approach, taking into account the clinical situation, her/his proficiency (and the experience of the team) with the various techniques, and the specific organizational setting in which she/he is working. This guideline has been developed bearing in mind that every surgeon could use the data reported to support her/his judgment.

Appendix stump closure with titanium clips in laparoscopic appendectomy

Purpose

Different techniques, including clips, have been used to close the stump in laparoscopic appendectomy. The aim was to investigate the results after application of a newly developed titanium clip for this operation.

Methods

From June 2008 to February 2010, 104 patients from two different hospitals undergoing laparoscopic appendectomy were included in this prospective study. Closure of the appendix base was generally intended with a titanium double-shanked clip (DS-Clip). The variables of interest were intra-and postoperative complications, operation time and hospital stay. Furthermore, an evaluation of the clip's practicability by the surgeon was performed using a standardised questionnaire.

Results

In 104 patients screened intraoperatively, four patients had to be excluded as the operating surgeon felt that the clip was not adequate for closing the stump, generally because of severe inflammation of the base of the appendix with involvement of the caecum. One patient developed an intra-abdominal abscess which had to be drained interventionally; no reoperations were necessary. The overall complication rate, the operation time and the hospital stay were well comparable with other devices for appendix stump closure such as staplers, loops or polymeric clips. The practicability of the clip was mainly rated as excellent or good by the operating surgeons.

Conclusion

This study suggests that the presented titanium DS-Clip is a safe and cost-effective technique for securing the appendix base in laparoscopic appendectomy. The application is easy and can be learned quickly, making it a good option also for teaching hospitals.

Tissue reaction to absorbable endoloop, nonabsorbable titanium staples, and polymer Hem-o-lok clip after laparoscopic appendectomy

BACKGROUND AND OBJECTIVES

The standard technique for securing the base of the appendix during laparoscopic appendectomy is by absorbable endoloop ligature, although clinical reports favor the use of the stapler. Nonabsorbable Hem-o-lok clips have been shown to be an alternative technique to this. However, it is currently not clear whether nonabsorbable clips have any effects on the intestine or promote infection in the surgical area.

MATERIALS AND METHODS

Sixty Wistar albino rats were randomized into 3 treatment groups: group I (n=20) the base of the appendix was secured by endoloop 2-0 ligature; group II (n=20) dissection of the appendix was performed by a 45-mm thick stapler; and group III (n=20) the base of the appendix was secured by a Hem-o-lok plastic clip. The animals were sacrificed on the 14th and 28th days after surgery. The secured stump was used for histopathological examination.

RESULTS

There were no significant differences in histopathological changes observed on the 14th postoperative day between the groups. On the 28th postoperative day, it was proved that mild and moderate inflammation is more frequent in the endoloop and Hem-o-lok groups than in the stapler group. Reaction to a foreign body is more frequent in the endoloop than in stapler and Hem-o-lok groups.

CONCLUSION

The mildest postoperative inflammatory changes were seen in the stapler group, followed by the Hem-o-lok group. However, because of the price of the plastic clip and the simplicity of its application, its use is still favored during laparoscopic appendectomy.

Short- and long-term results of open versus laparoscopic appendectomy

BACKGROUND

Clinical advantages of laparoscopic appendectomy have been shown in numerous trials and reviews. Most of these advantages are small and of limited clinical relevance, while laparoscopic operation costs are reported to be higher. The present study compares short- and long-term results of conventional appendectomy with or without diagnostic laparoscopy (OA), and laparoscopic appendectomy (LA).

METHODS

All adult patients who underwent appendectomy in our institution from 1995 to 2005 were included retrospectively. Patient data were retrieved from medical records, questionnaires sent by mail, and records of general practitioners. Primary outcome parameters were long-term complications, readmissions, and reinterventions (>30 days postoperatively). Secondary outcome parameters were short-term complications, readmissions, and reinterventions (≤30 days postoperatively).

RESULTS

A total of 755 patients were included, 545 of whom underwent OA, with the remaining 210 undergoing LA. In the long term there were few complications noted, and there were no significant differences in complications between the two groups. Within 30 days postoperatively, LA was associated with a significantly higher incidence of abdominal abscesses with consequent diagnostic investigations, interventions, and readmissions.

CONCLUSIONS

Although laparoscopic appendectomy is known to deliver clinical advantages, it is associated with a higher incidence of abdominal abscesses. Because the procedure is about to become the standard of care, future research must be directed at solving this issue. The expected lower incidence of incisional hernia and small bowel obstruction after laparoscopic appendectomy was not shown in the present study.

Consensus conference on laparoscopic appendectomy: development of guidelines

AIM

Laparoscopic appendectomy (LA) is not yet unanimously considered the gold standard treatment for appendicitis, despite the increasing use of advanced laparoscopic operations and the high incidence of the disease.

METHOD

Due to the results of an audit which classified LA as widespread in Italy, a Consensus Conference was organized, in order to give evidence-based answers to the most debated problems regarding the operation. After researching the literature, a panel of 20 experts were selected and interviewed on hot topics; a subsequent discussion using the Delphi methodology was utilized in the course of the consensus conference and submitted to the evaluation of an audience of surgeons.

RESULTS

Checkpoint statements were formulated whenever an agreement was reached. A level of evidence was then assigned to single statements and the process revised by two external reviewers.

CONCLUSION

Consensus development guidelines are herein reported and regard diagnostic pathway, diagnostic laparoscopy, indications, behaviour in case of innocent appendix, technical aspects, learning curve; however, some questions remain unsolved due to the lack of evidence.

Absorbable ligation loops for flexible endoscopy: a necessary tool for natural orifice transluminal endoscopic surgery

BACKGROUND

One of the main challenges of natural orifice transluminal endoscopic surgery (NOTES) remains the development of safe and reliable tools. In this study, we introduce the first absorbable ligatures specifically designed for NOTES.

OBJECTIVE

To determine the feasibility of a new absorbable ligation loop (NOTES loop) and to compare this new type of suture with the nonabsorbable loop (Endoloop) most commonly used until now.

DESIGN

Prospective, comparative animal trial/survival animal study (observation period 21 days) with subsequent histopathological assessment (blinded observer design).

SETTING

Veterinarian center.

SUBJECTS

This study used 12 female domestic piglets.

INTERVENTION

Every pig underwent two transgastric uterine horn ligations, one with an absorbable loop and one with a nonabsorbable loop. Additional uterine horn resections on both sides were done on 6 pigs.

MAIN OUTCOME MEASUREMENTS

Intervention success, loop reliability, foreign-body reaction, extent of inflammatory response (μm).

RESULTS

Transgastric flexible intra-abdominal ligation of the uterine horns was performed safely with both loops in all cases. During a 3-week observation period, 11 of 11 NOTES loops and 10 of 11 Endoloops were reliable. Microscopically, foreign-body reaction was minimal around both sutures (P = .303). The overall inflammatory response was larger around the Endoloops (P = .046). Uterine horn resection had an influence on the extent of inflammation.

LIMITATIONS

Animal study.

CONCLUSION

Ligation was feasible with both loops. The absorbable loops were reliable during a 3-week observation period and can be recommended for use during NOTES appendectomies.

Diffusion of laparoscopic appendectomies in Italy: a national audit

A national audit focused on laparoscopic appendectomy was promoted by the Italian Association of Hospital Surgeons (ACOI). Four-hundred and sixty surgical practices received an e-mail questionnaire. Data concerning epidemiology, timetable, surgeon's age, selection of patients, laparotomic conversion, behaviour in the case of a normal appendix, and technical aspects were investigated. The response rate was 51.7%. The median number of appendectomies performed is 50-100 each year in a surgery ward. Laparoscopic operations are very common (93%), but mostly performed in less than 50% of the observed cases. There is no significant difference between the number of operations during the day vs. at night, and they are performed by a limited (<30%) group of surgeons, equally composed of physicians aged above and below 40. The majority of surgeons adopt an "all comers" policy regarding laparoscopic appendectomy, including selected older patients (>70 years old). There are no standard indications for conversion, while the behaviour in the presence of a normal appendix is generally removal. Even if laparoscopic appendectomy is not yet considered a gold standard, it is widely diffused in Italy, and the audit's data show different behaviours between subgroups.

A brief review of laparoscopic appendectomy: the issues and the evidence

Laparoscopic appendectomy was first performed more than 25 years ago. We performed a systematic literature search on laparoscopic appendectomy and selected related topics. The technique should be considered the gold standard for surgical removal of the appendix in women of childbearing age (level of evidence Ia). There is minor but consistent evidence that it should also be advocated for men (level of evidence III), obese (level of evidence III), and elderly (level of evidence IIb) patients, while there is some evidence of unfavorable results on pregnant women (level of evidence IIb). Studies reporting higher incidence of intra-abdominal abscesses after laparoscopic appendectomy are difficult to interpret due to a lack of standardization of the operative technique and lack of uniformity related to the different grades of disease (ranging from uninflamed appendix to diffuse peritonitis, gangrene, or perforation of the organ). As far as surgical technique, the three-port procedure is superior to needleoscopy and single port access (level of evidence Ia). Costly high-tech instruments for dissection are mostly unnecessary (level Ib). Mechanical closure of the stump might prove safer (level Ib). The quantity of peritoneal lavage fluid is generally scanty (level III), and abdominal drains are not useful (level Ia). Fast-track protocols should be implemented (level Ic). Training and technical standardization are the key to devising future trials on this topic.

Laparoscopic versus open surgery for suspected appendicitis

BACKGROUND

Laparoscopic surgery for acute appendicitis has been proposed to have advantages over conventional surgery.

OBJECTIVES

To compare the diagnostic and therapeutic effects of laparoscopic and conventional 'open' surgery.

SEARCH STRATEGY

We searched the Cochrane Library, MEDLINE, EMBASE, LILACS, CNKI, SciSearch, study registries, and the congress proceedings of endoscopic surgical societies.

SELECTION CRITERIA

We included randomized clinical trials comparing laparoscopic (LA) versus open appendectomy (OA) in adults or children. Studies comparing immediate OA versus diagnostic laparoscopy (followed by LA or OA if necessary) were separately identified.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality. Missing information or data was requested from the authors. We used odds ratios (OR), relative risks (RR), and 95% confidence intervals (CI) for analysis.

MAIN RESULTS

We included 67 studies, of which 56 compared LA (with or without diagnostic laparoscopy) vs. OA in adults. Wound infections were less likely after LA than after OA (OR 0.43; CI 0.34 to 0.54), but the incidence of intraabdominal abscesses was increased (OR 1.87; CI 1.19 to 2.93). The duration of surgery was 10 minutes (CI 6 to 15) longer for LA. Pain on day 1 after surgery was reduced after LA by 8 mm (CI 5 to 11 mm) on a 100 mm visual analogue scale. Hospital stay was shortened by 1.1 day (CI 0.7 to 1.5). Return to normal activity, work, and sport occurred earlier after LA than after OA. While the operation costs of LA were significantly higher, the costs outside hospital were reduced. Seven studies on children were included, but the results do not seem to be much different when compared to adults. Diagnostic laparoscopy reduced the risk of a negative appendectomy, but this effect was stronger in fertile women (RR 0.20; CI 0.11 to 0.34) as compared to unselected adults (RR 0.37; CI 0.13 to 1.01).

AUTHORS' CONCLUSIONS

In those clinical settings where surgical expertise and equipment are available and affordable, diagnostic laparoscopy and LA (either in combination or separately) seem to have various advantages over OA. Some of the clinical effects of LA, however, are small and of limited clinical relevance. In spite of the mediocre quality of the available research data, we would generally recommend to use laparoscopy and LA in patients with suspected appendicitis unless laparoscopy itself is contraindicated or not feasible. Especially young female, obese, and employed patients seem to benefit from LA.

The impact of surgeon choice on the cost of performing laparoscopic appendectomy

INTRODUCTION

While laparoscopic appendectomy (LA) can be performed using a myriad of techniques, the cost of each method varies. The purpose of this study is to analyze the effects of surgeon choice of technique on the cost of key steps in LA.

METHODS

Surgeon operative notes, hospital invoice lists, and surgeon instrumentation preference sheets were obtained for all LA cases in 2008 at Cambridge Health Alliance (CHA). Only cases (N = 89) performed by fulltime staff general surgeons (N = 8) were analyzed. Disposable costs were calculated for the following components of LA: port access, mesoappendix division, and management of the appendiceal stump. The actual cost of each disposable was determined based on the hospital's materials management database. Actual hospital reimbursements for LA in 2008 were obtained for all payers and compared with the disposable cost per case.

RESULTS

Disposable cost per case for the three portions analyzed for 126 theoretical models were calculated and found to range from US $81 to US $873. The surgeon with the most cost-effective preferred method (US $299) utilized one multi-use endoscopic clip applier for mesoappendix division, two commercially available pretied loops for management of the appendiceal stump, and three 5-mm trocars as their preferred technique. The surgeon with the least cost-effective preferred method (US $552) utilized two staple firings for mesoappendix division, one staple firing for management of the appendiceal stump, and 12/5/10-mm trocars for access. The two main payers for LA patients were Medicaid and Health Safety Net, whose total hospital reimbursements ranged from US $264 to US $504 and from US $0 to US $545 per case, respectively, for patients discharged on day 1.

DISCUSSION

Disposable costs frequently exceeded hospital reimbursements. Currently, there is no scientific literature that clearly illustrates a superior surgical method for performing these portions of LA in routine cases. This study suggests that surgeons should review the cost implications of their practice and to find ways to provide the most cost-effective care without jeopardizing clinical outcome.

Current analysis of endoloops in appendiceal stump closure

BACKGROUND

An inadequate closure of the appendix stump leads to intra-abdominal surgical site infection. The effectiveness of various appendiceal stump closure methods, for instance, staplers or endoloops, was evaluated. Many analyses show that the use of a stapler for transection and closure of the appendiceal stump lowers the risk of this infection but a statistically significant risk of postoperative intra-abdominal abscess or wound infection was not considered in any randomized study. The aim of this study was to evaluate the complications after using endoloops in a high-volume center.

METHODS

The data of 1,790 patients who underwent laparoscopic appendectomy between January 1998 and December 2006 and a single center was prospectively acquired. The standard procedure used was an appendiceal stump closure using endoloops and a selective use of staplers. The outcome criteria for inclusion in the study were intra-abdominal abscess formations, other specific intraoperative and postoperative complications, and the different costs of the operation.

RESULTS

Laparoscopic appendectomy was performed in 1,790 (80.8%) patients and open appendectomy in 425 (19.2%) patients. Conversion to open surgery occurred in 74 (4.13%) patients. Laparoscopic appendectomy with stump closure using endoloops was performed in 1,670 (97.3%) patients and stump closure using a stapler in 46 (2.7%) patients. Among 851 patients with acute appendicitis, 284 patients with perforated appendicitis, and 535 patients with other or no pathology, the rate of intra-abdominal abscess after using an endoloop or a stapler was not significantly different (1.5 vs. 0%, p = 0.587; 3.5 vs. 4.2%, p = 0.870; 0.7% vs. 0, p = 0.881, respectively). There were no significant differences between the endoloop group and the stapler group with respect to the other specific intraoperative and postoperative complications.

CONCLUSION

This study shows the safety of the endoloop for clinical daily routine. A selective procedure for stump closure has been established. Appendiceal stump closure using an endoloop is an easy, safe, and cost-effective procedure.

LigaSure compared with ligatures and endoclips in experimental appendectomy: how safe is it?

PURPOSE

The present study aims to compare strength, healing, and inflammation of appendiceal stumps closed by LigaSure Precise (Valleylab, Boulder, CO, USA) device, ligatures using polyglactin 910 (Vicryl, Ethicon, Edinburgh, UK) and endoclips (Ligaclip ERCA, Ethicon, OH, USA), and operation time (OT) in experimental appendectomy.

METHODS

Forty-eight Sprague-Dawley rats were divided into two (Group A and B). Each group was further subdivided into three subgroups (AS, AC, AL, BS, BC, BL) containing eight rats. Appendectomy was performed and stump was closed by ligatures in S, by endoclips in C and by LigaSure in L subgroups. OT was recorded. In Group A, cecum bursting pressures (BP) were determined instantly after the operation. In Group B, BP, histological evaluations, and measurements of collagen contents estimated by the tissue hydroxyproline (HPL) level were made on the seventh postoperative day. Statistical analyses were performed with Kruskal-Wallis test and Mann-Whitney U test. P value was considered significant at less than 0.05.

RESULTS

BPs of subgroups were comparable on postoperative immediate period and day 7. HPLs and OTs were significantly better in L subgroups. BL had the least inflammation.

CONCLUSION

Better healing, less inflammation, shorter OT, and equal strength achieved with LigaSure device comparing with polyglactin 910 ties and endoclips in experimental appendectomy is encouraging.

[Laparoscopy for suspected appendicitis. Should an appendix that appears normal be removed?]

The question whether an appendix found to be macroscopically normal at laparoscopy for suspected appendicitis should be removed remains open to debate. Potential advantages of appendicectomy in all cases include early diagnosis of neoplastic lesions that cannot be detected macroscopically, diagnosis and cure of neurogenic appendicectomy, avoidance of diagnostic confusion in later episodes of abdominal pain, and prevention of appendicitis developing later in life. Therefore, adopting a strategy of always removing the appendix even if it is found to be uninflamed at laparoscopy seems justified as long as it does not imply an increase in postoperative morbidity. We retrospectively studied all patients undergoing laparoscopic appendicectomy in which a "normal appendix" was found and all patients undergoing diagnostic laparoscopy in our hospital during a 7-year period. Our data as well as a critical review of the literature show that removal of the appendix does not increase morbidity compared to simple diagnostic laparoscopy and should always be done when performing laparoscopy for suspected acute appendicitis.

[Laparoscopic appendectomy. The new standard?]

Since the introduction of laparoscopic appendectomy by Semm in 1983, the role of this minimally invasive surgical technique has been the focus of controversial discussion. Meta-analyses have identified its advantages as having significantly lower wound infection rates, less postoperative pain and earlier resumption of normal everyday activities. The disadvantages are higher rates of intra-abdominal abscesses, longer operating times and higher inpatient treatment costs. However, some of the advantages identified by meta-analyses have been called into question by the results obtained from research into aspects of care. These discrepancies are attributable to the different surgeons involved in the various studies. The results are greatly influenced by the qualifications and experience of the surgeons. Therefore conventional appendectomy using a right lower lateral McBurney incision should continue to be the gold standard. Surgeons who have extensive experience in the field of laparoscopic surgery can achieve better results with minimally invasive appendectomy than with open surgery. This also holds true for specific situations such as complicated appendicitis and for morbidly obese patients. However, the operating costs incurred for laparoscopic appendectomy are higher because it has been shown that removal of the appendix with a linear stapler is the most reliable method.

[Surgical techniques of appendectomy for acute appendicitis]

Over the last 20 years, the treatment of acute appendicitis has been transformed by the development of the laparoscopic approach. And yet the net value of this approach continues to be debated. Laparoscopic appendectomy is associated with a lower complication rate and a shorter period of disability in the general population. While operative costs are higher, the global cost of laparoscopic appendectomy is lower than for open appendectomy. There is a somewhat higher rate of abdominal abscess for the laparoscopic route. Laparoscopic appendectomy shows clear advantages in obese patients and in those with gangrenous or ruptured appendicitis. The laparoscopic approach is contra-indicated during pregnancy due to a higher incidence of miscarriage. Treatment of the appendiceal stump by ligature decreases the expense associated with the use of a surgical stapler. When Meckel's diverticulum is encountered during appendectomy, it should be removed in all pediatric patients; in adults, Meckel's diverticulectomy in adults should be performed only for clear-cut pathology. Surgeons continue to innovate and refine appendectomy techniques but many questions remain to be answered.

Laparoscopic appendectomy for complicated appendicitis: a comparison with open appendectomy

BACKGROUND

Although laparoscopic appendectomy (LA) is widely performed in many countries, LA for complicated appendicitis, which includes perforated or gangrenous appendicitis with or without localized or disseminated peritonitis, has not become a common practice yet.

METHODS

We retrospectively analyzed the clinical records of 230 patients who had undergone appendectomy for complicated appendicitis: 141 had undergone LA, 84 had conventional open appendectomy (OA), and 5 patients had conversion to the open procedure after laparoscopy. The LA group (total LA) was subdivided into "early experience (early LA: cases 1-56)" and "late experience (late LA: case 57 and higher)." We defined the early LA group as the comparison group to minimize selection bias.

RESULTS

Patient demographics were similar in the early LA and OA groups (P > 0.05). Wound infection was significantly more frequent in the OA group (P < 0.05). Intra-abdominal infection was equally common in these two groups. The overall rate of postoperative complications was significantly higher in the OA group (32.1%) than in the early LA group (18%; P < 0.05). This incidence was 12.8% in the total LA group. Hospital stay was significantly shorter in the early LA group (10.6 +/- 3.9 days; P < 0.05), and 8.9 +/- 3.7 days in the total LA group.

CONCLUSIONS

Our findings indicate that LA is safe and useful even for the treatment of complicated appendicitis if performed by an experienced surgeon.

[Enterobius vermicularis causing symptoms of acute appendicitis]

The authors present a case of enterobiasis of the appendix. Enterobius infection is an uncommon cause of acute appendicitis. Preoperative diagnosis of pinworm infestation is almost impossible unless there is a strong clinical suspicion. Parasites may produce symptoms which resemble acute appendicitis. Careful observation of the appendix stump may lead to intraoperative diagnosis of enterobiasis. A quick diagnosis and appropriate treatment may prevent future complications.