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Freys JC, Bigalke SM, Mertes M, Lobo DN, Pogatzki-Zahn EM, Freys SM. Perioperative pain management for appendicectomy: A systematic review and Procedure-specific Postoperative Pain Management recommendations. Eur J Anaesthesiol 2024; 41:174-187. [PMID: 38214556 DOI: 10.1097/eja.0000000000001953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
BACKGROUND Despite being a commonly performed surgical procedure, pain management for appendicectomy is often neglected because of insufficient evidence on the most effective treatment options. OBJECTIVE To provide evidence-based recommendations by assessing the available literature for optimal pain management after appendicectomy. DESIGN AND DATA SOURCES This systematic review-based guideline was conducted according to the PROSPECT methodology. Relevant randomised controlled trials, systematic reviews and meta-analyses in the English language from January 1999 to October 2022 were retrieved from MEDLINE, Embase and Cochrane Databases using PRISMA search protocols. ELIGIBILITY CRITERIA We included studies on adults and children. If articles reported combined data from different surgeries, they had to include specific information about appendicectomies. Studies needed to measure pain intensity using a visual analogue scale (VAS) or a numerical rating scale (NRS). Studies that did not report the precise appendicectomy technique were excluded. RESULTS Out of 1388 studies, 94 met the inclusion criteria. Based on evidence and consensus, the PROSPECT members agreed that basic analgesics [paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs)] should be administered perioperatively for open and laparoscopic appendicectomies. A laparoscopic approach is preferred because of lower pain scores. Additional recommendations for laparoscopic appendicectomies include a three-port laparoscopic approach and the instillation of intraperitoneal local anaesthetic. For open appendicectomy, a preoperative unilateral transverse abdominis plane (TAP) block is recommended. If not possible, preincisional infiltration with local anaesthetics is an alternative. Opioids should only be used as rescue analgesia. Limited evidence exists for TAP block in laparoscopic appendicectomy, analgesic adjuvants for TAP block, continuous wound infiltration after open appendicectomy and preoperative ketamine and dexamethasone. Recommendations apply to children and adults. CONCLUSION This review identified an optimal analgesic regimen for open and laparoscopic appendicectomy. Further randomised controlled trials should evaluate the use of regional analgesia and wound infiltrations with adequate baseline analgesia, especially during the recommended conventional three-port approach. REGISTRATION The protocol for this study was registered with the PROSPERO database (Registration No. CRD42023387994).
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Affiliation(s)
- Jacob C Freys
- From the Department of Surgery, Agaplesion Bethesda Krankenhaus Hamburg (JCF), Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany (EMP-Z, MM), Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham (DNL), MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, United Kingdom (DNL), Department of Anaesthesiology, Intensive and Pain Medicine, Ruhr-University Bochum, BG-University Hospital Bergmannsheil gGmbH, Bochum (SMB) and Department of Surgery, DIAKO Ev. Diakonie-Krankenhaus, Bremen, Germany (SMF)
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Gao J, Chu Z, Chen J, Zheng Y, Huang X, Hu K. Retrospective analysis of 9 cases of appendiceal mucocele in 3,071 cases of appendicitis. Biomed Rep 2022; 17:55. [PMID: 35719842 PMCID: PMC9198969 DOI: 10.3892/br.2022.1538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/12/2022] [Indexed: 11/14/2022] Open
Abstract
Appendiceal mucocele is a rare disease. Due to the lack of specific clinical symptoms, and the high misdiagnosis rate before operation, in the present study, the clinical data were assessed to determine a potential basis for the diagnosis and treatment of appendiceal mucocele. The clinical data of 3,071 patients with appendicitis admitted between January 2014 and July 2021, including 9 patients with appendiceal mucoceles were retrospectively analyzed. The data were retrieved from the hospital records and included the patients' age, sex, leukocyte counts (measured in the peripheral venous blood sample), the surgical methods, the pathological results and the postoperative follow-up information. Among the 3,071 patients with appendicitis, 9 cases were appendiceal mucocele. These 9 were treated by laparoscopic surgery in 6 cases (2 laparoscopic appendectomy, 2 laparoscopic partial cecectomy plus appendectomy, and 2 laparoscopic right hemicolectomy) and laparotomy in 3 cases (partial cecectomy plus appendectomy). Pathological examination was performed on the surgically resected specimens of all patients. The results showed that 7 cases were appendiceal mucoceles, and 2 cases were low-grade appendiceal mucoceles. During the follow-up after surgery, one patient with exploratory laparotomy plus partial cecectomy and appendectomy was pathologically diagnosed with low-grade appendiceal myxoma. The patient developed peritoneal implants appeared 2 years later, and the remaining patients are still alive, without any postoperative complications or obvious signs of recurrence. Appendiceal mucocele is a disease that usually causes clinical manifestations of acute appendicitis. Ultrasound and CT scans can be used for preoperative diagnosis. The surgical treatment options for mucoceles are open or laparoscopic appendectomy, cecectomy, and right hemicolectomy. Although the incidence of appendiceal mucocele is low, special attention should be paid to surgery due to its predisposition to peritoneal implantation and metastasis. Laparoscopic appendectomy with partial cecectomy is not a difficult procedure and is not likely to cause abdominal implantation metastasis, thus it should be the preferred surgical method. When conditions permit, intraoperative rapid cryotherapy can quickly identify the occurrence of malignant tumors.
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Affiliation(s)
- Jie Gao
- Department of Gastrointestinal Surgery, The First Hospital of Nanping Affiliated to Fujian Medical University, Nanping, Fujian 353000, P.R. China
| | - Zhenfei Chu
- Department of Acute Abdomen Surgery, The First Hospital of Chuzhou, Chuzhou, Anhui 239000, P.R. China
| | - Jun Chen
- Department of Gastrointestinal Surgery, The First Hospital of Nanping Affiliated to Fujian Medical University, Nanping, Fujian 353000, P.R. China
| | - Yiping Zheng
- Department of Respiratory Medicine, The First Hospital of Nanping, Nanping, Fujian 353000, P.R. China
| | - Xing Huang
- Department of Gastrointestinal Surgery, The First Hospital of Nanping Affiliated to Fujian Medical University, Nanping, Fujian 353000, P.R. China
| | - Kongwang Hu
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230000, P.R. China
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Geng J, Yuan J, Kong X, Wu M, Zeng L, Hu Y, Gong J. Laparoscopic Traction Device for Assistance of 2-Port Laparoscopic Appendectomy. Am Surg 2021; 87:1511-1513. [PMID: 33497250 DOI: 10.1177/0003134820920221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jinhong Geng
- 450496 Tinglin Hospital General Surgery Ward, Jinshan District, Shanghai, China
| | - Jinfeng Yuan
- Tinglin Hospital General Gynaecology Ward, Jinshan District, Shanghai, China
| | - Xiangdong Kong
- 450496 Tinglin Hospital General Surgery Ward, Jinshan District, Shanghai, China
| | - Ming Wu
- 450496 Tinglin Hospital General Surgery Ward, Jinshan District, Shanghai, China
| | - Linwen Zeng
- 450496 Tinglin Hospital General Surgery Ward, Jinshan District, Shanghai, China
| | - Yuhong Hu
- Tinglin Hospital Functional Departments, Jinshan District, Shanghai, China
| | - Jianming Gong
- 450496 Tinglin Hospital General Surgery Ward, Jinshan District, Shanghai, China
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Cho IS, Bae SU, Jeong WK, Baek SK. Single-port laparoscopic appendectomy for acute appendicitis during pregnancy. J Minim Access Surg 2021; 17:37-42. [PMID: 31929222 PMCID: PMC7945646 DOI: 10.4103/jmas.jmas_193_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Aim of Study: Acute appendicitis is the most common non-obstetric surgical problem in pregnant patients. As minimally invasive surgery has developed, minimising surgical trauma and improving cosmetic outcomes have led to the development of single-port laparoscopic surgery (SPLS). The aim of this study was to assess the feasibility and safety of SPLS for acute appendicitis during pregnancy. Patients and Methods: Between September 2014 and May 2016, 12 pregnant patients diagnosed with acute appendicitis and having single-port laparoscopic appendectomy were included in the study. Results: The median gestational age at surgery was 16 weeks (6–30 weeks). All operations were completed safely and without vascular or visceral injury. Four patients (33.3%) required conversion to a reduced-port laparoscopic surgery with 3 patients (25%) having a 5 mm port inserted because of perforated appendicitis with drain placement, and 1 patient (8.3%) having a 2-mm needle instrument insertion. Median operation time was 60 min (32–100 min), and a drainage tube was placed in 5 patients (41.7%). Median total length of incision was 2 cm (1.2–2.5 cm). The median time to soft diet initiation and length of stay in the hospital were 1 day (0–9 days) and 5 days (2–11 days), respectively. Two patients (8.0%) developed post-operative complications: One wound site bleeding and two surgical site infections. One case of abortion (8.3%) was noted on the post-operative day 1 and one case of imperforate hymen was noted after delivery. Conclusions: SPLS appendectomy is feasible and safe for treating patients with acute appendicitis during pregnancy.
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Affiliation(s)
- In Soo Cho
- Department of Surgery, School of Medicine, Dongsan Medical Center, Keimyung University, Daegu, Korea
| | - Sung Uk Bae
- Department of Surgery, School of Medicine, Dongsan Medical Center, Keimyung University, Daegu, Korea
| | - Woon Kyung Jeong
- Department of Surgery, School of Medicine, Dongsan Medical Center, Keimyung University, Daegu, Korea
| | - Seong Kyu Baek
- Department of Surgery, School of Medicine, Dongsan Medical Center, Keimyung University, Daegu, Korea
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Hata T, Hayashi N, Urabe S, Hayashi K, Nakagawa T, Michiura T, Yamabe K. Reduced-port laparoscopic appendectomy for acute appendicitis in pregnancy. J Surg Case Rep 2020; 2020:rjaa097. [PMID: 32577201 PMCID: PMC7297555 DOI: 10.1093/jscr/rjaa097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 12/13/2019] [Accepted: 03/30/2020] [Indexed: 12/18/2022] Open
Abstract
Current guidelines indicate that laparoscopic appendectomies are safe for pregnant patients with acute appendicitis. Recently, single- and reduced-port laparoscopic surgeries have gained popularity for nonpregnant patients, because they minimize abdominal wall trauma. Here, we describe a reduced-port laparoscopic appendectomy (RPLA) in a 31-year-old pregnant female performed at 27 weeks gestational age. Preoperative abdominal ultrasonography and computed tomography imaging showed an inflamed, swollen appendix and blood test results showed elevations in the white blood cell count and the C-reactive protein level. Accordingly, acute appendicitis was diagnosed. A surgical incision was performed at the umbilicus with an EZ-access device; an additional 5-mm trocar was placed at the right lower quadrant. Recovery was uneventful. The patient was discharged 8 days postoperatively. A vaginal delivery was achieved at term. The RPLA was a good surgical option for minimizing surgical invasiveness, without increasing the technical difficulty, in conditions where the uterus and fetus are growing.
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Affiliation(s)
- Tsuyoshi Hata
- Department of Surgery, Kinan Hospital, Tanabe, Wakayama, Japan
| | | | - Shoichiro Urabe
- Department of Surgery, Kinan Hospital, Tanabe, Wakayama, Japan
| | - Koji Hayashi
- Department of Surgery, Kinan Hospital, Tanabe, Wakayama, Japan
| | - Tomo Nakagawa
- Department of Surgery, Kinan Hospital, Tanabe, Wakayama, Japan
| | | | - Kazuo Yamabe
- Department of Surgery, Kinan Hospital, Tanabe, Wakayama, Japan
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Development of a Two Port Laparoscopic Appendectomy Technique at a Rural Hospital. Minim Invasive Surg 2019; 2019:9761968. [PMID: 31236293 PMCID: PMC6545795 DOI: 10.1155/2019/9761968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/18/2019] [Indexed: 01/25/2023] Open
Abstract
Background Laparoscopic appendectomy (LA) is most commonly performed using two 5-mm and one 10/12-mm ports. Various attempts to reduce the number and size of ports have been made and new technologies such as single port LA have been introduced. Appendix and mesoappendix are usually divided with a stapler or energy device with electrocautery, clips, and endoloop being cheaper options. Patients and Methods This study includes 51 consecutive LAs performed at a rural hospital. Patients were divided into 4 groups: group 1 was the standard technique group (n=12), group 2 served as a “try-out” (n=12), group 3 served as feasibility group (n=12), and group 4 was the final patient cohort in which the optimized technique was preferably used (n=15). Results Median age of the study cohort was 35.4 (range: 6.2-80.6) years, and 55% of patients were male. Whereas in G1 all patients had standard port placement (10/12-mm, 2x5-mm), in an increasing number of patients in G2-4 only two 5-mm ports and the 2.3-mm Teleflex minigrasper were inserted. Usage of staplers and/or energy devices was reduced from 100% in G1 to 20% in G4, and in the majority of cases both the appendix and the vascular pedicle were secured with an endoloop. The new technique did not add time to the procedure or total OR time. No stump-leaks or surgical site infections were encountered in this series, and there were no conversions to open surgery. Cost savings when not using a stapler or energy device are approximately 400$ per case; the minigrasper added approximately 200$ to the case. Discussion LA with use of two ports and a portless needle grasper is feasible in the majority of cases and was associated with high patient satisfaction and excellent cosmetic results. Avoiding energy devices and staplers is cost saving; the endoloop securely controls appendix and mesoappendix.
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Single-Incision, Two-Port Laparoscopic Appendectomy as an Alternative to Transumbilical Single-Port Laparoscopic Appendectomy. THE JOURNAL OF MINIMALLY INVASIVE SURGERY 2019; 22:11-17. [PMID: 35601706 PMCID: PMC8979846 DOI: 10.7602/jmis.2019.22.1.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 07/25/2018] [Accepted: 07/30/2018] [Indexed: 11/20/2022]
Abstract
Purpose We designed a modified technique to perform an advanced procedure using conventional instruments and did not employ specialized single-incision laparoscopic surgery (SILS) port equipment. We compared postoperative results for transumbilical, single-port laparoscopic appendectomy (TUSPLA) and single-incision, 2-port laparoscopic appendectomy (SITPLA). Methods This retrospective study enrolled 77 patients who underwent TUSPLA or SITPLA to provide more minimally invasive surgery between May 2017 and April 2018. TUSPLA was performed in 39 patients and 38 underwent SITPLA. In the SITPLA group, two 5-mm trocars were inserted through the umbilicus and an extra puncture site was used for a left-handed instrument. Demographic characteristics, operative data, and postoperative outcomes were collected and compared between the groups. Results The mean total operative time in the SITPLA group was shorter than in the TUSPLA group (p=0.003). The mean laparoscopic instrumental time was also shorter (p<0.001) in the SITPLA. The number of postoperative analgesics in the SITPLA group was less than in the TUSPLA group (p=0.002). The length of hospital day after surgery was shorter in the SITPLA group than in the TUSPLA group (p=0.008). There were no other significant differences between the groups. Conclusion SITPLA had a shorter operative time, required less pain management, and had a similar cosmetic outcome when compared with TUSPLA.
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