UPDATED TOPICS IN MINIMALLY INVASIVE ABDOMINAL SURGERY

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152 Updated Topics in Minimally Invasive Abdominal Surgery dimensional imaging. In these patients, the attending surgeon is looking for evidence of intra-abdominal collection to account for the apparent lack of improvement. However, in rare cases, there may be evidence of iatrogenic injury particularly during laparoscopic appendicectomy or other missed diagnosis. In such patients, there should be a low threshold for repeat laparoscopy or laparotomy. Any evidence of intra-abdominal collection should be managed by drainage and peritoneal lavage. Iatrogenic injuries will require expert surgical correction and appropriate post-operative management. A missed diagnosis will require appropriate management. Patients who had either percutaneous or laparoscopic drainage of an appendix abcess require careful monitoring for resolution of the inflammation and regression of the abcess. This is done clinically in the first instance but repeat three-dimensional imaging using contrast enhanced CT is usually more accurate than clinical evaluation. Failure of resolution of the inflammatory abcess or phelgmon associated with the abcess indicates either insufficient drainage together with incomplete or inappropriate antibiotics treatment. In such cases, the three dimensional imaging as well as bacteriological sensitivity testing of retrieved purulent material will guide further management. In some patients, revision of antibiotics requirement is necessary and in others revision of drainage is essential. In some patients, operative intervention is necessary due to intra-abdominal spread or rupture of the abcess. In these patients, the objective of operative intervention whether by laparotomy or laparoscopy is adequate drainage of any collection together with peritoneal lavage. When the abcess has been adequately drained, there is usually an accompanying improvement in the general condition of the patient. The drain should be withdrawn when no further purulent material is obtained. The patients can usually return to normal activity and can be safely discharged from hospital. However, due to the relatively high incidence of recurrent appendicitis, patients should be given a date for appendicectomy. This delayed appendicectomy should be done when all signs of inflammation have disappeared and should be attempted laparoscopically by an experienced surgeon. 6. Conclusion Despite the recent decline in the incidence of appendicitis, it remains the commonest surgical emergency. It is estimated that 10% of the population will have appendicitis during their life time. Approximately 20 % of those will have complicated appendicitis. The diagnosis of appendicitis remains clinical. However, reliance on clinical examination alone will result in an unnecessary number of patients having exploratory surgery. Clinical history and examination supplemented with routine inflammatory marker analysis improves the diagnostic accuracy. Although ultrasound and computed tomography are relatively accurate in the diagnosis of appendicitis, it is important to emphasise that CT is more accurate than ultrasound but carries a radiation burden. The use of both radiological investigations is limited in the emergency setting. The diagnosis of appendicitis is most difficult at the extremes of age and it is in these patients that additional investigations may be justified. In all other cases, if the history and examination is compatible with appendicitis with raised inflammatory markers, patients (both males and females) should have a diagnostic laparoscopy which can proceed to laparoscopic appendicectomy if the appendix was found to be inflamed. If an appendix abcess was found, the abcess should be drained. If the appendix was found to be perforated, conversion to open appendicectomy should be
Appendicitis and Appendicectomy considered. In all cases, adequate peritoneal lavage should be carried out. Post-operatively, all patients should have antibiotics for different periods depending on the degree of inflammation and contamination found at operation. Post-operatively, all patients should be monitored for the emergence of adverse events. Patients who develop signs of peritoneal infection or who fail to improve should have a CT in the first instance. Wound infections should be managed by open drainage and antibiotics. Intra-abdominal infection should be managed by laparoscopy/ laparotomy, drainage of collection and peritoneal lavage together with systemic antibiotics. Laparoscopic appendicectomy is safe for the majority of cases of simple appendicitis. If at laparoscopy, the appendix is found to have perforated, the surgeon should make a careful evaluation of whether to continue with laparoscopic surgery or convert to open surgery. In either situation, the surgical objective is appendicectomy together with adequate peritoneal lavage of all areas of the peritoneal cavity. 7. References Ball CG, Kortbeek JB, Kirkpatrick AW, and Mitchell P. Laparoscopic appendectomy for complicated appendicitis: an evaluation of postoperative factors. Surgical Endoscopy. 2004; 18: 969-973. Garbarino S, Shimi SM. Routine diagnostic laparoscopy reduces the rate of unnecessary appendicectomies in young women. Surg Endosc. 2009 Mar;23(3):527-33. Epub 2008 Mar 26. Hale DA, Molloy M, Pearl RH, Schutt DC, Jaques DP. Appendectomy: a contemporary appraisal. Annals of Surgery 1997 Vol. 225, No. 3, 252-261 Ingraham AM, Cohen ME, Bilimoria KY, Pritts TA, Ko CY, and Esposito TJ. Comparison of outcomes after laparoscopic versus open appendectomy for acute appendicitis at 222 ACS SQIP hospitals. Surgery 2010; 148: 625-37. Livingston EH, Woodward WA, Sarosi GA, and Haley RW. Disconnect Between Incidence of Nonperforated and Perforated Appendicitis: Implications for Pathophysiology and Management. Ann Surg. 2007 June; 245(6): 886–892. Stoker J, van Randen A, Lameris W, and Boermeester MA. Imaging patients with acute abdominal pain. Radiology 2009; 253: 31-46. Kirshtein B, Perry ZH, Avinoach E, Mizrahi S, Lantsberg L. Safety of laparoscopic appendectomy during pregnancy. World J Surg. 2009 Mar;33(3):475-80. Li X, Zhang J, Sang L, Zhang W, Chu Z, Li X, and Liu Y. Laparoscopic versus convential appendectomy – a meta-analysis of randomised controlled trials. BMC Gastroenterology 2010; 10: 129. Markides G, Subar D, Riyad K. Laparoscopic versus open appendectomy in adults with complicated appendicitis: systematic review and meta-analysis. World J Surg. 2010 Sep;34(9):2026-40. Review. Needham PJ, Laughlan KA, Botterill ID, Ambrose NS. Laparoscopic appendicectomy: calculating the cost. Ann R Coll Surg Engl. 2009 Oct;91(7):606-8. Park HC, Yang DH, Lee BH. The laparoscopic approach for perforated appendicitis, including cases complicated by abscess formation. J Laparoendosc Adv Surg Tech A. 2009 Dec;19(6):727-30. 153
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VI Contents Chapter 9 Appendicitis
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Part 1 Laparoscopic Biliary-Pancrea
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