Consensus conference on laparoscopic appendectomy: development of guidelines
Colorectal Disease, 02/08/2011
Exclusive author commentary
Nereo V et al. – Statements were formulated whenever an agreement was reached and a level of evidence was then assigned to each statement and revised when necessary by two external reviewers. The authors report the results in this article.
Vettoretto Nereo (02/09/2011) comments:
Laparoscopic appendectomy is, today, widely disseminated among surgical practices both in Italy and in western countries, partly due to an increase in advanced laparoscopic surgery and to the high incidence of the disease. ACOI (Association of Italian Hospital Surgeons) has organized a Consensus Conference, in order to give an evidence-based answer to the most debated issues. After a research in the literature a panel of 21 experienced surgeons were selected and interviewed; a subsequent discussion using the Delphi method was taken in the course of a national congress and submitted to the evaluation of an audience of surgeons. Checkpoint statements were formulated whenever an agreement was possible. A level of evidence was then assigned to single statements and the entire process was revised by two external and one internal reviewers. Consensus development guidelines regard diagnostic pathway (mainly clinical, gynaecological exam and pregnancy test recommended, computed tomography to be considered a second choice exam, C-reactive protein only in clinical trials), diagnostic laparoscopy (recommended as final diagnostic act, especially in fertile women, elderly and obese, after a period of active observation in doubtful cases), indications (opportune in women, men, obese, elderly), behaviour in case of innocent appendix (preservation in case of concomitant pathology), conversion (never mandatory, adequate laparotomy suggested whenever needed), technical aspects (proper triangulation of the trocars, bipolar coagulation for the mesoappendix, loop for the stump, stapler recommended for gangrene, mandatory protection of the abdominal wall in extraction, thorough peritoneal washing in peritonitis, drain not needed), learning curve (20 cases for the beginner, previous laparoscopic experience important); some questions remain unsolved (pregnancy, removal of an innocent appendix in case of absence of other diseases) due to the lack of participated evidence.