LAPAROSCOPIC SUBMUCOSAL APPENDECTOMY FOR DIFFICULT AND ADHERENT CASES

AIM OF THE SSTUDY: Recurrent appendicitis with the appendix tip in sub-hepatic area and late presentations of perforated appendicitis sometimes test the skills of the surgeon. Due to dense adhesions, looking for the appendicular artery may lead to troublesome bleeding and injure the adjacent gut. Submucosal appendectomy could be an answer in these situations.

METHODS: From 7, October 2005 to 7, October 2009, 1037 laparoscopic appendectomies have been performed in the Department of Pediatric Surgery, Chattagram Maa O Shishu Hospital of which 139 were recurrent, perforated or sub-hepatic. In 9 of these cases no plane could be established between the appendix and adjacent structures. So an incision on the anti-mesenteric wall of appendix made and the mucosal sleeve could be pulled out intact leaving the muscular wall. Post-operative management was similar to formal appendectomies.

RESUTS: Number of cases was 9 of which 5 were male. Age ranged from 4 years to 12 years. Three cases were perforated and 6 recurrent appendicitis. There was one retro-ileal, 1 sub-cecal, two pelvic and remainder retro-cecal appendices. Submucosal appendectomy was done in all these 9. There was no uncontrolled bleeding or gut injury during procedure. Time taken was average 47 minutes per case. Post-operative courses and follow-ups were uneventful in 8 cases and in one case feeding was tolerated after 5 days. 

CONCLUSIONS: Submucosal appendectomy is a safe option for difficult cases during laparoscopy.