The clinical application value of laparoscopic surgery for chronic appendicitis Abstract: Objective: To evaluate the clinical application value of laparoscopic surgical treatment for chronic appendicitis. METHODS: Laparoscopic appendectomy was performed on 18 cases of chronic appendicitis. RESULTS: All 18 cases were successfully operated laparoscopically, with an average operating time of 40 min and an average postoperative hospital stay of 3.5 d. There was no intermediate open abdomen and no surgical complications. CONCLUSION: Laparoscopic surgery for chronic appendicitis is safe and feasible, and in addition to the significant advantages of minimally invasive surgery, it can also be used for differential diagnosis of related diseases and management of incidental diseases. Open appendectomy for appendicitis has been performed for hundreds of years, whereas laparoscopic resection of the appendix has only been performed for more than 20 years. The use of laparoscopy for appendectomy was controversial in the beginning, especially in China. Currently, laparoscopic appendectomy is mostly used for the treatment of acute appendicitis. Both the diagnosis and management of chronic appendicitis are more complex compared to acute appendicitis. We performed surgical treatment of 18 cases of chronic appendicitis by laparoscopic method, with the aim of exploring the feasibility, methods and effects of its clinical application and making an assessment of its application value. 1 Data and methods 1. 1 Clinical data In this group of 18 cases of chronic appendicitis, 3 cases were male and 15 cases were female; the age ranged from 15 to 57 years, with an average age of 34 years. In each case, a barium meal or barium enema of the whole gastrointestinal tract or a colonoscopy was performed to exclude other diseases in the ileocecal region, and in female patients, gynecological examination was performed by gynecological consultation or ultrasonography of the uterus and its adnexa to exclude gynecological diseases if necessary. Postoperative paraffin sections were routinely performed for pathological verification. 1. 2 Surgical methods Epidural anesthesia was used in 15 cases, and general anesthesia was used in 3 cases. The right middle and lower abdomen was moderately elevated in a modified lithotomy or lying position. A pneumoperitoneal needle was placed 1 cm below the umbilical incision, properly inflated and a 10 mm Trocar trocar tube was placed as a 30° laparoscopic viewing port, and carbon dioxide pressure of 12 mm Hg was maintained. Under laparoscopic guidance, 5 mm and 10 mm Trocar tubes were placed in the left lower abdomen and left middle abdomen, respectively, with the latter being the main operating port. The abdominal cavity was routinely explored first, with emphasis on the ileocecal region and, if necessary, the uterus and its adnexa. The appendix or appendiceal tract is lifted with a grasping forceps, and the appendiceal tract is cut directly to the root with an ultrasonic knife. The appendix is removed from the main operation hole after the titanium clip is applied to the appendix root and then cut off directly with the ultrasonic knife, or cut off again after ligating with silk thread. The appendix is removed from the main operation hole. The appendiceal field and the trocar holes are checked for blood leakage, the pneumoperitoneum is deflated, the trocar holes are closed, and the skin is closed with intradermal sutures or one-stitch sutures. Gastric tube and urinary catheter were routinely placed before surgery and removed after surgery. 2 Results Among the 18 cases in this group, 6 cases were combined with dense adhesions in the ileocecal region and 3 cases with minor adhesions, and intestinal adhesions were released during the operation. The average operation time was 40 min, and there was almost no bleeding during the operation, and none of the cases were turned to open abdomen. The patients resumed eating on the same day of surgery, and only 3 cases were treated with analgesics once after surgery, and the postoperative hospital stay ranged from 2 to 7 d, with an average of 3.5 d. The follow-up period was at least 3 months, and no complications occurred in 1 case. According to the patients’ requirements, epidural anesthesia was used in 15 cases and general anesthesia was used in 3 cases. The effect of epidural anesthesia could fully meet the needs of laparoscopic surgery. 3 Discussion Since Dr. Semn [1 ] performed the world’s first laparoscopic appendectomy in 1983, laparoscopic appendectomy for chronic appendicitis has become a routine procedure in foreign countries. A large number of clinical cases have shown that laparoscopic surgery for chronic appendicitis has the advantages of small incision, less pain, faster recovery and shorter hospital stay, but there are shortcomings such as more expensive and the operation time may be longer due to the level of operation technique [2,3]. In China, with the introduction of routine laparoscopic appendectomy [4], there is a gradual increase in laparoscopic surgery for chronic appendicitis. In our experience, laparoscopic surgery for chronic appendicitis has the following significant and minimally invasive features: (1) The operation time is basically comparable to that of open surgery, and the average operation time in our group is 40 min. Since laparoscopic surgery does not require the opening and closing of the abdomen and omits the embedding of the appendiceal stump, the operation time can even be shorter than that of open surgery. (2) The ultrasonic knife gradient method is safe and convenient for treating the appendiceal vessels, and there is almost no bleeding, so it is a “bloodless surgery”. The postoperative pain is mild, and generally no analgesic drugs are needed after surgery, and fasting is not required. (3) The operation is easy and convenient, and the laparoscopic field is open, and the appendix is not affected by the location of the appendix and obesity, so the appendix can be easily found; whereas in traditional open surgery, if the appendix is not under the incision or the patient is obese, the operation is time-consuming and laborious. (4) Our group adopts the three-hole method to remove the appendix, and the two Trocar are chosen at the umbilicus and the hair on the pubic bone, which is a small and more concealed incision with good cosmetic effect, and is popular among young and middle-aged female patients. Chronic appendicitis usually needs to be differentiated from a variety of iatrogenic and gynecologic diseases. Preoperative “exclusion” tests are one aspect of a good differential diagnosis, but more important is the intraoperative exploration for confirmation. In traditional open surgery, due to the small incision, it is very difficult to explore other intra-abdominal organs and to manage concomitant diseases. Another significant advantage of laparoscopic surgery is that it allows easy exploration of the abdominal and pelvic cavities and easy management of concomitant diseases. In our group, there were 9 cases of intestinal adhesions, accounting for 50% of the group incidence, and it was difficult to diagnose intestinal adhesions preoperatively, but intraoperative exploration was clear, and all of them were treated promptly to avoid the legacy of diseases and complications. In the early days, laparoscopic appendectomy was carried out at high cost, mainly with endoscopic staplers or bipolar electrocoagulation with titanium clips, or traps to deal with the appendiceal tract and root. The cost has been reduced now that the appendiceal tract vessels can be treated directly with an ultrasonic knife. Also replacing general anesthesia with epidural anesthesia can greatly reduce the cost of the procedure. In addition, with the improvement of laparoscopic operation technology, the use of microscopic knot tying method to deal with the appendiceal tract vessels or roots without ultrasonic knife operation can make the operation cost roughly equal to that of open surgery.