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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 28  |  Issue : 1  |  Page : 29-31

Laparoscopic submucosal appendectomy for complicated appendicitis: A salvage technique to minimise complications


Department of Surgery, Koyili Hospital, Kannur, Kerala, India

Date of Submission02-May-2022
Date of Decision10-May-2022
Date of Acceptance11-May-2022
Date of Web Publication14-Jul-2022

Correspondence Address:
Dr. Jimmy C John
Department of Surgery, Koyili Hospital, Pallikunnu Post, Kannur - 670 002, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ksj.ksj_16_22

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  Abstract 


Background: Complicated appendicitis with delayed presentations is difficult to manage surgically due to dense adhesions and distorted anatomy. Submucosal appendectomy could be an option in these cases. Materials and Methods: Out of 789 laparoscopic appendectomies, 239 were complicated cases. In 79 of these cases, no plane could be established between the appendix and adjacent bowel. Hence, the mucosa was identified by blunt dissection through the wall of intact appendix or through the perforation site and the mucosal tube was pulled out, and then dissected out fully from the tip and up to the base by blunt dissection, leaving behind the muscular wall. The base was then ligated and divided distally. Post-operatively, the patients were managed with ERAS protocol. Results: Out of 79 cases, 56 were male. Age ranged from 14 to 55 years. Forty-six cases were perforated, and 33 had mass formation. Submucosal appendectomy was done in all. There were no intra-operative complications. The average operating time was 56 min. In 68 cases, oral feeds were tolerated early, 11 cases suffered from prolonged ileus and one case had post-operative faecal leak, which settled on conservative management for 10 days. The average post-operative hospital stay was 3–5 days. Follow-up ranged from 2 months to 2 years. Three cases required re-admission, reported occasional abdominal pain, which on clinical evaluation and imaging showed no residual collection or stump appendicitis. Two cases presented with residual abscesses, which were managed with image-guided tube drainage. Conclusions: Submucosal appendectomy minimises bowel injury, avoids the need for conversion, and is a safe option for difficult cases during laparoscopy and also an alternative for the Ochsner–Sherren regimen.

Keywords: Appendicular mass, complicated appendicitis, laparoscopy, perforation, submucous appendectomy


How to cite this article:
John JC, Srinivas I C, Arjunith P K. Laparoscopic submucosal appendectomy for complicated appendicitis: A salvage technique to minimise complications. Kerala Surg J 2022;28:29-31

How to cite this URL:
John JC, Srinivas I C, Arjunith P K. Laparoscopic submucosal appendectomy for complicated appendicitis: A salvage technique to minimise complications. Kerala Surg J [serial online] 2022 [cited 2022 Sep 24];28:29-31. Available from: http://www.keralasurgj.com/text.asp?2022/28/1/29/350889




  Introduction Top


Complicated appendicitis with delayed presentations and adhesions to adjacent bowel or perforated appendicitis with early mass formation is difficult to manage surgically due to dense adhesions and distorted anatomy, trying to do appendectomy or looking for the appendicular artery may lead to troublesome bleeding and injure the nearby bowel.[1],[2] Submucosal appendectomy could be an option in these cases.[3],[4] Laparoscopic appendectomy is one of the most common surgeries done worldwide.[5] Unlike laparoscopic cholecystectomy, which became the 'gold standard' for the removal of diseased gallbladder, there remains some difference of opinion regarding the laparoscopic management of appendicitis, particularly in complicated cases.[6],[7],[8] As more and more reports are published, the opinion is now shifting towards laparoscopy.[9] Complicated appendicitis can be defined as acute appendicitis in which there is gangrene or perforation of the appendix, localised or generalised peritonitis, or an intra-abdominal abscess or appendicitis complicated by mass formation.[10],[11],[12]Conventionally, conservative management with Ochsner–Sherren regimen followed by elective interval appendectomy after several weeks was recommended.[13],[14] Surgery, in the presence of appendicular mass, is limited to simple drainage of pus collected within the mass.[15] Various techniques, including retrograde appendectomy and its modifications, have been described to deal with these complicated cases.[16] Hence, according to our opinion for complicated appendicitis with delayed presentations and adhesions to adjacent bowel or perforated appendicitis with mass formation, trying to do retrograde appendectomy or looking for the appendicular artery may lead to bleeding which may be very difficult to control without injuring the adjacent bowel. Submucosal appendectomy could be a safe alternative in these type of cases[7],[12] and we describe here our experience with this new technique.


  Materials and Methods Top


From 1 January, 2015, to 31 December, 2019, 789 laparoscopic appendectomies were performed, of which 239 were complicated appendicitis. In 79 of these cases, no plane could be established between the appendix and surrounding structures. Hence, we used the submucosal dissection technique. Laparoscopy was done with the patient under general anaesthesia in all these cases. We have used the conventional three-port technique: an umbilical port for the camera, one port medial to the left anterior superior iliac spine and another just above and to the right of the pubic symphysis. For optimal viewing, the telescope was 10 mm with 30° for all our patients. The supraumbilical port was introduced by the Veress technique, and insufflation done with a CO2 pressure kept between 12 and 14 mm Hg. During laparoscopy, we encountered appendix forming a mass in the pelvic cavity or right iliac fossa that could not be separated from the adjacent intestine without risk of injury to adjacent bowel. However, in all these cases, the appendix could be identified by its tubular shape and non-compressibility, when grasped with a grasper or by doing blunt dissection with the suction cannula. The mucosa was identified by blunt dissection through the wall of intact appendix or through the perforation site and the mucosal tube was dissected out fully involving the tip and up to the base by blunt dissection, leaving the muscular wall. The base of the tube was then ligated flush with the caecum and divided distally. The muscular tube was left alone [Figure 1]. Most of the bleeding from the muscular tube settled by its own and the remaining were easily managed with bipolar cautery which was safely used over the muscular tube without injuring the adjacent bowel.
Figure 1: Mucosal tube dissection

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Then, the peritoneal cavity was irrigated with normal saline and aspirated. The patient was kept nil per oral for 6 h post-surgery and then feeding was allowed. Most of our patients were discharged on the 1st post-operative day and very few on the 2nd or 3rd depending on the degree of contamination. This retrospective study describes the age, sex, operative technique, post-operative stay, complications, and outcomes. The ethical review committee for thesis and research of the hospital gave permission to conduct this study.


  Results Top


Out of the 79 cases, 56 were male. Age ranged from 14 years to 55 years. Forty-six cases were perforated, and 33 were appendicular mass. Submucosal appendectomy was done in all 79 cases. There were no intra-operative complications. The average operating time was 56 min. The post-operative course was uneventful in 68 cases, 11 cases suffered from prolonged ileus and one case had post-operative faecal leak, which settled with conservative management for 10 days. The average post-operative hospital stay was 3–5 days. Follow-up ranged from 2 months to 2 years. Three cases required re-admission, reported occasional abdominal pain, which on clinical evaluation and imaging showed no residual collection or stump appendicitis. Two cases presented with residual abscess and were managed with image-guided tube drainage.


  Discussion Top


Appendicitis is essentially a mucosal disease. Inflammation of the muscular layer and serosa are secondary to microbial invasion of the mucosa.[2] Therefore, in adverse pathological anatomy, excision of the mucosal tube rather than the entire appendix is sufficient to contain the inflammation. Laparoscopy offers a better and safe alternative to the open technique for complicated appendicitis in terms of post-operative outcomes such as early recovery, less post-operative pain and very fewer complications such as surgical site infections, intra-abdominal collections and repeated procedures.[17],[18],[19] In our experience, almost all the complicated appendicitis cases could be completed laparoscopically with very good outcomes comparable to those of other references on the literature. The technique we described was practiced in difficult cases, where there was difficulty to get a plane between the appendix and the surrounding structures. The incision was made on the appendix using hook cautery or biplolar, taking care not to perforate the mucosa unless it was already perforated. In perforated cases, it was easier when we started our dissection from the perforation site. Once, the outer layers were separated, the mucosal tube could be visualised and was carefully dissected off from the wall of the appendix with minimal bleeding which easily settled down by itself as these vessels pass through the muscular wall. Care was taken, not to injure the caecum while dissecting towards the base. Minor bleedings were easily managed with bipolar cautery and safely used over the remnant wall as it was less likely to cause any bowel injury. The mucosal tube of appendix was tied at its base with endoloop, divided and removed.

Submucosal appendectomy decreases the risk of stump appendicitis,[20],[21] as it allows the dissection as far as the caecal–appendiceal junction without much difficulty. Post-operative wound infections and intra-abdominal abscesses were less common after laparoscopy.[22],[23] Laparoscopy provides direct visualisation during peritoneal toileting and prevents wound contamination, particularly if an endobag or a substitute is used during specimen retrieval.[15],[17],[22] This technique also significantly reduces the conversion into open surgery in difficult cases as the submucosal dissection can be easily done in these type of cases also. None of our cases had significant post-operative complications except for one with post-operative faecal leak through the drain which settled by itself on conservative management within 2 weeks and two cases presented with residual abscess and were managed with image-guided tube drainage.


  Conclusions Top


Submucosal appendectomy is a newer and safer technique that minimises intra-operative complications, avoids the need for conversion into open procedure, decreases the risk of stump appendicitis, and is a safe option for difficult cases during laparoscopy with reduced risk of bowel injury and troublesome bleedings in difficult appendectomy cases and also an alternative for the Ochsner–Sherren regimen, which requires more studies to substantiate.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
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3.
Martin LC, Puente I, Sosa JL, Bassin A, Breslaw R, McKenney MG, et al. Open versus laparoscopic appendectomy. A prospective randomized comparison. Ann Surg 1995;222:256-61.  Back to cited text no. 3
    
4.
Cunnigaiper ND, Raj P, Ganeshram P, Venkatesan V. Does Ochsner-Sherren regimen still hold true in the management of appendicular mass? Ulus Travma Acil Cerrahi Derg 2010;16:43-6.  Back to cited text no. 4
    
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Ortega AE, Hunter JG, Peters JH, Swanstrom LL, Schirmer B. A prospective, randomized comparison of laparoscopic appendectomy with open appendectomy. Laparoscopic Appendectomy Study Group. Am J Surg 1995;169:208-12.  Back to cited text no. 5
    
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Frazee RC, Bohannon WT. Laparoscopic appendectomy for complicated appendicitis. Arch Surg 1996;131:509-11.  Back to cited text no. 6
    
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Horwitz JR, Custer MD, May BH, Mehall JR, Lally KP. Should laparoscopic appendectomy be avoided for complicated appendicitis in children? J Pediatr Surg 1997;32:1601-3.  Back to cited text no. 8
    
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Ball CG, Kortbeek JB, Kirkpatrick AW, Mitchell P. Laparoscopic appendectomy for complicated appendicitis: An evaluation of postoperative factors. Surg Endosc 2004;18:969-73.  Back to cited text no. 9
    
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11.
Hannan J, Hoque M. Laparoscopic submucosal appendectomy for difficult and adherent cases: A novel technique to minimize complications. J Laparoendosc Adv Surg Tech A 2012;22:1017-20.  Back to cited text no. 11
    
12.
Rangarajan M, Palanivelu C, Senthilkumar R, Madankumar M. Appendicular abscess masquerading as a liver abscess: Value of laparoscopy in diagnosis and management. Internet J Third World Med 2006;4:4.  Back to cited text no. 12
    
13.
Wullstein C, Barkhausen S, Gross E. Results of laparoscopic vs. conventional appendectomy in complicated appendicitis. Dis Colon Rectum 2001;44:1700-5.  Back to cited text no. 13
    
14.
Cueto J, D'Allemagne B, Vázquez-Frias JA, Gomez S, Delgado F, Trullenque L, et al. Morbidity of laparoscopic surgery for complicated appendicitis: An international study. Surg Endosc 2006;20:717-20.  Back to cited text no. 14
    
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Guller U, Hervey S, Purves H, Muhlbaier LH, Peterson ED, Eubanks S, et al. Laparoscopic versus open appendectomy: Outcomes comparison based on a large administrative database. Ann Surg 2004;239:43-52.  Back to cited text no. 15
    
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Lin HF, Wu JM, Tseng LM, Chen KH, Huang SH, Lai IR. Laparoscopic versus open appendectomy for perforated appendicitis. J Gastrointest Surg 2006;10:906-10.  Back to cited text no. 16
    
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Kirshtein B, Bayme M, Domchik S, Mizrahi S, Lantsberg L. Complicated appendicitis: Laparoscopic or conventional surgery? World J Surg 2007;31:744-9.  Back to cited text no. 17
    
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Menezes M, Das L, Alagtal M, Haroun J, Puri P. Laparoscopic appendectomy is recommended for the treatment of complicated appendicitis in children. Pediatr Surg Int 2008;24:303-5.  Back to cited text no. 18
    
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Wang X, Zhang W, Yang X, Shao J, Zhou X, Yuan J. Complicated appendicitis in children: Is laparoscopic appendectomy appropriate? A comparative study with the open appendectomy-our experience. J Pediatr Surg 2009;44:1924-7.  Back to cited text no. 19
    
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Senapathi PS, Bhattacharya D, Ammori BJ. Early laparoscopic appendectomy for appendicular mass. Surg Endosc 2002;16:1783-5.  Back to cited text no. 20
    
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Thambidorai CR, Aman Fuad Y. Laparoscopic appendicectomy for complicated appendicitis in children. Singapore Med J 2008;49:994-7.  Back to cited text no. 21
    
22.
Nasher O, Patel RV, Singh SJ. Retrograde trans-mesoappendicular selective subserosal laparoscopic appendicectomy. J Pediatr Surg Case Rep 2013;1:50-2.  Back to cited text no. 22
    
23.
Zhu JH, Li W, Yu K, Wu J, Ji Y, Wang JW. New strategy during complicated open appendectomy: Convert open operation to laparoscopy. World J Gastroenterol 2014;20:10938-43.  Back to cited text no. 23
    


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