Laparoscopic appendectomy in modern gynecology

No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain

OBJECTIVE

To improve the understanding of chronic pelvic pain (CPP) and to provide evidence-based guidelines of value to primary care health professionals, general obstetricians and gynaecologists, and those who specialize in chronic pain.

BURDEN OF SUFFERING

CPP is a common, debilitating condition affecting women. It accounts for substantial personal suffering and health care expenditure for interventions, including multiple consultations and medical and surgical therapies. Because the underlying pathophysiology of this complex condition is poorly understood, these treatments have met with variable success rates.

OUTCOMES

Effectiveness of diagnostic and therapeutic options, including assessment of myofascial dysfunction, multidisciplinary care, a rehabilitation model that emphasizes achieving higher function with some pain rather than a cure, and appropriate use of opiates for the chronic pain state.

EVIDENCE

Medline and the Cochrane Database from 1982 to 2004 were searched for articles in English on subjects related to CPP, including acute care management, myofascial dysfunction, and medical and surgical therapeutic options. The committee reviewed the literature and available data from a needs assessment of subjects with CPP, using a consensus approach to develop recommendations.

VALUES

The quality of the evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations for practice were ranked according to the method described in that report (Table 1).

RECOMMENDATIONS

The recommendations are directed to the following areas: (a) an understanding of the needs of women with CPP; (b) general clinical assessment; (c) practical assessment of pain levels; (d) myofascial pain; (e) medications and surgical procedures; (d) principles of opiate management; (f) increased use of magnetic resonance imaging (MRI); (g) documentation of the surgically observed extent of disease; (h) alternative therapies; (i) access to multidisciplinary care models that have components of physical therapy (such as exercise and posture) and psychology (such as cognitive-behavioural therapy), along with other medical disciplines, such as gynaecology and anesthesia; G) increased attention to CPP in the training of health care professionals; and (k) increased attention to CPP in formal, high-calibre research. The committee recommends that provincial ministries of health pursue the creation of multidisciplinary teams to manage the condition.

Evaluation of Procedural Simulation as a Training and Assessment Tool in General Surgery-Simulating a Laparoscopic Appendectomy

BACKGROUND

Laparoscopic appendectomy is a commonly performed surgical procedure, but few training models have been described for it. We examined a virtual reality module for practising a laparoscopic appendectomy.

METHODS

A prospective cohort study with the following 3 groups of surgeons (n = 45): novices (0 procedures), intermediates (10-50 procedures), and experienced (>100 procedures). After being introduced to the simulator and 1 familiarization attempt on the procedural module, the participants practiced the module 20 times. Movements, task time, and procedure-specific parameters were compared over time.

RESULTS

The time and movement parameters were significantly different during the first attempt, and more experienced surgeons used fewer movements and less time than novices (p < 0.01), although only 2 parameters were significantly different between novices and intermediates. All 3 groups improved significantly over 20 attempts (p < 0.0001). The intraclass correlation coefficient varied between 0.55 and 0.68 and did not differ significantly between the 3 groups (p > 0.05). When comparing novices with experienced surgeons, novices had a higher risk of burn damage to cecum (odds ratio [OR] = 3.0 [95% CI: 1.3; 7.0] p = 0.03), pressure damage to appendix (OR = 3.1 [95% CI: 2.0; 4.9] p < 0.0001), and grasping of the appendix (OR = 2.9 [95% CI: 1.8; 4.7] p < 0.0001). The risk of causing a perforation was not significantly different among the different experience levels (OR = 1.9 [95% CI: 0.9; 3.8] p = 0.14). Only 3 out of 5 error parameters differed significantly when comparing novices and experienced surgeons. Similarly, when comparing intermediates and novices, it was only 2 of the parameters that differed.

DISCUSSION

The simulator module for practising laparoscopic appendectomy may be useful as a training tool, but further development is required before it can be used for assessment purposes. Procedural simulation may demonstrate more variation for movement parameters, and future research should focus on developing better procedure-specific parameters.

Could laparoscopic appendectomy in pregnant women affect obstetric outcomes? A multicenter study

PURPOSE

The purpose of this study was to compare the perioperative and obstetric outcomes of pregnant women between laparoscopic surgery and open surgery and to evaluate the predictive factors for overall obstetric outcomes.

METHODS

We retrospectively reviewed the medical records of pregnant women who underwent appendectomy between January 2008 and June 2015 at six hospitals affiliated to Hallym University.

RESULTS

Eighty patients were evaluated. Twenty-four underwent laparoscopic appendectomy (LA) and 56 underwent open appendectomy (OA). There were no significant differences in the patients' characteristics and gestational age at surgery between the two groups. Operation time, time to flatus, and time to soft food intake were similar in both groups. The length of stay was shorter in the LA group than in the OA group (5.1 vs 8.1 days, P = 0.044). Gestational age at delivery, birth weight, and delivery type were similar in both groups. There was no significant difference in overall obstetric poor outcome (20.8 vs 14.3 %, P = 0.516), including preterm delivery (8.3 vs 7.1 %, P = 1.000) and fetal loss (12.5 vs 7.1 %, P = 0.350). Multivariable analysis revealed that fever >38 °C (P = 0.022) and maternal age (P = 0.044) were independent predictors for the overall poor outcomes.

CONCLUSIONS

LA was associated with shorter length of stay compared with OA, but perioperative and obstetric outcomes were similar with both procedures. LA can be safely performed in pregnant women in any trimester.

Laparoscopy: a safe approach to appendicitis during pregnancy

BACKGROUND

The aim of this study was to evaluate laparoscopic versus open surgery for suspected appendicitis during pregnancy.

METHODS

A hospital-based retrospective review of 65 consecutive pregnant patients who underwent surgery for suspected appendicitis from 1999 to 2008 was performed. Significance was determined by Pearson's chi(2) test, Fisher's exact test, Mann-Whitney test, and Kruskal-Wallis test.

RESULTS

Of the 65 patients, 48 cases were laparoscopic and 17 open. Use of the laparoscopic versus open approach was significantly increased in the first (100% vs. 0%, p < 0.001) and second trimesters (73% vs. 27%, p < 0.001). The open approach was used more frequently in third-trimester patients (71% vs. 29%, p = NS). Significance was demonstrated in mean length of hospital stay in the laparoscopic versus open group (3.4 vs. 4.2 days, p = 0.001). No maternal mortalities occurred. Follow-up of fetal outcome was achieved in 89% of patients. No difference was demonstrated in fetal loss (1 in laparoscopic group), APGAR score, birth weight, and preterm delivery rate by operative approach. Adverse outcome was associated with maternal temperature greater than 38 degrees C, leukocytosis greater than 16 x 10(9)/l, or more than 48 h between onset of symptoms and emergency room presentation.

CONCLUSIONS

This article is the largest hospital-based series evaluating the laparoscopic versus open approach for pregnant patients with presumed acute appendicitis. While methodological limitations preclude a definitive recommendation, laparoscopy appears to be a safe, feasible, and efficacious approach for pregnant patients with presumed acute appendicitis. We conclude that it is likely not the surgical approach but the underlying diagnosis combined with maternal factors that determine the risk for pregnancy complications. A benefit of laparoscopy is the diagnostic ability to identify other intra-abdominal pathology which may mimic appendicitis and harbor pregnancy risks.

Appendectomy during Early Pregnancy: What is the Preferred Surgical Approach?

Appendectomy is the most common nongynecologic surgery performed during pregnancy. Although many surgeons offer laparoscopic appendectomy (LA) as an alternative to open appendectomy (OA) during early pregnancy, few studies have compared the effects of LA versus OA on the fetus and the outcome of the pregnancy. Twenty-eight consecutive females undergoing appendectomy for presumed appendicitis in the first two trimesters of pregnancy between January 2000 and December 2002 were identified retrospectively. Demographic information, weeks of pregnancy at operation, and surgical approach (LA or OA) were recorded. Study outcomes included operative and pregnancy-related complications, length of hospitalization, final outcome of pregnancy, and infant birth weight. Seventeen LA and 11 OA were performed. There were no significant differences in surgical or obstetrical complications, length of hospitalization, or birth weight between the two groups. Two cases of postoperative fetal demise were noted in the LA group. Although not statistically significant, the two fetal losses in the laparoscopic group are concerning. The current study did not demonstrate any advantages to the laparoscopic approach. Pending further investigation, the open approach may be preferred for appendectomy in pregnant patients during the first two trimesters of pregnancy.

Laparoscopic appendectomy in patients with endometriosis

STUDY OBJECTIVE

To report the frequency and spectrum of histologically proved diseases of the appendix in patients undergoing laparoscopic surgery for chronic pelvic pain in conjunction with endometriosis in a tertiary referral center.

DESIGN

Patient database with retrospective chart review (Canadian Task Force classification II-3).

SETTING

University ambulatory endoscopic surgery center-tertiary referral center.

PATIENTS

Two hundred thirty-one women.

INTERVENTIONS

Appendectomy during laparoscopic surgery for endometriosis.

MEASUREMENTS AND MAIN RESULTS

We reviewed the medical records of 231 patients who underwent appendectomy during laparoscopic treatment of endometriosis performed from January 1994 through July 2004. Of the 231 patients with pelvic endometriosis, concomitant appendiceal pathology was present in 115.

CONCLUSION

The appendix may be involved and may contribute to pelvic pain in patients with endometriosis.

Laparoscopic appendectomy: a gynecological approach

The removal of surgical specimen at operative laparoscopy through an incision of the posterior fornix is frequently performed for the removal of pelvic masses of the internal genital tract. We present a technique for the removal of the appendix through a laparoscopic colpotomy. Eight patients who underwent laparoscopy for a suspected pelvic or adnexal disease and intraoperatively found to be affected by an appendicular disease were included in the present series. After intrabdominal dissection, the appendix was removed from the abdomen transvaginally through a laparoscopic colpotomy. The median range of the operation was 45 minutes (range 25-95). There were no intraoperative complications. The postoperative hospitalization period ranged from 2 to 7 days. Vaginal spotting was present in one case and lasted 24 hours. At follow-up visit, no patients complained of pelvic pain or dyspareunia. Vaginal wall induration was not found in any of the patients at pelvic examination. The removal of the appendix through a posterior colpotomy after laparoscopic appendectomy is simple, safe, feasible, well tolerated, and can be considered a valid alternative to other methods.