Correspondence
La pa roscopic append icectomy Sir I was delighted to read the excellent Leading Article by Messrs Loh and Taylor ( B r J Surg 1992; 79: 289-90). There is no doubt that laparoscopic appendicectomy is often easier than laparoscopic cholecystectomy, provided the right technical approach is learnt and subsequently developed. The difficulty has been that most appendicectomies in this country are performed as an emergency, and in the first few cases the ‘learning curve’ means that the procedure will take of the order of 1 h 30 min to 2 h and in some units over 4 h. This engenders considerable reluctance on the part of theatre staff and hard-pressed surgical staff to fit it in with a busy emergency operating schedule. In addition, there are a number of surgical prejudices that need to be exorcised such as the use of non-absorbable staples in an area of potential infection and the need to bury the appendix stump. Likewise, many surgeons are worried that manipulation of a turgid appendix may precipitate a rupture and cause considerable contamination. Care and technical skill and the use of a plastic bag as mentioned by Loh and Taylor easily solve the problem, and even if the appendix has already perforated it is easy to lavage the peritoneal cavity under direct vision. Equally, there is no doubt that, even though the sum of the incisions for the various ports may exceed a small open incision, recuperation after laparoscopy is much faster and the cosmetic result superior. While it is true that there is some curtailment of hospital stay this is probably marginal as patients with peritonitis still require antibiotic therapy and that often forgotten therapeutic weapon, rest. Finally, the long retrocaecal appendix is actually easier to remove laparoscopically than by open surgery when the wound would often have to be extended. The need to try to improve the negative laparotomy rate (which is currently between 15 and 30 per cent 1, particularly in children and young women with gynaecological problems, is readily met by laparoscopy, which is perfect for diagnostic as well as therapeutic purposes. A considerable number of gynaecological problems can be dealt with laparoscopically and laparoscopic appendicectomy in children is very easy indeed, although great care has to be exercised in obtaining access. Loh and Taylor suggest a prospective randomized clinical trial, but while this is theoretically desirable the technique has outgrown the necessity, much as with cholecystectomy, provided the surgeon has obtained adequate experience and is not afraid to convert to an open procedure at the first sign of difficulty. My own experience to date numbers over 30 consecutive laparoscopic appendicectomies and compares very favourably with a personal audit of 254 open cases (unpublished data) in every parameter measured including operating time. Provided, therefore, that the technique is learnt to an acceptable standard and specialist supervision is available for emergency cases, there is no justification for a trial that would deny half of the patients the undoubted benefits of a superior technique.
C. A. Akle Nightingale House 90a Harley Street London W I N I A F UK
The missing appendix Sir The recent Leading Article on laparoscopic appendicectomy ( B r J Surg 1992; 79: 289-90) was timely. However, the precise role of diagnostic laparoscopy in patients with a clinical diagnosis of acute appendicitis remains unclear. One of the advantages of laparoscopic appendicectomy is that all patients with right iliac fossa pain have a diagnostic laparoscopy. This has been promoted as advantageous because it allows making an alternative diagnosis in those patients in whom the appendix is found to be normal. In a prospective study of 120 patients with a
0007-1323/92/09097345
a 1992 Butterworth-Heinemann
Ltd
clinical diagnosis of acute appendicitis, randomized to undergo laparoscopic or open appendicectomy, we have not found this to be so. In patients with a normal appendix, a diagnosis was established through a grid-iron incision just as often as with a laparoscope: open appendicectomy ( n = 61 ) six ‘alternative diagnoses’, three ‘no diagnosis’ compared with laparoscopic appendicectomy ( n = 59 ) eight ‘alternative diagnoses’, two ‘no diagnosis’ ( P not significant). Surgical dogma dictates that if a normal appendix is found at open operation it is removed, apparently because no patient can be trusted to tell a doctor in the future that they have not had their appendix out. An alternative diagnosis made by laparoscopy, however, rarely leads to a normal appendix being removed. We will have to trust patients who have had laparoscopic appendicectomy to tell us their appendix has been removed. The potential pitfalls are illustrated by the following conversation with a 33-year-old patient 2 weeks after undergoing laparoscopic appendicectomy for acute appendicitis. On leaving the outpatient’s clinic the patient enquired: ‘What was wrong with me?’ ‘Acute appendicitis’ ‘ W h y didn’t you remove m y appendix?’ ‘We did’ ’But there’s no scar!‘
Presumably, but for this last-minute question, this patient would have told any doctor consulted in the future that the appendix was still present. Beware the patient with lower abdominal pain and a I-cm scar at the umbilicus. J. W. Dawson J. J. T. Tate C. S. Robertson Department of Surgery Prince of Wales Hospital Chinese University of Hong Kong Hong Kong
Laparoscopic approach t o Meckel’s diverticulectomy Sir We read with interest the recent Surgical Workshop on laparoscopic diverticulectomy ( B r J Surg 1992; 79: 211) and wish to share our experience in this regard. Attwood et al. reputedly described the first laparoscopic approach to performing Meckel’s diverticulectomy for acute inflammation. We are currently conducting a study attempting to evaluate the use of laparoscopy in the investigation of ’obscure intestinal bleeding in paediatric patients in whom upper gastrointestinal endoscopy, colonoscopy and barium studies have all been nondiagnostic. Preliminary results have been encouraging. In this cohort of children with massive haemorrhagic episodes strongly suspicious of bleeding from a Meckel’s diverticulum, we elect to perform laparoscopy irrespective of the technetium scan findings, since the false-negative rate of the latter ranges from 25 to 50 per cent, and false-positive scans are encountered in a wide variety of conditions, some of which might also present with bleeding’,*. A 10-mm cannula placed in the folds of the umbilicus is used for the placement of the laparoscope. A 5-mm and a 10-mm cannula inserted in the mid-clavicular line on either side of the umbilical port are used for the passage of an Endo-Grasp and an Endo-Babcock (US Surgical, Norwalk, Connecticut, USA), respectively. Successive segments of small bowel held between the forceps are scrutinized, starting from its junction with the caecum. When a Meckel’s diverticulum is identified, the Endo-Babcock is removed to allow for the relocation of the laparoscope to its port. The Endo-Babcock is then passed through the umbilical sheath, directed to grasp the tip of the diverticulum, and withdrawn together with the sheath. The umbilical incision is extended until the whole diverticulum is delivered through the abdominal wall.
973
La pa roscopic append icectomy Sir I was delighted to read the excellent Leading Article by Messrs Loh and Taylor ( B r J Surg 1992; 79: 289-90). There is no doubt that laparoscopic appendicectomy is often easier than laparoscopic cholecystectomy, provided the right technical approach is learnt and subsequently developed. The difficulty has been that most appendicectomies in this country are performed as an emergency, and in the first few cases the ‘learning curve’ means that the procedure will take of the order of 1 h 30 min to 2 h and in some units over 4 h. This engenders considerable reluctance on the part of theatre staff and hard-pressed surgical staff to fit it in with a busy emergency operating schedule. In addition, there are a number of surgical prejudices that need to be exorcised such as the use of non-absorbable staples in an area of potential infection and the need to bury the appendix stump. Likewise, many surgeons are worried that manipulation of a turgid appendix may precipitate a rupture and cause considerable contamination. Care and technical skill and the use of a plastic bag as mentioned by Loh and Taylor easily solve the problem, and even if the appendix has already perforated it is easy to lavage the peritoneal cavity under direct vision. Equally, there is no doubt that, even though the sum of the incisions for the various ports may exceed a small open incision, recuperation after laparoscopy is much faster and the cosmetic result superior. While it is true that there is some curtailment of hospital stay this is probably marginal as patients with peritonitis still require antibiotic therapy and that often forgotten therapeutic weapon, rest. Finally, the long retrocaecal appendix is actually easier to remove laparoscopically than by open surgery when the wound would often have to be extended. The need to try to improve the negative laparotomy rate (which is currently between 15 and 30 per cent 1, particularly in children and young women with gynaecological problems, is readily met by laparoscopy, which is perfect for diagnostic as well as therapeutic purposes. A considerable number of gynaecological problems can be dealt with laparoscopically and laparoscopic appendicectomy in children is very easy indeed, although great care has to be exercised in obtaining access. Loh and Taylor suggest a prospective randomized clinical trial, but while this is theoretically desirable the technique has outgrown the necessity, much as with cholecystectomy, provided the surgeon has obtained adequate experience and is not afraid to convert to an open procedure at the first sign of difficulty. My own experience to date numbers over 30 consecutive laparoscopic appendicectomies and compares very favourably with a personal audit of 254 open cases (unpublished data) in every parameter measured including operating time. Provided, therefore, that the technique is learnt to an acceptable standard and specialist supervision is available for emergency cases, there is no justification for a trial that would deny half of the patients the undoubted benefits of a superior technique.
C. A. Akle Nightingale House 90a Harley Street London W I N I A F UK
The missing appendix Sir The recent Leading Article on laparoscopic appendicectomy ( B r J Surg 1992; 79: 289-90) was timely. However, the precise role of diagnostic laparoscopy in patients with a clinical diagnosis of acute appendicitis remains unclear. One of the advantages of laparoscopic appendicectomy is that all patients with right iliac fossa pain have a diagnostic laparoscopy. This has been promoted as advantageous because it allows making an alternative diagnosis in those patients in whom the appendix is found to be normal. In a prospective study of 120 patients with a
0007-1323/92/09097345
a 1992 Butterworth-Heinemann
Ltd
clinical diagnosis of acute appendicitis, randomized to undergo laparoscopic or open appendicectomy, we have not found this to be so. In patients with a normal appendix, a diagnosis was established through a grid-iron incision just as often as with a laparoscope: open appendicectomy ( n = 61 ) six ‘alternative diagnoses’, three ‘no diagnosis’ compared with laparoscopic appendicectomy ( n = 59 ) eight ‘alternative diagnoses’, two ‘no diagnosis’ ( P not significant). Surgical dogma dictates that if a normal appendix is found at open operation it is removed, apparently because no patient can be trusted to tell a doctor in the future that they have not had their appendix out. An alternative diagnosis made by laparoscopy, however, rarely leads to a normal appendix being removed. We will have to trust patients who have had laparoscopic appendicectomy to tell us their appendix has been removed. The potential pitfalls are illustrated by the following conversation with a 33-year-old patient 2 weeks after undergoing laparoscopic appendicectomy for acute appendicitis. On leaving the outpatient’s clinic the patient enquired: ‘What was wrong with me?’ ‘Acute appendicitis’ ‘ W h y didn’t you remove m y appendix?’ ‘We did’ ’But there’s no scar!‘
Presumably, but for this last-minute question, this patient would have told any doctor consulted in the future that the appendix was still present. Beware the patient with lower abdominal pain and a I-cm scar at the umbilicus. J. W. Dawson J. J. T. Tate C. S. Robertson Department of Surgery Prince of Wales Hospital Chinese University of Hong Kong Hong Kong
Laparoscopic approach t o Meckel’s diverticulectomy Sir We read with interest the recent Surgical Workshop on laparoscopic diverticulectomy ( B r J Surg 1992; 79: 211) and wish to share our experience in this regard. Attwood et al. reputedly described the first laparoscopic approach to performing Meckel’s diverticulectomy for acute inflammation. We are currently conducting a study attempting to evaluate the use of laparoscopy in the investigation of ’obscure intestinal bleeding in paediatric patients in whom upper gastrointestinal endoscopy, colonoscopy and barium studies have all been nondiagnostic. Preliminary results have been encouraging. In this cohort of children with massive haemorrhagic episodes strongly suspicious of bleeding from a Meckel’s diverticulum, we elect to perform laparoscopy irrespective of the technetium scan findings, since the false-negative rate of the latter ranges from 25 to 50 per cent, and false-positive scans are encountered in a wide variety of conditions, some of which might also present with bleeding’,*. A 10-mm cannula placed in the folds of the umbilicus is used for the placement of the laparoscope. A 5-mm and a 10-mm cannula inserted in the mid-clavicular line on either side of the umbilical port are used for the passage of an Endo-Grasp and an Endo-Babcock (US Surgical, Norwalk, Connecticut, USA), respectively. Successive segments of small bowel held between the forceps are scrutinized, starting from its junction with the caecum. When a Meckel’s diverticulum is identified, the Endo-Babcock is removed to allow for the relocation of the laparoscope to its port. The Endo-Babcock is then passed through the umbilical sheath, directed to grasp the tip of the diverticulum, and withdrawn together with the sheath. The umbilical incision is extended until the whole diverticulum is delivered through the abdominal wall.
973
