Laparoscopic appendectomy was described in 1983 and has become the gold standard approach for acute appendicitis in my daily clinical practice, as it is in worldwide hospitals. Nowadays, 75% of appendectomies performed in the USA are laparoscopically done. According to some authors, this minimally invasive technique has several advantages over open technique namely less pain, faster recovery and shorter hospital-stay. In my opinion, the great advantages of laparoscopic approach over open surgery are not those classical ones, but instead are the possibility to make a different diagnosis in case of non-inflamed appendix, possibility to diagnose concomitant pathologies, easier to perform appendectomy in cases of a retrocecal location of the appendix, easier to perform appendectomy in obese patients. Infectious complications are still a risk in laparoscopic appendectomy, with several authors concluding that there is a risk up to three-fold higher of organ space infection with laparoscopy comparing to open surgery. Is there anything we can do to solve this? Irrigation by itself has not proved to reduce infection. I personally use a retrieval bag in every laparoscopic appendectomy. Am I doing right? Am I only spending more time and money without an effective reduction of infectious risk?
Laparoscopic appendectomy is the gold standard of care in acute appendicitis. But organ space infection is still higher following this minimally invasive technique.
Dr Adam Fields et al from the Department of Surgery of Harvard Medical School, Boston, USA, studied whether the use of a retrieval bag has positive effect in reducing infection following laparoscopic appendectomy. A total of 11475 adult patients operated in 2016 were analyzed. A retrieval bag was used in 92,2%, and 7,8% of patients had the appendix removed without a bag. Both groups (with and without retrieval bag) were compared. According to complicated appendicitis (perforation or abscess), age, BMI, ASA score, smoking status and operative time, the two groups were similar. Primary outcome: infection rate (superficial site infection, intra-abdominal abscess).
There was no difference in superficial site infection rate between the two groups (p=0,28). However, there was a shift towards increase intra-abdominal abscess rate when the retrieval bag was not used, although p=0,06. In a multivariate analysis the authors concluded that the use of a retrieval bag was an independent factor to a decreased intra-abdominal abscess rate. They even state that a retrieval bag reduced organ space infection in 40%. Other independent factor for intra-abdominal abscess were complicated appendicitis, diabetes and preoperative sepsis. This means that operating as soon as possible has a positive impact in postoperative complications after appendectomy, I think. In fact, this idea has already been studied by doctors from Texas, whose results concluded that delaying surgery less than 3h decreases the risk of perforation and postoperative infection. These results were presented in a previous post in this blog: “How long from the CT to the OR for non-perforated appendicitis? ASAP!”, December 2017.
The use of a retrieval bag can reduce intra-abdominal abscess following laparoscopic appendectomy for acute appendicits.
Why does the use of a retrieval bag reduce organ space infection? There is not a consensus answer. The authors believe that using a bag will reduce abdominal contamination during irrigation or manipulation of an uncovered abscess. From this idea, I believe we should irrigate only after putting the inflamed appendix in the retrieval bag, avoiding “cleansing” bacteria from it to the entire peritoneal cavity.
Some surgeons do not use the retrieval bag to do not spend more time, or not to spend money. About the operating time, there was no difference between both groups, so this must not be an excuse. Will we save money by not using a bag? The authors present interesting data. Only patients in the no-bag group had intra-abdominal infection. Some needed a reoperation or a percutaneous procedure. The mean cost of a surgical site infection is $20785, a retrieval bag cost $50. In this study, the authors needed to treat 91 patients with a retrieval bag to prevent an intra-abdominal abscess. So… By spending $50 in 91 patients ($4550) it is possible to save $16235 ($20785-$4550). As about 370000 patients are submitted to appendectomy in the USA, by using a retrieval bag it is possible to save $66million each year. In conclusion, by using a retrieval bag in a laparoscopic appendectomy you are saving money by reducing postoperative infection rates.
By using a retrieval bag surgeons are saving money.
A previous posted educational movie of a laparoscopic appendectomy using a retrieval bag is available in Surgical Thoughts. Irrigation was performed only after putting the appendix in the bag. "Surgical Videos": assist the vídeo "Laparoscopic appendectomy".
Although being a retrospective study, this is the first study of its kind including such a great number of patients. The results presented are to be consider in clinical practice although antibiotic protocols were not analyzed, which are known to have impact in infection rate. In my opinion, the use of a retrieval bag should be standard practice in laparoscopic appendectomy. I will keep using it… And you?
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon