Laparoscopic appendectomy for acute appendicitis: How to discourage surgeons using inadequate therapy

Abstract

Acute appendicitis (AA) develops in a progressive and irreversible manner, even if the clinical course of AA can be temporarily modified by intentional medications. Reliable and real-time diagnosis of AA can be made based on findings of the white blood cell count and enhanced computed tomography. Emergent laparoscopic appendectomy (LA) is considered as the first therapeutic choice for AA. Interval/delayed appendectomy at 6-12 wk after disease onset is considered as unsafe with a high recurrent rate during the waiting time. However, this technique may have some advantages for avoiding unnecessary extended resection in patients with an appendiceal mass. Non-operative management of AA may be tolerated only in children. Postoperative complications increase according to the patient's factors, and temporal avoidance of emergent general anesthesia may be beneficial for high-risk patients. The surgeon's skill and cooperation of the hospital are important for successful LA. Delaying appendectomy for less than 24 h from diagnosis is safe. Additionally, a semi-elective manner (i.e., LA within 24 h after onset of symptoms) may be paradoxically acceptable, according to the factors of the patient, physician, and institution. Prompt LA is mandatory for AA. Fortunately, the Japanese government uses a universal health insurance system, which covers LA.

Keywords: Acute appendicitis; Delayed appendectomy; Interval appendectomy; Laparoscopic appendectomy; Surgery.

Figure 1

Port placement and laparoscopic view. A-C: If the left lateral port is set for laparoscope, a wider angle of working forceps can be made. However, a stab scar of 5 mm remains visible; D-F: Port placements for LA using an endostaple with the best cosmesis are shown. LA: Laparoscopic appendectomy.

Figure 2

Major techniques during laparoscopic appendectomy. A: A suprapubic port (5 mm) for a flexible laparoscope is placed within the area of pubic hair (dotted blue line) to hide the postoperative stab scar. A left lateral port (3 mm) is placed as low as possible, to enable an adequate angle for the working forceps and to hide the postoperative stab scar by underwear; B: The bladder wall (red arrows), the dome of the bladder (dotted blue line), and the central umbilical fold should be recognized. Although the suprapubic peritoneum easily extends during port insertion, a suprapubic port should be placed without bladder injury; C: Any injury of the left inferior epigastric vessels should be avoided; D: Countertraction of the mesoappendix (red arrow) should be made without obstruction of the abdominal wall. Gripping and rotating forces of 3-mm forceps are sufficient. The appendix can be shortened in a rolled-in fashion (blue arrow) to avoid any disturbance by the abdominal wall.

Figure 3

Key techniques during laparoscopic appendectomy. A: Appendiceal vessels should be clearly dissected and be sealed without a clip for subsequent use of an endostaple; B: Total resection of the appendiceal root should be made (red solid arrow). A flexible endostaple has an advantage in extended resection to the cecum (red dotted arrow); C: The ileocecal valve should be recognized before an endostaple is placed (red arrow). Any involvement of this valve should be avoided; D: The externally-inverted staple line should be carefully checked. If there is any concern about a stump, a couple of interrupted seromuscular sutures can be added. Unrelated and spilled staples (blue arrow) should be removed.