International Journal of Surgery 6 (2008) 374377

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International Journal of Surgery

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Prevention of intra-abdominal abscess following laparoscopic appendicectomy

for perforated appendicitis: A prospective study
A. Hussain*, H. Mahmood, J. Nicholls, S. El-Hasani
General Surgery Department, Princess Royal University Hospital, 7 Tregony Road, Orpington, Kent BR6 9XA, UK

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 4 June 2008
Accepted 20 June 2008
Available online 27 June 2008

Background: Laparoscopic appendicectomy is gradually being accepted as a procedure of choice in the

management of suspected acute appendicitis. (in female of childbirth and obese patients, working class,
children and elderly). The aim of this study is to assess the feasibility and safety of laparoscopic
appendicectomy for perforated appendicitis and to assess our simple technique to reduce postoperative
infective complications of perforated appendicitis.
Methods: This is a prospective study for all patients who were admitted through the Accident and
Emergency Department with a diagnosis of perforated appendicitis conrmed during diagnostic laparoscopy and subsequently managed by laparoscopic appendicectomy. All patients had surgery within
24 h of admission. There were no conversions to open appendicectomy, although patients were also
consented for this. All patients were followed up in the out patient clinic.
Results: A total of 283 patients were admitted with a diagnosis of acute appendicitis from May 2005 to
February 2008. Twenty-two (7.77%) patients were diagnosed with perforated appendicitis. There were 9
(40.90%) men and 13 (59.09%) women. The ages ranged from 7 to 76 years. The length of stay ranged
from 6 to 21 days. ASA ranged from 1 to 3. Morbidity was 18.18% and no mortality was reported.
Conclusion: Perforated appendicitis can be managed effectively and safely using a laparoscopic technique. Timing of intervention and operative technique which includes four abdominal quadrants copious
irrigation is important to prevent postoperative intra-abdominal abscesses.
2008 Published by Elsevier Ltd on behalf of Surgical Associates Ltd.

Keywords:
Laparoscopic appendectomy (LA)
Open appendicectomy (OA)
Length of stay (LOS)
Computerised axial tomography (CT)
American society of anesthesiologists (ASA)

1. Background
Minimal access surgery is increasingly accepted as a method of
choice in the management of acute surgical problems. High success
rates have been reported for laparoscopic appendicectomy, following non-invasive diagnostic studies.1 The categories who are
affected by acute appendicitis (AA) and who benet from laparoscopy is expanded to include female patients, working patients,
obese, children and complicated appendicitis.2,3 Modern laparoscopic equipment has made the management of difcult and
complicated pathology feasible and safe. Accordingly, laparoscopic
appendicectomy (LA) is associated with minimal hospital stay, less
postoperative pain and better diagnostic efcacy over an open
technique. It is increasingly replacing open appendicectomy (OA)
irrespective of degree of inammation of the appendix.4 Many
studies have proved the safety and efcacy of the laparoscopic
technique for the mildly inamed appendix, however, there are
a few series that discuss the laparoscopic management of complicated appendicitis, which includes perforated presentations.
Gaining experience and familiarity with the pathology associated
* Corresponding author. Mobile: 44 7949393892; fax: 44 1689864488.
E-mail address: azahrahussian@yahoo.com (A. Hussain).

with AA is a very important determinant in the instalment of the

procedure and its subsequent outcome. Although our study is
a small one, nevertheless it describes a specic entity of acute
appendicitis (only perforated appendicitis).
The aim of this article is to describe our initial experience in the
laparoscopic management of perforated appendicitis in a District
General Hospital.
2. Methods
2.1. Study design
This is a prospective study for patients who were admitted
through the Accident and Emergency Department with a diagnosis
of acute appendicitis, were conrmed to have perforated appendicitis during diagnostic laparoscopy, and subsequently underwent
laparoscopic appendicectomy.
2.2. Exclusion criteria
All patients with a diagnosis of other forms of acute appendicitis
(other than perforated appendicitis) are excluded from this study.

1743-9191/$ see front matter 2008 Published by Elsevier Ltd on behalf of Surgical Associates Ltd.
doi:10.1016/j.ijsu.2008.06.006

A. Hussain et al. / International Journal of Surgery 6 (2008) 374377

375

3. Denitions

10.74%

Criteria of intra-abdominal abscess localised collection of infected

uid. It could be simple unilocular or complex multilocular type.
The abscess could be any size and localised anywhere in the
peritoneal cavity but the commonest sites are peri-appendicular,
paracecal and pelvic collections.
Perforated appendicitis is acutely inamed appendix and conrmed to be perforated macroscopically and/or microscopically and
associated with peritonitis.
Pre-operative antibiotics patients received metronidazole and
cefuroxime before operation and subsequently for 57 days after
the operation.
4. Operative technique
We used our simple laparoscopic technique of managing this
pathology. All patients had the operation within 24 h of admission
and a single consultant performed all the operations. The patients
gave consent for laparoscopic and/or open appendicectomy.
A Verres needle is used to create pneumoperitoneum and three
5 mm ports are usually placed at the umbilicus, left lumbar and the
suprapubic area. The suprapubic port, which is used to deliver the
specimen, can be changed to 1015 mm depending on the size of
the appendix. An extra port is used without hesitation if needed.
After diagnostic laparoscopy, the perforated appendix is freed
from the mesentery using hook dissection, keeping as near as
possible to the appendicular wall, thus reducing the bulk of the
appendix and avoiding specimen delivery problems. Two vicryl
endoloops are used to secure the appendicular stump and an
additional vicryl endoloop is placed distal to the appendix. The
principle of suction of intraluminal contents after cutting the
appendix is of negligible benet in perforated appendicitis and
therefore was not of primary importance here. Approximately 3 l of
normal saline is used for per-operative lavage. Four quadrants,
pelvic and interloop lavage is ensured. We usually leave between
300 and 500 mm of saline in the peritoneal cavity.
Tilting the head of the operating table steeply up and down is
helpful in obtaining adequate lavage. If the perforation is near the
caecum, the vicryl endoloop is applied to include part of the caecal
wall. A drain is placed towards the pelvis in all patients. Delivery of
the specimen should be through the port and never through the
abdominal wall. The antibiotics cefuroxime and metronidazole are
used intravenously for 5 days postoperatively.
5. Results
A total of 283 patients were admitted with a clinical diagnosis of
acute appendicitis from May 2005 to February 2008. Macroscopical
appendicitis was reported in 196 (69.25%) cases. This includes 159
(56.18%) suppurative appendicitis, 15 (5.3%) gangrenous appendicitis, whilst 22 (7.77%) patients were diagnosed with perforated
appendicitis and included in this study (see Fig. 1). The operative
ndings of these patients includes19 (86.36%) generalised peritonitis (four quadrant pus) and 3 (13.63%) localised abscesses. There
were 9 (40.90%) men and 13 (59.09%) women. The mean age was 19
years (range776) .The duration of symptoms varied from 1 to 6
days (mean 3.4 days). The mean length of stay was 7 days (range
621). ASA ranged from 1 to 3. Two patients were ASA 3, three
patients were ASA 2 and 17 patients were ASA 1 (see Table 1). The
operative time ranges from 24 to 65 min (mean 36 min). None had
postoperative temperature more than 38  C. Two (9.09%) patients
needed postoperative computerised axial tomography CT scan to
exclude an intra-abdominal collection as they had prolonged
paralytic ileus. Both were clear. Two (9.09%) patients had wound
infections where the appendix was extracted. A total morbidity of

56.18%
20%

7.77%
5.3%

Normal appendix

Gangrenous appendicitis

Other pathology

Perforated appendicitis

Suppurative appendicitis
Fig. 1. Final diagnosis for 283 patients who were admitted with suspected
appendicitis.

18.18% and no mortality or conversion was reported in this series.

All patients are followed up and seen in out patient clinic. Single
postoperative visit usually within 46 weeks from the operation is
arranged and patients usually discharged if they are well. All
patients are informed to call our unit or to attend emergency
department if they develop complications (abdominal pain, vomiting, fever, and change in bowel habit).

6. Discussion
Minimal access surgery is developing to achieve the optimum
results through a small incision and the current era indicates wide
application of laparoscopy in general surgery including the emergency setting. Recent advances of Natural Orice Transluminal
Endoscopic Surgery NOTES have reported incisionless procedures
such as transgastric appendicectomy, which needs time for evolution before it is to be accepted on a practical basis. Laparoscopic
management of acute appendicitis on the other hand is evolving in
difcult and challenging types of complicated appendicitis.5 It has
been considered as the operation of choice for perforated appendicitis.6,7 Whilst the laparoscopic removal of a mildly inamed
appendix is a simple operation, complicated appendicitis involving
a perforated appendix can be a challenging one.
The literature is suggestive of feasibility and safety of laparoscopic removal of complicated appendicitis including perforated
appendicitis.8 It has comparative operative time, length of stay
(LOS), and complication rates.911 Some studies of LA are suggestive
of a signicantly higher intra-abdominal abscess rate and lower

Table 1
Patients characteristics
Age (years)

776 (mean 19)

ASA
1
2
3
Male
Female
Duration of symptoms (days)

17
03
02
09
13
16 (mean 3.4)

Operative ndings

Four quadrant pus

Localised abscess

19
03

Outcomes

Hospital stay (days)

Duration of operation (min)
Prolong ileus
Abdominal wall infection
Intra-abdominal abscess
Mortality

621 (mean 7)
2465 (mean 36)
2
2
0
0

Patients characteristics

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A. Hussain et al. / International Journal of Surgery 6 (2008) 374377

wound infection rate when compared with OA.12 In contrast, Cueto

et al.13 have shown in a study of 1017 patients with complicated
appendicitis including perforation less postoperative intraabdominal abscesses at 2.8% in comparison to the higher rate
records for OA. However, So et al.14 in a study of 85 cases of perforated appendicitis that underwent laparoscopic appendicectomy
concluded less infectious complications compared to OA. Therefore,
the fear of developing deep abscesses following laparoscopic
appendicectomy cannot be accepted as a general rule.15
No doubt, the most important postoperative concern is the
infectious complication. We developed our own simple technique
(see patient and method) and we think this has reduced this
morbidity further and helped to accelerate recovery. Furthermore,
postoperative pain, paralytic ileus, bowel adhesions and obstruction is anticipated to be less once peritonitis is prevented or controlled. There are two very important points we would like to
emphasise here: the rst is never deliver the inamed appendix
through the abdominal wall or let the appendix touch the wound.
We always retrieve the specimen through the port thus preventing
any contact and therefore no potential predisposition for abdominal wall infection.
The second important step in our technique is to copiously
irrigate the peritoneal cavity including the right and left paracolic,
supra and subhepatic, perisplenic, pelvic and interloop areas. At
least 3 l of saline are used for all patients (86.36%) who had four
quadrant pus. The other 3 (13.63%) patients had paracecal and
pelvic irrigation. This step, which cannot be achieved by OA, is
essential to dilute infection, which may be in different peritoneal
quadrants and regions. Leaving 300500 mm of normal saline
inside the peritoneal cavity at the end of the procedure and the
application of a drain will further dilute the infection foci. As
a result, less incidence of postoperative abscess and infectious
complications are anticipated and have been conrmed by our
study, whilst higher rates of intra-abdominal infections are
described by other studies.16,17
Studies are variable in conclusions and are indicative of different
parameters which govern the outcome.18 Among the important
parameters are the degree of inammation, surgeon experience,
type of technique and patient related factors. Therefore optimisation of the controllable variables will improve the outcome and that
is exactly what surgeons need to concentrate on.
In our series, two patients developed prolonged paralytic ileus.
These patients had four quadrant pus and generalised peritonitis.
Subsequent abdominal and pelvic CT scan excluded major intraabdominal problems and abscess. Although the size of our series is
relatively small, no single case of postoperative abdominal abscess
was reported. Another two patients developed wound infection
where the appendix was extracted, one at the suprapubic port and
one at the left side port. Both cases developed in our initial series,
when the appendix was delivered through the wound after
removal of the port. Then we changed to deliver the appendix
through the port itself to prevent direct contact with the port site.
These infections responded to drainage of the wound and antibiotic
treatment. No mortality was reported.
Short length of stay (LOS) is one of the advantages of laparoscopic appendicectomy.1921 The infectious complications and the
degree of inammation of the appendix are among the causes of
prolonged LOS. Our range of LOS is comparable to other studies.22,23
A prolonged stay of 21 days was reported for patients who
developed paralytic ileus and abdominal wall infection.
We operated on all cases within 24 h of admission and this has
been conrmed causing no signicant difference to morbidity.
There was no conversion to OA in our series, although the
conversion rate has been reported as high as 22% in some series.24 A
lower rate at 1.8% has been recorded also.25 Factors associated with
conversion are age (>65years), experience of surgeon, dense

adhesions due to inammation followed by localised perforation

and diffuse peritonitis.26
Laparoscopic appendicectomy has changed the management of
perforated appendicitis from an open procedure with a high complication rate and denite mortality to a safe, effective procedure
with a minimum morbidity and no mortality.

7. Conclusion
Perforated appendicitis can be managed effectively and safely
using a laparoscopic technique. Short hospital stay, no conversion,
less minor morbidity and no major complications including postoperative intra-abdominal abscess are consistent with teamwork,
timing of intervention and technique which includes four abdominal quadrants copious irrigation.

Conict of interest
None declared.
Funding
None declared.
Ethical approval
None declared.

References
1. Napolitano L, Waku M, Liddo G, Innocenti P. Laparoscopic approach to acute
abdomen: a single-center clinical experience. G Chir 2008;12:4750.
2. Corneille MG, Steigelman MB, Myers JG, Jundt J, Dent DL, Lopez PP, et al. Laparoscopic appendectomy is superior to open appendectomy in obese patients.
Am J Surg 2007;6:87780.
3. Lin HF, Wu JM, Tseng LM, Chen KH, Huang SH, Lai IR. Laparoscopic versus open
appendectomy for perforated appendicitis. J Gastrointest Surg 2006;6:90610.
4. Korlacki W, Dzielicki J. Laparoscopic appendectomy for simple and complicated
appendicitis in childrensafe or risky procedure. Surg Laparosc Endosc Percutan
Tech 2008;1:2932.
5. Yau KK, Siu WT, Tang CN, Yang GP, Li MK. Laparoscopic versus open appendectomy for complicated appendicitis. J Am Coll Surg 2007;1:605.
6. Stoltzing H, Thon K. Perforated appendicitis: is laparoscopic operation advisable? Dig Surg 2000;6:6106.
7. Yao CC, Lin CS, Yang CC. Laparoscopic appendectomy for ruptured appendicitis.
Surg Laparosc Endosc Percutan Tech 1999;4:2713.
8. Fukami Y, Hasegawa H, Sakamoto E, Komatsu S, Hiromatsu T. Value of laparoscopic appendectomy in perforated appendicitis. World J Surg 2007;1:937.
9. Kirshtein B, Bayme M, Domchik S, Mizrahi S, Lantsberg L. Complicated
appendicitis: laparoscopic or conventional surgery? World J Surg 2007;4:7449.
10. Mallick MS, Al-Qahtani A, Al-Bassam A. Laparoscopic appendectomy is
a favorable alternative for complicated appendicitis in children. Pediatr Surg Int
2007;3:2579.
11. Meguerditchian AN, Prasil P, Cloutier R, Leclerc S, Peloquin J, Roy G.
Laparoscopic appendectomy in children: a favorable alternative in simple and
complicated appendicitis. J Pediatr Surg 2002;5:6958.
12. Pokala N, Sadhasivam S, Kiran RP, Parithivel V. Complicated appendicitisis the
laparoscopic approach appropriate? A comparative study with the open
approach: outcome in a community hospital setting. Am Surg 2007;8:73741.
13. Pirro N, Berdah SV. Appendicitis: yes or no to laparoscopic approach? J Chir
(Paris) 2006;3:1559.
14. So JB, Chiong EC, Chiong E, Cheah WK, Lomanto D, Goh P, et al. Laparoscopic
appendectomy for perforated appendicitis. World J Surg 2002;12:14858.
15. Kouwenhoven EA, Repelaer van Driel OJ, van Erp WF. Fear for the intraabdominal abscess after laparoscopic appendectomy: not realistic. Surg Endosc
2005;7:9236.
16. Tanaka S, Kubota D, Lee SH, Oba K, Matsuyama M. Effectiveness of laparoscopic
approach for acute appendicitis. Osaka City Med J 2007;1:18.
17. Soler-Dorda G, Fernandez-Daz MJ, Martn-Parra I, Alonso-Gayon JL, ContySerrano JL, de Andres-Fuertes MA, et al. Intraabdominal septic complications in
laparoscopic appendectomy: description of a possible new intraabdominal
septic complication specic to laparoscopic appendectomy. Cir Esp 2007;1:
216.
18. Kiriakopoulos A, Tsakayannis D, Linos D. Laparoscopic management of complicated appendicitis. JSLS 2006;4:4536.
19. Gupta R, Sample C, Bamehriz F, Birch DW. Infectious complications following
laparoscopic appendectomy. Can J Surg 2006;6:397400.

A. Hussain et al. / International Journal of Surgery 6 (2008) 374377

20. Yagmurlu A, Vernon A, Barnhart DC, Georgeson KE, Harmon CM. Laparoscopic
appendectomy for perforated appendicitis: a comparison with open appendectomy. Surg Endosc 2006;7:10514.
21. Towgh S, Chen F, Mason R, Katkhouda N, Chan L, Berne T. Laparoscopic
appendectomy signicantly reduces length of stay for perforated appendicitis.
Surg Endosc 2006;3:4959.
22. do Amaral PC, Filho Ede M, Galvao TD, Junior EE, de Magalhaes Neto GE,
Mascarenhas F, et al. Factors leading to long-term hospitalization after laparoscopic appendectomy. JSLS 2006;3:3558.

377

23. Kapischke M, Bley K, Tepel J, Schulz T. Open versus laparoscopic operation for
perforated appendicitisa comparative study. Zentralbl Chir 2005;2:13741.
24. Alvarez C, Voitk AJ. The road to ambulatory laparoscopic management of perforated appendicitis. Am J Surg 2000;1:636.
25. Kang KJ, Lim TJ, Kim YS. Laparoscopic appendectomy is feasible for the complicated appendicitis. Surg Laparosc Endosc Percutan Tech 2000;6:3647.
26. Liu SI, Siewert B, Raptopoulos V, Hodin RA. Factors associated with conversion
to laparotomy in patients undergoing laparoscopic appendectomy. J Am Coll
Surg 2002;3:298305.