Risk Factors and Complication of Laparoscopic Appendectomy - Dr. R.K. Mishra

Risk Factors and Complication of Laparoscopic Appendectomy

Missed Diagnosis

There is report also of mucinous cystadenoma of the cecum missed at laparoscopic appendectomy. Less than 1 percent of all patients with suspected acute appendicitis are found to have an associated malignant process. During conventional appendectomy, through a laparotomy incision, the cecum and the appendix are easily palpated, and an obvious mass can be detected and properly managed at the time of appendectomy. The inability to palpate any mass is an inherent inadequacy of laparoscopic surgery.


Bleeding

Bleeding may occur from the mesoappendix, omental vessels, or retroperitoneum. Bleeding is usually recognized intraoperatively via adequate exposure, lighting, and suction. It is recognized postoperatively by tachycardia, hypotension, decreased urine output, anemia, or other evidence of hemorrhagic shock.


Visceral Injury

The risk of accidental burns is higher with a monopolar system because electricity seeks the path of least resistance which may be adjacent bowel. In a bipolar system since the current does not have to travel through the patient, there is little chance of injury to remote viscera. In laparoscopic appendectomy, the only bipolar current should be used. Laparoscopists should also routinely explore the rest of the abdomen.


Wound Infection

A proper tissue retrieval technique is required to prevent wound infection after appendectomy. It is recognized by erythema, fluctuation, and purulent drainage from port sites. The absence of wound infections after laparoscopic appendectomy can be attributed to the practice of placing the appendix in a sterile bag or into the trocar sleeve prior to removal from the abdomen. The regular use of retrieval bag is a very good practice for preventing infection of the wound.


Incomplete Appendectomy

If a surgeon is not experienced, the stump of the appendix may be too long. There is a report of intra-abdominal abscess formation due to retained fecolith after laparoscopic appendectomy. It is important that the surgeons performing laparoscopic appendectomy should remove fecolith if found, and the stump of the appendix should not be big enough to contain any remaining fecolith. An incomplete appendectomy is a result of ligation of the appendix too far from the base. It may lead to recurrent appendicitis, which presents with symptoms and signs of appendicitis even after laparoscopic appendectomy.

Some surgeons prefer stapling of the appendiceal stump for laparoscopic appendectomy for the treatment of all forms of appendicitis. But most of the surgeons now agree that ligation of the appendectomy stump is the best approach. There is a report of slippage of a clip, residual appendicitis followed by abscess formation after using a clip for an appendiceal stump. The ligation should be performed by using endoloop, an intracorporeal surgeon’s knot, or done extracorporeally using a Meltzer's knot or Tayside knot. The security of the knot is essential. It is influenced by the proper port location and experience of the surgeon.

Retrocecal appendix
Retrocecal appendix


Three Roeder’s or Meltzer's knot over appendix
Three Roeder’s or Meltzer's knot over the appendix


Amputation of an appendix
 Amputation of an appendix


Leakage of Purulent Exudates

It is usually seen intraoperatively while dissecting the appendix. Copious irrigation and suction followed by continued antibiotics can prevent this complication until a patient is afebrile with a normal white blood cell count. Retrieval bag should be used to prevent the spillage of infected material from the appendiceal lumen.


Intra-abdominal Abscess

This postoperative morbidity is recognized by prolonged ileus, sluggish recovery, rising leukocytosis, spiking fevers, tachycardia, and rarely a palpable mass. After confirmation of the intraabdominal abscess drainage of pus followed by antibiotic therapy is essential. Sometimes, laparotomy may be required.
 

Hernia

Trocar site hernia as the visible or palpable bulge is sometimes encountered. A possible occult hernia is manifested by pain or symptoms of bowel obstruction.
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