**8. References**

128 Updated Topics in Minimally Invasive Abdominal Surgery

department in advanced procedures. We performed incidental robotic appendectomy in three patients who underwent gynecologic surgery for endometriosis for chronic pelvic pain with good results. We believe that the robotic procedure has its place in complicated cases of

In our opinion future research should first of all determine the role of diagnostic investigations (such as laboratory parameters, US, CT and MRI) which could lower the percentage of negative laparoscopies, especially in pregnant women and high risk patients. Also, a cost-benetit analysis of the routine appliance of US and CT in order to avoid negative laparoscopies would be reasonable. Additionally, the importance of leaving back a macroscopically innocent appendix in several patient categories (women of childbearing age, patients with chronic pain, high-risk- patients, children) if no other pathology is found should be further investigated. Another issue are intraabdominal abscesses. The role of the patients characteristics, the surgeon's expertise, the stump closure, the intraabdominal lavage and the standardization of technique in abscess formation should be further explored. The value of new techniques like the single port, the needlescopic and the robotic procedure in special cases should be investigated, as should the place of laparoscopy in obese patients and pregnant patients. Finally the late results of laparoscopic appendectomy

In conclusion, laparoscopy seems to be as safe as open appendectomy for acute appendicitis. Laparoscopy has many advantages, such as higher diagnostic yield, fewer postoperative wound infections, less postoperative pain, shorter hospital stay, earlier return to normal and full activity, better cosmesis, and probably decreased late complications such as adhesion formation and incisional hernias. Also one cannot overemphasize the superior visualization of the abdominal cavity and the possibility of not only diagnosing other pathologies but also dealing with them without having to use a bigger incision. Fertile women can profit the most from these advantages. But also elderly, overweight and employed patients seem to profit from laparoscopy. If the safety of leaving a macroscopically innocent appendix in situ is clarified by future studies the value of laparoscopy as a diagnostic tool will be enhanced. One expects that the further expansion of laparoscopy will lead to much more experienced surgeons, and that the progress in technology will facilitate this approach even more in the future. The reported higher incidence of intraabdominal abscesses with laparoscopy in some series could be experience- or technique-related and is likely to decrease with the evolution of laparoscopic skills among surgeons that leads to more precise operative maneuvers, and the standardisation of surgical technique. The higher operative costs in most institutions can perhaps be outweighed by a shorter hospital stay, and quicker return to normal activities with the laparoscopic approach, as well as by the possible decrease in late complications. Operative costs themselves can be reduced by the application of reusable instruments, application of loops instead of staplers, and further reduction of operating times. Finally it is important to reduce negative laparoscopies. The exact role of imaging modalities,

inflammatory parameters and scoring systems in this purpose has yet to be defined.

appendicitis with dense peritoneal adhesions.

**5.2 Implications for future research** 

should be explored (adhesions, SBO).

**6. Conclusion** 


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**9** 

Sami M. Shimi

*University of Dundee Scotland, United Kingdom* 

**Appendicitis and Appendicectomy** 

*Department of Surgery, Ninewells Hospital and Medical School,* 

The term appendicitis was first used by an epic publication by FITZ (Harvard Medical School) in 1886. FITZ outlined the clinical diagnosis and suggested early removal of the appendix. This new concept was not readily accepted. The first recorded appendicectomy was reported from Australia and was done on a kitchen table in Toowoonba in 1893. Appendicectomy in the UK did not gain early acceptance until 1902, when Sir Frederick

The epidemiology of appendicitis has caused a lot of intrigue. Although appendicitis was unknown before the 18th Century, there was a striking increase in its prevalence from the end of the 19th Century. There were suggestions that it was a side effect of modern western life. Although evidence for this was lacking, the rapid emergence of appendicitis in developed countries in the 20th Century and its rarity in rural areas and in undeveloped countries was sited as evidence. By the mid 1920s appendicitis became sufficiently common. Several theories have been advanced to account for the prevalence of the disease. One theory suggested that diet was responsible for the geographical distribution of appendicitis. It was however clear that diet could not fully explain the epidemiology of appendicitis. An alternative hypothesis proposed that improved hygiene in developed countries reduced the exposure of infants to enteric organisms would, modify the immune response to virus infections which might then cause appendicitis. Although this theory was accepted for many years, the hygiene hypothesis does not adequately explain the recent decline in the frequency of appendicitis in the latter half of the 20th Century. It remains uncertain whether there has been a real change in the incidence of appendicitis or whether the presentation and

The current incidence of appendicitis is about 100 per 100,000 person-years in Europe/America. Whereas the appendectomy rate is still decreasing, the incidence of appendicitis is now nearly stable. During the last 30 years the incidence of perforated appendicitis has not changed (approximately 20 per 100,000 person-years). Established risk factors for acute appendicitis are age (peak: 10-19 years), sex, and ethnic group/race. Classical theories (diet, hygiene) present illuminating models to explain the rise and fall of incidence in the last century; however, from a contemporary perspective the evidence is insufficient. The study of the epidemiology of appendicitis is complicated by the influence

Treves operated on King Edward VII twelve days before his coronation.

**1. Introduction** 

**2. Epidemiology** 

course of the disease has indeed changed.

