Friday, May 18, 2007
Is there anyone out there who preferentially performs open appendectomies rather than laparoscopic? I know, there's that prospective randomized trial from Archives of surgery (1997) http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=9230853 that showed no benefit to laparoscopic versus open techniques. Moreover, it determined that OR time was longer and expenses higher with the laparoscopic approach. But let's be honest. 1997 was ten years ago. This was data accumulated by surgeons who were just getting comfortable with the technique. As a recent graduate of residency, I learned from talented laparoscopic surgeons, rather than making things up on the fly. People who regularly do laparoscopic appendectomies I think will concur that it's actually faster than an open approach. Pain usually is less. And, most important, the wound complication rate is negligible. The port sites simply don't get infected, but in rare cases, even in situations of advanced, perforated appendecitis. Abscess and fluid collections, even when located down in the pelvis, are easily irrigated and aspirated laparoscopically. Long term, fewer adhesions and a lower incidence of abdominal wall hernia would seem axiomatic. I don't get why people are electing to do these cases with open McBurney's incisions anymore. Similar to the holdovers who persisted in doing open cholecystectomies (albeit, with the so-called mini-incision) into the early nineties, I think if you're not doing laparoscopic appendectomies, you risk becoming a dinosaur much like them.
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My appys took (usually) fifteen or twenty minutes skin to skin. No dicking around with setting up the laparoscopy equipment, no frustrations at 2 am with the crew who didn't know how to turn on the gas. If you make the incision laterally enough, you need a very small one. Many of my patients went home in less than 24 hours. So: cost, speed, convenience, lack of midnight frustration -- all favor open.
Mini chole: my fastest, with xray, was 12 minutes. I did them at a surgery center. People went back to work in the same time frame as lap chole (couple of days to a week or so -- depending on whether they were self-employed!) The costs were enormously less.
And mind you: I enjoy the heck out of doing laparoscopy, in fact that's all I do now. I admit that my version of mini chole (believe it or not, often two, frequently three steri strips) is harder to do than a lap chole, and I'd hesitate to try to teach it. But I had people come from far and wide to have it in order to avoid lap chole. They'd heard stories, don't ya know...
Interesting. I trained at Cook County in Chicago, and I know full well the frustration of dealing with untrained OR personnel at 2am. But in private practice in this day and age, everyone knows which end is up. Lap appy is a ten minute procedure for straight foward acute appendicitis. I guess the biggest thing for me are the fewer wound headaches you have to deal with. People loathe wet to dry dressings. I had no idea as a resident; most people don't even want to look at the wound. So you have to set up home nursing visits with all the attendant cost.
But thanks for your insight.
I agree with Dr. Schwab. In my hands I cannot justify the cost of lap appy. If someone is ruptured and the wound needs to be left open I tie some nylon in long and the wound is ready to close within 3-4 days.
i never do lap app. why make a few cuts when usually you can whip the thing out through one 10mm cut in ten minutes. what is the advantage?
sid taught (sort of) me to do his mini chole. not 12 minutes but small cut. by the way i do do lap choles routinely.
I've had my appy out open, but I think I would like to have a lap one now (if only so they can have a look in the pelvis for other potential pathology at the same time) - my original one was negative. OTOH I would prefer an open chole - minor complications don't scare me, major ones do.
buckeye: do you leave the appy in if it looks normal at laparoscopy? the argument for taking it out in the old days was that people would be confused by an appy scar and presume that it was out.
I take it out. I've done two diagnostic laparoscopies in the past 12 months on pregnant patients with right sided abdominal pain. Both times the appendix was normal. It takes an extra 5 minutes to remove it. Then if they have recurrent pain later on in the preganacy (which seems to happen often) the appendix is ruled out and an expensive work up is potentially avoided.
This reminds me of my Surgery Professor a real old-timer who said: "Why should I go in for a lap appendectomy when I can remove the appendix faster and through a smaller incision than the combined length of the incisions for the ports?"
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