**1. Introduction**

Suspected acute appendicitis is the most frequent cause of emergency operations in visceral surgery worldwide. Acute appendicitis is the reason for most urgent admissions and unscheduled operations in general surgery. In the western world approximately 8% of the population are appendectomised (Addis et al., 1990). The treatment for acute appendicitis has been conventional appendectomy for more than a century. This procedure proved to be safe and effective. However, a problem that remained is the high percentage -up to 47% in women of child-bearing age- of negative appendectomies (Borgstein et. al, 1997). Laparoscopic appendectomy counts almost 30 years of presence, and its introduction has met with more hurdles than that of laparoscopic cholecystectomy. Especially during the last two decades numerous studies tried to define the role of laparoscopic appendectomy in the treatment of suspected acute appendicitis. In this chapter we aim to present our experience with the laparoscopic approach for suspected appendicitis during the last almost twenty years and discuss the diagnostic and therapeutic effects of laparoscopy in suspected appendicitis. We will present our diagnostic approach, our surgical technique, and our results, and will discuss the literature. The role of laparoscopy in fertile females will be analysed. Also the place of laparoscopy in special groups such as the elderly, the employed patients, the obese patients, the pregnant women, and the children will be discussed. Finally we will refer briefly to newer techniques including the single port laparoscopic appendectomy, the needlescopic procedure, and the incidental robotic appendectomy.

#### **1.1 Background**

#### **1.1.1 Literature**

 Since the introduction of endoscopic appendectomy by Kurt Semm in 1983 (Semm, 1983) the surgical community tried to determine its advantages and disadvantages compared to the open procedure. Especially during the last twenty years there have been over 60 randomized controlled trials comparing laparoscopic and open appendectomy in adults (Vettoretto et al., 2010) as well as many meta-analyses of randomized controlled trials (Bennett et al., 2007; Chung et al, 1999; Fingerhut et al., 1999; Garbutt et al., 1999; Golub et al., 1998; Liu et al., 2010; Sauerland et al., 1998, 2002, 2004, 2010). The number of publications on laparoscopic appendectomy is still increasing, while publications on laparoscopic cholecystectomy decline. The latter shows that the laparoscopic approach in suspected acute appendicitis has not yet been fully accepted as the gold standard. There are still open issues regarding the laparoscopic approach. These have to do with the indications, the results, the

Laparoscopic Appendectomy 117

From the diagnostic point of view it has been suggested that active observation leads to a consistently lower rate of negative laparotomies and laparoscopies (Jones, 2001). Several scoring systems have also been proposed as diagnostic tools, but none of them has achieved general acceptance. In the literature very low statistical association is reported between a temperature >37° C and the presence of appendicitis (Cardal et al., 2004). An elevated WBC count > 10.000 cells/mm, while statistically associated with the presence of appendicitis, is reported to have very poor sensitivity and specificity and almost no clinical utility (Cardall et al., 2004). On the other hand the combination of either leucocyte count and CRP value (Gronroos JM & Groroos P, 1999) or leucocyte count, CRP value, and neutrophil percentage (Yang et al., 2005) is considered very important in the exclusion of appendicitis. Finally helical CT and graded compression US are reported to be useful instruments in the diagnosis of acute appendicitis as they may lower the false negative rate (Balthazar et al, 1991, 1998; Birnbaum et al., 2000; Jones et al., 2001, Pacharn et al., 2010). CT is in most studies found to be superior to US as it misses fewer cases; nonetheless, they are both reliable in suspected acute appendicitis (van Randen et al., 2011). A diagnostic pathway using routine US, limited CT, and clinical re-evaluation is proposed by Toorenvliet et al. (Toorenvliet et al., 2010). US should be the first choice especially for pregnant patients (Butala et al, 2010). Finally a multicenter study is ongoing to define the role of MRI instead

of CT in the diagnostic approach of acute appendicitis (Leeuwenburgh et al., 2010).

Our patients are being given prophylactic antibiotics (1g cefotaxime and 500mg metronidazole intravenously) and in complicated cases antibiotics are continued. Our policy is to leave back a normal looking appendix, if another pathology is found at surgery, but to remove a normal looking appendix, if there are no other findings. We normally release patients in the first postoperative day. In complicated cases the hospital stay is prolonged. Patients are examined on the tenth postoperative day as well as one month postoperatively.

The surgical team involved in diagnosis and treatment consisted of specialized surgeons trained in laparoscopy and working together over several years. The team grew with time. The operating surgeon in most cases was the director of the department (K.M.K), performing about several hundred laparoscopic procedures every year, many of them being advanced procedures. The policy of the department is to approach patients laparoscopically whenever possible. This is facilitated by the fact that almost all of the abdominal operations in this department are performed by laparoscopy, over 50% of them being advanced procedures. There are also scrub nurses and technicians with experience in laparoscopy

Surgical technique evolved with time, experience and appearance of new technical devices. Our technique went through several stages and has been described before (Konstantinidis et al., 2008). The technique, which was performed in the last over 1600 patients will be described here: Surgery is performed under general anesthesia with the patient lying in supine position on a multi-positional operating table. There are two monitors. The surgeon stands on the patient's left side and the assistant on the right. The abdomen is entered at the umbilicus using the open Hasson technique routinely. If there are dense adhesions another approach can be used. A 10mm reusable port is placed at the umbilicus and the 30 degree

**2.2 Patient management** 

**2.3 Surgical team and surgical technique** 

during the day as well as after hours.

costs, the standardisation of the surgical technique, the severity of leaving back a macroscopically 'innocent' appendix and the learning curve. Last but not least the debate about the place of laparoscopy in complicated appendicitis, the incidence of intraabdominal abscesses after laparoscopic appendectomy and its relationship to the severity of the disease, the surgical technique, and the surgical expertise is still vivid.

In the last years it has become apparent that the laparoscopic approach does not have the same value for all subpopulations. The investigators tried to determine the importance of the laparoscopic method in several patient groups. So, one can maintain that recent studies tend to clarify the issues regarding the worth of laparoscopy in the fertile female group, the elderly, the obese and the employed patients. The debate is still ongoing about laparoscopy in men, in complicated appendicitis, laparoscopy in pregnancy and in the paediatric population.

#### **1.1.2 Own experience**

The first laparoscopic appendectomy in our department (surgical department specialized in laparoscopy in a big private hospital in Athens) was performed in 1992. Since then we have performed over 1800 laparoscopic appendectomies. We did not analyse all these cases, but we performed a retrospective analysis in more than a thousand patients. Patients with suspected appendicitis, who were treated in the Department of General, Laparoscopic, and Robotic Surgery at the Athens Medical Center between April 1993 and March 2003 were considered for our retrospective study on laparoscopic appendectomy published in 2008 (Konstantinidis et al, 2008). The study presented the results in 1026 patients and was not comparative. Only laparoscopic patients were included as laparoscopy has been the treatment of choice since the department was founded. Patients operated on during the learning curve (100 pts.) and the few patients approached from the start by open technique (15 pts.) were not included in the study. The inclusion criteria for our study on laparoscopic appendectomy were suspected acute appendicitis (after clinical examination, laboratory tests, and imaging tests) or chronic recurrent symptoms that could be attributed to appendicitis, age 15 years or more and laparoscopy as first approach. All patients in whom we performed a laparoscopic appendectomy or an appendectomy after conversion to an open procedure were included in our analysis (908 pts). Also, diagnostic accuracy of laparoscopy was analysed separately in the subgroup of fertile women (558 pts), and was compared to diagnostic accuracy in the rest of the patients (468 pts).

After standardisation of our technique the latter did not actually change. New developments were the single incision technique and the introduction of the DaVinci robotic (TM- Intuitive Surgical Inc.) system in 2006. In this chapter we will refer to the results we had between 1993 and 2003, as we measured and published them. With this exception we will comment only on major complications and new developments.

#### **2. Diagnostic approach, patient management and surgical technique**

#### **2.1 Diagnostic approach**

We perform routine preoperative control in all patients. Women in whom differential diagnosis includes gynaecological disorders are in many cases examined by the gynaecologist and a transabdominal or transvaginal ultrasound or a CT scan is being performed whenever indicated and possible. There are also some male patients, in whom we might perform ultrasound or CT scan.

costs, the standardisation of the surgical technique, the severity of leaving back a macroscopically 'innocent' appendix and the learning curve. Last but not least the debate about the place of laparoscopy in complicated appendicitis, the incidence of intraabdominal abscesses after laparoscopic appendectomy and its relationship to the severity of the disease,

In the last years it has become apparent that the laparoscopic approach does not have the same value for all subpopulations. The investigators tried to determine the importance of the laparoscopic method in several patient groups. So, one can maintain that recent studies tend to clarify the issues regarding the worth of laparoscopy in the fertile female group, the elderly, the obese and the employed patients. The debate is still ongoing about laparoscopy in men, in complicated appendicitis, laparoscopy in pregnancy and in the paediatric

The first laparoscopic appendectomy in our department (surgical department specialized in laparoscopy in a big private hospital in Athens) was performed in 1992. Since then we have performed over 1800 laparoscopic appendectomies. We did not analyse all these cases, but we performed a retrospective analysis in more than a thousand patients. Patients with suspected appendicitis, who were treated in the Department of General, Laparoscopic, and Robotic Surgery at the Athens Medical Center between April 1993 and March 2003 were considered for our retrospective study on laparoscopic appendectomy published in 2008 (Konstantinidis et al, 2008). The study presented the results in 1026 patients and was not comparative. Only laparoscopic patients were included as laparoscopy has been the treatment of choice since the department was founded. Patients operated on during the learning curve (100 pts.) and the few patients approached from the start by open technique (15 pts.) were not included in the study. The inclusion criteria for our study on laparoscopic appendectomy were suspected acute appendicitis (after clinical examination, laboratory tests, and imaging tests) or chronic recurrent symptoms that could be attributed to appendicitis, age 15 years or more and laparoscopy as first approach. All patients in whom we performed a laparoscopic appendectomy or an appendectomy after conversion to an open procedure were included in our analysis (908 pts). Also, diagnostic accuracy of laparoscopy was analysed separately in the subgroup of fertile women (558 pts), and was

After standardisation of our technique the latter did not actually change. New developments were the single incision technique and the introduction of the DaVinci robotic (TM- Intuitive Surgical Inc.) system in 2006. In this chapter we will refer to the results we had between 1993 and 2003, as we measured and published them. With this exception we

We perform routine preoperative control in all patients. Women in whom differential diagnosis includes gynaecological disorders are in many cases examined by the gynaecologist and a transabdominal or transvaginal ultrasound or a CT scan is being performed whenever indicated and possible. There are also some male patients, in whom

the surgical technique, and the surgical expertise is still vivid.

compared to diagnostic accuracy in the rest of the patients (468 pts).

will comment only on major complications and new developments.

**2. Diagnostic approach, patient management and surgical technique** 

population.

**1.1.2 Own experience** 

**2.1 Diagnostic approach** 

we might perform ultrasound or CT scan.

From the diagnostic point of view it has been suggested that active observation leads to a consistently lower rate of negative laparotomies and laparoscopies (Jones, 2001). Several scoring systems have also been proposed as diagnostic tools, but none of them has achieved general acceptance. In the literature very low statistical association is reported between a temperature >37° C and the presence of appendicitis (Cardal et al., 2004). An elevated WBC count > 10.000 cells/mm, while statistically associated with the presence of appendicitis, is reported to have very poor sensitivity and specificity and almost no clinical utility (Cardall et al., 2004). On the other hand the combination of either leucocyte count and CRP value (Gronroos JM & Groroos P, 1999) or leucocyte count, CRP value, and neutrophil percentage (Yang et al., 2005) is considered very important in the exclusion of appendicitis. Finally helical CT and graded compression US are reported to be useful instruments in the diagnosis of acute appendicitis as they may lower the false negative rate (Balthazar et al, 1991, 1998; Birnbaum et al., 2000; Jones et al., 2001, Pacharn et al., 2010). CT is in most studies found to be superior to US as it misses fewer cases; nonetheless, they are both reliable in suspected acute appendicitis (van Randen et al., 2011). A diagnostic pathway using routine US, limited CT, and clinical re-evaluation is proposed by Toorenvliet et al. (Toorenvliet et al., 2010). US should be the first choice especially for pregnant patients (Butala et al, 2010). Finally a multicenter study is ongoing to define the role of MRI instead of CT in the diagnostic approach of acute appendicitis (Leeuwenburgh et al., 2010).

#### **2.2 Patient management**

Our patients are being given prophylactic antibiotics (1g cefotaxime and 500mg metronidazole intravenously) and in complicated cases antibiotics are continued. Our policy is to leave back a normal looking appendix, if another pathology is found at surgery, but to remove a normal looking appendix, if there are no other findings. We normally release patients in the first postoperative day. In complicated cases the hospital stay is prolonged. Patients are examined on the tenth postoperative day as well as one month postoperatively.

#### **2.3 Surgical team and surgical technique**

The surgical team involved in diagnosis and treatment consisted of specialized surgeons trained in laparoscopy and working together over several years. The team grew with time. The operating surgeon in most cases was the director of the department (K.M.K), performing about several hundred laparoscopic procedures every year, many of them being advanced procedures. The policy of the department is to approach patients laparoscopically whenever possible. This is facilitated by the fact that almost all of the abdominal operations in this department are performed by laparoscopy, over 50% of them being advanced procedures. There are also scrub nurses and technicians with experience in laparoscopy during the day as well as after hours.

Surgical technique evolved with time, experience and appearance of new technical devices. Our technique went through several stages and has been described before (Konstantinidis et al., 2008). The technique, which was performed in the last over 1600 patients will be described here: Surgery is performed under general anesthesia with the patient lying in supine position on a multi-positional operating table. There are two monitors. The surgeon stands on the patient's left side and the assistant on the right. The abdomen is entered at the umbilicus using the open Hasson technique routinely. If there are dense adhesions another approach can be used. A 10mm reusable port is placed at the umbilicus and the 30 degree

Laparoscopic Appendectomy 119

trocar. The fascial incision at the umbilicus is closed with 2.0 Vicryl™ sutures. The skin is closed with 4.0 or 5.0 absorbable subcuticular sutures, unless there is an intraabdominal

mucosa

with the bipolar.

Many surgeons prefer routine stapling of the appendiceal stump. The stapling is reported to be quicker, easier, and lead to less postoperative infections (Kazemier et al., 2006). On the other hand it means greater costs and the obligatory use of a 12- mm trocar. Other investigators do not report a higher complication rate with the use of endoloops as is stated in a recent review. The only difference between the two methods is considered to be operating time (Sajid et al., 2009). A protocol recruitment is now running to investigate, whether routine stapling of the stump can lead to less intraabdominal abscesses (Sauerland & Kazemier, 2007). Peritoneal lavage is contradictory, as it may lead to spillage of infection according to some investigators (Gupta, 2006) but may prevent infection if performed copiously in all quadrants according to others (Hussain, 2008). We believe that a lavage with 3-5 liters of normal saline, as we described it, using a peristaltic pump is effective and saves time. One could argue that it is more expensive, but our experience in over 1.800 patients has been that it is worth the cost. Routine use of drains is not necessary, and may in some

Finally, standardisation of surgical technique leads to reduction of operative time, conversion rate, morbidity, and to a higher surgeon satisfaction in training centers (Ng et al.,

Fig. 6. Cauterisation of the appendiceal

Fig. 8. Cutting of the remaining appendix

contamination, in which case the skin is closed with 4.0 interrupted nylon sutures.

Fig. 5. Not the whole lumen of the appendix

Fig. 7. Cauterisation of the appendiceal

patients lead to cecal fistulae (Petrowsky, 2004).

2004; Hsieh et al., 2009).

is beeing cut

mucosa

laparoscope is inserted. The abdominal cavity can now be visualized. Two further 5mm reusable trocars are inserted in the suprapubic area and the left lower quadrant under visual control. The surgeon operates with two hands and the assistant holds the laparoscope. The small bowel is retracted away from the right lower quadrant with the patient lying in the Trendelenburg position and right side up. Atraumatic forceps are used. The dissection continues, sometimes using the Plasma Kinetics™ (Gyrus Medical, Cardiff, UK) bipolar electrocautery, until the base of the cecum is visualized, and the appendix can be elevated. The mesoappendix is managed in a retrograde fashion by lifting the apex of the appendix and using the cutting bipolar electrocautery until the cecum is reached. Three ligating Endoloops PDS II™(Ethicon, Sommerville, NJ, USA) are placed, the first one at the appendicular base, the second one next to the first loop, and the third one in about 1cm distance. The appendix is then transected using scissors. Before the transaction is complete the remaining appendicular mucosa is first suctioned and then burned with caution using the bipolar electrocautery. The laparoscope is changed from the 10 to the 5mm laparoscope

Fig. 1. Cauterisation of the mesoappendix Fig. 2. Cauterisation and cutting of the

mesoappendix

Fig. 3. Placement of the Endoloops PDS IITM Fig. 4. Cutting of the appendix

and placed through the LLQ port. If uncomplicated, the appendix is grasped and pulled through a reducer at the umbilical port. If ruptured or gangraenous the appendix is put in a retrieval bag and the bag grasped with a traumatic grasper and pulled through the umbilical port. The site of appendectomy, right paracolic gutter, and pelvis are irrigated with about 3 to 5 liters of normal saline irrigation solution with presure. Fluid from the suprahepatic area and the pouch of Douglas is suctioned. In cases of intraabdominal abscess a drain connected to a closed suction system is placed in the abscess cavity and brought out through the subrapubic

laparoscope is inserted. The abdominal cavity can now be visualized. Two further 5mm reusable trocars are inserted in the suprapubic area and the left lower quadrant under visual control. The surgeon operates with two hands and the assistant holds the laparoscope. The small bowel is retracted away from the right lower quadrant with the patient lying in the Trendelenburg position and right side up. Atraumatic forceps are used. The dissection continues, sometimes using the Plasma Kinetics™ (Gyrus Medical, Cardiff, UK) bipolar electrocautery, until the base of the cecum is visualized, and the appendix can be elevated. The mesoappendix is managed in a retrograde fashion by lifting the apex of the appendix and using the cutting bipolar electrocautery until the cecum is reached. Three ligating Endoloops PDS II™(Ethicon, Sommerville, NJ, USA) are placed, the first one at the appendicular base, the second one next to the first loop, and the third one in about 1cm distance. The appendix is then transected using scissors. Before the transaction is complete the remaining appendicular mucosa is first suctioned and then burned with caution using the bipolar electrocautery. The laparoscope is changed from the 10 to the 5mm laparoscope

Fig. 1. Cauterisation of the mesoappendix Fig. 2. Cauterisation and cutting of the

Fig. 3. Placement of the Endoloops PDS IITM Fig. 4. Cutting of the appendix

and placed through the LLQ port. If uncomplicated, the appendix is grasped and pulled through a reducer at the umbilical port. If ruptured or gangraenous the appendix is put in a retrieval bag and the bag grasped with a traumatic grasper and pulled through the umbilical port. The site of appendectomy, right paracolic gutter, and pelvis are irrigated with about 3 to 5 liters of normal saline irrigation solution with presure. Fluid from the suprahepatic area and the pouch of Douglas is suctioned. In cases of intraabdominal abscess a drain connected to a closed suction system is placed in the abscess cavity and brought out through the subrapubic

mesoappendix

trocar. The fascial incision at the umbilicus is closed with 2.0 Vicryl™ sutures. The skin is closed with 4.0 or 5.0 absorbable subcuticular sutures, unless there is an intraabdominal contamination, in which case the skin is closed with 4.0 interrupted nylon sutures.

Fig. 5. Not the whole lumen of the appendix is beeing cut Fig. 6. Cauterisation of the appendiceal mucosa

Fig. 7. Cauterisation of the appendiceal mucosa

Fig. 8. Cutting of the remaining appendix with the bipolar.

Many surgeons prefer routine stapling of the appendiceal stump. The stapling is reported to be quicker, easier, and lead to less postoperative infections (Kazemier et al., 2006). On the other hand it means greater costs and the obligatory use of a 12- mm trocar. Other investigators do not report a higher complication rate with the use of endoloops as is stated in a recent review. The only difference between the two methods is considered to be operating time (Sajid et al., 2009). A protocol recruitment is now running to investigate, whether routine stapling of the stump can lead to less intraabdominal abscesses (Sauerland & Kazemier, 2007). Peritoneal lavage is contradictory, as it may lead to spillage of infection according to some investigators (Gupta, 2006) but may prevent infection if performed copiously in all quadrants according to others (Hussain, 2008). We believe that a lavage with 3-5 liters of normal saline, as we described it, using a peristaltic pump is effective and saves time. One could argue that it is more expensive, but our experience in over 1.800 patients has been that it is worth the cost. Routine use of drains is not necessary, and may in some patients lead to cecal fistulae (Petrowsky, 2004).

Finally, standardisation of surgical technique leads to reduction of operative time, conversion rate, morbidity, and to a higher surgeon satisfaction in training centers (Ng et al., 2004; Hsieh et al., 2009).

Laparoscopic Appendectomy 121

Temple et al, 1999). It is nonetheless remarkable that - as laparoscopy evolves - the results of meta-analyses performed by the same investigators show through the years a decreasing difference in operating time between the two approaches (Sauerland et al., 1998, 2002, 2004, 2010). Sauerland et al. report in their most recent meta-analysis that laparoscopic appendectomy is on the average 10 minutes longer than the open one (Sauerland et al., 2010). The median operating time in our study was 26 minutes, which compares favourably with most other studies (The time from cutting the skin at the umbilicus until putting the last skin suture was defined as operating time). We believe that the short operating time is due to the surgeon's expertise, and the training of the surgical team. We also believe that it

It has been suggested, and seems logical, that surgical expertise has a great impact in conversion rate and operating time. The latter one as well as the lack of precision in

In our study we had an overall **complication rate** of 5,7%, consisting mostly of minor complications. At the beginning of our series we had to reoperate on a 28 year old female patient 3 days after surgery because of persisting abdominal pain. We performed a diagnostic laparoscopy. There were no findings. We attributed the pain to not properly washed instruments, with remainings of Cidex™ (Johnson& Johnson, Cincinatti, Ohio, USA) solution on them. We had no other reoperations or major complications except for one

The average **wound infection rate** for laparoscopic appendectomy is reported to be 2,8% in the meta-analysis by Golub et al. (Golub, 1998) and 2,5% in a big prospective multi-centerstudy (Lippert et al., 2002). Wound infection rate is reduced by a half after laparoscopic appendectomy in the most recent meta-analysis (Sauerland et al., 2010) based on the study of more than 6000 cases. This is consistent with the findings of a large data base analysis of over 40.000 in the US (Guller, 2004). Wound infection rate in our study was measured

**Intraabdominal abscesses** are reported in the older meta-analyses to be equally frequent as in the open procedure (Chung et al., 1999; Garbutt et al., 1999; Temple et al.) or even increased, but without reaching statistical significance (Golub, 1998). In the most recent review **intra-abdominal abscesses** are reported to be nearly threefold after laparoscopic appendectomy(Sauerland et al., 2010), and moderate heterogeneity was detectable. There were no notable differences in the results of trials using staplers versus loop. The problem with studies reporting higher incidence of intraabdominal abscesses with laparoscopic appendectomy is that they lack standardization of the surgical technique, and also that they do not uniformly describe the different grades of disease. A recent prospective randomised study on 220 patients reports less intraabdominal abscesses with the laparoscopic approach (Wei et al., 2010). Also, a very recent review on 2.264 patients (Asarias et al., 2011) did not find a significant difference in intraabdominal abscesses between the open and the laparoscopic approach. On the other hand a multivariate analysis from the American College of Surgeons on almost 40.000 appendectomies (77% laparoscopic) found that laparoscopy was associated with an increased risk for intraabdominal abscesses in the high risk patients (12,3% vs. 8,9%) but not for the low risk patients (Fleming et al., 2010). We had no intraabdominal abscesses after laparoscopic appendectomy in our study (Konstantinidis et al., 2008). Our only experience with an intraabdominal abscess after laparoscopic appendectomy was in a 59 year old man, in whom we performed one of the first operations for a ruptured appendix in January 1993, and who was not included in our study, as

manoeuvers by novices could affect complication rate and patients' outcome.

has to do with the standardisation of the surgical technique.

intraabdominal abscess outside our published series.

separately and was 1,1%.
