Pakistan Journal of Medical Sciences

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ISSN 1681-715X

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ORIGINAL ARTICLE

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Volume 25

January - March 2009

Number  1


 

Abstract
PDF of this Article

Initial experience of laparoscopic appendicectomy
with suprapubic Camera port

Muhammad Zubair1, Anis Hussain Jaffery2, Mahmood Yousuf3

ABSTRACT

Objective: To evaluate the results of Laparoscopic Appendicectomy using midline suprapubic port for camera.

Methodology: This prospective descriptive study was done from January 2007 to 30 April 2008. All patients undergoing Laparoscopic Appendicectomy during the study period were included. Operative time, conversion, complications & hospital stay were analyzed.

Results: Total number of patients was 34 which included 21(61.76%) males and 13(38.24%) females with mean age of 25.12 years. Mean operative time was 54.39 minutes. Three (8.82%) patients required conversion to open Appendicectomy whereas two (5.88%) patients developed wound infection. Mean hospital stay was 1.29 days.

Conclusion: Laparoscopic Appendicectomy with suprapubic camera port is a safe and attractive option.

KEY WORDS: Appendicitis, Laparoscopy, Appendicectomy, Laparoscopic Appendicectomy (LA) Suprapubic Camera port.

Pak J Med Sci    January - March 2009    Vol. 25 No. 1    83-86

How to cite this article:

Zubair M, Jaffery AH, Yousuf M. Initial experience of laparoscopic appendicectomy with suprapubic Camera port. Pak J Med Sci 2009;25(1):83-86


1. Muhammad Zubair
Senior Registrar of Surgery,
Dow University of Health Sciences, Karachi.
2. Anis Hussain Jaffery,
Associate Professor of Surgery
Ziauddin Medical University, Karachi.
3. Mahmood Yousuf
Professor of Surgery
Hamdard College of Medicine & Dentistry, Karachi.

Correspondence

Muhammad Zubair,
Assistant Professor of Surgery,
Hamdard College of Medicine & Dentistry,
Karachi – Pakistan.
Email: drmzubair@hotmail.com

* Received for Publication: October 11, 2008
* Revision Accepted: November 21, 2008


INTRODUCTION

Appendicectomy is one of the commonest general surgical procedures. Charles McBurney in 1889 presented a report on early operative intervention in acute appendicitis to the New York Surgical Society and five years later he formalized the procedure and described McBurney’s incision.1,2 First laparoscopic Appendicectomy (LA) was reported almost after a century in 1983 by a German Gynaecologist, Kurt Semm.3 Today even after a quarter century laparoscopic appendicectomy has not been able to gain the popularity and acceptance earned by laparoscopic cholecystectomy. Many early randomized trials failed to show any overall benefit for laparoscopy, the increased operation time, comparable hospital stay and increased risk of intra-abdominal collection or postoperative ileus with LA outweighed any improvement in wound complication, recovery time or cosmesis. Current studies indicate a shift in favour of laparoscopy, probably due to the increase in laparoscopic exposure at all levels of surgical training. They present evidence of reduction in operating time, faster recovery, and lower wound complication rate, with the reversal in the risk of developing ileus in favor of laparoscopy.4

Different techniques have been described by different authors for LA in respect to port placement, handling the base of appendix, division of mesoappendix and removal of appendix.5-12 Regarding camera port placement the main difference has been the use of either the periumblical or suprapubic site.6,7,13 We used the suprapubic port for camera as it has been reported to be safe and optimum in terms of ergonomics and cosmesis.5 As the most commonly performed laparoscopic surgery by general surgeons is cholecystectomy, this technique has an advantage that the functional three ports are moved one quadrant down, i.e. telescope from umbilicus to suprapubic, right hand working port from epigastrium to umbilicus and left hand working port from right hypochondrium to right iliac fossa, and thus the team and theatre setup essentially remains unchanged. This is an initial report of our experience with this technique of LA.

METHODOLOGY

All patients undergoing laparoscopic Appendicectomy from 1st January 2007 to 30th April 2008 were included in the study. Patients were placed supine on the operating table and general anesthesia was used in all patients. After induction, an indwelling urinary catheter was placed to decompress the bladder, which was removed at the end of surgery. The surgeon and camera assistant stood at the patient’s left side, facing the video monitor placed at the right side of the table.

Pneumoperitoneum was established using open Hasson technique through a 10-mm infraumblical incision. A forward-viewing 10-mm laparoscope was inserted into the abdominal cavity and diagnostic laparoscopy was performed, then under video guidance another 10mm port was inserted 2cm above the pubic symphysis in the midline and the telescope was transferred to suprapubic site. Another 5mm port was introduced in the right iliac fossa. (Fig-1) The umbilical and right iliac fossa ports were used for the right and left hand instruments respectively.

Retraction and dissection were done by the two-handed technique. Skeletonization of appendix was carried out either by dissection and application of clips to the mesoappendix or by cauterizing with bipolar forceps. The base was ligated with self made chromic catgut endoloops. Endobags were used for removal of thick appendix whereas thinner ones were removed through the reducer sleeve.

RESULTS

During the study period thirty four patients underwent laparoscopic Appendicectomy using the above technique out of which twenty one (61.76%) were male and thirteen (38.24%) female. Mean age was 25.12 years, ranging from 15 to 53 years. The mean operative time for these 34 patients was 54.39 minutes (range 25 to 120 minutes). After excluding three patients who were converted to open procedure the mean operative time was 49.19 minutes.

Three patients were converted to open Appendicectomy, two of them because of gangrenous bases and third because the appendix was embedded in the small bowel mesentry and could not be handled laparoscopically. Two (5.88%) patients developed wound infection which settled on conservative measures. Twenty six (76.47%) patients were discharged after one day, six (17.65%) after two days and two (5.88%) after three days of surgery with a mean hospital stay of 1.29 days.

DISCUSSION

The popularity of LA has increased since its conception but it is still far from attaining the status of "Gold Standard". The advantages of LA are quicker & less painful recovery, fewer complications, superior cosmesis and better assessment of other intra-abdominal pathologies.14

Different techniques have been described to perform LA by different authors.5-12 Either periumblical or suprapubic port has been used for placement of telescope. The location for the working ports also varies from right upper quadrant to Mc Burney’s point, lower midline and left iliac fossa in standard surgical and laparoscopic texts.15-17 We used the midline suprapubic port as camera port and periumblical and right iliac fossa ports as right and left working ports respectively. This port placement provides superior visualization of the inferior surface of the caecum and the appendiceal base. It simulates the port placement in Laparoscopic cholecystectomy as the three main ports are essentially moved one quadrant down and it has also been reported to be ergonomically and cosmetically superior by other authors.6

The operative time for LA is reported to be longer than open appendicectomy but it has been shown to decrease with increasing experience.18 The reported average operative time varies considerably from 18 minutes reported by Hussain et al19 to 110 minutes.20 Our mean operative time of 54.39 minutes is comparable to many published studies. Mustafa Kamal from Multan has also reported mean operative time of 55 minutes.21

Conversion to open appendicectomy was required in 3(8.82%) patients. Two of them had gangrenous base of appendix and anatomy was unclear in the third patient as the appendix was embedded in the small bowel mesentry. Different authors have reported conversion rates varying from 0.55% to 21.5%.22,23 Ng et al from Hong Kong using the same technique have reported conversion in 8.7% of their 795 patients.5 Conversion increases the operating time and hospital stay and in this study the average operating time for the converted patients was 90 minutes whereas excluding these three patients it was 49.19 minutes. The main reasons for conversion reported in the literature are difficult anatomy and complicated appendicitis (perforation, gangrene and abscess).24

Mean hospital stay of 1.29 days is in accordance with published local and international studies.18,25 In a Meta analysis Bennett et al demonstrated a statistically significant reduction in hospital stay for LA as compared to open appendicectomy.4 Gilliam et al have shown LA to be safe and effective even in day care setting for selected patients.26

In this study wound infection occurred in two (5.88%) patients and this matches well with that published by other authors.26,27 Wound infection has been reported to be lower with LA as compared to open appendicectomy.4,29 This is attributed to the technique of appendix removal, as removal in endobag or reducer sleeve avoids any contact between the inflamed appendix and wound.21,28,30 One of the reported disadvantages of LA is increased incidence of intra-abdominal abscess formation.4 None of the patients in this study developed intra-abdominal abscess and this may be because of limited number of patients.

CONCLUSION

Although the number of patients is small but as the results are comparable to the published literature, we conclude that Laparoscopic Appendicectomy with suprapubic camera port is a safe and attractive option.

Limitations of the study: Case control comparison would have definitely enhanced the value of the study but we had certain limitations. We did not perform any lap appendicectomies through umblical camera port, thus those who were submitted to Lap Appendicectomy had it only by this technique whereas others had open appendicectomy.

REFERENCES

1. McBurney C. Experience with early operative interference in cases of disease of the vermiform appendix. New York Med J 1889;1:676-84.

2. McBurney C. The incision made in the abdominal wall in cases of appendicitis, with a description of a new method of operating. Ann. Surg 1894;20:38

3. Semm K. Endoscopic appendicectomy. Endoscopy 1983;15:59-64.

4. Bennett J, Boddy A, Rhodes M. Choice of approach for Appendicectomy: A Meta-analysis of open versus Laparoscopic Appendicectomy. Surg Laparosc Endosc Percutan Tech 2007;17:245-55

5. Ng WT, Lee YK, Hui SK, Sze YS, Chan J, Zeng AGY, et al. An Optimal, Cost-effective Laparoscopic Appendectomy Technique for Our Surgical Residents. Surg Laparosc Endosc Percutan Tech 2004;14:125-9.

6. Ng WT. Port placement for laparoscopic appendectomy with the best cosmesis and ergonomics. Surg Endosc 2003;17:166-7.

7. Motson RW, Kelly MD. Simplified technique for laparoscopic appendectomy. ANZ J Surg 2002;72:294-5.

8. Shalaby R, Arnos A, Desoky A, Samaha AH. Laparoscopic Appendectomy in Children: Evaluation of Different Techniques. Surg Laparosc Endosc Percutan Tech 2001;11:22-7.

9. D’Souza FR, Anwar MA, Audisio RA, Memon MA. A simple and inexpensive method for laparoscopic appendectomy. Surg Technol Int 2007;16:93-6.

10. Aslan A, Karaveli C, Elpek O. Laparoscopic appendectomy without clip or ligature. An experimental study. Surg Endosc 2007;2084-7.

11. Saad M. Fisherman’s technique, introducing a novel method for using the umbilical port for removal of appendix during laparoscopic appendectomy. Surg Laparosc Endosc Percutan Tech 2007;17(5):422-4.

12. Hanssen A, Plotnikov S, Dubois R. Laparoscopic appendectomy using a polymeric clip to close the appendicular stump. J Society Laparoscopic Surg 2007;11(1):59-62.

13. Pedersen AG, Petersen OB, Wara P. Randomized clinical trial of laparoscopic versus open appendicectomy. Br J Surg 2001;88:200-5.

14. Sweeny KJ, Keane FBV. Moving from open to laparoscopic appendicectomy. Br J Surg 2003;90:257-8

15. Josloff RK, Zucker KA. Laparoscopic appendectomy. In: Zucker KA, ed. Surgical laparoscopy. Philadelphia: Lippincott Williams & Wilkins 2001;229-36.

16. Ferguson CM. Acute appendicitis. In: Morris PJ, Wood WC, eds. Oxford Textbook of Surgery. New York, Oxford University Press. 2000;1539-43.

17. Soybel DI. Appendix. In: Norton JA, Ballinger RR, Chang AE. eds. Surgery: basic science and clinical evidence. New York, Springer-Verlag 2001;647-67.

18. Ali A, Moser MA. Recent experience with laparoscopic appendectomy in a Canadian teaching centre. Can J Surg 2008;51(1):51-5.

19. Hussain A, Mahmood H, Singhal T, Balakrishnan S, El-Hasani S. Laparoscopic appendectomy in a district hospital: does the technique influence the outcome? J Laparoendosc Adv Surg Tech A 2008;18(2):204-8.

20. Long KH, Bannon MP, Zietlow SP. A prospective randomized comparison of laparoscopic appendectomy with open appendectomy: Clinical and economic analyses. Surgery 2001;129:390-400.

21. Kamal M, Qureshi KH. Laparoscopic versus open appendectomy. Pak J Med Res 2003;42:23-6

22. Konstantinidis KM, Anastasakou KA, Vorias MN, Sambalis GH, Georgiou MK, Xiarchos AG. A decade of laparoscopic appendectomy: Presentation of 1026 patients with suspected appendicitis treated in a single surgical department. J Laparoendosc Adv Surg Tech A 2008;18(2):248-58.

23. Paterson HM, Qadan M, DeLuca SM, Nixon SJ, Paterson-Brown S. Changing trends in surgery for acute appendicitis. Br J Surg 2008;95:363-8.

24. Hellberg A, Rudberg C, Enochsson L, Gudbjartson T, Wenner J, Kullman E, et al. Conversion from laparoscopic to open appendicectomy: a possible drawback of the laparoscopic technique? Eur J Surg 2001;167(3):209-13.

25. Parveen S, Sarwar G, Saeed N, Channa GA. Laparoscopic versus open appendicectomy as an elective procedure. Med Channel 2007;13(1):18-20.

26. Gilliam AD, Anand R, Horgan LF, Attwood SE. Day case emergency laparoscopic appendectomy. Surg Endosc 2008;22(2):483-6.

27. Tanaka S, Kubota D, Lee SH, Oba K, Matsuyama M. Effectiveness of laparoscopic approach for acute appendicitis. Osaka City Med J 2007;53(1):1-8.

28. Caravaggio C, Hauters P, Malvaux P, Landenne J, Janssen P. Is laparoscopic appendectomy an effective procedure? Acta Chir Belg 2007;107(4):368-72.

29. Pokala N, Sadhasivam S, Kiran RP, Parithivel V. Complicated appendicitis—is the laparoscopic approach appropriate? A comparative study with the open approach: outcome in a community hospital setting. Am Surg 2007;73(8):737-41.

30. Khan MN, Fayyad T, Cecil TD, Moran BJ. Laparoscopic versus open appendectomy: the risk of postoperative infectious complications. J Society Laparoscopic Surg 2007;11(3):363-7.


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