Additional information on laparoscopic appendectomy

1Comparison of Laparoscopic Appendectomy and ConventionalAppenˉdectomy (CA)

Open appendectomy has been performed for more than 100 years and is a classic and mature procedure. Most patients can be completed with small incisions, the complication rate is not high, and both have the same safety and therapeutic effect, but on the contrary, the incidence of intra-abdominal abscess after laparoscopic surgery is significantly higher. Therefore, some scholars question the necessity of laparoscopic appendectomy. However, many obese patients or patients with difficulty in finding the appendix need to enlarge the incision. The diagnosis and treatment of appendicitis in pregnancy or ectopic appendicitis is sometimes not simple. Laparoscopy improves the accuracy of its diagnosis. The scope of the examination is vast. The operator can better visualize the size of the pelvis and most of the other intra-abdominal organs, and can also detect other lesions such as Meckel's diverticulum, appendiceal carcinoid, and cecum diverticulum. Misdiagnosis of appendicitis in pregnancy can be as high as 35% to 55% and can lead to preterm labor and miscarriage, the incidence of which can be nearly 5% to 6%.Schreiber's success in the treatment of appendicitis in pregnancy has certainly informed us. In addition, when the appendix is found to be essentially normal intraoperatively, it is difficult to fully explore the abdominal organs to understand the true cause of abdominal pain because of the small incision. The incision infection rate of open surgery can reach 4% to 7%, and postoperative intestinal adhesions in appendicitis can lead to frequent postoperative abdominal pain and even adhesive bowel obstruction, so it is clear that CA has not been perfect.

2 Indications for laparoscopic appendectomy

(1) Elderly people and pediatric appendicitis; (2) Obesity; (3) Acute suppurative appendicitis, gangrenous perforated appendicitis combined with peritonitis; (4) Abdominal surgical diseases and diseases of the female internal reproductive system can't be completely excluded. However, in the following cases, timely open surgery must be performed [14, 15]: (1) necrotic perforation of the appendiceal root, and the appendiceal stump can not be reliably managed; (2) severe adhesion between the appendix and adjacent intestines or other organs, and the anatomical relationship is not clear; (3) the appendix is ectopic peritoneal or ectopic in the wall of the cecum, which makes it difficult to be dissected; (4) appendiceal malignant tumors; and (5) serious collateral injuries, such as injury to the adjacent intestines, have occurred.

3Preoperative preparation

Preoperative preparation is similar to conventional open appendectomy and does not add any tediousness, but it is necessary to explain to the family to switch to dissection in some cases. The contraindications to surgery [11, 16, 17] are:(1) Extensive intra-abdominal adhesions. Those who cannot create a satisfactory artificial pneumoperitoneum, but note that a history of multiple surgeries is not necessarily a contraindication. Kind of patients maybe the intra-abdominal adhesions are not extensive. On the contrary, some patients without a history of surgery have extensive intra-abdominal adhesions that become the cause of acute laparoscopic failure. (2) Acute peritonitis with a clear diagnosis (3) Intestinal paralysis, intestinal obstruction (4) Various abdominal hernias, especially esophageal hiatal hernia (5) Severe cardiopulmonary disease, acute myocardial infarction who cannot tolerate artificial pneumoperitoneum. Stale myocardial infarction, emphysema, excessive obesity and emaciation are relative contraindications (6) severe bleeding tendency or coagulation disorders (7) the patient is extremely uncooperative.

4 Comparison of complications after laparoscopy and open appendectomy

Laparoscopy is a safe and reliable method and complications are rare. Complications are usually due to improper handling, and a few serious complications are often due to artificial pneumoperitoneum, and burns during electrocoagulation [16-18].CA is a very safe procedure, and no surgical deaths have been reported.U. Guller et al [19] reported 43,757 cases of appendicitis, of which 7,618 were operated on by LA (17.4%), and 36,139 were operated on by open surgery. The mean hospitalization time was 2.06 days for laparoscopic surgery and 2.88 days for open surgery, P0.05; Momˉpean [21] reported 13 cases of normal appendix in 100 open surgeries, of which 5 failed to make a definitive diagnosis. In contrast, there were 15 cases of normal appendix in 100 LAs during the same period, all of which were found to be true lesions. The literature reports that 15% to 20% of patients undergoing cesarean section for suspected appendicitis have a normal appendix. The rate of negative appendectomy is higher in women of childbearing age [22].

5 Evaluation of laparoscopic appendectomy

Laparoscopic appendectomy was performed 4 years earlier than cholecystectomy, but is now much less commonly performed than the latter. The main reason for this is that because laparoscopic appendectomy requires expensive equipment, the operation is more expensive, and the long operation time and treatment are more expensive, which is difficult for a significant number of patients to accept. Some units take longer than open [23], ACariati reported that the time taken for conventional open appendectomy in group 1 averaged 43 min, while laparoscopic appendectomy took 63 min, which was significantly longer than the former.Loh [24] attributed this to the lack of familiarity with laparoscopic techniques during the initial learning phase. This disadvantage may be short-lived as the operative time of LA becomes shorter and the cost of treatment will decrease as the surgical skills of LA continue to improve and the laparoscopic equipment becomes more sophisticated [25].The material from the group of SSauerland [10]1 showed that the cost of laparoscopic surgery was significantly higher than that of open surgery, and the hospitalization expenditures were significantly higher, but due to shorter hospitalization time and reduction of other consumptions, the total However, due to the shorter hospitalization time and the reduction of other expenses, the total cost was not significantly higher, not to mention that the patients returned to normal activities and work earlier after laparoscopic surgery. Therefore, the economic benefit ratio is still appropriate. However, in developing countries such as China, the economic benefit ratio is clearly reversed due to the low cost of surgery and hospitalization.