Authors' reply.

Dear Sir,

Thank you very much for the attention paid to our paper, this letter permits me to clarify the aim of the paper and the technical note.

First of all we would like to underline that this paper was published only as a technical report with the aim of suggesting some tips coming from our experience. The global experience came out from a large volume series as you can see from previous paper published by the corresponding author.[1]

Secondly, we have to note that the bibliography cited by the commenter is quite old. Something has changed over the last 10 years.

We wrote “We operated 15 acute complicated appendicitis (retrocecal, with adhesions or with abscesses), 12 suppurative ones…”. Maybe the comma inserted between “retrocecal” and “with adhesion” is misinterpreted and the commenter believed that the appendicitis were both retrocecal and with adhesions. The comma is meant to divide and not join the words, the real intention was to say The appendicitis EITHER with adhesions or in a retrocecal position or with abscess is already a difficult situation per-se. In this situation, as suggested by the commenter, it is quite impossible to complete the operation laparoscopically.

The writer focused on the treatment carried out at the base of appendix hypothesizing that there are some surgeons who remove the appendix with the base friable cutting it far from the caecum. We never wrote this on the contrary we suggest that resident and less experienced surgeons apply the stapler over the caecum in a not suffering tissue and resect a quote of the caecum. In my experience, this approach has been utilized in open surgery too.

I know and I've written that costs are an important issue, but in the western world we must consider young people who know the opportunity of laparoscopic surgery and desire a faster recovery with less scars; obese patients obtain great benefits from the laparoscopic approach as well as young woman in whom is possible to evaluate the genital apparatus and wash all the pelvis as well or better than with a traditional open approach. Indeed the last review from Cochrane Database dated 2010[2] reports that “Especially young female, obese, and employed patients seem to benefit from LA (laparoscopic appendectomy)”. Moreover, two last papers from Irvine (CA) analizing data coming from the Nationwide Inpatient Sample database of USA, conclude by recommending the use of laparoscopic approach in elderly patients (both perforated and non-perforated appendicitis) and in children with perforated appendicitis.[34]

Concluding the discussion about costs, a paper from Germany published in 2011 reports that laparoscopic appendectomy is cheaper than open appendectomy and concludes that “LA is the treatment of choice from a provider's perspective.”[5]

As regards the use of the terms inexperienced and non-skilled surgeons: A recent paper from the USA reports a retrospective analysis of appendicitis operated on in a tertiary referral teaching hospital. In particular the paper evaluates the conversion rate and the causes related to patients and surgeons. Surgeons with a low- volume operations (<49 cases-per-year) obviously have a higher conversion rate as do surgeons trained before 1990!!![6]

The terms “inexperienced” and “non-skilled” surgeons, used in our paper, only refers to those not well trained in the laparoscopic approach, although they are obviously skilled and have sufficient experience in open surgery.