Mini-access in the surgery of acute appendicitis

The dissertation is devoted to the improvement of surgical treatment of acute appendicitis through the development and clinical substantiation of an oblique pararectal mini-access to the cecum, as well as a cosmetic method of closing a contaminated surgical wound. The work is based on a comparative analysis of laboratory and clinical results of appendectomy performed through the traditional McBurney–Volkovich–Dyakonov access and through the proposed mini-access in patients with low and normal body weight. The intensity of postoperative pain, the dynamics of laboratory parameters (leukocyte count, leukocyte intoxication index, C-reactive protein, circulating immune complexes), the pattern of pyoinflammatory complications, and the quality of life of patients in the inpatient and outpatient periods were studied.

On the basis of a topographic-anatomical investigation, the advantages and limitations of the new access were substantiated, and indications and contraindications for its use were formulated. It has been shown that the use of the mini-access in combination with the cosmetic wound closure reduces the traumatism of the intervention, decreases the frequency of wound complications, shortens hospital stay, and improves the cosmetic result. RF patents were obtained for the invention of the oblique pararectal mini-access and the cosmetic method of closing a contaminated surgical wound.

Acute appendicitis remains one of the most common acute surgical diseases (Kriger A.G. et al., 2002; Lemmeshko Z.A. et al., 2009). Operations for acute appendicitis are among the most frequent in the practice of a general surgeon. In the majority of cases, patients undergo a traditional open appendectomy through well-known accesses (McBurney–Volkovich–Dyakonov (1894–1898), Lennander's pararectal incision (1898), Winkelmann's transverse incision, Ridiger's oblique incision, and Schede's longitudinal incision) (Kochnev O.S., 1984; Rusanov A.A., 1979; Popkin C.A. et al., 2002). The traditional accesses were developed at the time of widespread use of local anesthesia. They are characterized by high traumatism and unsatisfactory cosmetic outcomes. Therefore, the development of surgical accesses capable of minimizing surgical stress and improving cosmetic results remains relevant (Popkin C.A. et al., 2002; Ramialison L., 1988).

Modern methods of anesthesia, such as total intravenous anesthesia with artificial pulmonary ventilation and inhalation low-flow anesthesia (anesthesia low flow), make it possible to ensure controllability, safety, adequate relaxation, and comfort of anesthesia (Gabitov M.V. et al., 2008; Likhvantsev V.V., 2005; Smit I. et al., 2002; Baum J.A., 1999). This enables surgeons to develop less traumatic operative techniques. Since any surgical operation represents an aggression and is accompanied by trauma to the organism, the search for the most sparing and safe methods of surgical treatment is continuously ongoing (Bondarev A.A. et al., 2003; Volkov O.I., 2002; Slesarenko S.S. et al., 1999).

Minimally invasive surgery is currently being developed (Barbera L., 2002; Timoshin A.D. et al., 2004; Blakely M.L. et al., 1998; Martin L.B. et al., 1998; Nowzaradan Y. et al., 1991). This concept unites all surgical interventions that pursue the same goals as traditional surgery but without large incisions of the skin and tissues for operative access (Vozlyublenny S.I. et al., 2005; Rozin D., 1998; Sakhautdinov V.G. et al., 2005; De Kok, 1977; Fleming J.S., 1985; Wilson T., 1986). These include endoscopic procedures and operations through mini-invasive accesses (Gotz F. et al., 1990; Horwitz J.R. et al., 1977; Wagner M. et al., 1996; Waleczek H. et al., 1993). The use of special instruments and precision technologies is the principal feature of this progressive direction of modern medicine (Dotsenko V.N. et al., 2004; Volkov O.I., 2002; Brosseuk D.T. et al., 1999; Da Silva L. et al., 2002; Giulianotti R. et al., 2003; Grandjean J.P. et al., 1999; Mc Kernan B.J. et al., 1990; Raguse T. et al., 1993).

The development of mini-invasive surgery has not only led to the replacement of conventional open operative techniques with minimally invasive ones but has also stimulated surgeons to analyze and evaluate both the methods themselves and postoperative outcomes (Ospanov O.B., 2003; Savel'yev V.S., 2002; Shrayber G.V., 1996).

At present, laparoscopic appendectomy (LA) (Kotlobovsky V.I. et al., 1993; Kriger A.G. et al., 1995, 1997; Sedov V.M. et al., 1994; Timoshin A.D. et al., 2004; Baker A., 1999; Corso D., 1994; Gangal H.T. et al., 1987; Leahi P.F., 1989; Olsen D., 1992; Semm K., 1988), laparoscopy-assisted appendectomy (LAA) (Fleming J.S., 1985; Wilson T., 1986), laparoscopy-augmented appendectomy (LDA) (Beburshvili A.G. et al., 2005; Prudkov M.I. et al., 1998; Sakhautdinov V.G. et al., 2005; Bonanni F. et al., 1994; De Kok, 1977; Johnson A.B. et al., 1998), appendectomy using the "mini-assistant" set (Prudkov M.I. et al., 2001), and open appendectomy through conventional accesses (Rusanov A.A., 1979) are used. Endoscopic operations have a number of disadvantages that limit their widespread use: 1) expensive equipment; 2) the need for a sufficient number of highly qualified personnel; 3) a high percentage of complications during the stage of mastering the technique; 4) expensive consumables (Beburishvili A.G. et al., 2005; Nikitenko A.I. et al., 1993; Sedov V.M. et al., 1995; Tarasov A.N., 2005; Timoshin A.D. et al., 2004; Ortega A.E. et al., 1995; Pier A. et al., 1991). Therefore, the majority of operations for acute appendicitis are still performed by the traditional open method.

Acute appendicitis is a chameleon-like disease (Doletsky S.Ya., 1990; Isakov Yu.F. et al., 1980; Rusakov V.I. et al., 1990; Fishchenko A.Ya., 1989). Mistakes in its management are made not only by young surgeons but also by highly qualified ones. A significant proportion of complications in acute appendicitis is associated with errors committed during surgery, as well as with inadequacies in the postoperative management of patients (Dronov A.F. et al., 1996; Miziyev I.A. et al., 2005; Sovtsov S.A., 2002; Torgunakov A.P., 2005).

Infiltrate, wound suppuration, and separation of wound edges are encountered most frequently and are directly related to the depth of destructive changes in the vermiform appendix and to the method of closing the skin and subcutaneous fat (Vashetko R.V., 2004; Kudinsky Yu.G. et al., 1981; Kuzin M.I., 2000; Rotkov I.L., 1980).

The complication rate in acute appendicitis ranges from 32.6 to 43%; postoperative wound infection occurs in 5.4–18.8% of operated patients, and its frequency depends on the form of appendicitis, the general condition of the organism, and various risk factors for complications. The frequency of postoperative pyoseptic complications in patients with acute appendicitis does not tend to decrease; therefore, the problem of their prevention and treatment remains relevant (Artishevsky L.I. et al., 1996; Volenko A.V. et al., 1998; Devyatov V.A. et al., 1991; Kanshin N.N. et al., 1991; Malyukov A.E. et al., 1990; Nekhayev A.N. et al., 2003; Rabidzhanov M.R. et al., 1989).

At present, many different measures aimed at reducing the number of wound complications have been proposed. None of them alone solves this problem (Abramov A.Yu., 1992; Vinnitsky L.I. et al., 1995; Davydov Yu.A. et al., 1991, 1995; Izmailov S.G. et al., 2001; Kanshin N.N. et al., 1986; Kostyuchenok B.M. et al., 1982; Larichev A.B. et al., 1994; Lakhno V.M., 1997; Loginov V.I. et al., 2003; Mamatkulov I.Kh., 1996, 1997; Matyashin I.M. et al., 1974; Mokhov E.M. et al., 2004; Ospanova K.B., 2003; Peregudov I.G. et al., 1989; Sivets N.F., 2006; Togayev T.R. et al., 2004; Khaitov R.M. et al., 2000; Fleischer E., 1982; Hamer M.L. et al., 1975). Prophylaxis should be comprehensive, taking into account the specific risk factors in a given patient and the most probable pathogens and routes of infection for a particular nosological entity (Myshkin K.I. et al., 1991).

Until now, the effectiveness of surgical interventions for acute appendicitis has been evaluated by such indicators as mortality, complication rate, length of hospital stay, and results of laboratory investigations. There are almost no reports on the psychosocial consequences of surgical treatment, changes in the patient's perception of his or her health, or the ability to function physically (Ostrovsky V.Yu., 1977; Bronshtein A.S. et al., 2001; Novik A.A. et al., 1999).

For an adequate evaluation of the results of an operation, one of the criteria of treatment effectiveness today is quality of life (QoL) — an indicator of the patient's physical, psychological, emotional, and social functioning based on the subjective perception of his or her condition. Various questionnaires are used to assess QoL; they are divided into general, disease-specific, and partial (for assessing individual QoL parameters). Disease-specific questionnaires are shorter, and the reliability of their results is higher. When general questionnaires are used, the risk of missing side and undesirable effects is reduced, since all parameters are gathered in one place (Novik A.A. et al., 1999; Fitzpatrik R. et al., 1992).

The foregoing considerations predetermined the goal of our work.

Aim of the study

Improvement of the surgical treatment of patients with acute appendicitis using the oblique pararectal mini-access developed by the author.

Objectives of the study

1. To develop a mini-access to the cecum and to determine indications and contraindications for its use;

2. To provide a topographic-anatomical substantiation of the oblique pararectal mini-access and to identify its advantages and disadvantages;

3. To substantiate the necessity of a cosmetic method of closing a contaminated surgical wound in appendectomy;

4. To study the results of laboratory and clinical investigations in patients after traditional appendectomy and appendectomy through the oblique pararectal mini-access;

5. To study the early and late results of treatment of acute appendicitis when using the traditional and the cosmetic method of closing a contaminated surgical wound;

6. To assess the quality of life of patients who underwent traditional appendectomy and appendectomy through the oblique pararectal mini-access.

Scientific novelty

The "Oblique pararectal mini-access" to the cecum in operations for acute appendicitis has been developed; indications and contraindications for its use have been determined (RF Patent for Invention No. 2346658).

The "Cosmetic method of closing a contaminated surgical wound in appendectomy" has been developed (RF Patent for Invention No. 2368335).

A comparative evaluation of the results of laboratory and clinical investigations after appendectomy through the traditional and the oblique pararectal mini-access has been performed.

The quality of life of patients after traditional appendectomy and appendectomy through the oblique pararectal mini-access has been studied.

Practical significance of the work

The use of the oblique pararectal mini-access in appendectomy leads to a reduction in the traumatism of the surgical intervention, faster postoperative rehabilitation of patients, shorter hospital stay, and savings in material costs.

The cosmetic method of closing a contaminated surgical wound makes it possible to improve the results of surgical treatment of patients with acute appendicitis, reduce the number of pyoinflammatory complications, and obtain a better cosmetic effect.

The quality of life of patients after traditional appendectomy and appendectomy through the oblique pararectal mini-access has been assessed. Factors influencing the quality of life of patients after appendectomy have been identified.

The absence of a need for complex technical equipment allows the author to recommend the use of the oblique pararectal mini-access in surgical hospitals.

Implementation of the results

The results of the performed investigations are used in the surgical treatment of patients with acute appendicitis at the Medical Sanitary Unit of the Yaroslavl' Oil Refinery (MKUZ MSCh NYa NPZ, Yaroslavl). The materials of the work are used in the educational process at the Department of Faculty Surgery of the Yaroslavl State Medical Academy.

Statements of the dissertation submitted for defense

1. The developed oblique pararectal mini-access makes it possible to perform operations for acute appendicitis in patients with low and normal body weight with less traumatism compared with the traditional McBurney–Volkovich–Dyakonov access.

2. The quality of life of patients after appendectomies performed through the oblique pararectal mini-access is higher than after appendectomy through the traditional McBurney–Volkovich–Dyakonov access.

3. The cosmetic method of closing a contaminated surgical wound makes it possible to reduce the number of pyoinflammatory complications and to obtain a better cosmetic result.

Approbation of the research materials and publications

The materials of the dissertation were reported and discussed at the Sixth International Remote Scientific-Practical Conference "New Technologies in Medicine — 2009" (Saint Petersburg, 2009); at the Yaroslavl Regional Scientific Society of Surgeons (Yaroslavl, 2009); at the International Remote Scientific-Practical Conference dedicated to the memory of the founder of the Ural scientific school of anatomists, histologists, and embryologists, Professor Viktor Karlovich Schmidt, "Implementation of Innovative Technologies in Surgical Practice (Fundamental and Applied Aspects)" (Perm, 2009); at the II Arkhangelsk International Conference of Young Scientists (Arkhangelsk, 2009); at the Second International Remote Scientific Conference (Kursk, 2009); and at the joint scientific conference of the surgical departments of the Yaroslavl State Medical Academy (Yaroslavl, September 2009).

Eighteen scientific works have been published on the topic of the dissertation. RF Patent for Invention No. 2346658 "Oblique pararectal mini-access in appendectomy" has been obtained. RF Patent for Invention No. 2368335 "Cosmetic method of closing a contaminated surgical wound in appendectomy" has been obtained.

Structure and scope of the dissertation