Laparoscopy Diagnostic applications in suspected appendicitis and access-related complications

Detta är en avhandling från Department of Surgery, Malmö University Hospital, Lund University

Sammanfattning: Laparoscopic surgery was introduced to minimize patient trauma. However, fatal technique specific complications, due to major vascular or visceral injury, were at times seen related to blind abdominal access using the Veress technique. A modified open access technique was developed and evaluated in 100 patients and found to be fast and easy to learn with few associated complications. This open technique was compared retrospectively to the Veress technique in 4363 patients after extensive educational efforts in optimizing both techniques were made. No major vascular and only five visceral injuries were seen with no difference between the groups. The diagnostic accuracy in patients operated due to suspected appendicitis varies between 60-90% depending on patient gender and age. The complication rate when having a healthy appendix removed is approximately 10 %. Laparoscopy was introduced for diagnostic purposes and a macroscopically normal appendix was left in place. Substantial educational efforts were made in developing teams for 24-hours-a-day service. In a study of 500 consecutive patients, we succeeded in performing a diagnostic laparoscopy (DL) in 75%, leaving 66 patients with their appendices left in place. No complications were seen in the DL group and no appendicitis was missed. In a multi-centre study of 1043 DL in suspected appendicitis 211 patients had a DL as a single procedure with a complication rate of 2% and no missed appendicitis. No randomized study comparing open and laparoscopic appendectomy has been performed in patients with confirmed appendicitis. Recovery after laparoscopic and open appendectomy was compared in 163 patients randomized after appendicitis was confirmed at DL when both techniques were applicable and the learning curve was passed. There was no significant difference in time to full recovery between the groups. However, a trend towards faster recovery was noted in the laparoscopic appendectomy group. In summary, the modified open access technique is recommended for safety reasons. It is fast, easy to learn and applicable in most patients. DL is safe and accurate for diagnosis and can be recommended in patients with suspected appendicitis. A macroscopically appearing appendix can be left in place. There is no difference in time to full recovery between open and laparoscopic appendectomy in appendicitis confirmed at DL. Choice of method for appendectomy depends on surgeon preference.