Prof. Dr. Faheem Aly Elbassiony Prof. Dr. Mostafa Abd ... · Mostafa Abd Elhamid Soliman , Professor of General Surgery, Cairo University for his effort, comments, ideas, ... This

Laparoscopic versus open appendectomy in females in childbearing period

Thesis Submitted for Partial Fulfillment of Master Degree

In General Surgery

By

Mohammed Abd Allah Fath Allah Salman

M.B.B.Ch

Supervised by

Prof. Dr. Faheem Aly Elbassiony

Professor of general surgery

Faculty of medicine

Cairo University

Prof. Dr. Mostafa Abd Elhamid Soliman

Professor of general surgery

Faculty of medicine

Cairo University

Dr. Tarek Osama Hegazy

Lecturer of General Surgery

Faculty of Medicine

Cairo Univesity

2012

Abstract

Laparoscopic appendectomy is safe and feasible. Despite that the

operating time for laparoscopic appendectomy is still higher than that for

open procedure, laparoscopic approach had several advantages over open

appendectomy in that, it has less incidence of wound infection, shorter

hospital stay, less need for post operative analgesia and faster return of

patients to normal activities. Moreover, it is very useful in reaching an

exact diagnosis in equivocal cases in females during their childbearing

period. We must convert laparoscopic procedure to open surgery when

indicated for the safety of the patient. A larger further study to evaluate

the cost, benefit of laparoscopic appendectomy is recommended.

Key words:

Laparoscopic appendectomy - open appendectomy - childbearing

period - wound infection - hospital stay - post operative analgesia- return

to normal activities

1

ACKNOWLEDGMENT

First and foremost, I feel always indebted to God, the kind and

merciful.

I’m very grateful and truly indebted for Prof. Dr .Faheem Aly

Elbassiony, Professor of General Surgery, Cairo University for his kind

support and generous co-operation to accomplish this work.

.

Words are not enough to express my great thanks and deep

appreciation to Prof. Dr . Mostafa Abd Elhamid Soliman, Professor of

General Surgery, Cairo University for his effort, comments, ideas,

constructive criticism and support throughout this thesis.

Many thanks to Dr. Tarek Osama Hegazy, Lecturer of General Surgery, Faculty of Medicine, Cairo University for his support , precious criticism and valuable advices throughout this work.

A very special thank to all my family for their support and

encouragement throughout this work.

2

Contents Introduction ......................................................................................................................... 6

Review of literature ............................................................................................................. 9

Patients and methods ....................................................................................................... 106

Results ............................................................................................................................. 112

Discussion ....................................................................................................................... 126

Summary ......................................................................................................................... 137

References ....................................................................................................................... 140

3

List of tables

Table 1: Bacteria commonly isolated in perforated appendicitis. ................ 28

Table 2: : Common Symptoms of Appendicitis. .......................................... 42

Table 3: The modified Alvarado score ......................................................... 58

Table 4: Differential diagnosis for acute abdominal pain ............................ 71

Table 5: Age distribution in the 2 groups ................................................... 113

Table 6: Intraoperative findings .................................................................. 115

Table 7: Methods to deal with the mesoappendix ...................................... 115

Table 8: Methods to deal with the appendiceal base. ................................. 115

Table 9: Operative time in the 2 groups ..................................................... 117

Table 10: Overall postoperative complicationsError! Bookmark not defined. 119

Table 11: Individual postoperative complications ...................................... 120

Table 12: Wound infection in both groups ................................................. 120

Table 13: Hospital stay, and time needed to return to work ....................... 122

Table 14:Time interval for analgesia needed and Fluid tolerance ............ 123

4

List of figures

Figure 1: Development of the appendix ............................................................................ 13 Figure 2: The interior of the cecum .................................................................................. 15

Figure 3: Endoscopic appearance of the appendix orifice ................................................ 16

Figure 4: Graphic illustration of appendiceal position ..................................................... 17 Figure 5: The attachment of the appendix to the cecum and terminal ileum .................... 19

Figure 6: Blood supply of the appendix ........................................................................... 20 Figure 7: Variations in the origin of the accessory appendicular arteries ......................... 20

Figure 8: Rate of appendiceal rupture by age group ......................................................... 26 Figure 9: Incidence of negative appendectomies by age group ........................................ 26

Figure 10: The psoas sign ................................................................................................. 47 Figure 11: Anatomic basis for the psoas sign ................................................................... 47 Figure 12: The obturator sign ............................................ Error! Bookmark not defined.

Figure 13: Anatomic basis for the obturator sign .............. Error! Bookmark not defined.

Figure 14: Normal appendix; barium enema radiographic examination .......................... 52

Figure 15: Perforated appendicitis with abscess; computed tomography scan ................. 54

Figure 16: Computed tomography scan reveals an inflammed appendix ......................... 55

Figure 17: Acute suppurative appendicitis; contrast-enhanced, fat-suppressed MRI ....... 56

Figure 18: Algorithm for the evaluation and management of patients with appendicitis . 61

Figure 19: Optional incisions for appendectomy .............................................................. 77 Figure 20: Muscle-splitting incision ................................................................................ 78 Figure 21: The appendix and the cecum are rolled out of the incision ............................. 78

Figure 22: The appendiceal vascular arcade is taken between clamps and ligated ........ 79

Figure 23: A purse sting suture is placed around the stump ............................................. 79

Figure 24: Position of the patient in laparoscopic appendectomy ................................... 89

Figure 25: Trocar placement ............................................................................................ 90 Figure 26: Trocar positioning ........................................................................................... 91 Figure 27: Camera in the left iliac fossa ........................................................................... 91 Figure 28: Laparoscopic appendectomy: Trocar placement ............................................. 92

Figure 29: Stapler technique: the transection of the mesoappendix ................................. 94

Figure 30: Stapler technique: the transection of the appendix. ......................................... 94

Figure 31: Exposure of the appendix and creation of a window in the mesoappendix .... 96

Figure 32: Mobilization of the cecum for retrocecal location of the appendix. ............... 96

Figure 33: Laparoscopic appendicectomy ........................................................................ 97 Figure 34: graphic illustration for age distribution ......................................................... 114 Figure 35: Intraoperative findings of laparoscopic cases ............................................... 116 Figure 36: Intraoperative findings of open cases ............................................................ 116 Figure 37: Comparison between time in both groups. ................................................... 117

Figure 38: Comparison between wound infection in both groups. ................................. 121

Figure 39: Comparison between hospital stay in both groups ........................................ 122

Figure 40: Comparison between time to return to work in both groups ......................... 123

Figure 41: Laparoscopic exploration of peritoneal cavity .............................................. 124

Figure 42: Laparoscopic appendiceal dissection t ......................................................... 124 Figure 43: Laparoscopic division of mesoappendix between clips ............................... 125 Figure 44 : Right ovarian cyst detected by laparoscope………………………..125

Introduction Introduction Introduction Introduction

5

Introduction


6

Introduction

Appendectomy is the most common surgical procedure performed

in general surgery with a life-time risk about 6%, (Guller et al.,2004).

For almost a century, open appendectomy (OA), first described by

Charles McBurney in 1889, has remained the gold standard treatment for

acute appendicitis. The overall mortality rate for open appendectomy is

around 0.3% and morbidity about 11%, (Guller et al., 2004).

The introduction of laparoscopic surgery has dramatically changed

the field of surgery and now it is possible to perform almost any kind of

procedure under laparoscopic visualization. Laparoscopic

appendectomy(LA) was first described by Kurt Semm in 1983and the

application of the laparoscopic approach for acute appendicitis was first

reported by Schreiber in 1987. With advances in technology and surgical

technique, laparoscopic appendectomy has become the novel alternative

in the treatment of appendicitis in the last 2 decades, (Kehgias et al.,

2008).

The idea of minimal surgical trauma found in laparoscopic

approach which results in significantly shorter hospital stay, less

postoperative pain, faster return to daily activities and better cosmetic

outcome has made laparoscopic surgery for acute appendicitis very

attractive, (Kurtz and Heimann ., 2001).

The reported rate of negative appendectomy for young women

remains high despite of improvement in the diagnostic methods.

Although a "negative" appendectomy carries very little mortality risk to

the patient its morbidity is not uncommon as there is a measurable

incidence of wound infections and other complications of laparotomy.


7

At minimum, several days with high cost in the hospital are required. The

rate of negative appendectomy in females is more than in males.

Consensus European Association of Endoscopic Surgeons (EAES)

guidelines have emphasized the value of routine laparoscopy as a

diagnostic tool in young women, (Garbarino and Shimi.,2009).

In premenopausal women the diagnosis of appendicitis is

suspicious because the differential diagnosis includes symptoms of

ovulation and menstruation. A management strategy involving early

laparoscopy could potentially provide a more accurate diagnosis, earlier

treatment and reduced risk of complications. In these patients laparoscopy

provides us both diagnostic and therapeutic values and even to deal with

other causes of acute abdomen. This advantage permits us to manage

even gynecological causes without extending or changing incisions, also

to decrease incidence of infertility after open technique, (Gaitán et al.,

2011).

Also when the origin of abdominal pain is unknown, removal of

appendix is indicated as a part of diagnostic laparoscopy to eliminate

appendicitis in differential diagnosis, (Popović et al., 2004).

This work aims to:

-Compare laparoscopic appendectomy versus open appendectomy as regards operative time, findings , postoperative complications, pain and postoperative hospital stay, and to

- Clarify the advantages of laparoscopic appendectomy over open technique as a diagnostic and therapeutic method in females in childbearing period with suspected appendicitis.

Review of Literature Review of Literature Review of Literature Review of Literature

Review of literature

Review of Literature Review of Literature Review of Literature Review of Literature AnatomyAnatomyAnatomyAnatomy

9

Anatomy

1. Historical Background

The appendix was probably first noted as early as the Egyptian

civilization (3000 BC). During the mummification process, abdominal

parts were removed and placed in Coptic jars with inscriptions describing

the contents. When these jars were uncovered, inscriptions referring to

the "worm of the intestine" were discovered, (Herrinton.,1991).

Aristotle and Galen did not identify the appendix because they both

dissected lower animals, which do not have appendices,

(Herrinton.,1991).

Leonardo da Vinci first depicted the appendix in anatomic drawings

in 1492, (Ho HS.,1999).

In 1521, Jacopo Beregari da Capri, a professor of anatomy in

Bologna, identified the appendix as an anatomic structure. In the 1500s,

Vesalius (1543) and Pare (1582) referred to the appendix as the caecum.

Laurentine compared the appendix to a twisted worm in 1600, and

Phillipe Verheyen coined the term appendix vermiformis in 1710,

(Herrinton.,1991).

In 1886, Reginald Fitz of Boston correctly identified the appendix as

the primary cause of right lower quadrant inflammation. He coined the

term appendicitis and recommended early surgical treatment of the

disease, (Ellis et al.,1997).

Credit for performance of the first appendectomy goes to Claudius

Amyand, a surgeon at St. George's Hospital in London in 1736.The first

published account of appendectomy for appendicitis was by Krönlein in

1886. However, this patient died 2 days postoperatively.


10

Fergus, in Canada, performed the first elective appendectomy in 1883,

(Ellis et al.,1997).

The greatest contributor to the advancement in the treatment of

appendicitis is Charles McBurney. In 1889, he published his landmark

paper in the New York Medical Journal describing the indications for

early laparotomy for the treatment of appendicitis. It is in this paper that

he described McBurney's point as the point of "maximum tenderness”,

when one examines a case with appendicitis, (John et al.,2007).

2. Embryology and development of appendix

The appendix and the cecum develop as outpouchings of the caudal

limb of the midgut loop in the sixth week of human development. The

appendix becomes distinguishable by its failure to enlarge as fast as the

proximal cecum. This difference in growth rate continues into postnatal

life. By the fifth month, the appendix elongates into its vermiform shape,

(Williams et al.,1994).

At birth, the appendix is located at the tip of the cecum, but due to

unequal elongation of the lateral wall of the cecum, the adult appendix

typically originates from the posteromedial wall of the cecum, caudal to

the ileocecal valve, (Soybel et al.,2000).

Congenital Anomalies:

Appendiceal variations are few, and are all rare.

• Absence of the Appendix: Congenital absence of the appendix is

extremely rare, (Hei.,2003).

• Ectopic Appendix:

In cases of malrotation of the bowel, where the caecum fails to

descend to its normal position, the appendix may be found in the


11

epigastrium, abutting against the stomach or beneath the right lobe

of the liver .In this situation, the symptoms and signs of acute

appendicitis may mimic acute cholecystitis, (Ellis et al.,1997).

• Left-Sided Appendix:

1. Situs inversus viscerum.

2. Nonrotation of the intestine.

3. Wandering cecum with a long mesentery.

4. Excessively long appendix crossing the midline, (Yang et

al.,2011).

• Duplication of the Appendix: A transient, appendix like structure,

appearing during week 5, has been described. It has been suggested

that persistence of this structure my explain certain forms of

duplication, (Williams et al.,1994).

Types of duplication: Duplication of the appendix is an anomaly

of extreme rarity and fewer than 100 cases have been reported.

Khanna 1983 and Wallbridge 1962, classified duplication of the

appendix into three types:

Type A: Partial duplication on single cecum.

Type B : Two completely separated appendices on single cecum.

Type C: Double cecum each bears appendix, (Edward et al.,2001).

• Congenital Appendiceal Diverticula, (Skandalakis et al.,2004).

• Heterotopic Mucosa in the Appendix , (Haque et al.,1996).


3. Anatomical description

In humans, The vermiform appendix is a small, finger sized

structure, arising from the

and behind the iliocecal valve

The appendix communicates with the caecum with an orifice which

is guarded by a crescent

absence or incompetence of which may account for the presence of fecal

material within the process. It is considered as a continuation of the

caecum arising from its inferior tip. During infancy, more rapid growth of

the right and anterior portions of the caecum causes rot

appendix posterior and medially to its adult

Telford.,1991).

Figure (1): A: Development of the appendix.

stage showing the future appendix below. T

pushed medially by the outgrowth of the right wall of the Caecum. B.

(Decker and Plessis.,1986).

The lumen may be widely patent in early childhood and is often

partially or wholly obliterated in the size from early adulthood later

decades of life. The appendix usually contains numerous patches of


12

Anatomical description


structure, arising from the posteromedial caecal wall 1.7- 2.5 cm below

and behind the iliocecal valve, (Blakemore et al.,2001).


guarded by a crescentic mucosal fold "Valvula processus vermiformis",

etence of which may account for the presence of fecal



the right and anterior portions of the caecum causes rot

appendix posterior and medially to its adult position, (Condon and

Development of the appendix. A. Caecum at an early development

ing the future appendix below. The dotted line shows how the

pushed medially by the outgrowth of the right wall of the Caecum. B.




cades of life. The appendix usually contains numerous patches of

AnatomyAnatomyAnatomyAnatomy


2.5 cm below


ic mucosal fold "Valvula processus vermiformis",

etence of which may account for the presence of fecal



the right and anterior portions of the caecum causes rotation of the

Condon and

Caecum at an early development

he dotted line shows how the appendix is

pushed medially by the outgrowth of the right wall of the Caecum. B. the adult,



cades of life. The appendix usually contains numerous patches of


13

lymphoid tissue although these tend to decrease in old age,

(Borley.,2008).

The adjective "vermiform" literally means "wormlike" and reflects

the narrow, elongated shape of the intestinal appendage. The appendix is

typically between two and eight inches long. It is longer in children and

may get atrophy or diminish after midadult life, (Borley.,2008).

The word "caecum" actually means "blind" in Latin, reflecting the

fact that the bottom of the caecum is blind pouch. The anatomical

definition of a vermiform appendix is a narrowed, thickened, lymphoid

rich caecal apex, (Blakemore et al.,2001).

Relations of the Caecum & the appendix:

The location of the appendix is dependent on the positions of the

caecum which usually lies in the right iliac fossa. Relations of the caecum

and appendix are as follows:

• Infront : If the caecum becomes distended, it may come in contact

with the anterior abdominal wall, but as a rule some coils of small

intestine and part of the greater omentum lie between it and the

anterior abdominal wall.

• Behind: it rests on the iliacus & psoas major muscles with femoral

nerve between the two muscles. It may lie also on the external iliac

artery.

• Medially : Coils of small intestine, (Skandalakis et al.,2004).

The relation of the base of the appendix to the caecum is constant

and it is the site of convergence of the three taeniae coli on the ascending

colon and caecum. The anterior caecal taenia is usually distinct and

traceable to the appendix, affording guide to it. The surface marking for

the appendicular base which is the point of on the posteromedial wall of


the caecum, is at the junction of the lateral and middle thirds of line

joining the right anterior superior iliac spine to t

surface of the abdomen this is called "McBurney's point

(Chummy.,2011).

Figure (2):

The appendix may occupy one of several positions:

− Behind the caecum and the lower part of

(retrocaecal and retrocolic), which is the most common position,

(65.28%).

− Dependent over the pelvic brim (pelvic or descending), in females

in close relation to the right uterine tube and ovary,

− Laying below the caecum,

− In front of the terminal part of the ileum,

it may be in contact with the anterior abdominal wall.


14


joining the right anterior superior iliac spine to the umbilicus. On the

surface of the abdomen this is called "McBurney's point

The interior of the cecum, (Agur et al.,2009).

The appendix may occupy one of several positions:

Behind the caecum and the lower part of the ascending colon


Dependent over the pelvic brim (pelvic or descending), in females

in close relation to the right uterine tube and ovary, (31.01%).

Laying below the caecum, (subcaecal), (2.26%).

In front of the terminal part of the ileum, (pre-ileal),

it may be in contact with the anterior abdominal wall.



he umbilicus. On the

surface of the abdomen this is called "McBurney's point” ,

(Agur et al.,2009).

the ascending colon


Dependent over the pelvic brim (pelvic or descending), in females

(31.01%).

(1%), where


− Behind the terminal ileum,(post

− -Paracolic, (0.4%).

The appendices specially the retrocaecal

retroperitoneally as far as the kidney

Laparoscopic positions of the appendix:

In one study, a total of 303 patients

appendectomy was performed in 67 patients, 49 had a diagnostic

laparoscopy, 179 underwent a laparoscopic cholecystectomy and eight

had other procedures. The appendix was pelvic in

ileal in (22.1%), retrocaecal in (20.1%)

ileal in (3.0%) patients

Contrary to the common belief the appendix is more often found in

the pelvic rather than the retrocaecal position. There is also considerable

variation in the position of the caecum

Figure (3): Endoscopic appearance of the appendix orifice.

small depression to an obvious lumenal structure


15

Behind the terminal ileum,(post-ileal), ( 0.5%); or

(0.4%).

The appendices specially the retrocaecal ones may extend

retroperitoneally as far as the kidney, (Guidry and Poole.,1994).

Laparoscopic positions of the appendix:

study, a total of 303 patients were studied. An emergency

ectomy was performed in 67 patients, 49 had a diagnostic


res. The appendix was pelvic in (51.2%) patients,

retrocaecal in (20.1%) , para-caecal in (3.6%)

patients.

common belief the appendix is more often found in


variation in the position of the caecum, (Irfan et al.,2007).

Endoscopic appearance of the appendix orifice. The orifice varies from a

small depression to an obvious lumenal structure, (Borley.,2008).


ones may extend

.,1994).

e studied. An emergency

ectomy was performed in 67 patients, 49 had a diagnostic


(51.2%) patients, post-

caecal in (3.6%) and pre-

common belief the appendix is more often found in


The orifice varies from a


The position of the tip of the appendix

The position of the tip of t

variable and has been linked to the hands of a clock.

1- 11 and 12 O'clock Positions

The appendix passes upwards, and may be to the outer side

[paracolic (11) ] or directly behind the caecum [ retrocolic (12) ].

2- 2 O'clock Positions:

The organ is entirely intraperitoneal and lies behind or infront of the

terminal ileum. If inflamed it may affect this part of the ileum and causes

incomplete obstruction of the small gut

3- 4 O'clock or Pelvic Position:

The appendix hangs over the pelvic brim into the pelvis,

inflamed , it may cause irritation of the r

4- 6 O'clock Position:

The appendix passes down towards the middle of the inguinal

ligament, (Decker and Plessis.,1986).

Figure (4): Graphic illustration of appendiceal


16

The position of the tip of the appendix:

The position of the tip of the appendix in relation to the

variable and has been linked to the hands of a clock.

11 and 12 O'clock Positions



2 O'clock Positions:



incomplete obstruction of the small gut.

4 O'clock or Pelvic Position:

The appendix hangs over the pelvic brim into the pelvis,

inflamed , it may cause irritation of the rectum and urinary bladder

6 O'clock Position:



: Graphic illustration of appendiceal position, (Skandalakis et al.,2004).


he appendix in relation to the caecum is





The appendix hangs over the pelvic brim into the pelvis, if

ectum and urinary bladder.


(Skandalakis et al.,2004).


17

The appendix is usually connected by a short mesoappendix which is

a prolongation of the left (inferior) layer of ileal mesentery. This fold is

usually triangular, extending almost to the appendicular tip along the

whole tube, enclosing the appendicular artery. If the mesoappendix is too

short, it may be attached to the posterior abdominal wall near the pelvic

brim. The appendix is usually free within its own mesentery, but

sometimes it may lie extra-peritoneally behind the caecum or the

ascending colon or may adhere to the posterior wall of these two

structures, (Anson and MacVay.,2000).

The appendix is involved in the formation of several recesses in

association with the cecum. The superior ileocecal recess (fossa of

Luschka) lies anterior to the terminal ileum. It is formed by a peritoneal

fold, the superior ileocecal or vascular fold which extends from the

mesentery of the terminal ileum, and after crossing the ileum, it attaches

to the lowest part of the colon and cecum. This fold contains the anterior

cecal artery. Similarly, the inferior ileocecal recess lies between the

mesoappendix and a fold of peritoneum referred to as the inferior

ileocecal fold or the bloodless fold of Treves. This fold extends from the

antimesenteric border of the terminal ileum to the base of the appendix or

the anterior surface of the mesoappendix, or to both areas. The fold

contains no sizable blood vessels, (Drake.,2007).


18

Figure (5): The attachment of the appendix to the cecum and terminal ileum,

which shows the superior and inferior ileocecal folds and the mesoappendix,

(Drake.,2007).

Blood supply of the appendix

Arterial supply:

The main appendicular artery originates posterior to the terminal

ileum as a branch of the lower division of the iliocolic artery, runs behind

the terminal part of the ileum to enter the mesoappendix a short distance

from the appendicular base. Here it gives off a recurrent branch which

anastomoses at the base of the appendix with a branch of the posterior

caecal artery, (Chumpelick.,2000).

The main appendicular artery approaches the tip of the organ, lying

at first near to and afterwards in the free border of the mesoappendix

however the terminal part of the artery, lies on the wall of the appendix

and may become thrombosed in appendicitis, resulting in distal gangrene

or necrosis, (Condon and Telford.,1991).

In addition to blood from the main appendicular artery, supply

from one or more accessory appendicular arteries may be present with

high frequency of arterial anastomoses, which could serve as alternate

Documents

Prof. Dr. Faheem Aly Elbassiony Prof. Dr. Mostafa Abd ... · Mostafa Abd Elhamid Soliman , Professor of General Surgery, Cairo University for his effort, comments, ideas, ... This