**5. Management**

Historically we have seen progression in the management of right iliac fossa pain from purgation to early appendicectomy. Early surgical dictum necessitated appendicectomy for patients with right iliac fossa pain admitted to hospital with convincing signs and symptoms. Appendicectomy was clearly overdone in the past as the delay in diagnosis of appendicitis contributed to an increase in morbidity and mortality. Indeed delayed diagnosis of appendicitis was the most common cause of litigation against emergency surgeons. In regard to laparoscopic appendicectomy, early reports suggested a high rate of complications particularly intra-abdominal abcess formation which was associated with laparoscopic appendicectomy. A more recent Cochrane review however, has found an equal rate of complications in open and laparoscopic appendicectomy. However, patients operated on by laparoscopy, realised the benefits of laparoscopy in terms of less pain, early discharge from hospital and return to normal activities.

Natural orifice translumenal endoscopic surgery (NOTES) has become an exciting area of surgical development. Significant limitations to this surgical concept include lack of surgical expertise and appropriate flexible instrumentation although both aspects are being addressed. An alternative and competing technology to NOTES is single-incision laparoscopic surgery (SILS). A number of reports have produced encouraging results for single incision appendicectomy but this technique remains in its infancy. A number of skeptics have expressed reservations about the applicability of these two techniques for appendicectomy and it will be a matter for the surgical community uptake and adoption of these two techniques over the next few years.

In terms of the cost of the utility of laparoscopic appendicectomy, the overall costs might be justified since the use of laparoscopy can increase diagnostic power, provide less postoperative pain and fewer wound infections, decrease hospital stay and return to normal

Appendicitis and Appendicectomy 145

'grumbling appendix' have been applied to these patients. However, there is no evidence to support this diagnosis. In some of these patients a faecolith was found in the lumen of the appendix which could in theory account for some of the symptoms without necessarily causing full fledged appendicitis. However, elective appendicectomy does not necessarily obviate the long term symptoms of many of these patients any more than a placebo effect. Consequently, the concept of elective appendicectomy for chronic right iliac fossa pain

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

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

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

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.

seems unjustified.

appendectomy.

**5.3 Non-operative management** 

individual must however be carefully considered.

**5.4 Management of acute appendicitis** 

source, appendicectomy should be considered.

activities, and decrease the number of postoperative adhesions. At least six randomized studies have addressed the cost issue. Some found that overall costs for laparoscopic appendectomy were less (but not significantly so), most of the other studies have shown consistently that laparoscopy is more expensive. There was however a wide range of costs. One study found a mean difference of £148 in operating room charges, which does not compensate the costs for the mean difference in analgesics requirement between laparoscopic and open appendicectomy. On the other hand, there is no doubt in the superiority of diagnostic laparoscopy and laparoscopic appendicectomy in terms of quality but only if the incidence of post-operative complications could be reduced. The key to this dilemma lies in separating simple appendicitis from complicated appendicitis. The former will almost invariably have a low incidence of post-operative complications while those with complicated appendicitis (perforation or abcess) seem to have a higher rate of complications after laparoscopic appendicectomy.

#### **5.1 Management of appendix abcess**

Patients presenting with an appendix mass should be treated non-surgically in the first instance. Once the abscess has been confirmed radiologically, percutaneous drainage is the best treatment of choice. Occasionally this drainage can be followed by the development of a faecal fistula but this is usually a low output fistula which normally heals spontaneously. If percutaneous drainage is inadequate, it may be necessary to carry out operative drainage. In patients who have had an appendix mass treated conservatively, about 15% will develop recurrent appendicitis. An interval appendicectomy should be considered.

If appendix mass was found at laparoscopy or laparotomy an attempt should be made to drain the abscess and leave the appendix in situ. Old surgical dogma which continues to apply is that it is 'fool hardy to remove the appendix in the presence of an appendix abcess'. The main reasons for this is the generalised inflammation of the adjacent caecum and small bowel. Attempts at appendicectomy in this scenario, invariably result with intra and post operative complications. Such attempts usually result in a more extensive resection of the adjacent small bowel and caecum. Given the emergency presentation of these patients, the potential for complications is large.

#### **5.2 Negative, incidental and elective appendicectomy**

If a normal appendix was found at laparoscopy, most surgeons would leave the appendix in-situ as an appendicectomy may carry some procedures specific complications. However some skilled surgeons have excellent results with removing a normal appendix laparoscopically. Based on the results of negative appendicectomies published, the complication rate tends to be low. However, if a right iliac fossa incision has been made over the appendix for open appendicectomy, it would seem reasonable to carry out an appendicectomy. This is mainly due to a future assumption that appendicectomy has been carried out when a patient presents at a later stage. It is also claimed that 20% of normal looking appendices may have evidence of mucosal appendicitis. Further, although rare, carcinoma of the appendix occurs in rare cases when the appendix looks microscopically normal.

There is little evidence to support the concept of chronic appendicitis. A number of patients mainly young females will have repeated acute presentations with right iliac fossa pain in the absence of raised inflammatory markers. Labels such as chronic appendicitis and

activities, and decrease the number of postoperative adhesions. At least six randomized studies have addressed the cost issue. Some found that overall costs for laparoscopic appendectomy were less (but not significantly so), most of the other studies have shown consistently that laparoscopy is more expensive. There was however a wide range of costs. One study found a mean difference of £148 in operating room charges, which does not compensate the costs for the mean difference in analgesics requirement between laparoscopic and open appendicectomy. On the other hand, there is no doubt in the superiority of diagnostic laparoscopy and laparoscopic appendicectomy in terms of quality but only if the incidence of post-operative complications could be reduced. The key to this dilemma lies in separating simple appendicitis from complicated appendicitis. The former will almost invariably have a low incidence of post-operative complications while those with complicated appendicitis (perforation or abcess) seem to have a higher rate of

Patients presenting with an appendix mass should be treated non-surgically in the first instance. Once the abscess has been confirmed radiologically, percutaneous drainage is the best treatment of choice. Occasionally this drainage can be followed by the development of a faecal fistula but this is usually a low output fistula which normally heals spontaneously. If percutaneous drainage is inadequate, it may be necessary to carry out operative drainage. In patients who have had an appendix mass treated conservatively, about 15% will develop

If appendix mass was found at laparoscopy or laparotomy an attempt should be made to drain the abscess and leave the appendix in situ. Old surgical dogma which continues to apply is that it is 'fool hardy to remove the appendix in the presence of an appendix abcess'. The main reasons for this is the generalised inflammation of the adjacent caecum and small bowel. Attempts at appendicectomy in this scenario, invariably result with intra and post operative complications. Such attempts usually result in a more extensive resection of the adjacent small bowel and caecum. Given the emergency presentation of these patients, the

If a normal appendix was found at laparoscopy, most surgeons would leave the appendix in-situ as an appendicectomy may carry some procedures specific complications. However some skilled surgeons have excellent results with removing a normal appendix laparoscopically. Based on the results of negative appendicectomies published, the complication rate tends to be low. However, if a right iliac fossa incision has been made over the appendix for open appendicectomy, it would seem reasonable to carry out an appendicectomy. This is mainly due to a future assumption that appendicectomy has been carried out when a patient presents at a later stage. It is also claimed that 20% of normal looking appendices may have evidence of mucosal appendicitis. Further, although rare, carcinoma of the appendix occurs in rare cases when the appendix looks microscopically

There is little evidence to support the concept of chronic appendicitis. A number of patients mainly young females will have repeated acute presentations with right iliac fossa pain in the absence of raised inflammatory markers. Labels such as chronic appendicitis and

recurrent appendicitis. An interval appendicectomy should be considered.

complications after laparoscopic appendicectomy.

**5.1 Management of appendix abcess** 

potential for complications is large.

normal.

**5.2 Negative, incidental and elective appendicectomy** 

'grumbling appendix' have been applied to these patients. However, there is no evidence to support this diagnosis. In some of these patients a faecolith was found in the lumen of the appendix which could in theory account for some of the symptoms without necessarily causing full fledged appendicitis. However, elective appendicectomy does not necessarily obviate the long term symptoms of many of these patients any more than a placebo effect. Consequently, the concept of elective appendicectomy for chronic right iliac fossa pain seems unjustified.
