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Indian Journal for the Practising Doctor

Case Report: Laparoscopic Appendicectomy in a Rural Set up - A Case Report

Author(s): Chalkoo M

Vol. 4, No. 6 (2008-01 - 2008-02)

Chalkoo M

ISSN: 0973-516X


Dr. Mushtaq Chalkoo, MS, FAMS, is consultant laparoscopic surgeon at Sub-district Hospital, Tangmarg, District Baramulla.


Abstract:

A 19 year old unmarried girl presenting with acute abdominal pain and vomiting was admitted in our sub-district hospital (Tangmarg). Her history, physical examination, routine blood studies, and urine analysis were in favour of acute appendicitis. We performed an ultrasound which confirmed the diagnosis of acute catarrhal appendicitis. We did laparoscopic appendicectomy and the postoperative period remained uneventful.

Key words: Appendicitis, pneumo-peritoneum, laparoscopy.


Introduction

Acute appendicitis is one of the commoner surgical problems in our social set up. It is very common in school-going children and the elderly. The commonest cause we encounter in rural area is worms; particularly the round worm. The indications for laparoscopic appendicectomy remain the same as for open appendicectomy, and can be applied to both perforated and non-perforated cases. Diagnostic laparoscopy for abdominal pain is becoming more common and when appendicitis is encountered, diagnostic procedure becomes therapeutic with appendicectomy being performed via the laparoscopic approach. A thorough preoperative discussion is necessary with the patient and the family about the risks and benefits of laparoscopic versus open appendicectomy.The advantages of laparoscopic approach generally include shorter hospital stay, early return to normal activity, and more cosmetically-acceptable scar. The complication specific to laparoscopic approach include intestinal or mesenteric injury, haemorrhage, and need to convert to open exploration.

Fig.1 Meso-appendix being cauterized

Meso-appendix being cauterized

Fig. 2 Base of appendix being freed

 Base of appendix being freed

Fig. 3 Dissection at the base of appendix

Dissection at the base of appendix

Fig. 4 Acute catarrhal Appendix dissected free upto the base

Acute catarrhal Appendix dissected

Fig. 5 Base of appendix being ligated at the base with vicryl

Base of appendix being ligated

Case Report

A 19 year old unmarried girl diagnosed as acute cataharal appendicitis after thorough history, physical examination, blood tests, urine analysis, and USG, was submitted for laparoscopic appendicectomy. After induction of general endotracheal anaesthesia, a Foley catheter and nasogastric tube were inserted for bladder and gastric decompression, respectively, in order to prevent trocar injury during cannula insertion.The abdomen was prepared and draped widely. A single video monitor was positioned at the foot of the operating table with the surgeon standing on the patient’s left and the assistant to the patients right. A second assistant was placed to the left of the operating surgeon. We created pneumoperitonium by Veress needle inserted through a small vertical incision within the umbilicus. The abdomen was insufflated with CO2 at low flow of 1lit/min.The maximum pressure was set at 15mmHg. With adequate insufflation, Veress needle was removed and a 5mm cannula with a trocar inserted through the umbilical fascia. Video laparoscopy was performed with continued insufflation through the cannula. The camera was turned to the right lower quadrant. A 5mm midline suprapubic incision was made and 5mm cannula inserted into the abdominal cavity. Another 10mm incision was made in the left lower abdominal quadrant on the same plane as the appendix. After visualizing appendix and caecum, Trendelenberg’s position was given to the table allowing the small bowel and omentum to fall away from the operative area. With elevation and retraction of the appendix using a grasping forceps through the SP port the meso-appendix was exposed for dissection. We cauterized the meso-appendix and cut it with the scissors. The endovascular clips were not used as they are costly and not available in rural areas. After freeing the mesoappendix upto the base, we did intra-corporeal knotting at the base of appendix – two proximal and one distal. The inflamed appendix was cut with scissors and removed through the left lower quadrant cannula. The abdomen was decompressed and the ports were closed.

Discussion

Laparoscopic appendicectomy was popularized in the early 1980s by the German gynecologists Semm and Schreiber. It has many advantages over open appendicectomy. A complete examination of the abdominal cavity can be performed laparoscopically than through a small Mcburnney incision. Another advantage is more complete abdominal lavage with removal of fibrinous exudates in cases of generalized peritonitis. Using the laparoscopic technique, there may be a reduced incidence of postoperative peritoneal adhesions, which often serve as a source of pain and infertility in females. In addition, a shorter hospital stay and a faster return to unrestricted activities such as school and play are associated with the laparoscopic technique.

References

  1. Attwood SEA, HillADK, Murphy PG, et al. A prospective randomized trial of laparoscopic versus open appendicectomy. Surgery1992;112:497-501.
  2. Gilchrist BF,Lobe TE, Schropp KP, et al. Is there a role for laparoscopic appendicectomy in pediatric surgery Pediat surg 1992;27;209-214.
  3. Richards W, Watson D, Lynch G et al. Laparoscopic versus open appendicectomy; Review of results using these two techniques. American College of Surgeons, Clinical Congress, 1992.
  4. Semm K. Laparoscopic appendicectomy. Dtsch Med Wochenschr 1988;113;3-5
  5. Schreiber JH. Laparoscopic appendicectomy in pregnancy. Surg Endosc 1990;4:100-102.
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