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Table of Content - Volume 12 Issue 3 - December 2019


 

A prospective study of lateralized transverse cosmetic incision appendicectomy and laparoscopic appendicectomy

 

Dayanand Biradar1*, Babu Kattimani2, Balakrishna G3

 

1Assistant Professor, 2Professor, 3Ex PG, Department of Surgery, BLDEU (Deemed to be) Shri B M Patil Medical college and research centre, Vijayapur, Karnataka, INDIA.

Email: drdayanandbiradar@gmail.com

 

Abstract               Background: Acute appendicitis is the most common acute surgical condition of the abdomen. Approximately 7% of the population will have appendicitis in their life time. Acute appendicitis may occur at all ages but most commonly seen in the second and third decades of life. Despite technological advances, the diagnosis of appendicitis is still based primarily on the patient’s history and the physical examination. Prompt diagnosis and surgical referral may reduce the risk of perforation and prevent complication. In this era of cosmesis, minimal scar formation is very much fascinated by young patients in the profession of dancing, modeling and those involved in film industry and sports. Methods: This is a randomized controlled trial study. All patients in B.L.D.E.U.‟s Hospital admitted or came to Surgery O.P.D., from Oct. 2010 to May 2012, in whom diagnosis of appendicitis was made, were alternatively allocated into the study and laparoscopy group. Patients in Group A underwent appendicectomy via lateral transverse incision (about 2cm transverse cosmetic incision made over the right iliac fossa centering the McBurney‟s point). Those belonging to Group B underwent laparoscopic appendicectomy. Results: In our study Male: female ratio was 2:1 Majority of patients belong to the group of 21-50 years of age (75.72%) Post-operative stay in Lateralized Transverse Cosmetic Incision (LTCI) is 2±0.68 days vs. 2±0.75 days in laparoscopy group which are comparable. Duration of surgery in minutes in LTCI group is 46 ± 18.65 vs. 91 ± 17.75 minutes in laparoscopic group and p-value ≤ 0.0001 which is highly significant. Cost of surgery is Rs.3331 ± 438 in LTCI vs. Rs.4482 ± 610.58 in laparoscopic group with p-value < 0.0001 which is highly significant. Conclusion: Enthusiasm among surgical fraternity for minimally invasive surgery has almost made the aphorism. The Bigger the Surgeon, the Bigger the incision‖ lose its essence. However in a set-up where laparoscopic setting is not available, this lateral transverse incision appendicectomy is as effective as laparoscopic appendicectomy. In our study lateral transverse cosmetic incision technique is safe, cosmetically much better without mortality and negligible morbidity. Furthermore, LTCI enables less hospital stay, less need for analgesics, less need for skilled personnel, early return to the routine, less surgery duration and less cost of surgery compared to laparoscopic surgery.

Key Words: appendicectomy, lateral transverse incision, laparoscopic appendectomy, McBurney‟s point.

 

INTRODUCTION

It is well known adage that abdomen is a temple of surprises and a magic box as well. Since the abdomen accommodates innumerable viscera and other anatomical complements, diseases of the abdomen constitute a topic full of clinical curiosities. A meticulous examination of abdomen is one of the most rewarding and the diagnostic procedures available to the doctor especially the surgeon helps to plan an ideal treatment. Acute appendicitis is the most common cause of an “acute abdomen‟ in young adults and, as such, the associated symptoms and signs have become a paradigm for clinical teaching 1. Acute appendicitis is the most common acute surgical condition of the abdomen 2. Approximately 7% of the population will have appendicitis in their life time 3. Acute appendicitis may occur at all ages but most commonly seen in the second and third decades of life 4. Despite technological advances, the diagnosis of appendicitis is still based primarily on the patient’s history and the physical examination. Prompt diagnosis and surgical referral may reduce the risk of perforation and prevent complication 5. The mortality rate in non-perforated appendicitis is less than 1%, but it may be as high as 5% as more in young and elderly patients in whom the diagnosis may often be delayed thus making perforation more likely. Preoperative diagnosis of acute appendicitis is sometimes challenging in young women, children and aged despite all round improvements in medical fieldand ultrasonography. Diagnostic scores are useful easy methods, which help to reach in decision making 6. Delay in diagnosis will lead to complication which increases morbidity, whereas overzealous diagnosis may lead to negative appendectomy .In this era of cosmesis, minimal scar formation is very much fascinated by young patients in the profession of dancing, modeling and those involved in film industry and sports. Apart from cosmesis, small transverse incision results in less pain, early mobility and lesser morbidity than standard incision. Even though laparoscopicappendicectomy provides similar advantage, to adopt laparoscopy in all centers is not feasible due to limitation in expertise, facilities and cost. This cosmetic incision offers better results post-operatively and avoids requirement of expertise, infrastructure for laparoscopy, thus reducing cost. Hence, we decided to take up this study to compare the effectiveness of lateral transverse cosmetic incision (LTCI) versus laparoscopic appendicectomy in all patients in B.L.D.E University’s Shri B.M. Patil Medical College hospital and Research Centre, Bijapur , admitted or coming to surgery O.P.D in whom diagnosis of appendicitis is made.

 

AIMS AND OBJECTIVES OF THE STUDY

To compare the effectiveness of lateral transverse cosmetic incision (LTCI) versus laparoscopic appendicectomy.

 

STANDARD TECHNIQUE and DIFFERENT TECHNIQUES FOR APPENDICECTOMY

A. ELECTIVE APPENDICECTOMY:-

Removal of appendix between attacks the so called of interval operation will be described first, since it is usually a simple procedure and a relatively standardized technique employed.

Incisions

1. GRIDIRON INCISION:-

2. LANZ’S TRANSVERSE INCISION:-

3. PARAMEDIAN INCISION:-

4. RUTHERFORD MORRISION’S INCISION:-

5. BATTLES’S PARA RECTAL INCISION:-

Shifting window technique

In 1993 Feb-March ASI conference at Hubli a paper was presented on shifting window technique for appendectomy. In this technique paraumbilical incision was taken and was shifted to the McBurney‟s point and appendicectomy was performed by the conventional method.

6. LATERAL TRANSVERSE COSMETIC INCISION OPEN APPENDICECTOMY 7, 8, 9, 10

Small transverse incision 2.5 to 3 cm long in the right lower abdomen starting just on the lateral border of rectus muscle and extended laterally in the line of Mc Burney‟s point. The only muscle in the operation field is rectus that was retracted medially. No other muscle was cut/splitted. Better cosmesis and almost invisible scar is the hallmark of small incision appendectomy. that In our study the incision was small and without much muscle/nerve muscle and extended transversally towards Mc Burney‟s point (2.5-3 cm). Anterior sheath cut in line of the skin incision and rectus muscle retracted with the help of long pronged Skin/Czerni‟s/Langenbuch ‟sretractors. Peritoneum approached, is picked up with the haemostats and cut in the line of skin incision. Once abdominal cavity is approached retractors are removed and subsequently it requires little effort and manipulation to trace the appendix.. Rest of the procedure of appendectomy is done as per the standard protocol. Peritoneum is not closed and the retracted muscle comes to centre once the anterior sheath is sutured with chromic catgut. Skin is closed either with interrupted silk or subcuticular prolene. No special retractors are required for the procedure.

7. LAPAROSCOPIC APPENDICECTOM Y 11

The most valuable aspect of laparoscopic in the management of suspected appendicitis is as a diagnostic tool particularly in women of child-bearing age. Essential Requirement for Laparoscopic appendicectomy: Instruments for visualization:

i) Light source

ii) Telescope

iii) Video camera system

iv) Beam splitter

v) Monitor

vi) Video recorder

vii) Video printer

viii) Instruments for exposure and manipulation

ix) Insufflator

x) Puncture instruments

xi) Grasping and dissecting instruments

xii) Occlusion and ligation instruments

xiii) Electro surgical unit. Laser equipment is unnecessary

xiv) Irrigation and suction instruments

xv) Wound closure instruments

Preparation of the patient for laparoscopic appendicectomy:-

Under the circumstances it is mandatory that the patient be totally prepared mentally and physically for the procedure. The steps of the laparoscopic procedure are explained to the patient. It is at all the times impressed that patients safety and the necessity of carrying out a complete and a through procedure may be terminated at any phase converted into a open surgery it is made clear that open surgery if require would be done during the same anesthesia. Specific informed consent must be taken. A fully informed patients confidence acceptance and cooperation and vital for the smooth conduct of the procedure. The preoperative evaluation of the patient is identical to that for open appendicectomy. As every case is done under general anesthesia the routine evaluation of the patient for fitness for anesthesia is carried out.

The pneumoperitoneum:

The most important single step in the safe an efficient conduct of any laparoscopic procedure be it diagnostic or operative is the creation of a adequate generalized pneumoperitoneum. The pneumoperitoneum created with help of a spring loaded verses needle. A sub incision is made in the infraumblical region. The versus needle is held like a dart between the thumb and the index finger, with the little finger placed on the abdomen wall to act as a guard to prevent too deep or sudden penetration. The left hand elevates the abdominal wall as high as possible and with the gentle progressive pressure exerted by dorsiflexing the wrist the tip of the versus needle is advanced through the various layers of the abdominal wall. The fact that the needle tip is in the free peritoneal cavity has to establish carefully. This is done by;

 

 

1. Injecting saline

2. Hanging drop test

3. Free movement of the needle tip

4. Once it is established that the needle tip is in the free peritoneal cavity, it is concerned with the electronic pneumoinsufflator andcarbondioxide insufflations is commenced at a flow rate of one liter per minute. These pressure readings on the insufflatiors at the tip of the needle and in the intraabdominal cavity are carefully monitored.

5. Percussions of the abdominal wall gives a resonant note and obliteration of liver dullness.

Next 4 trocars introduced into the peritoneal cavity using suitable incision on the abdominal wall.

Stapling techniques in laparoscopic appendicectomy:-

An automatic stapling device, the multifire endo-gia30, is an instrument, which can passed through 12mm trocar sleeve, compresses the appendix as well as the resting stump, occluding its lumen with 3 lines of titanium staples and cutting between them. Using this stapler, the mean operation time is 35-95 min which no complications of mortality. This new stapling device offers a simple and safe method for use in laparoscopic appendectomy.

MANAGEMENT OF APPENDIX MASS 12

If an appendix mass is present and the condition of the patient is satisfactory, the standard treatment is conservative Ochsner- Sherren regimen. This strategy is based on the premises that the inflammatory process is already localized and that inadvertent surgery is difficult and may be dangerous. It may be impossible to find the appendix andoccasionally, a fecal fistula may form for these reasons it is wise to observe a non operative programme but to be prepared to operate should clinical deterioration occurs that is rising pulse rate increasing or spreading abdominal pain or increase in the size of the mass. Careful record of the patient’s conditions and the extent of the mass should be made and the abdomen regularly reexamined. It is helpful to mark the limits of the mass on the abdominal wall using the skin pencil. A contrast enhanced CT examination of the abdomen should be performed and antibiotic therapy instigated. An abscess if present should be drained radio logically. Temperature and pulse rate should be recorded. 4thhourly and a fluid balance record maintained. Clinical deterioration is evidence of peritonitis is indication for early laparotomy. Clinical improvement is usually evident within 24-48hrs. Failure of the mass to resolve should raise suspicion of carcinoma or Crohns disease. Using this regimen approximately 90% of the cases resolve without incident. It is advisable to remove the appendix after an interval 6-8 weeks.

 

POST OPEATIVE COMPLICATIONS 13

Post-operative complication following appendicectomy are relatively uncommon and reflects the degree of peritonitis that was present at the time of operation and intercurrent diseases that may predispose to complications.

i) Wound infection

ii) Intra abdominal abscess

iii) Paralytic ileus

iv) Respiratory complications

v) Venous thrombosis and embolism

vi) Portal pyaemia

vii) Fecal fistula

viii) Adhesive intestinal obstruction

ix) Right inguinal hernia

PROGNOSIS:-

Early diagnosis as the general recognition of the necessity of early operation, improved anaesthesia, improved surgery, improved management of general peritonitis and newer antibiotics, all have added toward better prognosis in these days. Mortality is negligible in cases which are operated within 48 hrs after appearing of symptoms. Peltokallio and Tykka 15 (1981) reported 0.12% in non-perforated and 0.18% in perforated group. The morbidity and mortality rate for masses is the lowest if treated conservatively but high if early operation is done (Mcphersonand Kinmont)

 MATERIAL AND METHODS

Source of data

All patients in B.L.D.E.U.‟s Hospital admitted or came to Surgery OPD in whom diagnosis of appendicitis was made.

Method of collection of data

All patients in B.L.D.E.U.‟s Hospital admitted or came to Surgery O.P.D., from Oct. 2010 to May 2012, in whom diagnosis of appendicitis was made, were alternatively allocated into the study and laparoscopy group, after taking informed consent. Patients underwent necessary investigations. Patients in Group A underwent appendicectomy via lateral transverse incision (about 2cm transverse cosmetic incision made over the right iliac fossa centering the McBurney‟s point). Those belonging to Group B underwent laparoscopic appendicectomy.

Inclusion criteria

All patients attending the Surgical OPD or admitted in Surgery ward in whom the diagnosis of appendicitis is made.

Exclusion criteria

Patients with complicated appendicitis.

Patients who do not give consent to be included in the study. Patients who are obese i.e. B.M.I. > 30.

SAMPLING:

The study period was from Oct. 2010 to May 2012. The prevalence of appendicitis in cases of acute abdomen is 57.6%. Allowable error was considered as 20%.

Using the formula

n = [(1.96)2x p x (1-p)] / L2

The sample size calculated to be, n = 70, in each group.

OBSERVATION AND RESULTS

During the study period, i.e. from October 2010 to May 2012, a total of 140 patients underwent appendicectomy in our hospital. Out of these, alternatively patients were allotted to study i.e LTCI group (70 patients) and laparoscopy groups (70 patients). In this study, primarily the duration of surgery, cost of surgery and the duration of post-operative stay were analyzed in both groups. However, during the study, observations were also made regarding the age and sex distribution of the patients. Following are the observations made during this study shown in both tabular and graphical form:

AGE DISTRIBUTION

In this study, the age of patients ranged from 14 to 62 years. About 75.72% of the patients were in the age group of 21-50 years and about 10% to 12% below and above it, as shown below.

Table 1: Age distribution.

Age

Number

Percentage

11-20

14

10.00%

21-30

41

29.29%

31-40

40

28.57%

41-50

25

17.8%

51-60

16

11.43%

61-70

2

1.43%

 

SEX DISTRIBUTION

About two-third of the patients were male in this study. Male:female ratio was about 2:1, as shown in the following table:

DURATION OF SURGERY

The average duration of surgery was significantly longer for laparoscopic appendicectomy as compared to the study group (91 mins vs. 46 min, p<0.0001)

 

1

Figure 1: comparison of duration between LTCI vs. LAP

 

POST-OPERATIVE STAY

Post-operative stay was almost same in both groups, of about 2 days.

2

Figure 2: comparison of hospital stay between LTCI vs. LAP

 

COST OF SURGERY

Laparoscopic appendicectomy was significantly costlier than lateral transverse cosmetic incision appendicectomy (Rs. 4482 vs. Rs. 3331), when cost was calculated using same medicines for both the groups. The difference was mainly due to the higher cost of general anesthesia required for laparoscopic appendicectomy and the higher operative charges for laparoscopic appendicectomy.

 

3

Figure 3: comparison of cost of surgery between LTCI vs. LAP

 

Table II: Comparison of LAP vs. LTI

 

LAP

LTI

Z value

P value

Post op stay (days)

2±0.75

2±0.68

0.00

0.5

Duration of stay (min)

91±17.75

46±18.65

11.99

<0.0001

Cost of surgery (Rs.)

4482±610.58

3331±438.88

10.65

<0.0001

 

ANALYSIS AND DISCUSSION

AGE AND SEX DISTRUBUTION:

In this study majority of patients were males (male:female ratio was 2:1) with 67.86 of patients being males and 32.14 being females. This was comparable to the study done by Malik AA, Wani RA, SaimaBD, Wani AA. In our study 75% patients were in the age group 21-50 years which is comparable to the observation made by Das MK, Roy H in their study.

DURATION OF SURGERY:

Laparoscopic appendicectomy consumed longer duration compared to LTCI in our study. The average time duration of laparoscopic vs. LTCI being 91 minutes vs. 46 minutes respectively with a p value of which is highly significant .This is comparable with study done by Sanjay Shahin, Satyendra Dhar.

POST OPERATIVE STAY (DAYS):

Post-operative stay is comparable in patients undergoing LTCI and laparoscopic procedure i.e. 2 ± 0.75 and 2 ± 0.68 days.

COST OF SURGERY:

Cost of surgery is significantly reduced in LTCI compared to laparoscopic procedure with values being Rs. 3331 ± 438 vs. Rs. 4482 ± 610 respectively which is comparable to study done by Sanjay Shashin, Satyendra Dhar.

 

SUMMARY

This study was conducted from October 2010 to May 2012, where a total of 140 patients underwent appendicectomy in our hospital. 70 patients among them underwent LTCI and other 70 underwent laparoscopic appendicectomy. They were allotted alternatively to LTCI and laparoscopy group. The two groups were compared in terms of total surgery duration, post-operative stay and cost of surgery.

IN OUR STUDY

Male: female ratio was 2:1 Majority of patients belong to the group of 21-50 years of age (75.72%) Post-operative stay in LTCI is 2±0.68 days vs. 2±0.75 days in laparoscopy group which are comparable. Duration of surgery in minutes in LTCI group is 46 ± 18.65 vs. 91 ± 17.75 minutes in laparoscopic group and p-value ≤ 0.0001 which is highly significant. Cost of surgery is Rs.3331 ± 438 in LTCI vs. Rs.4482 ± 610.58 in laparoscopic group with p-value < 0.0001 which is highly significant.

CONCLUSION

Enthusiasm among surgical fraternity for minimally invasive surgery has almost made the aphorism. ―The Bigger the Surgeon, the Bigger the incision‖ lose its essence. However in a set-up where laparoscopic setting is not available, this lateral transverse incision appendicectomy is as effective as laparoscopic appendicectomy. In our study lateral transverse cosmetic incision technique is safe, cosmetically much better without mortality and negligible morbidity. Furthermore, LTCI enables less hospital stay, less need for analgesics, less need for skilled personnel, early return to the routine, less surgery duration and less cost of surgery compared to laparoscopic surgery.

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