Appendectomy: Background, Indications, Contraindications (original) (raw)

Background

Appendectomy is the surgical removal of the vermiform appendix. Although the incidence of appendicitis has markedly decreased in recent years, appendicitis remains one of the more common surgical emergencies. The development of nonoperative management approaches notwithstanding, appendectomy remains a common treatment for noncomplicated appendicitis.

Thousands of classic appendectomies (ie, open procedure) have been performed in the past two centuries. Mortality and morbidity have gradually decreased, especially in the past few decades, because of antibiotics, early diagnosis, and improvements in anesthesiologic and surgical techniques. Technical developments have included multiport and single-port laparoscopic appendectomy, as well as natural orifice transluminal endoscopic surgery (NOTES) appendectomy (eg, transvaginal appendectomy and transgastric appendectomy).

For patient education information, see the Digestive Disorders Center, as well as Appendicitis and Abdominal Pain in Adults.

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Indications

Patients with appendicitis always need urgent referral and prompt treatment. An appendectomy should be considered for patients with a history of persistent abdominal pain, fever, and clinical signs of localized or diffuse peritonitis, especially if leukocytosis is present.

If the clinical picture is unclear, a short period (4-6 hours) of watchful waiting and a computed tomography (CT) scan may improve diagnostic accuracy and help hasten the diagnosis. [1] However, if a patient is discharged from the medical center without a definite diagnosis at the end of the observation period, he or she should be instructed to return if symptoms continue or recur; a follow-up examination in 24 hours may be beneficial.

A retrospective study by Kim et al, designed to determine whether acute nonperforated appendicitis is a surgical emergency that necessitates immediate intervention or a condition that can be treated with a semielective approach, found that delaying appendectomy for 12-24 hours was safe for patients with acute nonperforated appendicitis. [2]

Antibiotic therapy may be an alternative to surgical therapy in some patients. [3] The Appendicitis Acuta (APPAC) multicenter randomized clinical trial comparing appendectomy with antibiotic therapy, in which 530 patients aged 18-60 years with CT-confirmed uncomplicated acute appendicitis were randomly assigned to undergo appendectomy (n = 273) or receive antibiotic therapy (n = 257) and followed for 5 years, found antibiotic treatment alone to be a feasible alternative to surgery for uncomplicated acute appendicitis. [4] In addition, antibiotics are less costly. [5]

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Contraindications

There are no known contraindications for appendectomy in patients with suspected appendicitis, except in the case of a patient with a long history of symptoms and signs of a large phlegmon. If a periappendiceal abscess or phlegmon exists secondary to appendiceal perforation or rupture, some clinicians may choose a conservative approach with broad-spectrum antibiotics and percutaneous drainage followed by appendectomy later (interval appendectomy).

Certain contraindications exist for laparoscopic appendectomy, including the following:

Laparoscopic appendectomy has been regarded as contraindicated in the first trimester of pregnancy. However, guidelines increasingly accept laparoscopic appendectomy in pregnant patients when surgical treatment is indicated. [6, 7]

Rarely, an appendiceal mucocele (ie, a collection of mucus within the appendiceal lumen) may occur. Occasionally, patients may present with a low-grade carcinoma of the appendix or the cecum. In such cases, the surgeon must avoid perforation during dissection, because it may cause seeding of the peritoneum with viable cells, leading to pseudomyxoma peritonei.

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Technical Considerations

Procedural planning

Patients with appendicitis always need urgent referral and prompt treatment. An appendectomy is generally indicated for patients with a history of persistent abdominal pain, fever, and clinical signs of localized or diffuse peritonitis, especially if leukocytosis is present (see Indications).

For reasons of time and cost, open appendectomy was long the most common approach. However, an increasing number of surgeons have come to prefer laparoscopic appendectomy, especially in female patients, because of its diagnostic ability (see Technique).

If, on open appendectomy, the surgeon finds an apparently normal appendix, he or she is faced with a dilemma: Remove the appendix or leave it in place? The argument for performing appendectomy is that even if the appendix is not removed, the patient will have a scar from a right-lower-quadrant incision. In the future, this may lead those who examine the patient to assume that an appendectomy has already been performed, in which case they will not include appendicitis in the differential diagnosis.

At the opposite extreme, in the past, appendicitis sometimes was so severe that the cecum appeared necrotic. Today, this finding is fortunately very rare. In such cases, perform an ileocecectomy or right hemicolectomy with a primary anastomosis.

Laparoscopic appendectomy has now been improved and standardized. [8] It has some advantages over open appendectomy, including decreased postoperative pain, better aesthetic result, a shorter time to return to usual activities, and lower incidence of wound infections or dehiscence. Although cost-effective, it may require more operating time than the corresponding open procedure. Kouhia et al found that by 2008, operating time was only 10 minutes longer with laparoscopic appendectomy than with the open approach; in addition, patients who underwent open appendectomy returned to work later and had more complications. [9]

Single-port versions of the laparoscopic procedure have been developed, such as the transumbilical laparoscopic-assisted appendectomy (TULAA). [10, 11]

The reported results of laparoscopic and open appendectomies seem to overlap. In fact, the average rates of abdominal abscesses, negative appendectomies, and hospital stays are very similar, according to an overview of 17 retrospective studies. [12] In a study comparing laparoscopic and open appendectomy for complicated appendicitis in adult patients, Taguchi et al found that the minimally invasive approach was safe and feasible in this setting, though it did not significantly reduce complications. [13]

In a meta-analysis of randomized controlled trials comparing laparoscopic with open appendectomy in adults and children, Dai et al found that in adults, laparoscopy was associated with a lower incidence of wound infection, fewer postoperative complications, shorter postoperative stays, earlier return to normal activity, and longer operating times. [14] In children, they found no significant differences between the two approaches with respect to rates of wound infection and postoperative complications, length of postoperative stay, and time to return to normal activity.

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Outcomes

Whether appendicitis is simple or complicated (ie, with gangrene or perforation), the prognosis is excellent and outcome is good. In fact, no mortality has been reported in patients with a nonperforated appendix. Mortality is lower than 1% if appendiceal perforation exists. An exception is elderly patients, who have a mortality that approaches 5%. An intermediate mortality (1-4%) is reported in infants because of the high frequency of perforation caused by delayed diagnosis due to the difficulties in distinguishing appendicitis from other conditions in the differential diagnosis.

Overall, patients may return to their activities soon after the operation. Once the patient has recovered after an appendectomy, no changes in lifestyle (eg, diet, exercise) are required.

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Author

Luigi Santacroce, MD Assistant Professor, Medical School, State University at Bari, Italy

Disclosure: Nothing to disclose.

Coauthor(s)

Juan B Ochoa, MD Assistant Professor, Department of Surgery, University of Pittsburgh School of Medicine; Medical and Scientific Director, HCN, Nestle Healthcare Nutrition

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

John Geibel, MD, MSc, DSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine

John Geibel, MD, MSc, DSc, AGAF is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous coauthor, Tommaso Loasacco, MD, to the development and writing of this article.