Objectives: To evaluate safety, feasibility and result of laparoscopic surgery in management of total appendicitis peritonitis. Subjects and methods: A prospective observational study on 82 patients with appendicitis peritonitis who were performed by laparoscopic surgery at 115 People’s Hospital from 1th January 2011 to 31th December 2016.
Trang 1EVALUATING THE RESULTS OF LAPAROSCOPIC SURGERY IN THE TREATMENT OF TOTAL APPENDICITIS PERITONITIS AT
115 PEOPLE’S HOSPITAL
Nguyen Quang Huy 1 ; Vu Huy Nung 2 ; Van Tan 1
SUMMARY
Objectives: To evaluate safety, feasibility and result of laparoscopic surgery in management
of total appendicitis peritonitis Subjects and methods: A prospective observational study on
82 patients with appendicitis peritonitis who were performed by laparoscopic surgery at
115 People’s Hospital from 1 th January 2011 to 31 th December 2016 Results: The rate of farting time over 72 hours was 52.2% The mean hospital stay was 5.9 ± 3.5 days The rate of postoperative complication was 9.7%, including five cases of paralytic intestine, two cases of wound infection and one case of post-operative intra-abdominal abscess The general result of surgery was excellent (92.8%), good (5.8%), fair (1.4%) and poor (0%) Conclusion: Laparoscopic surgery for total appendicitis peritonitis was safe, efficacious and feasible and could be widely applied
* Keywords: Appendicitis peritonitis; Laparoscopic surgery
INTRODUCTION
In Vietnam, the proportion of acute
appendicitis occupied from 40 to 45%
in emergent operations [1] Acute
appendicitis complicated exclusively with
peritonitis (ACP) accounts for 10 to 20%
Laparoscopic surgery is a good choice for
management of this disease We studied
this topic aiming: To evaluate the results
of laparoscopic surgery for the treatment
of appendicitis peritonitis in terms of the
safety, efficacy and feasibility of the
procedure
SUBJECTS AND METHODS
1 Subjects
82 patients (male: 49 cases, female:
33 cases) with the ages from 16 to 95
years old Mean age was 45.7 ± 21.4 All
patients were diagnosed ACP and treated
by laparoscopic surgery at 115 People’s Hospital from 1th January 2011 to 31th December 2016
2 Methods
Prospective observative and descriptive clinical study
* Selective criteria: Patients with
appendicitis peritonitis were diagnosed by clinical, paraclinical, abdominal endoscopy and biopsy, were applied by laparoscopic surgery for the treatment Adequate information for the study
* Exclusive criteria: Peritonitis with the
other causes, lack of information for the study
* The technical progress:
+ Indications: Appendicitis peritonitis in patient over 16 years old The patient agreed with the laparoscopic surgery
1 115 People’s Hospital
2 Vietnam Military Medical University
Corresponding author: Nguyen Quang Huy (huyphat.vn115@gmail.com)
Date received: 10/08/2018
Date accepted: 03/10/2018
Trang 2+ Contraindication: The patient cannot
be applied laparoscopic surgery (serious
disease of cardiovascular or lung…)
- Preparation: The patient lied on the
supine position, general anesthesia The
surgeon stood on the left of the patient,
the assistant stood beside of the surgeon
on the left
* Technical steps:
+ Trocar insertion, gaz pump: 3 trocars
(umbilicus, left iliac forsa, hypogastric area)
Abdominal pump CO2 with 12 - 14 mmHg
+ Check injuries: Check all abdominal
cavity, find appendix
+ Appendectomy: Using monopolair
electric surgery for appendix mesentery,
ligation of appendage with haemolock
+ Abdominal suction-irrigation: Natricloride
0.9% solution Abdominal drainage insertion
+ Check again all abdominal cavity,
removing appendix, incision suture
* Process of data: SPSS 22.0, Chi-
squared test
- Studying target: Hospital time, farting
time, the time of drainage, complication
rate and general results of the procedure
RESULTS
1 Characteristics of patients
82 patients with ACP was operated by
laparoscopic approach, males were more
than females (59.9% compared with 40.2%),
male/female ratio = 1.5
The mean age was 45.7 ± 21.4 years
old (from 16 to 95)
The proportion of patients with drainage over 72 hours was the most (72.5%); this rate under 25 hours was 1.4% and from
25 to 48 hours was 4.3%
Post-operative flatulence from 49 to
72 hours accounted for 23.2%, over 72 hours was 52.2%; below 25 hours was 2.9% The average length of hospital stay was 5.9 ± 3.5 days; the shortest time was
1 day and the longest was 30 days
* Post-operative complications (n = 82):
Post-operative complications were paralytic intestine 5 patients (6.1%); wound infection 2 patients (2.4%); intra-abdominal abscess 1 patient (1.2%) The rate of total post-operative complications was 9.7% (8/82 cases) The management of post-operative complications: Conservative management were 8/8 cases (100%) Successful result rate was 100%
* The early post-operative complications (n = 82):
The early post-operative complications were wound infection (2.4%) and intra-abdominal abscess (2.4%) The rate of the early post-operative complications was 4.8% (4/82 cases) The management of the early post-operative complications: Conservative management were 4/4 cases (100%) Successful result rate was 100%
* Post-operative mortality: The rate of
post-operative mortality was 0%
* The grade of result of laparoscopic appendectomy: This grade was based on
the criteria of 115 People’s Hospital
Trang 3Chart 1: The grade of result of laparoscopic appendectomy (n = 82)
Excellent results explained 92.8%, good 5.8%, fair 1.4% and bad 0%
Table 1: The relationship between successful laparoscopic appendectomy and
duration of peritonitis (n = 82)
Laparoscopy
laparotomy
Total Medical history
Number Percentage
(%)
Number Percentage
(%)
Number Percentage
(%)
p
The proportion of successful laparoscopic appendectomy between the groups with peritonitis ≤ 12 hours or > 12 hours; there was no statistically significant difference (χ2,
p > 0.05)
condition of intra-abdomen (n = 82)
Laparoscopy
Success Conversion to
laparotomy
(χ2)
Condition of intra-abdomen
- The proportion of successful laparoscopy in group with mild and moderate distended intestine was 91.4%, compared to that of group with severe distended intestine (41.7%): the higher rate was statistically significantly different (χ2, p < 0.05)
Trang 4- The proportion of successful laparoscopy in group with little and average pyogenic membrane was 92.5%, compared to that of group of much pyogenic membrane (69%): the higher rate was statistically significantly different (χ2, p < 0.05)
Table 3: The relationship between successful laparoscopic appendectomy and the
general clinical condition of appendix (n = 82)
Laparoscopy
laparotomy
Total General clinical
condition of appendix
p
(χ2)
- The proportion of successful laparoscopy in group with normal position of appendix was 84.3%, compared to that of group with abnormal position of appendix (83.9%): there was no statistically significant difference (χ2, p > 0.05)
- The proportion of successful laparoscopy in group with gangrenous base of appendix was 77.3%, which was 86.7% in the group with no gangrenous base; there was no statistically significant difference (χ2, p > 0.05)
DISCUSSION
The mean time of abdominal drainage
was 3.9 ± 1.7 days in all of the laparoscopy
and was 3.7 ± 1.1 days in open laparotomy
We took out the abdominal drainage
tube fairly early when patients’ condition
was acceptable (with fluid of abdominal
drainage was clear and no pus, which is
standard of getting out drainage)
Launay-Savary’s advice: Abdominal
drainage should be applied on appendicitis
with diffuse peritonitis Petrowsky’s
retrospective research indicated that
abdominal drainage after appendectomy
with perforated or ruptured cause more
infections in group with drainage (43 - 85%)
than group without (29 - 54%); about infection
of peritoneum cavity, there were two researches with results of increasing infectious rate in patients without abdominal drainage, one research admitted that this rate increased in the group with drainage and one research reported that there were the same rates in both of groups Typically, cecum leak was found in patients with abdominal drainage with proportion of 2 - 7% [2]
The mean time of flatus passage was 1.6 ± 0.9 days When patients had flatus passage, we advised them to eat This indicated that duration of paralytic intestine in diffuse peritonitis was relatively longer because of severe infectious conditions
Trang 5The shortest time of hospital stay was
3 days, the longest was 31 days and the
mean time was 6.6 ± 3.6 days The
reason for long hospital stay was due to
postoperative pain, especially postoperative
abdominal abscess and infectious wound
must be treated for a long time with
antibiotics
According to Ball’s research: The
mean time of hospital stay was 2.2 days
and the patients could return to work
normally after 9.3 days, the complication
rate was 6% The advantages of laparoscopy
in complicated appendicitis was shorter
hospital stay and patients could return to
normal activity quickly [3]
J Cueto indicated that the mean time
of hospital stay was 3.5 days [4]
We had a case (1.4%) of fluid
accumulation after surgery for residual
abscess after surgery In this case, the
abscess was small, patient was treated
with antibiotics, no need to puncture the
pus, did not have to resuscitate This cause
may be in the unclean peritoneum cavity
also left muchpyogenic membrane as well
as do not clean up the fluid washing, and
that the drainage tube, the remaining
residue will be out
We had 1 case of infectious wound in
trocar site for laparoscopy (1.2%) and
1 case of wound infection with conversion
to laparotomy (1.2%) These two cases
had been treated with patch replacement,
in combination with antibiotics
In this study, 5 patients had early
bowel paralysis on day 5 after surgery
with such symptoms: Vomiting, unable to
pass stool or gas, abdominal pain
Medical internal treatment: Continuous gastric emptying, antibiotics, electrolyte solution, then patients were released from the hospital on 10th day
Theoretically, trochanteric infections are more related to the traction of appendix through trocar holes and appendix lesions
In our opinion, this rate is acceptable Katkhouda found that 4 cases of postoperative laparoscopic appendectomy needed reoperation: Of which, there were
3 cases of injuring hypogastric artery due
to the site where the right iliac trocar inserted and bleeding from appendix artery, one case of burning ileum due to that monopolar cauterizing to stop bleeding caused intestinal leak [5] Fukami’s research found that the rate of postoperative abscess in peritonitis was 5.9% [6]
According to Katkhouda’s research, the proportion of postoperative complication was 17% such as infectious wound of trocar inserted site (6.2%), abdominal abscess (5.3%), these patients were managed by antibiotics and drainage following by CT-scanner
Fukami’s statistic indicated that the proportion of postoperative complications were infectious wound (8.9%), postoperative abdominal abscess (5.9%) and hernia in trocar site (2%) [6]
Our research found that there was no mortality However, in European and American researches with a great number of samples, they recorded some rate of mortality in appendicitis in general and in diffuse peritonitis appendicitis in particular, the causes were patients’ other diseases
Trang 6According to G.Mancini’s research, the
rate of mortality was 2.7 in general while
that rate of postoperative elder patient
was 0.4% because of complication of
myocardial ischemia [7]
CONCLUSION
The studying results of this topic showed
that: The farting time over 72 hours after
laparoscopic surgery for the treatment
of appendicitis peritonitis was 52.2%; the
mean hospital stay was 5.9 ± 3.5 days;
the rate of complication was 9.7%, including
paralytic intestine, wound infection and
peritoneal abscess The general results:
excellent (92.8%), good (5.8%), fair (1.4%)
and poor (0%)
The laparoscopic surgery for the treatment
of appendicitis peritonitis was safe, affective
and feasible
REFERENCES
1 Dương Mạnh Hùng Nghiên cứu ứng
dụng trong phẫu thuật nội soi viêm phúc mạc
ruột thừa Luận án Tiến sỹ Y học 2009
2 Launay-Savary M.V, Slim K Analyse
factuelle du drainage abdominal prophylactique,
abdominal drainage Annales de Chirurgie
2006, 131, pp.302-305
3 Ball C.G, Kortbeek J.B, Kirkpatrick A.W
et al Laparoscopic appendectomy for complicated
appendicitis: An evaluation of postoperative
factors Surg Endosc 2004, 18, pp.969-973
4 Cueto J, D’Allemange B, Vazquez-Frias J.A et al Morbidity of laparoscopic surgety for
complicated appendicitis: An international
study Surg Endosc 2006, 20, pp.717-720
5 Katkhouda N, Mason J, Twofigh S
Laparoscopic versus open appendectomy
A prospective randomized double-blind study
Annal of Surgery 2005, 242 (3), pp.439-450
6 Fukami Y, Hasegawa H, Sakamoto E et
al Value of laparoscopic appendectomy in
perforated appendicitis World J Surg 2007, DOI:10 1007/s00268-006-0065-x
7 Mancini G.J, Mancini M.L, Nelson H.S
Efficacy of laparoscopic appendectomy in appendicitis with peritonitis The American Surgeon 2005, 71, pp.1-5
Trang 7FLEXIBLE CALICO-PYELOSCOPY USING HOLMIUM LASER
LITHOTRIPSY DURING PYELOLITHOTOMY IN TREATMENT
OF KIDNEY STONES: INITIAL EXPERIENCE
Nguyen Duy Thinh 1 ; Dao Quang Minh 1 ; Nguyen Phu Viet 2
SUMMARY
Objectives: To report our initial experience with flexible calico-pyeloscopy using holmium
laser lithotripsy during pyelolithotomy in the treatment of renal stones Subjects and methods:
55 patients/56 kidney stones undergoing open pyelolithotomy combined with endoscopic control
of stone clearance, using laser homium energy to break stones at Thanhnhan Hospital from
March 2012 to October 2017 Patients with many stones in the kidney were only opened renal
pelvis for remove the stones Then use the flexible tube station 14Fr to control the entire renal
pelvis test sticks left The small stones were dragged out of the basket Dormia, the larger stones
will be approved by holmium laser The sonde JJ was placed and withdrawn after 3 weeks
Preoperative characteristics of renal stones and the results of pyelolithotomy associated flexible
calicopyeloscopy were assessed Operative time and complications were reviewed Results:
Endoscopic technique was performed in 47 cases (83.9%) 9 cases (16.1%) failed The
adsolute cleanlines ratio of gravel in 40/47 cases accounted for 82.2%, in which 7 cases
suffered from remaining stones, which caused bleeding during the gravel Among 9 cases of
failure, 4 cases of small kidney stones when the grafts bleed multiple tubes do not control the
neck of the kidney due to drainage out, 3 cases when the soft tube into the neck on the test
small neck corner, 2 narrowing the neck of the kidneys There were no cases where kidney tissue was
removed to remove stones No blood transfusion in surgery was taken Average surgery time
was 120 ± 30 minutes, no serious complication after surgery was observed Conclusion: The
flexible calico-pyeloscopy during pyelolithotomy was feasible and effective to control calculi
clearance in the treatment of complex renal stones with minimal damage of renal parenchyma
* Keywords: Kidney stones; Flexible endoscopy; Laser holmium
INTRODUCTION
Although significant progress has been
made in the treatment of multiple kidney
stones, the open pyelolithotomy surgery is
still largely applied in the treatment of
kidney stones In treatment of multiple
kidney stones, the rate of stone remains
relatively high In a recent research by Nguyen Hong Truong (2007), coral surgery
at Vietduc Hospital showed good result at only 19.8%, average 51.5%, bad 15.8%,
of which the rate of leftover stones in the surgery was 34.6% Research by Tran Van Hinh, Hoang Manh An et al in coral surgery, the leftover stone rate accounted
1 Thanhnhan Hospital
2 103 Military Hospital
Corresponding author: Nguyen Duy Thinh (nguyenthuha21@gmail.com)
Date received: 20/08/2018
Date accepted: 02/10/2018
Trang 8for 47% [1] Huynh Van Nghia (2010) applied
three techniques: Turner-Warwich, advanced
Gil-Vernet, renal kidney tissue enlargement
along Brodel in surgery for 100 patients,
its results were as followed: good 69%,
remaining stones 17% [3] On the other
hand, there is a high risk of renal parenchyma,
even multiple locations for the removal of
stones, renal function damage How to
overcome these two weaknesses is of
great concern today
There are many applications of anti-stone
in surgery such as ultrasound, X-ray or
endoscopy in surgery However, the results
are still limited The rate of leftover stones
after surgery has decreased but still met
with high rate [1]
Open surgeries for kidney coronary stones
combined with endoscopic hysterectomy
using homium laser are less invasive
methods bringing high efficacy [2]
In Vietnam, this method is relatively new
and has only been applied in some large
hospitals in Vietnam recently [4]
From March 2012 to July 2017,
we conducted the study at Institute of
Relaxation Technology for the application
of soft tube endoscopy and laser energy
to detect and deal with stones in calyx, in
the open multiple kidney stones surgery
for 56 cases The initial experience of this
application will be shared in this article
SUBJECTS AND METHODS
1 Subjects
55 patients/56 kidneys were diagnosed
with multiple kidney stones using renal
endoscopy to detect and treat the remaining
stones with homium laser in surgery from
3 - 2012 to 7 - 2017
* Requirements:
- Multiple kidney stones
- Endoscopy combined with using homium laser
2 Methods
Research to perform process, description
* Tools and methods:
- Soft 10F urography can turn heads in any directions
- Light source, screen, camera, wires light
- Homium laser
- Other tools: Dormia goblet, stone plier
- Continuous watering system (Nacl 0.9%)
RESULTS
1 Characteristics of multiple kidney stone in the study (n = 56)
Renal pelvis + upper calyx: 0; renal pelvis + middle calyx: 3 kidney stones (5.4%); renal pelvis + lower calyx: 2 kidney stones (3.6%); renal pelvis + middle, lower calyx:
24 kidney stones (42.9%); renal pelvis + upper, middle calyx: 15 kidney stones (26.8%); renal pelvis + upper, lower calyx: 3 kidney stones (5.4%); renal pelvis + upper, middle, lower: 9 kidney stones (16.1%)
* Level of renal insufficient:
No water stagnant: 45 kidney stones (80.4%); water stagnant lv I: 4 kidney stones (7.1%); water stagnant lv II:
6 kidney stones (10.7%); water stagnant
lv III: 1 kidney stones (1.8%)
* Characteristics of the kidney:
Outside of sinuses: 32 cases (57.1%); reservoir in the sinus: 15 cases (26.8%); intermediate: tanks: 9 cases (16.1%)
Trang 9Table 1: Number of stones per patient
Number of
stones/kidney
Number
of kidney
Number
of stone
Percentage (%)
2 Results of Calyx - renal pelvis
endoscopy with soft tube
The success of the technique:
- Successful endoscopic treatment for
47 cases of stones
- Soft tube endoscopy failure: 09 cases
(4 cases of torning renal pelvis, 3 cases of
small angle of renal pelvis - lower calyx of
small minor calyx angle, 2 cases of
narrow neck of calyx)
- The rate of stone clearance immediately
after surgery was achieved in 47 cases,
accounting for 82.2% of total cases performed
successful laparoscopy
Table 2: Treatment of stone in the
group of patients with stone clearance
Method of
removing stones
Number
of kidney
Number of stone
Percentage (%)
Crush with
Holmium laser
Stones were found in 16 patients,
accounting for 28.6%; its cause was due
to tornadoes of the neck damage, small
angle of the kidneys, corner, neck, neck
damage
* Surgery time: Average operation time
was 140 ± 30 minutes, the fastest was
100 minutes, the longest was 200 minutes
3 Postoperative complications
Urine monitoring in 24 hours after surgery:
14 patients with dark red urine, 42 patients with pink urine These cases were received medical treatment and hemostatic drugs After treatment for 3 - 5 days, the patient did not need any interventions No serious complications were found
DISCUSSION
Extralotomy and multiple kidney stones were the first choice in treating multiple kidney stones However, after long-term use, many authors have indicated that certain limitations such as kidney parenchymal injury are difficult to apply to many tablets scattered in the kidney Fabrizio (1998) used a soft endoscopy through endoscopic urethral retrograde renal catheterization in general, achieving a success rate of 89% Grasso et al (1999) achieved a 91% success rate In 1964, Victor F Marshall used soft endoscopy for ureteral stones and pyelonephritis Terris M.K then tested for corneal grafting using a soft-cannula,
a stethoscope, or even a cystoscope to check, locate and remove some small stones in the kidney [5] In 1980, Zingg E.J
et al used rigid endoscopy for corneal renal excretion and multiple pelvic examinations, which resulted in more than 60% of multiple kidney stones, remainly located in the kidney [6] In 2004, Unsal A used a "pulsed" stone scoop that passed through the pelvic opening to graft the stone and
Trang 10pebbles in the stools after grafting stones
in the pelvis [7] Traxel O (2005) used soft
lasers and laser energy to find and dissolve
small stones in the kidney [8] This rate in
Pham Ngoc Hung et al’s study (2012) was
63.6% [4]
Compared with other methods of
limiting stones in coronary renal excretion
and multiple pelvic exams such as X-rays
or ultrasound in surgery, endoscopic surgery
is more effective than just detecting and
treating the remaining stones, multiple
kidney stones With a soft 6.5Fr tube, it
can be inserted into all the neck to find
stones However, this method also has
certain disadvantages This is a difficult
technique, depending on many factors If
the technique of opening the kidneys is
not good, picking up multiple kidney
stones causes bleeding in the kidneys,
performing endoscopy in the surgery is so
difficult, even impossible
Indications for multiple-dose granulomatous
colposcopic catheterization with homium
laser are well suited For kidney openings
alone, multiple kidney stones and some
tablets in the station can be picked up
The remaining stones will be removed
or broken through the endoscopy
Particularly for coral stones and multiple
pellets, the indication of the method of
opening the kidneys alone to remove
stones combined with soft endoscopy
should be strictly specified Not every
coral is taken through the opening of the
kidneys, but also to extend the opening
into the kidney parenchyma Therefore,
the opening of the kidney is very wide,
causing bleeding again so the ability to use the tube is very difficult Some authors recommend coral reefs through open kidney lines alone We have no experience with this technique
In 9 cases failed to perform pyeloscopy, there were 4 cases of pyelonephritis in the sinus cavity, because of small size,
we can not bring the soft tube through the kidney into the kidney, especially the lower station, 3 cases of angle The lower craniofaciens can not enter the coronary tube, 2 cases of neck obstruction
Placement of a soft tube through the kidneys into the middle neck, upper and lower is a decisive step to the success of the procedure For the small neck, we had calcicectomy In the process of calcicectomy, bleeding occurred and we must stop surgery
Combination in the procedure, we used the supportive tools such as pumping in the surgery to collect the stone as well as use Dormia or pens to see through the endoscope to extend the soft tube A total of 157 stones needed to
be treated with a soft tube We collected
47 capsules/34 kidneys (26.5%) and the remaining 110 tablets were used laser The use of lithotripsy laser energy in renaloscopy has many advantages We have not seen any cases where the stone
is not cracked when using holmium laser pebble Grafts are usually quite smooth and do not cause damage to the kidney mucosa This is a superior advantage of the laser compared to the electric pulses Due to the use of endoscopic surgery, surgical time is considerably longer