Laparoscopic appendectomy is particularly indicated for obese patients and premenopausal women with an undiagnosed right lower abdominal pain. Perforated appendicitis is not a contraindication to this procedure.
Open appendectomy is a reliable and effective method for the treatment of acute appendicitis. However, in clinical practice, the rate of misdiagnosis of acute appendicitis is 30%, higher in female patients, and the rate of negative appendectomy is also 20-30% Now there are 6 meta-analyses and more than 35 randomized clinical studies confirming the accuracy of laparoscopic surgical exploration over conventional surgery.
Currently laparoscopic appendectomy is not the gold standard procedure for acute appendicitis and perforated appendicitis, but like other laparoscopic procedures, its safety and feasibility are unquestionable. The decision to adopt this procedure depends on the patient’s condition, the hospital’s equipment and the surgeon’s laparoscopic skill level.
Indications
The indications for laparoscopic appendectomy surgery are similar to those for conventional surgery.
1. Acute appendicitis is the most important indication. This includes simple, purulent and gangrenous appendicitis of the head and body of the appendix
2.Acute appendicitis is suspected in acute right lower abdomen, especially in premenopausal women, and other diseases need to be excluded.
3, patients with chronic appendicitis and chronic right lower abdominal pain. The etiology of chronic right lower abdominal pain includes chronic appendicitis, chronic pelvic inflammatory disease, chronic adnexitis, endometriosis, Crohn’s disease, intestinal tuberculosis, etc. It is difficult to clarify the etiology of chronic right lower abdominal pain before surgery, and laparoscopic appendectomy allows a comprehensive view of the appendix, pelvis, adnexa and other organs of the abdominal cavity to prevent unnecessary appendectomy.
4. Perforated appendicitis. Not an absolute contraindication to this procedure. Research data show that surgeons with extensive experience in traditional surgery and skilled laparoscopic techniques are fully capable of performing this procedure.
5. Laparoscopic appendectomy is also indicated for pediatric patients. To ensure the safety of the procedure, the involvement of a pediatric surgeon and special pediatric laparoscopic instruments are required.
6. The use of laparoscopic appendectomy in pregnant women with acute appendicitis has yet to be clinically studied. Some investigators have found it safe to perform the procedure in the first six months of pregnancy, after which the uterus increases above the level of the umbilicus, thus compromising the operation of laparoscopy.
Contraindications
1. history of abdominal surgery or other diseases that may lead to severe abdominal adhesions
2.Patients with heart and lung diseases and other important organs that cannot tolerate general anesthesia.
3.Patients with septal hernia.
4.Patients with coagulation disorders.
5.Women who are more than 6 months pregnant.
6.Acute appendicitis with periappendiceal abscess, appendiceal mass, combined with severe peritonitis and severe systemic infection.
Surgical equipment requirements.
1.0 degree or 30 degree laparoscope.
2.Laparoscopic light source of more than 150 watts.
3.Single chip or triple chip laparoscope mainframe.
4.Pneumoperitoneum machine.
5, High definition monitor.
6, unipolar or bipolar electrocoagulator.
7, 10mm puncture cannula 2.
8.5mm puncture trocar 1
9, 10mm-5mm converter.
10.5mm scissors.
11.5mm laparoscopic separation forceps.
12.5mm non-invasive grasping forceps or 5mm Babcock forceps.
13, 10mm titanium clips.
14, Looper or laparoscopic knot tying device.
15.A pair of suction and irrigation cannula.
Optional equipment.
1.Ultrasound knife.
2.Endo-GIA (linear cutting shutter).
3.Laparoscopic specimen bag.
Surgical operation techniques.
1, The patient is placed in the Trenbelenberg position with the operating table tilted 10-20 degrees to the left. The monitor is placed on the right side of the patient. Pneumoperitoneal pressure was established to 15 mm Hg. A 10 mm poke hole was made at the umbilical port and a trocar was placed. The laparoscopic lens is placed and the abdominal cavity is explored. If the patient has a history of previous abdominal surgery and is considered to have abdominal adhesions, the pneumoperitoneum is established using an open approach, with a 10-mm trocar placed under direct vision and then inflated to establish the pneumoperitoneum. A 5-mm trocar was placed in the left lower abdomen at the midclavicular line and in the right lower abdomen at the McKinsey point, and instruments were placed to help with exposure and exploration.
2. Abdominal exploration. The ileocecal region, pelvis, small and large intestine and other parts of the abdominal cavity are carefully examined to exclude other acute abdominal conditions. Locate the appendix along the three colonic bands of the cecum to clarify the inflammation and extent of the appendix.
3. Appendiceal tract and root management. Clamp the head of the appendix and the tractus with non-invasive grasping forceps or Babcock forceps, lift upward, and separate the tractus to the root of the appendix by electrocautery or ultrasonic knife with separating forceps. A double ligature with a circlip is applied at the root. Alternatively, the appendix is closed with an Endo-GIA at the root together with the thylakoid. Cut off the appendix and cauterize the appendiceal stump with electrocoagulation.
4.Appendix removal. The way of appendix removal is important, if the appendix is small, it can be removed by 10mm trocar, if the appendix is larger or has been gangrenous or perforated, the appendix should be removed by placing it in a specimen bag. In principle, contact between the appendix and the abdominal wall incision should be avoided to prevent incisional infection.
5. Rinse the surgical field with saline, check the appendiceal stump again, release the pneumoperitoneum and close the incision after it is clear that there is no bleeding. In case of appendiceal perforation or severe local inflammation and more exudation, drainage can be placed.
Other surgical approaches Some patients with a thin body frame can have their appendix removed using a double-perforation extraperitoneal technique, because the appendix and cecum are more mobile in such patients. The first perforation hole remains at the umbilicus and is used to place the laparoscope for visualization, and the second perforation hole is chosen at the level of the root of the appendix in the right iliac fossa.
The head of the appendix and the tether are grasped with a grasping forceps, a 10 mm trocar is dragged in, the pneumoperitoneum is released, and the trocar is pulled out of the abdominal wall together with the grasping forceps so that the appendix is freed outside the abdominal cavity. The appendix is then removed as in conventional surgery. The appendix is retracted, the pneumoperitoneum is re-established, the surgical field is examined, and the puncture hole is closed.
Complications and management
The same complications as in conventional surgery.
1. Intraoperative peripheral organ damage. In addition to intestinal injury caused by improper anatomical separation during surgery, puncture during the establishment of pneumoperitoneum can cause intestinal poke laceration injury or puncture rupture of large abdominal vessels. Such complications mostly occur when there are adhesions in the abdominal cavity, when the patient is thin or when the operator does not operate properly. For patients with a history of previous abdominal surgery, adhesions in the abdominal cavity or partial acute appendicitis complicated by intestinal paralysis, an open approach to establish a pneumoperitoneum is recommended. In the event of intraoperative organ damage, most cases should be handled by intermediate open surgery.
2. Incisional infection: Compared with traditional surgery, the incidence of incision after laparoscopic appendectomy is much lower. This is mainly due to the fact that the appendix is removed through a trocar or placed in a specimen bag during surgery, avoiding contact with the abdominal wall incision. In addition, since the peritoneum of the perforation hole of the abdominal wall is not sutured, the exudate from the abdominal wall incision can be drained into the abdominal cavity. When infection occurs at the poke hole, the sutures should be removed promptly and the wound drained.
3, abdominal bleeding: intraoperative failure to properly treat the appendiceal tract, or loosening of the ligature line or slippage of the titanium clip can cause abdominal bleeding. The appendiceal mesenteric vessels cannot be simply treated with electrocoagulator during surgery, and titanium clips or silk ligatures must be used to close them. It is safe and reliable to use ultrasonic knife to treat the appendiceal tract, and the protein denaturation of the vascular stump after ultrasonic knife cutting will not cause bleeding due to scab shedding like after electrocoagulation treatment.
4, abdominal abscess: in laparoscopic surgery, the incidence of this is lower than that of traditional surgery. The incidence of this complication is lower than that of conventional surgery because of adequate exposure and thorough flushing of the surgical field during laparoscopic surgery. After the abdominal abscess that has occurred is clarified, appropriate treatment is taken according to the size and location of the abscess. In general, anti-infection, support and local physiotherapy can be administered. If the above treatments are ineffective, ultrasound-guided puncture drainage or laparoscopic drainage can be performed. In principle, open surgical drainage is not necessary.
5. Appendiceal stump fistula: It is a serious complication after appendectomy. It is mostly caused by edema, gangrene and perforation of the appendiceal root, which dislodges the ligature wire or inadequate treatment of the appendiceal stump. In patients with perforated and gangrenous appendiceal roots that cannot be satisfactorily managed by laparoscopy, timely intermediate open surgery should be performed.
Complications specific to laparoscopy.
1, puncture injury: including intestinal tube injury and large abdominal vessels injury.
2, gas embolism.
3, perforation hole hernia.
4, carbon dioxide accumulation syndrome: numbness of the mouth, lips, hands and feet, radiating pain in the low back and shoulder, etc.
Evaluation
Traditional appendectomy has a history of more than 100 years and is a classical and mature procedure for the treatment of acute appendicitis and is the gold standard method. Some people believe that its surgical incision is only 4~125px, and the surgical trauma is mild, so it seems unnecessary to perform laparoscopic surgery. However, in practice, obese patients or patients with difficulties in finding the appendix often need to extend the incision, and when the appendix is found to be normal intraoperatively, further exploration is compromised by the small incision and limited exposure of the surgical field.
In clinical care, sometimes physicians are faced with patients with right lower abdominal pain of unknown diagnosis and are indecisive whether to take aggressive surgical treatment. To a large extent, laparoscopic appendectomy overcomes the drawbacks of traditional surgery by comprehensively exploring the abdominal cavity and discovering as many lesions in the abdominal cavity as possible and treating them accordingly, which greatly improves the diagnosis and cure rate of such patients.