title: Lessons learned with laparoscopic management of complicated grades of acute appendicitis.
abstract: BACKGROUND
  Laparoscopy has not been consolidated as the approach of first choice in the management of complicated appendicitis. Methodological flaws and absence of disease stratification criteria have been implicated in that less evidence. The objective is to study the safe and effectiveness of laparoscopy in the management of complicated appendicitis according to laparoscopic grading system.
  
  
  METHODS
  From January 2008 to January 2011, 154 consecutive patients who underwent a laparoscopic appendectomy for complicated appendicitis were evaluated in the prospective way. The patient's age ranged from 12 to 75 years old (31.7 ± 13.3) and 58.3% were male. Complicated appendicitis refers to gangrenous and/or perforated appendix and were graded as 3A (segmental necrosis), 3B (base necrosis), 4A (abscess), 4B (regional peritonitis) and 5 (diffuse peritonitis). The outcomes including operative time, infection complication, operative complications and conversion rate were chosen to evaluate the procedure.
  
  
  RESULTS
  The grade 3A was the most frequent with 50 (32.4%) patients. The mean operative time was 69.4 ± 26.3 minutes. The grade 4A showed the highest mean operative time (80.1 ± 26.7 minutes). The wound and intra-abdominal infection rates were 2.6 and 4.6%, respectively. The base necrosis was the most important factor associated with the conversion (5.2%). The grades 4A and 5 were associated with greater possibility of intra-abdominal collection. There were no operative complications.
  
  
  CONCLUSIONS
  The laparoscopic management of all complicated grades of acute appendicitis is safe and effective and should be the procedure of first choice. The laparoscopic grading system allows us to assess patients in the same disease stage.
authors.affiliation: Surgery Department, Hospital Universitario (HU) Terezinha de Jesus da Faculdade de Ciencias Medicas e da Saude de Juiz de Fora (SUPREMA), Brasil; Hospital Universitario (HU) Universidade Federal de Juiz de Fora (UFJF), Brasil.
authors.forename: Carlos Augusto
authors.initials: CA
authors.lastname: Gomes
authors.affiliation: Surgery Department, Hospital Universitario (HU) Terezinha de Jesus da Faculdade de Ciencias Medicas e da Saude de Juiz de Fora (SUPREMA), Brasil; Hospital Universitario (HU) Universidade Federal de Juiz de Fora (UFJF), Brasil.
authors.forename: Cleber Soares
authors.initials: CS
authors.lastname: Junior
authors.affiliation: Anestesiology Unit, Hospital Terezinha de Jesus da Faculdade de Ciencias Medicas e da Saude de Juiz de Fora (SUPREMA), Brasil.
authors.forename: Evandro de Freitas Campos
authors.initials: Ede F
authors.lastname: Costa
authors.affiliation: Surgical Unit, Hospital Terezinha de Jesus da Faculdade de Ciencias Medicas e da Saude de Juiz de Fora (SUPREMA), Brasil.
authors.forename: Paula de Assis Pereira
authors.initials: Pde A
authors.lastname: Alves
authors.affiliation: Surgical Unit, Hospital Terezinha de Jesus da Faculdade de Ciencias Medicas e da Saude de Juiz de Fora (SUPREMA), Brasil.
authors.forename: Carolina Vieira
authors.initials: CV
authors.lastname: de Faria
authors.affiliation: Surgical Unit, Hospital Terezinha de Jesus da Faculdade de Ciencias Medicas e da Saude de Juiz de Fora (SUPREMA), Brasil.
authors.forename: Igor Vitoi
authors.initials: IV
authors.lastname: Cangussu
authors.affiliation: Internal Medicine Departament, Hospital Universitario (HU), Universidade Federal de Juiz de Fora (UFJF), Brasil.
authors.forename: Luisa Pires
authors.initials: LP
authors.lastname: Costa
authors.affiliation: Internal Medicine Departament, Hospital Universitario (HU), Universidade Federal de Juiz de Fora (UFJF), Brasil.
authors.forename: Camila Couto
authors.initials: CC
authors.lastname: Gomes
authors.affiliation: Morphology Unit, Faculdade de Ciencias Medicas e da Saude de Juiz de Fora (SUPREMA), Brasil.
authors.forename: Felipe Couto
authors.initials: FC
authors.lastname: Gomes
keywords: Appendectomy; Appendicitis; Laparoscopy; Treatment