eMedicine Specialties > General Surgery > Abdomen

Appendicitis: Treatment

Author: Luigi Santacroce, MD, Assistant Professor, Medical School, State University at Bari, Italy
Coauthor(s): Juan B Ochoa, MD, Assistant Professor, Department of Surgery, University of Pittsburgh
Contributor Information and Disclosures

Updated: May 1, 2009

Treatment

Medical Therapy

Appendectomy remains the only curative treatment of appendicitis.

Although many controversies exist over the nonoperative management of acute appendicitis, antibiotics have an important role in the treatment of patients with this condition. Antibiotics considered for patients with appendicitis must offer full aerobic and anaerobic coverage. Duration of the administration is closely related to the stage of appendicitis at the time of the diagnosis, considering either intraoperative findings or postoperative evolution. According to several studies, antibiotic prophylaxis should be administered before every appendectomy. When the patient becomes afebrile and the WBC count normalizes, antibiotic treatment may be stopped. Cefotetan and cefoxitin seem to be the best choices of antibiotics.

Surgical Therapy

Thousands of classic appendectomies (open procedure) have been performed in the last 2 centuries. Mortality and morbidity have gradually decreased, especially in the last few decades because of antibiotics, early diagnosis, and improvements in anesthesiologic and surgical techniques.

Since 1987, many surgeons have begun to treat appendicitis laparoscopically. This procedure has now been improved and standardized.10

The reported results of laparoscopic and open-procedure appendectomies seem to be overlapping. In fact, the average rate of abdominal abscesses, negative appendectomies, and hospital stays are very similar, according to an overview of 17 retrospective studies.

Laparoscopy has some advantages, including decreased postoperative pain, better aesthetic result, a shorter time to return to usual activities, and lower incidence of wound infections or dehiscence. This procedure is cost effective but may require more operative time compared with open appendectomy.

Preoperative Details

Preparation of patients undergoing appendectomy is similar for open and laparoscopic procedures.

Because they may mask the underlying disease, do not administer analgesics and antipyretics to patients with suspected appendicitis who have not been evaluated by the surgeon.

Perform complete routine laboratory and radiologic studies before intervention.

Venous access must be obtained in all patients diagnosed with appendicitis. Venous access allows administration of isotonic fluids and broad-spectrum intravenous antibiotics prior to the operation.

Prior to the start of the surgical procedure, the anesthesiologist performs endotracheal intubation to administer volatile anesthetics and to assist respiration.

The abdomen is washed, antiseptically prepared, and then draped.

Intraoperative Details

Open appendectomy

Prior to incision, the surgeon should carefully perform a physical examination of the abdomen to detect any mass and to determine the site of the incision.

Open appendectomy requires a transverse incision in the RLQ over the McBurney point (ie, two thirds of the way between the umbilicus and the anterior superior iliac spine). The vertical incisions (ie, the Battle pararectal) are rarely performed because of the tendency for dehiscence and herniation.

The abdominal wall fascia (ie, Scarpa fascia) and the underlying muscular layers are sharply dissected or split in the direction of their fibers to gain access to the peritoneum. If necessary (eg, because of concomitant pelvic pathologies), the incision may be extended medially, dissecting some fibers of the oblique muscle and retracting the lateral part of the rectus abdominis. The peritoneum is opened transversely and entered. Note the character of any peritoneal fluid to help confirm the diagnosis and then suction it from the field; if purulent, collect and culture the fluid.

Retractors are gently placed into the peritoneum. The cecum is identified and medially retracted. It is then exteriorized by a moist gauze sponge or Babcock clamp, and the taenia coli are followed to their convergence. The convergence of teniae coli is detected at the base of the appendix, beneath the Bauhin valve (ie, the ileocecal valve), and the appendix is then viewed. If the appendix is hidden, it can be detected medially by retracting the cecum and laterally by extending the peritoneal incision.

After exteriorization of the appendix, the mesoappendix is held between clamps, divided, and ligated. The appendix is clamped proximally about 5 mm above the cecum to avoid contamination of the peritoneal cavity and is cut above the clamp by a scalpel. Fecaliths within the lumen of the appendix may be detected. The appendix must be ligated to prevent bleeding and leakage from the lumen. The residual mucosa of the appendix is gently cauterized to avoid future mucocele. The appendix may be inverted into the cecum with the use of a pursestring suture or z-stitch. Although performed by several surgeons, the appendiceal stump inversion is not mandatory.

The cecum is placed back into the abdomen. The abdomen is irrigated. When evidence of free perforation exists, peritoneal lavage with several liters of warm saline is recommended. After the lavage, the irrigation fluid must be completely aspirated to avoid the possibility of spreading infection to other areas of the peritoneal cavity. The use of a drain is not commonly required in patients with acute appendicitis, but obvious abscess with gross contamination requires drainage.

The wound closure begins by closing the peritoneum with a running suture. Then, the fibers of the muscular and fascial layers are reapproximated and closed with a continuous or interrupted absorbable suture. Lastly, the skin is closed with subcutaneous sutures or staples. In cases of perforated appendicitis, some surgeons leave the wound open, allowing for secondary closure or a delayed primary closure until the fourth or fifth day after operation. Other surgeons prefer immediate closure in these cases.

Laparoscopic appendectomy

The surgeon typically stands on the left of the patient, and the assistant stands on the right. The anesthesiologist and the anesthesia equipment are placed at the patient's head, and the video monitor and the instrument table are placed at the feet.

Although some variations are possible, 3 cannulae are placed during the procedure. Two of them have a fixed position (ie, umbilical, suprapubic). The third is placed in the right periumbilical region, and its position may vary greatly depending on the patient's anatomy.

According to the preferences of the surgeon, a short umbilical incision is made to allow the placement of a Hasson cannula or Veress needle that is secured with 2 absorbable sutures.

Pneumoperitoneum (10-14 mm Hg) is established and maintained by insufflating carbon dioxide. Through the access, a laparoscope is inserted to view the entire abdomen cavity.

A 12-mm trocar is inserted above the pubic symphysis to allow the introduction of instruments (eg, incisors, forceps, stapler). Another 5-mm trocar is placed in the right periumbilical region, usually between the right costal margin and the umbilicus, to allow the insertion of an atraumatic grasper to expose the appendix. The appendix is grasped and retracted upward to expose the mesoappendix. The mesoappendix is divided using a dissector inserted through the suprapubic trocar. Then, a linear Endostapler, Endoclip, or suture ligature is passed through the suprapubic cannula to ligate the mesoappendix. The mesoappendix is transected using a scissor or electrocautery. To avoid perforation of the appendix and iatrogenic peritonitis, the tip of the appendix should not be grasped.

The appendix may now be transected with a linear Endostapler, or, alternately, the base of the appendix may be suture ligated in a similar manner to that in an open procedure. The appendix is now free and may be removed through the umbilical or the suprapubic cannula using a laparoscopic pouch to prevent wound contamination. Peritoneal irrigation is performed with antibiotic or saline solution. Completely aspirate the irrigant. The cannulae are then removed and the pneumoperitoneum is reduced.

The fascial layers at the cannula sites are closed with absorbable suture, while the cutaneous incisions are closed with interrupted subcuticular sutures or sterile adhesive strips.

Postoperative Details

Administer intravenous antibiotics postoperatively. The length of administration is based on the operative findings and the recovery of the patient. In complicated appendicitis, antibiotics may be required for many days or weeks.

Antiemetics and analgesics are administered to patients experiencing nausea and wound pain.

The patient is encouraged to ambulate early. When appendicitis is not complicated, the diet may be advanced quickly postoperatively and the patient is discharged from the hospital once a diet is tolerated. In patients with complicated appendicitis, a clear liquid diet may be started when bowel function returns. These patients may be discharged after complete restitution of infection.7

Follow-up

After hospital discharge, patients must have a light diet and limit their physical activity for a period of 2-6 weeks based on the surgical approach (ie, laparoscopic, open appendectomy). The patient should be evaluated by the surgeon in the clinic to determine improvement and to detect any possible complications.

Complications

Complications may occur in patents with appendicitis, accounting for an average morbidity near 10%. Death is rare but can occur in patients who have profound peritonitis and sepsis.

Severe infection may result in adynamic ileus. Postoperatively, wound infection or dehiscence may occur, especially in patients with gangrenous or perforated appendicitis, persistent ileus, cecal fistulas, and pelvic or abdominal abscess. Patients with these conditions present with wound tenderness or soreness, drainage of fluid from the incision, or swelling and redness at the incision site.

Cardiovascular complications (eg, myocardial infarction, pulmonary embolism) and pulmonary complications (eg, pneumonia) have been reported.

Patients with postoperative infections usually present with a mild fever, abdominal pain, and disorders of bowel transit (ie, diarrhea, constipation). Persistent nausea, vomiting, difficulty with micturition, and persistent pain in the lower limbs may also occur.

If a complication occurs, further diagnostic and therapeutic procedures could be required, leading to additional cost and prolonged hospitalization.

A rare complication after appendectomy, the stump appendicitis, is a special concern. The stump appendicitis may occur from a few months to up to 20 years after the appendix resection, as reported by Uludag et al.11

More on Appendicitis

Overview: Appendicitis
Workup: Appendicitis
Treatment: Appendicitis
Follow-up: Appendicitis
Multimedia: Appendicitis
References
Further Reading
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Keywords

appendicitis, appendix, appendectomy, appendix pain, symptoms of appendicitis, appendix symptoms, appendicitis signs, appendix side, human appendix, abdominal pain, appendicitis children, appendix surgery, after appendectomy, acute appendicitis, acute abdominal pain, perforated appendix, peritonitis, appendix inflammation, acute inflammation of the appendix, appendiceal lumen, vermiform appendix, typhlitis, lymphoid hyperplasia, irritable bowel disease, IBD, fecal stasis, fecaliths, lymphoid hyperplasia of the appendix, obstruction of the appendiceal lumen, periappendicular abscess

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Contributor Information and Disclosures

Author

Luigi Santacroce, MD, Assistant Professor, Medical School, State University at Bari, Italy
Disclosure: Nothing to disclose.

Coauthor(s)

Juan B Ochoa, MD, Assistant Professor, Department of Surgery, University of Pittsburgh
Disclosure: Nothing to disclose.

Medical Editor

Oscar Joe Hines, MD, Assistant Professor, Department of Surgery, University of California at Los Angeles School of Medicine
Oscar Joe Hines, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Endocrine Surgeons, American College of Surgeons, Association for Academic Surgery, Society for Surgery of the Alimentary Tract, and Society of American Gastrointestinal and Endoscopic Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Michael A Grosso, MD, Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital
Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons, and Society of University Surgeons
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other

 
 
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