Technique of Laparoscopic Appendectomy
Abstract and Commentary
By Frank W. Ling, MD, Clinical Professor, Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, TN, is Associate Editor for OB/GYN Clinical Alert
Synopsis: Laparoscopic coagulating shears a/k/a harmonic scalpel, is as efficacious as other techniques used to perform laparoscopic appendectomy.
Source:Yauger BJ, et al. Laparoscopic appendectomy: a series of cases utilizing laparosonic coagulating shears as compared to endo-GIA and endoshears. J Reprod Med. 2005; 50:231-234.
Cases of laparoscopic appendectomies at Walter Reed Army Medical Center were retrospectively reviewed. Emergency cases and ruptured appendixes were excluded. The instrument used to transect the appendix was the primary focus of the review, the alternative technologies to the harmonic scalpel being endoshears and the endo-GIA. Mean estimated blood loss, mean operative time, number of hospital days, and complications were comparable among the various surgical modalities.
The technique used depended on the instrument chosen by the surgeon. Most cases involved separating the mesoappendix using either the endoshears or the harmonic scalpel, with special attention paid to not cutting past the mesoappendix. Two endoloops were placed at the base with another placed 1 cm distal. The endoshears or harmonic scalpel was then used to transect the appendix between the base and the distal endoloop. If the endo-GIA was the technique used, one of 2 variations was utilized. In one technique, a window was made in the mesoappendix, followed by firing the instrument across the mesoappendix, then across the base of the appendix. The second variation called for firing across the mesoappendix and base simultaneously.
Commentary
The reason I offer this article for review is that the topic of appendectomy continues to be controversial among gynecologic surgeons. Whether at the time of laparotomy or laparoscopy, removal of the appendix as a procedure incidental to more traditional gynecologic procedures is a decision made totally separate from that of the primary surgery. Occasionally, as in the case of enigmatic pelvic pain, appendectomy is, in fact, the primary procedure under consideration. Although the article’s focus is on the actual laparoscopic technique rather than the decision-making, and even though it is a retrospective report, some important lessons can be learned nevertheless.
First, let’s focus on the article itself. Is the harmonic scalpel better than either electrocautery or the endo-GIA? Based on this retrospective study, we’re looking at comparable outcomes. For me, this is more of a feasibility study. What the study does is cause the gynecologic surgeon to think about what piece of equipment will be used if appendectomy is performed. The harmonic scalpel uses ultrasonic energy to both cut and coagulate. Its technology avoids the risk of arcing electrical sparks, prevents charring of tissue, minimizes smoke that might obscure vision, and reduces the need for changing instruments because it serves multiple functions. So even though the results are not statistically different from the other techniques, it is reassuring to see that it is at least in the same ballpark. Why is this important? It’s because the harmonic scalpel has caught on as a significant tool for many gynecologic surgeons performing various types of laparoscopic hysterectomy. Extending the comfort level to appendectomy provides the surgeon with options that he/she may not heretofore been aware of.
As with a laparotomy, where there are multiple techniques described to perform an appendectomy, a laparoscopic approach does not require a particular technique be used to transect the appendix. More important is the question of whether to do it or not. Is the subsequent lifetime risk for appendicitis or significant pathology high enough to warrant the potential complications of the procedure? Could the appendix be the cause of the pain that the patient has?
Although the appendix cannot be palpated at the time of laparoscopy, it can be visualized for adhesions, endometriosis, or abnormalities of contour, which might suggest intra-luminal pathology. Using a probe as an extension of the surgeon’s finger, gentle stroking of the appendix can often suggest changes in texture. Although the literature does not support the routine removal of an otherwise normal appendix as treatment for chronic pelvic pain located in the right lower quadrant, many is the surgeon and patient who can point to their respective success with this procedure.
Whenever an appendectomy is performed at the time of another procedure, there is the potential of contamination/infection of the other surgical site from the appendiceal stump. Given appropriate surgical technique, the risk is minimal, but, nevertheless, more than if the appendectomy was not performed.
So where does this leave us? Have we solved the appendectomy quandary? Unfortunately, the questions asked are not easily resolved, particularly as we try to manage individual patients and their idiosyncratic problems. My recommendation to each reader who performs laparoscopy, is to file this article in their mind for consideration whenever laparoscopy is being performed for pain or when an incidental appendectomy might seem warranted based on a relatively young patient undergoing laparoscopic surgery. Since older patients are less likely to subsequently develop pathology of the appendix, it is the relatively young patient population who might be considered candidates for incidental appendectomy. Now it’s up to each of us to define what "relatively young" means. Think about it. It may well be a consideration for your next case.
Cases of laparoscopic appendectomies at Walter Reed Army Medical Center were retrospectively reviewed. Emergency cases and ruptured appendixes were excluded.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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