EL-MINIA MED., BULL., VOL. 18, NO. 2, JUNE, 2007
Saleh
LAPAROSCOPIC-ASSISTED APPENDECTOMY
(an economic safe exploratory procedure)
By
Gamal S. Saleh, M.D.
Department of General Surgery,
Minia Faculty of Medicine
ABSTRACT:
A prospective study was designed to evaluate results of laparoscopic-assisted
appendectomy (LAA) versus both open appendectomy (OA) and conventional
laparoscopic appendectomy (LA).
Comparison includes operative time, operative complications, efficiency of diagnosis
of equivocal cases, postoperative analgesia, hospital stay as well as return of patients
to normal activity. Cost-effectiveness was considered in LAA compared to LA.
Study included randomized 60 patients (21 males and 39 females with mean age of
18-43years), who presented with acute abdominal pain and provisionally diagnosed as
acute appendicitis.
Cases were classified into three groups : First 20 as an open appendectomy group
(OA) and the second 20 as a laparoscopic appendectomy group (LA) and third 20 as a
laparoscopic-assisted appendectomy group (LAA). Mean operating time in LAA
was shorter than either LA and OA significantly. Difference in postoperative
complications between three groups was not significant. One case is converted from
LAA to OA as appendix was very friable and one case is converted from LA to OA
due to uncontrollable bleeding from meso-appendix.
Mean hospital stay was shorter in LAA and LA groups than OA group but was not
significant. Postoperative analgesia was less in LAA and LA groups than open
group significantly. Time to return to normal activities was shorter in LAA and LA
patients than OA significantly. In 2 young females, severe adhesions were found in
peritoneal cavity which was probably the cause of primary infertility, laparoscopic
adhesiolysis was done as well as appendectomy which add another great advantage to
laparoscopic procedures.
Overall, it is obvious that the use of laparoscope in suspected appendicitis is much
better than the open method especially in equivocal cases to reach the exact diagnosis
as it gives an excellent exploration of the abdominal cavity, with possibility of
discovering extra-appendiceal lesions, with easy and rapid localization of appendix.
LAA and LA are superior to OA as regard the benefits gained through shorter
operating time and improved quality of life. LAA collect benefits than LA and OA.
However, for sake and safety of patients if friable or perforated appendix we must not
hesitate to convert LAA or LA to open procedure. Finally, LAA avoids the cost for
stapling devices reloads & endo-loops used for LA and reduces abdominal trauma,
thus, potentially reducing cost compared to conventional LA.
sufficient specificity and sensitivity to
diagnose appendicitis. Now many
surgeons are turning from philosophy
of "when in doubt, take it out" to
"when in doubt, check it out", as
laparoscopy provides the surgeons with
INTRODUCTION:
Laparoscopy has an important
diagnostic role in cases with equivocal
symptoms of appendicitis. Despite
advances in technology, there is no
laboratory test or examination with
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EL-MINIA MED., BULL., VOL. 18, NO. 2, JUNE, 2007
a tool to rule out appendicitis and then
inspect other organs to determine the
real cause of the patient's symptoms.
Laparoscopy is far superior to the
limited exploration that can be
accomplished through a classic McBurney's incision (Baker and Fisher,
2001).
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hospital stay with faster return to
unrestricted daily activity.
As well, theoretical reduction
of wound infection by minimizing its
contact of appendix with the wound
and better cosmesis, particularly for
obese patients in whom a large incision
would be necessary. Finally, LAA
obviates the need for disposable
laparoscopic instruments with the
potential of reducing the costs associated with laparoscopic appendicectomy (Baker and Fisher, 2001).
During the last decade of
twentieth century, improved technical
ability of surgeons has served to
decrease the complication rate,
especially catastrophic laparoscopic
accidents such as major vascular injury
so that laparoscopic appendectomy has
been shown to be a safe alternative to
open
appendicectomy (Reiertsen,
1997; Hellberg et al., 1999). However
some inherent disadvantages of this
procedure have prohibited its universal
acceptability as longer operating time
and high cost (Reiertsen, 1997;
Hellberg et al., 1999; Kald et al.,
1999).
Safety, economy, and speed of
surgery are all maximized for each
individual case so that each patient has
the maximal benefits of minimally
invasive surgery with the decreased
costs of open techniques (Enochsson et
al., 2001). Thus, Nicholson and
Tiruchelvam (2001) concluded that the
laparoscopic-assisted
method
of
appendix removal can be performed as
efficient as the open technique but at
less than 67% of the cost of the
complete
laparoscopic
method.
Enochsson et al., (2001) showed that
LAA was performed safely in obese
male and female and in premenopausal females. These findings
reflect the similar advantages of LAA
and LA as the LAA has been
demonstrated to have advantages in
certain situations such as surgery in the
obese patient. D'Alessio et al., (2002)
reported that advantages of a onetrocar appendectomy compared with
open surgery are the same as those
reported for conventional laparoscopic
appendectomy i.e., excellent exploration of the abdominal cavity, the
possibility of discovering extraappendiceal lesions, easy and rapid
localization of the appendix and a
shorter hospital stay.
Laparoscopic-assisted appendectomy (LAA) is a modified technique
of laparoscopic appendicectomy at
which the appendix is delivered
through the port-site incision near
McBurney's point where mesoappendix and vessels are ligated and
divided, as is the appendix base (or
ligation of appendicular vessels is
done inside peritoneal cavity and
exteriorization of appendix with
divided mesentery and complete the
procedure in a conventional manner.
Thus, LAA inherits the advantages of
both
laparoscopic
and
open
appendectomy, so that it can be
performed in most cases, except where
the appendix is very friable. Also,
advantages includes reduction of the
operating time by extra-peritoneal
ligation of appendix base and
appendicular vessels, reduction of
postoperative pain and reduction of
The additional advantages of
LAA compared with conventional
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EL-MINIA MED., BULL., VOL. 18, NO. 2, JUNE, 2007
laparoscopic appendectomy are a low
rate of intra-operative incidents,
minimal scarring, less postoperative
pain and a more rapid return to
unrestricted activities (Katkhouda et
al., 2005).
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incision with muscle-cutting when
indicated to provide a good exposure.
Technique of laparoscopic-assisted
appendectomy:
- A l2-mm umbilical port is inserted
- Pneumoperitoneum is achieved, and
the laparoscopic camera inserted.
- Patient is placed in Trendelenburg
position with a 15° tilt to left side.
- Revision of abdominal cavity is
achieved by fine handling of the
viscera and solid organs searching for
any associated pathology such as
Meckel's
diverticulitis,
polypi,
inflammatory bowel diseases, etc.
In females, searching for associated
ovarian, tubal or uterine lesions should
be performed.
- Appendix is identified and diagnosis
of appendicitis is established.
- A 10-mm port is inserted near the
McBurney point, guided by the site of
the appendix or cecum, under direct
vision.
- Appendix is grasped with a nontraumatic grasper, from the distal
mesentery in line with the grasper, and
pulled into the port for some distance.
As our department which was
the first one in Egyptian Universities to
start laparoscopic surgery, it was the
first one to use LAA in selective cases.
PATIENTS AND METHODS:
This study was carried out on
sixty patients presented to the Surgical
Emergency Unit of Minia University
Hospital, in the period from March
2004 to July 2006 with acute
abdominal pain who are provisionally
diagnosed as acute appendicitis. The
criteria of inclusion were females in
childbearing period and obese patients.
All patients were submitted to
full
history
taking,
clinical
examination, laboratory investigations
as total leucocytic count, urine
examination
and
ultrasonic
examination.
Patients were randomized to
undergo surgery either by open
appendectomy (OA) or conventional
laparoscopic appendectomy (LA) or
laparoscopic-assisted
appendectomy
(LAA). Before randomization, patients
were informed of the risks and benefits
of each procedure. Then, patients were
divided into 3 groups, each group
included 20 patients:
First group: 20 patients underwent
open appendectomy (OA).
Second group: 20 patients underwent
laparoscopic appendectomy (LA).
Third group: 20 patients underwent
laparoscopic-assisted
appendectomy
(LAA).
The open appendectomy group (OA)
included the standard Grid-iron
At the same time, the pneumoperitonium is evacuated to allow
approximation of the caecal wall to the
anterior abdominal wall.
- The grasper holding the appendix and
the port are delivered into the port site.
Mesentery is grasped with a Babcock
forceps; and the port and non-traumatic
grasper removed. Appendicectomy is
carried out in the conventional fashion,
by gradually delivering the whole of
the appendix. The cecum is dropped
back into peritoneal cavity.
Caecum and stump are visualized
using the camera, for checking haemostasis and security.
Muscles at the site of the right iliac
fossa port rarely need a suture for
closure.
After the appendix has been
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EL-MINIA MED., BULL., VOL. 18, NO. 2, JUNE, 2007
amputated, the area should be
inspected for any signs of bleeding as
well as for security of appendiceal
closure.
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2- Intra-operative complications : as
bleeding, abdominal wall haematoma
and
fragmentation of the appendix
fecal soilage.
3- Postoperative analgesics.
4- Hospital stay : from end of
operation till the patient was
discharged.
5- Return to normal activity was
determined by questioning during
postoperative clinic.
6- Cost : comparing LA and LAA.
In addition to the above comparison,
rate of conversion to open
appendectomy (OA) from LA or from
LAA if indicated considering the
indication of conversion.
If the appendix is to be
removed either through a trocar or a
sleeve, it should be removed at this
point. Area is then copiously irrigated
with saline prior to decompression of
pneumoperitoneum and removal of the
trocars.
If the appendix is to be
removed through an enlarged trocar
site, this should be done after
abdominal irrigation is carried out and
the operation is completed because the
pneumoperitoneum
will
be
decompressed once the trocar is
removed. If there is difficulty in
removing the appendix or if the
surgeon wants to inspect the peritoneal
cavity further, the incision that is used
to extract the appendix can be closed
and the pneumoperitoneum reinflated.
Data processing:
Data entry and analysis were all
done with I.B.M. compatible computer
using a software called SPSS for
windows version 11. Graphics were
bone using Harvard graphics for
windows.
Descriptive statistics:
1- Mean (x)
2- Standard deviation (SD)
3- Minimum and maximum values.
Two trocar sites will still be
available for inspection, manipulation,
and irrigation.
- After the trocars are removed, the
incisions are all dosed. The 11 and
12mm trocar sites should have the
fascia closed with a single suture to
prevent visceral herniation.
Analytical statistics:
1- Student's "t" test compare 2
independent mean.
P value = level of significance: P> 0.05
= insignificant
P < 0.05 = significant
P < 0.001 = highly significant
2- Chi - square test to compare
between
different
groups;
i.e.
qualitative data. Variables were cross
tabulated in all possible combinations
against each other.
3~ Z - test was used to compare
between two proportions.
* Another technique :
We can ligate the appendicular
vessels inside the peritoneal cavity
then we exteriorize the appendix
through the abdominal wall and
ligation of the appendicular base is
done.
Comparison between 3 groups in the
study included :
1- Mean operative time : calculated
from time of incision till wound
closure - not renect the time to set up
the laparoscopic equipments.
RESULTS:
Demographic data :
OA group: 20 patients (8 males and 12
females) with mean age of 28.5 years
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EL-MINIA MED., BULL., VOL. 18, NO. 2, JUNE, 2007
(18-39).
LA group: 20 patients (7 males and 13
females) with mean age of 29.5 years
(20-41).
LAA group: 20 patients (6 males and 14
females) with mean age of 30.7 years
(19-43).
There was insignificant difference in
age and sex between both groups (Istudent test was used).
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Mean length of hospital stay was 1.8
days in OA group and 1.3 & 1.4 days
in other groups.
No significant reduction in length of
hospital stay in LA & LAA groups.
I-student test was used. P*: significant.
Return to normal daily activity
(convalescence duration):
Mean convalescence duration was 12.7
days in OA group and 7.4 & 6.2 days
in other groups.
There is significant reduction in
convalescence duration (return to
normal daily activity) in LAA group.
T-student test was used.
Inclusion criteria:
OA group : included 8 (40%) obese
patients and 12 (60%) premenopausal
patients.
LA group : included 10 obese (50%)
and 10 (50%) premenopausal patients.
LAA group : included 10 obese (50%)
and 10 (50%) premenopausal patients.
No significant difference between both
groups (Chi-square test was used).
Conversion to open appendectomy
from LA or from LAA:
One case is converted from LAA to
OA as the appendix was very friable (?
Perforated).
Another case is converted from LA to
OA due to uncontrollable bleeding
from meso-appendix.
Operating time:
Mean operating time was 73.5 minutes
in OA group, 64 minutes in LA group
and 43 minutes in LAA group.
There was a highly significant
reduction of operating time in LAA
group.
I-student test was used. P* *: high
significant.
Accidental discovery: in 2 young
females we found severe adhesions in
the peritoneal cavity which was
probably the cause of primary
infertility, laparoscopic adhesiolysis
was done as well as appendectomy.
Intra-operative complications:
No intra-operative complications in all
groups.
DISCUSSION:
Laparoscopic appendectomy is
becoming increasingly popular since
1990s, as surgeons strive to manage
surgical problems via minimally
invasive techniques. However, this
new approach is not clearly superior to
open appendectomy despite theoretical
advantages (Varlet et al., 1994).
Postoperative morbidity:
No post-operative complications in all
groups.
Postoperative wound infection: in
OA group, postoperative wound
infection occurred in 1 obese female
patient (5%), but this did not occur in
other groups. This was insignificant
statistically.
In order to reduce abdominal
trauma and operative costs, it is
adopted to use a laparoscopic-assisted
appendectomy (LAA) for patients with
acute appendicitis. This technique is a
combination of laparoscopic and open
Length of hospital stay:
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EL-MINIA MED., BULL., VOL. 18, NO. 2, JUNE, 2007
techniques and is not widely used
(Konstadoulakis et al., 2006).
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Safety, economy, and speed of
surgery are all maximized for each
individual case so that each patient has
the maximal benefits of minimally
invasive surgery with the decreased
costs of open techniques (Enochsson et
al., 2001).
In the current study, the
proposed
technique
(LAA)
is
prospectively
evaluated
against
conventional open appendectomy (OA)
with respect to feasibility, safety, and
postoperative outcome. It showed that
laparoscopic-assisted appendectomy is
superior to open appendectomy in
terms of shorter operative duration,
shorter hospital stay, few postoperative
complications, and early return to
normal daily activities.
Thus,
NichoIson
and
Tiruchelvam (2001) concluded that the
laparoscopic-assisted
method
of
appendix removal can be performed as
efficient as the open technique but at
<67% of the cost of the complete
laparoscopic method.
Enochsson et al., (2001) showed that
LAA was performed safely in obese
male and female and in premenopausal females. These findings
reflect the similar advantages of LAA
and LA as the LAA has been
demonstrated to have advantages in
certain situations such as surgery in the
obese patient. D'Alessio et al., (2002)
reported that advantages of a onetrocar appendectomy compared with
open surgery are the same as those
reported for conventional laparoscopic
appendectomy
i.e.,
excellent
exploration of the abdominal cavity,
the possibility of discovering extraappendiceal lesions, easy and rapid
localization of the appendix and a
shorter hospital stay.
Few
studies
compare
laparoscopic-assisted (LAA) to open
appendectomy (OA) as reported by
Nicholson and Tiruchelvam, 2001;
D'Alessio et al., 2002 and Koontz et
al., 2006.
Laparoscopic-assisted
appendectomy (LAA) combining safe
open and laparoscopic techniques,
remains a safe operation. It allows for
enhanced safe decision making, as
well, allowing for addition of trocars
and devices when the need arise.
LAA combines techniques,
allowing for each operation to be
individualized. Starting with an
operating laparoscope at the umbilicus
does not disallow placement of
additional trocars (for retraction,
cauterization, different camera angles,
or devices such as endo-loops or
staplers), but instead allows a surgeon
to eviscerate the appendix, if possible.
Having the option to deliver, the
appendix through the single wound
permits an open operation, avoiding
the cost of highly technical devices.
Should additional devices be needed,
they can be added as the case
determines.
The additional advantages of
LAA compared with conventional
laparoscopic appendectomy are a low
rate of intra-operative incidents,
minimal scarring, less postoperative
pain and a more rapid return to
unrestricted activities (Katkhouda et
al., 2005).
In our study, there was a
significant reduction in the operative
time with LAA compared to OA.
Shorter operative time means less
operative room charge per surgery,
thus, reducing the charge for the
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EL-MINIA MED., BULL., VOL. 18, NO. 2, JUNE, 2007
operation. Financial economy of the
operation as a whole is difficult to
enumerate but easy to understand. Cost
of the operation is determined not only
by the operating room time used, but
also by the cost of the instruments used
i.e. fewer instruments, less cost. The
cost of 1 trocar for the LAA is less
than the cost of 3 trocars. The LAA
technique, using a single ligature and a
single suture, will reduce suture
charges when compared with either the
open
or
standard
laparoscopic
operation. In addition, the cost for
stapling devices, reloads, and endoloops that are used for Laparoscopic
appendectomy is also avoided.
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77.1 minutes, however, laparoscopicassisted technique was performed with
a surgical time of 28 minutes.
In the present study, there was
no mortality, which is consistent with
majority of past publications. The
overall
reported
mortality
of
appendectomy is very low and was
estimated in a review by Guller et al.,
(2004) of a large administrative
database at 0.05% for LA and 0.3% for
OA, reinforcing the fact that
appendectomy in the absence of
peritonitis is a safe procedure,
regardless of the technique performed.
In studies by Koontz et al., (2006), D'
Alessio et al., (2002) and Nicholson &
Tiruchelvam (2001), the overall
mortality was 0% with LAA.
Katkhouda et al., (2005)
revealed that the operating room time
is longer with LA when compared to
OA. There is no study demonstrating a
shorter time for LA, despite the
subjective perception that it can be an
easier operation. This may be due to
the inclusion of additional steps for
setup, insufllation, trocar entry under
direct
vision,
and
diagnostic
laparoscopy.
In the present study, as regard
intra-operative
complications,
difference was insignificant. This is
similar to most studies. It is significant,
though, that the most serious early
complications occurred in the LAA
group and required conversion to OA.
Intraoperative bleeding is a
well-known complication noted by
others and avoidable with the
placement of additional trocars under
direct vision. In the study by Koontz et
al., (2006), an additional trocar was
placed in 2 patients, and 2 patients
were converted to open. Five patients
had additional procedures.
Despite the present study did
not compare LA and LAA, the longer
operating time of LA, in addition to the
cost of the disposable equipment used,
may increase the direct cost of LA.
Thus, LAA may have more benefits
than LA and OA regarding the shorter
operating time with LAA.
In a study by Koontz et aI.,
(2006), operative time with LAA was
36 minutes (9-140 minutes).
In the present study, there was
no
significant
reduction
of
postoperative morbidity with LAA
regarding postoperative ileus and
postoperative
bleeding.
These
complications were also absent in the
studies by Valioulis et al., (2001) and
Koontz et al., (2006). However, in a
study by Meyer et al.,(2004), the rate
of these postoperative complications
with was 3.6 %.
In a study by D'Alessio et al.,
(2002), the mean operative time with
LAA was 35 minutes.
In a study by Nicholson and
Tiruchelvam (2001), open technique
was performed with a surgical time of
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EL-MINIA MED., BULL., VOL. 18, NO. 2, JUNE, 2007
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(2001), the mean postoperative stay
was 2.4 days with OA and 1.8 days
with LAA.
In the present study, there was
no significant difference in the
incidence of postoperative wound
infection when LAA and OA were
compared together. Wound infections
may not be serious complications per
se but represent a major inconvenience
to the patient, impacting convalescence
time and quality of life. We found that
the incidence of wound infections is
similar to the studies compared OA to
LA as in the study by Katkhouda et al.,
2005. On the other band, in a study by
Klingler et al., (1998), the incidence of
wound infections in was 6% and 7% in
the laparoscopic and open groups,
respectively.
Early publications in the 1990s
demonstrated a significantly shorter
hospital stay in favor of LA as reported
by Frazee et al., 1994, yet perhaps this
is one area where OA has caught up
with the laparoscopic techniques. Lord
and Sloane (1996) showed that a 48hour discharge policy for OA could be
implemented with the appropriate
staffing infrastructure. Longer hospital
stays in European studies after stays
appendectomy
could
be
the
consequence of different social
standards and insurance systems as
reported by Kazemier et al., 1997 and
Hellberg et al., 1999.
In a study by Koontz et al.,
2006 infectious complications of LAA
included
intra-abdominal
abscess
(0.9%) and wound infection (6.9%). In
a study by Valioulis et al., (2001),
there
were
two
infectious
complications after 38 LAA (5.2%).
In the present study, there was
a
significant
reduction
in
convalescence duration after LAA. The
convalescence duration and return to
activity following appendectomy is the
subject of intense debates. LAA allows
for a quicker recovery, shorter
convalescence at home, and quicker
return to work.
In our study, there was no
patients
presented
with
pe\vic
abscesses in all groups. It is possible to
reduce the incidence of intraabdominal pelvic abscesses if the
sigmoid colon is retracted, the patient
placed in Trendelenburg, and the pelvis
is completely irrigated and aspirated
under direct vision as stated by
Katkhouda et al., 2000. This maneuver
was systematically performed in our
study.
In the present study, the
converted case of LAA to OA lead to
increased hospital stay, delayed
convalescence and higher morbidity
because it was a perforated appendix.
Similar findings were reported by
Koontz
et
al.,
2006,
and
Konstadoulakis et al., 2006. Those
authors suggested that obesity and non
available good vision might be a direct
causes of conversion. In the study by
Konstadoulakis et al., 2006, the
conversion of the initial procedure was
associated with increased wound
infection rate and higher morbidity.
In the present study, the length
of hospital stay was shorter with LAA,
and there was no significant difference
between the groups. This finding is
similar to others. In a study by Koontz
et al., 2006, length of stay with LAA
was 1.8 days (1- 11 days). In a study
by D' Alessio et a1., 2002, the mean
hospital stay with LAA 2.5 days. In a
study by Nicholson and Tiruchelvam
Overall, it is obvious that LAA
is superior to OA. The benefits gained
through improved quality of life,
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EL-MINIA MED., BULL., VOL. 18, NO. 2, JUNE, 2007
shorter operating times and less serious
early postoperative complications.
LAA minimizes equipment needs and
reduces abdominal trauma, thus,
potentially reducing cost compared to
LA. The additional advantages of LAA
compared with conventional LA are
low rate of intra-operative incidents,
minimal scarring, less postoperative
pain and a more rapid return to
unrestricted activities.
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