Vermiform Appendix Treatment & Management

Although appendectomy is still the standard treatment, Wilms et al concluded that antibiotic treatment might be used as an alternative treatment in a good quality randomized, controlled trial or in specific patients or conditions in which surgery is contraindicated.^[24]

A total of 17 prospective randomized trials have compared laparoscopic versus open appendectomy. The two techniques are similar with respect to the negative appendectomy rate (lap = 14.4% vs open = 14.5%), length of hospital stay (lap = 3 d vs open = 3.7 d), and intra-abdominal abscess (lap = 1.9% vs open = 0.8%).

Laparoscopic appendectomy appears to have a slightly lower wound infection rate (2.9%) compared to open appendectomy (7.4%).^[5]

The benefits of a laparoscopic approach seem to be more pronounced among obese patients, where a recent study found a significantly shorter length of hospital stay (lap = 3.4 d vs open = 5.5 d) and a higher wound closure rate (lap = 90% vs open = 68%).^[25]

All patients diagnosed with appendicitis should be adequately hydrated with isotonic intravenous fluids. In addition, broad-spectrum intravenous antibiotics (ampicillin, gentamicin, and metronidazole or a third-generation cephalosporin and metronidazole) should be started prior to the operation. Newer single agent, broad-spectrum antibiotics may also be used, and they are at least as effective as the traditional triple therapy.^[26]

Antibiotics, analgesics, or antipyretics should not be administered to patients admitted for serial examination because these medications may mask the underlying disease process.

To minimize the time from presentation to the time of appendectomy, surgical consultation should be obtained prior to obtaining additional diagnostic studies, as these tests are often unnecessary.^[3]

The basic technique for open and laparoscopic appendectomy is described below and is individualized to the authors' preference.^[5] Other approaches, suture materials, or techniques may be used with equal success.

Open appendectomy

Incision: Most surgeons perform appendectomy through a RLQ incision over the McBurney point (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. Once the peritoneum is entered, any purulent fluid should be cultured.

Delivering the appendix: Small Richardson retractors are placed into the peritoneum, and the cecum is identified and partially exteriorized using a moist gauze pad or Babcock clamp. The taenia coli is followed to the point where it converges with the other taenia, leading to 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 the mesoappendix and ligation of the 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 (PG) 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 mucous 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 potentially 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 following drainage of a well-developed abscess.

Closure of the incision: The peritoneum is identified, and hemostats are placed on the cut ends at both apices and the midpoint of the superior and inferior sides. The peritoneum is closed with a continuous 3-0 PG suture. The inferior oblique muscles are reapproximated with a figure-of-eight 3-0 PG suture, and the external oblique fascia is closed with a continuous 2-0 PG 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.

Laparoscopic appendectomy

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 feet.

A 6-mm infraumbilical incision is made, followed by placement of the Veress needle. After confirmation of intraperitoneal placement, a pneumoperitoneum (14 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, 30-degree laparoscope is used. Alternatively, the 5-mm trocar can be placed directly into the abdominal cavity using an open cutdown approach.

Under direct visualization, a 12-mm trocar is inserted into the left lower quadrant (LLQ) and another 5-mm trocar in the right periumbilical region. Through the right periumbilical trocar, a grasper is used to gain control of the appendix. A small hole in the mesoappendix is made using a dissector placed through the LLQ port at the base of the appendix. An endo-gastrointestinal assistant 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 LLQ port. Appropriate peritoneal irrigation is then performed. The fascia of the LLQ and infraumbilical port sites are closed with 0-PG suture, and the skin incisions are closed with subcuticular sutures.

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, it has been associated with significantly higher morbidity (odds ratio 3.3) than nonsurgical treatment in a meta-analysis of 19 studies by Andersson et al.^[27]

With nonoperative management, patients are initially treated with broad-spectrum, intravenous antibiotics alone or in combination with percutaneous aspiration of the abscess and/or drain placement.^[28] Intravenous 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. The need for routine interval appendectomy has recently been challenged given the low incidence of recurrent appendicitis.^{[10, 29]}

If acute appendicitis is encountered, perioperative antibiotics covering skin flora should be continued for 24 hours. If suppurative appendicitis is encountered, intravenous antibiotics covering enteric flora should be continued for 48-72 hours and can be safely discontinued once the patient remains afebrile for 24 hours. In both instances, clear liquids can be started once the patient is stable from anesthesia, and diet can be advanced as tolerated.

If gangrenous or perforated appendicitis is encountered, continue intravenous antibiotics until the patient is afebrile and has return of bowel function and 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.^[30]

The patient should return to the clinic 1-2 weeks following discharge for wound evaluation and discussion of the pathology.

Full activity may resume in 2 weeks following appendectomy if performed through an RLQ incision. If a midline incision was used, activity should be limited for 6 weeks.

The overall morbidity rate of appendicitis is approximately 10%. Most perioperative morbidity is caused by infectious complications. Wound infections occur in approximately 5% of all appendectomies; however, 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 following appendectomy occurs in 2-5% of patients. The incidence is higher for gangrenous or perforated appendicitis (6-8%) compared to early or suppurative appendicitis (1-2%).^[3]

Other complications include persistent ileus, small bowel obstruction, and pulmonary complications, such as atelectasis and pneumonia. Deep venous thrombosis, pulmonary embolism, and myocardial infarction have also occurred in the early postoperative period.

The outcome following appendectomy for acute or suppurative appendicitis is excellent. Most patients return to full activity within 2 weeks; however, when perforated appendicitis is encountered, prolonged hospitalization and additional diagnostic and therapeutic procedures may be required.

The prognosis for all stages of appendicitis is excellent, with a mortality rate of less than 1%. This low mortality rate is largely the result of early diagnosis and treatment, antibiotics, and improved anesthesia care.

Controversy continues over the most accurate, cost-effective, and rapid method of making the diagnosis of atypical appendicitis. Surgical consultation remains the most effective method of determining what additional diagnostic tools are needed.