Our experience with selective laparoscopy through an open appendectomy incision in the management of suspected appendicitis.
ABSTRACT An accurate preoperative diagnosis of suspected appendicitis at times can be extremely difficult. We report our experience with a simple strategy of selective laparoscopy through an open appendectomy incision after finding a noninflamed appendix in the management of suspected appendicitis.
Patients presenting with suspected appendicitis after regular office hours (6 pm to 8 am weekdays and weekends) were recruited prospectively from January 2002 to December 2003. Laparoscopy through an open appendectomy incision was performed only when the appendix was found to be normal.
Twenty-five (18.5%) of 135 patients underwent laparoscopy through an open appendectomy incision because of a normal-looking appendix. Laparoscopy through an open appendectomy incision helped to identify additional intra-abdominal pathology in 13 (52%) of the 25 patients; thus improving the overall detection rate of underlying pathology from 81.5% (110 of 135) to 91.2% (123 of 135).
Selective laparoscopy through an open appendectomy incision in patients with a noninflamed appendix is a simple technique that can identify potentially fatal pathology and also maintains a valuable training opportunity for young surgeons to perform open abdominal surgery. We recommend using this technique in the management of suspected appendicitis.
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ABSTRACT: Computed tomography (CT) and ultrasonography (US) do not improve the overall diagnostic accuracy for acute appendicitis. Retrospective review. University tertiary care center. Seven hundred sixty-six consecutive patients undergoing appendectomy for suspected appendicitis from January 1, 1995, to December 31, 1999. Epidemiology of acute appendicitis and the roles of clinical assessment, CT, US, and laparoscopy. The negative appendectomy rate was 15.7%, and the incidence of perforated appendicitis was 14.6%. A history of migratory pain had the highest positive predictive value (91%), followed by leukocytosis greater than 12 x 10(9)/L (90.1%), CT (83.8%), and US (81.3%). The false-negative rates were 60% for CT and 76.1% for US. Emergency department evaluation took a mean +/- SD of 5.2 +/- 5.4 hours and was prolonged by US or CT (6.4 +/- 7.4 h and 7.8 +/- 10.8 h, respectively). The duration of emergency department evaluation did not affect the perforation rate, but patients with postoperative complications had longer evaluations (mean +/- SD, 8.0 +/- 12.7 h) than did those without (4.8 +/- 3.3 h) (P =.04). Morbidity was 9.1%, 6.4% for nonperforated cases and 19.8% for perforated cases. Seventy-six patients had laparoscopic appendectomy, with a negative appendectomy rate of 42.1%, compared with 15.4% for open appendectomy (P<.001). Laparoscopy, however, had minimal morbidity (1.3%) and correctly identified the abnormality in 91.6% of patients who had a normal-appearing appendix. Migratory pain, physical examination, and initial leukocytosis remain reliable and accurate in diagnosing acute appendicitis. Neither CT nor US improves the diagnostic accuracy or the negative appendectomy rate; in fact, they may delay surgical consultation and appendectomy. In atypical cases, one should consider the selective use of diagnostic laparoscopy instead.Archives of Surgery 05/2001; 136(5):556-62. · 4.30 Impact Factor
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ABSTRACT: The frequency of computed tomography (CT) ordered by emergency department physicians at our facility was noted to sharply increase in early 1998 after a New England Journal of Medicine (NEJM) article recommending routine CT in patients with suspected appendicitis. Numerous studies have proven the accuracy of CT for detecting acute appendicitis; however, the most appropriate use of CT continues to evolve. We sought to evaluate the effect of increased CT use on negative appendectomy rate and perforation rate at our institution and to better delineate in whom CT is most beneficial. CT use was retrospectively evaluated and found to sharply increase in April 1998. The authors then reviewed the medical records of 291 consecutive patients undergoing appendectomy 18 months before and after the NEJM article. Patients with interval appendectomies and those 12 years of age or younger were excluded. The remaining 226 patients constitute the study cohort. The study cohort was then divided into the two groups. The "Discriminate Group" consists of patients from the 18 months before the NEJM article impact and a period of selective CT use. The "Indiscriminate Group" comprises patients from the subsequent 18 months in which CT use was substantially higher and routinely obtained before surgical evaluation. After chart review an objective clinical score (Alvarado score) was assigned to each patient. Comparison was then made between the two groups on perforation rate, negative appendectomy rate, time delay to operating room, and Alvarado score. Additionally patients undergoing preoperative CT were compared with those without CT. These groups were also evaluated on the basis of negative appendectomy rate, perforation rate, and delay to the operating room. CT in patients with abdominal symptoms associated with appendicitis increased from 188 in the Discriminate Group to 1035 in the Indiscriminate Group. In the Discriminate Group the negative appendectomy rate was 15.1 per cent. After the indiscriminate use of CT the negative appendectomy rate decreased to 13.3 per cent, but this was not significant. Males experienced a decrease in the negative appendectomy rate from 10.1 to 6.9 per cent, whereas the rate for females increased slightly from 21.3 to 22.9 per cent. Again we found no statistical significance in these changes. The overall perforation rate of 17.9 per cent in the first 18 months decreased to 13.3 per cent in the following 18 months but again was not statistically significant. The Alvarado scores between the Discriminate and Indiscriminate groups were 6.7 and 7.3, respectively (P = 0.02). Patients with preoperative CT averaged 11.9 hours to the operating room compared with 6.5 hours for those without CT (P = 0.03). Use of CT did not decrease perforation rate but did globally reduce negative exploration (P = 0.05). This reduction in negative exploration however was not discriminated by sex. CT use in suspected acute appendicitis has greatly increased over the past several years. The dramatic increase in CT use at our institution has not resulted in dramatic decreases in negative appendectomy rate or statistically significant changes in perforation rate. The optimal use of CT in evaluating patients with suspected appendicitis has yet to be determined. Surgical consultation should be obtained early to avoid indiscriminate tests.The American surgeon 12/2001; 67(11):1017-21. · 0.92 Impact Factor
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ABSTRACT: Laparoscopic techniques are increasingly used in common surgical procedures. Many of these procedures are used to teach basic surgical trainees (BST) and therefore introduction of these techniques may have implications for training. To establish whether the introduction of laparoscopic techniques reduced the opportunity of BSTs to perform surgical procedures. Patients undergoing hernia repair or appendicectomy in 1991 (when laparoscopy was first introduced) and 1997 (when laparoscopy was readily available) were identified using the Hospital In-Patient Enquiry (HIPE) database. The principal operator and whether the procedure was open or laparoscopic were identified by chart review. The data showed a 50% reduction in the number of appendicectomies performed by BSTs following the introduction of laparoscopic techniques. The number of hernia repairs performed by BSTs has been preserved but the proportion by BSTs fell from 10 to 6%. The proportion of BST-performed procedures carried out laparoscopically has been reduced compared with the registrar-performed group. The use of minimally invasive techniques has had a negative effect on surgical training. Appropriate measures must be taken to minimise this and such measures should include a structured approach to laparoscopic training and greater access to laparoscopic training facilities.Irish Journal of Medical Science 03/2003; 172(1):27-9. · 0.57 Impact Factor
How I do it
Our experience with selective laparoscopy through an open
appendectomy incision in the management of suspected appendicitis
Subhasis K. Giri, M.B.B.S., D.M.R.D., M.S., D.N.B., F.R.C.S.I., F.R.C.S.E.D., M.Ch.*,
Faisal M. Shaikh, M.B.B.S., A.F.R.C.S., Debasri Sil, M.B.B.S.,
John Drumm, F.R.C.S.I., F.R.C.S., M.Ch., Syed A. Naqvi, M.B.B.S., F.R.C.S.I.
Department of Surgery, University Hospital, Dooradoyle, Limerick, Ireland
Manuscript received June 29, 2006; revised manuscript October 11, 2006
Background: An accurate preoperative diagnosis of suspected appendicitis at times can be extremely
difficult. We report our experience with a simple strategy of selective laparoscopy through an open
appendectomy incision after finding a noninflamed appendix in the management of suspected appendicitis.
Methods: Patients presenting with suspected appendicitis after regular office hours (6 PM to 8 AM
weekdays and weekends) were recruited prospectively from January 2002 to December 2003. Laparoscopy
through an open appendectomy incision was performed only when the appendix was found to be normal.
Results: Twenty-five (18.5%) of 135 patients underwent laparoscopy through an open appendectomy
incision because of a normal-looking appendix. Laparoscopy through an open appendectomy incision
helped to identify additional intra-abdominal pathology in 13 (52%) of the 25 patients; thus improving the
overall detection rate of underlying pathology from 81.5% (110 of 135) to 91.2% (123 of 135).
Conclusions: Selective laparoscopy through an open appendectomy incision in patients with a nonin-
flamed appendix is a simple technique that can identify potentially fatal pathology and also maintains a
valuable training opportunity for young surgeons to perform open abdominal surgery. We recommend
using this technique in the management of suspected appendicitis. © 2007 Published by Excerpta Medica
Keywords: Suspected appendicitis; Open appendectomy; Laparoscopy
Acute abdominal pain and suspected appendicitis are the
most common causes of emergency surgical admissions. An
accurate preoperative diagnosis at times can be extremely
difficult. The negative appendectomy rate in a large series
ranged from 15% to 33% . Although imaging modalities
such as ultrasound (US) and computed tomography (CT)
to emergency clinicians, especially outside of regular office
hours, and may in fact delay the diagnosis with high false-
negative rates for the diagnosis of acute appendicitis [1,2].
Open appendectomy is still the most common emergency
surgery performed in most hospitals. McBurney’s surgery
usually is well tolerated by most patients. Universal lapa-
roscopy may be an option in suspected appendicitis, but
issues such as higher cost and reduced exposure to open
abdominal surgeries among surgical trainees have been the
main concern in adopting the technique widely [3–5]. In this
article we report our experience with a simple strategy of
selective laparoscopy through an open appendectomy inci-
sion after finding a noninflamed appendix in the manage-
ment of suspected appendicitis.
Patients presenting with acute abdominal pain and sus-
pected appendicitis outside of regular office hours (6 PM to
8 AM and weekends) were recruited prospectively from
January 2002 to December 2003. Our exclusion criteria
were patients who underwent preoperative imaging studies
such as US and CT scan. Preoperatively, all patients were
evaluated by taking a full history and performing a physical
examination. Patients received broad-spectrum antibiotic
prophylaxis. All procedures were performed under general
* Corresponding author. Tel.: ?35-3879227648; fax: ?35-314284090.
E-mail address: firstname.lastname@example.org
The American Journal of Surgery 194 (2007) 231–233
0002-9610/07/$ – see front matter © 2007 Published by Excerpta Medica Inc.
All patients underwent an open appendectomy for sus-
pected appendicitis through either a McBurney or Lanz
incision (Fig. 1A). It was our standard practice to check the
terminal ileum, the mesentery, and the right ovary during
the appendectomy. Laparoscopy was performed through an
appendectomy incision only when the appendix was found
to be normal and no obvious pathology was detected in the
local area. A purse-string suture-using 2/0 polydioxanone
was placed at the peritoneal edge of the open appendectomy
incision. The blunt 10-mm port with an inflatable balloon
(Blunt Tip Trocar; Auto Suture, Norwalk, CT) was used to
maintain the pneumoperitoneum (Fig. 1B). Then standard
laparoscopy using a 0° telescope was performed to identify
any underlying pathology. Appropriate intervention was
taken after identification of pathology. The purse-string
suture was tied to close the peritoneum and the grid-iron
incision was closed in layers using 0 polyglactin. The skin
was closed with subcuticular 4/0 polyglactin.
Postoperatively, patients were assessed closely for any
complications. Patients were evaluated further at 6 weeks
and 3 months postoperatively in the outpatient clinic. Fol-
low-up data consisted of details of the postdischarge course.
Our primary outcome measures were the rate of detection of
additional underlying pathology using this technique and
any associated complications.
A total of 135 patients underwent an emergency open
appendectomy outside of regular office hours during the
study period. None of these patients had preoperative im-
aging studies such as US or CT scan because of the high
clinical suspicion of acute appendicitis and because of the
restricted availability of imaging facilities in our hospital
outside of regular office hours. The median patient age was
21 years. The male to female ratio was 1.4:1. Twenty-five
(18.5%) of 135 patients underwent laparoscopy through an
appendectomy incision because of a normal-looking appen-
dix during the appendectomy. Laparoscopy through the
appendectomy incision helped to identify intra-abdominal
pathology in 13 (52%) of the 25 patients (Table 1). In the
remaining 12 patients, histologic examination showed acute
appendicitis in 2 (despite a normal macroscopic appear-
ance), whereas in 10 patients (7.4%) the cause of the pain
remained unclear. Thus, our technique not only improved
the overall diagnosis of cause of pain from 81.5% (110 of
135) to 91.2% (123 of 135), but also identified some poten-
tially fatal underlying pathology (Table 1). None of these
patients developed any wound-related complications.
One patient developed a urinary tract infection in the
postoperative period that was treated successfully with
Acute abdominal pain and suspected appendicitis often
present as a diagnostic dilemma. In treating such patients
the surgeon mostly makes the decision to perform an ap-
pendectomy by mainly relying on clinical features, rather
than on laboratory and radiologic investigations. Open ap-
pendectomy has been the gold standard treatment for acute
appendicitis. By virtue of its small incision, open appendec-
tomy is already a type of minimal-access surgery, and is
well tolerated, well accepted, and thus the benefits of rou-
tine laparoscopic appendectomy are likely to be small and
difficult to prove. The potential advantages of the laparo-
scopic approach include reduced pain and hospital stay and
a more rapid return to normal activities [6,7]. However, the
validity of these points remains unconvincing to some sur-
Distribution of additional pathology detected by laparoscopy through an
open appendectomy incision in patients with suspected appendicitis
Additional pathologyNo. of patients
Perforated anterior duodenal ulcer
Twisted left ovarian cyst
Ruptured left follicular ovarian cyst
Ruptured right follicular ovarian cyst
Hemorrhage in left follicular cyst
Torsion of appendices epiploicae
Fig. 1. (A) Lanz incision for an open appendectomy. (B) Laparoscopy
using an inflatable balloon port through the Lanz incision.
S.K. Giri et al. / The American Journal of Surgery 194 (2007) 231–233
geons, and the efficacy and indications for emergency lapa-
roscopic appendectomy still are debated [8,9]. When com-
pared with the open procedure, laparoscopic appendectomy
is relatively expensive, mainly because of its longer surgical
time and costly disposable equipment .
Being one of the most common emergency surgical pro-
cedures, open appendectomy is traditionally a valuable
training exercise for surgical trainees, giving them their
initial chance to perform surgery independently. This is not
only enjoyable but also fruitful in building their confidence
in performing open surgery before learning to treat appen-
dicitis laparoscopically . It has been shown that this
introductory opportunity may be lost if the laparoscopic
procedure is chosen because in most centers laparoscopic
procedures are more likely to be performed by more senior
personnel than junior trainees. A recent study by McCor-
mick et al  showed a 50% reduction in the number of
appendectomies performed by surgical trainees after the
introduction of laparoscopic techniques. Radiologic inves-
tigations such as US and CT scan may be used in addition
to our strategy, but the main limitation is 24-hour availability.
By adopting our technique of selective laparoscopy
through an open appendectomy incision, trainees will have
ample opportunity to perform an open appendectomy and at
the same time can diagnose additional, potentially fatal,
pathology. We diagnosed 13 further underlying pathology
(some potentially fatal) in patients with a noninflamed ap-
pendix, thus improving the overall management outcome in
Selective laparoscopy through an open appendectomy
incision in patients with a noninflamed appendix is a simple
technique that can identify potentially fatal pathology and
also maintains a valuable training opportunity for young
surgeons to perform open abdominal surgery. We recom-
mend using this technique in the management of suspected
 Lee SL, Walsh AJ, Ho HS. Computed tomography and ultrasonog-
raphy do not improve and may delay the diagnosis and treatment of
acute appendicitis. Arch Surg 2001;136:556–62.
 McDonald GP, Pendarvis DP, Wilmoth R, et al. Influence of preop-
erative computed tomography on patients undergoing appendectomy.
Am Surg 2001;67:1017–21.
 Cothren CC, Moore EE, Johnson JL, et al. Can we afford to do
laparoscopic appendectomy in an academic hospital? Am J Surg
 McCormick PH, Tanner WA, Keane FB, et al. Minimally invasive
techniques in common surgical procedures: implications for training.
Ir J Med Sci 2003;172:27–9.
 McCahill LE, Pellegrini CA, Wiggins T, et al. A clinical outcome and
cost analysis of laparoscopic versus open appendectomy. Am J Surg
 Frazee RC, Roberts JW, Symmonds RE, et al. A prospective ran-
domised trial comparing open versus laparoscopic appendectomy.
Ann Surg 1994;219:725–31.
 Hansen JB, Smithers BM, Schache D, et al. Laparoscopic versus
open appendectomy: prospective randomised trial. World J Surg
 Katkhouda N, Mason RJ, Towfigh S, et al. Laparoscopic versus open
appendectomy: a prospective randomized double-blind study. Ann
 Ignacio RC, Burke R, Spencer D, et al. Laparoscopic versus open
appendectomy: what is the real difference? Results of a prospective
randomized double-blinded trial. Surg Endosc 2004;18:334–7.
 Carrasco-Prats M, Soria Aledo V, Lujan-Mompean JA, et al. Role of
appendectomy in training for laparoscopic surgery. Surg Endosc
S.K. Giri et al. / The American Journal of Surgery 194 (2007) 231–233