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FIGURE 1B • Drain placement for abscess 1.
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FIGURE 1C • Drain placement 2.
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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
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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
antibi o ti cs. Fig u r es 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.
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FIGURE 2 • Phlegmon without definite abscess.
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FIGURE 3A • Small perforation on lateral wall of appendix.
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FIGURE 3B • Perforation with small pocket of air.
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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
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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
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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
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