Endovideosurgical technologies for the treatment of patients with acute appendicitis and its complications in the setting of a regional center

The dissertation is devoted to the study of the capabilities of endovideosurgical technologies in the treatment of patients with acute appendicitis and its complications in the setting of a multidisciplinary hospital of a regional center. The research covers the issues of incidence, diagnosis, and surgical treatment of acute appendicitis, including an analysis of the dynamics of hospitalization and surgical interventions, the evaluation of the capabilities of ultrasound diagnostics, as well as the development of indications and contraindications for laparoscopic appendectomy. Special attention is paid to the technical aspects of performing laparoscopic interventions, including in complicated forms of the disease accompanied by peritonitis, as well as to the management of the postoperative period.

The work presents a comparative analysis of the results of videolaparoscopic and traditional appendectomy, examines the reasons for conversion to traditional access, analyzes postoperative complications, and proposes an algorithm of diagnostic and therapeutic measures in patients with suspected acute appendicitis. A separate place is occupied by the medico-social assessment of the results of minimally invasive endosurgical interventions on the basis of sociological studies among patients.

Acute appendicitis is a disease of the abdominal organs requiring emergency surgical care. The incidence of acute appendicitis is 4–5 persons per 1000 population [59]. Appendectomies account for about 30% of all emergency operations on the abdominal organs in our country [20, 48]. In Russia, according to various authors, about 1–1.5 million patients with acute appendicitis undergo appendectomy annually [16]. In Saint Petersburg, removal of the vermiform appendix for acute appendicitis is performed annually on 7,000 to 17,000 persons [12, 13, 14, 69]. Appendicitis occurs predominantly in young persons and more frequently in women than in men [59].

Issues related to the diagnosis and treatment of acute appendicitis have been repeatedly discussed at scientific forums of various levels. However, many aspects of medical care for patients with this disease remain unresolved [29]. For example, diagnostic errors in the examination of patients with suspected acute appendicitis are observed in 12–31% of cases [29, 45, 62]. In 10–15% of patients appendectomy is performed without sufficient indications [62].

Despite certain advances in the diagnosis and treatment of appendicitis associated with the introduction of new technologies, the number of postoperative complications remains rather high, within 59% [43, 59]. The mortality rate from acute appendicitis in Russia over recent years has remained at 0.05%–0.8% [36, 37, 58, 62], while in complicated forms of the disease mortality reaches 4.3–5.8% [59], with the majority of deaths from acute appendicitis occurring in elderly patients [8]. According to the majority of authors, in specialized departments of multidisciplinary medical institutions of regional administrative centers the rate of complications after appendectomy is significantly lower than in medical and preventive institutions in rural areas [13, 14, 38, 69, 71].

The use of laparoscopic appendectomy in surgical practice for acute appendicitis makes it possible to improve treatment outcomes and spare them from traumatic laparotomy and its associated complications [43, 59, 124, 173, 174]. In recent years, reports have appeared on the use of laparoscopic appendectomy in acute appendicitis complicated by peritonitis and appendiceal abscess [41, 102, 113, 140, 157, 164, 200].

The European Association of Endoscopic Surgeons in its recent guidelines approved the laparoscopic approach in the treatment of acute appendicitis; however, despite the published materials, there is no consensus on indications and contraindications, as well as on the tactical and technical aspects of emergency endovideosurgical interventions in acute appendicitis [140].

The foregoing indicates the need for further search for ways to improve the results of surgical treatment of patients with acute appendicitis and its complications.

AIM OF THE STUDY:

To improve the results of surgical treatment of patients with acute appendicitis through the use of endovideosurgical interventions.

RESEARCH OBJECTIVES:

1. To carry out a comparative assessment of the dynamics of acute appendicitis incidence in Veliky Novgorod over the last 10 years.

2. To study the capabilities of ultrasound examinations in the diagnosis of acute appendicitis, and to determine direct and indirect ultrasonographic signs of acute inflammation of the vermiform appendix.

3. To evaluate the reliability of endovideosurgical exploration of the abdominal cavity in establishing the diagnosis of acute appendicitis, and to develop indications and contraindications for laparoscopic removal of the vermiform appendix.

4. To conduct a comparative analysis of videolaparoscopic and traditional appendectomy, and to develop an algorithm of diagnostic and therapeutic measures upon admission of a patient with suspected acute appendicitis.

5. To develop a method for the medico-social assessment of the results of minimally invasive endosurgical interventions for acute appendicitis.

SCIENTIFIC NOVELTY.

Indications and contraindications for videolaparoscopic appendectomy have been substantiated on the basis of an analysis of ultrasound diagnostics results, and methods of videoendosurgical operation have been determined taking into account the localization of the vermiform appendix and the severity of perifocal and peritoneal phenomena.

Improved known and newly developed methods of videolaparoscopic appendectomy make it possible to reduce the trauma of the operation and the drug load on the patient, decrease the number of wound complications, and improve the cosmetic effect of the operation.

Methods of endovideosurgical sanitation and drainage of the abdominal cavity in various forms of peritonitis caused by destructive appendicitis have been developed.

The carried-out evaluation of the results of traditional and videolaparoscopic appendectomy convincingly demonstrates the advantages of the latter.

A new method for assessing the results of minimally invasive surgical interventions in acute appendicitis based on sociological survey data has been proposed.

PRACTICAL SIGNIFICANCE OF THE WORK:

An algorithm of the surgeon's actions in patients admitted with a diagnosis of acute appendicitis has been developed and introduced into practice. Methods of videolaparoscopic appendectomy and methods of sanitation and drainage of the abdominal cavity in destructive forms of acute appendicitis have been developed. A comparative evaluation of the immediate and long-term results of laparoscopic appendectomy has been carried out, and the medico-social aspects of minimally invasive endosurgical interventions have been studied.

As a result of the conducted research, a new medical technology in the diagnosis and treatment of acute appendicitis has been created and is proposed for practical use; it allows increasing the effectiveness of treatment of patients by improving outcomes, reducing the trauma of the operation and improving the cosmetic effect of the operation, shortening the length of hospital stay, and reducing the period of temporary disability.

STATEMENTS FOR DEFENSE.

Over the last decade, acute appendicitis has moved to the second place in terms of incidence after acute cholecystitis, but occupies the first place in the number of operations in the general surgical hospital of a multidisciplinary city hospital.

The use of ultrasound scanning of the abdominal cavity in patients with suspected acute appendicitis significantly improves diagnosis and makes it possible to clarify the indications for surgical intervention in atypical forms of acute appendicitis.

The use of the endovideosurgical method makes it possible to significantly reduce the trauma of the operation for removal of the vermiform appendix and the drug load on the patient, decrease the number of postoperative complications, shorten the period of hospital stay, and improve the cosmetic effect of the operation.

The videolaparoscopic method of sanitation and drainage of the abdominal cavity in various forms of peritonitis of appendiceal origin makes it possible to perform thorough toilet and adequate rational drainage of any parts of the abdominal cavity.

APPROBATION OF THE WORK.

The materials and main statements of the work were reported at the meeting of the Novgorod Regional Scientific Society of Surgeons in 2007; at the Third International Congress “Scientific Research in the Implementation of the Program ‘Health of the Population of Russia’” — Moscow, February 21–24, 2008; at the XII Moscow International Congress on Endoscopic Surgery, April 23–25, 2008; at the 3rd International Conference of Endoscopic Surgeons, Saint Petersburg, May 15–16, 2008; at the First International Conference on Thoracoabdominal Surgery dedicated to the 100th anniversary of B.V. Petrovsky, Moscow, June 5–6, 2008; and at the 16th International Congress of the European Association of Endoscopic Surgeons, Stockholm, Sweden, June 11–14, 2008.

PERSONAL CONTRIBUTION OF THE AUTHOR.

The author carried out a study of acute appendicitis incidence, the dynamics of hospitalization and surgical interventions for inflammation of the vermiform appendix in the general surgical hospital of a multidisciplinary hospital of the regional center. Studies of the effectiveness of ultrasound examination in the diagnosis of acute appendicitis were performed; a comparative evaluation of the results of laparoscopic and traditional appendectomy was conducted; a method for the medico-social assessment of the results of minimally invasive endosurgical interventions was developed; and sociological studies were carried out to examine the patients' opinions and their subjective assessment of the new endovideosurgical technology in the treatment of acute appendicitis. The share of participation in data accumulation and research conduction was over 90%, and in synthesis and analysis — up to 100%.

PUBLICATIONS ON THE TOPIC.

On the topic of the dissertation, 6 printed works have been published, including 1 in a journal recommended by the Higher Attestation Commission of the Russian Federation.

IMPLEMENTATION OF THE RESEARCH RESULTS.

The research results have been introduced into the practical work of the surgical departments of the First City Clinical Hospital, the Novgorod Regional Clinical Hospital, and the Novgorod Central City Clinical Hospital. The materials of the dissertation are used in the educational process of the Department of Postgraduate Education, the Department of General and Faculty Surgery, and the Department of Hospital Surgery of the Institute of Medical Education of Yaroslav-the-Wise Novgorod State University.

VOLUME AND STRUCTURE OF THE DISSERTATION.

The dissertation is written on 118 pages of text. It consists of an introduction, 4 chapters, a conclusion, findings, and practical recommendations. The list of references includes 201 sources, of which 82 are domestic and 119 are foreign. The work is illustrated with 8 tables and 34 figures.