EARLY LAPAROSCOPIC

WASHOUT MAY RESOLVE

PERSISTENT INTRA-
ABDOMINAL INFECTION
POST-APPENDICECTOMY
Presenter- Dr Pallavi
Moderator- Dr Jiju Mohan
AUTHORS AND PUBLICATIONS
➤ Matthew G. R. Allaway, Kristenne Clement, Guy D. Eslick, Michael R. Cox

➤ Department of Surgery, Nepean Hosptial, Australia

➤ World journal of Surgery- 26 Nov 2018

INTRODUCTION
➤ Persistent intra-abdominal sepsis and development of intra-abdominal abscess (IAA) is a
significant complication following both laparoscopic and open appendicectomy.

➤ The overall rates of post-operative IAA formation are low, between 2 and 3%. The incidence
increases signifcantly in the context of complicated (gangrenous or per- forated) appendicitis,
with rates in some studies exceeding 20%.

➤ Considering the large number of appendicectomies performed, this complication affects a

significant number of people in our communities.
➤ The standard management approach for post-operative IAA following appendicectomy is
percutaneous drainage.
➤ Some post-operative collections can be managed successfully with antibiotics alone,
particularly in the paediatric population.

➤ Both these treatment strategies have been shown to be effective, but frequently necessitate a
prolonged hospital admission.
➤ Open surgical drainage is normally reserved for patients with overwhelming sepsis or who fail
less invasive treatment modalities, and it is associated with significant morbidity.
➤ Timely, ‘‘on-demand’’ as opposed to planned re-la- parotomy and washout is the only
surgical option that significantly reduces morbidity and mortality in patients with persisting
intra-abdominal sepsis (for any cause) post- initial laparotomy.

➤ The aims of this study were to present our experience with early laparoscopic washout in
children and adults with evidence of persistent intra-abdominal sepsis post-appendicectomy
and compare these outcomes with percutaneous drainage and open drainage of established
IAA post- appendicectomy.
MATERIALS AND METHODS
➤ Study design- retrospective case note review. Data were collected by retrospective review of
medical records.

➤ Study period- January 2006 to December 2017.

➤ The indication for early laparoscopic washout was persistence of abdominal sepsis based on
clinical grounds.
➤ This included the persistence of some or all of the following: systemic inflammatory response
syndrome (SIRS), ileus, fevers, not progressing with diet, persistent or worsening abdominal
signs, and raised C-reactive protein (CRP) and raised white cell count (WCC).

➤ Complications were graded according to the Clavien- Dindo Classification of surgical

complications.

➤ Laparoscopic washout was performed with the patient under a general anaesthetic and
positioned supine.
➤ All patients received pre-operative intravenous antibiotics. Adults ([18 years) received
pharmacological and mechanical venous thromboembolism prophylaxis prior to skin incision.

➤ Laparoscopic entry into the peritoneal cavity was obtained via the original laparoscopic port
sites.

➤ Surgical technique comprised gentle blunt separation of inflammatory adhesions, entry into
any abscess cavity, careful disruption of loculations, aspiration of any purulent fluid and
generous saline lavage of the entire peritoneal cavity.
➤ All patients having laparoscopic washout, percutaneous drainage or open drainage were
treated with intravenous antibiotics in the perioperative period.
➤ Patients were prescribed ampicillin, gentamicin and metronidazole, or ceftriaxone and
metronidazole, based on the hospital protocol at the time, until sensitivity results guided
further antibiotic selection.

➤ Statistical analysis were carried out as mean and standard deviation (SD) or median and
interquartile range (IQR), odds ratios (OR).
➤ A p value of <0.05 was considered significant
RESULTS
DISCUSSION
➤ Intra-abdominal abscess (IAA) formation is a serious complication following
appendicectomy.

➤ Whilst this complication can occur following negative appendicectomy, the risk of intra-
abdominal abscess formation increases four to fivefold in patients with complicated
(gangrenous and perforated) appendicitis

➤ There were initial reports that laparoscopic appendicectomy was associated with increased
risk of intra-abdominal abscess formation when compared to open appendicectomy.
➤ However, recent meta-analyses have demonstrated no difference in the incidence of intra-
abdominal abscesses comparing laparoscopic with open appendicectomy

➤ Following appendicectomy, most surgeons wait until there is an established collection or

abscess prior to performing any intervention

➤ The decision for early re-laparoscopy was based on clinical assessment of persistent intra-
abdominal infection.
➤ Imaging was used to confirm a collection in almost half of the cases.

➤ Whilst the rate of negative laparoscopy was low in our series, the role of routine pre-operative
imaging should be considered, particularly in patients who do not fulfil SIRS criteria, in an
effort to reduce the incidence of unnecessary operations.

➤ The treatment strategies for established IAA post-appendicectomy include non-operative

management with intravenous antibiotics, percutaneous drainage or open surgical drainage.
➤ The non-operative approach has been shown to be effective in the paediatric population, with
treatment failure necessitating intervention in 8–31% of patients.

➤ In the adult population, there are no specific data for the non-operative treatment cohort.

➤ Percutaneous drainage is used for patients who fail non- operative treatment or who have
collections larger than 3 cm in diameter
➤ Whilst percutaneous drainage is less invasive than surgical drainage, its use is typically
restricted to the radio- logically accessible, unilocular abscess

➤ Open surgical drainage is used in patients requiring urgent management of overwhelming

sepsis, or who fail less invasive treatment modalities.

➤ The major difference in our study from previous reports was that the majority of the patients
had the intervention early prior to the establishment of an IAA.
➤ The intention of this approach was to treat persistent intra-abdominal infection early to
decrease the morbidity associated with IAA formation and reduce overall LOS.

➤ These findings have been reported in re-laparotomy and washout for other causes of persistent
intra-abdominal infection

➤ The intervention of early laparoscopic washout was associated with resolution of SIRS within
24 h in 62.5% of patients, with only 12.2% having persistent SIRS at 72h. Four (80%) of
these patients with persistent SIRS progressed to develop an IAA requiring further
intervention.
➤ Our results demonstrate that early laparoscopy and washout in patients with suspected
persistent intra-abdominal sepsis post-appendicectomy may be an appropriate management
strategy.

➤ However, it may not be any better than non-operative management with prolonged antibiotics
and delayed intervention for an established IAA with either percutaneous drainage or open
drainage.

➤ A prospective randomised comparison is required to further evaluate the indications and role
of early laparoscopic washout post-appendicectomy.
REFERENCES
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Incidence of postoperative intraabdominal abscesses in open versus laparoscopic appen- dectomies. Surg
Endosc 25(8):2678–2683
➤ Nataraja RM, Loukogeorgakis SP, Sherwood WJ, Clarke SA, Haddad MJ (2013) The incidence of
intraabdominal abscess formation following laparoscopic appendicectomy in children: a systematic
review and meta-analysis. J Laparoendosc Adv Surg Tech A 23(9):795–802
➤ Katkhouda N, Friedlander MH, Grant SW, Achanta KK, Essani R, Paik P et al (2000) Intraabdominal
abscess rate after laparo- scopic appendectomy. Am J Surg 180(6):456–9 (discussion 460–1)
➤ Allaway MGR, Eslick GD, Kwok GTY, Cox MR (2017) The established acute surgical unit: a reduction
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