Neue Wege in der operativen Behandlung der akuten Appendizitis?

Zusammenfassung

Die akute Appendizitis ist einer der häufigsten abdominellen Notfälle, die eine operative Therapie nötig machen. Nach fast einem Jahrhundert, in dem bei einer akuten Appendizitis als Therapie der Wahl die offene Appendektomie durchgeführt wurde, hat sich durch Einführung der Laparoskopie ein Paradigmenwechsel angedeutet. Auch scheinbar unumstößliche Standards in der Viszeralchirurgie sind nicht davor geschützt, kritisch hinterfragt zu werden. Inzwischen hat sich die laparoskopische Appendektomie, da zumindest deren Gleichwertigkeit, wenn nicht sogar bei einzelnen Patientengruppen eine Überlegenheit gezeigt werden konnte, zum dominierenden Verfahren entwickelt. Aber auch mit der Laparoskopie scheint das Ende des Trends zur weiteren Minimierung des Zugangstraumas noch nicht erreicht zu sein. Seit 2004 erstmalig durch Kalloo im Tierexperiment die transgastrale Peritoneoskopie beschrieben wurde, findet ein beeindruckender Wandel in der Nutzung verschiedener Zugangswege in das Abdomen statt. Bei diesem neuen chirurgischen Ansatz handelt es sich um Operationen, die über natürlich vorhandene Zugangswege durchgeführt werden, Natural Orifice Translumenal Endoscopic Surgery (NOTES). Die Vorstellung, ein intaktes Organ wie z. B. den Magen zu penetrieren, um damit einen Zugang zur Bauchhöhle zu erhalten, widerspricht dem bisherigen Denken in der Chirurgie. Nach Jahren der tierexperimentellen Versuche hat NOTES inzwischen auch bei der akuten Appendizitis Einzug in die klinische Anwendung gefunden. Bis heute gibt es jedoch nur vereinzelte Fallvorstellungen von NOTES-Appendektomien. Tendenziell scheinen die postoperativen Schmerzen verringert sowie eine schnellere Erholung von dem Eingriff vorzuliegen. NOTES hat von Anfang an die Aufmerksamkeit sowohl der Ärzte als auch der Patienten auf sich gezogen. Gleichwohl brauchen neue Entwicklungen Zeit und müssen als OP-Technik standardisiert werden, bevor sie an etablierten Techniken mit jahrelanger Erfahrung bemessen werden. Unbestritten ist, dass, bevor NOTES fest im klinischen Alltag etabliert sein wird, neue Instrumente und entsprechende Operationsendoskope weiter entwickelt und getestet sowie prospektiv-randomisierte Studien durchgeführt werden müssen, die die konventionelle und laparoskopische Appendektomie mit der NOTES-Appendektomie vergleichen.

Abstract

Acute appendicitis is still one of the most common abdominal emergencies necessitating operative treatment. For the past century, the conventional management of appendicitis has been open appendectomy. Since the introduction of laparoscopic appendectomy, it has been performed with increased frequency. Clinical trials evaluating outcomes comparing open appendectomy with laparoscopic appendectomy indicate that laparoscopic appendectomy is associated with lower complication rate and lower mortality and is to be considered the procedure of choice for patients with suspected acute appendicitis. Ever since Kallooʼs first report on transgastric peritoneoscopy in a porcine model in 2004, this dramatic surgical revolution has prompted many surgeons and endoscopists to study this new technique. This complex technique involves breaching the wall of a hollow organ to gain access into the peritoneum: Natural Orifice Translumenal Endoscopic Surgery (NOTES). In recent years, several NOTES experiments have been carried out in animal models and even on humans, including appendectomy. NOTES may help to reduce surgical pain and shorten recovery time. The concept of NOTES has generated intensive interest in the medical community as well as in the group of patients. Although the novel procedure is still far from being mature and many technical problems have to be overcome and more clinical studies have to be done before its widespread application in human appendectomy, NOTES is a promising procedure for the future.

Schlüsselwörter

akute Appendizitis - Appendektomie - NOTES - Minimalinvasivchirurgie

Key words

acute appendicitis - appendectomy - NOTES - minimally invasive surgery

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