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Laparoscopic Appendicectomy

Niranjan Agarwal*, MM Begani***, T Naresh Row***
 

Historical Background
After the successful performance of laparoscopic cholecystectomy by Muhe in 1985, various other procedures have been developed and reported. Open Appendicectomy (OA) has stood the test of time, but has a high incidence (20 – 30 %) of negative appendicectomy.1 Laparoscopic Appendicectomy (LA) has proved to be safe and effective procedure, both as a diagnostic and a therapeutic tool reducing the negative Appendicectomy rates. After the first reported laparoscopic appendicectomy by Semm2 in 1983, many reports of laparoscopic appendicectomy3 have established appendicectomy as a logical extension of diagnostic laparoscopy.

Review of Literature
In a series of 678 patients reported by Peir and Goetz4 of patient with symptoms of appendicitis, acute appendicitis was present in 69%, normal appendix in 14%, sub acute appendicitis in 12%, chronic recurring appendicitis in 3%, perforated appendicitis in 2%. Average operating time for LA was 38 minutes. Complications were reported in 1% and conversion to open in 2.2%. Metanalysis of 17 Randomized controlled trial that compared LA with OA, Ching et al5 found an advantage to LA procedure with regards to less postoperative pain, faster recovery and lower wound infection rates. There are another study6 wherein the average hospital stay was statistically significantly shorter following LA but did not improve the results regarding infectious complications and was a cause of serious complications. Some of them required operational revision. In yet another studies by Katkhouda N7 et al, LA did not offer a significant advantage over OA. Laparoscopic appendicectomy assisted procedure has been described by Browne8 where in the combination of the advantage of a wide vision of a laparoscope with direct digital control of tissues of open method is used. LA can also be performed as a Day-case.9

Indications for Laparoscopic appendicectomy :
1. Clinically suspected acute appendicitis
2. Clinically suspected acute complicated appendicitis
3. Uncertain diagnosis especially in a premenopausal women
4. Recurrent appendicitis
5. Obese patients where conventional appendicectomy would require large incision
6. Athletes and others who need to return to early work
7. Incidental appendicectomy in an otherwise normal diagnostic laparoscopy

Pregnancy like previous surgery and obesity should no longer be considered contraindication to laparoscopic surgery. Proper patient selection, meticulous surgical techniques and thorough preparations for planned procedures, awareness regarding increased conversion rate goes a long way in offering the benefits of MIS to these patients

Postoperative course
Is similar to open but overall convalescence decreases and return to normal activity is earlier. However superiority of LA is not established in all cases.

Laparoscopic versus open appendicectomy
The potential benefits of LA includes improved diagnostic capabilities, reduced morbidity owing to fewer wound infections and other complications and reduced post operative disability. However OA through a muscle splitting incision for non-complicated appendicitis is associated with low complication rate and shorter hospital stay. Perhaps the most important advantage provided by LA is an improved ability to diagnose other intra abdominal disease process. Whether these improved diagnostic capabilities of laparoscopy will significantly alter patient outcome is unclear. LA also appears to be more expensive than the OA which may offset the cost savings due to earlier discharge of the patient from the hospital.

Current status
Though safe and efficacious the superiority over traditional method is often debated and the factor influencing its use includes time of the day, availability of instruments and experience of the surgeons. However the question whether LA should replace OA will still remain until further randomized prospective studies are performed specifically targeting the clinical and economic benefits to patients in the weeks after hospital discharge.

References

  1. Change FC, Hogle HH, Welling DR. The fate of negative appendicectomy. Am J Surg 1973; 126 : 752-4.
  2. Semm K. Endoscopic appendicectomy. Endoscopy 1983; 15 : 59-64.
  3. Saye WB, Rives DA, Cochran E. Laparoscopic appendicectomy 3 years experience. Surg Laparosc Endosc 1991; 1 : 109-15.
  4. Pier A, Goetz F. Laparoscopic appendicectomy. Prob Gen Surg 1991; 8 : 416-25.
  5. Ching R. A meta analysis of RCT of laparoscopic appendicectomy v/s conventional appendicectomy. Am J Surg 1999; 177 : 250-6.
  6. Subrt Z, Ferko A, Oberreiter M. Elective open appendicectomy versus elective laparoscopic appendicectomy in women. A retrospective study. Rozhl Chir 2005; 84 (5) : 233-7.
  7. Katkhouda N, Mason RJ, Towfigh S, et al. Laparoscopic Appendicectomy versus open appendicectomy: a prospective randomized double-blind study. Ann Surg 2005; 242 (3) : 439-50.
  8. Browne DS. Laparoscopic guided appendicectomy. A study of 100 consecutive cases. Aust Nz Obstet Gynaecol 1990; 30 : 231.
  9. Begani MM, Row TN, Agarwal N. Day Care Appendicectomy. Paper presented, at: 26th Annual Conference of Maharashtra State Chapter of Association of Surgeons of India (MASICON 04), 8th Feb. 2004, at Thana.

 

SHOULD EVERYONE OVER 50 TAKE ASPIRIN PROPHYLAXIS?

Two sides of the argument are presented on whether aspirin should be used for primary prevention of vascular disease in all people over a certain age, and what that age should be. Elwood and colleagues believe that evidence shows that aspirin should be taken from around 50 years of age, but they also argue that the topic should be widely discussed and that the final decision should lie with each individual person. Baigent is not convinced by the available evidence and argues that such practice could result in net harm.

BMJ, 2005; 330 : 1440,1442.

*Honorary Associate Consultant Surgeon, **Honorary Consultant Surgeon, Bombay Hospital, Mumbai, ***Consultant Surgeon, Abhishek Day Care Institute and MRC, Lady Ratan Tata Medical Centre, Cooperage, Mumbai.
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