Primary experiences with laparoscopic appendectomy

The material comprises 77 patients with suspected appendicitis seen in a district community hospital. In the presence of a surgeon with laparoscopic experience laparoscopy was performed in 23 patients. In two patients the laparoscopy was only diagnostic, and in two patients adhesions or friable gangrenous appendicitis necessitated conversion to conventional appendicectomy. Nineteen patients thus had a laparoscopic appendicectomy performed with a median operation time of 63 minutes and a median hospital stay of two days. One patient with gangrenous appendicitis and a periappendicular abscess was readmitted after three weeks because of deep infection, which resolved after antibiotic treatment. The remaining 54 patients had a conventional appendicectomy performed, with a median operation time of 40 minutes and a median hospital stay of three days. There were six complications in this group. We conclude that laparoscopic appendicectomy is a safe alternative to open operation with benefits for the patient in form of lesser pain, shorter hospital stay, fewer complications, better cosmetic outcome, and shorter time to normal activity.     

Cost-effective appendectomy. Open or laparoscopic? A prospective randomized study

BACKGROUND: Laparoscopic hernia repair has often been criticized for its high costs. METHODS: To compare the costs of laparoscopic and open hernia repair, 40 patients were randomized for either transabdominal laparoscopic or Lichtenstein mesh repair (under local anesthesia) in a day-case surgery unit. RESULTS: Median operative times for the laparoscopic and open groups were 62 and 65 min, respectively. Postoperative pain was comparable for the two groups. The period before return to normal life was 14 days in the laparoscopic group and 21 days in the open group. The hospital costs were 2051 FIM ($1 US = 4.6 FIM) higher in the laparoscopic group, but the total costs for employed patients (including expenses due to lost work days) were lower. CONCLUSION: Although the Lichtenstein operation is cheaper for the hospital, the total costs for working patients are lower with the laparoscopic technique, when the cost of lost work days is factored into overall expense.     

Pre-peritoneal bisaccular umbilical and subcutaneous abscess after laparoscopic appendectomy

Laparoscopic surgery has gained much interest since its advent the late eighties. A 36-year-old patient underwent laparoscopic appendicectomy via the transumbilical route. She was rehospitalized three times thereafter for subumblical pain. At day +48, an abscess was evacuated at the point of the umbilical trocar insertion. This hour-glass shaped abscess had a preperitoneal and subcutaneous localization, blocked by the epiploic reaction. The infection this patient developed is an unusual clinical finding as pain was localized at a distance. The umbilical site and the preperitoneal subcutaneous nature of the abscess are also unusual. This case emphasizes the gravity of post-operative abscess of the abdominal wall and the necessity for adequate prophylaxy.     

Laparoscopic appendectomy. A comparison with open appendectomy

PURPOSE: As laparoscopy becomes a greater part of a general surgeon's practice, each new application must be analyzed. The purpose of this article is to report a four-year experience with laparoscopic appendectomy, with special attention to complications. METHODS: All patients undergoing appendectomy by members of the General Surgery Department of Columbia Hospital between December 20, 1990, and December 24, 1994, were included (n = 434). Medical records were reviewed, and data were analyzed using multiple regression analysis, analysis of variance, and Pearson's chi-squared test. RESULTS: The number of post-operative intra-abdominal abscesses following laparoscopic appendectomy tended to be higher; however, this did not reach statistical significance. Conversely, all other complications combined demonstrated a rate of 4.3 percent for laparoscopic procedures and a rate of 8.5 percent for open procedures. Again this tended toward, but did not reach, statistical significance. Advantage in length of stay was approximately two days, with a mean length of stay for patients undergoing laparoscopic appendectomy of 3.3 days, whereas that for open appendectomy was 5.7 days. CONCLUSION: Laparoscopic appendectomy has significant advantages in terms of patient comfort and length of stay, and its overall complication rate seems to be lower than with open procedures; however, its rate of intra-abdominal abscess may actually be higher. Further study is recommended.     

Should laparoscopic appendectomy be avoided for complicated appendicitis in children?

BACKGROUND/PURPOSE: Laparoscopic appendectomy is becoming the preferred technique for treating acute appendicitis. However, recent literature on adults suggests that laparoscopic appendectomy may increase the risk for postoperative infectious complications in complicated (gangrenous or perforated) cases. This study was undertaken to compare the results of open versus laparoscopic appendectomy for complicated appendicitis in children. METHODS: A retrospective review from two institutions was performed for all children treated operatively for complicated appendicitis from January 1994 through November 1996. RESULTS: Fifty-six cases were identified. Twenty-seven children underwent laparoscopic appendectomy, whereas 22 underwent open appendectomy. Seven children underwent conversion from laparoscopic to open surgery. Operating times and length of hospital stay did not differ significantly between the laparoscopic and open groups. Postoperative complications developed in 24 children (42.8%). Complications were more frequent after laparoscopic appendectomy compared with open appendectomy (56% v 18%, P = .002). A postoperative intraabdominal abscess (IAA) developed in 14 children (25%). An IAA occurred in two children after open appendectomy compared with 11 children after laparoscopic appendectomy (9% v 41%, P = .01). CONCLUSION: The findings suggest that laparoscopic appendectomy should be avoided in children who have complicated appendicitis because of the increased risk for postoperative intraabdominal abscesses. The authors propose a prospective, randomized trial to verify this finding.     

Simplified appendectomy without stump embedding. Experiences of 20 years conventional and 5 years laparoscopic application

Since 1975, the Department of Surgery in the Grevenbroich Community Hospital (Germany) has applied a simplified technique of open appendectomy. The inhouse modified procedure without stump embedding has been performed in 3,448 cases to date. The same approach has been used in 1,463 laparoscopic appendectomies since 1991. In the laparoscopic procedure the stump is ligated solely with Roeder's loop. None of the 4,911 patients who have undergone either open or laparoscopic appendectomy have developed stump inadequacy or stercoral fistulae. According to the special literature, the complication rate after appendectomies without stump embedding is lower than that after standard procedures. In retrospect, laparoscopic appendectomy with simple ligation has confirmed the results achieved with simple ligation in open appendectomies. The technique should therefore become more common practice in open appendectomies, as well.     

Randomized, single-blinded trial of laparoscopic versus open appendectomy in children: effects on postoperative analgesia

BACKGROUND: The benefit of laparoscopy to patients has been clearly established in adults undergoing cholecystectomy. Results are less clear for appendectomy. The current study was undertaken to compare the respective 3-day postoperative periods after laparoscopic and open appendectomy in children. METHODS: Sixty-three children (aged 8-15 yr) scheduled for appendectomy were randomly assigned to two groups: open and laparoscopic. Postoperative evaluation included delay of postoperative recovery (walking and feeding), pain assessment by visual analog scale during the 3 subsequent days, amount of nalbuphine administered via a patient-controlled analgesia system during the first 48 h and responses by children, parents, and nurses on the overall quality of analgesia. RESULTS: There was no difference between groups for demographic data (particularly macroscopic aspect of appendix) analgesia, sedation, delay before eating and walking, incidence of urinary retention, nausea, vomiting. Operative time was long (P < or = to 0.05) in the laparoscopic group (54 +/- 17 min) than in the open group (39 +/- 18 min). Thirty five percent of the children had pain at the shoulder in the LAP group versus ten percent in the open group (P < or = 0.05). CONCLUSIONS: Laparoscopy did not improve analgesia and postoperative recovery after appendectomy in children.     

预注帕瑞昔布对腹腔镜阑尾切除术患者术后疼痛和炎性反应的影响

目的 观察预注帕瑞昔布对腹腔镜阑尾切除患者术后疼痛和炎性反应的影响.方法 于行腹腔镜阑尾切除术患者麻醉前静注帕瑞昔布40mg.术后对腹部及肩背部疼痛进行评估.抽血测定白细胞计数和C反应蛋白(CRP)浓度.结果 术后各时点腹部VAS评分、肩背痛的发生率和程度实验组均低于对照组(P＜0.05);术后1 d白细胞计数和CRP浓度实验组均低于对照组(P＜0.05).结论 预注帕瑞昔布可抑制腹腔镜阑尾切除术患者术后疼痛和早期炎性反应.     

Appendicular mucocele. Clinical cases and review of the literature

The authors report three cases of mucocele of the appendix. They review the literature on this argument and discuss the hypotheses on etiology, pathologic and clinical classification, problems in diagnosis, principles of therapy and prognosis.     

Appendicular mucocele. A report of a case diagnosed preoperatively

Mucocele of the appendix is an unusual clinical entity. Despite a recognized constellation of findings, the diagnosis is not usually made prior to surgical exploration. A 35 year old man is reported in whom clinical evaluation, including US and CT scans, resulted in the correct preoperative diagnosis confirmed at surgery and leading to appropriate operative decisions.     

Appendiceal CT in 140 cases. Diagnostic criteria for acute and necrotizing appendicitis

Computed tomography (CT) was performed in 140 patients with suspected acute appendicitis. Thin collimation (5 mm), intravenous contrast enhancement, 1-second scan times, and supplementary cecal air insufflation were emphasized. CT accuracy was 98% overall (137/140), and 99% in the 124 cases with early surgery. Necrotizing appendicitis was diagnosed by CT with 86% accuracy and 90% positive predictive value.     

Return to work after laparoscopic cholecystectomy

Hoffmann's reflex or H-reflex (HR) is an electrically elicited reflex that measures excitability of motoneurons and shares some physiologic properties with the deep tendon reflex. Children with tendon hyperreflexia due to cerebral palsy usually have higher amplitude HRs. Nitrous oxide (N2O) depresses the HR in patients with normal spinal reflexes, although the effect of N2O in conditions with hyperreflexia such as cerebral palsy is not known. We propose to determine the effect of N2O on the amplitude of the HR under general anesthesia in children with hyperreflexia due to cerebral palsy. We studied eight children undergoing selective dorsal rhizotomy (SDR) for the relief of spasticity. The maximum amplitudes of the HR (HRmax) and direct motor response (MRmax) were routinely evoked under the following anesthetic conditions: 1) sufentanil and 66% N2O/33% oxygen; and 2) sufentanil and 100% oxygen. The HRmax amplitude was significantly lower when N2O was part of the inspired gas mixture. The differences between the no N2O and the 66% N2O groups were significant. The MRmax did not change significantly. Abnormal spinal reflexes seen in spastic diplegia can be abolished by inhaled N2O. This finding also suggests that N2O-induced depression of spinal reflexes should be a consideration during physiologic monitoring of the spinal cord under general anesthesia.     

Cytologic diagnosis of peritoneal fluids. Applicability to the laparoscopic diagnosis of endometriosis

OBJECTIVE: To determine the accuracy of cytologic examination of laparoscopically obtained peritoneal fluid in the diagnosis of endometriosis. STUDY DESIGN: This investigation analyzed 50 laparoscopic fluid specimens received over a three-year period. Retrospective cytologic findings were correlated with clinical history and laparoscopic diagnoses. Touch preparations were also collected from necropsies to develop cytologic criteria necessary to distinguish endometrial cells from mesothelial cells. RESULTS: The presence of hemosiderin-laden macrophages in peritoneal fluids was more specific but less sensitive than the presence of endometrial cells for the diagnosis of endometriosis. CONCLUSIONS: In women undergoing laparoscopy to detect endometriosis, the identification of endometrial cells alone in peritoneal fluids may not be sufficient to render a definitive diagnosis of endometriosis. However, the presence of hemosiderin-laden macrophages in this population should alert the cytologist to that possibility.     

Open laparoscopic approach--an alterative to the Veress needle. Experiences after 1,000 laparoscopies

A mini-laparotomy as described by Hasson was used in a modified way in 1000 laparoscopic procedures. In comparison with the insertion of a Veress needle we find the open approach to be a safer and quicker way of obtaining pneumoperitoneum.