by Michael S. Kavic, MD, Kurt Semm, Prof. Med
The appendix lay hidden in the right lower abdominal quadrant for millennia, its function and role in disease obscure. Egyptians, 2000 years before the Christian era, noted the presence of the appendix and during post-mortem preservation referred to it as the “worm” of the bowel.1 The appendix, along with other viscera, was preserved during the ritual process of mummification.
Galen (A.D. 130-200), an exhaustive compiler of Greco-Roman medicine and incisive thinker, did not recognize the appendix as a distinct organ. A physician to Marcus Aurelius and surgeon to gladiators, Galen performed post mortems and dissections only on the bodies of lower animals. An appendix, unfortunately, was not present in these studies. The first known drawings of the appendix were made by Leonardo da Vinci in 1492. The first published illustrations of the appendix were by Andreas Vesalius in the fifth volume of his work, De Humani Corporis Fabrica, in 1543.1
Many physicians of the late middle ages and pre-industrial period observed the appendix during autopsy studies in which foreign bodies and abscesses were noted about the appendix and cecum. The appendix, however, was not considered as a cause of right lower quadrant inflammation. Rather, infectious processes in this area were felt to originate in the cecum as a typhlitis. Throughout the 1800’s, perityphlitis was the term used to describe infectious disease of the iliac-fossa which was thought to have begun in the cecum and not the appendix.
Claudius Amyand, a surgeon to King George II, performed the first surgical removal of an appendix in 1735.2 An eleven year old boy presented with scrotal hernia and fecal fistula. Amyand explored the hernia and removed a perforated appendix. The boy survived.
There were isolated reports of appendectomy in the late 19th century. However, it remained for Reginald Fitz, a Harvard pathologist, to call attention to the appendix as a cause of right lower quadrant inflammatory disease. Fitz, a brilliant physician, described the signs and symptoms of acute appendicitis, advocated surgical intervention and coined the term “appendectomy.”3 The genius of Fitz was not so much that he suggested surgical intervention for appendicitis, but rather that he recognized that the disease existed and reasoned it could proceed to perforation and abscess.
Charles McBurney, a surgeon and contemporary of Fitz, described the point of maximal tenderness in the right lower quadrant associated with appendicitis that bears his name. He helped popularize the gridiron incision and, along with Fitz, was a strong advocate of early surgical intervention.4
Kurt Semm, a German gynecologist, performed the first laparoscopic appendectomy on May 30, 1980.5 A brilliant surgeon, Semm developed many new instruments and designs so that standard surgical skills could be applied to a laparoscopic environment. In his report, Semm recommended securing the mesoappendix with endosutures and ligating the skeletonized appendix with pre-tied Roeders loops. The technique was effective, efficient and frugal. Semm pointed out that in 15% of all chronic appendicitis periappendicular endometriosis is visible in the peritoneum. If this is not treated, i.e. coagulated, chronic pain remains after appendectomy.
Appendicitis is a common surgical emergency. Approximately 240,000 appendectomies were performed for acute appendicitis in 1991.6 The highest incidence of appendicitis occurs in persons 10 to 19 years of age. Males have a higher rate of appendicitis than females for all age groups. Life table models suggest that the life-time risk for appendicitis is 8.6% for males and 6.7% for females.7
The incidence of appendicitis decreased by 14.6% during the period 1979-84. The reason for this decrease is unknown but changing dietary habits, better nutrition and perhaps the wide availability of antibiotic may have been significant factors.
ETIOLOGY AND PATHOGENESIS
The principal cause of acute appendicitis is obstruction of the appendiceal lumen.8 Common causes of obstruction include fecalith, hypertrophy of submucosal lymphoid tissue and kinking of the appendiceal wall. Less common causes of appendiceal lumen obstruction include blockage secondary to vegetable seeds, foreign bodies and intestinal worms.
Proximal blockage of the appendiceal lumen produces a closed loop obstruction. Inflammation of the mucosa is followed by ulceration and subsequent inflammation of the entire wall of the appendix. Stagnation distal to the site of obstruction permits growth of aerobic and anaerobic colonic flora. Progressive distention of the appendix may lead to vascular occlusion and infarction of the anti-mesenteric border. Perforation with frank peritonitis can result.
SIGNS AND SYMPTOMS
Patients typically present with right lower quadrant abdominal pain, fever and emesis.9 Abdominal pain may begin in the peri-umbilical area but eventually localizes to the right lower quadrant. Leukocytosis of 11,000 to 18,000 WBC’s per cubic millimeter is common. Plain abdominal X-rays are usually non-specific. Abdominal ultrasound may demonstrate a “bulls-eye” of the distended appendix.10 CAT scans of the abdomen may reveal a right lower quadrant mass or phlegmon.
TECHNIQUE OF LAPAROSCOPIC
After appropriate diagnostic workup, the patient is brought to the operating theater. Sequential pneumatic compression devices are applied to the lower extremities and a Foley catheter is inserted to decompress the urinary bladder. A nasogastric tube may be inserted into the stomach to reduce its size and lessen the danger of trocar injury. Antibiotic, ceftizoxime one gram, is given intravenously prior to beginning the procedure.11
The abdominal wall is prepped with povidone iodine soap and solution. The umbilicus is carefully cleansed. A Veress needle is used to initiate pneumoperitoneum. The needle is inserted transumbilically while upward traction is maintained on the abdominal wall with towel clips. The needle is directed towards the pelvis and its appropriate position ascertained with the water drop test.
A very effective and safe method of instituting pneumoperitoneum with the Veress needle has been described by Semm.12 In this common-sense method, a series of steps or “tests” are outlined that contribute to patient safety.
Test 1: Preoperatively, palpate the abdomen with attention paid to the location of the aorta (Figure 1).
Test 2: Check needle patency and insufflation pressure through the Veress needle prior to its passage into the abdominal cavity (Figure 2).
Test 3: Snap test: Observe the spring-loaded Veress needle indicator while the needle traverses the abdominal wall into the abdominal cavity (Figure 3).
Test 4: Hiss test: Once the Veress needle has been positioned, listen for the ingress of air through the opened needle while lifting the abdominal wall (Figure 4).
Test 5: Aspiration test: Aspirate the Veress needle with a syringe after it has been inserted into the abdominal cavity; check for blood or GI content (Figure 5).
Once the Veress needle has been connected to an insufflator, a “quadrotest” of insufflator parameters are checked to confirm proper needle placement (Figure 6).
These four parameters include the following:
1) actual insufflation pressure
2) insufflation volume (liter flow per minute)
3) static insufflation pressure
4) the amount of CO2 gas used.
Patients with previous lower abdominal surgery are at risk for abdominal adhesions. In these cases, an alternate access site may be selected for Veress needle insertion, or the open Hasson technique may be used to gain entrance to the abdomen. The most desirable sites for alternate access are those remote from previous abdominal incisions. Typically, a midclavicular, subcostal position in the left upper quadrant or right upper quadrant is the most common site for alternate access Veress needle insertion.
An alternative to the open Hasson or blind alternate access technique is the use of a 5 mm conical tipped trocar with a beveled trocar sheath (bias plane cannula) to traverse the abdominal wall. Semm recommended that this unit be inserted via a “Z” track incision, through the abdominal wall down to the level of the musculature which is penetrated halfway through (Figure 7). The conical tip trocar is removed and a laparoscope inserted to a) assure position and b) to seek the peritoneum. Rotation of the beveled trocar sheath facilitates passage through the remaining muscle as the cannula is advanced under direct visual control. Opaque white peritoneal surface is indicative of underlying adhesions as adhesive scar tissue reflects back the illuminating light of the laparoscope. A translucent peritoneal surface with visualization of peritoneal vessels suggests an undersurface free of adhesions. At this location the 5 mm cannula may be thrust through the peritoneum under direct vision and intra-abdominal laparoscopy initiated (Figure 8).
After pneumoperitoneum has been established, a 10.5 mm trocar and cannula is inserted via an infraumbilical or umbilical incision. Initial diagnostic abdominal survey is carried out and additional trocar and cannulae inserted under direct vision. Generally, three additional cannulae are used (Figure 9). A 5 mm cannula is placed in the right upper quadrant, lateral to the rectus sheath in the midclavicular subcostal position. A second 5 mm cannula is placed in the left lower quadrant, lateral to the rectus sheath on a plane inferior to the crest of the ileum. Finally, an 11.5 mm cannula is placed midway between the umbilicus and symphysis pubis, lateral to the rectus sheath in the left lower quadrant. The operating surgeon stands on the patient’s left side, the camera operator on the right (Figure 10).
After diagnostic abdominal survey, the appendix is identified and mobilized (Figure 11). A pre-tied Roeders endo loop is applied to the tip of the appendix (Figure 12). The endo loop suture is cut long and the tail of suture used to elevate and manipulate the appendix. In this way, the risk of iatrogenically damaging the appendix with laparoscopic graspers is reduced.
It may be necessary to divide the cecal fascia fusion line to more completely mobilize the appendix (Figure 13). The base of the appendix is defined and the mesoappendix secured with endoclips, intracorporeal suture, or serial applications of the laparoscopic Endo-GIA stapler (U.S. Surgical Corp., Norwalk, CT, USA) (Figure 14, Figure 15).
The laparoscopic Endo-GIA fires a triple row of hemostatic staples on either side of an integral cutting blade. The Endo-GIA is introduced through the left lower quadrant 11.5 mm cannula. One or two firings of the 30 mm stapler is usually sufficient to transect the mesoappendix. Small bleeders that persist through the divided stump of mesoappendix may be secured with endoclips.
After the appendix has been skeletonized, its base is secured with three loops of pre-tied chromic catgut and divided between the distal second and third ligature. Alternatively, the appendix may be stapled and divided with the Endo-GIA stapler. Prior to firing the stapler, however, the base of the appendix should be secured with a ligature of chromic catgut so that leakage cannot occur if postoperative swelling disrupts the staple line (Figure 16, Figure 17). The appendiceal stump need not be inverted13 (Figure 18).
To prevent intra-abdominal or abdominal wall contamination, the divided appendix is placed into an endo retrieval bag or cut finger of a sterile glove. The bagged appendix is extracted through the 11.5 mm cannula (Figure 19).
If perforation with peritonitis or abscess has occurred, extensive irrigation of the appendiceal fossa is performed (Figure 20). Sterile saline mixed with one gram of cefoxitin per liter is an effective irrigant. Abdominal drains are usually not necessary; however, they may be used at the discretion of the operating surgeon.
Fascia defects are closed in all cannula sites greater than 5 mm with 2-0 Polydioxanone (PDS, Ethicon, USA). Plain catgut suture is used to close subcutaneous tissue. Cannula sites are infiltrated with 0.25% bupivacaine chloride solution, and adult patients are given 60 mg of ketrolac tromethamine IM to alleviate immediate postoperative discomfort. Skin incisions are closed with steri-strips (3M, St Paul, MN, USA). Clear liquids are begun post-anesthesia and diet progressed as ileus permits.
COMPLICATIONS OF APPENDECTOMY
The complications of open appendectomy have included the following:
Right inguinal hernia
Complications related to infection are the most common cause of morbidity following open appendectomy. Perforation of the appendix has been reported to occur in 19-32% of patients undergoing appendectomy and is related to delay in seeking medical attention. Perforation has been noted more frequently in very young patients and in elderly patients. Forty percent (40%) of patients with perforated appendix are less than 10 years of age. In those over 60 years of age, 90% present with perforated appendix. Delay in diagnosis and perhaps a more rapid disease progression has been suggested as major factors for the high rate of perforation in these two patient populations.14
Perforation is followed by a polymicrobial peritonitis. Commonly isolated organisms include Eschericiae coli, Streptococcus, Pseduomonas aeroginosa and Bacteroides.15,16
Appendiceal abscess occurs in 2-3% of cases of acute appendicitis and is less common than diffuse peritonitis in those who have perforated (Figure 21). Complications following an appendiceal abscess include wound infection, fecal fistula, small bowel obstruction and recurrent abscess.
Wound infection is the most common complication following open appendectomy and occurs in up to 30% of cases.17 Not surprisingly, wound infection is more common following cases of perforated appendix than in those cases of removal of an intact organ.
Pelvic abscess occurs in 1.4-18% of patients undergoing appendectomy, usually becoming apparent 5-10 days post-exploration.18 Symptoms include abdominal discomfort, loose bowel movements and fever. Percutaneous CAT scan guided drainage of these abscesses is an attractive alternative to re-exploration and drainage or trans-rectal drainage.
Appendiceal stump abscess has been reported to occur in 0.5% of cases following open appendectomy.19 In these instances, it has been suggested that stump inversion with purse string suture may compromise the blood supply in the wall of the cecum and lead to necrosis, perforation and abscess formation.14 For this reason, ligation and amputation of the appendix is recommended without stump inversion.13 No difference in postoperative infection has been noted with simple ligation and amputation of the appendix. Additionally, this technique does not result in the development of a cecal mass secondary to stump inversion that may be noted on subsequent barium enema examination.
Appendicitis in pregnancy is encountered with a frequency of 1 in 1500 to 1 in 2100 deliveries.20 The long-term effects of pneumoperitoneum and laparoscopy in pregnancy are unknown and limits this approach to those patients who are in the first term of their pregnancy.
Right inguinal hernia occurs three times more frequently in those patients who have undergone open appendectomy.21 Factors that may contribute to this phenomenon include injury to the transverse abdominus-internal oblique muscle and shutter mechanism, or injury to the abdominal wall and ilio hypogastric nerve.
Complications particular to the laparoscopic approach for appendectomy include those problems associated with laparoscopic access, instrumentation and pneumoperitoneum. Inadvertent injury to the bowel, viscera, or blood vessels can occur with Veress needle insertion or passage of the initial trocar and cannula in a scarred abdomen. This complication may be lessened by passing the Veress needle in a site remote from previous surgical incisions. Typically, the left subcostal, midclavicular line position affords safe Veress needle entry. Alternatively, an open technique of entering the abdomen under direct vision may be used. After safe entry has been gained, a blunt tip Hasson type cannula may be used to establish pneumoperitoneum and permit laparoscopic exploration.
Patients of small body habitus should be carefully assessed prior to any laparoscopic procedure. A thin abdominal wall and decreased intra-abdominal working space dictates that laparoscopic instrumentation be suitable for the small-framed patient. Large cannulae and adult-sized laparoscopic instruments are crowded in a small abdominal space and may predispose to inadvertent injury to bowel, viscera and bladder. Open exploration with a small McBurney incision directly over an acute appendix is well tolerated in children and expeditious to perform.
Risks Involved in Traversing the Abdominal Wall for Laparoscopic Access Include the Following:
Skin infection is an uncommon complication of laparoscopic access. Wound infection has been noted in 0.1% of laparoscopic procedures.22 Properly sterilized laparoscopic instruments and strict attention to skin disinfection, particularly the umbilicus, will lessen the risk of this complication (Figure 22).
Emphysema of the subcutaneous tissue or omentum may result from incorrect placement of the Veress needle or dislodgment of cannulae while insufflation is in progress (Figure 23). Carbon dioxide is rapidly absorbed by the body and tissue emphysema is usually well tolerated. Rapid absorption of carbon dioxide, however, may cause hypercarbia with a rise in pCO2 and fall in pH. These changes are usually easily corrected with controlled ventilation.23
Hemorrhage from the anterior abdominal wall may occur from transection from the inferior epigastric artery or one of its branches.24 Inferior epigastric vessels may be avoided by inserting trocar and cannulae under visual control lateral to the rectus sheath. Small, subcutaneous vessels may be avoided by transilluminating the abdominal wall and identifying these vessels prior to trocar insertion.
Slight bleeding from the anterior abdominal wall may be controlled with bipolar or monopolar electrodesiccation (Figure 24). Larger transected vessels should be secured with suture ligature.25 Special needles and fascial closure devices are available to suture abdominal wall tissue and vessels including the Semm Emergency Needle, Gore needle and Carter-Thomason closure system (Figure 25, Figure 26).
Insufflation of gas into a major vessel or vascular channel may result in gas embolism.24,26 Obstruction of right heart outflow can occur with complete cardiovascular collapse. Emergency treatment of major gas embolism includes the following:
1) Discontinue CO2 insufflation.
2) Evacuate pneumoperitoneum.
3) Place patient in the head down, left lateral
4) Insert CVP line for possible aspiration of gas
5) Maintain vigorous ventilatory support.
Visceral trauma can occur at any time during a laparoscopic procedure. There is increased risk in those patients who have undergone previous surgical procedures with abdominal adhesions and in those with distended hollow organs (i.e. urinary bladder, stomach and intestine).27 Nasogastric decompression of the stomach and Foley catheter drainage of the bladder will reduce the risk of injury to these organs.
Veress needle punctures can usually be managed conservatively; however, larger visceral tears or lacerations must be repaired. Visceral injury must be considered in any patient not “doing well” after laparoscopic surgery. A high index of suspicion, prompt diagnostic work up and early exploration are necessary to reduce the potential lethality of these injuries.
Port site hernias typically occur in those sites in which cannulae greater than 5 mm have been used and not closed with suture or those ports that have been extensively manipulated.28,29 Fascial closure of all ports in excess of 5 mm is necessary to prevent herniation. Special needles, such as the Semm Emergency Needle, Gore needle, Exit device or Carter-Thomason closure system are of assistance in closing cannula fascial defects.
The most important complication following appendectomy is that of infection. Those patients with appendiceal perforation, abscess or peritonitis require treatment with antibiotic until the infection is cleared. And though laparoscopic access decreases postoperative pain, it does not change the underlying disease pathology. Intravenous antibiotic and adequate hydration must be administered to those patients with gross infection and not curtailed because laparoscopic procedures have been associated with early discharge. Patients who can be discharged early should be treated with intravenous antibiotic through home care programs until an appropriate course of therapy has been completed. The benefits of laparoscopic access do not extend to changing disease pathophysiology.
Laparoscopic access has provided a new dimension in the diagnosis and treatment of acute abdominal disorders. In those cases of obscure abdominal pain, laparoscopic examination not only provides excellent visualization of abdominal recesses but also permits definitive treatment of conditions such as appendicitis, ruptured ovarian cyst and endometriosis. The diagnostic capability of the laparoscope is especially important in obese patients and in those with abnormal anatomy. In these instances, an extensive abdominal incision is avoided and treatment usually rendered through the small puncture wounds of laparoscopic access.
1. Herrington JL Jr. The vermiform appendix: its surgical history. Contemp Surg. 1991;39:36-43.
2. Amyand C. Of an inguinal rupture with a pin in the appendix cocci, incrusted with stone and some observation on wounds in the gut. Philosophical Transaction of the Royal Society, London. 1736;39:329.
3. Fitz RH. Perforating inflammation of the vermiform appendix with special reference to its early diagnosis and treatment. Transactions of the Association of American Physicians. 1886;1:107-44.
4. McBurney C. The incision made in the abdominal wall in cases of appendicitis with a description of a new method of operating. Ann Surg. 1894;20:38.
5. Semm K. Advances in pelviscopic surgery: appendectomy. In Gynecology, Vol. V, No. 10 Chicago-London: Year Book Medical Publishers Inc; 1982.
6. Socio-Economic Factbook for Surgery. Schneidman DS, Rogers CM, eds. American College of Surgeons, 1994:50.
7. Addis DG, Shaffer N, Fowler B, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiology. 1990;132:910-25.
8. Chandrasoma P, Taylor C. Concise Pathology. London: Appelton & Lange; 1991:605-606.
9. Swartz S, et al. Principles of Surgery. New York: McGraw Hill, 1969; 1020-1030.
10. Rossi P, Covarelli P, Mosci F, Bisacci R, Sensi B, Moggi L. Ultrasonography in management of acute appendicitis. Surg Endosc. 1996;10:619-621.
11. Kavic MS. Laparoscopic appendectomy. In Grochmal S, ed. Minimal Access Gynecology. Oxford: Radcliffe Medical Press; 1995:149-162.
12. Semm K. Pelviscopy - operative guidelines. Technical section. WISAP;1992:75.
13. Engstrom L, Fenyo G. Appendectomy: assessment of stump invagination versus simple ligation: a prospective, randomized trial. Br J Surg. 1985;72:971-972.
14. Cooperman M. Complications of appendectomy. Surg Clin N Amer. 1983;63(6):1233-1247.
15. Lau WY, Teoh-Chan CH, Fan ST, Yam LOC, Lau KF, Wong SH. The bacteriology and septic complications of patients with appendicitis. Ann Surg. 1994;200(5):576-581.
16. Christou NV, Turgeon P, Wassef R, Rotstein O, Bohnen J, Potvin M. Management of intra-abdominal infections. Arch Surg. 1996;131:1193-1201.
17. Gilmore OJA, Martin TDM. Aetiology and prevention of wound infection in appendectomy. Br J Surg. 1974;61:281-287.
18. Finne CO. Transrectal drainage of pelvic abscess. Dis Colon Rectum. 1978;23:293-297.
19. Sihha AP. Appendectomy: an assessment of the advisability of stump invagination. Br J Surg. 1977;64:499-500.
20. Gomez A, Wood M. Acute appendicitis during pregnancy. Am J Surg. 1979;137:180-183.
21. Arnbjornsson E. Development of right inguinal hernia after appendectomy. Am J Surg. 1982;143:174-175.
22. Phillips JM. Complications in laparoscopy. Int J Gynaecol Obstet. 1977;15:157-162.
23. Kent RB. Subcutaneous emphysema and hypercarbia following laparoscopic cholecystectomy. Arch Surg. 1991;126:1154-1156.
24. Berci G, Cuscheri A. Complications of laparoscopy. In Practical Laparoscopy. Berci G, Cuscheri A, eds. Philadelphia: Bailliere Tindall; 1986:165-175.
25. Semm K. Pelviscopy - operative guidelines. Technical Section. Table 4-9.1. Instruments for emergencies. WISAP; 1992:70.
26. Mintz M. Risks and prophylaxis in laparoscopy: a survey of 100,000 cases. Reprod Med. 1977;18(5):269-272.
27. Soderstrom RM, Levy BS. Bowel injury during laparoscopy: causes and medico-legal questions. Contemp Obstet Gynecol. 1986;27:41-45.
28. Hogdall C, Rodsen JU. Incarcerated hernia following laparoscopy. Acta Obstet Gynecol Scand. 1987;66:735-736.
29. Williams MD, Swaim-Flowers S, Fenoglio ME, Brown Tr. Richters hernia following laparoscopy. Surg Rounds. February 1995;61-65.