Preventing wound infection after appendicectomy: a review

Post-Operative Outcomes of Laparoscopic Appendectomy in Acute Complicated Appendicitis: A Single Center Study

BACKGROUND

Acute appendicitis (AA) is a surgical emergency because of inflammation in the appendix leading to swelling, whereas acute complicated appendicitis is characterized by a gangrenous or perforated appendix with or without periappendicular abscess, peritonitis, and an appendicular mass. The laparoscopic approach in complicated acute appendicitis is a viable alternative method but is not practiced in all cases because of technical difficulties and unpredictable complications. Thus, the present study aimed to evaluate the primary and secondary outcome predictors of laparoscopic appendectomy in complicated appendicitis.

METHODS

A single-center prospective observational study was carried out after the approval of the Institutional Ethics Committee (IEC). A total of 87 complicated acute appendicitis patients were included in the study. Clinico-demographic features such as age, gender, duration of surgery, post-operative pain, and hospital stay were monitored in different age groups of <20, 20-39, and >40 years, and the primary and secondary outcomes of laparoscopic surgery in acute complicated appendicitis were measured.

RESULT

Acute complicated appendicitis cases were observed mostly in people older than 42 years in the total study population. Laparoscopic appendectomy was conducted in all 87 acute complicated appendicitis patients, and the major surgical outcome predictors were monitored, such as mean operating time (87.9 minutes), post-operative pain (3.9 scores), and post-operative stay (6.7 days). Post-operative complications such as drain site infection (1.14%), enterocutaneous fistula (2%), and intra-abdominal abscess (7%) were observed.

CONCLUSION

Based on our observations, a laparoscopic appendectomy can be considered a viable alternative with an acceptable complication rate. Operative time varies from 84 to 94 minutes in different age groups and with the extent of the disease.

Intra-operative wound irrigation to reduce surgical site infections after abdominal surgery: a systematic review and meta-analysis

PURPOSE

Surgical site infection (SSI) remains to be one of the most frequent infectious complications following abdominal surgery. Prophylactic intra-operative wound irrigation (IOWI) before skin closure has been proposed to reduce bacterial wound contamination and the risk of SSI. However, current recommendations on its use are conflicting especially concerning antibiotic and antiseptic solutions because of their potential tissue toxicity and enhancement of bacterial drug resistances.

METHODS

To analyze the existing evidence for the effect of IOWI with topical antibiotics, povidone-iodine (PVP-I) solutions or saline on the incidence of SSI following open abdominal surgery, a systematic review and meta-analysis of randomized controlled trials (RCTs) was carried out according to the recommendations of the Cochrane Collaboration.

RESULTS

Forty-one RCTs reporting primary data of over 9000 patients were analyzed. Meta-analysis on the effect of IOWI with any solution compared to no irrigation revealed a significant benefit in the reduction of SSI rates (OR = 0.54, 95 % confidence Interval (CI) [0.42; 0.69], p < 0.0001). Subgroup analyses showed that this effect was strongest in colorectal surgery and that IOWI with antibiotic solutions had a stronger effect than irrigation with PVP-I or saline. However, all of the included trials were at considerable risk of bias according to the quality assessment.

CONCLUSION

These results suggest that IOWI before skin closure represents a pragmatic and economical approach to reduce postoperative SSI after abdominal surgery and that antibiotic solutions seem to be more effective than PVP-I solutions or simple saline, and it might be worth to re-evaluate their use for specific indications.

The preoperative serum C-reactive protein level is a useful predictor of surgical site infections in patients undergoing appendectomy

PURPOSE

Although surgical site infections (SSI) are a major postoperative complication of appendectomy, few studies have focused on the risk factors for SSI. In this study, we investigated the risk factors for SSI in patients who had undergone appendectomy.

METHODS

Three hundred patients who had undergone open appendectomy were enrolled. The patients were divided into two groups based on the presence or absence of SSI. A statistical analysis was performed to assess the clinical features associated with SSI after appendectomy.

RESULTS

A multivariate analysis using the results of univariate analyses revealed that the serum C-reactive protein (CRP) level (≤ 65/> 65, mg/l), length of the operation (≤ 80/> 80, min) and pathology (catarrhal, phlegmonous/gangrenous) were associated with SSI. Among these three clinical features, only the CRP level was found to predict the risk of SSI prior to appendectomy (odds ratio 3.797; 95 % confidence intervals 1.305-11.04; P = 0.014).

CONCLUSION

Preoperative elevation of the serum CRP level (> 65 mg/l) is a valuable predictor of SSI in patients undergoing appendectomy.

A prospective randomized comparison of single-port laparoscopic procedure with open and standard 3-port laparoscopic procedures in the treatment of acute appendicitis

BACKGROUND

This prospective randomized study aimed to evaluate the surgical outcomes of single-incision laparoscopic appendectomy (SILA) comparing with open appendectomy (OA) and standard 3-port laparoscopic appendectomy (SLA) in the treatment of acute appendicitis (AA).

METHODS

Adult patients older than 18 years presenting with AA were randomized into 3 groups to undergo OA, SLA, and SILA from September 2010 to May 2011. The groups were compared with regard of patient's characteristics, perioperative findings/complications, operative time, pain severity, analgesic requirement, time to oral tolerance and flatus, length of hospital stay, and cosmetic results.

RESULTS

A total of 75 consecutive patients enrolled in the study. Each group included 25 patients. The groups showed no significant differences in patient's characteristics. The mean operative time was significantly longer in SILA than OA with a mean difference of 7 minutes (P < 0.05). Postoperative pain after OA were significantly higher than SLA and SILA (P < 0.05). The average time to oral tolerance and flatus was significantly higher in OA than the laparoscopic groups with a mean difference of 1 and 2.5 hours (P = 0.04 and 0.023, respectively). The length of hospital stay in SLA and SILA was significantly lower than OA with a mean difference of 0.8 days (P < 0.05). There was no difference in overall complications between the groups. There was no difference between SLA and SILA in terms of surgical outcomes.

CONCLUSIONS

Either SLA or SILA offer patients faster recovery period with acceptable complications than OA. Hence, laparoscopic approach might be considered as first option in the treatment of AA. However, all 3 techniques provide equivalent clinical outcomes despite the significant findings. Therefore, technique selection is based on surgeon's decision, experience, and availability of laparoscopic instruments.

Laparoscopic appendectomy in complicated appendicitis: Is it safe?

BACKGROUND

Because of lack of good evidence supporting laparoscopic approach for complicated appendicitis, we carried out this study to evaluate efficacy of laparoscopic appendectomy (LA) in management of patients with complicated appendicitis.

MATERIALS AND METHODS

This study was carried out in Surgical Department, Minia University, Egypt involving 214 patients underwent appendectomy for complicated appendicitis over three years. 132 patients underwent LA and remaining 82 patients underwent OA. Parameters studied included operating time, return to oral feeding, postoperative pain, wound infection, intra-abdominal abscess, duration of abdominal drainage and hospital stay.

RESULTS

There were four conversions, two due to extensive cecal adhesions and two due to friable appendix. LA took longer time to perform (p = 0.0002) but with less use of analgesics (p < 0.0001), shorter hospital stay (p < 0.0001), shorter duration of abdominal drainage (p < 0.0001) and lower incidence of wound infection (p = 0.0005). Nine patients in LA and seven patients in OA group developed intra-abdominal abscess treated successfully with sonographic guided percutaneous drainage. Postoperative ileus was recorded in two patients in LA group and three patients in OA group, chest infection in one patient in OA group, hernia in one patient in LA and fecal fistula was present in one patient in OA. Overall complications were significantly lower in laparoscopy group and managed conservatively with no mortality in either group.

CONCLUSIONS

LA in complicated appendicitis is feasible and safe with lower incidence of complications than OA and should be the initial choice for all patients with complicated appendicitis.

Laparoscopic appendectomy for complicated appendicitis: a comparison with open appendectomy

BACKGROUND

Although laparoscopic appendectomy (LA) is widely performed in many countries, LA for complicated appendicitis, which includes perforated or gangrenous appendicitis with or without localized or disseminated peritonitis, has not become a common practice yet.

METHODS

We retrospectively analyzed the clinical records of 230 patients who had undergone appendectomy for complicated appendicitis: 141 had undergone LA, 84 had conventional open appendectomy (OA), and 5 patients had conversion to the open procedure after laparoscopy. The LA group (total LA) was subdivided into "early experience (early LA: cases 1-56)" and "late experience (late LA: case 57 and higher)." We defined the early LA group as the comparison group to minimize selection bias.

RESULTS

Patient demographics were similar in the early LA and OA groups (P > 0.05). Wound infection was significantly more frequent in the OA group (P < 0.05). Intra-abdominal infection was equally common in these two groups. The overall rate of postoperative complications was significantly higher in the OA group (32.1%) than in the early LA group (18%; P < 0.05). This incidence was 12.8% in the total LA group. Hospital stay was significantly shorter in the early LA group (10.6 +/- 3.9 days; P < 0.05), and 8.9 +/- 3.7 days in the total LA group.

CONCLUSIONS

Our findings indicate that LA is safe and useful even for the treatment of complicated appendicitis if performed by an experienced surgeon.

Laparoscopic versus open appendectomy: Which way to go?

AIM: To compare the outcome of laparoscopic versus open appendectomy.

METHODS: Prospectively collected data from 293 consecutive patients with acute appendicitis were studied. These comprised of 165 patients who underwent conventional appendectomy and 128 patients treated laparoscopically. The two groups were compared with respect to operative time, length of hospital stay, postoperative pain, complication rate and cost.

RESULTS: There were no statistical differences regarding patient characteristics between the two groups. Conversion to laparotomy was necessary in 2 patients (1.5%). Laparoscopic appendectomy was associated with a shorter hospital stay (2.2 d vs 3.1 d, P = 0.04), and lower incidence of wound infection (5.3% vs 12.8%, P = 0.03). However, in patients with complicated disease, intra-abdominal abscess formation was more common after laparoscopic appendectomy (5.3% vs 2.1%, P = 0.002). The operative time and analgesia requirements were similar in the two groups. The cost of treatment was higher by 370 € in the laparoscopic group.

CONCLUSION: Laparoscopic appendectomy is as safe and efficient as open appendectomy, provided surgical experience and equipment are available.

Is peritoneal drainage necessary in childhood perforated appendicitis?--a comparative study

PURPOSE/BACKGROUND

In this study, we aimed to evaluate the effect of peritoneal drainage (PD) on postoperative infective complications in cases with perforated appendicitis.

METHOD

One hundred nine patients (with PD) were evaluated retrospectively and 117 cases (with no drainage [ND]) were evaluated prospectively regarding complications like wound infection (WI), intraabdominal abscess (IAA), and small bowel obstruction caused by adhesions (SBO) in perforated appendicitis cases. The abdomen was irrigated with isotonic NaCl solution and the wounds were closed primarily in all patients.

RESULTS

The total number of patients was 226 (male, 66.4%; female, 33.6%), with a mean age of 8.6 +/- 3.4 years (range, 1-15 years). The WI rates in PD and ND groups were 28.4% to 16.2%, respectively. The ratio of IAA in the PD group was 12.8% which decreased to 3.4% in the ND group. The difference was statistically significant (P < .05). The postoperative hospitalization period in the PD and ND groups were 10.2 +/- 6.5 and 8.3 +/- 3.3 days, durations of antibiotic use were 9.5 +/- 5.5 and 7.7 +/- 2.7 days, durations of NG tube usage were 3.2 +/- 1.5 and 2.2 +/- 1.2 days, time to oral feeding was 3.7 +/- 1.7 and 2.5 +/- 1.4 days, and time to normalization of the body temperatures was 3.7 +/- 2.3 vs 2.3 +/- 1.7 days. All differences were statistically significant (P < .05). The ratio of SBO increased from 2.8% to 3.4% in the ND group, but this result was not statistically significant.

CONCLUSIONS

As a result of this study, we recommend that peritoneal drainage should be abandoned in childhood appendicitis.

The Efficacy of Postoperative Oral Antibiotics in Appendicitis: A Randomized Prospective Double-Blinded Study

The conventional treatment of acute appendicitis is appendectomy followed by intravenous (IV) antibiotics until intraabdominal infection has resolved. It is controversial as to whether it is efficacious to add a course of oral antibiotics after cessation of IV antibiotics. All consenting patients who presented to Kern Medical Center between October 2000 and June 2003 with acute appendicitis were entered into the study. Perforated/gangrenous appendicitis was equally represented in the two study arms. After appendectomy, and when IV antibiotics were ready to be discontinued, patients were randomized to receive a 7-day outpatient course of either placebo (Group 1) or oral antibiotics (Group 2). Patients were monitored for infectious complications for a minimum of 3 months, and there was no statistical difference (11.5% in Group 1 vs 12.1% in Group 2, P = 0.61). The data suggest that adding a course of outpatient oral antibiotics, after completing a course of IV antibiotics, does not decrease postoperative infectious complications in appendicitis patients.

Laparoscopic appendectomy for perforated appendicitis

Although laparoscopic appendectomy for uncomplicated appendicitis is feasible and safe, its application to perforated appendicitis is uncertain. A retrospective study of all patients with perforated appendicitis from 1992 to 1999 in a university hospital was performed. A series of 231 patients were diagnosed as having perforated appendicitis. Of these patients, 85 underwent laparoscopy (LA), among whom 40 (47%) required conversion to an open procedure. An open appendectomy (OA) was performed in 146 patients. The operating time was similar for the two groups. Return of fluid and solid diet intake were faster in LA than OA patients (p < 0.01). Postoperative infections including wound infections and abdominal abscesses occurred in 14% of patients in the laparoscopy group and in 26% of those with OA (p < 0.05). The surgeon's experience correlated with the conversion rate. Laparoscopic appendectomy is associated with a high conversion rate for perforated appendicitis. If successful, it offers patients faster recovery and less risk of infectious complications.

Antiseptic wick: does it reduce the incidence of wound infection following appendectomy?

The role of prophylactic antibiotics is well established for contaminated wounds, but the use of antiseptic wound wicks is controversial. The aim of this work was to study the potential use of wound wicks to reduce the rate of infection following appendectomy. This prospective randomized controlled clinical trial was conducted at a university hospital in the department of surgery. The subjects were patients undergoing appendectomy for definite acute appendicitis. They were randomized by computer to primary subcuticular wound closure or use of an antiseptic wound wick. For the latter, ribbon gauze soaked in povidone-iodine was placed between interrupted nylon skin sutures. Wicks were soaked daily and removed on the fourth postoperative day. All patients received antibiotic prophylaxis. They were reviewed while in hospital and 4 weeks following operation for evidence of wound infection. The main outcome measures were wound infection, wound discomfort, and cosmetic result. The overall wound infection rate was 8.6% (15/174). In patients with wound wicks it was 11.6% (10/86) compared to 5.6% (5/88) in those whose wounds were closed by subcuticular sutures (p = NS). We concluded that the use of wound wicks was not associated with decreased wound infection rates following appendectomy. Subcuticular closure is therefore appropriate in view of its greater convenience and safety.

Laparoscopic approach for acute appendicular peritonitis: efficacy and safety: a report of 96 consecutive cases

SUMMARY

Several authors have demonstrated the feasibility and efficacy of the laparoscopic approach in the acute abdomen. The aim of this study was to evaluate the diagnostic performance and safety of laparoscopy as a routine approach in the management of appendicular peritonitis. This retrospective study included 96 consecutive cases of acute appendicular peritonitis. All patients underwent a laparoscopic approach. The mean APACHE II score and Mannheim Peritonitis Index were 7.6 and 17.4, respectively. Laparoscopic diagnostic accuracy was 98%. Laparoscopy allowed the physician to correct the preoperative suspected diagnosis in 6 patients (6.5%). The results of preoperative clinical evaluation of the peritonitis severity were corrected by laparoscopic exploration in 26% (25/96) of cases. Complete laparoscopic management was achieved in 79% (76/96). Overall, the postoperative morbidity rate was 13% (13/96). Postoperative intra-abdominal abscess and wound sepsis rates in patients treated by laparoscopy were 2% and 1%, respectively. There were no deaths. The laparoscopic approach for the management of appendicular peritonitis is safe and effective and does not result in any specific complication. Advantages include the high quality of laparoscopic exploration, a very low incidence of septic complications, and a comfortable postoperative recovery.

Laparoscopic approach for acute appendicular peritonitis: efficacy and safety: a report of 96 consecutive cases

Several authors have demonstrated the feasibility and efficacy of the laparoscopic approach in the acute abdomen. The aim of this study was to evaluate the diagnostic performance and safety of laparoscopy as a routine approach in the management of appendicular peritonitis. This retrospective study included 96 consecutive cases of acute appendicular peritonitis. All patients underwent a laparoscopic approach. The mean APACHE II score and Mannheim Peritonitis Index were 7.6 and 17.4, respectively. Laparoscopic diagnostic accuracy was 98%. Laparoscopy allowed the physician to correct the preoperative suspected diagnosis in 6 patients (6.5%). The results of preoperative clinical evaluation of the peritonitis severity were corrected by laparoscopic exploration in 26% (25/96) of cases. Complete laparoscopic management was achieved in 79% (76/96). Overall, the postoperative morbidity rate was 13% (13/96). Postoperative intra-abdominal abscess and wound sepsis rates in patients treated by laparoscopy were 2% and 1%, respectively. There were no deaths. The laparoscopic approach for the management of appendicular peritonitis is safe and effective and does not result in any specific complication. Advantages include the high quality of laparoscopic exploration, a very low incidence of septic complications, and a comfortable postoperative recovery.

Intraabdominal abscess rate after laparoscopic appendectomy

BACKGROUND

Studies suggest increased intraabdominal abscess (IA) rates following laparoscopic appendectomy (LA), especially for perforated appendicitis. Consequently, an open approach has been advocated. The aim of our study is to compare IA rates following LA performed by a laparoscopic surgery and a general surgical service within the same institution.

METHODS

Data of LA patients treated at Los Angeles County-University of Southern California (LAC-USC) Medical Center between March 1992 and June 1997 were reviewed. The main outcome measure was postoperative IA.

RESULTS

In all, 645 LA were reviewed. A total of 413 LA (285 acute, 61 gangrenous, 67 perforated appendicitis) were performed by three general surgical services (10 attendings). Ten abscesses occurred postoperatively (2.4%), 6 with perforated appendicitis. After the laparoscopic service was introduced, 232 standardized LA (126 acute, 46 gangrenous, 60 perforated) were performed by two attendings. One IA occurred (gangrenous appendicitis). The IA rate for perforated appendicitis was significantly lower on the laparoscopic service (P = 0.025). There was no difference in IA rates for acute and gangrenous appendicitis. There was no mortality in either group.

CONCLUSION

IA rate following LA for perforated appendicitis was significantly reduced on the laparoscopic service. Mastery of the learning curve and addition of specific surgical techniques explained this improved result. Therefore, laparoscopic appendectomy for complicated appendicitis may not be contraindicated, even for perforated appendicitis.

Complicated Appendicitis: Is There a Minimum Intravenous Antibiotic Requirement? A Prospective Randomized Trial

The proper duration of postoperative intravenous (IV) antibiotics in patients suffering complicated (perforated or gangrenous) appendicitis is debatable. Some advocate a set minimum number of IV antibiotic days whereas others discontinue IV antibiotics depending on the patient's clinical course regardless of the length of therapy. Our objective was to determine whether there are differences in morbidity and resource utilization between the two treatment methodologies. Ninety-four patients with intraoperative findings of complicated appendicitis were included. In all patients IV antibiotics were discontinued on the basis of clinical factors. However, Group 1 patients were given a minimum 5-day IV antibiotic course whereas Group 2 patients had no minimum IV antibiotic requirement. Group 1 patients received more IV antibiotics than Group 2 patients did (5.9 vs 4.3 days; P = 0.014). Infectious complications were not statistically different between the two groups (13.0% in Group 1 and 12.5% in Group 2). Average hospital stay was also not statistically different between the two groups. The data suggest that a protocol with no minimum IV antibiotic requirement in patients with complicated appendicitis does not increase morbidity. Furthermore, the protocol arm with no minimum IV antibiotic requirement led to less IV antibiotic use but did not significantly decrease hospital stay.

Risk factors for post-appendicectomy intra-abdominal abscess

BACKGROUND

Appendicectomy is a common emergency operation, after which major complications are uncommon, however when they do occur they are a major cause of concern to patient and surgeon. This study aims to determine the incidence and risk factors for post-appendicectomy intra-abdominal abscess formation.

METHOD

A retrospective review was undertaken of all appendicectomies undertaken in Christchurch Hospital between 1 January and 31 December 1995. Appendicectomies were identified from a database of histology. The patients' notes were reviewed and the surgical approach, histological diagnosis and postoperative complications identified.

RESULTS

A total of 417 appendicectomies was identified of which 331 were open, 66 laparoscopic, and 20 undertaken at laparotomy. Mean day stays for each group were 4.4, 4.2 and 11.5 days, respectively. The percentages of patients with acute appendicitis in each group were 87, 58 and 35%. Histologically the appendix was inflamed in 80% (334) of patients (acute 232, chronic 15, perforated 56 and gangrenous 24). There were six postoperative intra-abdominal abscesses (1.4%), all occurring in the open appendicectomy group when the histology was either perforated or gangrenous appendicitis (P < 0.001). There were no cases of postoperative abscess formation following laparoscopic appendicectomy. All cases of postoperative intra-abdominal abscess were associated with perforated and/or gangrenous appendicitis (P < 0.001). The incidence of intra-abdominal abscesses was 7.5% with a perforated and/or gangrenous appendix. There were two cases of iatrogenic perforation following laparoscopic appendicectomy.

CONCLUSION

The incidence of intra-abdominal abscess is 1.4% of all appendicectomies. The only identified risk factor for development of post-appendicectomy intra-abdominal abscess was the underlying pathology of gangrenous or perforated appendicitis.

Can Oral Metronidazole Substitute Parenteral Drug Therapy in Acute Appendicitis?: A New Policy in the Management of Simple or Complicated Appendicitis with Localized Peritonitis: A Randomized Controlled Clinical Trial

To demonstrate the efficacy of oral metronidazole (OM) in simple or complicated appendicitis with localized peritonitis, a randomized prospective study was carried out in 1083 patients, ranging in age from 4 to 50 years (mean age, 21.38).

The patients were randomly divided into two groups. The study group (SG) (524 patients) received OM (500 mg for adults, 7–10 mg/kg if less than 15 years) 2–3 hours before operation. The drug was continued 4 to 5 hours after operation, every 8 hours, for three doses if the appendix was mild to severely inflamed. In the case of complicated appendicitis (114 patients), the same dose was given for 3 to 6 days, depending on the absence or presence of pus. Ceftizoxime was administered to the control group (CG) (559 patients) 2 to 3 hours before operation and then postoperatively every 6 hours for three doses if the appendix was mild to severely inflamed. The complicated cases in the CG (120 patients) received a combination of penicillin, chloramphenicol, and gentamicin for 3 to 6 days, depending on the absence or presence of pus.

The serum concentration of metronidazole measured in 43 patients was at bactericidal level in 40 (mean ± SD standard deviation, 10.65 ± 4.89 μg/mL).

The rate of wound infection was not significantly different in the SG and the CG with the same degree of pathology (3.17% vs 2.96% if uncomplicated; 15.78% vs 14.16% if complicated, respectively). Pelvic collection occurred in four adults and one child in the CG with perforated appendicitis (4.16%). The same complication developed in two adults and two children in the SG with perforated appendicitis (3.5%). All six adults and one of the children in the SG had to be re-explored, whereas the remaining two children responded to conservative management (OM and gentamicin). In uncomplicated cases, hospital stay and hospital charge were both almost the same in both groups. However, length of hospitalization was nearly 1 day shorter and hospital cost per day was about 30 per cent less in complicated cases in the SG as compared with the CG.

Conclusively, OM may not only substitute parenteral antibiotics in acute appendicitis as a prophylactic agent, but it may also be used as a cost-effective drug and is more convenient to the patient.

Leg wound infections associated with coronary revascularization

BACKGROUND

Wound infections after saphenous vein harvest for coronary revascularization are common but they are infrequently examined. The aim of the present study was to investigate the risk factors for infection and the possible beneficial effects of saline lavage.

METHODS

From April 1996 to July 1996, 152 consecutive patients who underwent saphenous vein harvest for coronary artery bypass graft were recruited. Factors that may influence infection rates were analysed.

RESULTS

A total of 22 of the 125 (18%) patients included in the present study developed a wound infection. The length of the wound was the only variable found to have a statistically significant association with wound infection. In the analysis of patients with multiple leg wounds, the development of infection correlated with the absence of mechanical wash-out.

CONCLUSION

The use of saline lavage may prevent wound infections by diluting the bacterial population prior to closure. The use of antiseptic or antibiotic lavage may offer an additional benefit.

Laparoscopic stapler appendectomy. A prospective study of 267 consecutive cases

BACKGROUND

The value of laparoscopic appendectomy remains controversial. Therefore, we investigated the accuracy of diagnostic laparoscopy in detecting acute appendicitis and tested the applicability and safety of stapling appendectomy as a routine procedure.

METHODS

Data from 267 consecutive patients with suspicion of acute appendicitis were recorded prospectively.

RESULTS

Histopathological examination revealed nonperforated and perforated appendicitis in 63.3% and 13.1%, respectively, and no inflammation in 10.8%. Other pathological findings were observed in 12.7%. Diagnostic laparoscopy detected appendicitis with a sensitivity and specificity of 95.6% and 96.6%, respectively; the positive and negative predictive value were 99.5% and 74.3%, respectively. Morbidity was 10.2% in total and 40% for perforated appendicitis. Planned laparoscopic reexploration reduced morbidity by 23.4% in patients with perforated appendicitis and substantial peritonitis. Mortality was 0.4%.

CONCLUSIONS

Laparoscopy improves diagnostic accuracy for acute appendicitis and laparoscopic stapling appendectomy is a safe and efficient procedure for all forms of appendicitis.

Laparoscopic procedure for suspected appendicitis. A prospective study in 283 consecutive patients

Between September 1990 and December 1993, 283 consecutive patients were admitted with clinical symptoms of acute appendicitis. These patients underwent primary laparoscopic approach so that an appendicectomy could be performed by this method. In 49 cases (17.3%), primary laparoscopic examination corrected the preoperative diagnosis and the appendix was left in situ. Appendicectomy was performed in 234 cases (149 women, 85 men) with a mean age of 30 years. Requirement for open surgery occurred in 29 cases. The main cause of unsuccessful procedures was inflammation due to local or generalized peritonitis. Median operative time for a successful procedure was 60 min (range, 25-160). Four postoperative complications (one related to laparoscopic procedure), one case of wound infection, and no mortality resulted. After laparoscopic appendicectomy, the median hospital stay was 3 days (range, 1-16). These results suggest that a laparoscopic approach for suspected appendicitis is reliable, allowing abdominal exploration and safe appendicectomy.

Peritoneal lavage versus drainage for perforated appendicitis in children

A total of 231 children with acute appendicitis were treated at our hospitals during the 10 years between 1984 and 1993, 53 of whom had a perforated appendix. These 53 patients were randomly assigned to two groups at the time of surgery according to the different procedures performed. Thus, 29 children were managed by appendectomy followed by peritoneal lavage using a large amount of saline, and intravenous antibiotic therapy consisting of aminoglycoside and cephem (lavage group), while the other 24 children were treated by appendectomy with silicon tube drainage and the same systemic antibiotic therapy (drainage group). The mean length of hospitalization, and the mean durations of fever and the need for fasting after laparotomy in the lavage group were significantly less than those in the drainage group: 10.1 versus 18.8 days, 2.8 versus 7.7 days, and 1.8 versus 3.5 days, respectively. The operation wounds healed well in the lavage group due to the fact that there was no drain. Wound infections occurred in two children from the lavage group and six from the drainage group. Intra-abdominal abscesses occurred in two children from the drainage group. Accordingly, peritoneal lavage appears to be superior to intraperitoneal tube drainage for the management of perforated appendicitis in children.

A randomized prospective study of cefoxitin versus piperacillin in appendicectomy

A randomized prospective study of antibiotic prophylaxis using a single dose of either cefoxitin or piperacillin is presented. The trial was carried out in Al Ain Hospital in the period 1989-1992 on 250 adult patients with non-perforated appendicitis. One group (124 patients) received 2 g cefoxitin, the other group (126 patients) 2 g piperacillin. Antibiotics were administered intravenously in the operating theatre immediately before surgery. Wound infection occurred in three patients, 2.4% of the cefoxitin group and in five patients (4%) of the second group (with no significant difference). The commonest infecting organisms were Escherichia coli (5 out of 8). Mean hospital stay for patients with wound infection was 15 days (range 12-21) compared with 6 days, (range 4-8) for non-infected cases. Prophylactic cefoxitin or piperacillin were each therefore similarly effective in minimizing the rate of wound infections in patients with non-perforated appendicitis.

[Laparoscopic appendectomy. A review of the literature]

Laparoscopic methods are becoming increasingly popular in surgery. In the course of a review concerning laparoscopic appendectomy undertaken up to 31 December 1993 all publications were evaluated by computer-assisted research. Out of a total of 90 publications only 14 deal with the comparison of the laparoscopic versus open appendectomy. Two prospective randomized studies are published. Because of the low number of patients the evaluation of the laparoscopic method is not yet definite.

[Antibiotic prophylaxis in colorectal surgery]

In elective colorectal surgery, the benefit of preoperative antibiotic prophylaxis is well established, with a reduction in wound infection rate to less than 10%. The antimicrobial agent used has to be active against aerobic and anaerobic pathogens such as Escheria coli and Bacteriodes fragilis. The efficacy of three schemes of administration: oral and/or parenteral prophylaxis associated with a mechanical preparation, has been demonstrated. Oral antibiotic administration is current practice in USA; the most widely used oral regimen is the combination of erythromycin and neomycin given the day before surgery. Parenteral prophylaxis with a cephalosporin active against Bacteriodes fragilis such as cefoxitin and cefotetan, is preferred in Europe. The issue of whether a systemic prophylaxis should be added to the oral regimen or not has not yet been resolved. However it seems that the association should be proposed in various situations: patients with a high risk factors score (rectal resection and operations lasting more than three hours), patients with incomplete mechanical preparation, delay of the onset of surgery after the last oral dose.

Randomized controlled trial comparing laparoscopic and open appendicectomy

A study was carried out of 137 patients with a diagnosis of acute appendicitis who were randomized to either laparoscopic or open appendicectomy. Patients found to have perforated or normal appendices at histological examination were excluded. Fifty-two patients undergoing laparoscopic appendicectomy and those receiving 57 open procedures were analysed. Laparoscopic appendicectomy took no longer than the open procedure (mean 43 versus 40 min). The number of doses of pethidine (1 mg per kg body-weight) required in the immediate postoperative period did not differ between the two groups but the mean number of doses of oral analgesic (naproxen sodium 550 mg twice daily) required was less in patients undergoing laparoscopic appendicectomy (2.8 versus 5.0, P < 0.05). There was no significant difference between time to resumption of fluid and diet intake and length of hospital stay. There were five (9 per cent) wound infections after open appendicectomy compared with none after the laparoscopic operation (P < 0.01). Patients who underwent laparoscopy returned to full home (17 versus 30 days, P < 0.01) and social (19 versus 32 days, P < 0.05) activities earlier than those who underwent open operation. Laparoscopic appendicectomy may allow reduction in the number of wound infections and earlier return to normal activities.

A modified technique of delayed primary closure using a povidone iodine wick: influence on wound healing in an experimental model

We report a modified technique of delayed primary wound closure using a wound wick. A rodent model was used to determine its influence on healing. After loose primary closure of two paravertebral incisions on the dorsum of male rats, a 10 cm length of ribbon gauze, soaked in either saline or 1% povidone-iodine, was inserted into the right sided wound. Wicks were soaked daily with the same solution until removal on the third post-operative day. The inclusion of a wick soaked in saline had an early transient effect on healing. A more prolonged impairment of healing was demonstrated in povidone-iodine wicked wounds and their respective controls. These data suggest that povidone-iodine impaired healing not only in the wicked wound, but also inhibited healing in the adjacent unwicked wound which was not directly exposed to the antiseptic. The observed delay in healing in povidone-iodine wicked wounds must however be balanced against its beneficial effect on wound infection rates. We suggest that further evaluation of this method of closure in contaminated wounds is warranted.

Conventional versus laparoscopic surgery for acute appendicitis

A total of 155 consecutive patients with suspected acute appendicitis were studied to compare laparoscopic and conventional operations. Patients were not randomized: laparoscopy was performed when a suitably trained surgeon and laparoscopic instruments were available. Laparoscopic appendicectomy was attempted in 51 patients and was successful in 46 (90 per cent); all conversions to open operation were because of marked inflammatory adhesions around the appendix. There were no intraoperative complications. Reintroduction of normal diet and discharge from hospital occurred earlier after laparoscopic than open surgery (P < 0.05). The requirement for analgesia after successful laparoscopic surgery was less than that after conventional appendicectomy, but the difference was not significant. The incidence of wound infection was reduced after the laparoscopic procedure (P = 0.06). It is concluded that laparoscopic appendicectomy is practical and may have advantages over conventional operation, although a randomized study is necessary.

Need to measure outcome after discharge in surgical audit

OBJECTIVE

To assess the accuracy of outcome data on appendicectomy routinely collected as part of a surgical audit and to investigate outcome in the non-audited period after discharge.

DESIGN

Retrospective analysis of audit data recorded by the Medical Data Index (MDI) computer system for all patients undergoing emergency appendicectomy in one year; subsequent analysis of their hospital notes and notes held by their general practitioners for patients identified by a questionnaire who had consulted their general practitioner for a wound complication.

SETTING

One district general hospital with four consultant general surgeons serving a population of 250,000.

PATIENTS

230 patients undergoing emergency appendicectomy during 1989.

MAIN MEASURES

Comparison of postoperative complications recorded in hospital notes with those recorded by the MDI system and with those recorded by patients' general practitioners after discharge.

RESULTS

Of the 230 patients, 29 (13%) had a postoperative complication recorded in their hospital notes, but only 14 (6%) patients had these recorded by the MDI system. 189 (82%) of the patients completed the outcome questionnaire after discharge. The number of wound infections as recorded by the MDI system, the hospital notes, and notes held by targeted patients' general practitioners were three (1%), eight (3%), and 18 (8%) respectively. None of 12 readmissions with complications identified by the hospital notes were identified by the MDI system.

CONCLUSIONS

Accurate audit of postoperative complications must be extended to the period after discharge. Computerised audit systems must be able to relate readmissions to specific previous admissions.

Laparoscopic versus open appendicectomy: a prospective evaluation

A prospective evaluation of laparoscopic surgery for acute appendicitis over a 6-month period is reported. Sixty-five patients with signs and symptoms of appendicitis necessitating surgery were assigned to open (n = 36) or laparoscopic (n = 29) appendicectomy. Thirty-seven patients were female (22 open) and 28 were male (14 open). The median age was 24 (range 14-64) years for open appendicectomy and 18 (range 14-60) years for the laparoscopic procedure. The mean postoperative stay for open operation was 4.8 (range 1-21) days and for the laparoscopic route 2.2 (range 1-11) days (P < 0.05). Inflammation was confirmed histologically in 72 per cent of the open cases and in 74 per cent of the laparoscopic cases (P not significant). The wound infection rate was 11 per cent (n = 4) for open and 4 per cent (n = 1) for laparoscopic appendicectomy (P < 0.05). The median anaesthesia time was 52 (range 15-90) min for open appendicectomy and 48 (range 20-120) min for laparoscopic surgery (P not significant). After open appendicectomy patients had a median of 5 (range 2-12) intramuscular injections of analgesia compared with a median of 1 (range 0-5) in the laparoscopic group (P < 0.05). Two laparoscopic operations were converted to an open procedure. The results suggest that emergency laparoscopic appendicectomy should be explored further as an alternative to open surgery for acute appendicitis.

The necessity of prophylactic antibiotics in uncomplicated appendicitis during childhood

A prospective, randomized, clinical study was done to evaluate the place of prophylactic antibiotics in uncomplicated childhood appendicitis. One hundred patients with uncomplicated appendicitis were randomly assigned to one of four groups, each consisting of 25 cases. Group 1 patients did not receive prophylactic antibiotic. Group 2, group 3, and group 4 patients received ornidazole, penicillin plus tobramycin, and piperacillin, respectively. The use of prophylactic antibiotics did not yield better results than the use of placebos. The rarity of infectious complications after uncomplicated appendicectomy may be unique for children. Although the need for antibiotic prophylaxis is well documented in adults, the rarity of infectious complications makes it highly questionable in the treatment of uncomplicated appendicitis in children.

Emergency appendicectomy: a one year audit

A retrospective study of emergency appendicectomy over a one-year period at Beaumont Hospital was carried out. The overall normal appendicectomy rate was 22.8%, and was twice as high in women (31%) as in men (15%). Gangrenous or perforated appendicitis was present in 20% of cases. The overall mean assessment-surgery interval was 16.7 hours. Considerable variation in the use of antimicrobial agents was noted in the study, and many haematological and radiological investigations performed did not appear to improve diagnostic accuracy. Among patients with clinical features typical of appendicitis, 16% proved to have a normal appendix. These results point to a number of aspects of the diagnosis and management of appendicitis where there appears to be room for future improvement.