SP3.1.12 A Comparison of Polymeric Clips vs Endoloops to Secure Appendicular Stump in Adult Emergency Laparoscopic Appendicectomy

Aims To assess the use of polymeric clips (PC) as an alternative to Endoloops (EL) to secure appendicular stump in adult emergency laparoscopic appendicectomy. Method A retrospective analysis of all patients who underwent emergency laparoscopic appendicectomy from 1/11/19 to 31/10/20, following introduction of polymeric clips in our institute as a safe alternative to endoloops to secure appendicular stump in October 2019. Patient demographics, operative duration, intraoperative findings, methods to control the appendicular mesentery and stump, post-operative length of stay, complications and grade of operating surgeon were compared in both groups (PCvsEL) and data analysed using SPSS. Results A total of 333 patients were included, who underwent laparoscopic appendicectomy and satisfied the inclusion criteria. PC were used in 160 (48%) patients and EL in 173 (52%). Patient demographics, surgeon grade and intra-operative severity of disease were statistically similar between both groups. Mean operative time was 10 minutes shorter in PC group (71 vs 81minutes, p = 0.001). Mesoappendix was ligated by applying laparoscopic titanium clips in EL group 25%, vs 6% PC group (p < 0.001), while 42% of the PC group, used PC on mesoappendix, which was without any additional cost. Post-operative complication rates were similar in both groups, apart from post-operative ileus, which was more in EL group (p = 0.003). Conclusion The use of PC in emergency laparoscopic appendicectomy is a safe and effective way to secure the appendicular stump, which results in, not only reduced operating time, but also a significant cost saving (£49/3x Endoloops vs £21/pack of 6x Polymeric clips) to NHS.

Coexistence of Stump Appendicitis and Ovarian Fibro-Thecoma in a Young Women with Recurrent Right Iliac Fossa Pain During Pregnancy; A Rare Case Report

Ovarian Fibro-thecoma is a rare, benign, sex cord-stromal neoplasm, with a typically unilateral location in the ovary, characterized by mixed features of both fibroma and thecoma. Ovarian Fibro-thecoma is Uncommon tumor of gonadal stromal cell origin accounting for 3-4% of all ovarian tumors. We describe a rare case of Fibro-thecoma in a 27- year women with a history of recurrent right iliac fossa pain during pregnancy associated with fever and vomiting with previous history of laparotomy for appendicular abscess 10 years back. She presented to us during pregnancy with this complain for which she was managed conservatively. She did not maintain her follow up regularly at our hospital and visited again after delivery of her baby with a still birth outcome with a newly diagnosed complex bilateral ovarian cyst demonstrated on ultrasound and computed tomography showed inflammatory Right sided tubo-ovarian mass along with inflammatory thickening of ileum in right lower quadrant adjacent to right ovarian mass lesion. The patient underwent laparotomy for this with the removal of mass along with the removal of appendicular stump for appendicular stump appendicitis which was diagnosed intraoperatively. The finding from histopathological examination of the mass was consistent with the diagnosis of Fibro-thecoma.

NONINVAGINATION VS. INVAGINATION OF APPENDICULAR STUMP: A RETROSPECTIVE STUDY

Appendicitis is the most common abdominal surgical emergency. The standard treatment of acute appendicitis is appendicectomy which can be performed by either open or laparoscopic approach. While during laparoscopic approach the stump is mostly not invaginated, in open method management of stump remains debatable- simple ligation or ligation and invagination of the stump. Aim of the study was to compare results of simple ligation alone or ligation and invagination of the appendicular stump during appendicectomy. Materials And Methods: Altogether 74 patients were included in this study and divided into two groups. Group I ligation and invagination of the stump with purse string suture and Group II simple ligation of the stump. The two methods were compared with respect to operative time, intraoperative and post-operative complications. Results: There was no signicant difference in either the rate of post-operative complication and post-operative hospital stay between the two groups. The average operative time was shorter in group without invagination. Conclusion: simple ligation of appendicular stump is a safe, simpler good technique associated with shorter operative time.

PROMPT RECOGNITION OF STUMPAPPENDICITIS IS IMPORTANT TO AVOID SERIOUS COMPLICATIONS: A CASE REPORT

Retroperitoneal abscess is a rare condition which is difficult to diagnose and treat because of its insidious onset. Herein, we present a case of retroperitoneal abscess secondary to stump appendicitis. A 50-year-old female was admitted with history of abdominal pain more in the right lower quadrant for 1 week. History of fever present since week associated with chills, History of poor stream of urine for 1 week, not associated with burning micturition. Her past medical history showed a laparoscopic appendectomy operation performed 5 months ago. Computed tomography of abdomen and pelvis showed features suggestive of right psoas abscess with possible communication with the tubular structure arising from IC junction (? appendicular stump), Ill-defined peripherally enhancing collection in presacral region and bilateral ischiorectal region -? Abscess. CECT Abdomen and pelvis showed right mild Hydroureteronephrosis. Cystoscopy + DJ stenting was done post which Exploration with drainage of retroperitoneal abscess with stump appendectomy done on 15/2/19. Intraoperatively 50cc pus with caseous material was drained, psoas was bulky. 3cm appendicular stump was noted, dissected, ligated and buried. A drain was placed in the site of the operation. Post-operative course was uneventful and he was discharged 9 days after surgery. The histologic evaluation reported suppurative stump appendicitis. Residual long stump of the appendix after appendectomy might lead to persistence of infection and possibly late complications such as intraperitoneal, retroperitoneal or iliopsoas abscess. Surgical exploration may be necessary in persistent cases of Retroperitoneal abscess, to allow for recognition and treatment of the underlying pathology.

Current technical surgical practice of emergency appendicectomy: a cross-sectional survey of surgical registrars in the UK

Introduction Appendicectomy remains one of the most commonly performed procedures in general surgery. The aim of this study was to explore variation in operative techniques of an appendicectomy among surgical registrars in England. Materials and methods An anonymised survey was sent out to surgical registrars in the UK via email and social media. Subgroup analyses were performed comparing respondents based on their level of seniority and subspecialty background. Results A total of 168 respondents completed the survey, of whom 77.4% (130/168) were specialty trainees years 3–8 and 44.6% (75/168) were colorectal trainees. The majority (98.8%) preferred a laparoscopic approach to appendicectomy. Overall, 73.2% opted to use diathermy to divide an uninflamed mesoappendix. Half of the respondents (50%) preferentially used diathermy to control the appendicular artery, followed by 44% preferring use of metal or polymeric clips. The appendicular stump was most often secured with Endoloops (85.7%) when removing a macroscopically uninflamed appendix but less readily used in the visibly inflamed appendix (75.6%, p = 0.01). Colorectal and upper gastrointestinal registrars were more likely to use diathermy on the mucosa of the appendix stump compared with other subspecialties (p = 0.03). The majority (82.1%) of respondents extracted the appendix via a retrieval bag. Regarding skin closure, most respondents (69%) adopted absorbable subcuticular sutures. Preferential duration of postoperative antibiotic use following appendicectomy for complicated appendicitis varied among the respondents. Conclusion There are similarities and differences across surgical registrars in terms of technical practice in appendicectomy, partially attributed to prior experience and training.

A study to evaluate the safety and cost effectiveness of preformed catgut endoloops and polyglactin 910 extracorporeal ligation in the management of appendicular stump closure in laparoscopic appendicectomy

Background: The most essential component of laparoscopic appendectomy is the closure of appendicular stump. Failure of which can result in catastrophic complications including intra-abdominal and surgical site infections and rarely faecal fistula. The aim of this study was to verify the effectiveness of preformed catgut endoloop and extracorporeal polyglactin 910 for appendicular stump closure.Methods: This prospective study was carried out in 64 patients. We compared patient demographics, duration of surgery, intra and post-operative complications, hospital stay and cost of surgery between the two groups.Results: A total of sixty-four patients were finally included in the analysis, catgut group (n=34), polyglactin 910 group (n=30). The demographics between the two groups were similar. The mean age in catgut group was 23.94 years and polyglactin 910 groups was 23.33 years. Mean duration of surgery was 41.6 and 41.8 minutes in catgut and endoloop group respectively. Mean hospital stay was 3 days. There was no mortality but complications were seen in 6 patients. However, there was no statistical significance in between the two groups with any of the parameters studied.Conclusions: Multiple studies have demonstrated safety and effectiveness of various techniques of appendicular stump. The use of extracorporeal single polyglactin 910 extracorporeal suture knot is safe and cost-effective technique for closure of appendicular stump in rural and resource poor regions.