Laparoscopic Appendectomy For Acute Appendicitis Research Articles

A comparative study on surgical site infection in cases of open and laparoscopic appendicectomy

Background: Diagnosis of acute appendicitis is mostly based on clinical features pointing towards appendicitis. Several biochemical parameters, such as the white blood cell (WBC) count, and neutrophil percentage, are currently used to aid clinical diagnosis. Without immediate surgery, appendicitis may progress to perforation of the appendix. This study was carried out to determine rate of SSI in open versus laparoscopic appendicectomy for acute appendicitis and to identify independent risk factors for SSI.Methods: Appendicitis is a common cause of pain in right iliac fossa worldwide. The present study was carried out in the Department of General Surgery, Acharya Vinoba Bhave Rural Hospital, affiliated to Jawaharlal Nehru Medical College, Sawangi, Wardha, from August 2015 to July 2017. This study was conducted after the due clearance from Institutional Ethical committee. Total 132 patients admitted to the surgery ward with acute lower abdominal pain with clinical features of acute appendicitis on clinical examination, were studied prospectively.Results: In the present study, maximum patients were seen in less than 20 years of age and next commonest age group of presentation was 21-30 years. The male to female sex ratio was 1:1.3 in the laparoscopic appendectomy group while in the open appendectomy group was 1.81:1. The incidence of complicated intra-operative findings and mean white blood cell count was more in the open appendectomy group. The mean operative time, days for use of analgesics, time taken to return to soft diet and length of hospital stay for laparoscopic appendectomy group was less than the open appendectomy group. There were more cases of surgical site infection in the patients operated by open approach than laparoscopic approach.Conclusions: Wound class II versus III and NNIS index were found to be significantly associated with surgical site infection.

Application of laparoscopy in acute appendicitis for the elderly: A single center experience

Background and Purpose: Laparoscopic appendectomy for acute appendicitis is gold standard for adult patients in the world. The incidence of appendicitis in the elderly has risen. The aim of this study was to compare post-operatory outcomes in old patients with acute appendicitis approached by laparoscopy versus open surgery. Methods: We retrospectively analysed the data of elderly patients who underwent appendectomy for acute appendicitis from 1st of January 2010 to the 1st of August 2017. We analysed 286 appendectomies in elderly patients: 214 patients were operated by laparoscopic appendectomy (LA) and 72 patient were underwent Open Appendectomy (OA). Results: The operation time was slightly longer in the LA group (P<0.001), but the time of recovery inflammatory response, time for diet and hospital stay were significantly shorter in LA group than that in OA group. Complications: The rate of surgical site infection in LA group was less than that in OA group, and the rate of pneumonia between LA group and OA group was similar. Conclusions: Laparoscopic appendectomy can be recommended as first choice for old patients with appendicitis.

A Case of Laparoscopic Appendectomy for Acute Appendicitis in Patient in her 26TH Week of Pregnancy

A Case of Laparoscopic Appendectomy for Acute Appendicitis in Patient in her 26^TH Week of Pregnancy

Laparoscopic Appendectomy for Acute Appendicitis in a Patient with a Lumboperitoneal Shunt

Laparoscopic Appendectomy for Acute Appendicitis in a Patient with a Lumboperitoneal Shunt

Two Cases of Laparoscopic Appendectomy for Acute Appendicitis in the Second Trimester of Pregnancy

Two Cases of Laparoscopic Appendectomy for Acute Appendicitis in the Second Trimester of Pregnancy

Antibiotic Powder Reduces Surgical Site Infections in Children After Single-Incision Laparoscopic Appendectomy for Acute Appendicitis.

Single-incision laparoscopic appendectomy (SILA) has a higher rate of wound infection than the multiport technique. The purpose of this project was to determine whether the use of topical antibiotic powder reduces surgical site infections (SSIs) in pediatric patients who undergo SILA. Patients aged 0-21 years who underwent SILA for acute appendicitis from April 2015 to November 2016 were included in this quality improvement initiative. Cefoxitin powder was placed in the umbilical wound before skin closure. Data were prospectively collected and outcome measures were compared with a historical cohort who underwent SILA before the implementation of antibiotic powder. There were 108 patients in the historical group (HIST) and 126 in the powder group (POWD). The groups were similar in age (HIST: 11.5 ± 3.6 versus POWD: 12.2 ± 3.7 years, P = .15) and body mass index percentile (HIST: 57.6 ± 30.7 versus POWD: 58.8 ± 27.8, P = .84). Operative time was longer in the powder group (HIST: 26.5 ± 7.5 versus POWD: 29.7 ± 8.9 minutes, P = .004). Length of stay (HIST: 0.2 ± 0.4 versus POWD: 0.1 ± 0.4 days, P = .06), 30-day return to emergency department (HIST: 7% versus POWD: 8%, P = 1.0), and hospital readmissions (HIST: 5% versus POWD: 2%, P = .8) were similar. There was a significantly lower rate of superficial SSIs in the powder group (HIST: 4.6% versus POWD: 0%, P = .02). In pediatric patients undergoing SILA for acute appendicitis, the use of cefoxitin powder in the umbilical wound is a simple intervention to reduce the incidence of superficial SSIs.

Transumbilical extracorporeal laparoscopic-assisted appendectomy

Aim of the studyThe perfect balance between safety, cosmesis, and cost effectiveness in a world with ever growing healthcare costs has yet to be found for nonperforated appendicitis. The aim is to present our data regarding safety and cost effectiveness of the transumbilical extracorporeal laparoscopic-assisted appendectomy technique. MethodsA retrospective review was performed for all laparoscopic appendectomies for acute appendicitis from October 2014 to October 2016. All cases of perforated appendicitis were excluded (visible hole/abscess/free pus). Included cases were divided into two groups by operative technique: transumbilical (TU) or laparoscopic 3-port (L3P). Operating room charges were billed in 30-min intervals, and hospital charges billed per night in-house. The technique was that the appendix is identified with the laparoscope, grabbed with a grasper that is inserted parallel to the laparoscope, and exteriorized through the umbilicus. The appendectomy is completed extracorporeally. ResultsA total of 494 cases of nonperforated appendicitis were included in the study. One surgeon attempted all cases with the TU technique (n=161), and all other surgeons used the L3P technique (n=333), which required an endostapler and a vascular sealing device. The TU technique was successful in 99 of the attempted cases. The mean operative time of the TU cases and the L3P cases was 21 (8–43) and 37 (12–73) min, respectively (P<0.001). The mean hospital stay for the TU and the L3P cases was 1.6 (1–5) days (one-night admission) and 2.4 (1–14) days (two-night admission), respectively (P<0.001). There were no operative complications or readmissions in either group. The overall cost of the L3P cases was 30% higher than the cost of the TU cases. ConclusionThe transumbilical extracorporeal laparoscopic-assisted technique was as safe as the laparoscopic 3-port technique. It offered all the advantages of a minimally invasive procedure, was associated with a significantly shorter hospital stay, and was remarkably more cost effective than the standard laparoscopic 3-port technique. Level of evidenceIII

Resource savings and outcomes associated with outpatient laparoscopic appendectomy for nonperforated appendicitis

BackgroundPostoperative admission for acute appendicitis utilizes health care system resources. We evaluated outcomes and hospital charges for children with nonperforated appendicitis who underwent outpatient laparoscopic appendectomy. MethodsA retrospective chart review was performed for patients ≤18years old who underwent laparoscopic appendectomy for acute appendicitis in 2015. Patients were categorized into discharge from postanesthesia care unit (PACU) (outpatient), admission for <24-h, and admission for >24-h. Continuous variables were compared using analysis of variance and categorical variables were compared using chi-square test, with p<0.05 considered significant. ResultsOf the 171 patients identified, 63 (37%) were discharged from the PACU, 94 (55%) were admitted <24-h, and 14 (8%) were admitted >24-h. There were no differences in postoperative emergency department/clinic visits, complications, or readmissions. Hospital charges for admission <24-h and >24-h were $1007 and $2237 more per patient than the PACU-discharge group, respectively. Outpatient laparoscopic appendectomies became more common over time, occurring in only 20% of patients with acute appendicitis in the first quarter of the year versus 49% of patients in the last quarter. ConclusionOutpatient laparoscopic appendectomy for nonperforated appendicitis in children is a safe practice that decreases length of stay and hospital charges. Adoption of an outpatient strategy allows for better standardization of care and can lead to savings in health care resources. Level of evidenceIII (Treatment: retrospective comparative study).

Laparoscopic appendectomy for acute appendicitis: How to discourage surgeons using inadequate therapy.

Acute appendicitis (AA) develops in a progressive and irreversible manner, even if the clinical course of AA can be temporarily modified by intentional medications. Reliable and real-time diagnosis of AA can be made based on findings of the white blood cell count and enhanced computed tomography. Emergent laparoscopic appendectomy (LA) is considered as the first therapeutic choice for AA. Interval/delayed appendectomy at 6-12 wk after disease onset is considered as unsafe with a high recurrent rate during the waiting time. However, this technique may have some advantages for avoiding unnecessary extended resection in patients with an appendiceal mass. Non-operative management of AA may be tolerated only in children. Postoperative complications increase according to the patient’s factors, and temporal avoidance of emergent general anesthesia may be beneficial for high-risk patients. The surgeon’s skill and cooperation of the hospital are important for successful LA. Delaying appendectomy for less than 24 h from diagnosis is safe. Additionally, a semi-elective manner (i.e., LA within 24 h after onset of symptoms) may be paradoxically acceptable, according to the factors of the patient, physician, and institution. Prompt LA is mandatory for AA. Fortunately, the Japanese government uses a universal health insurance system, which covers LA.

Missed diagnosis of acute stanford Type A aortic dissection presenting with abdominal pain in the setting of acute appendicitis

Acute Stanford Type A aortic dissection (ATAAD) has a high mortality rate, particularly with delayed diagnosis and treatment. A 30-year-old male Marfan patient presented to the emergency department with acute abdominal pain and underwent laparoscopic appendectomy for acute appendicitis about 15 h later. Postoperatively, the patient developed acute pulmonary edema and respiratory failure. Transthoracic echocardiogram revealed severe aortic insufficiency, 7.5 cm root aneurysm, severe left ventricular dysfunction, and probable ATAAD. Following computed tomography angiogram confirmation of ATAAD, he underwent emergency root and ascending aortic replacement with a composite mechanical valve graft 48 h after hospitalization. The patient had Escherichia coli pericarditis at time of sternotomy likely hematogenous from appendicitis and later also developed postoperative pneumonia. At 2 years follow-up, he was doing well without any evidence of prosthetic valve conduit infection. The simultaneous presentation of two unrelated pathologies with acute abdominal pain led to the initial missed diagnosis of ATAAD, which delayed treatment and increased risks for morbidity and mortality. Therefore, Marfan syndrome patients presenting with acute abdomen should be ruled out for acute aortic dissection despite any other obvious concomitant pathology, especially in younger patients.

Interventions to optimize recovery after laparoscopic appendectomy: a scoping review

No enhanced recovery after surgery protocol has been published for laparoscopic appendectomy. This was a review of evidence-based interventions that could optimize recovery after appendectomy. Interventions for the review Clinical pathway, fast-track or enhanced recovery protocols; needlescopic approach; single incision laparoscopic (SIL) approach; natural orifice transluminal endoscopic surgery (NOTES); regional nerve blocks; intraperitoneal local anaesthetic (IPLA); drains. Data sources MEDLINE, EMBASE, the Cochrane Library, and the Web of Science Core Collection. Study eligibility criteria Randomized controlled trial (RCT); prospective evaluation with historical controls for studies assessing clinical pathways/protocols. Participants People undergoing laparoscopic appendectomy for acute appendicitis. Study appraisal and synthesis methods Meta-analysis, random effects model. Clinical pathways for laparoscopic appendectomy were safe in selected patients, but may be associated with a higher readmission rate. Needlescopic surgery offered no recovery advantage over traditional laparoscopic appendectomy. SIL afforded no recovery advantage over conventional laparoscopic surgery, but may increase operative time in children. The search found no RCT on NOTES appendectomy. Transversus abdominis plane blocks did not significantly reduce pain after laparoscopic appendectomy. IPLA should be considered in laparoscopic appendectomy; studies in paediatric surgery are needed. The search found no RCT on the use of drains in appendectomy. This review identified gaps in the literature on optimizing recovery after laparoscopic appendectomy and found the need for more randomized controlled trials on regional anaesthesia and intraperitoneal local anaesthesia in children.

Postoperative antibiotic use and the incidence of intra-abdominal abscess in the setting of suppurative appendicitis: a retrospective analysis

BackgroundAlthough guidelines exist for postoperative antibiotic use in acute appendicitis that is perforated, gangrenous, or simple/uncomplicated, there are less data about its use in suppurative appendicitis. Here, we targeted this subgroup of patients to determine whether postoperative antibiotic administration affects incidence of intra-abdominal abscess formation. MethodsWe retrospectively examined 1,192 patients who underwent laparoscopic appendectomy for acute appendicitis at Kaiser Permanente Fontana Hospital between August 2010 and August 2013. Suppurative appendicitis was described for 143 (12%) patients. Fifty-two patients received postoperative antibiotics for at least 1 week on discharge home, 91 did not. ResultsOf 143 patients with suppurative appendicitis, 1 (1.9%) who received postoperative antibiotics came back with an intra-abdominal abscess within 1 month. Of the 91 patients in the no antibiotic group, 1 (1.1%) came back with an intra-abdominal abscess. ConclusionsThe administration of postoperative antibiotic in the setting of suppurative appendicitis has no effect on the rate of intra-abdominal abscess formation. Routine postoperative antibiotics may not be necessary in this patient population, and more evidence is needed to justify its use.

Endoloops or endostapler use in laparoscopic appendectomy for acute uncomplicated and complicated appendicitis : No difference in infectious complications.

The most appropriate closure for the appendicular stump with either endoloops or an endostapler in laparoscopic appendectomy remains unclear and under debate because of limited and conflicting evidence. In a 2-month prospective, observational, resident-led nationwide cohort study, patients undergoing laparoscopic appendectomy for both uncomplicated and complicated appendicitis were analysed. Logistic regression analyses were performed for identifying the possible effect of stump closure type and other risk factors for infectious complications. Laparoscopic appendectomy for acute appendicitis was performed in 1369 patients in 62 hospitals; endoloops were used in 76.7% and an endostapler in other patients. Median operating time was not different between endoloop and endostapler use (42.0 vs. 44.0min, P=0.243). A superficial surgical site infection was seen in 2.0% after uncomplicated appendicitis and in 0.8% after complicated appendicitis. The intra-abdominal abscess rate was 1.9% after uncomplicated and 11.0% after complicated appendicitis. No significant effect of stump closure type was observed for any infectious complication (OR 1.05; 95% CI 0.625-1.766, P=0.853) or an intra-abdominal abscess (OR OR 0.96; 95% CI 0.523-1.768, P=0.899). In multivariable analysis, complicated appendicitis was identified as the only independent risk factor for an intra-abdominal abscess (OR 6.26; 95% CI 3.454-11.341, P<0.001). The infectious complication rate is not influenced by the type of appendicular stump closure with either endoloops or an endostapler in this study. If technically feasible, closure with endoloops is advised for cost considerations.

Umbilical Negative Pressure Dressing for Transumbilical Appendectomy in Childern.

Background and Objectives:Transumbilical laparoscopic-assisted appendectomy (TULAA) carries a high risk for surgical site infection. We investigated the effect of a bio-occlusive umbilical vacuum dressing on wound infection rates after TULAA for patients with acute appendicitis and compared to it with a conventional 3-port appendectomy with a nonvacuum dressing.Methods:This study was a retrospective chart review of 1377 patients (2–20 years) undergoing laparoscopic appendectomy for acute appendicitis in 2 tertiary care referral centers from January 2007 through December 2012. Twenty-two different operative technique/dressing variations were documented. The 6 technique/dressing groups with >50 patients were assessed, including a total of 1283 patients.Results:The surgical site infection rate of the 220 patients treated with TULAA and application of an umbilical vacuum dressing with dry gauze is 1.8% (95% CI, 0.0–10.3%). This compares to an infection rate of 4.1% (95% CI, 1.3–10.5%) in 97 patients with dry dressing without vacuum. In the 395 patients who received an umbilical vacuum dressing with gauze and bacitracin, the surgical site infection rate was found to be 4.3% (95% CI, 2.7–6.8%).Conclusions:Application of an umbilical negative-pressure dressing with dry gauze lowers the rate of umbilical site infections in patients undergoing transumbilical laparoscopic-assisted appendectomy for acute appendicitis.

骨髄異形成症候群（MDS）経過中に発症し，腹腔鏡下interval appendectomyを施行した急性虫垂炎の1例

骨髄異形成症候群（MDS）経過中に発症し，腹腔鏡下interval appendectomyを施行した急性虫垂炎の1例

Effect of Hospital Volume on Outcomes of Laparoscopic Appendectomy for Acute Appendicitis: an Observational Study

BackgroundThis study investigated the effect of hospital volume on outcomes of laparoscopic appendectomy for acute appendicitis. MethodsIn total, 30,525 patients who underwent laparoscopic appendectomy for acute appendicitis were referred to 825 hospitals in Japan from 2010 to 2012. We compared appendectomy-related complications, length of stay (LOS), and medical costs in relation to hospital volume. For this study period, hospitals were categorized as low-volume hospitals (LVHs, <50 cases), medium-volume hospitals (MVHs, 50–100 cases), or high-volume hospitals (HVHs, >100 cases). ResultsSignificant differences in appendectomy-related complications were observed among the LVHs, MVHs, and HVHs (6.9, 7.2, and 6.0 %, respectively; p = 0.001). Multiple logistic regression revealed that HVHs were associated with a lower relative risk of appendectomy-related complications than were LVHs and MVHs (odds ratio [OR], 0.84; 95 % confidence interval [CI], 0.74–0.95; p = 0.006). Multiple linear regression showed that HVHs were associated with shorter LOS and lower medical costs than were LVHs and MVHs. The unstandardized coefficient for LOS was −0.92 days (95 % CI, −1.07 to −0.78; p < 0.001), whereas that for medical costs was − $167.4 (95 % CI, −256.2 to −78.6; p < 0.001). ConclusionsHospital volume was significantly associated with laparoscopic appendectomy outcomes.

Rectus sheath block for laparoscopic appendicectomy: a randomized clinical trial

The rectus sheath block is effective in elective paediatric operations, but has not been previously studied in acute laparoscopic surgery. We investigated its effect on pain after laparoscopic appendicectomy for acute appendicitis. Children aged 8-14 years admitted to a paediatric teaching hospital participated in a randomized clinical trial comparing a rectus sheath block using bupivacaine plus adrenaline with saline control. The primary outcomes were pain scores and opiate use, and secondary outcomes were time in the post-anaesthetic care unit, duration of hospitalization and recovery. Children in the nerve block group reported significantly reduced global pain scores compared with controls in the first 3 h after surgery, estimated mean 2.22 versus 3.94, effect size -1.80 (P = .008). Pain scores after 3 h did not differ between the groups. The groups did not differ in opiate requirements, length of hospital stay or recovery after discharge. In children undergoing acute laparoscopic appendicectomy, a rectus sheath block reduced early post-operative pain, and could contribute to a multimodal recovery programme.

急性虫垂炎に対するReduced port surgeryによる腹腔鏡下虫垂切除術の検討

急性虫垂炎に対するReduced port surgeryによる腹腔鏡下虫垂切除術の検討

Isolated appendicular tuberculosis: A rare cause of acute appendicitis

Primary appendicular tuberculosis is a rare form of abdominal tuberculosis, occuring in 0.1-0.6% of the cases, and it is almost always diagnosed post-surgical on histopathology. In the present case, a 14-year-old girl underwent laparoscopic appendicectomy for acute appendicitis. During operation, only appendix and mesoappendix were found inflamed and thickened, and there was no other abnormality. Histopathology revealed tuberculosis of appendix. Anti-tuberculous treatment was started, and the patient was doing well with weight gain of 5 kg at the follow-up of 3 months.

Disease severity, not operative approach, drives organ space infection after pediatric appendectomy.

This study examines patient and operative factors associated with organ space infection (OSI) in children after appendectomy, specifically focusing on the role of operative approach. Although controversy exists regarding the risk of increased postoperative intra-abdominal infections after laparoscopic appendectomy, this approach has been largely adopted in the treatment of pediatric acute appendicitis. Children aged 2 to 18 years undergoing open or laparoscopic appendectomy for acute appendicitis were selected from the 2012 American College of Surgeons Pediatric National Surgical Quality Improvement Program database. Univariate analysis compared patient and operative characteristics with 30-day OSI and incisional complication rates. Factors with a P value of less than 0.1 and clinical importance were included in the multivariable logistic regression models. A P value less than 0.05 was considered significant. For 5097 children undergoing appendectomy, 4514 surgical procedures (88.6%) were performed laparoscopically. OSI occurred in 155 children (3%), with half of these infections developing postdischarge. Significant predictors for OSI included complicated appendicitis, preoperative sepsis, wound class III/IV, and longer operative time. Although 5.2% of patients undergoing open surgery developed OSI (odds ratio = 1.82; 95% confidence interval, 1.21-2.76; P = 0.004), operative approach was not associated with increased relative odds of OSI (odds ratio = 0.99; confidence interval, 0.64-1.55; P = 0.970) after adjustment for other risk factors. Overall, the model had excellent predictive ability (c-statistic = 0.837). This model suggests that disease severity, not operative approach, as previously suggested, drives OSI development in children. Although 88% of appendectomies in this population were performed laparoscopically, these findings support utilization of the surgeon's preferred surgical technique and may help guide postoperative counsel in high-risk children.