Stadiengerechte Versorgung der Appendixbasis im Rahmen der laparoskopischen Appendektomie

 

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Zusammenfassung

Die operative Therapie der Appendizitis muss in Chirurgischen Kliniken routinemäßig und jederzeit in hoher Qualität gewährleistet sein. Die laparoskopische Appendektomie setzt sich mehr und mehr als Standardverfahren durch. Dies begründet den hohen Stellenwert der Aus- und Weiterbildung der Chirurgen in dieser Technik. Aufgrund der hohen Fallzahl hat die Appendektomie eine erhebliche sozio-ökonomische Bedeutung. Entscheidender Schritt der laparoskopischen Appendektomie ist die Versorgung der Appendixbasis. Drei Verfahren des Appendixbasisverschlusses haben sich routinemäßig im klinischen Alltag etabliert: Der Endoloop, der Clip und der Endostapler. Der Stapler kombiniert den Verschluss und die Durchtrennung der Appendix in einem Schritt und ermöglicht zudem auch eine partielle tangentiale Resektion des Zökums. Daher kann der Stapler auch bei einer entzündlich veränderten Appendixbasis sicher angewendet werden. Sein Nachteil spiegelt sich im Wesentlichen in den hohen Kosten wieder. Der Endoloop und der Clip sind demgegenüber kosteneffektiver. Der Clip erscheint einfacher in der Anwendung als der Loop und ermöglicht ebenso wie der Stapler den Verschluss der Appendixbasis vor der Dissektion der Mesoappendix. Dagegen ist beim Clip der zu versorgende Durchmesser der Appendixbasis mit 16 mm limitiert. Diesen Nachteil bietet der Endoloop nicht. In dieser Übersicht diskutieren wir die Vor- und Nachteile der einzelnen Verfahren und geben eine Empfehlung zu deren stadiengerechtem Einsatz. Endoloop oder Clip sind bei der unkomplizierten Appendizitis das Verfahren der Wahl, während der Endostapler bei fortgeschrittener Entzündung, insbesondere der Appendixbasis, zum Einsatz kommen sollte. So können die im Vergleich zur offenen Appendektomie höheren Kosten des laparoskopischen Vorgehens kontrolliert werden.

Abstract

The frequency of laparoscopic appendectomy has dramatically increased with it now being the standard procedure for acute appendicitis in many hospitals in Germany. Hence, these hospitals require the personnel, the technique as well as the expertise to guarantee a top standard and quality of appendectomies at all times. Only this will meet the requirements of the high case load and the socio-economical importance of appendectomies. The closure of the appendicular stump is a critical step of this procedure. The three most commonly used techniques consist of the endo-loop, the clip and the endo-stapler. The endo-stapler has the advantage of offering closure and transection of the appendix in one step; it can be employed in all cases of appendicular inflammation; and it allows a partial caecal resection. However, it is quite expensive. The clip and the endo-loop offer the same cost-effectiveness, yet the clip appears to be simpler in use compared to the loop. Also, sharing this feature with the stapler, it offers the possibility of closing and transecting the appendix before dissecting the mesoappendix. A disadvantage of the clip not being shared with the loop is the limitation of clips to appendicular diameters of only up to 16 mm. In summary, we propose a cost-effective disease-adapted closure of the appendicular stump employing the clip in standard appendectomies, with the endo-loop being a good alternative. If clip or loop cannot be applied the stapler is the technique of choice. In particular, it should be used if the base of the appendix is inflamed. Adopting this pathway helps to control the still somewhat higher costs of laparoscopic appendectomies compared to classical open appendectomies.

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