Therapeutic effectiveness and influencing factors of laparoscopic appendectomy with mesoappendix dissection in the treatment of acute appendicitis

Abstract

BACKGROUND

Acute appendicitis (AP) is a frequently encountered surgical emergency, and appendectomy is conventionally regarded as the predominant treatment modality. Nevertheless, the therapeutic efficacy of this surgical approach remains to be improved. Thus, the exploration and implementation of surgical refinements are necessary.

AIM

To elucidate the therapeutic effectiveness and influencing factors of laparoscopic appendectomy (LA) with mesoappendix dissection in the treatment of AP.

METHODS

First, 150 patients with AP who visited Shangrao Municipal Hospital between January 2022 and June 2024 were enrolled in this study. Among them, 72 patients were assigned to the control group to receive conventional LA, whereas 78 cases were included in the observation group for LA with mesoappendix dissection. Subsequently, indicators such as therapeutic effectiveness, surgical indices (operation time, intraoperative blood loss, and hospital stay), postoperative recovery indices (time to ambulation, gastrointestinal function recovery time, and time to food intake), incidence of adverse events (postoperative bleeding, pelvic infection, puncture site infection, and ileus), and serum inflammatory factors [tumor necrosis factor (TNF)-α, interleukin (IL)-6, and C-reactive protein (CRP)] were collected and comparatively analyzed, and the influencing factors of therapeutic effectiveness in patients with AP were analyzed.

RESULTS

Compared with the control group, the observation group had higher clinical therapeutic effectiveness, less operation time, intraoperative blood loss, and hospital stay; shorter time to ambulation, gastrointestinal function recovery, and food intake; and a lower total incidence of adverse events, and this difference is statistically significant. In addition, the expression levels of various serum inflammatory factors in the observation group were significantly reduced postoperatively, which were markedly lower than those in the control group. Moreover, sex, age, body mass index, time from acute onset to admission, family medical history, preoperative TNF-α, preoperative IL-6, preoperative CRP, and treatment modality were identified to be not independent factors affecting the therapeutic effectiveness of LA with mesoappendix dissection in patients with AP.

CONCLUSION

Overall, LA with mesoappendix dissection has a remarkable curative effect in treating patients with AP, which is worthy of clinical promotion.

Key Words: Laparoscopy; Appendectomy with mesoappendix dissection; Acute appendicitis; Therapeutic effectiveness; Analysis of influencing factors

Core Tip: At present, relevant research focusing on the efficacy and influencing factors of laparoscopic appendectomy with mesoappendix dissection in treating patients with acute appendicitis is limited. In this study, 150 patients who are suffering from acute appendicitis were enrolled. Comparative analyses regarding the clinical application of conventional laparoscopic appendectomy and laparoscopic appendectomy with mesoappendix dissection were performed among these patients, taking into account therapeutic effectiveness, surgical parameters, postoperative rehabilitation, the occurrence rate of adverse events, and serum inflammatory factors. Finally, we concluded that laparoscopic appendectomy with mesoappendix dissection, when applied to treat patients with acute appendicitis, can enhance the treatment efficacy and surgical outcomes, facilitating patients’ postoperative recovery, decreasing the incidence of adverse events, and averting the excessive increase of inflammatory markers, including tumor necrosis factor-α, interleukin-6, and C-reactive protein triggered by surgical stimuli. Hence, this approach shows great potential in clinical application.

INTRODUCTION

Acute appendicitis (AP) is a common surgical emergency with a lifetime morbidity risk in the range of 6%-7%, with 300000 appendectomies performed annually in the United States alone[1,2]. Statistically, AP has a higher incidence in males, with a morbidity risk of 8.6%, than in females (6.7%)[3]. This disease is primarily induced by fecaliths, fecal impaction, lymphoid hyperplasia, or tumors, which can trigger edema, vascular congestion, ischemia, appendiceal perforation, and intra-abdominal abscess or generalized peritonitis[4]. The main clinical manifestations of AP include nausea, vomiting, anorexia, abdominal pain, and fever, which have diverse degrees of negative impacts on the physical health of patients[5]. Appendectomy is the first treatment option for AP. Given the development and widespread application of laparoscopic technology, laparoscopic appendectomy (LA) has advantages such as small wounds, aesthetically pleasing incisions, and rapid postoperative recovery in clinical practice[6,7]. LA involves extracting the patient’s appendix through the trocar puncture hole. However, for patients with severe swelling, LA is challenging[8,9]. Moreover, if the patient has relatively severe mesenteric edema and adhesion, then LA is often accompanied with mesenteric torsion, thereby increasing the difficulty of the operation and the risk of mesenteric bleeding at the root of the appendix[10-12]. Thus, this study aims to improve the surgical outcome of patients with AP by LA combined with mesoappendix dissection. LA with mesoappendix dissection is an improved surgical modality of conventional LA, which reduces the size of the specimen by removing the appendix root and mesoappendix, making the specimen easy to remove and reducing the risk of active bleeding[13,14]. Given the current dearth of research on the therapeutic effectiveness and influencing factors of LA with mesoappendix dissection for the treatment of AP, this study aims to conduct relevant analysis to improve surgical outcomes in such patients.

MATERIALS AND METHODS

Collection of patient information

Patients were included in the study if they met the following criteria: Patients were diagnosed of AP by computerized tomography, surgical physical examination, abdominal B-ultrasound, and blood routine examination in combination with physical examination and medical history[15]; patients with acute onset; patients presented with typical clinical symptoms such as vomiting and right lower abdominal pain; patients completed the surgical indications for appendectomy; patients have complete clinical data. The exclusion criteria were as follows: Perforated appendix; inability to tolerate general anesthesia; history of laparoscopic surgery and conversion to open surgery during the operation; impaired cardiac, pulmonary, and renal functions; severe complications such as appendiceal abscess and perforation; suppurative portal phlebitis, peritonitis, and internal and external fistulas; onset time > 3 days. This research was approved by the Shangrao Municipal Hospital Ethics Committee without reserves. After rigorous screening in accordance with the abovementioned inclusion and exclusion criteria, 150 patients with AP who were admitted to Shangrao Municipal Hospital from January 2022 to June 2024 were selected as the research subjects. These patients were divided into two groups, 72 in the control group who received conventional LA and 78 in the observation group who were treated by LA with mesoappendix dissection.

Surgical procedures

Both groups of patients maintained a supine position during the surgery. A three-port approach was used. First, a 10 mm trocar was placed 1 cm above the upper edge of the umbilicus, which served as the intraoperative observation port and connected to the pneumoperitoneum tube. Carbon dioxide pneumoperitoneum was routinely established with a pressure range of 11-12 mmHg. Then, a 10 mm trocar was inserted 2 cm below and parallel to the umbilicus on the midline of the patient’s left clavicle, which served as the main intraoperative operating port. A 5 mm trocar was placed at the left counter-McBurney’s point, which served as the intraoperative traction port.

The control group was treated with conventional LA. A puncture was created between the serosal surface of the appendix and the mesoappendix at the root of the patient’s appendix by using a surgical ultrasonic scalpel, and the distal end of the appendix and mesoappendix was clamped. Subsequently, the appendix and mesoappendix were sequentially severed and removed via the main operation port. Thereafter, the puncture site was disinfected with iodophor solution and routinely sutured. Both groups were treated under intraoperative conditions to determine whether an indwelling drain was placed.

For the observation group, LA combined with mesoappendix dissection was performed. A surgical ultrasonic scalpel was used to cut the mesoappendix to the serosal surface of the appendix from the end to the apex of the patient’s appendix. Then, the mesoappendix was peeled off along the serosal surface of the appendix toward the end of the appendix until the root of the appendix. Next, the appendix and distal end of the mesoappendix root were clamped. The appendix and mesoappendix were sequentially severed using the surgical ultrasonic scalpel and then removed from the main operation port (trocar). Finally, the interior of the puncture site was disinfected with iodophor solution and routinely sutured.

Evaluation indexes

Therapeutic effectiveness: The clinical effectiveness of the two groups was comparatively analyzed in accordance with the following criteria for efficacy determination: The complete disappearance of symptoms and signs is considered markedly effective; the partial alleviation of symptoms and signs is regarded as effective; the absence of change or aggravation of symptoms and signs is deemed ineffective. The total effective rate of treatment was measured as the sum of the number of markedly effective cases and effective cases as a percentage of the total number of cases.

Surgical indices: Operation time, intraoperative blood loss, and hospital stays were observed and recorded.

Postoperative recovery indices: The time to ambulation, gastrointestinal function recovery, and food intake of both groups of patients were observed and recorded.

Incidence rate of adverse events: The incidence of adverse reactions such as postoperative bleeding, pelvic infection, puncture site infection, and ileus was observed and recorded.

Serum inflammatory factors: Five milliliters of fasting venous blood was collected from patients before and after treatment, and the serum was centrifuged to determine the level of tumor necrosis factor (TNF)-α, interleukin (IL)-6, and C-reactive protein (CRP) levels by enzyme-linked immunosorbent assays.

Statistical analysis

Statistical analysis was conducted using SPSS 19.0, with P < 0.05 indicating statistical significance. Measurement data were statistically described as (mean ± SD), with inter-group and intra-group comparisons before and after treatment performed by using an independent sample t-test and paired t-test, respectively. Count data were represented as n (%), and a χ² test was performed for inter-group comparisons.

RESULTS

Patient general information

No notable differences in sex, age, body mass index (BMI), time from acute attack to admission, and family medical history were found between the control and observation groups (P > 0.05; Table 1).

Table 1 Patient general information.

General information	Control group (n = 72)	Observation group (n = 78)	χ2/t	P value
Sex (male/female)	42/30	44/34	0.057	0.812
Age (years)	48.36 ± 6.18	49.03 ± 7.56
Body mass index (kg/m2)	23.58 ± 2.37	24.32 ± 2.55
Time from acute onset to admission (hour)	24.01 ± 3.16	23.64 ± 3.24
Family medical history (without/with)	64/8	67/11	0.303	0.582

Measurement data were statistically described as (mean ± SD).

Comparative analysis of therapeutic effectiveness

The total number of effective cases in the control and observation groups was 60 and 74, respectively, with a markedly higher total effective rate in the observation group than in the control group (P < 0.05; Table 2).

Table 2 Therapeutic effectiveness of the two groups, n (%).

Therapeutic effectiveness	Control group (n = 72)	Observation group (n = 78)	χ2	P value
Markedly effective	25 (34.72)	35 (44.87)
Effective	35 (48.61)	39 (50.00)
Ineffective	12 (16.67)	4 (5.13)
Total	60 (83.33)	74 (94.87)	5.231	0.022

Surgical indices of the two groups

Compared with the control group, the operation time, intraoperative blood loss, and hospital stay in the observation group were statistically shorter (P < 0.001; Table 3).

Table 3 Surgical indices of the two groups.

Surgical indices	Control group (n = 72)	Observation group (n = 78)	t	P value
Operation time (minute)	50.76 ± 6.42	43.96 ± 4.97	7.285	< 0.001
Intraoperative blood loss (mL)	37.00 ± 7.38	24.64 ± 6.24	11.104	< 0.001
Hospital stay (day)	7.24 ± 2.63	5.47 ± 1.73	4.905	< 0.001

Measurement data were statistically described as (mean ± SD).

Postoperative recovery indices of the two groups

The observation group had markedly shorter time to postoperative ambulation, gastrointestinal function recovery, and food intake than the control group (P < 0.001; Table 4).

Table 4 Postoperative recovery indices of the two groups.

Postoperative recovery index	Control group (n = 72)	Observation group (n = 78)	t	P value
Time to ambulation (hour)	27.90 ± 4.80	22.37 ± 3.98	7.703	< 0.001
Time to gastrointestinal function recovery (day)	3.42 ± 1.32	2.15 ± 0.90	6.930	< 0.001
Time to food intake (day)	3.76 ± 1.27	2.69 ± 1.02	5.709	< 0.001

Measurement data were statistically described as (mean ± SD).

Incidence rate of adverse events in two groups

By counting the incidence of adverse events such as postoperative bleeding, pelvic infection, puncture site infection, and ileus in the two groups, we found that the total incidence of adverse events was significantly lower in the observation group than in the control group (P < 0.05; Table 5).

Table 5 Incidence rate of adverse events in two groups, n (%).

Postoperative recovery indexes	Control group (n = 72)	Observation group (n = 78)	χ2	P value
Postoperative bleeding	5 (6.94)	2 (2.56)
Pelvic infection	3 (4.17)	1 (1.28)
Puncture site infection	3 (4.17)	0 (0.00)
Ileus	1 (1.39)	0 (0.00)
Total	12 (16.67)	3 (3.85)	6.838	0.009

Serum inflammatory factors between the two groups

The two groups showed the same preoperative TNF-α, IL-6, and CRP levels (P > 0.05). Postoperatively, these indexes evidently increased in both groups but with lower levels in the observation group than in the control group (all P < 0.05; Figure 1).

Figure 1 Serum inflammatory factors in two groups. A: Pre- and post-operative tumor necrosis factor-α levels in the two groups; B: Pre- and post-operative interleukin-6 levels in the two groups; C: Pre- and post-operative C-reactive protein levels in the two groups. ^aP < 0.05 and ^bP < 0.01 compared with the preoperative level within the group; ^cP < 0.05 compared with the control group; TNF-α: Tumor necrosis factor-α; IL-6: Interleukin-6; CRP: C-reactive protein.

Analysis of factors influencing patient efficacy

Based on logistic regression analysis, sex, age, BMI, time from acute attack to admission, family medical history, preoperative TNF-α, preoperative IL-6, preoperative CRP, and treatment modality were considered to be not independent factors influencing patient efficacy (P > 0.05; Table 6).

Table 6 Multivariate analysis of factors influencing patient efficacy.

Factor	β	SE	Wald	P value	Exp (β)	95%CI
Sex	-0.088	0.566	0.024	0.876	0.915	0.302-2.777
Age	-0.015	0.044	0.122	0.726	0.985	0.904-1.073
Body mass index (kg/m2)	-0.109	0.116	0.883	0.347	0.897	0.714-1.126
Time from acute onset to admission (hour)	0.144	0.105	1.902	0.168	1.155	0.941-1.418
Family medical history	-0.214	0.916	0.054	0.816	0.808	0.134-4.861
Preoperative TNF-α (ng/L)	-0.872	0.941	0.859	0.354	0.418	0.066-2.643
Preoperative IL-6 (pg/mL)	-0.007	0.030	0.058	0.809	0.993	0.937-1.052
Preoperative CRP (mg/L)	0.065	0.115	0.319	0.572	1.067	0.852-1.335
Treatment modality	1.214	0.621	3.820	0.051	3.368	0.997-11.380

TNF-α: Tumor necrosis factor-α; IL-6: Interleukin-6; CRP: C-reactive protein.

DISCUSSION

The etiology of AP is intricate. Factors such as diet, genetics, ischemia, inflammation, and fecalith-induced lumen obstruction serve as risk factors for the occurrence of AP[16]. The pathological mechanism of AP entails appendiceal dilation resulting from the obstruction of the appendiceal orifice, thereby influencing the normal drainage of its contents. The stagnant contents and increased bacterial load in the appendix can initiate excessive inflammation, which leads to appendiceal infection and inflammation, thereby triggering AP[17,18]. Timely and effective surgical intervention for this disease is conducive to averting serious complications such as appendiceal perforation[19]. In this study, LA with mesoappendix dissection was proposed for the treatment of AP, and this treatment modality was compared with conventional LA to validate its clinical superiority.

First, the total effective rate of treatment in the observation group of patients undergoing LA with mesoappendix dissection was remarkably high, indicating that LA with mesoappendix dissection for patients with AP can maximize the therapeutic efficacy and facilitate the amelioration of patients’ symptoms and signs. In addition, the operation time, intraoperative blood loss, hospital stay, time to ambulation, gastrointestinal function recovery, and food intake in patients with AP treated by LA with mesoappendix dissection were significantly less, indicating that this therapeutic approach can improve the surgical outcomes of patients with AP and promote postoperative recovery compared with conventional LA. Moreover, LA with mesoappendix dissection can simplify intraoperative hemostasis compared with conventional LA, which is conducive to shortening the operation time[20]. Meanwhile, this therapy can separate and remove the appendix and mesoappendix, which reduces the surgical difficulty of appendectomy[21]. With regard to safety, the overall incidence of adverse events such as postoperative bleeding, pelvic infection, puncture site infection, and ileus in patients under LA with mesoappendix dissection was significantly low, indicating that this surgical procedure can reduce the risk of the abovementioned adverse events. During LA with mesoappendix dissection, a laparoscope was used to magnify the fine structure of the body and to achieve broad exploration of the abdominal cavity, which not only facilitates the determination of the appendix location and reduces the interference with the abdominal cavity, but also decreases the risk of surgery-related adverse events to a certain extent[22]. Furthermore, this surgical technique utilizes a surgical ultrasonic scalpel to transect the mesentery at the distal end of the mesoappendix and to dissect the mesentery at the serosal surface of the appendix, which can prevent active bleeding during the operation to the greatest extent and reduce the stimulation to the patient’s abdominal organs[23]. Moreover, the small sample size obtained can reduce the risk of contact with intra-abdominal pus and purulent coating, thereby decreasing the incidence of adverse events[24]. The safety of LA with mesoappendix dissection, which to a certain extent prevents the occurrence of postoperative adverse events, can promote the smooth postoperative recovery of patients[25]. In addition, this surgical method can reduce postoperative abnormally elevated inflammatory markers such as TNF-α, IL-6, and CRP, indicating that LA with mesoappendix dissection can markedly suppress serum inflammation. This effect may be attributed to the small trauma to the body during the operation of this surgical therapy, which to a certain extent ameliorates inflammatory stress[26]. Finally, binary logistic regression analysis confirmed that sex, age, BMI, time from acute attack to admission, family medical history, preoperative TNF-α, preoperative IL-6, preoperative CRP, and treatment modality were not risk factors affecting patient’s curative effect. Many researchers have also considered other modified approaches to appendectomy. For example, Liu et al[27] reported that single-incision transumbilical LA, when implemented in children with AP, has remarkable superiority with regard to pain alleviation and enhancement of cosmetic appearance compared with the conventional three-port LA. Moreover, Zhang et al[28] noted that the modified endoscopic retrograde appendicitis therapy can achieve a surgical success rate of 96.9% among children with uncomplicated (simple) AP, and the recurrence risk within a 1-year period is merely 6.9%.

Notwithstanding the demonstration of the clinical effectiveness, safety, and other clinical advantages of LA with mesoappendix dissection in patients with AP, this study still has several limitations that necessitate further amelioration. First, the sample recruitment for this study was confined to a single center, and the temporal scope of the investigation was hindered. The expansion of the research sample pool by incorporating data from multiple centers over a more prolonged period would incontrovertibly augment the accuracy and reliability of the research findings. Second, the allocation of surgical modalities in this study might be susceptible to biases caused by the age of patients upon admission, the duration of symptom manifestation, and the predilection of the surgeons involved. Finally, relevant investigations regarding immune-related indices are lacking. The supplementation of such analyses could provide deeper insights into the potential influence of the two surgical methods on the immune function of patients. Future research initiatives will be directed toward progressively enhancing and refining this study by addressing the aforementioned concerns.

CONCLUSION

Based on the results, LA with mesoappendix dissection for the treatment of patients with AP can enhance curative efficacy and surgical outcomes, facilitate postoperative rehabilitation, decrease the incidence of adverse events, and prevent excessive elevation of inflammatory markers such as TNF-α, IL-6, and CRP caused by surgical stimulation, indicating its great potential for clinical applications.