Inflammation of Vermiform Appendix Treatment & Management
- Author: Steven L Lee, MD; Chief Editor: John Geibel, MD, DSc, MSc, MA more...
Indications for surgical consultation
A surgeon should evaluate any patient with classic migrating abdominal pain and right-lower-quadrant (RLQ) tenderness. Given that only a little more than half of patients with appendicitis present with a classic history and physical findings, acute appendicitis should be on the list of possible diagnoses for any patient with abdominal pain. Thus, a surgeon should also evaluate patients with focal RLQ tenderness or progressively worsening abdominal pain.
To minimize the time between presentation and appendectomy, obtain surgical consultation before performing additional diagnostic studies, such as computed tomography (CT) and ultrasonography.
Indications for operation
Appendectomy is typically performed after the diagnosis of appendicitis is made. Patients with a classic history and physical examination findings, along with a normal urine analysis (or pyuria) and an elevated white blood cell (WBC) count with a left shift, usually do not need any additional imaging studies prior to appendectomy. Surgery is also indicated in patients with an atypical presentation and radiographic findings consistent with appendicitis.
Any patient with atypical abdominal pain who (1) experiences persistent pain and becomes febrile, (2) has a rising WBC count, or (3) exhibits worsening clinical examination findings should undergo diagnostic laparoscopy and appendectomy. In patients with an atypical presentation, serial physical examinations are the most important tool in deciding if a patient needs surgery. The WBC count often does not increase after the patient is admitted and hydrated; therefore, any patient sent home from the emergency department should undergo a follow-up evaluation the next day.
Contraindications for operation
No contraindications to performing an appendectomy in patients with suspected appendicitis exist; however, patients with a well-developed abscess (detected on CT) following perforated appendicitis may be initially treated with percutaneous drainage and intravenous (IV) antibiotics.
Once bowel function resumes, the patient may be discharged on oral antibiotics (total IV plus oral antibiotics for 7-10 days) with consideration for interval appendectomy in 6 weeks.
Although appendectomy is still the standard treatment, a meta-analysis by Wilms et al led to the conclusion that antibiotic treatment alone might be feasible in specific patients or conditions in which surgery is contraindicated, or in a well-designed randomized, controlled clinical trial.[30, 31] These findings suggest that once broad-spectrum IV antibiotics have been initiated, it is likely that the progression of disease has been halted or reversed.
The multicenter, open-label, randomized Appendicitis Acuta (APPAC) clinical trial was designed to compare antibiotic therapy with appendectomy for treatment of CT-confirmed uncomplicated acute appendicitis. The aim was to determine whether antibiotic treatment was noninferior to surgery; the rpespecified noninferiority margin was 24%. The primary end point for surgically treated patients (n=273) was successful completion of appendectomy; that for antibiotic-treated patients (n=257) was hospital discharge without need for surgery and no recurrence of appendicitis over 1 year of follow-up.
On intent-to-treat analysis, there was a –27% difference in treatment efficacy between the two groups, favoring surgery. Thus, the researchers did not demonstrate antibiotic treatment to be noninferior to surgery according to the prespecified noniferiority margin. However, most patients randomized to antibiotic treatment for uncomplicated appendicitis did not require appendectomy during the 1-year follow-up period, and those who required appendectomy did not experience significant complications.
Current findings suggest that appendectomy may be considered a semielective operation rather than an automatically urgent or emergency procedure, as it had been considered in the past. A retrospective study by Kim et al found that delayed appendectomy is safe for patients with acute nonperforated appendicitis.
All patients diagnosed with appendicitis should be adequately hydrated with isotonic IV fluids. In addition, broad-spectrum IV antibiotics (ampicillin, gentamicin, and metronidazole or a third-generation cephalosporin and metronidazole) should be started prior to the operation. Newer single-agent broad-spectrum antibiotic regimens are at least as effective as the traditional triple therapy and may also be used.
Antibiotics, analgesics, and antipyretics should not be administered to patients admitted for serial examinations, because these medications may mask the underlying disease process.
To minimize the time from presentation to appendectomy, surgical consultation should be obtained before additional diagnostic studies are obtained; these tests are often unnecessary.
The basic technique for open and laparoscopic appendectomy is described below and is individualized to the authors' preference. Other approaches, suture materials, or techniques may be used with equal success.
Most surgeons perform appendectomy through a RLQ incision over the McBurney point, located two thirds of the distance between the umbilicus and the anterior superior iliac spine. The subcutaneous tissue and Scarpa fascia are dissected until the external oblique aponeurosis is identified. This aponeurosis is divided sharply along the direction of its fibers. A muscle-splitting technique is then used to gain access to the peritoneum. Although historically, intraoperative cultures of purulent peritoneal fluid were obtained, cultures have not been shown to be helpful at the time of initial operation.
Delivery of appendix
Small Richardson retractors are placed into the peritoneum, and the cecum is identified and partially exteriorized with a moist gauze pad or Babcock clamp. The taeniae coli are followed to the point where they converge at the base of the appendix. The rest of the appendix is then brought into the field of vision. Gentle manipulation may be required to bluntly dissect any inflammatory adhesions.
Division of mesoappendix and ligation of appendix
Once the appendix is exteriorized, the mesoappendix is divided between clamps, divided, and ligated. The base of the appendix is clamped after milking potential fecaliths into the lumen of the appendix. The appendix is then tied off with a 0 polyglycolic acid suture. The appendix is amputated and passed off the field as a specimen.
The mucosa of the appendiceal stump may be cauterized to avoid future mucus production. Inverting the appendiceal stump is not necessary. The cecum and appendiceal stump are then placed back into the abdomen. The pelvis and the right pericolic gutter are suctioned to remove any fluid. If no evidence of free perforation exists, further peritoneal lavage is not necessary and may be harmful; however, if free perforation is encountered, the authors prefer to thoroughly irrigate the abdomen with warm saline solution. A drain is not required unless an obvious cavity is present after drainage of a well-developed abscess.
The peritoneum is identified, and hemostats are placed on both apices and on the midpoints of the superior and inferior sides. The peritoneum is closed with a continuous 3-0 polyglycolic acid suture. The inferior oblique muscles are reapproximated with a figure-eight 3-0 polyglycolic acid suture, and the external oblique fascia is closed with a continuous 2-0 polyglycolic acid suture. The skin may be closed with staples or subcutaneous sutures. Use of staples is recommended if the appendix was perforated and skin closure is to be performed. Some authors believe that the skin should be left open in cases of perforated appendicitis, with delayed primary closure performed on postoperative day 4 or 5.
A urinary bladder catheter is placed, and the surgeon typically stands on the left side of the patient. Video monitors are placed at the patient's right side.
A 12-mm supraumbilical incision is made, followed by placement of the Veress needle. After confirmation of intraperitoneal placement, pneumoperitoneum (15 mm Hg) is established and maintained using a carbon dioxide insufflator. The Veress needle is replaced with a 5-mm trocar, and a 5-mm 30º laparoscope is inserted into the peritoneal cavity. Alternatively, the 5-mm trocar can be placed directly into the abdominal cavity using an open cutdown approach. This 5-mm port will be eventually upsized to a 12-mm port once the other ports are placed.
Under direct visualization, a 5-mm trocar is inserted into the left lower quadrant (LLQ), and another 5-mm trocar is placed in the suprapubic region. The camera is moved to the LLQ port, and the patient is placed in Trendelenburg position with a leftward tilt to maximize intraperitoneal exposure of the RLQ. Through the suprapubic trocar, a grasper is used to gain control of the appendix. A dissector placed through the supraumbilical port is used to create a small hole in the mesoappendix at the base of the appendix. An endoscopic gastrointestinal anastomosis (GIA) stapler is then used to staple the base of the appendix, and a vascular reload is used to staple across the mesoappendix.
Once the appendix is free, it is removed through the 12-mm port by using an endoscopic retrieval bag. Any free fluid in the abdomen and pelvis is suctioned. Appropriate peritoneal irrigation is then performed. The fascia of the supraumbilical port site is closed with 0 polyglycolic acid suture, and the skin incisions are closed with subcuticular sutures.
Single-incision laparoscopic appendectomy
Single-incision laparoscopic appendectomy (SILA) has been described and has shown to be safe and effective. This procedure is typically performed through the umbilicus via a multichannel trocar. The main benefit of SILA is cosmetic; however, early studies reported longer operating times.
Treatment of perforated appendicitis with abscess
Patients with perforated appendicitis and abscess formation or phlegmon may be treated with either immediate operative intervention or initial nonoperative management. Although there are some proponents of immediate surgical intervention, a meta-analysis of 19 studies by Andersson et al found a significantly higher morbidity (odds ratio 3.3) than with nonsurgical treatment.
With nonoperative management, patients are initially treated with broad-spectrum IV antibiotics alone or in combination with percutaneous aspiration of the abscess or drain placement. IV antibiotics are continued until the patient is afebrile for 24 hours, has a return of normal gastrointestinal function, and has a normal WBC count with a normal differential. At this time, patients are switched to oral antibiotics for a total antibiotic course of 10-14 days.
Traditionally, interval appendectomy is performed 6-8 weeks later. In view of the low incidence of recurrent appendicitis, the need for routine interval appendectomy has been challenged.[29, 39]
If acute appendicitis is encountered, only one perioperative dose of broad-spectrum antibiotics is needed to decrease the risk of wound infection and abscess formation. Some surgeons prefer to continue antibiotics for 24 hours after appendectomy. A clear liquid diet can be started once the patient has recovered from anesthesia, and diet can be advanced as tolerated.
If gangrenous or perforated appendicitis is encountered, IV antibiotics are continued until the patient is afebrile, has return of bowel function, and has a normal WBC count with a normal differential. Once bowel function returns, clear liquids can be started and the diet advanced as tolerated. In most patients, a nasogastric tube is not needed.[41, 42]
The overall morbidity of appendicitis is approximately 10%. Most perioperative morbidity is caused by infectious complications. Wound infections occur in approximately 5% of all appendectomies; however, the incidence of this complication is related to the stage of appendicitis. The wound infection rate is 1.4% for nonacute appendicitis, 3% for acute appendicitis, and 10-15% for perforated or gangrenous appendicitis. Formation of intra-abdominal or pelvic abscess after appendectomy occurs in 2-5% of patients. The incidence is higher for gangrenous or perforated appendicitis (6-8%) than for early or suppurative appendicitis (1-2%).
Other complications include persistent ileus, small-bowel obstruction, and pulmonary complications, such as atelectasis and pneumonia. Deep venous thrombosis, pulmonary embolism, and myocardial infarction may also occur in the early postoperative period.
The patient should return to the clinic 1-2 weeks after discharge for wound evaluation and discussion of the pathology.
Full activity may be resumed 2 weeks after an appendectomy if the procedure was performed laparoscopically or through an RLQ incision. If a midline incision was used, activity should be limited for 6 weeks.
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