laparoscopic versus open appendicectomy in young …
TRANSCRIPT
LLAAPPAARROOSSCCOOPPIICC VVEERRSSUUSS OOPPEENNAAPPPPEENNDDIICCEECCTTOOMMYY IINN YYOOUUNNGG
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شمسشمسعینعینجامعةجامعةــالطبالطبكلیةكلیة
الطبالطبكلیةكلیةشمسشمسعینعینجامعةجامعة
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LIST OF CONTENTS
Subject Page
Introduction………………………………………………………. 1
Aim of the work………………………………………………….. 3
Chapter (I): Anatomy of the Vermiform Appendix ………….... 4
Chapter (II): Pathophysiology of Acute Appendicitis ………… 24
Chapter (III): Differential Diagnosis of Acute Lower Abdominal
Pain in Young Females…………………………
41
Chapter (IV):Investigations of Acute Appendicitis…………….. 79
Chapter (V): Technique of Laparoscopic Appendicectomy…….. 86
Chapter (VI): Advantages of Laparoscopic Appendicectomy….. 108
Chapter (VII): Complications of Laparoscopic Appendicectomy 135
Summary and Conclusion …………………………………….. 151
References ………………………………………………………. 155
Arabic Summary ………………………………………………..
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LIST OF TABLES
Table Comment Page
Table (1) : The Alvarado (MANTRELS) score……………….. 80
Table (2) : Results of a randomized prospective study
comparing laparoscopic and open
appendicectomy……………………………………. 92
Table (3) : Terminology of single-incision laparoscopic
surgery……………………………………………… 115
Table (4) : Laparoscopic appendicectomy and surgical
experience………………………………………….. 134
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LIST OF FIGURES
Figure Comment PageFig. (1) : Three types of caecum and appendix. A and B. Infantile
forms. When present in the adult, they represent milddevelopmental arrest. C. Mature and most common form 6
Fig. (2) : Duplication classification system of Cave and Wallbridge. 10
Fig. (3) : Diverticulosis of the appendix…………………………….. 11
Fig. (4) : Variations in topographic position of the appendix. Fromits base at the caecum, the appendix may extend……….. 14
Fig. (5) : Anterior and posterior positions of the appendiceal tip… 15
Fig. (6) : Blood supply to the appendix………………………………. 18
Fig. (7) : Variations in the origin of the accessory appendiculararteries………………………………………………………. 19
Fig. (8) : Anterior view of the external lymphatic drainage of theappendix with the position of the lower ileocolic lymphnodes indicated (L)………………………………………… 21
Fig. (9) : Posterior view of the external lymphatic drainage of theappendix and caecum with the position of the lowerileocolic lymph nodes indicated (L)……………………….. 21
Fig. (10) : Incision for appendectomy (blue line) in relation toMcBurney's point. Inset: Actual location of 30 appendicesin 30 patients…………………………………………………. 23
Fig. (11) : Changes in position and direction of appendix duringpregnancy……………………………………………………. 23
Fig. (12) : Frequent sites of referred pain and common causes…….. 44
Fig. (13) : Abdominal contrast-enhanced computerised tomographyscan showing a faecolith (open arrow) at the base of adistended (> 0.6 cm) appendix with intramural gas (whitearrows)……………………………………………………… 83
Fig. (14) : A. Patient positioning and trocar placement for alaparoscopic appendicectomy , showing the surgeon (S),assisting surgeon (AS), surgical nurse (SN), instrumenttable (IT), endoscopic instrument control console (EICC),anesthesia (AE), and video monitor (VM). B. Trocarpositioning: A is a 12-mm trocar and B and C are 5-mmtrocars……………………………………………………… 95
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Figure Comment PageFig. (15) : Trocar placement. A. Male patient. B. Female patient…… 97
Fig. (16) : Exposure of the appendix and creation of a window in themesoappendix……………………………………………….. 99
Fig. (17) : Mobilization of the cecum for retrocecal location of theappendix……………………………………………………. 100
Fig. (18) : Endoloop technique: the transection of the appendixbetween two loops…………………………………………… 101
Fig. (19) : Stapler technique: the transection of the mesoappendix. 101
Fig. (20) : Stapler technique: the transection of the appendix………. 102
Fig. (21) : Retrograde dissection with transection of the appendixbase, followed by its mobilization towards the tip…….. 105
Fig. (22) : If the appendiceal base is necrotic, a stapler should be usedto transect a portion of the cecum in order to achieveviable tissues………………………………………………. 106
Fig. (23) : McBurney incision, laparoscopic incision, SILS incisions 113
Fig. (24) : Types of Port in single port access in single-incision-laparoscopic sugary………………………………..……… 116
Fig. (25) : Given the risks of visceral and bowel injuries associatedwith prior abdominal and pelvic surgery, entry may beachieved safely in the upper left quadrant of the abdomen.Reproduced with permission from………………………… 138
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LIST OF ABBREVIATIONS
Abbreviations MeaningAAA : Abdominal aortic aneurysm.APACHE : Acute physiology and chronic health evaluation.AV : Atrioventricular.BMI : Body mass index.CA125 : Cancer antigen 125.CBC : Complete blood count.CBD : Common bile duct.CDC : Centers for disease control and prevention.COPD : Chronic obstructive pulmonary disease.CT : Computed tomography.D & C : Dilatation and curettage.DVT : Deep venous thrombosis.ENOTS : Embryonic natural orifice transumbilical surgeryESR : Erythrocyte sedimentation rate.GI : Gastrointestinal.GIT : Gastrointestinal tract.hCG : Human chorionic gonadotrophin.Hct : Haematocrite.Hgb : Haemoglobin concentration.HIV : Human immunodeficiency virus.HNPCC : Hereditary non polyposis colon cancer.HPV : Human papilloma virus.IBD : Inflammatory bowel disease.IUD : Intra uterine device.LA : Laparoscopic appendicectomy.LESS : Laparo-endoscopic single-site surgery
LLQ : Left lower quadrant.
MRI : Magnetic resonance imaging.
NOTUS : Natural orifice tansumbilical surgery
NSAID : Non steroidal anti inflammatory drug.
OA : Open appendicectomy.
OCPs : Oral contraceptive pils.
OPUS : One port umbilical surgery
PEEP : Positive end expiratory pressure.
-VI-
Abbreviations MeaningPET : Position emission tomography.
PET CO2 : Pressure endtidal carbon dioxide concentration.
PID : Pelvic inflammatory disease.
RLQ : Right lower quadrant.
RUQ US : Right upper quadrant ultrasonography.
SA : SILS Appendicectomy.
SILS : Single incision laparoscopic surgery.
SPA : Single port access
TOAs : Tubo-ovarian abscess.
US : Ultrasonography.
UTI : Urinary tract infection.
VOC : Vaso- occlusive crises.
WBC : White blood cell.
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Introduction
IntroductionThe introduction of laparoscopic surgery has dramatically changed
the field of surgery, with improvement in the equipment and increasing
clinical experience it is now possible to perform almost any kind of
procedure under laparoscopic visualization (Kehagias et al., 2008).
Although more than a century has elapsed since Mc Burney first
performed open appendectomy, this procedure remains the treatment of
choice for acute appendicitis for most surgeons (Kehagias et al., 2008).
Semm (1983) performed the first laparoscopic appendectomy,
ever since then, the efficiency and superiority of laparoscopic approach
compared to the open technique has been the subject of much debate
(Semm, 1983; Kurtz and Heimann, 2001).
The idea of minimal surgical trauma, resulting 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 (Kehagias et al., 2008)
However, several retrospective studies, several randomized trails
and meta analysis comparing laparoscopic with open appendectomy
have provided conflicting results (Ortega et al., 1995; Kurtz andHeimann, 2001; Guller et al., 2004).
Some of these studies have demonstrated better clinical outcomes
with laparoscopic approach (Ignacio et al., 2004).
The most valuable aspect of laparoscopy in management of
suspected appendicitis is as diagnostic tool, particularly in women of
child-bearing age, patients who undergo laparoscopic appendectomy are
likely to have less post operative pain and to be discharged from hospital
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Introduction
and return to activities of daily living sooner than those who have
undergone open appendectomy, while the incidence of post operative
wound infection is lower after the laparoscopic technique, the incidence
of post operative intra abdominal sepsis may be higher in patients
operated on gangrenous or perforated appendicitis, there may be an
advantage for laparoscopic over open appendectomy in obese patients
(O’Connell, 2008).
Laparoscopic inspection of the abdominal cavity enables the
surgeon to diagnose acute appendicitis accurately. Moreover, it has been
showed that leaving an appendix that appears normal during
laparoscopic inspection is safe, criteria for the diagnosis of appendicitis
during laparoscopic inspection are the presence of unequivocal
inflammatory changes, such as pus, fibrin or vascular injection of the
serosa, rigidity and lack of mobility at manipulation are less certain signs
of inflammation (Cuesta et al., 2008).
Removing a normal appendix at open surgery is associated with a
7-13%risk of early complications and 4% of late complication such as
incisional hernia and chronic pain in the first year after operation. If a
normal appendix is left in situ during diagnostic laparoscopy, the number
of unnecessary appendicectomies will decrease, particularly in fertile
women (17-45%). The diagnostic yield of laparoscopy in patients with
suspected appendicitis is high, but laparoscopy may be considered too
invasive to justify its use only for diagnostic purposes. This reason
seems particularly true in the era of helical CT (Cuesta et al., 2008).
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Aim of the Work
Aim of the Work
The aim of this work is to review the advantages and
disadvantages of laparoscopic surgery in the management of acute
appendicitis in young female patients compared to management by open
appendicectomy.
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Chapter I Anatomy of the Vermiform
Appendix
The Caecum and VermiformAppendix
The caecum is a large blind pouch of large intestine lying in the
right iliac fossa below the ileocaecal valve and continuing distally as the
ascending colon. The blind-ending vermiform appendix usually arises on
its medial side at the level of the ileal opening. The average axial length
of the caecum is 6cm and its breadth 7.5cm. The caecum rests
posteriorly on the right iliacus and psoas major, with the lateral
cutaneous nerve of the thigh interposed. Posteriorly lies the retrocaecal
recess which frequently contains the vermiform appendix. The anterior
abdominal wall is immediately anterior to the caecum except when it is
empty, when the greater omentum and some loops of the small intestine
may be interposed (Borley, 2008).
Usually the caecum is entirely covered by peritoneum, but
occasionally this is incomplete posterosuperiorly where it lies attached to
the iliac fascia by loose connective tissue. In early fetal life the caecum
is usually short, conical and broad at the base, with an apex turned
superomedially towards the ileocaecal junction. As the fetus grows, the
caecum increases in length more than in breadth, to form a longer tube
with a narrower base but retaining the same inclination. Distal growth
later ceases, but the proximal part continues to grow in breadth, so that at
birth a narrow vermiform appendix extends from the apex of a conical
caecum. This infantile form persists throughout life in only a very small
percentage of individuals. Occasionally the conical caecum takes on a
quadrate shape as a result of the outgrowth of a saccule on each side of
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Chapter IAnatomy of the Vermiform
Appendixthe anterior taenia: the saccules are of equal size and the appendix arises
from the depression between them instead of from the apex of a cone. In
the normal adult form, the right saccule grows more rapidly than the left,
forming a new 'apex'. The original apex, with the appendix attached, is
pushed towards the ileocaecal junction (Borley, 2008).
The caecum commences the process of fluid and electrolyte
reabsorption, which occurs to a large extent in the ascending and
transverse colon. The distensible nature and 'sac-like' morphology of the
caecum are adaptations for the storage of larger volumes of semi-liquid
chyme entering from the small bowel via the ileocaecal valve
(Borley, 2008).
Embryogenesis of the vermiform appendix
Normal Development
The appendix is the terminal portion of the embryonic caecum.
The appendix becomes distinguishable by its failure to enlarge as fast as
the proximal caecum. This difference in growth rate continues into
postnatal life. At birth, the diameter of the colon is 4.5 times that of the
appendix; at maturity, it is 8.5 times larger (Skandalakis et al., 2006).
The appendix is visible at about the eighth week of gestation.
At first, it projects from the apex of the caecum. As the caecum grows,
the origin of the appendix shifts medially toward the ileocaecal valve
(Fig.1C). The taeniae of the longitudinal muscle coat of the colon
originate from the base of the appendix, showing the same displacement.