UPDATED TOPICS IN MINIMALLY INVASIVE ABDOMINAL SURGERY

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128 Updated Topics in Minimally Invasive Abdominal Surgery department in advanced procedures. We performed incidental robotic appendectomy in three patients who underwent gynecologic surgery for endometriosis for chronic pelvic pain with good results. We believe that the robotic procedure has its place in complicated cases of appendicitis with dense peritoneal adhesions. 5.2 Implications for future research In our opinion future research should first of all determine the role of diagnostic investigations (such as laboratory parameters, US, CT and MRI) which could lower the percentage of negative laparoscopies, especially in pregnant women and high risk patients. Also, a cost-benetit analysis of the routine appliance of US and CT in order to avoid negative laparoscopies would be reasonable. Additionally, the importance of leaving back a macroscopically innocent appendix in several patient categories (women of childbearing age, patients with chronic pain, high-risk- patients, children) if no other pathology is found should be further investigated. Another issue are intraabdominal abscesses. The role of the patients characteristics, the surgeon’s expertise, the stump closure, the intraabdominal lavage and the standardization of technique in abscess formation should be further explored. The value of new techniques like the single port, the needlescopic and the robotic procedure in special cases should be investigated, as should the place of laparoscopy in obese patients and pregnant patients. Finally the late results of laparoscopic appendectomy should be explored (adhesions, SBO). 6. Conclusion In conclusion, laparoscopy seems to be as safe as open appendectomy for acute appendicitis. Laparoscopy has many advantages, such as higher diagnostic yield, fewer postoperative wound infections, less postoperative pain, shorter hospital stay, earlier return to normal and full activity, better cosmesis, and probably decreased late complications such as adhesion formation and incisional hernias. Also one cannot overemphasize the superior visualization of the abdominal cavity and the possibility of not only diagnosing other pathologies but also dealing with them without having to use a bigger incision. Fertile women can profit the most from these advantages. But also elderly, overweight and employed patients seem to profit from laparoscopy. If the safety of leaving a macroscopically innocent appendix in situ is clarified by future studies the value of laparoscopy as a diagnostic tool will be enhanced. One expects that the further expansion of laparoscopy will lead to much more experienced surgeons, and that the progress in technology will facilitate this approach even more in the future. The reported higher incidence of intraabdominal abscesses with laparoscopy in some series could be experience- or technique-related and is likely to decrease with the evolution of laparoscopic skills among surgeons that leads to more precise operative maneuvers, and the standardisation of surgical technique. The higher operative costs in most institutions can perhaps be outweighed by a shorter hospital stay, and quicker return to normal activities with the laparoscopic approach, as well as by the possible decrease in late complications. Operative costs themselves can be reduced by the application of reusable instruments, application of loops instead of staplers, and further reduction of operating times. Finally it is important to reduce negative laparoscopies. The exact role of imaging modalities, inflammatory parameters and scoring systems in this purpose has yet to be defined.
Laparoscopic Appendectomy 7. Acknowledgements The authors thank Mrs. Sofia Monastirioti for her assistance in editing the text of this chapter. We also thank Dr. Petros Hiridis for his assistance with the illustrations. 8. References Addis, DG.; Shaffer, N.; Fowler, BS. & Tauxe, RV. (1990). The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol , Vol. 8, No. 4, pp.910-925, ISSN 0963-7486 Agresta, F.; De Simone, P.; Michelet, I. & Bedin, N.(2003). Laparoscopic Appendectomy: why it should be done. JSLS, Vol. 16, No.1, pp. 347-352, ISSN 1679-1796 Akl, MN.; Magrina, JF.; Kho, RM.; Magtibay, PM. (2008). Robotic appendectomy in gynaecological surgery: technique and pathological findings. Int J Med Robot, Vol. 4, Issue 3, pp.210-213, ISSN 0029-7844 Andersson, E.; Lambe, M. & Bergstrom, R. (1999). Fertility patterns after appendicectomy: historical cohort study. BMJ, Vol. 318, No. 7189 pp. 963-967, ISSN 1464-3685 Andersson, RE.(2001). Small bowel obstruction after appendicectomy. Br J Surg, Vol.26, No. 2, pp.1387-1391, ISSN 0003-4932 Andersson, RE. & Lambe, M. (2001). Incidence of appendicitis during pregnancy. Int J Epidemiol, Vol., No., pp. 1281-1285, ISSN Asarias, JR.; Schlussel, AT.; Cafasso, DE.; Carlson, TL.; Kasprenski, MC.; Washington, EN.; Lustik, MB.; Yamamura, MS.; Matayoshi, EZ. & Zagorski, SM.(2011). Incidence of postoperative intraabdominal abscesses in open versus laparoscopic appendectomies. Surg Endosc, Vol.136, No.4, ISSN 003-4932 Ball, CG.; Kortbeek, JB.; Kirckpatrick, AW. & Mitchell, P. (2004). Laparoscopic appendectomy for complicated appendicitis: an evaluation of postoperative factors. Surg Endosc, Vol.8, No.1, pp.969-973, ISSN 0003-1348 Balthazar, EJ.; Megibow, ACCJ.; Sieger, SE.; & Birnbaum, BA. (1991). Appendicits: prospective evaluation with high resolution CT. Radiology, Vol. 28(2), pp.21-24, ISSN 0033-8419 Balthazar, EJ.; Rofsky, NM. & Zucker, R. (1998). Appendicitis: the impact of computer tomography imaging on negative appendectomy and perforation rates. Am J Gastroenterol, Vol.93, No.5, pp. 768-771, ISSN 1528-8404 Barbaros, U.; Sümer, A.; Tunca, F.; Gözkün, O.; Demirel, T.; Bilge, O.; Randazzo, V.; Dinççağ, A.; Seven, R.; Mercan, S.; Budak, D. (2010). Our early experiences with singleincision laparoscopic surgery: the first 32 patients. Surg Laparosc Endosc Percutan Tech, Vol. 20, Issue 5, pp.306-311, ISSN 1072-7517 Benjamin, IS. & Patel, AG. (2002). Managing acute appendicitis: Laparoscopic surgery is particularly useful for women. BMJ, Vol.22, No.2, pp.505-506, ISSN 0749-5161 Bennett, J; Boddy, A; Rhodes, M. (2007). Choice of approach in appendicectomy: a metaanalysis of open versus laparoscopic appendicectomy. Surg Laparosc Endosc Percutan Tech. Vol. 14. No. 4., pp: 245-255, ISSN 1130-0108 Bijnen, CL.; Van den Broek, WT.; Bijnen, AB.; De Ruiter, P. & Gouma DJ. (2003). Implications of removing a normal appendix. Dig Surg, Vol.20, No.2, pp.215-219; discussion pp. 220-221, ISSN 0303-5212 129
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VI Contents Chapter 9 Appendicitis
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Part 1 Laparoscopic Biliary-Pancrea
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