Laparoscopic Appendectomy Case File

Laparoscopic Appendectomy Case File

Eugene C. Toy, MD, Konrad P. Harms, MD, Keith O. Reeves, MD, Cristo Papasakelariou, MD, FACOG

Case 14

A 25-year-old G1P1001 woman presents to the emergency room complaining of worsening right lower quadrant pain for approximately 12 hours. The pain started around the umbilicus, then moved to the right lower quadrant region. She reports nausea and vomiting that started approximately 6 hours previously. She denies any vaginal discharge. Her past medical and surgical history is negative. She reports one vaginal delivery without complications. She has been with the same partner for 7 years. The vital signs include temperature 100.6°F, pulse rate 90 beats/min, RR 20 breaths/min, and BP 110/60 mm Hg. On examination, she appears to be in moderate distress. Her abdomen is tender to palpation in the right lower quadrant with guarding and possible rebound tenderness. The pelvic examination is within normal limits. Laboratory evaluation shows a white blood (cell) count (WBC) 15,000/mm3, urinalysis is negative, and the serum β human chorionic gonadotropin (β-hCG) is negative.

➤ What is the most likely diagnosis?

➤ What radiological imaging should be considered to help confirm the diagnosis?

➤ What is the best treatment for this patient?

ANSWERS TO CASE 14:

Laparoscopic Appendectomy

Summary: This is a 25-year-old woman with new-onset, worsening, right lower quadrant pain associated with nausea and vomiting. She has a low-grade fever and the abdomen is tender to palpation on examination. The serum leukocyte count is elevated and the pregnancy test is negative.

➤ Most likely diagnosis: Appendicitis.

➤ Imaging test to help confirm the diagnosis: Helical CT.

➤ Best treatment: The patient should be started on broad-spectrum antibiotics to cover gram-positive and -negative as well as anaerobic bacteria. She should then undergo a laparoscopic appendectomy.

ANALYSIS

Objectives

1. Know the pathophysiology of appendicitis.
2. Know the most common presentation of appendicitis.
3. Know the best diagnostic test for appendicitis.
4. Know the advantages and disadvantages of incidental laparoscopic appendectomy.

Considerations

This is a 25-year-old woman in the reproductive years with the acute onset of right lower quadrant abdominal pain. The pregnancy test is negative. The pelvic examination is unremarkable, which is helpful. The possibility of acute appendicitis, gastroenteritis, ruptured ovarian cyst, atypical pelvic inflammatory disease, or urinary tract infection should be considered. A CT scan of the abdomen and pelvis may be helpful in the diagnosis. General surgery consultation should be considered. If the patient is taken to the OR, the gynecologist should be available to view the pelvis should the patient have a tubal or ovarian pathology.

APPROACH TO

Laparoscopic Appendectomy

DEFINITIONS

PSOAS SIGN: Increase in pain in the right lower quadrant of the abdomen as the right leg is extended at the hip when the patient is in the left lateral decubitus position is a positive psoas sign. This is a result of the inflamed appendix irritating the psoas muscle.

ROVSING SIGN: Pain in the right lower quadrant of the abdomen when palpating the left lower quadrant.

OBTURATOR SIGN: Increased pain in the right lower quadrant of the abdomen with passive flexion of the right leg at the hip and knee with internal rotation of the leg is a positive obturator sign. This is a result of the inflamed appendix causing irritation of the obturator muscle.

MCBURNEY POINT: One-third of the distance from the right anterior superior iliac spine to the umbilicus. The inflamed appendiceal serosa causes irritation of the parietal peritoneum at this location, resulting in pain from appendicitis.

ELECTIVE COINCIDENTAL APPENDECTOMY (INCIDENTAL APPENDECTOMY): The removal of a normal appendix at the time of another surgical procedure. This is distinguished from the removal of a normal appendix in a patient who undergoes surgery for right lower quadrant pain.

LAPAROSCOPIC APPENDECTOMY

Background

Appendectomy for acute appendicitis is the most common emergency surgery performed in the United States. Women have a lifetime risk of 7% for having appendicitis, and their overall lifetime risk of undergoing appendectomy is 25%. Women are twice as likely to undergo a negative appendectomy during which a normal appendix is removed for suspected appendicitis as compared to men.1

Pathophysiology

Acute appendicitis results from occlusion of the appendiceal lumen in 85% of the cases and from unknown causes in 15% of the cases. Any process that obstructs the drainage of the appendiceal secretions can cause appendicitis.2 Hyperplasia of lymphoid follicles, fecaliths, intestinal parasites, torsion of the appendiceal artery can all cause obstruction of the appendix.2,3 The appendix continues to secrete mucus causing increased intraluminal pressure distal to the obstruction. The increased pressure obstructs lymphatic and venous drainage, which causes the appendix to become edematous. Mucosal ulceration allows bacteria to penetrate the wall of the appendix and cause inflammation of the serosa. With continued increase in pressure, blood flow through the appendiceal artery is obstructed; and since there is no collateral circulation, ischemic necrosis and gangrene cause perforation of the appendix. Bacterial contamination from the perforated appendix causes peritonitis. As long as the rupture of the appendix has not occurred at the base, further fecal contamination of the peritoneal cavity is prevented by the primary obstruction. In young healthy patients, the infection can be walled off and contained in an abscess; in females, this may contain the right adnexa.3

Signs and Symptoms   The clinical diagnosis of acute appendicitis based on a detailed history and physical examination may be unreliable. Women with the clinical diagnosis of acute appendicitis have normal appendixes 22% to 47% of the time.4 The difficulty in diagnosis is often from the varied presentation of the symptoms. Varied symptoms may be due to pregnancy, atypical location of the appendix, and extremes of age.5Women older than 50 often have pathology-like diverticulitis or cancer that is unrelated to the appendix when right lower quadrant pain suggests appendicitis. Elderly patients who have appendicitis may present with vague pain or no pain at all, so the diagnosis may be delayed.6 The symptoms of acute appendicitis may be similar to gynecologic pathology, so in the female patient, the differential diagnosis of right lower quadrant pain includes acute appendicitis, ovarian cyst rupture, adnexal torsion, ectopic pregnancy, endometriosis, pelvic inflammatory disease, and acute postpartum ovarian vein thrombosis.4

The classic symptom sequence is present in approximately 50% of patients.2 Complaints include vague periumbilical abdominal pain that may localize to the right lower quadrant over McBurney point. This is followed by anorexia, then nausea and vomiting. Low-grade fever is associated with these symptoms.7 If emesis occurs prior to the pain, the diagnosis of appendicitis may be in doubt.3 The initial physical examination shows a low-grade fever (approximately 37.8°C [100.04°F]), mild tachycardia, hypoactive bowel sounds, and tenderness to palpation over McBurney point. The psoas, obturator, and Rovsing sign may or may not be present. The progression of inflammation to perforation usually takes 24 to 36 hours. A rigid abdomen with rebound and guarding may indicate a perforated appendix leading to peritonitis. Laboratory data may show a mildly elevated leukocytosis with a left shift.2

Imaging

The most frequently used radiographic techniques for the diagnosis of appendicitis include helical CT and ultrasound. Helical CT has a 90% to 100% sensitivity and a 91% to 99% specificity for the diagnosis of acute appendicitis.5 The procedure is readily available, independent of operator error, and highly accurate. Intravenous contrast can better image a thickened appendix. Periappendiceal inflammation, present in 98% of cases with acute appendicitis, is demonstrated on the helical CT by periappendiceal fluid collection, fat stranding, fascial thickening, and a hazy change in the adjacent mesenteric fat. Appendicolith, periappendiceal phlegmon, or abscess on helical CT is highly suggestive of appendicitis. High-resolution ultrasound with posterior manual compression, color and power Doppler has sensitivity of 75% to 90% and specificity of 86% to 100% in the diagnosis of appendicitis. It is mobile, widely available, relatively inexpensive, and does not use ionizing radiation. Sonography is, however, operator dependent.8

Treatment The options for treatment of acute appendicitis include open appendectomy (OA), laparoscopic appendectomy (LA), and nonsurgical therapy. Nonsurgical therapy includes a combination of prolonged antibiotics and close monitoring. Of significance, 40% of patients treated with nonsurgical therapy eventually required surgical therapy.2 Consequently, the treatment of choice for acute appendicitis is surgery. Antibiotic therapy with percutaneous drainage followed by interval appendectomy in 6 to 12 weeks has been used successfully in selected cases of appendiceal perforation and abscess formation.2

The choice of surgical approach to appendicitis may depend on the clinical presentation and surgeon’s preference.9 LA is associated with a higher rate of normal appendices, less advanced appendicitis, and is used in cases where the diagnosis is uncertain. Conversely, OA is associated with a higher rate of perforated appendicitis, more critically ill patients, and is used in cases of certain diagnosis of appendicitis.10 Although these associations have been reported in retrospective reviews, randomized controlled trials and metaanalyses report that both LA and OA are effective in treating acute, gangrenous, and perforated appendicitis.11 Conflicting evidence exists regarding the increased incidence of intra-abdominal abscess formation after LA is performed for a perforated appendix.4 There is some concern that the pneumoperitoneum required for laparoscopy may spread infected material throughout the peritoneal cavity.12 Advantages of LA include lower wound infection rates, decreased postoperative pain, and faster return to normal activity. This procedure is both diagnostic and therapeutic.4,11 LA does increase operative costs and may increase the risk of postoperative abscess. Overall, pregnant women and obese patients seem to gain the most benefit from LA.2

LA Technique There are various techniques for performing an LA. The surgery is generally performed under general anesthesia. The patient is supine with both arms tucked close to the body (Figure 14–1). Women are positioned in a modified dorsal lithotomy position to allow for transvaginal uterine manipulation. The surgeon and the assistant stand on the left of the patient while the instrument nurse stands on the right. The video monitor is placed

Figure 14–1. Laparoscopic identification of the appendix.

on the right near the patient’s feet. The first cannula, 12 to 15 mm, is placed infraumbilically by either an open or closed technique. The abdomen is insufflated with carbon dioxide; the laparoscope is then inserted. After intraabdominal access has been established, tilting the operating table 15 degrees to the left is usually helpful. A thorough examination of the entire peritoneal cavity is performed to confirm the diagnosis of appendicitis and to evaluate gynecologic pathology. Once the decision has been made to perform the appendectomy, two trocars, 5 and 10 mm, are placed in the right and left lower quadrants. If an additional trocar is needed, it is placed two finger breadths above the symphysis pubis. If fluid or abscess is noted around the cecum or the cul-de-sac, it should be aspirated and sent for Gram stain and culture. The appendix is retracted anteriorly and cephalad with an atraumatic grasper through the lower right trocar to place the mesoappendix on tension. The mesoappendix and the appendicular artery are coagulated from the tip of the appendix down to the base (see Figure 14–2). The base can be secured using various techniques. Two endoloops (1-0 or 2-0 chromic catgut) are used to secure the base of the appendix. The area distal to the ties is milked and the third endoloop is placed 2 to 4 mm distal to the other ties. The appendix is transected between the second and third loops, leaving the appendiceal stump doubly ligated. Staples, clips, stitches, and electrocautery are alternatives to endoloops. The appendix is then removed through the 10-mm trocar. If the appendix is thicker than 10 mm or perforated, a plastic bag is introduced into the abdominal cavity, and the appendix is placed inside it. The bag containing the appendix is removed through the umbilical port. The entire abdominal cavity should be irrigated. The base of the transected margin is

Figure 14–2. A mesenteric window is created, and an endoscopic stapler is used to ligate and divide the appendix.

inspected for hemostasis. Cauterization of the stump is not recommended because this can result in cecal fistula. Invagination of the stump is not necessary. Once satisfactory hemostasis has been achieved, the fascia at the 10-mm or larger trocar sites is reapproximated. All of the skin incisions are

then closed. If an appendiceal mass or abscess is encountered, the surgeon must decide whether the appendectomy should continue via laparoscope or if the patient would benefit from conversion to an open appendectomy.3,4 Contraindications to LA include inflammation of cecum with necrosis or phlegmon, perforation at the base of the appendix, and suspicion of appendiceal malignancy.4 The pathology and need for antibiotics will determine the hospital stay. Hospitalization is not required for an unruptured appendix and an uncomplicated LA.

Incidental Appendectomy Elective coincidental appendectomy involves the removal of a normal appendix at the time of another surgery unrelated to the pathology of the appendix. Reasons to perform elective coincidental appendectomy are (a) to reduce the risk of mortality and morbidity from appendicitis in the future, including infertility resulting from a perforated appendix; (b) to eliminate undiagnosed incidental pathology in the appendix; and (c) to exclude the appendix from the differential diagnosis when the patient has abdominal or pelvic complaints.3,13 Other groups that may benefit from this prophylactic procedure include women who may undergo pelvic or abdominal radiation or chemotherapy, women undergoing extensive pelvic or abdominal surgery after which extensive adhesions are anticipated, and patients in whom establishing the diagnosis of appendicitis may be difficult due to diminished ability to recognize or convey symptoms (eg, the developmentally disabled). Studies with retrospective design, small sample size, lack of appropriate control group, and large number of confounding factors indicate that there is probably a small increased risk of nonfatal complications associated with elective coincidental appendectomy. Given this small but increased risk of complications, the debate then is whether the added cost and morbidity incurred at the time of the appendectomy outweigh the cost and morbidity from developing appendicitis in the future. Risks associated with acute appendicitis increase with age, so the risk-benefit ratio change with the patient’s age.13 A retrospective study involving healthy women who underwent open coincidental appendectomies at the time of gynecologic procedures concluded that the most benefit was for patients younger than 35 years, especially if they have a history of PID, pelvic pain, or endometriosis.3,13 However, the study concluded that under specific clinical circumstances, patients between the age of 35 and 50 may benefit from elective coincidental appendectomy. The data did not support elective coincidental appendectomy in patients older than 50 years. The decision to perform this prophylactic procedure should be based on specific clinical scenarios and after discussion of risks and benefits with the patient.13

Comprehension Questions

14.1 A 30-year-old woman presents with periumbilical pain that migrated to the right lower quadrant pain and nausea and vomiting. Which of the following symptoms occur most rarely in a patient with appendicitis?

A. Migration of pain

B. Presence of right lower quadrant pain

C. Nausea

D. Vomiting

14.2 A 44-year-old man is diagnosed with probable acute appendicitis. He is being counseled about the advantages of laparoscopic appendectomy. The patient has been researching about organ injuries with the laparoscope. In counseling the patient, which of the following is the most accurate statement regarding laparoscopic appendectomy?

A. More chance of wound infections

B. More chance of incisional hernia

C. More pain medication needed as outpatient

D. More chance of vascular injury

14.3 A 47-year-old woman undergoes a diagnostic laparoscopy for acute right lower quadrant pain. Upon examination of the abdominal cavity, the appendix appears edematous and there is a purulent collection of fluid in the cul-de-sac. In which of the following circumstances is a laparoscopic appendectomy advisable?

A. Purulent drainage is noted from the tip of the appendix

B. Purulent drainage is noted from the base of the appendix

C. A 3-cm mass is noted at the base of the appendix

D. The cecum is inflamed in appearance

ANSWERS

14.1 A. Frequency of common symptoms in appendicitis is abdominal pain approximately 100%, nausea 90%, vomiting 75%, and pain migration 50%.

14.2 D. Laparoscopy is associated with a higher risk of vascular injury as compared to open laparotomy due to the insertion of the instruments. Nevertheless, it is associated with decreased wound infection rates, shorter hospitalization, and less postoperative pain.

14.3 A. Contraindications to LA include inflammation of cecum with necrosis or phlegmon, perforation at the base of the appendix, and suspicion of appendiceal malignancy.

Clinical Pearls

See Table 1-2 for definition of level of evidence and strength of recommendation

➤ Only 50% of women will present with the classic symptom sequence: periumbilical pain migration to right lower quadrant pain,associated anorexia and nausea and vomiting, and low-grade fever (Level B).

➤ Helical CT is 90% to 100% sensitive for the diagnosis of appendicitis (Level B).

➤ Contraindications to LA include inflammation of cecum with necrosis or phlegmon, perforation at the base of the appendix, and suspicion of appendiceal malignancy (Level B).

➤ Elective coincidental appendectomy is highly beneficial for patients younger than 35 years and in selected cases for patients between the age of 35 and 50 (Level A).

REFERENCES

1. Flum D, Loepsell T. The clinical and economic correlates of misdiagnosed appendicitis: nationwide analysis. Arch Surg. 2002;137:799-804. 

2. Shelton T, McKinlay R, Schwartz RW. Acute appendicitis: current diagnosis and treatment. Curr Surg. 2003;60(5):502-505. 

3. Jarnigan BK. The Vermiform Appendix in Relation to Gynecology in TeLinde’s Operative Gynecology. 9th ed. Philadelphia, PA: Lippincott, Williams & Wilkins. 

4. Kumar R, Erian M, Sinnot S, Knoesen R, Kimble R. Laparoscopic appendectomy in modern gynecology. J Am Assoc Gynecol Laparosc. 2002;9(3):252-263. 

5. Rao PM, Feltmake CM, Rhea JT, et al. Helical computed tomography in differentiating appendicitis and acute gynecologic conditions. Obstet Gynecol. 1999;93(2): 417-421. 

6. Velanovich V, Harkabus M, Tapia F, et al. When it’s not appendicitis. Am Surg. 1998;64:7-11. 

7. Hardin DJ Jr. Acute appendicitis: review and update. Am Fam Phys. 1999;60: 2027-2034. 

8. Birnbaum BA, Wison SR. Appendicitis at the millennium. Radiology. 2000;215: 337-348. 

9. Cervini P, Smith LC, Urbach DR. The surgeon on call is a strong factor determining the use of a laparoscopic approach for appendectomy. Surg Endosc. 2002;16:1774-1777. 

10. McGreevy JM, Finlayson SR, Alvarado R, et al. Laparoscopy may be lowering the threshold to operate on patients with suspected appendicitis. Surg Endosc. 2002;16:1046-1049. 

11. Golub R, Siddiqui F, Pohl D. Laparoscopic versus open appendectomy: a metaanalysis. J Am Coll Surg. 1998;186:545-553. 

12. Cuschieri A. Appendectomy—laparoscopy or open? Surg Endosc. 1997;11:319-320. 

13. American College of Obstetricians and Gynecologists. Elective coincidental appendectomy. ACOG Committee Opinion No. 323, 2005.

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