Terry Shih
Mark R. Hemmila
Justin B. Dimick
Presentation
A 25-year-old man with no previous medical or surgical history presents to the emergency room with 5 days of abdominal pain. His pain was initially periumbilical, but has since migrated to his right lower quadrant (RLQ), and finally became diffuse. For the past 3 days, he has had nausea, vomiting, and fevers. He presents now as he could no longer tolerate oral intake. His vital signs include a fever of 39.2°C, tachycardia, with a heart rate in the 110s, and a normal blood pressure. On physical examination, his abdomen is nondistended and he has tenderness to palpation in the RLQ with focal rebound tenderness and voluntary guarding.
Differential Diagnosis
RLQ pain with fevers, nausea, and vomiting with localized tenderness is the classic presentation of acute appendicitis. In a young, otherwise healthy male, there is a limited list of other potential diagnoses, such as gastroenteritis or the initial presentation of Crohn’s disease. In a female patient, gynecologic pathologies must be considered, including ovarian torsion, ectopic pregnancy, ruptured ovarian cyst, or pelvic inflammatory disease.
This patient has a delayed presentation (5 days) with a high fever, which raises suspicion for perforated appendicitis, as perforation typically occurs 24 to 36 hours following onset of symptoms. Patients with perforation often also present with more substantial systemic inflammatory response, including higher fevers and tachycardia. Patients may have more substantial abdominal pain and tenderness as the underlying inflammatory process may be more significant (e.g., phlegmon or abscess). Because of the different presentation, the differential diagnosis is different for early acute appendicitis and should include rightsided diverticulitis, perforated right-sided colon cancer, cecal perforation due to a distal obstruction (cancer or diverticular stricture), and typhlitis in immunosup-pressed patients.
Workup
Patients with suspected appendicitis, either early or late in their course, should undergo laboratory tests, including a complete blood count (CBC) and basic metabolic panel (i.e., electrolytes, BUN, and creatinine). In our patient, the CBC and basic metabolic panel reveal a leukocytosis with a white blood cell count of 18,000 with an elevated creatinine 1.8 mg/dL. All other laboratory tests are within normal limits.
In young healthy males who present with signs and symptoms of classic appendicitis, routine further imaging with computed tomography (CT) scan may not be necessary before proceeding to surgery. However, female patients should be evaluated with further imaging such as a CT scan or transabdominal and transvaginal ultrasound, as pathology of RLQ structures may mimic the presentation of appendicitis.
This case demonstrates several key differences from early appendicitis. The patient has had pain for 5 days with high fevers and tachycardia, increasing the chance of perforation, abscess, or phlegmon. Contrary to early appendicitis, where CT scan is used selectively, cross-sectional imaging is always warranted when perforation is suspected. In our patient, a CT scan of the abdomen and pelvis reveals a dilated appendix to 1.2 cm with extraluminal air and fat stranding surrounding the appendix. There is a periappendiceal fluid collection that measures 4 × 5 cm with rim enhancement (Figure 1).
FIGURE 1A • Right lower quadrant abscess.
FIGURE 1B • Drain placement for abscess 1.
FIGURE 1C • Drain placement 2.
FIGURE 1D • Drain placement with resolution of abscess.
Discussion
Once the diagnosis of perforated appendicitis is established, treatment depends on the extent of the inflammatory process. Patients with evidence of early perforated appendicitis without a large abscess may benefit from appendectomy at the time of presentation. However, if the patient has evidence of a large amount of inflammation (i.e., periappendiceal phlegmon or abscess), immediate surgical intervention may do more harm than good. In this setting, appendectomy is associated with a significantly higher rate of complications and concomitant bowel resection (e.g., ileocecectomy or right colectomy) than an operation performed for nonperforated appendicitis.
Patients with phlegmon but no definitive abscess (Figure 2) will often improve with intravenous antibiotics alone. Patients with evidence of abscess (e.g., contained collections of air and fluid on CT scan) (Figures 1 and 3A–C) potentially benefit from radiology-guided percutaneous drainage, in addition to intravenous antibiotics. Figures 2A–D demonstrate CT-guided percutaneous aspiration with placement of a drain. Resolution of symptoms and leukocytosis will determine the duration of IV antibiotics. Typically, antibiotics may be transitioned to an oral regimen for the patient to complete a 1- or 2-week course as an outpatient.
FIGURE 2 • Phlegmon without definite abscess.
FIGURE 3A • Small perforation on lateral wall of appendix.
FIGURE 3B • Perforation with small pocket of air.
FIGURE 3C • Periappendiceal abscess.
Once the inflammation in the area has decreased after 6 to 8 weeks, the patient may proceed with interval appendectomy. Although recent studies suggest routine interval appendectomy may not be warranted in an asymptomatic patient, it is still our practice to perform subsequent appendectomy to eliminate the risk of recurrent appendicitis. Patients who are of appropriate age (>50 years) or have suspicious findings on imaging should undergo colonoscopy to rule out malignancy.
Surgical Approach
The decision to operate in a patient with perforated appendicitis should be made after a careful assessment of the degree of inflammation. Most patients will be managed nonoperatively with intravenous antibiotics with (abscess) or without (phlegmon) percutaneous drainage. Operation in patients with advanced degrees of inflammation could result in a much larger operation (e.g., ileocecetomy) because the base of the appendix may be involved in the process, making it unsafe to remove the appendix in isolation.
There are two specific clinical scenarios where surgery should be considered with perforated appendicitis. First, prompt exploratory laparotomy should be pursued in patients who present with diffuse peritonitis due to free perforation of appendicitis. Often the precise diagnosis will be unknown at the time of exploration. However, if a patient with perforated appendicitis becomes clinically worse (e.g., develops diffuse peritonitis and/or worsening systemic inflammatory response) despite conservative management, emergent laparotomy should be undertaken. Exploratory laparotomy, ileocecetomy, and irrigation are usually necessary in this scenario. Second, appendectomy can be pursued in patients with early perforation (e.g., insignificant inflammation but small amounts of extra-appendiceal fluid and air on CT scan). This latter scenario is somewhat controversial and clinical practice varies across surgeons. In our practice, we believe that a laparoscopic appendectomy and irrigation in early perforated appendicitis will be less bothersome to the patient than a long hospital stay for intravenous antibiotics and bowel rest.
As with early acute appendicitis, appendectomy can be performed via an open or laparoscopic approach. Studies comparing these approaches have shown a decrease in the incidence of wound infection but an increase in the incidence of intra-abdominal abscess with the laparoscopic approach. Patients who undergo laparoscopic appendectomy also experience less postoperative pain, have shortened hospital stays, and return to normal activity earlier. However, the advantages in this regard are very small.
There are several clinical scenarios where laparoscopy may be favored over an open approach. Laparoscopy may be favored in women or in men with an unclear diagnosis because it allows more thorough abdominal exploration. In patients with obesity, an open approach may be difficult due to the depth of the incision, potentially requiring a large incision to navigate successfully into the peritoneal cavity. Laparoscopy allows for easier access to the peritoneal cavity in such cases.
Laparoscopic Appendectomy
The procedure is performed in the supine position with the left arm tucked under general anesthesia. An orogastric tube and Foley catheter is placed. The entire abdomen is prepped and draped. A 12-mm infraumbilical incision can be made either curvilinearly or vertically in the midline. Access to the abdomen is made either with Veress needle or open Hasson technique. The abdomen is insufflated with CO2to 15 mm Hg. A 5-mm 30° laparoscope is then inserted and diagnostic laparoscopy is performed.
Thorough exploration is crucial in patients with perforation. The degree of inflammation should be assessed carefully. In case of abscess or phlegmon or if it looks like a “bomb went off” in the RLQ, the procedure can be aborted and the patient treated conservatively with antibiotics and percutaneous drainage, if indicated.
If the decision is made to proceed, two additional 5-mm ports are placed, one in the midline above the pubic symphysis and another in the upper midline. Transillumination of the abdominal wall is recommended to allow avoidance of abdominal wall blood vessels during the additional port placement process. Port placement may vary with position of the appendix and the patient’s body habitus. For example, in young, thin patients, ports should be placed further away from the appendix to ensure adequate working room. Placement of the patient in Trendelenburg position with right side up will improve exposure of the cecum and appendix. Attention is turned to the RLQ, and the appendix may be identified by following the teniae of the cecum toward its base. Terminal ileum and all loops of small bowel are swept away from the pelvis. Adhesions may often be encountered, especially in the case of previous perforated appendicitis (i.e., interval appendectomy). These adhesions can often be divided using blunt dissection, but may require sharp dissection or cautery. Once free of adhesions, the appendix is retracted anteriorly and a window in the mesentery at the base of the appendix is created using a Maryland dissector. Prior to dividing the appendix, carefully assess the degree of inflammation at its base. If the base is inflamed, a cuff of uninvolved cecum should be included. If this is not possible, ileocecetomy should be considered. The mesoappendix is divided with an Endo-GIA with a 2.5-mm (vascular) staple load and the appendix is then divided at its base with 3.5-mm staples (bowel load). The appendix is retrieved with an Endocatch bag and removed through the infraumbilical incision. The appendiceal and mesoappendiceal staple lines are thoroughly inspected to assure hemostasis. If the appendix is perforated, the RLQ should be thoroughly irrigated. The 5-mm ports are removed under camera visualization followed by desufflation of the abdomen. The infraumbilical port is then removed and the fascia is closed with absorbable sutures. Skin is closed with either monofilament suture or Indermil glue (Table 1).
TABLE 1. Key Technical Steps and Potential Pitfalls in Laparoscopic Appendectomy
Open Appendectomy
The patient is placed in supine position under general anesthesia. The entire abdomen is prepped and draped. A transverse skin incision is made at McBurney’s point, two-thirds the distance from the umbilicus to the anterior superior iliac spine. The incision is carried down to the external oblique aponeurosis using Bovie electrocautery. The aponeurosis is opened sharply parallel to the direction of its fibers to expose the internal oblique muscle. The muscle fibers are bluntly separated at right angles. The peritoneum is identified, elevated, and incised sharply, avoiding abdominal viscera.
The appendix is then identified and delivered into the incision. The appendix can often be found by locating the cecum and grasping the teniae with Babcock forceps and following the teniae down to their convergence at the base of the cecum. The mesoappendix is then divided between clamps and ligated with silk sutures. A silk purse-string suture is placed at the base of the appendix. A straight clamp is used to crush the appendix at its base and then moved distally and applied again. The appendix is then ligated with absorbable suture and divided sharply proximal to the clamp. Electrocautery is used to obliterate the mucosa of the appendiceal stump. The appendiceal stump is then invaginated into the cecum with the purse-string silk suture.
The surgical field is then irrigated and the peritoneum, fascia, and skin are closed in layers. In cases with gross contamination, leaving the wound open or a loose closure may be a better option (Table 2).
TABLE 2. Key Technical Steps and Potential Pitfalls in Open Appendectomy
Special Intraoperative Considerations
If extensive inflammation is encountered involving the base of the appendix or cecum, it may be necessary to perform a larger resection such as an ileocecectomy or right colectomy. The resection should extend to healthy noninflamed bowel both proximally and distally. This may be performed laparoscopically, depending on the surgeon’s experience. The anastomosis may be either stapled or hand-sewn based on surgeon preference.
Postoperative Management
In the setting of acute perforation, the patient often has an ileus. Broad spectrum intravenous antibiotics are administered and the patient is kept NPO. The patient’s diet may be advanced as tolerated once symptoms improve. Antibiotics can be transitioned to an oral regimen and the patient may be discharged home with close follow-up.
After allowing inflammation to subside (6 to 8 weeks), an interval appendectomy may be performed. Pain is usually controlled with oral narcotics or NSAIDs. Interval appendectomy may be performed as an outpatient procedure. The patient should be educated to monitor for signs of postoperative infection: fevers, chills, fatigue, nausea, vomiting, or diarrhea from possible pelvic abscess.
Case Conclusion
The patient undergoes ultrasound-guided percutaneous drain placement upon admission. He is made NPO, given fluid hydration, and treated with IV piperacillin/tazobactam for broad-spectrum coverage of enteric flora. This is transitioned to oral amoxicillin/clavulanic acid when his leukocytosis resolves after 3 days and he is able to tolerate an oral diet. He is discharged home to complete a 2-week course of antibiotics and seen in clinic in 2 weeks. His drain is discontinued in clinic as its output is <30 mL per day. He is seen 8 weeks after initial presentation, at which time a CT scan reveals no residual abscess. He is taken to the operating room for an interval laparoscopic appendectomy and discharged home on the same day of his procedure. He is seen in clinic 2 weeks after surgery and noted to be doing well.
TAKE HOME POINTS
· Patients with RLQ pain with delayed presentation, high fevers, or marked leukocytosis should receive CT scan as they may have perforated rather than early appendicitis.
· Perforated appendicitis with intra-abdominal abscess should initially be managed conservatively with percutaneous drain placement and intravenous antibiotics.
· There is no significant difference in patient outcomes between laparoscopic and open appendectomy in perforated appendicitis.
· Interval appendectomy may no longer be routinely indicated for carefully selected patients.
SUGGESTED READINGS
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Hemmila MR, Birkmeyer NJ, Arbabi S, et al. Introduction to propensity scores: a case study on the comparative effectiveness of laparoscopic vs open appendectomy. Arch Surg. 2010;145:939–945.
Kaminski A, Liu IL, Applebaum H, et al. Routine interval appendectomy is not justified after initial nonoperative treatment of acute appendicitis. Arch Surg. 2005;140(9):897.
Oliak D, Yamini D, Udani VM, et al. Initial nonoperative management for periappendiceal abscess. Dis Colon Rectum. 2001;44:936.
Sauerland S, Lefering R, Neugebauer EA. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev. 2004;4:CD001546.
Simillis C, Symeonides P, Shorthouse AJ, et al. A metaanalysis comparing conservative treatment versus acute appendectomy for complicated appendicitis (abscess or phlegmon). Surgery. 2010;147(6):818.