**5.3 Non-operative management**

Acute appendicitis is considered a surgical emergency. The incidence decreases with increasing adult age, and the overall incidence in the general population has probably been decreasing during the last 50 years. Classically, appendectomy is performed to avoid perforation, which typically occurs within 48 hours. With the development of the preoperative use of antibiotics, early investigators reported that the peritonitis associated with appendicitis usually resolved before appendectomy. A number of publications have reported cases of appendicitis treated conservatively with a small number of deaths, a further number requiring abscess drainage, and a large number of failures requiring appendectomy. Several more recent studies have shown that perforated appendicitis can be treated nonoperatively with IV antibiotics with the performance of percutaneous drainage if an abscess is present. Success rates have been reported as between 88% and 100%, with the incidence of recurrent appendicitis 5% to 38%. The use of conservative (non-surgical) management of appendicitis is currently reserved to situations where access to surgical management is limited such as on board of ships, fishing vessels, submarines, space missions, polar and Antarctic expeditions . Medical evacuation is performed when possible, and is expedited if improvement does not occur. For some programs, prophylactic appendectomy has been considered. The benefits and long term risks of performing a prophylactic appendectomy in an otherwise healthy individual must however be carefully considered.

There are no studies that have looked at the complications associated with prophylactic appendectomy.

### **5.4 Management of acute appendicitis**

Based on current evidence, all patients presenting with convincing symptoms and signs of appendicitis with raised serological markers of inflammation, should have a diagnostic laparoscopy to confirm the diagnosis where possible. Patients found to have evidence of appendicitis by virtue of serosal inflammation and / or the presence of fibrinous exudates should be considered for appendicectomy. The consideration for open or laparoscopic appendicectomy hinges on the experience of the surgeon, the availability of suitable assistance and appropriate instruments and the express wishes of the patient if these have been made in advance. In equivocal cases, all surgeons would search for an alternative source to account for the patient's symptoms and signs and in the absence of an alternative source, appendicectomy should be considered.

In patients found to have perforated appendicitis surgeons should attempt to evaluate the risks and benefits of laparoscopic surgery for the individual patient based on the amount of contamination of the peritoneal cavity, the spread and intensity of inflammation against the general condition of the patient together with surgical technical factors including the experience of the surgeon and the availability of appropriate instruments.

Appendicitis and Appendicectomy 147

dioxide *via* a Verres canula, positioned in the sub-umbilical area. Following gas insufflation, a 12 mm canula for the 30 degree angled laparoscope should be placed in the periumbilical area (preferably on the left). Alternatively, a 12 mm canula can be introduced by the Hasson's technique (introduction of first trocar into the peritoneum through a sub-umbilical small incision) for initial insufflations of gas. Two additional canulae are required. A 12 mm canula should be placed in the suprapubic area at the midline point to accommodate the grasping or stapling device and/or to facilitate specimen extraction, and a third 5 mm canula in the right (or left) lower abdominal quadrant is introduced under direct vision. When the third cannula is placed on the right, it must be sufficiently far from the appendix to allow a safe and comfortable working distance. The abdominal cavity is thoroughly inspected in order to exclude other intra-abdominal or pelvic pathology. If the appendix is normal, it is important to seek other sources to account for the patient's presentation. If no other cause is identified, it will be up to the discretion of the surgeon at the operating table to decide on removing an apparently normal looking appendix. This has to be guided by prior knowledge of the patient's history, acute presentation, examination findings and

The appendix should be identified at the base of the caecum. Atraumatic bowel graspers should be used to lift the caecum. Part of the appendix should start coming to view. A second pair of atraumatic graspers (or blunt suction probe) should be used to separate the appendix from adherent tissue by blunt dissection. The mesoappendix should be identified and divided with bipolar forceps (or mono-polar diathermy and scissors). Alternatively, the mesoappendix could be divided using clips, *Ligature,* ultrasonic dissector or endoscopic stapler. The base of the appendix should then be identified and secured with one or two ligating loops of absorbable sutures placed at the base of the appendix close to the caecum. This is followed by blunt dissection distal to the second loop using a curved dissector. The appendix should then be divided between the 2 loops. The visible part of the mucosa is usually electro-coagulated. There is no need to bury the appendix stump. Alternatively, the base of the appendix could be stapled using one of the commercially available staplers. This achieves both closure and division of the appendix. In all cases, the specimen should be removed through the trocar without contact with the wound. Alternatively, if the appendix is too bulky, it should be placed in an endobag (a variety are available on the market) which can be extracted through one of the larger canulae sites. All removed tissue should be sent for histopathology. A thorough wash is then carried out. Although this should centre on the operative site, it should cover all sites of contamination encountered at the initial evaluation. Any faecoliths or necrotic material which have escaped from a perforated appendix should be removed if encountered. On occasion it may be necessary to look for inter-bowel fluid or pus collections and wash these out as well. The procedure should terminate by abdominal desufflation and removal of all cannulae. Patients should have two additional doses of antibiotics post operatively unless widespread contamination and peritonitis was evident. In these cases, antibiotics coverage should be continued for several days post operatively until the patient is no longer septic. If bleeding is encountered during the procedure, an additional trocar may be required to place a suction device while looking for the source of bleeding. Once this is identified,

The use of staplers and more complex energy devices in appendicectomy saves time but adds to the cost of the operation. In general, they are not recommended unless time is a significant issue or these are used due to complexity or difficulty encountered during the

serological markers of inflammation.

control of bleeding may be achieved using clips or ligatures.

procedure.

In all patients undergoing appendicectomy, prophylactic antibiotics should be used. In patients who have had a perforated appendix, appendicectomy should be followed by peritoneal lavage. When perforation has occurred it is common practice to continue intravenous antibiotics for a period postoperatively depending on the degree of infection and contamination. Recent evidence suggests that metronidazole would be sufficient for simple appendicitis. Additional broad-spectrum antibiotics may be necessary for complicated appendicitis. If an adequate peritoneal lavage has been carried out, abdominal drains do not confer any benefit.

### **5.4.1 Technique of open appendicectomy**

An open procedure involves a muscle splitting gridiron incision at McBurneys point. The muscle layers are separated along the line of the fibres allowing for the identification and opening of the peritoneum. Upon entry into the peritoneum the caecum is identified and appendix is located. This can be achieved through using the merging of the teniae coli as a reference point. The vessels in the meso-appendix are ligated until the appendix is free. The base of the appendix can then be ligated with two loops of absorbable sutures and the appendix divided between the two loops. The appendix can then be removed. Some surgeons invaginate the appendix stump either using a purstring absorbable suture or a Z stitch. The majority of surgeons do not invaginate the appendix stump but use electrocoagulation on the visible edge of the mucosa. After ensuring haemostasis, a thorough wash is carried out. The wound is then closed in layers.

#### **5.4.2 Laparoscopic appendicectomy**

In 1983, Semm performed the first laparoscopic appendectomy. Ever since then, the efficiency and superiority of laparoscopic approach compared to the open technique has been the subject of much debate. The idea of minimal surgical trauma, resulting in significantly shorter hospital stay, less postoperative pain, faster return to daily activities, and better cosmetic outcome has made laparoscopic surgery for acute appendicitis very attractive. However, several retrospective studies, several randomized trials and metaanalyses comparing laparoscopic with open appendectomy have provided conflicting results. Some of these studies have demonstrated better clinical outcomes with the laparoscopic approach, while other studies have shown marginal or no clinical benefit and higher surgical costs. The European Association of Endoscopic Surgeons have published their guidelines on laparoscopic appendicectomy. In summary, the EAES have found that laparoscopic appendicectomy is feasible and safe with a slightly longer operating time than open appendicectomy. However, they expressly state that the safety of laparoscopic appendicectomy during pregnancy is not established. Laparoscopic appendicectomy has advantages over open appendicectomy but there is potential for serious injuries. EAES recommends that at least 20 cases of laparoscopic appendicectomy should be done before surgeon's accreditation for this procedure.

#### **5.4.3 Technique of laparoscopic appendicectomy**

The patient is placed in a Trendelenburg position, with a slight rotation to the left. The surgeon should stand on the patients left side and the primary monitor should be placed on the right side of the patient (opposite the surgeon). The patients arms should be tucked at the sides to allow sufficient room for the surgeon and camera operator to move cepahalad as required. Pneumoperitoneum is produced by continuous pressure of 10-12 mmHg of carbon

In all patients undergoing appendicectomy, prophylactic antibiotics should be used. In patients who have had a perforated appendix, appendicectomy should be followed by peritoneal lavage. When perforation has occurred it is common practice to continue intravenous antibiotics for a period postoperatively depending on the degree of infection and contamination. Recent evidence suggests that metronidazole would be sufficient for simple appendicitis. Additional broad-spectrum antibiotics may be necessary for complicated appendicitis. If an adequate peritoneal lavage has been carried out, abdominal

An open procedure involves a muscle splitting gridiron incision at McBurneys point. The muscle layers are separated along the line of the fibres allowing for the identification and opening of the peritoneum. Upon entry into the peritoneum the caecum is identified and appendix is located. This can be achieved through using the merging of the teniae coli as a reference point. The vessels in the meso-appendix are ligated until the appendix is free. The base of the appendix can then be ligated with two loops of absorbable sutures and the appendix divided between the two loops. The appendix can then be removed. Some surgeons invaginate the appendix stump either using a purstring absorbable suture or a Z stitch. The majority of surgeons do not invaginate the appendix stump but use electrocoagulation on the visible edge of the mucosa. After ensuring haemostasis, a thorough wash

In 1983, Semm performed the first laparoscopic appendectomy. Ever since then, the efficiency and superiority of laparoscopic approach compared to the open technique has been the subject of much debate. The idea of minimal surgical trauma, resulting in significantly shorter hospital stay, less postoperative pain, faster return to daily activities, and better cosmetic outcome has made laparoscopic surgery for acute appendicitis very attractive. However, several retrospective studies, several randomized trials and metaanalyses comparing laparoscopic with open appendectomy have provided conflicting results. Some of these studies have demonstrated better clinical outcomes with the laparoscopic approach, while other studies have shown marginal or no clinical benefit and higher surgical costs. The European Association of Endoscopic Surgeons have published their guidelines on laparoscopic appendicectomy. In summary, the EAES have found that laparoscopic appendicectomy is feasible and safe with a slightly longer operating time than open appendicectomy. However, they expressly state that the safety of laparoscopic appendicectomy during pregnancy is not established. Laparoscopic appendicectomy has advantages over open appendicectomy but there is potential for serious injuries. EAES recommends that at least 20 cases of laparoscopic appendicectomy should be done before

The patient is placed in a Trendelenburg position, with a slight rotation to the left. The surgeon should stand on the patients left side and the primary monitor should be placed on the right side of the patient (opposite the surgeon). The patients arms should be tucked at the sides to allow sufficient room for the surgeon and camera operator to move cepahalad as required. Pneumoperitoneum is produced by continuous pressure of 10-12 mmHg of carbon

drains do not confer any benefit.

**5.4.1 Technique of open appendicectomy** 

is carried out. The wound is then closed in layers.

**5.4.2 Laparoscopic appendicectomy** 

surgeon's accreditation for this procedure.

**5.4.3 Technique of laparoscopic appendicectomy** 

dioxide *via* a Verres canula, positioned in the sub-umbilical area. Following gas insufflation, a 12 mm canula for the 30 degree angled laparoscope should be placed in the periumbilical area (preferably on the left). Alternatively, a 12 mm canula can be introduced by the Hasson's technique (introduction of first trocar into the peritoneum through a sub-umbilical small incision) for initial insufflations of gas. Two additional canulae are required. A 12 mm canula should be placed in the suprapubic area at the midline point to accommodate the grasping or stapling device and/or to facilitate specimen extraction, and a third 5 mm canula in the right (or left) lower abdominal quadrant is introduced under direct vision. When the third cannula is placed on the right, it must be sufficiently far from the appendix to allow a safe and comfortable working distance. The abdominal cavity is thoroughly inspected in order to exclude other intra-abdominal or pelvic pathology. If the appendix is normal, it is important to seek other sources to account for the patient's presentation. If no other cause is identified, it will be up to the discretion of the surgeon at the operating table to decide on removing an apparently normal looking appendix. This has to be guided by prior knowledge of the patient's history, acute presentation, examination findings and serological markers of inflammation.

The appendix should be identified at the base of the caecum. Atraumatic bowel graspers should be used to lift the caecum. Part of the appendix should start coming to view. A second pair of atraumatic graspers (or blunt suction probe) should be used to separate the appendix from adherent tissue by blunt dissection. The mesoappendix should be identified and divided with bipolar forceps (or mono-polar diathermy and scissors). Alternatively, the mesoappendix could be divided using clips, *Ligature,* ultrasonic dissector or endoscopic stapler. The base of the appendix should then be identified and secured with one or two ligating loops of absorbable sutures placed at the base of the appendix close to the caecum. This is followed by blunt dissection distal to the second loop using a curved dissector. The appendix should then be divided between the 2 loops. The visible part of the mucosa is usually electro-coagulated. There is no need to bury the appendix stump. Alternatively, the base of the appendix could be stapled using one of the commercially available staplers. This achieves both closure and division of the appendix. In all cases, the specimen should be removed through the trocar without contact with the wound. Alternatively, if the appendix is too bulky, it should be placed in an endobag (a variety are available on the market) which can be extracted through one of the larger canulae sites. All removed tissue should be sent for histopathology. A thorough wash is then carried out. Although this should centre on the operative site, it should cover all sites of contamination encountered at the initial evaluation. Any faecoliths or necrotic material which have escaped from a perforated appendix should be removed if encountered. On occasion it may be necessary to look for inter-bowel fluid or pus collections and wash these out as well. The procedure should terminate by abdominal desufflation and removal of all cannulae. Patients should have two additional doses of antibiotics post operatively unless widespread contamination and peritonitis was evident. In these cases, antibiotics coverage should be continued for several days post operatively until the patient is no longer septic.

If bleeding is encountered during the procedure, an additional trocar may be required to place a suction device while looking for the source of bleeding. Once this is identified, control of bleeding may be achieved using clips or ligatures.

The use of staplers and more complex energy devices in appendicectomy saves time but adds to the cost of the operation. In general, they are not recommended unless time is a significant issue or these are used due to complexity or difficulty encountered during the procedure.

Appendicitis and Appendicectomy 149

Despite numerous prospective randomised trials, systematic reviews and meta-analysis the superiority of laparoscopic over open appendicectomy remains unclear particularly for complicated appendicitis. Previous studies have produced conflicting conclusions regarding the incidence of postoperative adverse events after laparoscopic and open appendicectomy. Retrospective cohort studies, randomised controlled trials and meta-analysis have demonstrated similar rates of overall morbidity. However, significant differences have been demonstrated in a few studies. With regards to operating time, there is a clear trend of extended operating time with laparoscopic appendicectomy in earlier studies with a further trend towards parity between the two procedures. This is a reflection of the experience of surgeons with the technique. With regards to hospital stay, the length of hospital stay after surgery was shortened in laparoscopic appendicectomy by a fraction of a day. This

Early return to full activity is accepted as an obvious advantage of laparoscopic appendicectomy which is supported by a large scale meta-analysis conducted by the Cochrane Colorectal Cancer Group. Clearly the smaller incisions of laparoscopic appendicectomy contribute to reduce trauma to the abdominal wall and less pain allowing faster recovery. Fast resumption of a normal diet following laparoscopic appendicectomy was another appealing advantage, resulting from minimal manipulation of bowel. The difference between laparoscopic and open appendicectomy in terms of resumption of normal diet intake represents a fraction of a day. Although this is significant numerically it is of doubtful practical significance. Reduced postoperative pain is another quality attribute of laparoscopic surgery. Although difficult to assess, a number of meta-analysis found that laparoscopic appendicectomy offered significant advantages in relieving postoperative pain mainly due to its minimal abdominal wall trauma. Reduction of wound infection is a significant advantage of laparoscopic appendicectomy. The chance of wound infection is greater in open appendicectomy partly because the inflamed appendix is removed from the abdominal cavity directly through the wound whereas in laparoscopic appendicectomy it is extracted via a bag or trocar. In addition the port-site wounds in laparoscopic

difference although numerically significant is of little practical significance.

Fig. 8. The appendix is divided between loops

and then delivered.

Fig. 7. Two pre-tied loops of absorbable sutures are applied to the base of the

**5.5 Laparoscopic versus open appendicectomy** 

appendix.

Fig. 3. Operating room set-up for diagnostic laparoscopy and appendicectomy.

Fig. 4. Trocar positions for appendicectomy. Trocar 1 is used for the laparoscope. Trocars 2 and 3 are the main dissection sites. Trocar 4 can be added if necessary.

Fig. 5. Vesseles in the meso-appendix are dissected and clipped.

Fig. 6. The appendix is freed by blunt dissection to its base on the caecum.

Fig. 4. Trocar positions for appendicectomy. Trocar 1 is used for the laparoscope. Trocars 2 and 3 are the main dissection sites. Trocar 4

Fig. 6. The appendix is freed by blunt dissection to its base on the caecum.

can be added if necessary.

Fig. 3. Operating room set-up for diagnostic

Fig. 5. Vesseles in the meso-appendix are

dissected and clipped.

laparoscopy and appendicectomy.

Fig. 7. Two pre-tied loops of absorbable sutures are applied to the base of the appendix.

Fig. 8. The appendix is divided between loops and then delivered.

#### **5.5 Laparoscopic versus open appendicectomy**

Despite numerous prospective randomised trials, systematic reviews and meta-analysis the superiority of laparoscopic over open appendicectomy remains unclear particularly for complicated appendicitis. Previous studies have produced conflicting conclusions regarding the incidence of postoperative adverse events after laparoscopic and open appendicectomy. Retrospective cohort studies, randomised controlled trials and meta-analysis have demonstrated similar rates of overall morbidity. However, significant differences have been demonstrated in a few studies. With regards to operating time, there is a clear trend of extended operating time with laparoscopic appendicectomy in earlier studies with a further trend towards parity between the two procedures. This is a reflection of the experience of surgeons with the technique. With regards to hospital stay, the length of hospital stay after surgery was shortened in laparoscopic appendicectomy by a fraction of a day. This difference although numerically significant is of little practical significance.

Early return to full activity is accepted as an obvious advantage of laparoscopic appendicectomy which is supported by a large scale meta-analysis conducted by the Cochrane Colorectal Cancer Group. Clearly the smaller incisions of laparoscopic appendicectomy contribute to reduce trauma to the abdominal wall and less pain allowing faster recovery. Fast resumption of a normal diet following laparoscopic appendicectomy was another appealing advantage, resulting from minimal manipulation of bowel. The difference between laparoscopic and open appendicectomy in terms of resumption of normal diet intake represents a fraction of a day. Although this is significant numerically it is of doubtful practical significance. Reduced postoperative pain is another quality attribute of laparoscopic surgery. Although difficult to assess, a number of meta-analysis found that laparoscopic appendicectomy offered significant advantages in relieving postoperative pain mainly due to its minimal abdominal wall trauma. Reduction of wound infection is a significant advantage of laparoscopic appendicectomy. The chance of wound infection is greater in open appendicectomy partly because the inflamed appendix is removed from the abdominal cavity directly through the wound whereas in laparoscopic appendicectomy it is extracted via a bag or trocar. In addition the port-site wounds in laparoscopic

Appendicitis and Appendicectomy 151

appendix was found to be normal at appendectomy in childhood seem to belong to a subgroup with a higher fertility than the general population. The majority of these studies suffer from small numbers, selected populations, design or analysis flaws. A recent systematic review and appraisal of the evidence for evaluating if perforation of the appendix was a risk factor for tubal infertility and ectopic pregnancy found 4 studies with an appropriate epidemiological design with reasonable quality. It found that the risk of the association for perforation of the appendix ranged from a high of 4.8 % for tubal infertility to an insignificant association for ectopic pregnancy. The reviewed studies were consistent in demonstrating a modest increase in risk, with all results in the same direction of increased risk. Based on diagnostic tests for causation, the authors of the review did not accept a causal relationship between perforation of the appendix and tubal infertility or ectopic pregnancy although they have accepted the association and the risk of the exposure. A subsequently published case control study did not provide substantial evidence that perforation of the appendix was an important risk factor for female tubal infertility. A further study examined fertility after appendectomy during pregnancy. This study found that appendectomy during pregnancy of a normal, inflamed or perforated appendix did not affect subsequent fertility. A recent epidemiological study concluded that appendicitis appears to be low risk factor in subsequent infertility. However, Appendicectomy is associated with increased fertility. On the basis of this data, a policy of liberal and prompt laparoscopy used routinely on young women presenting with signs and symptoms of appendicitis is encouraged. If the appendix is found to be inflamed or equivocal, then

This epic study is likely to be cited for encouraging the practice of laparoscopic appendicectomy for all cases presenting with right iliac fossa pain. This is based on the fact that early mucosal appendicitis is thought to be a real entity and this is not apparent at the time of laparoscopy. However, caution must be exercised due to apparent complications of

All patients require adequate post-operative monitoring. Those patients who had percutaneous drainage of appendix abcess also require monitoring. In addition to vital parameters, these patients require daily evaluation of the wound and abdomen by clinical examination. Serial measurement of inflammatory parameters is also useful in showing trends of improvement or otherwise. This should be continued until patients are discharged

Superficial wound infection can start to manifest 48 hours after surgery. Patients who show signs of wound infection by virtue of inflammation of wound edges, should continue on antibiotics treatment until the wound inflammation settles. As a marker of progress of the inflammation, the area of cellulitis surrounding the wound should be marked on the skin and monitored for progression or regression. In addition, palpation of the wound itself may suggest accumulation of infected material under the wound, in the superficial tissues. In such cases, the wound should be opened either fully or partially to allow drainage of the infected material. In some cases, operative drainage under anaesthesia should be

Patients who do not show signs of improvement after appendicectomy or those who show further deterioration, either clinically or serologically, should be considered for three

**5.7 Post operative monitoring and management of complications** 

appendicectomy is justified.

laparoscopic appendicectomy.

from hospital.

considered.

appendicectomy are considerably smaller with less potential space and less interruption of blood supply around wound.

Several explanations have been advanced for the reduction of ileus following laparoscopic appendicectomy. Firstly, decreased handling of the bowel during the procedure leads to less postoperative adhesion and such adhesions may be responsible for ileus. Secondly patients after laparoscopic appendicectomy had less opiate analgesics which inhibited bowel movements in the postoperative period. Thirdly earlier mobilisation after laparoscopic appendicectomy may also contribute to the reduction of ileus. Several meta-analysis have found that the incidence of intra-abdominal infections, intra-operative bleeding and urinary tract infections after laparoscopic appendicectomy was higher compared with open appendicectomy. It is not clear why intra-operative bleeding and urinary tract infections are higher after laparoscopic appendicectomy. With regards to intra-abdominal infections and abscess formation, there was suggestions that aggressive manipulation of the infected appendix and increased use of irrigation fluid might have increased the incidence of intraabdominal infections after laparoscopic appendicectomy. The majority of studies however have not separated the results for simple uncomplicated appendicitis. It does however appear that patients with complicated appendicitis managed by laparoscopic appendicectomy have a higher tendency for intra-abdominal abscess formation.

The conversion rate from laparoscopic to open appendicectomy is around 10%. This is not surprising when considering the proportion of complicated appendicitis and the emergency setting of the procedure.

Appendicectomy carries a fairly low risk of mortality. Consequently many studies do not report mortality rates or multi-variate analysis on these rates. Amongst studies that do report mortalities, the event rate ranges between 0.16 and 0.24.

 During pregnancy, laparoscopic appendectomy was found to be safe and effective and at least equivalent to open appendicectomy. Despite the raised intra-abdominal pressure associated with pneumoperitoneum, laparoscopic appendicectomy is associated with good maternal and fetal outcome. Further confirmatory studies are awaited before the safety of laparoscopic appendicectomy can be accepted.

#### **5.6 Long-term complications and implications**

Both the acute inflammatory condition of appendicitis and the surgical operation carried out to remove the appendix can potentially promote adhesion formation particularly around the fallopian tubes which may lead to tubal dysfunction in females of child bearing age. There is controversy surrounding the association between previous appendicectomy with subsequent infertility in females. Some reports found perforated appendicitis in childhood is not an appreciable cause of subsequent tubal infertility, while other reports found a high incidence of tubal infertility in women previously treated for appendicitis complicated by perforation, pelvic peritonitis or abscess. Three studies considered non-perforated appendicitis as well as perforated appendicitis on subsequent infertility and their result suggest that neither acute appendicitis nor perforation of the appendix was associated with a significant risk of infertility. Other studies, considered the question of the association between appendectomy and infertility. Some studies showed no association between a history of appendicectomy and subsequent infertility while others found a higher incidence of infertility in patients who have had a previous appendicectomy. One of these studies analysed fertility after removal of a normal appendix. This study found that women whose

appendicectomy are considerably smaller with less potential space and less interruption of

Several explanations have been advanced for the reduction of ileus following laparoscopic appendicectomy. Firstly, decreased handling of the bowel during the procedure leads to less postoperative adhesion and such adhesions may be responsible for ileus. Secondly patients after laparoscopic appendicectomy had less opiate analgesics which inhibited bowel movements in the postoperative period. Thirdly earlier mobilisation after laparoscopic appendicectomy may also contribute to the reduction of ileus. Several meta-analysis have found that the incidence of intra-abdominal infections, intra-operative bleeding and urinary tract infections after laparoscopic appendicectomy was higher compared with open appendicectomy. It is not clear why intra-operative bleeding and urinary tract infections are higher after laparoscopic appendicectomy. With regards to intra-abdominal infections and abscess formation, there was suggestions that aggressive manipulation of the infected appendix and increased use of irrigation fluid might have increased the incidence of intraabdominal infections after laparoscopic appendicectomy. The majority of studies however have not separated the results for simple uncomplicated appendicitis. It does however appear that patients with complicated appendicitis managed by laparoscopic

appendicectomy have a higher tendency for intra-abdominal abscess formation.

report mortalities, the event rate ranges between 0.16 and 0.24.

laparoscopic appendicectomy can be accepted.

**5.6 Long-term complications and implications** 

The conversion rate from laparoscopic to open appendicectomy is around 10%. This is not surprising when considering the proportion of complicated appendicitis and the emergency

Appendicectomy carries a fairly low risk of mortality. Consequently many studies do not report mortality rates or multi-variate analysis on these rates. Amongst studies that do

 During pregnancy, laparoscopic appendectomy was found to be safe and effective and at least equivalent to open appendicectomy. Despite the raised intra-abdominal pressure associated with pneumoperitoneum, laparoscopic appendicectomy is associated with good maternal and fetal outcome. Further confirmatory studies are awaited before the safety of

Both the acute inflammatory condition of appendicitis and the surgical operation carried out to remove the appendix can potentially promote adhesion formation particularly around the fallopian tubes which may lead to tubal dysfunction in females of child bearing age. There is controversy surrounding the association between previous appendicectomy with subsequent infertility in females. Some reports found perforated appendicitis in childhood is not an appreciable cause of subsequent tubal infertility, while other reports found a high incidence of tubal infertility in women previously treated for appendicitis complicated by perforation, pelvic peritonitis or abscess. Three studies considered non-perforated appendicitis as well as perforated appendicitis on subsequent infertility and their result suggest that neither acute appendicitis nor perforation of the appendix was associated with a significant risk of infertility. Other studies, considered the question of the association between appendectomy and infertility. Some studies showed no association between a history of appendicectomy and subsequent infertility while others found a higher incidence of infertility in patients who have had a previous appendicectomy. One of these studies analysed fertility after removal of a normal appendix. This study found that women whose

blood supply around wound.

setting of the procedure.

appendix was found to be normal at appendectomy in childhood seem to belong to a subgroup with a higher fertility than the general population. The majority of these studies suffer from small numbers, selected populations, design or analysis flaws. A recent systematic review and appraisal of the evidence for evaluating if perforation of the appendix was a risk factor for tubal infertility and ectopic pregnancy found 4 studies with an appropriate epidemiological design with reasonable quality. It found that the risk of the association for perforation of the appendix ranged from a high of 4.8 % for tubal infertility to an insignificant association for ectopic pregnancy. The reviewed studies were consistent in demonstrating a modest increase in risk, with all results in the same direction of increased risk. Based on diagnostic tests for causation, the authors of the review did not accept a causal relationship between perforation of the appendix and tubal infertility or ectopic pregnancy although they have accepted the association and the risk of the exposure. A subsequently published case control study did not provide substantial evidence that perforation of the appendix was an important risk factor for female tubal infertility. A further study examined fertility after appendectomy during pregnancy. This study found that appendectomy during pregnancy of a normal, inflamed or perforated appendix did not affect subsequent fertility. A recent epidemiological study concluded that appendicitis appears to be low risk factor in subsequent infertility. However, Appendicectomy is associated with increased fertility. On the basis of this data, a policy of liberal and prompt laparoscopy used routinely on young women presenting with signs and symptoms of appendicitis is encouraged. If the appendix is found to be inflamed or equivocal, then appendicectomy is justified.

This epic study is likely to be cited for encouraging the practice of laparoscopic appendicectomy for all cases presenting with right iliac fossa pain. This is based on the fact that early mucosal appendicitis is thought to be a real entity and this is not apparent at the time of laparoscopy. However, caution must be exercised due to apparent complications of laparoscopic appendicectomy.

#### **5.7 Post operative monitoring and management of complications**

All patients require adequate post-operative monitoring. Those patients who had percutaneous drainage of appendix abcess also require monitoring. In addition to vital parameters, these patients require daily evaluation of the wound and abdomen by clinical examination. Serial measurement of inflammatory parameters is also useful in showing trends of improvement or otherwise. This should be continued until patients are discharged from hospital.

Superficial wound infection can start to manifest 48 hours after surgery. Patients who show signs of wound infection by virtue of inflammation of wound edges, should continue on antibiotics treatment until the wound inflammation settles. As a marker of progress of the inflammation, the area of cellulitis surrounding the wound should be marked on the skin and monitored for progression or regression. In addition, palpation of the wound itself may suggest accumulation of infected material under the wound, in the superficial tissues. In such cases, the wound should be opened either fully or partially to allow drainage of the infected material. In some cases, operative drainage under anaesthesia should be considered.

Patients who do not show signs of improvement after appendicectomy or those who show further deterioration, either clinically or serologically, should be considered for three

Appendicitis and Appendicectomy 153

considered. In all cases, adequate peritoneal lavage should be carried out. Post-operatively, all patients should have antibiotics for different periods depending on the degree of inflammation and contamination found at operation. Post-operatively, all patients should be monitored for the emergence of adverse events. Patients who develop signs of peritoneal infection or who fail to improve should have a CT in the first instance. Wound infections should be managed by open drainage and antibiotics. Intra-abdominal infection should be managed by laparoscopy/ laparotomy, drainage of collection and peritoneal lavage together

Laparoscopic appendicectomy is safe for the majority of cases of simple appendicitis. If at laparoscopy, the appendix is found to have perforated, the surgeon should make a careful evaluation of whether to continue with laparoscopic surgery or convert to open surgery. In either situation, the surgical objective is appendicectomy together with adequate peritoneal

Ball CG, Kortbeek JB, Kirkpatrick AW, and Mitchell P. Laparoscopic appendectomy for

Garbarino S, Shimi SM. Routine diagnostic laparoscopy reduces the rate of unnecessary

Hale DA, Molloy M, Pearl RH, Schutt DC, Jaques DP. Appendectomy: a contemporary

Ingraham AM, Cohen ME, Bilimoria KY, Pritts TA, Ko CY, and Esposito TJ. Comparison of

Livingston EH, Woodward WA, Sarosi GA, and Haley RW. Disconnect Between Incidence

Stoker J, van Randen A, Lameris W, and Boermeester MA. Imaging patients with acute

Kirshtein B, Perry ZH, Avinoach E, Mizrahi S, Lantsberg L. Safety of laparoscopic appendectomy during pregnancy. World J Surg. 2009 Mar;33(3):475-80. Li X, Zhang J, Sang L, Zhang W, Chu Z, Li X, and Liu Y. Laparoscopic versus convential

Markides G, Subar D, Riyad K. Laparoscopic versus open appendectomy in adults with

Needham PJ, Laughlan KA, Botterill ID, Ambrose NS. Laparoscopic appendicectomy:

Park HC, Yang DH, Lee BH. The laparoscopic approach for perforated appendicitis,

calculating the cost. Ann R Coll Surg Engl. 2009 Oct;91(7):606-8.

appraisal. Annals of Surgery 1997 Vol. 225, No. 3, 252-261

and Management. Ann Surg. 2007 June; 245(6): 886–892.

222 ACS SQIP hospitals. Surgery 2010; 148: 625-37.

abdominal pain. Radiology 2009; 253: 31-46.

Gastroenterology 2010; 10: 129.

Sep;34(9):2026-40. Review.

A. 2009 Dec;19(6):727-30.

complicated appendicitis: an evaluation of postoperative factors. Surgical

appendicectomies in young women. Surg Endosc. 2009 Mar;23(3):527-33. Epub 2008

outcomes after laparoscopic versus open appendectomy for acute appendicitis at

of Nonperforated and Perforated Appendicitis: Implications for Pathophysiology

appendectomy – a meta-analysis of randomised controlled trials. BMC

complicated appendicitis: systematic review and meta-analysis. World J Surg. 2010

including cases complicated by abscess formation. J Laparoendosc Adv Surg Tech

with systemic antibiotics.

Mar 26.

**7. References** 

lavage of all areas of the peritoneal cavity.

Endoscopy. 2004; 18: 969-973.

dimensional imaging. In these patients, the attending surgeon is looking for evidence of intra-abdominal collection to account for the apparent lack of improvement. However, in rare cases, there may be evidence of iatrogenic injury particularly during laparoscopic appendicectomy or other missed diagnosis. In such patients, there should be a low threshold for repeat laparoscopy or laparotomy. Any evidence of intra-abdominal collection should be managed by drainage and peritoneal lavage. Iatrogenic injuries will require expert surgical correction and appropriate post-operative management. A missed diagnosis will require appropriate management.

Patients who had either percutaneous or laparoscopic drainage of an appendix abcess require careful monitoring for resolution of the inflammation and regression of the abcess. This is done clinically in the first instance but repeat three-dimensional imaging using contrast enhanced CT is usually more accurate than clinical evaluation. Failure of resolution of the inflammatory abcess or phelgmon associated with the abcess indicates either insufficient drainage together with incomplete or inappropriate antibiotics treatment. In such cases, the three dimensional imaging as well as bacteriological sensitivity testing of retrieved purulent material will guide further management. In some patients, revision of antibiotics requirement is necessary and in others revision of drainage is essential. In some patients, operative intervention is necessary due to intra-abdominal spread or rupture of the abcess. In these patients, the objective of operative intervention whether by laparotomy or laparoscopy is adequate drainage of any collection together with peritoneal lavage. When the abcess has been adequately drained, there is usually an accompanying improvement in the general condition of the patient. The drain should be withdrawn when no further purulent material is obtained. The patients can usually return to normal activity and can be safely discharged from hospital. However, due to the relatively high incidence of recurrent appendicitis, patients should be given a date for appendicectomy. This delayed appendicectomy should be done when all signs of inflammation have disappeared and should be attempted laparoscopically by an experienced surgeon.
