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Laparoscopic appendectomy for adult acute appendicitis: improving patient compliance

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  • Save Clinical M edicine and Diagnostics 2013, 3(5): 105-107 DOI: 10.5923/j.cmd.20130305.01 Acute Appendicitis with Surgical Procedure of Laparoscopic Appendectomy in Adult Patient: Betterment towards Patient’s Compliance Andee Dzulkarnaen Zakaria1,*, Syed Hassan1, Ashfaq Ahmad2, Mohamad. I. Lazhari2, Amer Hayat Khan3 1Department of Surgery, School of M edical Sciences, Universiti Sains M alaysia, Health Campus, Kelantan, 16150, M alaysia 2Cardiovascular and Renal lab of Physiology, School of Pharmaceutical Sciences Universiti Sains M alaysia, Penang, 11800, M alaysia 3Department of Clinical Pharmacy, School of Pharmaceutical Sciences Universiti Sains M alaysia, Penang, 11800, M alaysia Abstract Introduction: Acute appendicitis is a condition where the appendix beco mes in flamed or swollen and filled with pus. If left untreated, the appendix may rupture (burst) and cause severe abdominal pain and infect ion (peritonitis). Laparoscopic appendectomy is a surgery which is considered to be better option over the conventional surgery to treat acute appendicitis. Our current study aimed to increase the level of confidence on laparoscopic surgery and emphasizes the accurate diagnosis and prompt treat ment that can avoid post-surgical comp licat ions. Case presentation: The patient is 31 years old, Malay man which has been ad mitted to Hospital. Patient was co mplain ing of right iliac fossa (RIF) pain since before being admitted. Pain was associated with nausea, loss of appetite. Patient also complains of incomp lete voiding, dysuria, history of passing out sandy urine, fever, sore throat and also loose stool. Patient was treated IV Tramadol, IV Cefoperazone and IV Metronidazole. Conclusion: The best treatment of acute appendicitis is laparoscopic appendectomy. Laparoscopic appendectomy has advantage over open appendectomy. Pro mpt diagnosis of appendicitis ensures timely treat ment and prevents complications. Keywords Appendicitis, Right iliac fossa, Laparoscopic appendectomy, Open appendectomy 1. Introduction A p pend icit is is relat iv ely co mmo n en t it y an d its prevalence is uniform in all over the world. Fu rthermore, the prevalence of appendicitis is about 7% and peak age of those patients is between 10 to 30 years so making appendectomy most frequent procedure for abdo minal surgery .[1] Open appendectomy (OA) has been a gold standard treatment for acute appendicit is. Since the int roduct ion of OA by Mc Burney this p rocedure has generated a lot of confidence among the surgeons.[2] Mo rbid ity and mo rtality p lays a major ro le in selecting a better option among the availab le options. Data reported showed that mortality with OA is 0.3 % while mo rbid ity is 11%.[3] Irrespective of scientific data, risk factors that are associated with open appendectomy are high in nu mber. Nosocomial infections are frequently occurring infections in hospitalized patients. Open wounds and healing o f wounds always hav e been t remendous ch alleng e fo r th e su rg eo ns . W it h adv en t o f mo d ern techn iques , t he quest fo r dev elop ment o f n ew surg ical t echn iq ue wh ich reduce th e in vas iv en ess in d ifferent * Corresponding author: (Andee Dzulkarnaen Zakari a) Published online at Copyright © 2013 Scientific & Academic Publishing. All Rights Reserved therapeutic ailments. With these objectives, most popular procedures were those which have fewer trau mas, less hospital stay and better quality o f life.[4] These objectives lead to the advent of laparoscopic procedures. Laparoscopic appendectomy (LA) was done by Semm in 1983, has gradually got acceptance worldwide but the context of superiority between LA and OA remains remain controversial t ill upto date.[5] Laparoscopic appendectomy is relatively new procedure as co mpared to laparoscopic cholecystectomy. Laparoscopic cholecystectomy is now considered as gold standard procedure but LA yet has to get such popularity.[6] Large body of ev idence supports the health effective and cost effect ive benefits of LA. Laparoscopic appendectomy is considered as a safer technique, shorter hospital stay, early patients’ mobilizations, early bowel function and acceptable complication along with enthusiasm of reduced invasive surgery have given reasons to authors to support LA as favorable procedure for acute appendicitis.[7,8] A im of current case report is to increase the height of awareness and confidence of Laparoscopic appendectomy over open appendectomy among surgeons and emphasize the potential benefits to the patients like early mobilization and regaining of routine activity after appendectomy. Furthermore , in conte xt of educational point of view, this case report will c rit ically evaluate the treatment protocols adopted for this disease. 106 Andee Dzulkarnaen Zakaria et al.: Acute Appendicitis with Surgical Procedure of Laparoscopic Appendectomy in Adult Patient: Betterment towards Patient’s Compliance 2. Case Report The patient is a 31 years old, Malay man wh ich has been admitted to Hospital. Patient was complaining of right iliac fossa (RIF) pain since 3 am before being admitted. the pain was sudden with sharp in nature, localized and aggravated on movement. It was also associated with nausea but not yet vomit ing, loss of appetite. The patient did not take andy dry or solid food since 6 pm yes terday (7th of May 2012). Patient also complaint of incomp lete voiding, dysuria, history of passing out sandy urine, fever, sore throat and also loose stool. His wife also revealed that patient took traditional med icine at around 4 p m to get relief fro m the pain. The patient’s blood pressure, pulse rate, and temperature during the day of admission were in normal condition. Patient is ale rt and conscious (but in pain condition), lung a re clear, dual rhythm non murmur (DRNM) and S1 and S2 sound are heard on the assessment of cardiovascular system. Patient is a non-smoker, a factory worker, no known drug allergy and no medical and medication history before. Surgeon diagnosed it a case of acute appendicitis and decided to proceed with Laparoscopic Appendectomy. Following drugs were started, IV d rip 40 (20 normal saline + 20 dextrose 5%) over 24 hours, IV Tramadol 50 mg stat (pain killer), IV Cefoperazone (antib iotic) 1 g BD. IV Metronidazole (anaerobes bacteria) 500 mg TDS. Patient was kept on n il by mouth (NBM) in order to undergo surgical procedure. Patient was reviewed and traces the treatment result. Patient safely underwent surgical p rocedure of laparoscopic appendectomy. Th is surgery was perfo rmed successfully without any complicat ions. Patient was alert and conscious, vital signs are normal, and input/output were balanced. Cu rrently, patient co mplaint of pain at operation site, no nausea or vomit ing but reluctant to take food orally yet and patient is afebrile. Progression of the patient was noted. Patient was allowed to take food orally and can be discharged on the evening if patient’s condition is s tab le. 3. Discussion Acute appendicitis is a condition where the appendix becomes inflamed or swollen. A p iece of food or hardened stool may get trapped in the appendix. Th is may cause the appendix to get blocked, infected, swollen, and filled with pus. If left untreated, the appendix may rupture (burst) and cause severe abdominal pain and infections like peritonitis and septicemia.[9] In present case patient was subjected to Laparoscopic appendectomy and surgeon avoided open appendectomy due to many risk factors. Nosocomial infections have been another reason for postoperative comp lications as invasive techniques have been used and patient’s immune system is co mpro mised after surgery. Findings of European Prevalence of Infection in Intensive Care Study (EPIC) demonstrate that among 4500 patients in ICU, prevalence of nosocomial infections was 20.6%.[9] So me data reports its prevalence as 14-16 % of inpatient infections.[10] Usually nosocomial infections are acquired within 24 hours after admission or 3 days of surgery or 30 days of post-operative surgery. It not only affects quality of patients but also add on financial burden. Keeping in view, LA is superior to open appendectomy due to shorter stay in hospital and chances of nosocomial infections are less as no open wounds are there for bacteria to grow. Financial burden is also reduced. Co mparat ive study which shows hospital stay comparison between LA and OA[11] is shown in table 1. Open appendectomy and laparoscopic appendectomy surgery time is matter of great concern fo r surgeon. Table 2 shows the surgery time co mparative study between Laparoscopic and open appendectomy which shows minor advantage to OA over LA.[11] These results have been compiled when laparoscopic techniques were early adopted, it is e xpected in future as treat ment gets longer hospital stay and surgery time duration will not remain significantly different. Fro m patient point of v iew, surgery procedure duration is not important but only thing that matters is duration in hospital stay and early mobilization of the patient. LA is superior over OA by facilitat ing early mobilization to the patients, rapid healing and shorter stay in hospital. In open surgeries healing of wound is majo r concern for surgeon other than treating the primary cause. Proper selection of antibiotic for appropriate duration in post-operative cases is marker of successful treatment outcome. Proper and aggressive treatment of antibiotics in serious infection save patient from secondary complicat ions. [12] In present case, cefoperazone, a third generation cephalosporin is used via intravenous route which is excellent choice to cover gram + ve aerobic bacteria wh ile metronidazole is also reco mmended to cover anaerobes. Later on, patient was shifted to oral 2nd generation cephalosporin for mentioned period of time to eliminate the risk of g rowth of microorganism. So, antibiotic selection has been one of the factors for this successful bed discharge case. Use of analgesic to minimize the pain and inflammation usually results in gastric u lcer. In adherence with the objectives of study, laparoscopic appendectomies also minimizes the long term use of antibiotics due to minimal scars on body and also minimize the long term use of opoid analgesics to avoid gastric ulcer and addiction to drugs as it is associated with opoid analgesics. Besides, it also can mask the onset and progression of an in fection. Both drugs were given as management of post-operative pain. In addition to all advantages over open appendectomy, patient does not have any complications during and after surgery. Therefore, patient is allowed eating orally and can be discharged within 24 to 36 hours if the patient’s condition is stable. Clinical M edicine and Diagnostics 2013, 3(5): 105-107 107 Table 1. Comparison of Laparoscopic and Open Procedure Hospital Stay Surgery Laparoscopic Open Normal 2.8 ± 1.5 (1-7) 3.8 ± 5.7(1-124) Acute 3.0 ± 2.8 (1-19) 3.5 ± 3.5 (1-108) Values are given as days[mean ± standard deviation (range in parenthes es)] P erfo rat ed 5.8 ± 4.1 (1-17) 7.3 + 4.2 (1-36) Table 2. Comparison of Laparoscopic and Open Procedure T ime Surgery Laparoscopic Open Normal 86.6 ± 51 (37-280) 57.4 ± 28 (9-265) Acute 81.9 ± 27 (30-173) 55.7 ± 30.9 (10-675) Values are given as minutes[mean ± standard deviation (range in parentheses)] P erfo rat ed 55.7 ± 30.9 (10-675) 68.8 ± 32 (10-265) 4. Conclusions Pro mpt diagnosis of appendicitis ensures timely treat ment and prevents complications. As a conclusion, the best treatment of acute appendicitis in an adult patient is a surgical removal of the appendix by Laparoscopic Appendectomy. It is much better surgical procedure compared to open procedure. It is more convenient for the patient to undergo laparoscopic appendectomy as it has less post-operative pain, faster recovery and early return to normal activity, shorter hospital stay, less post-operative complications and finally min imal sized incisions/scars as compared to open appendectomy. This study is expected to increase the height of confidence of surgeon on laparoscopic appendectomy which is objective of this study. REFERENCES [1] Kumar B, Samad A, Khanzada TW, Laghari M H, Shaikh AR. Superiority of Laproscopic appendectomy over open appendectomy: The Hyderabad experience. Rawal M ed J 2008; 33: 165-8. [2] M cBurney C. The incision made in the abdominal wall in case of appendicitis with a description of a new method of operating. AnnSurg.1894;20 –38. [3] Guller U, Hervey S, Purves H, et al. Laparoscopic versus open appendectomy: outcomes comparison based on a large administrative database. Ann Surg. 2004; 239:43–52. [4] Chung RS, Rowland D Y, LiP, Diaz J. A meta-analysis of randomized controlled trials of laparoscopic versus conventional appendectomy. Am J Surg 1999; 177: 250-6. [5] Semm K: Endoscopic appendectomy. Endoscopy 1983, 15:59-64, (PM ID: 6221925) [6] Kehagias I, Karamanakos SN, Panagiotopoulos S, Panagopoulos K, Kalfarentzos F. Laparoscopic versus open appendectomy: which way to go? World J Gastroenterol 2008; 14: 4909-1. [7] Gross E, et al. Laproscopic versus conventional appendectomy – a comparison with reference to early postoperative complication.Zentralbl Chir 1998; 123: 858-62. [8] Tranoff M , Atabek U, Goodman M , Alexander JB, Chrzano wski F, Mortman K,et al. A comparison of laparoscopic and open appendectomy. J Soc LaparoendoscSurg 1998; 2: 153-8. [9] Louis V, Bihari M B, Suter P, et al. The prevalence of nosocomial Infections in intensive care units in Europe. European. Prevalence of infection in Intensive care (EPIC) study. JAM A 1995; 274: 639–44. [10] Skarzynska J, Cienciala A, M adry R, Barucha P, Kwasniak M, Wojewoda T, Sroga J: Hospital infection in general surgery wards.Przegl Epidemiol 2000, 54(3–4):299-304. [11] Douglas A. Hale, M ark M olloy, Richard H. Pearl, David C. Schutt, and David P. Jaques. Appendectomy; A Contempora ry Appraisal. ANNALS OF SURGERY. 1997.Vol. 225, No. 3, 252-261. [12] Ashfaq Ahmad, Amer Hayat Khan, M uhammad Atif, M uhammad Ihtisham Umar, Haroon Khalid Syed, Nadia Shamshad M alik and Atif Usman. Precautionary measurements and rationale use of antibiotics in diabetic foot ulcer can save amputation: A case report. African Journal of Pharmacy and Pharmacology 2012; Vol. 6(22);1569-1572.

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