The "BASE-FIRST" technique in laparoscopic appendectomy.

BACKGROUND: Appendicitis is the most common cause of acute abdomen, and appendectomy is the most frequent surgical procedure performed in the world. In recent times, laparoscopic appendectomy has been gaining increasing consensus, although comparison with traditional open surgery is still debated. Recent reports seem to agree in recognizing laparoscopy as the favourable approach in cases of non-complicated appendicitis, in women and in obese patients. The use of a linear stapler to close the appendiceal stump also seems to guarantee a dramatic decrease of complications and this observation could be the rationale for considering the laparoscopic approach to also be safe in complicated appendicitis. In these cases, dissection of the mesoappendix and isolation of the viscum could be very difficult and could cause complications. By proposing this technique using a laparoscopic approach, we try to permit a simple and safe section of the appendix leaving the detachment from vessels and from the neighbourhood to a second moment.
MATERIALS AND METHODS: We report our initial experience including the first 50 cases and proposing our personal technique of laparoscopic appendectomy. RESULTS AND
CONCLUSION: We recorded only one intraoperative haemorrhage, one bladder perforation due to trocar insertion and no conversion. Our goal is to standardize and simplify the laparoscopic approach in order to give any surgeon, even non-expert ones, a simple way to remove the viscum especially in complicated pictures.

INTRODUCTION

Open appendectomy has been considered the gold standard operation by general surgeons for more than a century. However, the first description of laparoscopic appendectomy dates from 1983 when Semm performed the first one in Germany.[1] It gained popularity in the 1990s and in the last few years the number of laparoscopic appendectomies performed around the world has dramatically increased.[2] Despite numerous studies, it is still debated whether open or laparoscopic appendectomy is the recommended surgical approach for acute appendicitis, especially in complicated forms. Meta-analyses have shown that this approach reduces postoperative pain and ileus, hospital stay and wound infection rates compared to the open technique.[3-5] This approach is currently recommended in the event of unclear diagnosis, and in the treatment of female, elderly and obese patients.[6-8] To standardize the execution of laparoscopic appendectomy and to approach difficult cases, we present our more simple technique that firstly resects the base of appendix and subsequently the meso-appendix in a fast and safe way by using two linear stapler cartridges.

MATERIALS AND METHODS

In the period November 2007 to August 2009, we treated 50 unselected patients affected by acute abdomen with a great suspicion of appendicitis. They were 28 females and 22 males and were operated by a single surgeon like those enrolled for the initial evaluation of this approach. The patients are laid on the table with their legs closed. The surgeon is on their left and the assistant to the right of the surgeon. We used one 10 mm trocar in periumbilical site for the camera, one 5 mm trocar in the suprapubis area and one further 12 mm trocar in the left flank. The monitor is positioned on the right of patients.

After a careful exploration of the abdomen, we immediately look for the base of the appendix at the end of the antimesenteric tenia of the caecum. We then identify the avascular space among the caecum, the appendix and the mesoappendix [Figure 1]. This is our working window. We open the peritoneum alone with a dissector or with a blunt clamp. Once the window is opened the ATW 35 linear stapler (ETHICON EndoSurgery, Cincinnati, Ohio) is passed through and the base of the appendix is sectioned [Figure 2]. A blue cartridge could also be used if tissue is thinned or friable. The viscum is now only attached on its mesenter. A retroperitoneal or adhese appendicitis is easier to dissect from the peritoneal attachments. A second white cartridge is then used to cut the meso-appendix [Figure 3]. The organ is placed in a bag and extracted possibly through the trocar. Widespread peritoneal irrigation with a saline solution is performed each time. The operation is concluded by leaving a drainage in the pelvis through the suprapubic orifice.

Figure 1

Avascular space between the caecum, the appendix and the mesoappendix

Figure 2

Appendix is sectioned firstly with ATW 35

Figure 3

A second white cartridge is used to cut the meso-appendix

Drainage removal is decided when the intraperitoneal fluid is clear.

RESULTS

After the first 10 cases that, in our opinion, are necessary for the learning curve, the operation time varied from a minimum of 15 to a maximum of 45 min. We operated 15 acute complicated appendicitises (retrocecal, with adhesions or with abscesses), 12 suppurative ones, and 23 acute focal ones. Intraoperative complications due to the technique were limited to two cases of immediate bleeding after the stapling of the mesoappendix treated by application of two clips. This was due to not respecting the suggested tissue squeezing-time before firing with the ATW stapler. The constructor suggests waiting about 15 s with the stapler jaws closed before firing. We had no conversion. One young girl (16 y/o) experienced a bladder perforation caused by the 5 mm trocar in the suprapubic position. The lesion was treated conservatively by an urinary catheter, and she was discharged 1 week after a radiological contrast control. Patients with acute focal appendicitis were discharged after at least 48 h. Drainage removal and re-feeding were performed after 24 h in all these 23 patients. Another 27 patients recovered bowel movement in at least 48 h and the drainage was removed in 48–72 h. These 27 were discharged in a time ranging from 2 to 4 days. No peritoneal abscess or infection of trocar site was observed.

DISCUSSION

Laparoscopic appendectomy is gaining widespread acceptance. In our previous experience, the published results have been really encouraging in all cases and especially in the complicated ones.[9] From our and others’ database, it has been found that performing laparoscopic appendectomy requires a learning curve to reduce the conversion rate and to manage complicated pictures. There are various methods for closing vessels and the appendiceal stump and the most widespread are currently bipolar forceps, ultracision and endoGIA for vessels while clips, endoLOOP and endoGIA are the most common techniques used for the stump.[3] Recent reviews have underlined that the safest method for appendiceal stump closure is the endoGIA[1011] especially when the base of the appendix appears edematous and friable. The only contraindication is the cost also in comparison with the use of two loops. On the other hand, the triple staple line just at the base of the appendix closed the stump hermetically while the use of the loop needs to be adjusted according to the size and the quality of the tissue and, finally, leaves a redundant “flower” of infected mucosa free in the peritoneum as well as leaving the opportunity to “cut” or to necrotize the stump if it is too tight or allow leakage if it is too lose. Although there is no clear demonstration of local infection consequent to loop stump closure[1011] it is obvious that the Base-First technique needs the stapling device to resect the appendix before devascularization. As we suggested previously[9] a proper laparoscopic technique is mandatory and may influence infectious complications and this technique is particularly indicated in the case of phlegmonous, gangrenous and perforated appendicitis where the appendix is handled little, thus avoiding its disruption and peritoneal contamination.

We finally proposed this technique by thinking of inexperienced surgeons who wanted to approach appendicitis and suspected appendicitis with a laparoscope by trying to suggest a simple and safer technique to avoid a prolonged learning curve. Regarding the increased cost reported by some authors,[10] we believe that this technique is useful and must be used in complicated cases where the employment of loops and clips could be dangerous. A non-skilled surgeon would of course prefer this technique in the presence of uncomplicated forms of the disease. We think that our goal must be to solve the pathology without complications and the learning curve of every surgeon is expensive. Anyway we are proposing the possibility of introducing a cheaper custom kit to the manufacturer which is expressly prepared for laparoscopic appendectomy that includes one stapling device with two cartridges and three trocars.