Videolaparoscopic appendectomy : the current outlook

Videolaparoscopic appendectomy: the current outlook G. C. Roviaro1, C. Vergani1 , F. Varoli2, M. Francese1, R. Caminiti2 and M. Maciocco1 (1)  Department of Surgery, University of Milan, Ospedale Maggiore Policlinico IRCCS, Via Francesco Sforza, 35, 20122 Milan, Italy (2)  Department of Surgery, Ospedale San Giuseppe FbF, A.Fa.R, Milan, Italy C. Vergani Email: contardo.vergani@unimi.it Received: 4 April 2007  Accepted: 20 April 2007  Published online: 18 August 2007 Without Abstract We thank Drs. in’t Hof and Kazemier for appreciating our series of 1,347 laparoscopic appendectomies. Drs. in’t Hof and Kazemier recognize that this is a fairly large series, but they have raised some perplexities about our emergency and interval appendectomies ratio. In the literature, the reported rate for elective (interval) appendectomies is approximately 20% [1, 2]. In our series, it was higher. We definitely agree that appendectomy is more appropriate in emergency conditions (acute appendicitis). As described in the article, we decided to go for surgical resection in nonemergency situations only when the patients had been reporting pluri-recurrent episodes of appendiceal pain. The hospital in which we worked during the study was generally considered by the citizens of our city (which has many big emergency departments) as traditionally dedicated to elective operations rather than emergency situations. On the other hand, the emergency activity of the same hospital was rather limited. These facts, together with the appeal for the extensive application of minimally invasive techniques, have certainly influenced the choice of patients experiencing recurrent appendiceal pain. This led to an inversion of the interval and emergency appendectomies rate. Notwithstanding, among the patients who underwent an interval appendectomy, 140 patients were found to have “acute alterations” of the appendix at postoperative histology (52 phlegmonous, 4 gangrenous, and 92 catharral appendicitis cases), as reported in the article. Currently, in our new hospital, we have again observed a reverse situation although we have not changed our criteria. We agree with Drs. in’t Hof and Kazemier that interval appendectomies and acute complicated appendectomies cannot be compared tout court. We were simply reporting our results of a fairly large series, for which the composition of the population studied was declared from the onset. Drs. In’t Hof and Kazemier remark that our rate of complications is low, but stress that some of our complications (they say 16.7%) might have been attributable to the use of a less safe technique for introduction of the trocars. Indeed, as reported in our article, during our experience we have observed eight vascular lesions and one visceral lesion due to the insertion of the Veress needle or the trocars. This accounts for 0.69% of all the 1,310 procedures, and for 9.1% of the 99 conversions. The vascular and visceral lesions, due to the insertion of trocars or the Veress’needle, reported in our article occurred before 1996. We agree with our colleagues that open introduction of the first trocar is safer. Actually, as we report in our paper, Major Vascular Injuries in Laparoscopic Surgery, which appeared in the May 2002 issue of Surgical Endoscopy, since 1996 we have shifted to the open technique and have observed no further major vascular lesions [3]. With regard to the last point, about the rate of conversions attributed to senior surgeons, we apologize if the English translation of the Italian sentence misled the reader into thinking that 86% of the conversions occurred in the hands of “one single particular surgeon.” Our sentence actually meant that 85 (85.9%) of 99 conversions were performed by senior surgeons of the staff and 14 (14.1%) by residents in training. The greater number of conversions attributed to senior surgeons is due to the fact that the senior surgeon strictly supervises the procedure and thus is always present in the theater. The attribution of 85 of 99 conversions to the senior surgeon is due to the fact that the senior surgeon decided to take command of the procedure in difficult circumstances. References 1. Dixon RM, Haukoos JS, Park IU, Oliak D, Kumar RR, Arnell TD, Stamos MJ (2003) An assessment of the severity of recurrent appendicitis. Am J Surg 186:718–722   2. Eriksson S, Styrud J (1998) Interval appendectomy: a retrospective study. Eur J Surg 164:771–774   3. Roviaro GC, Varoli F, Saguatti L, Vergani C, Maciocco M, Scarduelli A (2003) Major vascular injuries in laparoscopic surgery: still of interest? Surg Endosc 16:1192–1196