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302 Moshe Schein · Ahmad Assalia
administration to the operative findings. Gangrenous AA, without any pus formation, represents a “resectable infection,” which does not require more than
24 hrs of postoperative administration. Perforated AA with or without intraperitoneal pus should be treated longer, but for no more than 5 days—unless serious
infectious complications develop. (> Chaps. 7, 12, and 47).
Nonoperative Management of Acute Appendicitis
Perhaps you are not aware that most attacks of simple AA respond to nonoperative management with antibiotics. Complicated AA may also respond to antibiotics or at least could mature into an abscess. So, why not treat most cases of AA
initially conservatively, along the same lines as acute diverticulitis (< Chap. 26) of
the sigmoid colon? This is because the surgical management of AA is simpler and
less morbid than that of diverticulitis and because we are dogmatic. However, there
are several situations for which you should consider a nonoperative approach:
In a patient who had just suffered a myocardial infarction
In a morbidly obese patient
During the first weeks of pregnancy
On submarines
On a trip to Mars
In 1961, Leonid Rogozov (1933–2000), a young Russian surgeon, on an
Antarctic expedition, had to remove his own inflamed appendix—he used a
mirror! However, in this day and age we would recommend antibiotics rather
than autoappendectomy.
Also, the preferred management of an appendiceal mass (phlegmon) is
conservative as discussed separately in this chapter.
The Operation
“The appendix is generally attached to the cecum.” (Mark M. Ravitch, 1910–198 9)
“The point of greatest tenderness is, in the average adult, almost exactly 2 inches
from the anterior iliac spine, on a line drawn from this process through the umbilicus.”
(Charles McBurney, 1845–1913)
When to Operate?
You do not have to rush to the operating room as soon as possible with each
patient diagnosed with AA. Obviously, if your patient is systemically sick and the
abdominal findings are impressive (denoting a perforation), operate immediately.
28 Acute Appendicitis 303
Otherwise, a delay of a few hours while the patient receives antibiotics is acceptable. You do not rush to the operating room with acute diverticulitis (> Chap. 26),
so what is the difference?
Open Versus Laparoscopic Approach?
As pointed out, liberal use of diagnostic laparoscopy for suspected AA leads
to a high incidence of unnecessary removal of normal appendices, procedures that
are not free of complications. But, what about LA if the diagnosis has been established? Evidence suggests that—and this is how one can summarize the voluminous
literature steadily being published on this controversy—compared to the open procedure, LA is associated with some reduction in postoperative pain, marginally earlier discharge, and lower incidence of wound infection. However, LA is associated
with a higher risk of intra-abdominal infective complications when performed for
complicated AA. Concerning costs, the money saved by an earlier discharge after
LA is spent on a more expensive and longer procedure. It appears thus that surgeons
who prefer open appendectomy (OA) (MS among them) have the support of the
literature, but it does not mean that they should avoid LA altogether; it surely has a
place in very obese patients (avoiding a large incision) or in those with nonperforated appendicitis who specifically demand the laparoscopic approach.
Technical Points
The open procedure is discussed here. Should you prefer to play with gas,
sticks, and staplers, help yourself. (See the commentary in this chapter by coeditor
AA.) We presume that you have done your share of appendectomies already as an
intern. However, having seen many surgeons transform a customary appendectomy to an elaborate operation resembling a Whipple’s procedure, we remind you
of the KISS principle (keep it simple, stupid! ☺)
Incision: you do not need the long, unsightly oblique incision except in the
muscular young man whose possible retrocecal appendix may be unreachable
through a transverse hole. Use the transverse one. A common error is to place it
too medially over the rectus sheath; stay lateral to it. Incise the fascia, split the
muscles, and open the peritoneum. Start with a mini-incision; it can always be
extended by cutting the lateral edge of the rectus fascia or muscle.
Appendectomy: you can remove the appendix in an antegrade or retrograde
fashion, but there is no need to invert the stump unless you are hooked on useless
rituals. Just ligate or suture-transfix the appendix at its base and chop the rest off.
When the tissue is friable, overrun the divided mesoappendix with a running
suture. The commonly performed fetishes of painting the stump with Betadine or
burning it with diathermy are ridiculous. If the appendix has perforated just at its
304 Moshe Schein · Ahmad Assalia
base, to secure the stump safely you have to include in it some healthy cecal wall;
just place a linear stapler across the cecum distal to the perforation and fire.
Peritoneal toilet: just suck out the fluid with a Poole sucker and mop up
whatever pus is present with a dry gauze stick (do not forget the pelvis). Peritoneal lavage through this keyhole incision is useless. But, if you are a dedicated
irrigator, limit the lavage to the affected area (i.e., pelvis, peri-cecal). Why would
you want to spread bacteria all over the abdomen?
Drains: drains are never necessary. In theory, they may be indicated after
the drainage of a large appendicular abscess, but in practice we never use them
and have never regretted it.
Closure : theoretically, closing the peritoneum is unnecessary because it adds
no strength to the repair, and we know that the peritoneum repairs itself within 48
hrs; however, this step “covers” the bulging viscera, facilitating careful closure of
the abdominal wall layers. Next, the muscles are approximated loosely with a few
sutures of 2–0 vicryl to obliterate dead space, the fascia is closed with running 0
PDS, taking large bites at both edges. The subcutaneous layer, if thick, may be approximated with a few fine sutures of vicryl.
Instillation of an antibiotic in the fat protects against wound infection (in ad-
dition to systemic administration). Our bias is for primary closure of the skin in all
cases. A few will develop wound infection managed by removal of (a few) stitches.
Isn’t this better than delayed secondary closure, which condemns all patients to
further manipulations and an ugly scar (> Chaps. 43 and 55)? We close the skin in
continuous subcuticular fashion in cases of noncomplicated appendicitis; in complicated ones, we use interrupted nylon 4–0.
The White Appendix
What should you do when the appendix proves to be pristine (white)? Well,
you can rub it to allow the pathologist to diagnose mild acute inflammation (just
kidding). The classical dictum is that whenever an abdominal appendectomy incision exists the appendix should be removed in order not to confuse matters in the
future. What about a normal appendix visualized at laparoscopy? Should it also be
removed? The emerging consensus is to leave it alone, informing the patient or the
parents that the appendix has been left in situ. However, most laparoscopists do
not feel comfortable with this recommendation, always worrying that what appears
normal through the video camera may prove diseased at histology. Thus, for most
surgeons, diagnostic laparoscopy for suspected appendicitis leads to appendectomy regardless of whether the appendix is normal or diseased.
Obviously, when the appendix appears normal you should search for alternative diagnoses such as Meckel’s diverticulitis (> Chap. 35), adnexal pathology
(> Chap. 33), perforated cecal diverticulitis (> Chap. 26), or mesenteric lymph-
adenitis (whatever that is). In most instances, however, you will find nothing. What
28 Acute Appendicitis 305
should you do if foul smelling, murky, or bile-stained peritoneal fluid is encountered, suggesting serious alternate pathology elsewhere? Bile should guide you
into the upper abdomen. Close the incision and place a new one where the action
is. Feces or its odor direct you toward the sigmoid; just extend the incision across
the midline, and you are there. But of course, a preoperative CT (or laparoscopy)
would have saved you all these old-fashioned headaches.
The “Valentino” Appendix
Intraperitoneal inflammation from any cause can inflame-inject the appendix and the adjacent parietes from the outside, mimicking AA. This was the case
with the famous movie actor and womanizer Rudolph Valentino, who underwent
an appendectomy for suspected AA in New York (1926). He became gravely ill after
the operation and died; autopsy revealed a perforated peptic ulcer. Old texts teach
us that contaminants forming in the right upper abdomen tend to spread down
along the right gutter into the lower abdomen, thus producing a misleading clinical picture. Therefore, the findings of peritoneal fluid and suppuration together
with a mildly inflamed and nongangrenous and nonperforated appendix should
raise your suspicions that the pathology is elsewhere. Look for it!
The Post-appendectomy Appendiceal Stump Phlegmon
Your patient had an uneventful appendectomy for AA following which the
patient happily went home. Seven days later, the patient re-presents with RLQ pain,
a temperature, and high white cell count. The wound looks okay. This is a typical
presentation of an appendix stump phlegmon. Now, the diagnosis is simple; a CT
will demonstrate a phlegmon that involves the cecum, as opposed to a drainable
abscess. A few days of antibiotic therapy will cure this relatively rare complication,
which for some reason is not mentioned by standard texts.
Stump appendicitis: be aware that patients can develop classical AA at any
time after appendectomy. Historically, this followed appendectomy for compli-
cated appendicitis, often by a relatively inexperienced family doctor or surgeon. It
is now becoming more common in the era of LA; during the procedure, surgeons
may misidentify the cecal base of the appendix and consequently leave a longer
than usual appendiceal stump, which is prone to stump appendicitis and requires
a re-appendectomy.
Fecoappendicopathy or the Painful Fecalith
The patient presents with clinical features of early appendicitis. Abdominal
X-ray may show a large fecalith. CT shows a fecalith or a grossly dilated appendix
306 Moshe Schein · Ahmad Assalia
with no surrounding inflammatory features. At operation, the enlarged appendix
does not appear inflamed, but when you open it (after removal) you will find it stuffed
with feces like a sausage or containing a large hard fecalith. So, do not feel bad when
the pathology report mentions no “acute inflammation”—the distended appendix
was responsible for the patient’s symptoms, and the appendectomy was indicated.
Appendiceal Mass (Phlegmon)
Typically, patients with an appendiceal mass present late in the course of
the disease, with abdominal symptoms lasting a week or more. Occasionally, they
report spontaneous improvement in their symptoms, reflecting localization of
the inflammatory process. This is also more common in diabetic patients. On
clinical examination, you will find a right iliac fossa mass. Overlying tenderness
or obesity may obscure the presence of the mass. Therefore, suspect an appendiceal mass in the “late presenters” or those with an atypical smoldering picture.
When palpation is not rewarding, obtain a CT scan, which is the best way to
document an appendiceal mass. Another indication for CT is associated evidence
of undrained pus, such a spiking fever and toxicity, signifying an appendiceal
abscess.
Why should y ou d istinguish b etwe en A A a nd app end icea l mass (or abs cess)
if the management of these conditions is the same (i.e., operation and antibiotics)? This is because the appendiceal mass (and abscess) can (and should) be
managed nonoperatively. You could operate on both, as you operate on AA, but
removal of the appendix involved in an inflammatory mass may be more hazardous than usual, occasionally necessitating a right hemicolectomy. On the other
hand, conservative treatment with antibiotics leads to resolution of the mass in
the vast majority of cases. Failure of the mass to respond to antibiotics signifies
an abscess. CT or US-guided percutaneous drainage is the most rational approach
(> Chap. 49). Failure to improve clinically within 48 hrs means that an operation
is needed. At operation, drain the pus and remove the appendix if it is not too
difficult.
Interval Appendectomy?
As no more than one of ten patients treated conservatively for appendiceal
mass will suffer a recurrence of AA (usually within 1 year and not a “complicated”
attack), the dogma of routine interval appendectomy within 6 weeks has become
obsolete. Interestingly, in many of these patients at interval appendectomy the
appendix is found to be rudimentary and scarred. In patients over the age of
40 years, we suggest elective colonoscopy/colonic imaging after 3 months to exclude
28 Acute Appendicitis 307
the rare situation in which cecal carcinoma was the cause of the mass. Cecal cancer
or inflammatory bowel disease will be detected in only 1 of 100 such patients.
With a high degree of suspicion, you can avoid an operation in the majority
of patients with an appendiceal mass. And remember: an appendiceal mass rep-
resents an unfavorable situation for your laparoscopic skills.
Appendicitis Epiploica (Appendagitis)
We mention the appendicitis epiploica condition here because of its name,
because you probably have not heard much about it, and because it is not so rare
and often imitates AA. Appendicitis epiploica (some call it “appendagitis”) follows
a spontaneous torsion of an appendix epiploica, the peritoneum-covered tabs of
fat attached along the tenia coli. It is more common in obese individuals and in the
cecum and sigmoid. Since the sigmoid colon often crosses the midline, the most
common manifestation is localized tenderness and peritoneal signs in the right
iliac fossa. Typically, patients do not feel or appear sick despite these findings.
Thus, “AA on examination” in an afebrile and healthy-looking patient should raise
your suspicions. The natural history is spontaneous remission as the appendix
epiploica sloughs off, transforming into that loose calcified peritoneal body that
you occasionally find during unrelated abdominal procedures. CT scan may identify the localized area of peri-colonic inflammation (> Chap. 5). If you are misled
into an operation, just remove the necrotic piece of fat.
Laparoscopic Appendectomy
Ahmad Assalia
The open approach described is acceptable to most surgeons. But, I see things
a bit differently and I would opt for LA in virtually every case of early AA. According
to the current evidence and my personal experience, LA has immediate advantages as well as late ones. The immediate ones include less pain, speedier recovery
(although not that dramatic compared to OA), and significantly decreased rates of
wound infection. The long-term advantages include better cosmetic results (we
cannot overlook this, especially in young women), lower rates of wound pain and
hernia, and fewer adhesions, which is important for prevention of future small
bowel obstruction and fertility problems in young women. The allegedly high
rates of intra-abdominal infection in advanced cases of AA are no longer found in
newer studies and in competent hands. On the top of this, let us not forget the
preferences of patients in this modern era. As for the duration of operation, in
experienced hands LA should not take longer to complete than OA.
308 Moshe Schein · Ahmad Assalia
There is no doubt that all of this is true provided you have solid laparoscopic skills. If you do not have them, play it safe and proceed with OA. This is
good clinical practice, and no one will sue you for not doing LA, especially since
there is still some controversy surrounding the issue.
I do agree with the notion that in the young thin male an OA with a keyhole
incision is totally acceptable. My attitude dictates that if you are comfortable
with LA, every case is suitable unless there is some problem with the laparoscopic approach, namely, previously operated lower abdomen, a patient on aspirin, advanced AA and generalized peritonitis.
Although in experienced hands virtually every case of AA is doable laparoscopically it should be emphasized that in the following conditions LA is preferable beyond any controversy (well … almost): young fertile women, obese patients,
and cases with unclear diagnosis even after imaging (yes, there are such cases).
The laparoscopic approach enables you easily to explore the whole abdomen,
including the small bowel, the female genital organs, and every other possible
pathology. Feel free to convert when you are not comfortable with the anatomy
or have any possible conflict with the right ureter, uncontrollable bleeding, or an
injury to the small bowel or cecum. This reflects a victory of your judgment over
the inflated ego of most of us.
Technical Tips for Laparoscopic Appendectomy
1. Make sure that the patient has voided shortly before the procedure and do
not let your anesthetist overload the poor patient with fluids; a full bladder
will interfere with your vision, and you may perforate the bladder while
inserting your lower trocar.
2. The patient should lie supine with the left arm adducted. This will enable
you and your assistant both to work on the patient’s left side.
3. Secure the patient above the knees to the table. This will prevent the patient
from sliding while rotating the table to the left and in steep reverse
Trendelenburg position.
4. Use a good 5-mm scope. This will enable you to move the scope between the
trocars for later retrieval of the appendix.
5. There are many ways to insert the trocars, depending on the habitus of the
patient, but I find the following the most useful: place the first, 10-mm tro-
car, just under the umbilicus for the scope and later removal of the appen-
dix; the second, a 5-mm working trocar is placed in the LLQ or suprapubic
position; the third, a 5-mm working trocar, is at the upper midline, about
5–6 cm above the umbilicus. An acceptable alternative set-up of trocars
would be: 5-mm at the umbilicus for the camera, 5-mm in the LLQ and a
10-mm suprapubically for retrieval.
28 Acute Appendicitis 309
6. The operating table should be tilted to the left with the head down, so that
the entire small bowel moves to the left and cranially, thus exposing the
cecum and the appendix.
7. Use an ultrasonic scalpel or 5-mm Ligasure for dissection and to take down
the mesoappendix. Alternatively, you use bipolar diathermy or monopolar
and clips. You do not need an endostapler. After dividing the mesoappendix and exposing the base arising from the cecum, ligate the appendix
twice with an endoloop. If it is too wide or the base is involved in the inflammatory process, you may use an endostapler (35 mm), sometimes even
including a normal-looking wall of the cecum in the bite. But, make sure
you are not incorporating the ileocecal junction (valve).
8. If the appendix is in the retrocecal position, you may have to mobilize the
cecum partially. Do not hesitate to do so. In the majority of cases, you will
not have any conflicts with the right ureter.
9. Remove the appendix through the umbilical trocar. If it is a small one, there
is no need for a bag. But, if it is bulky, you better use a retrieval bag. Do not
hesitate to enlarge the umbilical opening for easy removal.
10. Aspirate (and irrigate if you wish) the gutter and the pelvis. For the pelvis,
you will have to place the patient in a steep Trendelenburg position and
retract the entire bowel out of the pelvis. Finally, before leaving the abdomen, do not forget to take a final look at the meso and the stump.
Rebuttal: Dr. Ahmad Assalia is trying to convince you (probably many of
you have already been convinced) that the laparoscopic approach is almost always
preferable. Perhaps in his own expert hands it is true, but in general, looking
around us—beyond what is published in the literature—we see an epidemic of
complications developing after LA that we have (almost) never seen before: intraperitoneal abscesses, intestinal obstruction, cecal fistula, recurrent appendicitis,
bowel injury, bladder injury. AA mentioned decreased hernia formation with LA,
but I have never seen a patient with post-OA hernia, and what about hernias
developing in the trocar site? So, decide for yourself and play it safe.
The good thing about standards of care is that there are so many to choose from.
Conclusions
Acute appendicitis, like any other surgical condition, has a spectrum. To reach
the diagnosis, consider historical, physical, and laboratory findings together. No isolated variable can confirm or exclude AA; the more typical variables that are present,
the higher the chance that you are dealing with AA. Whether you operate immediately or tomorrow, whether you observe or obtain additional tests is determined
selectively based on your individual patient.
310 Moshe Schein · Ahmad Assalia
Never become blasé about AA; it can kill even today and may humble even
the most experienced surgeon.
“The surgeon who can describe the extent of an appendiceal peritonitis has
convicted himself of performing an improper operation.”
1
(Mark M. Ravitch, 1910–
1989)
There are two things in life that I will never understand: women and acute
appendicitis.
1
If you do not understand this aphorism feel free to e-mail us.
Anorectal Emergencies
Luis A. Carriquiry
We suffer and die through the defects that arise in our sewerage and drainage
systems. (William A. Lane, 1856–1943)
Why have a chapter about anorectal emergencies in a book about emergency abdominal surgery? The easiest answer would be one based on anatomy:
the rectum is an abdominal viscus, and the anus, although not strictly abdominal, belongs to the perineum, which latu sensu is the floor of the abdominal cavity. But, the main reason for inclusion is pragmatic: anorectal emergencies are
managed by the general surgeon on duty, who has to provide optimal care to
these frequent emergencies (> Fig. 29.1).
First, consider the three leading causes of acute anal pain:
Acute fissure
Acute perianal hematoma
Perianal abscess
29
Fig. 29.1. “I know I’m a pain in the ass, but please help me!”
Luis A. Carriquiry
Maciel Hospital School of Medicine, Universit y of the Republic, Montevideo, 11600, Uruguay
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_29, © Springer-Verlag Berlin Heidelberg 2010
311
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