Safety and efficacy of laparoscopic appendectomy in patient with acute appendicitis
2 مشترك
منتـديات مكتـــوب الاستراتيجية للبحث العلمي MAKTOOB :: الأبحــــاث الــطبيـــة :: رسـائل ماجستـيــر ودكتـــوراة الأبحــــاث الــطبيـــة والعــلميـــة :: أبحاث التمريض
صفحة 1 من اصل 1
Safety and efficacy of laparoscopic appendectomy in patient with acute appendicitis
من طرف ♔ اَلَملَكهَ بَلَقَيــس♔ الخميس فبراير 28, 2008 12:27 pm
[]
Safety and efficacy of laparoscopic appendectomy in patients with acute appendicitis[/size]
Dr.Mohammad Alkanderi, Dr.Marek Šoltés PhD, Dr.Peter Pažinka PhD, Dr.Jozefína Petrovičová
Nemocnica Košice-Šaca, Surgical Dept., Košice, Slovak Republic
P. J. Šafárik University, Institute of medical informatics, Trieda SNP 1, 040 66 Košice, Slovak Republic
Abstract
Introduction: Laparoscopic appendectomy (LA) is considered to be safe and effective treatment for patients with chronic appendicitis. Nevertheless, there is still ongoing debate about its use in conditions of acute appendicitis (AA).
Material and methods: Prospective clinical cohort study. 83 patients who underwent appendectomy for AA at our institution between April 1999 and March 2002 were included in the study. Acute inflammation was confirmed by histological examination in all cases. 64 patients (group I) were operated via laparotomy and 19 (group II) laparoscopically. LA was performed in all cases when experienced laparoscopic surgeon was available. Analysed endpoint variables included operating time, conversion rate, readmission, reoperation, mortality, length of hospitalisation, incisional complications and abdominal abscess formation.
Results: LA is associated with significantly prolonged operating time. On the contrary length of hospital stay is significantly shorter. There seem to be fewer incisional complications; difference is not statistically significant though. No difference in abdominal abscess formation and reoperation or readmission rate was found.
Conclusions: LA represents equally safe and effective treatment modality for AA compared to open procedure. Its main advantage is possibility of complete visualisation of the abdominal cavity. Further randomised controlled trials are needed to confirm anticipated advantages of LA for AA.
Key words: laparoscopy – appendectomy – laparoscopic appendectomy – appendicitis – acute abdomen
Background
Since its introduction by McBurney in 1894, appendectomy is the treatment of choice for acute appendicitis [4]. It soon became one of the most frequently performed surgical procedures. Nowadays, in the developed countries, about 8 % of the population is appendectomised for acute appendicitis at some point of their lifetime [1]. The evolution of endoscopic surgery led to idea of performing appendectomy via laparoscopy. In 1981 Semm introduced the first laparoscopic appendectomy in Germany [7]. Nevertheless, the new method has only gained partial acceptance, because the advantages of laparoscopic appendectomy are not as obvious as those of laparoscopic cholecystectomy. Possibility of complete visualization of the abdominal cavity allowing differential diagnosis of chronic or recurrent right iliac fossa/pelvic pain is the principal advantage of laparoscopic approach which determined its use particularly in patients with anticipated chronic appendicitis.
It is still laparotomy though that prevails in condition of acute inflammatory changes. Open appendectomy is considered to be a safe and effective operation for acute appendicitis. Potential benefits of laparoscopic approach that besides optimal visualisation include simple localization of an ectopic appendix, operative tactic flexibility, easy thorough peritoneal lavage, decreased level of pain and number of the incisional complications along with shortened hospital stay and layoff from normal activity remain still controversial in terms of clinical significance [2].
The aim of this study was to assess safety and efficacy of laparoscopic appendectomy in patients with acute appendicitis.
Methods
Type of study: prospective clinical cohort study.
Clinical setting: General surgical department with sufficient institutional experience concerning laparoscopic procedures (more than 2000 laparoscopic operations performed prior beginning of the study, out of those over 100 appendectomies for chronic appendicitis); well experienced laparoscopic surgeons.
Inclusion criteria: Every patient undergoing appendectomy for acute appendicitis at our institution between April 1999 and March 2002 was included in the study. Diagnosis was confirmed by histological examination in all cases. Patients operated for right iliac fossa pain of different origin than acute appendicitis were not included.
Choice of procedure: Laparoscopic appendectomy was agreed to be the method of choice provided all necessary basic conditions for successful performance were fulfilled (availability of experienced laparoscopic surgeon, operating room space, technical equipment). Otherwise procedure was performed by laparotomy.
Operating technique: laparoscopic procedure – 3 ports (11 mm at umbilicus, 11 mm in the left mesogastrium in midclavicular line, 6 mm at the level of pubic hair in midline), 10 mm 45 degree optic, mesoappendix secured by stripping technique with use of monopolar electrocautery, alternatively use of titanium clips, appendical stump secured by single endoloop (Roeder`s knot), specimen extracted via 10 mm reduction sleeve or in the endobag after removing 11 mm port in the left mesogastrium; open procedure – standard technique
Endpoint variables: to assess efficacy and safety of the procedure following endpoint variables were recorded: operating time, conversion, length of hospitalisation, readmission, reoperation, mortality and morbidity – incisional complications and intraabdominal abscess formation. Operating time was measured from the skin incision until its closure.
Statistical analysis: obtained data were statistically analysed with the aid of statistical software. Unpaired t-test, Mann-Whitney U test and Chi square test were used where applicable. Statistical difference was concerned significant for p value < 0.05.
Material
83 patients with histopathologically confirmed acute appendicitis underwent appendectomy at our institution between April 1999 and March 2002. 64 patients were operated via laparotomy (group I.), 19 laparoscopically (group II.).
Tab. 1. Age and sex description – open vs. laparoscopic group
Variable Open group (n=64) Laparoscopic group (n=19) p value
Age 31.4 years (SD=16.5) 30.1 years (SD=13.6) NS
Male sex 39 (61%) 11 (57.9%) NS
Female sex 25 (39%) 8 (42.1%) NS
Group I: mean age 31.4 years (SD=16.5, min 9, max 79), 39 males (61%), 25 females (39%). Group II: mean age 30.1 years (SD=13.6, min 15, max 59), 11 males (57.9%), 8 females (42.1%). There is no statistical difference in age and male/female ratio between groups.
Results
There were no deaths; all patients were cured in terms of intention to treat analysis. Mean operating time in laparoscopic group was 61 minutes (SD=20.4, min 30, max 90) while that in the open group was 48 minutes (SD=17, min 20, max 115). One laparoscopic operation was converted due to retrocoecal perforated appendicitis (5.2%). There were 5 incisional complications (7.8%) in the open group (2 x seroma, 1 x abscess, 1 x phlegmona, 1 x dehiscence), 1 reoperation (wound dehiscence), 1 intraabdominal abscess (1.5%) requiring readmission and antibiotic treatment. No incisional complication, intraabdominal abscess, reoperation or readmission was recorded in laparoscopic group. Mean hospital stay in the open group was 5.57 days (SD=2.4) vs. 3.66 (SD=1.2) in laparoscopic group.
Tab. 2. Results – open vs. laparoscopic appendectomy for acute appendicitis
Variable Open group Laparoscopic group p value
Operating time 48 min (SD=17) 61 min (SD=20.4) p<0.001
Incisional complications 5 (7.8%) 0 NS
Intraabdominal abscess 1 (1.5%) 0 NS
Hospital stay 5,57 days (SD=2.4) 3,66 days (SD=1.2) p<0.001
Readmission 1 (1.5%) 0 NS
Reoperation 1 (1.5%) 0 NS
Discussion
Principal problem of laparoscopic appendectomy for acute appendicitis is emergency setting of the procedure. Although laparoscopic procedure was stated to be a method of choice in our study, providing conditions were fulfilled for its successful completion, it was performed only in 22.9 % of patients. Limiting factors such as availability of experienced laparoscopic team (on call), operating theatre space (elective laparoscopic operations) and technical limitations (availability of equipment) do interfere with employing laparoscopic interventions in emergency conditions.
Several studies indicated prolonged operating time for laparoscopic appendectomy in acute appendicitis compared to open procedure [3,6,8]. In our study this difference was 13 minutes (p<0.001). Nevertheless, with growing number of operations performed in acute inflammatory setting we noticed a tendency towards shortening of operating time. There is no doubt that learning curve bias is present in our study, which explains above mentioned facts. It is evident that increasing experience with laparoscopic appendectomy in acute appendicitis may lead to diminishing of difference in operating times compared to open procedure. This assumption, however, has to be confirmed by further investigations.
Difference in hospital stay in favour of laparoscopic approach (-1.91 days, p<0.001) is probably influenced by two factors. First of all, incisional complications that prevailed in the open group led to prolonged hospitalisation. Secondly, a tendency towards earlier mobilisation and better postoperative course was seen in patients after laparoscopic intervention that might have influenced their earlier return from hospital.
Although numbers of patients included in the study are too small to drive definitive conclusions about the difference in incisional complications, their increased prevalence (7.8%) was noted in the open group. These results, although not significant, agree with previously published reports, including several meta-analyses of randomised controlled trials [3,5,8].
No difference in intraabdominal abscess formation, readmission and reoperation figures indicates that they seem to be dependent rather on the stage of peritonitis and presence of concomitant diseases than on type of surgical approach. Similar results were obtained in majority of clinical trials [3,8].
This study did not address one principal advantage of laparoscopic procedure that is clear: possibility of complete visualisation of the abdominal cavity. Diagnostic superiority of laparoscopic approach that is obvious seems to be a very strong argument in favour of miniinvasive method.
Conclusions
Laparoscopic appendectomy is considered to be safe and effective treatment for patients with chronic appendicitis. This study confirmed that despite ongoing debate about its indication for acute appendicitis, it is equally safe and effective in conditions of acute inflammatory changes as well. Diagnostic superiority of laparoscopy along with shortened hospital stay and smaller number of incisional complications speak in favour of miniinvasive approach. Prolonged operating time, which is potential drawback of laparoscopic treatment, seems to be biased by learning curve and decreases with growing experience. Further randomised controlled trials are needed to answer all the questions regarding superiority of open or laparoscopic appendectomy for acute appendicitis.
References
[1] Addiss D.G., Shaffer N., Fowler B.S., Tauxe R.V.: The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol, 1990, 132, 910-925
[2] Fingerhut A., Millat B., Borrie F.: Laparoscopic versus Open Appendectomy: Time to Decide. World J Surg, 1999, 23, 835-845
[3] Garbutt J.M., Soper N.J., Shannon W.D., Botero A., Littenberg B.: Meta-analysis of randomised controlled trials comparing laparoscopic and open appendectomy. Surg Laparosc Endosc, 1999, 9, 17-26
[4] McBurney C.: The incision made in the abdominal wall in cases of appendicitis, with a description of a new method of operating. Ann Surg, 1894, 20, 38
[5] Meynaud-Kraemer L., Colin C., Vergnon P., Barth X.: Wound infection in open versus laparoscopic appendectomy. A meta-analysis. Int J Technol Assess Health Care, 1999, 15, 380-91
[6] Sauerland S., Lefering R., Holthausen U., Neugebauer E.A.M.: Laparoscopic vs conventional appendectomy – a meta-analysis of randomised controlled trials. Langenbeck`s Arch Surg, 1998, 383, 289-295
[7] Semm K.: Die endoskopishe Appendektomie. Gynakol Prax, 1982, 7, 26
[8] Temple L.K., Litwin D.E., McLeod R.S.: A meta-analysis of laparoscopic versus open appendectomy in patients suspected of having acute appendicitis. Can J Surg, 1999, 42, 377-83
Safety and efficacy of laparoscopic appendectomy in patients with acute appendicitis[/size]
Dr.Mohammad Alkanderi, Dr.Marek Šoltés PhD, Dr.Peter Pažinka PhD, Dr.Jozefína Petrovičová
Nemocnica Košice-Šaca, Surgical Dept., Košice, Slovak Republic
P. J. Šafárik University, Institute of medical informatics, Trieda SNP 1, 040 66 Košice, Slovak Republic
Abstract
Introduction: Laparoscopic appendectomy (LA) is considered to be safe and effective treatment for patients with chronic appendicitis. Nevertheless, there is still ongoing debate about its use in conditions of acute appendicitis (AA).
Material and methods: Prospective clinical cohort study. 83 patients who underwent appendectomy for AA at our institution between April 1999 and March 2002 were included in the study. Acute inflammation was confirmed by histological examination in all cases. 64 patients (group I) were operated via laparotomy and 19 (group II) laparoscopically. LA was performed in all cases when experienced laparoscopic surgeon was available. Analysed endpoint variables included operating time, conversion rate, readmission, reoperation, mortality, length of hospitalisation, incisional complications and abdominal abscess formation.
Results: LA is associated with significantly prolonged operating time. On the contrary length of hospital stay is significantly shorter. There seem to be fewer incisional complications; difference is not statistically significant though. No difference in abdominal abscess formation and reoperation or readmission rate was found.
Conclusions: LA represents equally safe and effective treatment modality for AA compared to open procedure. Its main advantage is possibility of complete visualisation of the abdominal cavity. Further randomised controlled trials are needed to confirm anticipated advantages of LA for AA.
Key words: laparoscopy – appendectomy – laparoscopic appendectomy – appendicitis – acute abdomen
Background
Since its introduction by McBurney in 1894, appendectomy is the treatment of choice for acute appendicitis [4]. It soon became one of the most frequently performed surgical procedures. Nowadays, in the developed countries, about 8 % of the population is appendectomised for acute appendicitis at some point of their lifetime [1]. The evolution of endoscopic surgery led to idea of performing appendectomy via laparoscopy. In 1981 Semm introduced the first laparoscopic appendectomy in Germany [7]. Nevertheless, the new method has only gained partial acceptance, because the advantages of laparoscopic appendectomy are not as obvious as those of laparoscopic cholecystectomy. Possibility of complete visualization of the abdominal cavity allowing differential diagnosis of chronic or recurrent right iliac fossa/pelvic pain is the principal advantage of laparoscopic approach which determined its use particularly in patients with anticipated chronic appendicitis.
It is still laparotomy though that prevails in condition of acute inflammatory changes. Open appendectomy is considered to be a safe and effective operation for acute appendicitis. Potential benefits of laparoscopic approach that besides optimal visualisation include simple localization of an ectopic appendix, operative tactic flexibility, easy thorough peritoneal lavage, decreased level of pain and number of the incisional complications along with shortened hospital stay and layoff from normal activity remain still controversial in terms of clinical significance [2].
The aim of this study was to assess safety and efficacy of laparoscopic appendectomy in patients with acute appendicitis.
Methods
Type of study: prospective clinical cohort study.
Clinical setting: General surgical department with sufficient institutional experience concerning laparoscopic procedures (more than 2000 laparoscopic operations performed prior beginning of the study, out of those over 100 appendectomies for chronic appendicitis); well experienced laparoscopic surgeons.
Inclusion criteria: Every patient undergoing appendectomy for acute appendicitis at our institution between April 1999 and March 2002 was included in the study. Diagnosis was confirmed by histological examination in all cases. Patients operated for right iliac fossa pain of different origin than acute appendicitis were not included.
Choice of procedure: Laparoscopic appendectomy was agreed to be the method of choice provided all necessary basic conditions for successful performance were fulfilled (availability of experienced laparoscopic surgeon, operating room space, technical equipment). Otherwise procedure was performed by laparotomy.
Operating technique: laparoscopic procedure – 3 ports (11 mm at umbilicus, 11 mm in the left mesogastrium in midclavicular line, 6 mm at the level of pubic hair in midline), 10 mm 45 degree optic, mesoappendix secured by stripping technique with use of monopolar electrocautery, alternatively use of titanium clips, appendical stump secured by single endoloop (Roeder`s knot), specimen extracted via 10 mm reduction sleeve or in the endobag after removing 11 mm port in the left mesogastrium; open procedure – standard technique
Endpoint variables: to assess efficacy and safety of the procedure following endpoint variables were recorded: operating time, conversion, length of hospitalisation, readmission, reoperation, mortality and morbidity – incisional complications and intraabdominal abscess formation. Operating time was measured from the skin incision until its closure.
Statistical analysis: obtained data were statistically analysed with the aid of statistical software. Unpaired t-test, Mann-Whitney U test and Chi square test were used where applicable. Statistical difference was concerned significant for p value < 0.05.
Material
83 patients with histopathologically confirmed acute appendicitis underwent appendectomy at our institution between April 1999 and March 2002. 64 patients were operated via laparotomy (group I.), 19 laparoscopically (group II.).
Tab. 1. Age and sex description – open vs. laparoscopic group
Variable Open group (n=64) Laparoscopic group (n=19) p value
Age 31.4 years (SD=16.5) 30.1 years (SD=13.6) NS
Male sex 39 (61%) 11 (57.9%) NS
Female sex 25 (39%) 8 (42.1%) NS
Group I: mean age 31.4 years (SD=16.5, min 9, max 79), 39 males (61%), 25 females (39%). Group II: mean age 30.1 years (SD=13.6, min 15, max 59), 11 males (57.9%), 8 females (42.1%). There is no statistical difference in age and male/female ratio between groups.
Results
There were no deaths; all patients were cured in terms of intention to treat analysis. Mean operating time in laparoscopic group was 61 minutes (SD=20.4, min 30, max 90) while that in the open group was 48 minutes (SD=17, min 20, max 115). One laparoscopic operation was converted due to retrocoecal perforated appendicitis (5.2%). There were 5 incisional complications (7.8%) in the open group (2 x seroma, 1 x abscess, 1 x phlegmona, 1 x dehiscence), 1 reoperation (wound dehiscence), 1 intraabdominal abscess (1.5%) requiring readmission and antibiotic treatment. No incisional complication, intraabdominal abscess, reoperation or readmission was recorded in laparoscopic group. Mean hospital stay in the open group was 5.57 days (SD=2.4) vs. 3.66 (SD=1.2) in laparoscopic group.
Tab. 2. Results – open vs. laparoscopic appendectomy for acute appendicitis
Variable Open group Laparoscopic group p value
Operating time 48 min (SD=17) 61 min (SD=20.4) p<0.001
Incisional complications 5 (7.8%) 0 NS
Intraabdominal abscess 1 (1.5%) 0 NS
Hospital stay 5,57 days (SD=2.4) 3,66 days (SD=1.2) p<0.001
Readmission 1 (1.5%) 0 NS
Reoperation 1 (1.5%) 0 NS
Discussion
Principal problem of laparoscopic appendectomy for acute appendicitis is emergency setting of the procedure. Although laparoscopic procedure was stated to be a method of choice in our study, providing conditions were fulfilled for its successful completion, it was performed only in 22.9 % of patients. Limiting factors such as availability of experienced laparoscopic team (on call), operating theatre space (elective laparoscopic operations) and technical limitations (availability of equipment) do interfere with employing laparoscopic interventions in emergency conditions.
Several studies indicated prolonged operating time for laparoscopic appendectomy in acute appendicitis compared to open procedure [3,6,8]. In our study this difference was 13 minutes (p<0.001). Nevertheless, with growing number of operations performed in acute inflammatory setting we noticed a tendency towards shortening of operating time. There is no doubt that learning curve bias is present in our study, which explains above mentioned facts. It is evident that increasing experience with laparoscopic appendectomy in acute appendicitis may lead to diminishing of difference in operating times compared to open procedure. This assumption, however, has to be confirmed by further investigations.
Difference in hospital stay in favour of laparoscopic approach (-1.91 days, p<0.001) is probably influenced by two factors. First of all, incisional complications that prevailed in the open group led to prolonged hospitalisation. Secondly, a tendency towards earlier mobilisation and better postoperative course was seen in patients after laparoscopic intervention that might have influenced their earlier return from hospital.
Although numbers of patients included in the study are too small to drive definitive conclusions about the difference in incisional complications, their increased prevalence (7.8%) was noted in the open group. These results, although not significant, agree with previously published reports, including several meta-analyses of randomised controlled trials [3,5,8].
No difference in intraabdominal abscess formation, readmission and reoperation figures indicates that they seem to be dependent rather on the stage of peritonitis and presence of concomitant diseases than on type of surgical approach. Similar results were obtained in majority of clinical trials [3,8].
This study did not address one principal advantage of laparoscopic procedure that is clear: possibility of complete visualisation of the abdominal cavity. Diagnostic superiority of laparoscopic approach that is obvious seems to be a very strong argument in favour of miniinvasive method.
Conclusions
Laparoscopic appendectomy is considered to be safe and effective treatment for patients with chronic appendicitis. This study confirmed that despite ongoing debate about its indication for acute appendicitis, it is equally safe and effective in conditions of acute inflammatory changes as well. Diagnostic superiority of laparoscopy along with shortened hospital stay and smaller number of incisional complications speak in favour of miniinvasive approach. Prolonged operating time, which is potential drawback of laparoscopic treatment, seems to be biased by learning curve and decreases with growing experience. Further randomised controlled trials are needed to answer all the questions regarding superiority of open or laparoscopic appendectomy for acute appendicitis.
References
[1] Addiss D.G., Shaffer N., Fowler B.S., Tauxe R.V.: The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol, 1990, 132, 910-925
[2] Fingerhut A., Millat B., Borrie F.: Laparoscopic versus Open Appendectomy: Time to Decide. World J Surg, 1999, 23, 835-845
[3] Garbutt J.M., Soper N.J., Shannon W.D., Botero A., Littenberg B.: Meta-analysis of randomised controlled trials comparing laparoscopic and open appendectomy. Surg Laparosc Endosc, 1999, 9, 17-26
[4] McBurney C.: The incision made in the abdominal wall in cases of appendicitis, with a description of a new method of operating. Ann Surg, 1894, 20, 38
[5] Meynaud-Kraemer L., Colin C., Vergnon P., Barth X.: Wound infection in open versus laparoscopic appendectomy. A meta-analysis. Int J Technol Assess Health Care, 1999, 15, 380-91
[6] Sauerland S., Lefering R., Holthausen U., Neugebauer E.A.M.: Laparoscopic vs conventional appendectomy – a meta-analysis of randomised controlled trials. Langenbeck`s Arch Surg, 1998, 383, 289-295
[7] Semm K.: Die endoskopishe Appendektomie. Gynakol Prax, 1982, 7, 26
[8] Temple L.K., Litwin D.E., McLeod R.S.: A meta-analysis of laparoscopic versus open appendectomy in patients suspected of having acute appendicitis. Can J Surg, 1999, 42, 377-83
♔ اَلَملَكهَ بَلَقَيــس♔- ♔ السمو الملكي ♔
- جائزه تسجيل للعام 10 اعوامجائزه الاعجاباتتاج 100 موضوعتاج المواضيعجائزه المواضيع امميزهعدد المشاركات بالمواضيع المميزهوسام التميزجائزه التميز
- عدد الرسائل : 3097
العمل/الترفيه : /لـآ شَي أوجَع منْ الحَنينْ ..~
الابراج :
الموقع : هوَ يشَبِه السّعادَةَ ؛ كلِ ماَ فكَرت فيَه ابتسَم !*
احترام القانون :
المزاج : ♡༽رفُُقُُآ بًًنِِبًًض قُُلََبًًيََ༼♡
نقاط : 55996
السٌّمعَة : 30
تاريخ التسجيل : 26/02/2008
تعاليق : الحب يزهر إذ التقينا بما يجمعنا لا بما يعجبنا !
-
رد: Safety and efficacy of laparoscopic appendectomy in patient with acute appendicitis
من طرف آهـــوآكـــ الأربعاء أكتوبر 28, 2009 11:11 am
. . .
,’
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يعطيكـ ـآلف عآفية ،،
كل الشكر والتقدير
,’
يسلمو دياتك على روعة الموضوع
يعطيكـ ـآلف عآفية ،،
كل الشكر والتقدير
آهـــوآكـــ- ♛ مجلس الوزراء ♛
- جائزه تسجيل للعام 10 اعوامجائزه المواضيع المميزهجائز المجموعاتجائزه عدد النقاطعدد المشاركات بالمواضيع المميزهجائزه الاعجابات
- عدد الرسائل : 246
الابراج :
الموقع : بستان ورود
احترام القانون :
نقاط : 15075
السٌّمعَة : 8
تاريخ التسجيل : 09/04/2008
تعاليق : { .. أبيــــــــــك .. }
بكل مآفيني أبيك ..
تعآل و رجع لي البسمه .. تعآل و رجع لي كيآني ..
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منتـديات مكتـــوب الاستراتيجية للبحث العلمي MAKTOOB :: الأبحــــاث الــطبيـــة :: رسـائل ماجستـيــر ودكتـــوراة الأبحــــاث الــطبيـــة والعــلميـــة :: أبحاث التمريض
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