Laparoscopic appendectomy (LA) has gradually gained attention and recognition in recent years because of its characteristics such as less injury, faster recovery, less possibility of postoperative intestinal adhesions, and few infections in the surgical incision; according to the statistics of the United States from 2005 to 2008, 77% of the 39,950 patients with appendiceal disease underwent laparoscopic appendectomy. At present, laparoscopic appendectomy has been widely carried out in many hospitals in China, and good results have been achieved.
Each person has his own experience and experience in the management of the appendiceal root. The author improved the treatment of the appendiceal root in laparoscopic appendectomy and achieved good results, which is reported as follows.
1. Information and methods
1.1 General information There were 86 patients with laparoscopic appendectomy, 50 men and 36 women, with an average age of 33.7 years (11-73 years); 76 cases with acute appendicitis and 10 cases with chronic appendicitis. The average hospitalization days were 3.8d (1-14d).
1.2 Surgical methods The bladder was emptied before surgery, and no catheter was placed. Tracheal intubation was performed under general anesthesia, and the patient was reclined to a low head and high foot position with appropriate left-sided tilt. After establishing the pneumoperitoneum, a 10-mm perforation hole was placed at the superior umbilical margin as an observation hole to determine the position of the appendix under direct vision, and a 5-mm perforation hole was placed above the body projection of the appendix root, and another 5-mm perforation hole was placed above the midpoint of the pubic symphysis. Pay attention to the position of the bladder to avoid injury.
The appendix was found along the colonic band with tubal grasping forceps and then lifted so that the appendiceal tract was unfolded, and the appendiceal tract could be cut off to the root by single-stage electrocoagulation, bipolar electrocoagulation, or electrocoagulation tearing; the appendix was pre-ligated at the root with 3-0 absorbable needle sutures in the pulpy muscle layer at two points, and the root was ligated, and the same site was ligated again with one ligature, and the distal end of the appendix was cut off after ligation, and the mucosal tissue of the stump was destroyed by electrocautery; the resected appendix specimen was packed into The resected appendix specimen was put into a specimen bag and removed through the umbilical incision.
2.Results
All 86 patients completed the operation successfully, without intermediate open abdomen. The operation time was 20-60 min, with an average of 30 min; the intraoperative bleeding was low; the patients were encouraged to get out of bed for 6 h after the operation, and were given fluid or semi-liquid food if they did not have abdominal distension and nausea and vomiting, and could reach the discharge standard (no fever, no obvious abdominal pain, could get out of bed by themselves, could eat semi-liquid food, and could urinate and defecate by themselves) 1-3 d after the operation. No painkillers were applied after surgery.
There were no complications such as bleeding, intestinal leakage and wound infection. Only one 18-year-old female patient with postoperative fever and insignificant abdominal distension and pain was considered to have residual abdominal infection and was discharged after 3 d of antibiotic treatment. The complication rate in this group of cases was 1.16%, which was similar to that reported in the literature. No intestinal adhesions, intestinal obstruction and incisional hernia occurred in all patients after follow-up to date.
3. Discussion
In recent years, laparoscopic appendectomy has been proven to be safe and somewhat superior to open appendectomy, with the advantages of less trauma, less painful incision, less interference with abdominal organs, faster recovery of gastrointestinal function, shorter hospital stay, lower incidence of postoperative intestinal adhesions, lower incision infection rate, less obvious postoperative scar, and faster patient recovery. At present, the diagnosis of acute appendicitis mainly relies on clinical diagnosis, and the preoperative misdiagnosis rate is very high, ranging from 9% to 36% according to the relevant literature, and the misdiagnosis rate is even higher for female patients with atypical symptoms.
In contrast, laparoscopic surgery is easier to explore the abdominal cavity, which is both an effective diagnostic tool and a simultaneous treatment of the disease, and can also detect and treat diseases of other organs in the abdominal cavity, avoiding unnecessary caesarean sections. Since laparoscopy has a magnifying effect and a clear field of view, it is more conducive to the detection and management of complex appendiceal lesions and other lesions, and can better avoid misdiagnosis and leakage.
The treatment methods of appendiceal root in laparoscopic appendectomy are: silk ligation, titanium clip or absorbable clip closure method, endoscopic cutting and suturing device method, trap ligation and suture ligation method, etc.
(1) Silk ligation method to treat the appendiceal root: for good exposure, the ligation can reach the ideal position, on the contrary, for not very satisfactory exposure, especially the appendiceal root is near the dorsal side of the cecum, it is often not easy to ligate to the desired position.
(2) Titanium clip or absorbable clip closure method: It can be used for thinner appendix and when the edema and inflammation are not obvious, which can reduce the operation time due to easy operation, but in the case of obvious edema and thick appendix root, it is not only easy to clip the appendix root, but also cannot completely clip the appendix root, which leads to complications.
(3) Endoscopic cutting and suturing device method: Not only is it very expensive, but there is also the same risk of clamping the appendiceal root.
(4) Looper ligature method: It has the advantage of using Roeder knots, which are easy to operate and well positioned. The disadvantage is that the strength is not well controlled during ligature, too tight and easy to cut the appendiceal root, too loose knots are easy to slip off, and the knots collapse with heat when electrocautery is applied to the appendiceal root.
Since February 2009, we have been using the two-point fixed suture method to ligate the appendiceal roots, and the results are more satisfactory. The method is as follows: after the appendiceal tract has been treated, 3-0 absorbable needle sharp sutures are placed in the abdominal cavity, and one suture is placed at each of the two points of the pre-ligated appendiceal root, and the tract at 90° and 180°, avoiding the suture at the edge of the appendiceal tract as much as possible.
When it is difficult to expose, it can also be fixed on the plasma membrane of the appendiceal root mesentery to ensure that the mesentery and the appendiceal root are tied together during ligation, which can keep the appendix at the root of the appendix with complete peritoneal coverage and avoid leaving untied branch vessels of the mesentery and avoiding the risk of bleeding. When tying the knot, first draw the suture tightly and feel that the suture position is more satisfactory before tying the knot, so that the knot can be tied until the appendiceal lumen can be blocked, and the knot should not be tied too tightly to avoid cutting.
Since two stitches are fixed at the root of the appendix, there is no need to worry about the displacement and slippage of the ligature. Then another reinforcement is ligated at the same site and the appendix is cut about 5 mm away from the ligation. Since the ligation is not very tight and there is a fan-shaped vascular distribution, a small amount of fresh blood oozing from the appendix root section can be seen. Intermittent electrocautery of the mucosa and appendiceal stump with electrocoagulation serves the purpose of hemostasis, destruction of the mucosa, and high temperature disinfection of the appendiceal stump; since there is a small amount of blood supply to the appendiceal stump, it will not be necrotic and fall off quickly, which will reduce the incidence of stump fistula.
When removing the stitches laparoscopically at the end of surgery, do so slowly under direct laparoscopic vision. If the needle is removed too quickly it may cause the stitches to disintegrate into the abdominal cavity and cause unnecessary medical errors.
In laparoscopic appendectomy, when the two-point suture fixation method is used to treat the appendiceal root, the ligature site, direction and force can be well controlled by the operator, and it is less affected by the variation of appendiceal position, inflammation, edema and adhesions, which can effectively reduce the postoperative complications and is worthy of clinical promotion and application.