Department of Surgery, BIRDEM General Hospital, Dhaka, Bangladesh
and Objective: Currently,
laparoscopic appendectomy (LA) is widely practiced for the management of acute
appendicitis (AA). The application of laparoscopic technique for appendectomy
is expanding very rapidly and now performed in almost all major cities and
tertiary level hospitals. This study addressed to determine the outcomes of
laparoscopic appendectomy in our surgical setup at Bangladesh Institute of
Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorder (BIRDEM).
All admitted patients at BIRDEM hospital and clinically diagnosed as acute
appendicitis considered eligible for the study. Based on clinical history relevant
and routine biochemical investigations were done. A board of experienced
surgeons selected the eligible cases for LA. The study continued from Sept 2014
to Sept 2016.
A total of 47 (M / F = 21 / 26) patients with acute appendicitis were admitted
during this period. The mean (SD) age was 21 (±1.4) years in male and 19 (±1.7)
years in female. The mean age of the total patients was 20 (±1.6) years. Eighty
percent of the patients were of age 30 years or less. Per-operative
laparoscopic findings revealed that five cases (10.6%) were misdiagnosed as appendicitis.
Two (4.2%) cases were found to have other pathology and necessitated open appendectomy (OA). One was suspected for malignancy
and other had appendicitis with adhesion. Overall, four important post-operative
outcomes were observed: (a) post-operative pain was found reducing gradually
and it fell below pain score 2 or even less after 30 hours; (b) port-site bleeding
and infection were observed in 4.3% and 2.1%, respectively; (c) none had
visceral bleeding or subcutaneous emphysema and (d) more than 80% were
discharged within 72 hours.
Most of the patients admitted with acute appendicitis were of younger age
(<30 years). Though there was no comparative group undergoing open
appendectomy (OA), it was apparent that laparoscopic approach was proved to
have reduced pain, less complication and shorter hospital stay thus reducing
the treatment cost. Thus, LA was found relatively safe and resilient procedure.
An additional benefit of laparoscopy was that it revealed about 10% case were
misdiagnosed as having appendicitis. Thus, this approach may be considered as a step forward in the treatment of appendicitis making easier to explore the abdominal cavity while
keeping an option to perform an OA.
IMC J Med Sci 2017; 11(1): 15-18
Address for Correspondence: Dr. Tapash Kumar
Maitra, Associate Professor & Head, Department of Surgery, BIRDEM General
Hospital, 122 Kazi Nazrul Islam Avenue,
Shahbag, Dhaka, Bangladesh. Email: firstname.lastname@example.org
laparoscopic surgery technique has rapidly spread because of its several
advantages over conventional open surgery . The diminishment of
postoperative pain and the reduction of length of hospital stay as well as the
earlier return to work generated a positive socioeconomic impact [2,3].
However, despite being minimal invasive this surgical method, postoperative
complications and open conversion cannot be disregarded [4,5].
Open appendectomy (OA)
has been the gold standard for the treatment of acute appendicitis since its
introduction by Charles McBurney in 1894 . Unfortunately, the diagnosis of
acute appendicitis is often difficult, mainly clinical and always challenging.
An accepted negative appendectomy rate for presumed appendicitis ranges from
15% to 20%, even higher in women of childbearing age (20% to 30%) [7,8].
appendectomy (LA) has evolved since the first performed by a German Gynecologist
Kurt Semm (1983) . Laparoscopic appendectomy has gained acceptance as a
diagnostic and treatment method for acute appendicitis with the technological
advances of the past two to three decades. Since then, this procedure has been
widely used. In spite of its wide acceptance, there remains a continuing
controversy in the literature regarding the most appropriate way of removing
the inflamed appendix because of a set of new operative complications relating
to laparoscopic surgery [8,9]. Minimal access surgery has been proved to be a
useful surgical technique. The application of the recent technology and skills
can now provide a better and a cheaper choice of treatment. Despite a lot of
randomized trials which have compared laparoscopic and open appendectomy, the indications
for laparoscopy in patients with suspected appendicitis remains controversial
and clinical trials comparing LA versus OA, a consensus concerning the relative
advantages of each procedure has not yet been reached [10-11].
present study was designed to assess the post-operative complications, pain,
conversion rate and duration of hospital stay following LA in our surgical
Materials and methods
population and Methods: This study was carried
out in Surgery Unit 1 of BIRDEM General Hospital, Dhaka, Bangladesh from
30.09.14 to 30.09.16. All patients admitted at BIRDEM hospital with the
diagnosis of acute appendicitis (AA) were considered eligible and included in
the study. But, those patients with congenital anomaly, morbid obesity and
other systemic failure were excluded.
The laparoscopic technique was performed after a Hasson trocar was
placed through the umbilical scar with the open technique [3,5]. The camera was
introduced into the abdomen through this trocar, two more trocars were
positioned. The first one (5-mm) was placed in the midline just above the pubis
and the second one (10 mm) in the left iliac fossa, in a point on the left-side
perfectly symmetrical to the McBurney point. The appendicular artery was
coagulated with a bipolar electrocautery. The procedure was completed by using
two endoloops (ready-made or handmade) and the appendix extracted with an
endobag. The patients were discharged after the passage of flatus.
socio-demographic data and the post-surgical information (duration of pain,
hospital stay, per-operative findings) were noted and presented. The assessment
of pain was done as suggested by Dansie EJ and Turk DC . The
qualitative data were presented in percentages and quantitative in mean with
standard deviation (SD).
and sex distribution of the study population is presented in Table 1 which
suggest that majority of the patients were female (55.3%). Mean age of male and
female patients were 21±1.4 and 19±1.7 years respectively (Table 1). Of the
total 47 clinically diagnosed cases of acute appendicitis, 5 (10.6%) were
misdiagnosed as appendicitis and 2 (4.3%) patients underwent conversion to open
surgery (OA), as required per-operatively, based on the laparoscopic findings.
Those two were found to have other pathology that necessitated conversion to
open appendectomy. One was suspected to be malignant though later proved
otherwise and the other had extensive adhesion.
Table-1: Age and
sex distribution of study population.
result of postoperative assessment of pain is shown in Figure-1. It was found
that the pain score of all cases was gradually reducing and fell below 2 or
even less after 30 hours (pain scale: 0 to 10, where 0 reflects no pain and 10 indicate
severe intractable pain) .
The assessment of post-laparoscopic pain
with duration .
Average duration of hospital stay
following laparoscopic appendectomy
complications were minimal. Port site bleeding was found only in 4.3% and port
site infection was only 2.1%. There were no other complications like visceral
bleeding, subcutaneous emphysema
hospital stay was also very less. More than 80% patients were discharged from
the hospital following laparoscopic appendectomy within 72 hours; whereas, only
4.3% patients required hospitalization after 72 hours for follow-up and
management of bleeding (figure 2).
studies compared clinical
outcomes of laparoscopic appendectomy (LA) versus open appendectomy (OA) [3-5,7].
Most studies opined in favor of LA [1-3,4,5,7]. In this study, we
found female preponderance and younger age. This finding is consistent with
other studies [2,3,5]. As for other reported studies this study findings are
consistent with the past experience in other population with regards to
post-operative outcomes [8,10,11,13]. For example, the study patients had less
duration of pain and hospital stay thus reducing treatment cost. Obviously,
these are very much consistent with other studies as mentioned earlier. Again,
the incidence of per- and post-operative bleeding were also negligible
(<5%). The infection rate was also less (<3%). However, these findings
could have been better judged or compared if we could have a comparative group
undergoing open appendectomy. This was an important limitation of the study.
appendectomy (LA) was found relatively safe and resilient procedure. We had an
additional benefit of LA. It revealed ten percent were misdiagnosed as having
appendicitis. Though there was no comparative group, it was apparent that
laparoscopic approach was proved to have reduced pain, less complication and
shorter hospital stay thus reducing the treatment cost.
very much grateful to the physicians working at outpatient department and
Emergency department of BIRDEM for referring the patients to the department of
Surgery. We are indebted to the nursing and other supporting staff for assisting
in supervision and follow-up of the study patients.
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