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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_725_Библиотеки_им_академика_М_И_Перельмана
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Ididafewcecalresectionsforperforatedcecaldiverticulitisandsigmoidresectionsforsigmoid
diverticulitisthroughanextendedRLQincision.Butagain,inthisdayandage,apre-
operative CT (or laparoscopy) would have saved you all those old-fashioned headaches.
Moshe
Postoperative appendiceal stump phlegmon/abscess and stump
appendicitis
Your patient had an uneventful appendectomy for acute appendicitis
followingwhichhehappilywenthome.Sevendayslaterhepresentswith
rightlowerquadrantpain,atemperatureandahighwhitecellcount.The
woundlooksOK.Thismaybeapostoperativeabdominalabscessoran
appendix stump phlegmon.Nowadays the diagnosis is simple — a CT
will demonstrate an abscess ora phlegmon which involves thececum.
Bothare cured byafewdays ofantibiotictherapybut anabscess
mayneedpercutaneousdrainage,especiallyiflargerthan5cm.
Withstumpappendicitisbeawarethat patients can develop classic
acute appendicitis at any time after appendectomy. Historically this
followedappendectomyforcomplicatedappendicitis,oftenbyarelatively
inexperiencedfamily doctor/surgeon. It is now becoming morecommon
in the era of laparoscopic appendectomy, where during the procedure
surgeons may misidentify the cecal base of the appendix and
consequently leave a long appendiceal stump — prone to stump
appendicitis and requiring a re-appendectomy. Few ER or family
practicedocs realize thatpost-appendectomy patientscan (rarely)
sufferfromacuteappendicitis—doexplainittothem!
Appendicealmass(phlegmon)
Typically,patientswithanappendicealmasspresentlateinthecourse
of the disease, and this should be suspected when symptoms have
persistedformorethan3days.Occasionally,theyreportaspontaneous
improvementintheirsymptoms,reflectinglocalizationoftheinflammatory
process. On clinical examination you will find a right iliac fossa
mass.Overlyingtendernessorobesitymayobscurethepresenceofthe
mass.Therefore,suspectanappendicealmassinthe‘latepresenters’or
those with an atypical smoldering picture. When palpation is not
rewarding,obtainaCTscan,whichisthebestwaytodocumentan
appendicealmass. Anotherindication forCTisassociated evidenceof
undrained pus such as a spiking fever and toxicity, signifying an
appendicealabscess.
Why should you distinguish between AA and appendiceal mass or
abscess? Because the appendiceal mass (and abscess) can (and
should)bemanaged non-operatively. You could operateon both,as
you operate on AA, but removal of the appendix involved in an
inflammatory mass may be more hazardous than usual, occasionally
necessitatinga right hemicolectomy. Ontheother hand,conservative
treatmentwithantibioticsleadstoresolutionofthemassinthevast
majorityofcases.Failureofthemasstorespondtoantibioticssignifies
anabscess(rare).CTorultrasound-guidedpercutaneousdrainageisthe
mostrationalapproach( Chapter46).
I would like to point out that a recent randomized study from our institution in Helsinki,
comparingimmediatelaparoscopicappendectomytoconservative
managementinpatientswithappendicealabscess(MentulaP,etal.Ann
Surg 2015), demonstrated immediate surgery to be a safe option — associated with fewer
readmissions and additional interventions, and not prolonging hospital stay. The rate of
uneventfulrecoverywas90%followingearlylaparoscopyand50%
after conservative treatment, respectively. Since then we have
adopted a new policy: patients with an appendiceal mass (phlegmon or abscess)
undergo early ‘day-time’ laparoscopic surgery. The abscess is located with blunt dissection
usingthesuctiontip,andisemptied.Anyresidualappendixthatcanbefoundisremovedand
thestumpsecuredwith an endoloop,sutureorstapler.So,ifyouareagreatlaparoscopist—
insert the scope and deal with it! Otherwise do what the others do. Everything in life is
controversial.Ari
Intervalappendectomy
As no more than one out of ten patients treated conservatively for
appendiceal mass will suffer a recurrence of AA (usually within 1 year
and not a complicated attack), the dogma of routine interval
appendectomy has become obsolete. In patients over the age of40
years,wesuggestelectivecolonoscopy/colonicimagingafter1monthto
excludetheraresituationin whichcarcinoma ofthe appendixor cecum
wasthecauseofthemass.Cancerorinflammatoryboweldiseasewillbe
detectedonlyin2outof100suchpatients.Soapplythe“ifitwereme
(IIWM)” test and do not recommend interval appendectomies to
yourpatients!
Appendicitisepiploica(appendagitis)
We mention this condition here because of its name. You have
probablynotheardmuch aboutitbutitisnotsorareandoften imitates
AA.Appendicitis epiploica(some callit ‘epiploicappendagitis’) follows
spontaneoustorsionofanappendixepiploica—theperitoneum-covered
tabs of fat attached along the tenia coli. It is more common in obese
individualsandinthececumandsigmoid.Sincethesigmoidcolonoften
crosses the midline, the most common manifestation is localized
tendernessandperitonealsignsintherightiliacfossa.Typically,patients
do not lose their appetite and do not feel or appearsick despite these
findings.Thus,‘AAonexamination’inanafebrileandhealthylooking
patient should raise your suspicions. The natural history is
spontaneous remission as the appendix epiploica sloughs off,
transforming into that loose calcified peritoneal body that you
occasionally find during unrelated abdominal procedures. A CT scan
usuallyidentifiesthelocalizedareaofpericolonicinflammation,excludes
AA and thus helps you to avoid unnecessary surgery or diagnostic
laparoscopy ( Chapter5). If youare misled into an operationjust
removethenecroticpieceoffat.Thenlookinthemirrorandsay:“How
stupidIwastooperate!”
2
Laparoscopicappendectomy
3
DannyRosin
Up to the decision to operate, there should be no difference in the
decision process between surgeons who prefer laparoscopic
appendectomy and the ‘open’ enthusiasts. They all aim to diagnose
correctly, as explained above, and proceed with the treatment. But, as
mentionedbriefly in Chapter 4, some perceive laparoscopy to be an
extension of the diagnostic effort: “We are not sure if the appendix is
inflamed or not, let’s avoid the CT radiation, let’s avoid the annoying
observation, let’s stick thescope in andknow for sure!”And while this
approach may make sense, we tend to forget its downsides, the
invasiveness and its risks, the anesthesia and its risk (minimal,
admittedly, but existent), and the tendency ‘to do something’, even
remove a normal appendix, just a souvenir from a nice trip to the
abdomen.
So, while we cannotclaim that diagnostic laparoscopyfor suspected
appendicitisisagrossmistake,orGodforbidacrime,wetrytominimize
itsuse.
Whylaparoscopy?
Myfirstinstinctivereplywouldbe:it’sagoodprocedure,Idoitwell,I
feelcomfortablewithitandthepatientsarehappy.Afteryearsofalmost
exclusive appendectomy by laparoscopy I feel it’s a good and honest
answer, and manyyoungsurgeonswho trained with lap appendectomy
as the routine procedurefeel thesame, and mainly feel it’seasier and
‘cleaner’thantostrugglethroughaminiincision.ButIrealizethatsome
oldersurgeonswillreadtheabovesinceretextandsay“bulls**t!”,andI
acknowledgethe factthata seriousbook like thisdeserves somemore
scientifictext.Andit’snotasifwedon’thavegoodarguments:
•
Differential diagnosis. Despite all modern diagnostic modalities,
wehavenotcompletelyeliminatedsurgicalsurprises,andanormal
appendix may still wait for us inside, along with some other
unexpectedpathology.Laparoscopyisamuchbetterdiagnosticand
therapeutic tool in these cases than a limited RLQ incision. And
while ‘young fertile women’ are nearly in the consensus for lap
appendectomy,evenValentinohadanunexpectedpathology4.
•
Woundinfection.Dealingwith aninfectiveprocess,it’snowonder
laparoscopyis associatedwith fewerincisional problems.Even ifa
wound infection occurs (surelyit’s less frequent) — the result is a
smallannoyingwoundinfectionandnotanopenlargeone,destined
foralongsecondaryhealingandanuglyscar.Althoughherniaina
McBurney scar is rare, we have seen it following wound infection
andimpairedwoundhealing.
•
Pain and recovery. The problem with ‘small’ operations, like
appendectomy, is that the advantages of laparoscopy are more
subtle and more difficult to prove. This does not mean that the
advantagesarenotthere,andwe(andthepatients)witnessitona
daily basis. McBurney aficionados will wave papers about “no
statistical difference” in QOL scores measured by scales we don’t
really understand, but we know our patients do well and, and
recoverswiftly.
•
Cosmesis.Yes,thisisaminorissue.Andyet...
Whynotlaparoscopy?
•
You don’t know how to do it. This may be the most important
contraindication for lap appendectomy. Neverattempt a procedure
youdon’tmaster,justbecauseit’sfashionable.Noonehereclaims
that open appendectomy is bad, only that maybe, under optimal
conditions,lapappendectomymayhavesomeadvantages.Lackof
experience,andlackofproperequipment,areverygoodreasonsto
stickwith the safeand proven openapproach.Alittlemorepain is
preferable to some horrendous complications we sometimes see
after misguided attempts to keep this simple procedure ‘minimally
invasive’.(YouhavetoreadChapter17inSchein’sCommonSense
Prevention and Management of Surgical Complications, tfm
publishing,2013.)
•
Intra-abdominalcollections. I’m notsurethisissue is solved yet.
There have been claims for a higher incidence of postappendectomypelviccollectionsafterlaparoscopy.Whilewedosee
this occasionally, many studies claim that the rate is not really
differentcomparedtotheopenprocedure.Itmaybethatexcessive
irrigation by laparoscopy contributes to spreading the localized
infection. We are not sure it’s true — but we don’t irrigate, just
aspirate the pus, and it seems to work just fine. The other
Editorsagreewithmeaboutthis—justsuckthemuckout!
•
Relative contraindications. In situations like pregnancy, or
perforated appendicitis with generalized peritonitis, one mayargue
that laparoscopy is less advisable, or more risky. The level of
surgicalexperiencemayplayarolehere,aswellasalargedoseof
common sense. Remember that obese patients may actually
benefitfrom laparoscopy,despitethefact that a moredifficult
operationisexpected.
•
Cost.No,wewillnotgointothis.Costissuchacomplicatedtopic!
It’senoughtosaythatifyoudohavebasiclaparoscopicequipment,
you can remove the appendix quite cheaply, with reusable
instruments, a cheap energy source, a fewties and a homemade
bag. Leave the
Harmonic Scalpel
®
and the staples to others, use
yourexcellentmanualskills,andbethankfulyouhavefewerobese
patientstooperateonthanthosepoorguysintheUSA.
Howtodoit?
Figure23.3.Optionsfortrocarplacementinlaparoscopicappendectomy.
You may have learned your technique from your chief resident, and
been convinced that this is the ‘correct’wayto do it. Please remember
that surgical variability is good; I will avoid the horrible ‘cat skinning’
aphorismbutjusttellyouthatafteralmost20yearsoflapappendectomy
Istillmodifythetechniquefromtimetotime,ifonlyforthefunofit.See
Figure23.3forsomeof thetrocarplacementoptionsthatare favored
bydifferentsurgeons.NotethatIskippedthesingleportandtherobotic
configurations.Iadviseyoutoskipthemtoo…Butwithallthevariability,
there are several key points you should remember, to make the
procedurerunsmoothlyandsafely.Heretheyare:
•
Urine.Letthepatientemptythebladderbeforesurgery.Iknow
that many surgeons prefer a Foley catheter for every lower
abdominal laparoscopy, but why give those who oppose
laparoscopyanothergoodargumentagainstit?Andwhygiveyour
patientan increased risk forUTI?An empty bladder willkeepthe
pelvicspace free foryou, and allowyousafely to insertthe lower
trocar.Andno,you don’tneed urinarymonitoring forsuch ashort
operation, unless it takes you more than 2 hours… but then you
shouldn’tdoit…
•
Position. Make the operation convenient for you. Tuck the arms
along the body so you’ll be able to stand comfortably, with the
assistantstandingnearyou.Securethepatienttothetablesothe
anesthetistwillhavenoexcuseagainstasteepTrendelenburgand
left tilt. You don’t need the small bowel obstructing your surgical
fieldofinterest.
•
Equipment. Use the best equipment you can have. Make your
laparoscopicconditionsoptimal;thelessyoustrugglethebetteris
youroperation
optics and lightsource should prevent you from working in
thedark.Ifyouhaveagood5mmscope(thatwillallowyouto
movebetweenthetrocarsasneeded)—fine.Ifnot—usethe
10;
energy sources, depending on availability, can make life
easier. The
Harmonic Scalpel
®
,
LigaSure
®
and other variants
fromdifferentcompanies, can all save you timeandsavethe
patient his erythrocytes. But remember that a good
laparoscopic surgeon can achieve the same with simple
monopolar or bipolarenergy,and some pre-tied loopsor
evensimplesurgicalties.Weencourageyoutomasterthese
skillsevenifyouliveinUtopiaandstaplersarefree.
•
Mobilization. Not every appendix willwait foryou in full erection
(oyvey).Thehigh,low,retrocecal,subhepaticor“WTF—whereis
it for heaven’s sake” appendix may playhide andseek withyour
nerves and ego. But here comes the real advantage of
laparoscopy: you are not limited to the confines of a strange
incisioninthecorneroftheabdomen.Lookaround,explore,follow
the tenia, follow the terminal ileum, mobilize thececum, mobilize
the whole right colon —do whateverit takesto findthe bastard;
youcandoitandyouhavethetechnology!
•
Mesenteric transection. Once you have localized the appendix
you have to start workingon it.You may needto separatesome
more adhesions around it, peel the omentum that is already
attachedtoit,orevenadherentbowel.Youmustdothisinorderto
elevatetheappendixandexposethemesentery.“CanIgrabit?!”
you ask, sheepishly, and the president’s answer would be,
surprisingly, “Yes you can!” But that is only because you are a
commonsensesurgeon,youknowhowtomanipulateitgently,
or grab the mesentery just underneath, and avoid crushing,
perforating, ripping and spreading the infection. The
mesenteric transection can be accomplished by any means you
prefer(andafford)—ties,clips,bipolar,anymodernenergysource
or even a vascular stapler, but please remember — this is not
cancer surgery: you don’t have to cut too proximal if the
mesenteryisthickenedandinflamed.Itisperfectlysafetotransect
close to or on the appendix itself, decreasing the risk of bleeding
andthebulkinessofthespecimentoberemoved.
•
Appendiceal transection. Although, at times, you start with
transecting the base (retrograde appendectomy, when the tip is
buriedsomewhere),thisisusuallythephasewhensuccesscanbe
declared,the anesthetistcan be wokenup, andthenurse canbe
promised that coffee is really soon. Do you know how to tie,
intracorporeallyorextracorporeally,andimpresstheintern?Doyou
wanttousethefriendly
Endoloop
®
?Doyouexpecta‘conference’
sponsored by one of the stapler companies? All methods are
legitimateaslongasthebaseissecured.Andifitisallswollenor
necrotic down to the base — get a piece of the cecum with a
stapler—exactlylikeyouwouldinanopencase.
•
Extraction. Please don’t ruin your beautiful operation with non-
elegantextractionofthespecimen;thiswillnotonlymakeyoulook
badintheeyesofthenursesbutwillalsoincreasethechance of
infectivecomplications.Useanextractionbag(unlessyouremove
a slender, white appendix…). Enlarge the incision a bit if the
appendixis toobulky.Makeitlookeasy andeffortless,and don’t
worryaboutfourmoremillimeterstotheincisionlength.It is
betterthananinfectedshortincision.
Toconclude,laparoscopicappendectomyisaverygoodoption.
It’syourresponsibilitytoplayitsafely,andprovethatIamright!
Gosh,Ialmostforgot,takecaretoremovethewholeappendix,not
onlypartof it— notarareoccurrencein laparoscopichandswhichare
notasskilledasyours…(see Figure23.4).
Figure 23.4. Patient: “But Doc, how could it be possible? I had my appendix removed
laparoscopicallylastyearattheMayonnaiseClinic!CouldIhavetwoappendixes?”
Acuteappendicitis, like anyother surgical condition,has a spectrum. To reach the diagnosis,
considerhistorical,physicalandlaboratoryfindingstogether.Noisolatedvariablecanconfirmor
excludeAA,butthemoreofthe classic abnormalities that are present, the higher the chance
that you are dealing with AA. Whether you operate immediately or tomorrow, whether you
observeorobtainadditionaltests,isdeterminedselectivelybasedonyourindividualpatient.
It has been said that “The good thing about standards of care is that there are so many to
choosefrom.”Andthisis true of course conceringthechoicebetweenopenandlaparoscopic
appendectomy. If you are as good a laparoscopist as Danny and his disciples then the
laparoscopicapproachisalmostalwayspreferable.Sostriveforlaparoscopicexcellencebutbe
careful.Lookingaroundus—beyondwhatispublishedintheliterature—weseeanepidemic
of complications developing after laparoscopic appendectomy which we have (almost) never
seen before: intraperitoneal abscesses, intestinal obstruction, cecal fistula, recurrent
appendicitis,bowelinjury,bladderinjury,vascularinjury5.Andyes,herniascandevelopatthe
trocarsite.Sodecideforyourselfandplayitsafe!
Never become blasé about AA; it can kill even today, and may
humbleeventhemostexperiencedsurgeon.Moshe
You may askyourself: why such an extra long chapter,dedicated to
suchatinyworm-likeorgan?
“There are two things in life that we will never
understand:womenandacuteappendicitis.”
1
ThelaparoscopicappendectomysectionhasbeenwrittenbyDannyRosin.
2
Andersson RE. The natural history and traditional management of appendicitis revisited:
spontaneous resolution and predominance of prehospital perforations imply that a correct
diagnosisismoreimportantthananearlydiagnosis.WorldJSurg2007;31:86-92.
3
Prof.AhmadAssaliacontributedtothissectioninthethirdeditionofthisbook.
4
Remember the case of the famous movie actor and womanizer Rudolph Valentino who
underwent an appendectomy for suspected acute appendicitis in New York (1926). He
becamegravelyillaftertheoperationanddied;autopsyrevealedaperforatedpepticulcer...
5
Fora more detailed discussion ofthecomplications of appendectomy and howto prevent
themreadChapter17inSchein’sCommonSensePreventionandManagementofSurgical
Complications.Shrewsbury,UK:tfmpublishing,2013.
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