complications during and after laparoscopic appendectomy

PROFESSIONAL PAPER
(2012) 2:49-53
COMPLICATIONS DURING AND AFTER
LAPAROSCOPIC APPENDECTOMY
Anhel Koluh
ABSTRACT
Background: In Bosnia and Herzegovina laparoscopic appendectomy (LA) has been randomly
introduced as a method of treatment of acute appendicitis, and this method is accompanied
by frequent postoperative complications. Therefore, we undertook a prospective
study of patients treated by classical and laparoscopic methods to determine the
presence of intraoperative and postoperative complications, and the potential advantages
of laparoscopic appendectomy compared with the classical approach.
Patients and methods: The study included 120 patients of both sexes with acute appendicitis,
treated at the Clinic for Surgery, University Clinical Center Tuzla in the period from 2009
to 2010. A control group of 60 patients was treated by the classical method, and 60 patients
were treated by the laparoscopic method. During the study intraoperative and postoperative
complications were monitored.
Results: There were no intraoperative complications in the group of patients treated by
the classical method. Intraoperative complications were noted in the laparoscopic group:
incised taenia of the cecum, opened 2-3 cm in length and bleeding from a branch of arteria
appen-dicularis. Postoperative complications in the group of patients treated by the classical
method were: infection of wound occurred in 3 (5%) patients, phlegmon of wound occurred
in 2 (3.3%) patients, wound healing per secundam occurred in 9 (15%) patients, and
ileus occurred in one (1.6%) patient. In the laparoscopic group two (3.3%) patients had umbilical
wound infection. Intra-abdominal abscess occurred in one case in the laparoscopic
group (1.5%).
Conclusion: In patients treated by laparoscopy the risk of wound infection was smaller and
intraoperative complications had no impact on postoperative recovery.
KEY WORDS: acute appendicitis, classic appendectomy, laparoscopic appendectomy.
INTRODUCTION
Laparoscopic appendectomy (LA) has only recently become a commonly used method in the
treatment of acute appendicitis, despite of its proven advantages over classic appendectomy
Anhel Koluh
Cantonal Hospital of Zenica
Department of Surgery
Crkvice 67, 72000 Zenica
Bosnia and Herzegovina
E-mail:
anhel.koluh@gmail.com
49

(CA) 1,2 . In Bosnia and Herzegovina laparoscopic appendectomy
has been randomly introduced, only in several
centers, as a method of treatment of acute appendicitis.
One of the reasons is that CA with McBurney’s incision
is a simple, fast and efficient procedure. LA requires
certain knowledge of laparoscopic surgery and more
expensive equipment. Potential advantages such as the
reduced number of wound infections, shorter hospital
stay, faster recovery and return to everyday activities,
were accompanied by a longer operative time and higher
costs and more frequent postoperative complications at
the time when the method was being accepted 3,4,5 . In the
last two decades since laparoscopic appendectomy was
introduced many papers have been published showing
that it is a safe and feasible procedure in the treatment
of acute appendicitis 6,7,8 .
However, there are also some diverse reports demonstrating
that the incidence of intra-abdominal abscess
is higher, the time of surgery is extended and costs of
treatment are significantly increased, whereas some
reports do not find any significant difference in intraabdominal
abscess, wound infections and the quantity
of analgesics applied 9 . For that reason we conducted a
prospective study involving patients treated by the classical
and laparoscopic methods in order to establish the
occurrence of intraoperative and postoperative complications.
PATIENTS AND METHODS
The study included 120 patients of both sexes with acute
appendicitis, treated at the Clinic for Surgery, University
Clinical Center Tuzla in the period from 2009 to
2010. A control group of 60 patients were treated by the
classical method, while 60 patients were treated by the
laparoscopic method. Of the total number of operated
patients using the classical method, 37 we are (61.66%)
females with an average age of 26.05 years, at an interval
from 15 to 55 years old and 23 (38.33%) were men, with
an average age of 38 years, from 15 to 70 years old. In
the group of patients treated by the laparoscopic method,
30 (50%) were females and 30 (50%) were males.
Criteria for inclusion in the study were: patients with
acute appendicitis older than 14 and LA was performed
by a surgeon who had done at least five such procedures
in the past. Patients with secondary appendicitis caused
by another clinical entity and patients, who had a laparoscopic
appendectomy converted into a classical one,
were excluded from the study. The study monitored
intraoperative and postoperative complications during
hospitalization.
TECHNIQUE
Classical appendectomy
Classical appendectomy was performed through the
right iliac fossa using an alternate incision according to
Sprengler. Having established acute appendicitis, dissection
and ligation of the mesoappendix and appendix
were performed. The wound was ligated with the Safil
suture (Braun, Tuttlingen, Germany).
Laparoscopic appendectomy
A patient is positioned on the surgery table in a deep
Trandelenburg position. The patient is leaned towards
a surgeon. The surgeon and assistant stand on the left
side and a monitor is positioned on the right side of
the patient. Shortly before the surgery we apply a urinary
catheter to decompress the urinary bladder and to
avoid its injury during the application of the suprapubic
ports. Pneumoperitoneum is achieved by insertion of
the Veress needle through the umbilicus. Three ports
are inserted: 10 mm port in the supraumbilical area using
the closed technique, and thereafter two additional
5 mm ports controlled by a camera – one in the suprapubic
area, more to the left, and the other one in the
right lower quadrant, at the level of the first 5 mm port
in order to get a triangulation.
When a decision to perform appendectomy is made,
the mesoappendix is mobilized and recessed by an ultrasonic
dissector (Ultrasonic Coagulating Shears, Ethicon,
Endosurgery, Cincinnati, OH). Three endoloop 1/0
Vicryl (Ethicon, Endosurgery) ligatures are thereafter
applied around the base of the appendix or two nonabsorbable
hem-o-lok plastic clips of XL size are applied
(Hem-o-lok, Weck Closure Systems, Research Triangle
Park, NC, USA). The appendix is cut between ligatures
or plastic clips with the ultrasonic dissector inserted
through the 5 mm port. Abdominal toilet of the right
paracolic gutter and Douglas pouch is performed using
suction/irrigation. Whenever exudate appeared drainage
was inserted into the pouch of Douglas.
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Table 1. Intraoperative and postoperative complications in classical and laparoscopic appendectomy
Pathohistological evaluation
Gangrenous
Phlegmonus
Perforated
Diffuse peritonitis
Local peritonitis
Intraoperative complication
Opened cecum 2-3 cm
Bleeding from arteria
appendicularis
Incised taenia
Postoperative complication
Properly coalesced wound
Wound per secundam
Wound infection
Phlegm of wound
Ileus
Intraabdominalni abscess
* laparoscopically situated
** 5 i 10 mm clips with surgical
*** laparoscopically situated
Laparoscopic appendectomy
(n=60)
33 (55%)
27 (45%)
7 (11,6%)
3 (5%)
3 (5%)
1 (1,6%) *
1 (1,6%) **
1 (1,6%) ***
57 (95%)
0
2 (3,3%)
0
0
1 (1,6%)
Classical appendectomy
(n=60)
28 (46,6%)
31 (51,6%)
18 (30%)
4 (6,6%)
6 (10%)
0
0
0
45 (75%)
9 (15%)
3 (5%)
2 (3,3%)
1 (1,6%)
0
RESULTS
In the group of patients treated by classical appendectomy
the largest number of them had phlegmonous
changes of the appendix – 31 (51.66%) patients, whereas
gangrenous appendix occurred in 33 (55%). patients
treated with laparoscopic method.
Comorbidity and intraoperative complications
Intraoperative complications noted in the laparoscopic
group included a cecum opened for 2-3 cm and bleeding
from a branch of the arteria appendicularis and an
incised taenia. No intraoperative complications were
noted in the group of patients treated by the classical
method.
Postoperative complications
Among the patients treated with the CA, 3 (5%), had
a wound infection, 2 (3.3%) experienced phlegmon of
the surgical wound, 9 (15%) had a wound healing per
secundam, and ileus occurred in 1 patient (1.6%). Two
LA patients (3.3%) had an infection of the umbilical
wound. Intraabdominal abscess occurred in LA in one
patient (1.6%) (Table 1.).
DISCUSSION
Laparoscopic appendectomy has proven advantages
over the open method. The risk of infection is lower,
postoperative pain is less severe, and the hospital stay
is shorter.
Intraoperative complications were noted in the group of
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patients treated by the laparoscopic method (intestinal
lesions and bleeding from mesoappendix) which were
handled during surgery, did not lead to conversion into
an open procedure and had no impact on postoperative
recovery.
Trocar injuries represent a significant complication of
laparoscopic surgery resulting in the most serious injuries,
such as vascular injuries. The most common intraoperative
complication of laparoscopic appendectomy
was bleeding from the mesoappendix 4,14 . There are different
under-lying causes of an unsuccessful procedure
– the most frequently stated reasons include the position
of the appendix, adhesions, obesity, bleeding and
abscess 10,15 . Most of the reasons for conversions occur
due to the insufficient experience of the surgeons. Of
course they are very rare in cases of experienced surgeons.
The learning curve of laparoscopic appendectomy gives
five appendectomy, when the number of intraoperative
and postoperative complications is reduced, and this
operation can be recommended as a model for learning
in laparoscopic surgery.
Laparoscopy is characterized by decreased traumatization
of tissue and lesser irritation of intestines, less severe
postoperative pain and shorter stays in hospitals as
well as faster recovery and return to normal activities,
which is of special importance for patients who are supposed
to return to work 11,12 .
Five-millimeter trocars do not require the closure of the
parietal wall, resulting in less postoperative pain and a
smaller scar. As stated by other studies, the lower rate
of infections of surgical wounds may be explained by
the extraction of the inflamed appendix in an endobag,
while in the group of patients treated by the classical
method the healing of wounds was delayed in 25%. Delayed
healing of wounds in combination with longer
hospitalization and treatment with antibiotics significantly
increases the cost of treatment 13,16 .
Intra-abdominal abscess occurred in LA in only one
case of uncomplicated appendicitis.
It was treated with ultrasound guided drainage, the
method that should have preference in the treatment of
such kinds of complications. In open appendectomy intra-abdominal
abscess occurs in 2 to 3% of cases. Most
studies have noted a slightly higher incidence of abscess
in laparoscopic appendectomy. Inappropriate techniques,
which certainly include, for example, squeezing
of the appendix during appendectomy, instead
of seizing the mesentery, and inadequate toilet of the
peritoneal cavity, result in a slightly higher incidence 9,17 .
However, there is an increasing number of reports stating
that there is no difference in the creation of an abscess
in classical and laparoscopic appendectomy. This
will certainly be achieved by improved experience of
surgeons and better toilet of the intraperitoneal space6.
In cases of perforated appendicitis there is an increased
incidence of the creation of abscess, regardless of the
kind of technique used.
A limitation of this study is the size of the sample, but
its results are consistent with other published studies.
This study confirms previously conducted studies and
demonstrates that in patients treated by the laparoscopic
method the risk of wound infection is smaller;
intraoperative complications, which do not affect the
postoperative period, decrease with the number of surgeries
performed.
Acknowledgment:
I thank the Department of Surgery of the University
Clinical Centre, Tuzla, and my mentor, Prof.
Delibegović for his assistance in undertaking this
study.
Received: 12 November 2011/Accepted: 14 May 2012
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