complications during and after laparoscopic appendectomy

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(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. 50
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 51
Page 1: PROFESSIONAL PAPER (2012) 2:49-53 C
Page 5: 2. Semm K. Endoscopic appendectomy.

complications during and after laparoscopic appendectomy

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