Laparoscopic appendectomy in destructive forms of acute appendicitis complicated by typhlitis

Abstract

The improvement of laparoscopic technologies, today, makes it possible to expand the indications for laparoscopic appendectomy and successfully carry out interventions even in destructive forms of acute appendicitis complicated by typhitis [304,305,306]. At the same time, the choice of the method of peritonization of the appendix stump against the background of typhlitis in each specific case is a significant problem [4]. The use in conditions of infiltration of the wall of the caecum of various methods of hiding the stump of the appendix, including intussusception, is associated with significant technical difficulties and the probability of developing purulent complications (abscesses of the abdominal cavity, colonic fistula, phlegmon of the retroperitoneal tissue, etc.) after laparoscopic appendectomy, which in the structure postoperative complications with this surgical intervention are in the first place (4.1%) [1]. It is purulent complications that cause an increase in intra-abdominal hypertension (IAH). This can also contribute to a burn of the dome of the cecum, which is observed quite often (12.6% of cases) when using electrocoagulation to treat the mucous membrane of the stump of the appendix [3]. The above data determine the need for further improvement of the technology of laparoscopic interventions in acute destructive appendicitis. The aim of this study was improvement of the method of laparoscopic appendectomy in destructive forms of acute appendicitis complicated by typhitis. Materials and Methods. The method is performed as follows. After applying the carboxyperitoneum and introducing the laparoscope into the abdominal cavity, the abdominal organs are inspected, the diagnosis of acute destructive appendicitis is visually confirmed, the topography of the appendix, the degree of its destruction, the presence and type of complications are clarified. The appendix is cut off from the mesentery by staged bipolar coagulation. Ligation of its base is carried out by sequentially overlapping two Roeder's endopetals. The appendix is removed and the mucosa of its stump is treated with electrocoagulation. With a continuous sero-muscular suture, the sections of the terminal part of the ileum are sutured to the cecum with an atraumatic needle, thus peritonizing the stump of the appendix. Infiltrated areas of the cecum are avoided. The operation ends with thorough sanitation of the abdominal cavity, drainage of the latter with a tubular drain and suturing of punctures of the abdominal wall. According to this technique, 28 patients were operated on in the period from 2018 to 2021, the average duration of observation was 3.5 years. The obtained results were compared with the results of treatment of patients with destructive appendicitis against the background of infiltrative changes of the cecum, who underwent appendectomy with the help of an everted flap of the peritoneum. We did not use the prototype method when peritonization of the medial section of the cecum was necessary, as well as in the case of close location of the base of the appendix to the Bauginian valve. Results of the research. According to literature data, in 13.04% of patients (6 out of 46 patients) with standard covering of the stump of the appendix with own tissues of the cecum with single knotted sutures, an external colonic fistula occurred within 3 to 7 days [6]. The patients of the main group did not develop postoperative complications (χ2=3.9, Р=0.048). The average duration of this surgical intervention is 42.2 ± 5.3 min., which was almost identical to the standard caecopexy. On average, patients were in the hospital for 3.9 ± 1.5 days. In comparison, the average bed-day after the standard covering of the stump with own tissues of the cecum was 13.8 ± 2.1 days (t=3.1, Р=0.003), and in patients who developed an external intestinal fistula, the bed-day was 36.8 ± 4.7 days (t=8.9, P<0.0001) [5]. As shown by statistical processing of the results of using this method, it provides a statistically reliable prevention of purulent complications (Р<0.05). In our opinion, this is due to taking into account the anatomical features of the ileocaecal transition, which allows covering the stump of the appendix without intussusception of the latter into the cecum and deformation of the Bauginian valve in the case of a close location of the base of the appendix to the latter. The procedure of applying sutures to the infiltrated cecum is not associated with the danger of cutting through the sutures, since in this case there is no stretching of the tissues, which allows to avoid purulent complications, but as a consequence of the development of ICH [2]. Conclusion. Thus, the application of the stated method of laparoscopic appendectomy in destructive forms of acute appendicitis complicated by typhitis made it possible to improve the immediate results of surgical treatment of this category of patients and to avoid the development of purulent complications, and as a consequence of ICH, due to the choice of the method of peritonization of the stump of the appendix taking into account individual anatomical features ileocaecal transition. References 1. Cohen-Arazi O, Dabour K, Bala M, Haran A, Almogy G. Management, treatment and outcomes of acute appendicitis in an elderly population: a single-center experience. Eur J Trauma Emerg Surg. 2017 Oct;43(5):723-7. 2. Constantin V, Popa F, Carap A, Socea B. Stump appendicitis – an overlooked clinical entity. Chirurgia (Bucur). 2014 Jan-Feb;109(1):128-31 3. Dikicier E, Altintoprak F, Ozdemir K, Gundogdu K, Uzunoglu MY, Cakmak G, et al. Stump appendicitis: a retrospective review of 3130 consecutive appendectomy cases. World J Emerg Surg. 2018 May 24;13:22. 4. Gandhi JA, Shinde PH, Digarse RD. Role of limited caecal resection in patients with acute gangrenous appendicitis. Int Surg J. 2016 Nov;3(4):1893-7. 5. . Kolosovych I., Hanol I., Tsyganok A. et al. Ways to improve the results of surgical treatment of patients with atypical forms of acute appendicitis// Wiadomości Lekarskie.- 2022. - V. LXXV, Issue 5 Part 1, May 2022: 1095-1099. 6. Kumar S, Jalan A, Patowary BN, Shrestha S. Laparoscopic appendectomy versus open appendectomy for acute appendicitis: a prospective comparative study. Kathmandu Univ Med J (KUMJ). 2016 Jul-Sep;14(55):244-8.