Rezola E, Villanueva A, Garay J, Suñol M, Arana J, Intxaurrondo M I, Eizaguirre I
Servicio de Pediatría, Hospital Donostia, Osakidetza-Servicio Vasco de Salud, San Sebastián.
Cir Pediatr. 2008 Jul;21(3):167-72.
Despite its increasing popularity, laparoscopic appendectomy does not put an unanimous end to the answer to the best treatment for appendicitis. Although the postoperative stay is shorter, the wound infection practically does not exist and scars are minimal, some publications question its advantages due to the incidence of intra-abdominal absceses, postoperative analgesia requirements and the recently described "postlaparoscopic appendectomy complication" (PLAC), an intra-abdominal infection, without abscess formation, which develops after laparoscopic appendectomy for non-complicated appendicitis. Some of this series include the "learning curve", wherein they compare results of inexperienced surgeons in laparoscopic techniques with those obtained after with the firmly established open appendectomy (OA) technique. With the aim to clarify this aspects, we reviewed our experience in laparoscopic appendectomy during (LDC) and after (LAC) the "learning curve" and we compared their complications with the open appendectomies' ones.
We retrospectively reviewed 807 appendectomies: 208 laparoscopic (LA) and 599 open (OA) from January 2001 to December 2007 performed in our hospital. In the laparoscopic group, 83 of them (40%) were done during the learning curve (each surgeon's 35 first interventions, LDC) and 125 (60%) after the learning curve (LAC). We have compared both laparoscopic subgroups to each other and to the open appendectomies group. We analysed the age, sex, length of stay, kind of appendicitis (simple or perforated appendicitis) and five of the most serious complications: intra-abdominal abscess, postoperative intestinal occlusion, intestinal perforation, haemorrhage and PLAC.
The mean age (9 years), sex (58% men; 42% women) and the peritonitis rate (30%) were similar among the 3 groups. The mean length of stay was reduced from 5.4 days in OA group to 4.2 days in LA group and 3.6 days in LAC group (p < 0.01). The simple appendicitis cases had the shortest length of stay: 3.41 days in OA group and 2.16 days in LA group (p < 0.0001). There were no differences in stay for the peritonitis group. In the OA group, we detected 56 severe complications (9,3%): 49 abcesses, 2 occlusions, 2 PLAC, 1 haemorrhage, 1 intestinal perforation and 1 liver abscess. Nineteen severe complications were found in LDC group (22,9%): 9 abscesses, 4 occlusions, 4 haemorrhages, 1 intestinal perforation and 1 PLAC (p < 0.01 vs OA group). In the LAC group, we found 13 complications (10,4%): 9 abscesses, 1 occlusion, 1 PLAC and 2 haemorrhages (p = 0.3 vs OA group).
尽管腹腔镜阑尾切除术越来越受欢迎，但对于阑尾炎的最佳治疗方法，它并未给出一个一致的答案。虽然术后住院时间较短，伤口感染几乎不存在，疤痕也很小，但一些出版物对其优势提出了质疑，原因包括腹腔内脓肿的发生率、术后镇痛需求以及最近描述的“腹腔镜阑尾切除术后并发症”（PLAC），即一种在非复杂性阑尾炎的腹腔镜阑尾切除术后发生的无脓肿形成的腹腔内感染。该系列研究中的一些纳入了“学习曲线”，他们将腹腔镜技术不熟练的外科医生的手术结果与采用成熟的开放式阑尾切除术（OA）技术所获得的结果进行比较。为了阐明这些方面，我们回顾了我们在“学习曲线”期间（LDC）和之后（LAC）进行腹腔镜阑尾切除术的经验，并将其并发症与开放式阑尾切除术的并发症进行了比较。
我们回顾性分析了2001年1月至2007年12月在我院进行的807例阑尾切除术：208例腹腔镜手术（LA）和599例开放式手术（OA）。在腹腔镜组中，其中83例（40%）在学习曲线期间完成（每位外科医生的前35例手术，LDC），125例（60%）在学习曲线之后完成（LAC）。我们将两个腹腔镜亚组相互比较，并与开放式阑尾切除术组进行比较。我们分析了年龄、性别、住院时间、阑尾炎类型（单纯性或穿孔性阑尾炎）以及五种最严重的并发症：腹腔内脓肿、术后肠梗阻、肠穿孔、出血和PLAC。
三组患者的平均年龄（9岁）、性别（男性58%；女性42%）和腹膜炎发生率（30%）相似。平均住院时间从OA组的5.4天降至LA组的4.2天和LAC组的3.6天（p < 0.01）。单纯性阑尾炎病例的住院时间最短：OA组为3.41天，LA组为2.16天（p < 0.0001）。腹膜炎组的住院时间无差异。在OA组中，我们检测到56例严重并发症（9.3%）：49例脓肿、2例肠梗阻、2例PLAC、1例出血、1例肠穿孔和1例肝脓肿。在LDC组中发现19例严重并发症（22.9%）：9例脓肿、4例肠梗阻、4例出血、1例肠穿孔和1例PLAC（与OA组相比，p < 0.01）。在LAC组中，我们发现13例并发症（10.4%）：9例脓肿、1例肠梗阻、1例PLAC和2例出血（与OA组相比，p = 0.3）。
