Laparoscopic‐Guided Appendicectomy A Study of 100 Consecutive Cases

EDITORIAL COMMENT:We accepted this paper for publication because it shows readers that laparoscopic‐guided appendicectomy is possible. The author does not mention his operating time, a point raised by the reviewer, who stated that the operation often takes more than 60 minutes when performed laparoscopically. The need to restrict time spent in hospital is becoming increasingly important in public hospital practice as we follow the North American example and teach ourselves to maximize outpatient and short‐stay surgery with minimization of postoperative morbidity. One might wonder why the most affluent nations practise the worst medicine since surely painful parts should be rested, yet we are told that in some American centres discharge home the day after surgery is now happening even after vaginal hysterectomy! What are they trying to prove? Such is the trend imposed by our administrative masters that we consider that more data should be collected in such studies to assess postoperative morbidity. Patients having laparoscopy and early discharge of tens state that the postdischarge days were unpleasant or even intolerable. Day cases ideally should be planned flexibly so that the patient may remain in hospital overnight if she so wishes when questioned after the operation. Early discharge after operation is not an easy option for medical and nursing staffs — it requires careful postoperative assessment and follow‐up; these women require intensive care and counselling during their shortened sojourn in hospital if they are to remain healthy and happy customers . We wish to question one of the premises of this paper, namely that chronic recurring lower abdominal pain is due to a pathological appendix. Most surgical literature accepts the existence of recurrent appendicitis, but the data in this paper does not substantiate this diagnosis since follow‐up was inadequate. The surgical literature on appendicectomy for recurring nonspecific lower abdominal pain shows that there is a very poor cure rate with follow‐up of more than 12 months (Creed F. Life events and appendicectomy. Lancet 1981; 1381–1385). Our reviewer was also concerned with the diagnosis of mild chronic appendicitis based upon the finding of lymphocytes and plasma cells found in the submucosa — these findings are nonspecific and pathologists usually regard them as a normal finding rather than evidence of mild chronic appendicitis . This paper shows that laparoscopic appendicectomy can be performed with minimal morbidity and much shortened hospitalization. How much is new?— when the editor did his first locum in a small Mallee township in 1954 the cheerful inhabitants boasted that their local doctor, who he was relieving, had removed all their appendices via a tiny wound that required no stitch and could be covered by a florin!— the main difference is that he had not used a laparoscope . AUTHOR'S REPLY TO EDITORIAL COMMENT It was an omission not to mention operating time. The procedure takes no more than 20 minutes, i.e. adds 5–10 minutes to the time of a diagnostic laparoscopy. Since the paper was written diathermy is not used to cut through with the mini‐McBurney's incision. A scalpel is used and this gives better results with the scar. The paper by Creed is not applicable. His series of 125 cases was of patients with acute lower abdominal pain who had an appendicectomy performed, the indications were not mentioned, whereas my series concerns patients with chronic or recurring pain and strict criteria were adopted for removal of the appendix .