Laparoscopic Appendectomy
Part II
 
MANAGEMENT OF ACCEPTABLE COMPLICATIONS

1. Postoperative Sepsis: The fact that we can lavage the intraabdominal cavity with copious amounts of normal saline under direct vision has decreased the number of postoperative septic episodes or postoperative intraabdominal abscesses. However, several patients were readmitted to the hospital with severe abdominal pain and sepsis within ten days after this procedure. Our protocol mandates the following in this clinical setting: 1) Admission to the surgical service, 2) IV antibiotics (Cefizox and Flagyl), 3) CT scan (preferably Spiral) of the abdomen and pelvis, 4) If no localized fluid collection or abscess can be demonstrated on the CT, the patients will continued IV antibiotics only, 5) If an abscess is demonstrated, a CT guided drainage versus laparoscopic drainage is decided upon.

2. Trocar Site Infection: At the beginning of our series, before the introduction of the ENDO CATCH* instruments, we reported a significant number of trocar site infections. These incisions were opened at the bedside and drained. Since we started using the ENDO CATCH* instrument to remove the infected specimen from the intraabdominal cavity, we have had only one reported incident. The irrigation of the trocar site with normal saline at the end of the procedure should also always be done.

SURGICAL PERFORMANCE

 

Laparoscopic Appendectomy Series (Performance Analysis)   Notes
Number of Cases Analyzed

438

  
Conversions 4(0.6%) Conversion for technical problems only 
Negative Appendectomy Rate 41(9.3%)  
Mortality 0  
Intra-op. Injuries without alteration of outcome 1 (0.2%) (Bowel Injury with Grasper) No increased morbidity or Recovery 
Intra-op. Injuries with alteration of outcome 0  
Postop Bleeding Requiring Transfusion 1 (0.2%)  
Postop Re-exploration for Bleeding 0  
Postop Re-exploration for Postop Abscess 3 All re-exploration and drainage via laparoscopy
Readmission Re Postop ileus 2 (0.4%)  
Readmission Re Postop infection 6 (1.2%)  
Mean Operative Time 29min.  
Trocar Site Abscess 6 Prior to the introduction of the EndoCatch instrument
Trocar Site Abscess 1 After the introduction of the EndoCatch instrument
Trocar Site Hernia 0  

     

LOS <24Hrs. <36Hrs. <48Hrs. <60Hrs. <72Hrs.
% 31% 59% 78% 89% 96%
 

 LOS is defined as the time elapsed between the laparoscopic intervention and the discharge of the patient from the hospital.

COST ANALYSIS

LAPAPPY - Cost Analysis US $ 1996 -Providence Saint Joseph Medical Center

Identification of Costs Hard Costs Bill to Patient/Insurance Plan
OR- All Disposable Instruments (ONLY) 722.34  
UNBUNDLED HOSPITAL COST FOR LAP-APPY
24 Hr. Stay / All Costs Included
   4,210.30
BUNDLED HOSPITAL COST FOR LAP-APPY
24 Hr. Stay / All Costs Included
   2,966.00
HOSPITAL COST FOR LAP-APPY
Two Days Stay / All Costs Averaged
   5,158.00

 

THE FUTURE
Laparoscopic appendectomy is a procedure which has rapidly matured in the early nineties due to the introduction of the ENDO GIA* instruments. Although some authors have criticized this technique for its cost, there is no doubt this procedure will become the standard of care in patients with acute appendicitis and undiagnosed RLQ pain.

References: