complications during and after laparoscopic appendectomy

(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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