The Case for Laparoscopic Appendicectomy 2018
-
Upload
mohamad-al-gailani -
Category
Health & Medicine
-
view
124 -
download
0
Transcript of The Case for Laparoscopic Appendicectomy 2018
The Case for
LAPAROSCOPIC
APPENDICECTOMY
2018
Dr. Mohamad Al-Gailani FRCS
Consultant Surgeon
Al Hammadi Hospital, Suwaidi
Riyadh, KSA
THE CASE FOR
LAPAROSCOPIC
APPENDICECTOMY
2018
Dr. Mohamad Al-Gailani FRCS
Consultant Surgeon
Al Hammadi Hospital, Suwaidi
Riyadh, KSA
ACUTE APPENDICITIS
One of the most common causes of the Acute
Abdomen
One of the most frequent indications for
emergency abdominal surgical procedure
worldwide
Occurs most frequently in the second and third
decades of life
The incidence is approximately 233/100,000
population and is highest in the 10 to 19-year-old
age group
Male to Female ratio 1.4:1
Lifetime incidence 8.6 %
The Case For Laparoscopic Appendicectomy 2018 DR. Mohamad Al-Gailani FRCS Al Hammadi Hospital, Suwaidi, Riyadh, KSA
2
Advantages of the Laparoscopic
Approach 1
A lower rate of wound infections
(Odds Ratio [OR] 0.43, 95% CI
0.34-0.54)
Less pain on postoperative day 1 by
the VAS pain score (8 mm, CI 5-11
mm)
Shorter duration for return of
bowel function
The Case For Laparoscopic Appendicectomy 2018 DR. Mohamad Al-Gailani FRCS Al Hammadi Hospital, Suwaidi, Riyadh, KSA
3
Advantages of the Laparoscopic
Approach 2
Shorter duration of Hospital Stay
(1.1 days, CI 0.7-1.5 days)
Fewer Complications (13 % v 22 %)
Less chance of Incisional Hernia
Lower Mortality Rate (0.4 % v 2.1
%)
The Case For Laparoscopic Appendicectomy 2018 DR. Mohamad Al-Gailani FRCS Al Hammadi Hospital, Suwaidi, Riyadh, KSA
4
Special Indications for the
Laparoscopic Approach
1. An Uncertain Diagnosis since it permits
inspection of the whole peritoneal cavity
2. Women of Childbearing Age in whom
laparoscopy may reveal other causes of
pelvic pathology
3. Obese patients since exposure of the right
lower quadrant during open appendectomy
may require larger morbidity-prone
incisions
The Case For Laparoscopic Appendicectomy 2018 DR. Mohamad Al-Gailani FRCS Al Hammadi Hospital, Suwaidi, Riyadh, KSA
5
1.An Uncertain
Diagnosis
Initial Laparoscopy through a small
incision permits inspection of the whole
peritoneal cavity and is good as a general
laparotomy without the big incision!
The appendix, pelvic organs, gall bladder
and the presence or absence of pus or free
fluid may be visualized.
Any need to proceed to open laparotomy
could be planned then through an
appropriate incision.
The Case For Laparoscopic Appendicectomy 2018 DR. Mohamad Al-Gailani FRCS Al Hammadi Hospital, Suwaidi, Riyadh, KSA
6
2.Women of Child
Bearing Age
Improved visualization of the
entire abdomen
Improves the diagnostic accuracy
and can identify the definitive
pathology more often than the open
approach
Potential less adhesions and so less
chance of potential future fertility
concerns
The Case For Laparoscopic Appendicectomy 2018 DR. Mohamad Al-Gailani FRCS Al Hammadi Hospital, Suwaidi, Riyadh, KSA
7
3.Obesity
Laparoscopic Appendectomy is safe and
effective in obese patients and may be
the preferred approach
The Laparoscopic approach may convey
some advantages over the open approach
in access to the appendix, visualization,
and decrease in wound complications.
In the morbidly obese longer trocars and
instruments may be needed.
The Case For Laparoscopic Appendicectomy 2018 DR. Mohamad Al-Gailani FRCS Al Hammadi Hospital, Suwaidi, Riyadh, KSA
8
Disadvantages of the Laparoscopic
Approach
A learning curve is
required
Potential injury during
port insertion
Higher costs of equipment
The Case For Laparoscopic Appendicectomy 2018 DR. Mohamad Al-Gailani FRCS Al Hammadi Hospital, Suwaidi, Riyadh, KSA
9
Complications of Appendicectomy
in General
Average morbidity near 10%
Adynamic Ileus secondary to
severe sepsis
Surgical Site Infection (SSI)
Dehiscence (open)
Incisional hernia
Pelvic or abdominal abscess
Caecal fistulas
The Case For Laparoscopic Appendicectomy 2018 DR. Mohamad Al-Gailani FRCS Al Hammadi Hospital, Suwaidi, Riyadh, KSA
10
Remove an Apparently
Normal Appendix at Laparoscopy?
Should you remove a
macroscopically apparently
Normal Appendix at
Laparoscopy?
The Case For Laparoscopic Appendicectomy 2018 DR. Mohamad Al-Gailani FRCS Al Hammadi Hospital, Suwaidi, Riyadh, KSA
11
Remove an Apparently
Normal Appendix at Laparoscopy?
YES
Macroscopically normal appendixes may have
abnormal histopathology
19% - 40% rate of pathologically abnormal
appendix in the setting of no visual abnormalities
The risk of leaving a potentially abnormal
appendix must be weighed against the risk of
appendicectomy in each individual scenario
Cases of postoperative symptoms requiring
reoperation for appendicectomy have been
described in patients whose normal appendix was
left in place at the time of the original procedure.
The Case For Laparoscopic Appendicectomy 2018 DR. Mohamad Al-Gailani FRCS Al Hammadi Hospital, Suwaidi, Riyadh, KSA
12
Need for Interval (Elective)
Appendectomy? 1
Following successful treatment
of an appendicular mass,
should you plan later for an
Interval or Elective
Appendicectomy?
The Case For Laparoscopic Appendicectomy 2018 DR. Mohamad Al-Gailani FRCS Al Hammadi Hospital, Suwaidi, Riyadh, KSA
13
To prevent recurrence of appendicitis
To exclude neoplasms (such as carcinoid,
adenocarcinoma, mucinous cystadenoma, and
cystadenocarcinomas) especially in older adults
who have higher incidences of appendiceal
neoplasm
Older patients should also have a colonoscopy or
barium enema to rule out caecal pathology
The need for interval appendectomy is debated
with some studies suggesting that interval
appendectomy is unnecessary?
The Case For Laparoscopic Appendicectomy 2018 DR. Mohamad Al-Gailani FRCS Al Hammadi Hospital, Suwaidi, Riyadh, KSA
14
Need for Interval (Elective)
Appendectomy? 2
Need for Interval (Elective)
Appendectomy?YES!
Retrospective review of 1012 patients treated non-
operatively for acute appendicitis
864 patients did not undergo an interval appendectomy
Of those (4.5 percent) required an appendectomy at a
median follow-up of four years
A malignant disease was detected in 1.2 %
Recurrent Appendicitis developed in 7.4 %
Interval Appendectomy for most adult patients is
Recommended
Colonoscopy should be considered prior to
Appendectomy in patients over 50 who have not had a
recent colonoscopy
*UptoDate
The Case For Laparoscopic Appendicectomy 2018 DR. Mohamad Al-Gailani FRCS Al Hammadi Hospital, Suwaidi, Riyadh, KSA
15
SUMMARY
Diagnostic ability of laparoscopy especially in
female patients
Decreased postoperative pain
Earlier discharge
A shorter time to return to usual activities
Lower incidence of wound infections or
dehiscence
Training opportunity for laparoscopic skills
Better aesthetic result
Disadvantages: cost!
The Case For Laparoscopic Appendicectomy 2018 DR. Mohamad Al-Gailani FRCS Al Hammadi Hospital, Suwaidi, Riyadh, KSA
16
CONCLUSION
1. Laparoscopic Appendectomy
Should be the Standard Approach
for patients with Appendicitis or
Suspected Appendicitis.
2. Consider removing a
Macroscopically Normal
Appendix
3. Consider Interval
Appendicectomy for most adult
patients
The Case For Laparoscopic Appendicectomy 2018 DR. Mohamad Al-Gailani FRCS Al Hammadi Hospital, Suwaidi, Riyadh, KSA
17
REFERENCES
UptoDate
Society of American
Gastrointestinal and
Endoscopic Surgeons (SAGES)
The Case For Laparoscopic Appendicectomy 2018 DR. Mohamad Al-Gailani FRCS Al Hammadi Hospital, Suwaidi, Riyadh, KSA
18
19