ORIGINAL ARTICLE


https://doi.org/10.5005/jp-journals-10033-1586
World Journal of Laparoscopic Surgery
Volume 16 | Issue 3 | Year 2023

Omental Wrapping of the Cecum and Appendix Stump Reduces Postoperative Pain and Speeds Recovery after Laparoscopic Appendectomy: A Prospective Randomized Controlled Trial


Rihan Maged https://orcid.org/0000-0001-9323-9405

Department of General Surgery, Cairo University Kasr Alainy Faculty of Medicine, Cairo Governorate, Egypt

Corresponding Author: Maged Rihan, Department of General Surgery, Cairo University Kasr Alainy Faculty of Medicine, Cairo Governorate, Egypt, Phone: +00966596519744, e-mail: magedrihan@hotmail.com

How to cite this article: Rihan M. Omental Wrapping of the Cecum and Appendix Stump Reduces Postoperative Pain and Speeds Recovery after Laparoscopic Appendectomy: A Prospective Randomized Controlled Trial. World J Lap Surg 2023;16(3):158–162.

Source of support: Nil

Conflict of interest: None

Received on: 23 October 2023; Accepted on: 18 November 2023; Published on: 11 January 2024

ABSTRACT

Introduction: Many factors contribute to pain after laparoscopic appendectomy. We devised a method to reduce pain after laparoscopic appendectomy by wrapping the cecum with the greater omentum. This study aimed to investigate the effectiveness of this method.

Materials and methods: This study was conducted to compare the operative and postoperative outcomes in patients with omental wrapping and traditional laparoscopic appendectomy patients. The primary endpoints were the degree of postoperative intra-abdominal pain intensity evaluated by visual analogue scale (VAS), and analgesic use.

The secondary endpoints were the operation time, time to pass gas, white blood cell count, C-reactive protein (CRP) on the second postoperative day, numerical rating scale for postoperative nausea, frequency of antiemetic medications frequency, and length of hospital stay. The study was registered in the International Standard Randomised Controlled Trial Number (ISRCTN) registry (ISRCTN 89363255).

Results: This study evaluated 106 patients. Fifty patients were assigned to the traditional group and 56 to the wrapping group. Pain scores in the first postoperative 24 hours were significantly higher in traditional group patients (p = 0.007). Between 24 and 48 hours, pain score was also higher in traditional group patients (p = 0.01). Time to pass gas was achieved earlier in the wrapping group (p < 0.001).

Conclusion: Omental wrapping of the cecum and appendix stump in laparoscopic appendectomy can provide postoperative pain relief by reducing the intensity of visceral pain.

Keywords: Laparoscopic appendectomy, Omental wrapping, Postoperative pain, Randomized controlled trial.

INTRODUCTION

Acute appendicitis is the most common indication for emergency abdominal surgical intervention. Approximately 7% of people will have acute appendicitis, with the highest incidence in the second and third decades.1 Open appendectomy has remained the gold standard surgery for over a century with low morbidity and mortality. Laparoscopic appendectomy has become the standard procedure over the last two to three decades. It results in less postoperative pain, shorter hospital stay, faster postoperative recovery, better visualization of lower abdominal quadrants, and fewer complications than the open method.2,3

However, laparoscopy is not a pain-free intervention, and control of pain after laparoscopy remains a major concern.4 There are many factors that contribute to pain induction after laparoscopic appendectomy, including intraabdominal or visceral causes like pneumoperitoneum, diaphragmatic stretching, and direct tissue injury, and abdominal wall or parietal pain from the incision sites.5 Different methods have been tried to reduce intraabdominal pain after laparoscopic appendectomy as local anesthetic solutions injection into the peritoneal cavity.6,7

The omentum is a dynamic organ, it wanders here and there in the peritoneal cavity handling the contaminations and infections. It controls inflammation, and enhances revascularization and tissue regeneration.8 It is usually seen covering sites of inflammation and damage and has the ability to hinder the propagation of intra-abdominal infections and isolate it from the surrounding healthy tissues. It achieves this immune job by sticking to inflamed tissues, absorbing contaminants, and providing leukocytes.9,10

We devised a method to minimize postoperative pain after laparoscopic appendectomy by wrapping the cecum and the appendix stump by the greater omentum at the end of laparoscopic appendectomy. We named the procedure “omental wrapping of the cecum and appendix stump”. This current study aimed to find out the benefits and effectiveness of this method compared to the traditional method.

MATERIALS AND METHODS

Study Design

This prospective randomized controlled study was designed to compare the operative and postoperative outcomes in omental wrapping patients and traditional laparoscopic appendectomy patients from June 2020 to May 2023 at Jeddah National Hospital (in Jeddah, Kingdom of Saudi Arabia). The study was registered on 7-8-2023 at the International Standard Randomised Controlled Trial Number (ISRCTN) registry (ISRCTN 89363255).

Eligibility and Exclusion Criteria

This study included patients aged more than 18 years, diagnosed with acute appendicitis by clinical examination, ultrasonography, or CT scan. Patients with complicated appendicitis by perforation or abscess formation were excluded. Pregnant women were excluded.

Randomization

Randomization was done by the computational random number generator method. The evaluators for participants and pain were blinded to the appendectomy operation details. The traditional and wrapping groups underwent stratification-randomization in a 1:1 ratio.

Withdrawal Criteria

The patient was withdrawn from evaluation if the surgical technique was changed (conversion to open laparotomy or further surgery was done), the intraoperative finding of short omentum, the drainage tube was placed, the patient could not distinguish between intra-abdominal pain and pain originating from abdominal wounds, or if a patient expressed his desire to terminate the study.

Surgical Technique

In all patients, laparoscopic appendectomy was done by laparoscopic surgery experienced surgeons. Under general anesthesia; the patient was positioned in the Trendelenburg position. The three-port technique (a 10 mm visual in the periumbilical area, a 5 mm in the left iliac region, and a 5 mm in the right upper quadrant) was used. This distribution of the port sites made the lower right region of the abdomen free and far from the wounds, which made it easier for patients to differentiate between the pain coming from inside the abdomen and the pain coming from the wounds after surgery.

In both groups, the harmonic scalpel was used to divide the mesoappendix, and the appendicular base was controlled by three endo loops (two at the cecal side and one at the distal appendix). In the second group, at the end of the procedure the patient position was changed to the anti-Trendelenburg position to allow easy mobilization of the distal part of the greater omentum, and placed over the cecum to cover the appendix stump to act as an insulator between the stump and the parietal peritoneum, using one or two resorbable tacks to fix the lower surface of the omentum to the peritoneal folds or appendices epiploicae of the cecum and not to the cecal wall itself (Fig. 1). In the end, the inflation pressure is gradually decreased, while ensuring that the omentum remains within the scope of vision until it is confirmed that it is in the same place until the abdomen is completely emptied and becomes completely adherent to the parietal peritoneum.

Figs 1A to C: Operative procedure: The distal greater omentum is mobilized to cover the cecum with appendix stump. Arrow: appendix stump

Endpoints

The primary endpoints were the degree of postoperative intraabdominal (visceral) pain intensity evaluated by visual analogue scale (VAS), and analgesics administration in the form of parenteral nonsteroidal anti-inflammatory drugs (NSAIDs). Control of postoperative pain for the two groups followed the same standards and was carried out according to the patient’s preference. Patients and nursing staff were blinded to the randomization results. The VAS score was explained to the patients to rate their pain on the specified scale, where 0 is no pain and 10 is the worst imaginable pain.

The secondary endpoints were the operation time, time to pass gas, white blood cell count, and C-reactive protein (CRP) on the second postoperative day. We also evaluated the numerical rating scale for postoperative nausea, frequency of antiemetic medications frequency, and length of hospital stay.

Statistical Analysis

We designed this study to test the hypothesis that omental wrapping is better than traditional laparoscopic appendectomy in relieving postoperative pain. Values are shown as median numbers and the interquartile range (IQR) or mean numbers ± standard deviations (SDs). Continuous variables were analyzed by t-test, Mann–Whitney U test, or repeated measures design. Discrete variables were compared by Chi-squared test or Fisher’s exact test. Analysis used IBM SPSS Statistics version 23.0 (IBM Corp., Armonk, NY, USA). Probability (p-value) was considered of significance if ≤ 0.05.

RESULTS

This study finally evaluated 106 patients. Fifty patients were assigned to the traditional group and 56 patients to the wrapping group. All patients were evenly allocated concerning age, sex, body mass index, American Society of Anesthesiologists physical status (ASA) classification, and history of abdominal surgery. There was no difference regarding the previous variables between the two groups (Table 1).

Table 1: Patients’ demographic data

  Traditional group (No. 50) Wrapping group (No. 56) p-value
Age (year) 36.8 ± 14.7 (18–72) 40.9 ± 13.9 (18–67) 0.282
Male 31 (62%) 29 (51.8%) 0.513
Body mass index (kg/m2) 24.54 ± 3.58 (18.13–40.12) 23.42 ± 4.16 (17.84–37.24) 0.278
ASA classification      
I 41 (82%) 46 (82.1%)  
II 8 (16%) 9 (16.1%)  
III 1 (2%) 1 (1.8%)  
History of abdominal surgery 6 (12%) 9 (16.1%) 0.462
Values are presented as number only; mean ± standard deviation (range); No, number of patients; ASA, American Society of Anesthesiologists

Postoperative Pain Assessment

Pain scores are shown in Table 2. Pain score in the first postoperative 24 hours was significantly higher in traditional group patients (p = 0.007). Between 24 and 48 hours, pain score was also higher in traditional group patients (p = 0.01). No differences were present for 48 to 72 hours following operation (Fig. 2).

Table 2: Postoperative pain score using visual analogue scale

  Traditional group (No. 50) Wrapping group (No. 56) p-valuea
<24 hours 5 (4–6) 3 (2–5) 0.007
  5.2 ± 1.2 3.6 ± 1.5  
>24 and <48 hours 3 (2–4) 1 (1–2) 0.01
  3.2 ± 1.4 1.1 ± 1.2  
>48 and <72 hours 0 (0–1) 0 (0–3) 1.000
  0.5 ± 0.3 0.4 ± 0.9  
Values are presented as median (interquartile range) and mean ± standard deviation; aThe Mann–Whitney U-test; p-values were corrected by Bonferroni’s method

Fig. 2: Postoperative pain score on the visual analogue scale in the two groups

There was a significant difference between the two groups as regards the change in pain score during the postoperative days (Fig. 3).

Fig. 3 The change in the visual analogue scale pain score during the postoperative days was significantly different between the two groups (p = 0.027 by repeated measures analysis of variance)

Higher doses of analgesics were prescribed for patients in the traditional group during the two days following surgery, with no significant difference (Table 3).

Table 3: The mean number of analgesic doses following surgery

  Traditional group (No. 50) Wrapping group (No. 56) p-value
<24 hours 1.35 ± 0.74 0.76 ± 0.68 0.068
>24 hours 0.16 ± 0.41 0.07 ± 0.18 0.16
Values are presented as mean ± SD

Other Postoperative Outcomes

Times to pass gas were shorter in the wrapping group patients (p < 0.001), which was an unexpected finding. Operative time, inflammatory markers (WBC and CRP) levels, nausea degree, antiemetics doses, and hospital length of stay had no significant difference between the two groups (Table 4).

Table 4: Other postoperative outcomes

Variable Traditional group (No. 50) Wrapping group (No. 56) p-value
Operative time (min) 40.3 ± 18.4 (21–90) 38.2 ± 20.6 (18–105) 0.864
Time to pass gas (hour) 32 ± 13.6 (18–46) 18 ± 8.4 (9–32) <0.001
WBC count (×103/μL)
Preoperative 13.32 ± 3.74 (5.28–19.46) 12.48 ± 3.65 (4.86–20.22) 0.824
>24 and <48 hours 9.15 ± 2.48 (5.62–15.34) 8.87 ± 3.92 (4.43–22.65) 0.632
CRP level (mg/L)
Preoperative 17.6 ± 32.8 (0.5–135.3) 15.5 ± 26.4 (0.4–125) 0.486
>24 and <48 hours 54.7 ± 51.2 (3.1–185) 64.2 ± 63.6 (4.3–225) 0.763
Nausea (by NRS)
<24 hours 0.43 ± 1.71 (0–8) 0.12 ± 0.52 (0–4) 0.258
>24 and <48 hours 0.18 ± 1.12 (0–6) 0.41 ± 1.64 (0–8) 0.364
>48 and <72 hours 0.00 ± 0.00 (0–0) 0.04 ± 0.22 (0–2) 0.246
Antiemetics
<24 hours 0.05 ± 0.32 (0–1) 0.04 ± 0.24 (0–2) 0.778
>24 and <48 hours 0.04 ± 0.20 (0–1) 0.01 ± 0.15 (0–1) 0.352
>48 and <72 hours 0.00 ± 0.00 (0–0) 0.01 ± 0.12 (0–1) 0.164
Hospital stay (day) 1.5 ± 0.6 (1–4) 1.4 ± 0.7 (2–4) 0.867
Values are presented as number only; mean ± standard deviation (range); NRS, numerical rating scale

DISCUSSION

Patients after laparoscopic surgeries report severe pain, which is often underestimated. Pain ratings after laparoscopic appendectomy are similar to those after knee joint replacement and sternotomy.11 Both visceral (intra-abdominal), and parietal (abdominal wall wounds) pain causes a lot of suffering for patients after laparoscopic appendectomy.12 In a study of traditional three ports laparoscopic appendectomy patients, The VAS scores were presented as median (interquartile range) and mean ± standard deviation, on 1st day 4 (3–6) 4.7 ± 1.6, on 2nd day 2 (2–3) 2.1 ± 1.3, and on 3rd day 0 (0–3) 0.4 ± 0.8.13 These scores are slightly lower than those in our study as regards the traditional group, and more than those in the wrapping group.

Different methods have been tried to minimize the intensity of intra-abdominal pain and to improve outcomes after laparoscopic surgeries, including low-pressure insufflation, subcutaneous anesthetic infiltration, saline washout, and intra-peritoneal instillation of local anesthetics.14,15 However, the findings of these trials were of low significance.16

Transposition of the omentum over the injured organ or tissue is a common surgical procedure. It can be done by simple placing and fixation, or by doing an omental flap (omentoplasty) which is prepared for elongation and better positioning of the omentum on the desired site. It has been used to circumvent around the sites of the intestinal anastomosis to strengthen it, and to prevent leakage. Some characteristics of the omentum such as mobility and adherence to contaminated areas are fully recognized in the context of appendicitis.17 One study included 112 patients with colorectal resections, and reported positive results with omentoplasty. Only 3.8% of patients with omentoplasty had leaks from the anastomosis, compared to 11.8% of patients who did not have omentoplasty.18

Our prospective study presented that the pain score in the two days following laparoscopic appendectomy was higher in the traditional laparoscopic appendectomy group and that a significant difference was present between the two groups regarding the change in pain intensity after surgery. Pain evaluation was blinded and done by the nursing staff that was ignorant of the study details. The time to pass gas was shorter in the omental wrapping group, which may prove the relationship between postoperative pain and delayed recovery of bowel function. Minimizing postoperative pain in laparoscopic appendectomy patients is very important, especially on the first day after surgery. In this study, the traditional group patients were prescribed more total doses of analgesics within 24 hours after the operation, but the difference had no statistical significance because of the relatively small size of the sample and the number of doses of analgesics prescribed in the two groups. In this study, the mean number of doses prescribed during the first day after surgery was 1.35 in the traditional group and 0.76 in the omental wrapping group. In another study, the mean number of analgesic doses in the 24 hours after laparoscopic appendectomy ranged from 0.9 to 3.8.1921

This study was carried out by surgeons who primarily perform traditional laparoscopic appendectomy and a surgeon who developed the omental wrapping technique and mainly performed it. So, it possesses the strength of having less possibility of biased results. Another strength point is that the patients and the pain score evaluators were blinded to eliminate subjective confusion as much as possible. Although pain scoring is subjective, it is thought appropriate endpoint because it is well known to be one of the main indicators in the clinical monitoring of any patient.

The weak point is that the difference in scores between the two groups was not as great as was expected at the planning stage.

More studies will be necessary to evaluate the beneficial effects of omental wrapping of the cecum and appendix stump in laparoscopic appendectomy especially in patients with complicated appendicitis and more difficult surgeries.

CONCLUSION

Omental wrapping of the cecum and appendix stump in laparoscopic appendectomy can provide postoperative pain relief by reducing the intensity of visceral or intra-abdominal pain and can be considered an easy technique to aid in rapid recovery after the operation.

Clinical Significance

To the best of our knowledge, this is the first study that demonstrated the technique of wrapping the omentum around the cecum and appendix stump after laparoscopic appendectomy. We concluded that this technique minimized the pain score and bowel recovery time after surgery.

Ethical Approval

The study was approved by the research ethics board in the Jeddah National Hospital (IRB number: R 20.43). All patients were informed about the nature and the protocol of the study. Written informed consent was collected from each patient before enrollment.

ORCID

Maged Rihan https://orcid.org/0000-0001-9323-9405

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