chapter 43

APPENDICITIS
Shawn D. St. Peter, MD
ver 70,000 cases of appendicitis are seen in chil- dren in the United States each year, making it the most common ac te s rgical condition. !," # lifetime risk of appendicitis has $een estimated at %.7& for $oys and '.7& for girls. ( )he age-specific incidence progresses from e*tremely low in the neonatal period to a peak incidence $etween ages !" and !% years. #l- tho gh the disease is common eno gh to make famil- ial predisposition diffic lt to identify, there are data to s ggest a higher family risk in children who s ffer ap- pendicitis $efore ' years of age.+

NATURAL HISTORY
#ppendicitis is simply a version of divertic litis in which the appendi* represents a long, tr e divertic - l m with a narrow l men. ,nflammation of the appen- di* is initiated as the res lt of an o$str ctive process within the l men. )his was initially demonstrated in an e*perimental model 70 years ago. - )he offending mechanism o$str cting the l men can $e lymphoid hyperplasia, inspissated fecal matter, a foreign $ody, or parasites. )here is a temporal relationship aligning the incidence of appendicitis with the development of s $m cosal lymphoid follicles at and near the $ase of the appendi*. )hese collections of reactive imm ne cells are sparse at $irth $ t increase with age to a peak in adolescents followed $y a sharp decline after age (0.' #n epidemiologic association $etween fecaliths and appendicitis is seen in developed co ntries with a high cons mption of low-fi$er diets where $oth are more common than in developing nations with high- fi$er diets.7 #fter appendiceal o$str ction, intral minal pres- s re increases from the acc m lation of ndrained m c s and contained $acterial proliferation. )his press re progresses ntil lymphatic and veno s drain- age are impaired, directly res lting in local edema. ,f ntreated, this congestion will limit arterial inflow and there$y limit cell lar s $strate e*change. )his res lts in impaired tiss e integrity to the end point of necrosis with s $se. ent perforation. /owever, l minal o$str ction is not always fo nd on histologic

e*amination, in which case the o$str ction may $e physiologic or static and not mechanical. #lternatively, the tiss e may $e locally inflamed as the res lt of a no*io s inciting agent. Yersinia, Salmonella, and Shigella and vir ses s ch as m mps vir s, co*sackievir s 0, and adenovir s have $een implicated in appendicitis.%,1 ,n children with cystic fi$rosis, painf l distention of the appendi* may develop from a$normal prod ction of m c s witho t inflammation.!0 #ppendicitis in neonates is rare and warrants eval ation for cystic fi$rosis as well as /irschspr ng2s disease.!! 3eonatal appendi- citis also can $e indisting isha$le from focal necroti4- ing enterocolitis confined to the appendi*.!" #ltho gh the nat ral history of ntreated appendicitis is s ally perforation and a$scess development, this co rse is not ass red $eca se resol tion witho t treatment can occ r.!( 5arly inflammation that does not progress to perforation appears to $e the mecha- nism $ehind the clinical phenomena of relapsing or chronic appendicitis. !+ 6hen the disease does progress to perforation, the patient will present with peritoneal irritation. ,f the presentation is f rther delayed, the patient may present with an a$scess. 7o ng children have less a$ility to nderstand or artic late their devel- oping symptomatology compared with adolescents. )herefore, they more commonly present with perfora- tion. Perforation rates have $een reported to $e as high as %"& in children yo nger than - years and nearly !00& of !-year olds.!- /owever, all perforation rates reported in the literat re m st $e viewed with ca tion $eca se these rates are reported witho t a consistent definition of perforation. )his acco nts for the wide range of "0& to 7'& perforation rates reported from (0 pediatric hospitals in the United States.!' Delays in presentation or diagnosis ca sing elevated perforation rates have $een doc mented to occ r for reasons other than age. 8hildren with perforation are m ch more likely to have $een initially referred to a pediatrician rather than a s rgeon.!7 ,t wo ld logically follow that patients who do not have good access to medical care wo ld $e more likely to present with per- foration. ,n ad lts, lack of ins rance or financial cover- age stat s has $een shown to $e related to an increase in perforation. !% ,n children, a review of a national 549

chapter +(

n #PP53D,8,),S

38

data$ase reports perforation disproportionately affects minority children with a "+& to (%& higher rate of r pt re than white children, ad9 sting for age and gender. !1 # separate data$ase review also fo nd the rate of r pt re in school-aged children was associated with race and lack of health ins rance."0 5nco rag- ingly, a more recent single instit tion st dy fo nd no relation to race or financial stat s."!

CLINICAL PRESENTATION
)he clinical co rse of appendicitis in its simplest and classic presentation $egins with anore*ia and vag e peri m$ilical pain. )his pain is of visceral origin and is referred to the common dermatome of the %th to !0th thoracic dorsal ganglia, which res lts in the peri m$ilical pain. ,t is important to remem$er that inflammation of any midg t derivative will ca se similar symptoms. )he description of peri m$ilical pain migrating to the right lower . adrant is not a tr e migration of the pain nor is it migration of the inflammatory so rce. :ocali4ation occ rs when the inflammation of the appendi* progresses to irritate the peritone m, which has potent somatic sensation. More typically, na sea leading to vomiting follows the onset of pain, $ t this is not a relia$le finding in children. Diarrhea is more commonly seen with perfo- rated appendicitis $ t is also more common in infants and toddlers, which may direct the diagnosis toward gastroenteritis."" ,n general, gastroenteritis is more likely with a history of repeated episodes of vomiting and diarrhea starting at a similar time or preceding the onset of pain, partic larly when the a$dominal pain is the minor symptom, is not locali4ed, and is witho t focal tenderness on e*amination. )he most discrete physical finding is tenderness, e*hi$ited $y the o$9ective demonstration of pain s ch as wincing, moving, or fle*ing on gentle press re applied in the right lower . adrant near Mc0 rney2s point. )his point was originally descri$ed as ;one and a half to two inches from the anterior s perior iliac pro- cess along a line drawn from the process to the m$ili- c s.< "( ,f the patient is nder the infl ence of narcotic analgesia at the time of e*amination, tenderness in the right lower . adrant is considera$ly of more concern for appendicitis. 3arcotic analgesics improve the level of comfort $ t do not change the inflammatory foc s, which may still $e tender on palpation. /owever, a negative e*amination done on a patient on analgesics does not e*cl de appendicitis. )he search for re$o nd tenderness, $y deep palpa- tion with a$r pt removal of press re, is inherently ncomforta$le for the patient and is a poor indicator of peritonitis and sho ld $e avoided. =entle press re applied to the left side of the a$domen or placing a hand in the center of the a$domen with mild shak- ing of the a$domen will elicit tenderness in the set- ting of peritonitis. ,f these mane vers precipitate sharp pain in the right lower . adrant, ac te appendicitis is e*tremely likely. # palpa$le mass in the right lower a$domen is diffic lt or impossi$le to identify in the

patient with g arding or rigidity. >)his mass often $ecomes evident on the operating ta$le after anesthe- sia has $een ind ced.? ,t is important to remem$er that locali4ed symptoms depend on peritoneal irritation that is detecta$le $y e*amination. )herefore, o$esity, a retrocecal appendi*, or a medial appendi* walled off $y oment m, mesentery, or small intestine may never locali4e and the patient may maintain vag e symp- toms. one or more of these factors are often present in patients who present with perforation or a$scess. 5*amination of a crying, resistant child can $e dif- fic lt. )his re. ires patience, deflection of the child2s attention, and@or a reass ring parent. /owever, seda- tion may $e necessary. Despite previo s dogma, a rectal e*amination is a tra mati4ing and nonspecific ad9 nct that is nlikely to contri$ te to the eval a- tion. "+ 5ven in the setting of a s spected pelvic a$scess or ovarian pathologic process, these diagnoses cannot $e affirmed witho t imaging. 0owel so nds are also . ite nonspecific $ t may $e a$sent with perforation compared with $eing hyperactive with gastroenteritis. Aever is common and is s ally low grade in ac te appendicitis. /owever, a lack of doc mented fever does little to e*cl de the disease. /igh fever is more common after appendiceal r pt re d e to the inflammatory response of peritoneal contamination. # patient with high fever and no peritoneal signs is less likely to have appendicitis and sho ld alert the physician toward a viral infection or rinary tract condition. Ser m st dies are generally not very sensitive nor specific for appendicitis. # mild elevation of the le ko- cyte co nt >!!,000 to !',000@mm(? is the most com- mon finding. # markedly elevated le kocyte co nt s ggests perforation or another diagnosis. # case- control series has shown that patients with perforated appendicitis have, on average, a significantly higher le kocyte co nt than those with ac te appendicitis.")his series also fo nd that the le kocyte differential co nt showing ne trophilia and lymphopenia were $oth fairly predictive of appendicitis. /owever, a nor- mal le kocyte co nt does not e*cl de appendicitis. )he rine is s ally free of $acteria, whereas a few or moderate n m$er of red or white $lood cells are common $eca se the inflammation may affect the reter or $ladder. 0eca se patients are often dehydrated, a concentrated rine is e*pected with ketones from decreased oral intake and the release of ins lin-antagoni4ing inflammatory mediators. Ser m electrolytes, liver en4ymes, and liver f nction st d- ies are s ally normal. 8-reactive protein is s ally increased and $ecomes markedly elevated with perforation."',"7 /owever, this finding is less relia$le in children compared with ad lts, and no st dies have yet demonstrated 8-reactive protein to $e s perior to the le kocyte co nt. #s with a le kocyte co nt, a normal 8reactive protein does not e*cl de appendi- citis, even when com$ined with a normal le kocyte co nt. "% )herefore, 8-reactive protein is not ro tinely meas red. "7,"1 6hereas the aforementioned clinical pict re repre- sents the most common manifestation of appendicitis,

it m st $e recogni4ed that children often present with wide deviations from the classic pict re, which makes a confident diagnosis often nlikely witho t imag- ing. Moreover, the location of the appendi* is not consistent, owing to the variation in the position of the cec m. )he appendi* can $e in the right pper a$domen if the patient has an incomplete rotation. :ikewise, if the patient has ntreated nonrotation, the appendi* co ld lie anywhere in the a$domen. 0eca se there are commonly one or more components of the presentation not consistent with appendicitis, several gro ps have attempted to apply clinical scoring sys- tems tili4ing elements of the history, physical e*ami- nation, and la$oratory st dies to . antitate the s m of the clinical feat res that are consistent with the diag- nosis. one series fo nd scoring to $e rather acc rate, (0 whereas others have fo nd their overall sensitivity and specificity to $e only modest with little advantage over e*perienced clinical 9 dgment.(!,(" Becently, a scoring system was sed to stratify which patients sho ld have s rgical cons ltation >high score?, proceed to imaging >moderate score?, or $e discharged >low score?.(" )his is the most applica$le se of a scoring system $eca se imaging has $ecome an important ad9 nct in patients with nclear symptoms.

RADIOLOGIC IMAGING
Misdiagnosis can lead to an e*tremely prolonged delay in treatment d e to family reass rance from the first caregiver interaction, which may delay them from seeking f rther care. )his res lts in an increase in mor$idity from advanced disease. 5pidemiologic data have shown the risk of a missed diagnosis in children to $e higher in hospitals with a vol me of less than one pediatric appendectomy per week.(( Parents sho ld $e enco raged to take their children to pediatric hospi- tals for a$dominal pain when possi$le. /istorically, negative appendectomy rates of !0& to "0& were not only considered appropriate $ t advisa$le to mini- mi4e the n m$er of patients with a missed diagnosis. More recently, some a thors have . estioned this phi- losophy, citing the risk and e*pense of an avoida$le operation.(+ Diagnostic imaging is necessary if physi- cians are going to $alance minimi4ing the risk of nega- tive appendectomy and the risk of a missed diagnosis. 8 rrently, data from children2s hospitals demonstrate e*tremely low negative appendectomy rates with the se of diagnostic imaging. !',(Plain films may demonstrate a fecalith in -& to !-& of patients.('-(% /owever, these st dies are e*tremely nonspecific and almost never serve as the determinant for operation. )herefore, they fr itlessly cons me time and reso rces and are not recommended nless $owel o$str ction, or free peritoneal air is s spected.(1 Ultrasonography offers the advantages of $eing an efficient $edside techni. e that is noninvasive, re. ires no contrast, and emits no radiation. =raded compres- sion ltrasonography is performed $y placing pres- s re on the transd cer to displace $owel loops and

identify the appendi*. )he press re is ade. ate if the psoas m scle and the iliac vessels are identified, which ass re the range of view is posterior to the appendi*. )he common signs of appendicitis incl de a fl id-filled, noncompressi$le appendi*, a diameter greater than ' mm, appendicolith, periappendiceal or pericecal fl id, and increased periappendiceal echogenicity ca sed $y inflammation.+0,+! Bes lts from m ltiple pediatric series totaling more than -000 patients have doc mented that the sensitivity of ltrasonography ranges from 7%& to 1+& and the specificity ranges from %1& to 1%&.+"--0 /owever, ltrasonography is operator dependent. )h s, the p $lished res lts m st $e interpreted relative to local e*perience and e*pertise with this imaging modal- ity. )he effectiveness of ltrasonography is hindered $y a$dominal wall thickness and fat, which acco nts for the generally inferior res lts reported in the ad lt litera- t re. -!--' 8a ses of false-positive res lts incl de a nor- mal large appendi*, the psoas m scle $eing mistaken for the appendi*, and inspissated stool. # false-negative st dy can res lt from a retrocecal appendi*, perforated appendi*, gas-filled appendi*, involvement of only the tip, and, most importantly, the ina$ility to vis ali4e the appendi*. (7,+0 6hereas a normal appendi* m st $e vis ali4ed to e*cl de appendicitis, ltrasonography is not typically efficacio s in identifying the normal appen- di*, $eca se early reports showed only !0& to -0& of normal appendices co ld $e identified in children.(7,+0 /owever, as with other modalities, appendicitis is effectively e*cl ded $y the ina$ility to identify the appendi* in com$ination with the identification of a pathologic process that e*plains the symptoms. -7 A rthermore, recent data from a large series employing pward graded compression, posterior man al compression, left o$li. e lateral dec $it s position, and a low fre. ency conve* transd cer, demonstrated that nearly all appendices co ld $e identified with over 1%& acc racy for diagnosing appendicitis.-% #nother recent report in -0 patients sing contrast-enhanced power Doppler ltraso nd imaging demonstrated similar acc racy. -1 8omp ted tomography >8)? provides a complete three-dimensional image of the entire a$domen and pelvis, is not operator dependent, and is e*tremely acc rate. #ltho gh there is some overlap in the ranges of sensitivity and specificity reported for 8) with the ranges reported for ltrasonography, most series report $oth sensitivity and specificity aro nd 1-& or greater for 8).((,+(,-(,'0-'' )hese data are diffic lt to interpret $eca se of the range in sample si4es, . ality of patient selection for imaging, and instit tional variation in technology and e*pertise. )herefore, more insight is gained $y e*amining intrainstit tional comparative series $etween US and 8), which have almost niver- sally fo nd 8) to $e significantly more acc rate than ltrasonography. ((,+(,-(,'0,'",'7 )here are, however, sev- eral concerns with 8). Some protocols re. ire a delay in the emergency department for contrast agent administration, and the smaller children may re. ire sedation. Badiation has $ecome a growing concern with the wide application of 8). ,t has $een estimated that a complete a$dominal 8) is e. ivalent to "-.7 months of nat ral $ackgro nd radiation e*pos re.'%

)he risk of radiation-ind ced malignancy from a 8) scan decreases with age. '1 )he lifetime risk of a fatal radiation-ind ced malignancy is estimated at 0.!%& for a !-year-old child. Stated another way, one malig- nancy wo ld res lt from a 8) scan done on --- one-year-old patients, whereas a$o t twice as many !--year-olds wo ld need to $e scanned to e. al that risk. #ltho gh this risk may appear minisc le, it is important information when eval ating a patient with the classic symptoms of appendicitis. Magnetic resonance imaging >MB,? is an intrig ing nonradiation alternative to 8) and is e*tremely acc - rate in diagnosing appendicitis.70 )he c rrent version of this technology makes it impractical for widespread application, $ t f t re generations of scanners co ld allow this technology to $e the initial imaging st dy. Badion clide-la$eled white $lood cell scans have $een employed, $ t the reported diagnostic capacity appears to offer little advantage over the aforementioned modalities and they have the disadvantage of $eing more c m$ersome to o$tain.7! ,maging is inval a$le in the eval ation of children with a$dominal pain, allowing for an acc rate diag- nosis, avoiding nnecessary operations, and decreas- ing the risk of a repeat presentation with perforation. Perhaps the most important contri$ tion of imaging is the a$ility to pinpoint an alternative diagnosis that entirely redirects therapy.!1,(7,+0,7"

DIFFERENTIAL DIAGNOSIS
,n the patients with lower a$dominal pain, the work p toward a diagnosis of appendicitis m st also consider the alternative possi$le ca ses. 8a ses of ac te right lower . adrant pain that is indisting isha$le from appendicitis witho t la$oratory or imaging st dies incl de a t $oovarian pathologic process, 8rohn2s dis- ease, mesenteric adenitis, cecal divertic litis, Meckel2s divertic litis, constipation, viral gastroenteritis, and regional $acterial enteritis >Yersinia and Campylobacter, partic larly?. :ower a$dominal pain or vag e nonfo- cal pain can res lt from a rinary tract infection, kid- ney stone, reteropelvic 9 nction o$str ction, terine pathologic process, right lower lo$e pne monia, sig- moid divertic litis, cholecystitis, pancreatitis, gastro- enteritis, vasc litis, $owel o$str ction, and malignancy >lymphoma?. )he most common diagnosis made in the presence of missed appendicitis has $een reported to $e gastroenteritis. !7 #ltho gh many of these condi- tions may seem easily disting ished from appendicitis, they all possess a spectr m of presentation that over- laps the possi$le symptoms of appendicitis.

,n simple, ac te appendicitis, a single dose of anti$iotics is ade. ate preoperative coverage. #fter appendectomy, patients with ac te appendicitis are s ally discharged within "+ ho rs. 8 rrent evidence s ggests that an additional dose of anti$iotics after appendec- tomy is not necessary or recommended.7(,7+ )he patients with perforated appendicitis will re. ire anti$iotic therapy postoperatively ntil clini- cal resol tion has occ rred. )he anti$iotic regimen employed in this sit ation has traditionally $een triple-anti$iotic therapy >ampicillin, gentamicin, and clindamycin?, which is still practiced in many pediat- ric s rgery centers despite several reports of simpler anti$iotic regimens.7--77 Monotherapy with piperacillin@ta4o$actam for intra-a$dominal infections has recently $een shown to $e e. ally efficacio s as traditional triple-anti$iotic therapy. 7-,7' Similarly, cefota*ime, a third-generation cephalosporin, has $een shown to $e e. al to the monotherapy sched le of piperacillin@ta4o$actam in children with complicated perforated appendicitis when com$ined with metronida4ole.77 Monotherapy has the disadvantage of $eing costly and re. ires three to fo r doses per day. )he financial charges to the patient are insepara$ly linked to the dosing sched le. )his impact of decreased dosing on anti$iotic e*penses has $een emphasi4ed $y several a thors.7%-%" ,n several st dies, a decrease in e*pense has $een shown with once-daily dosing of ceftria*one compared with $road-spectr m monotherape tic agents in the penicillin and cephalosporin families.%0-%7 # retrospective comparative st dy fo nd once-daily dosing with ceftria*one and metronida4ole was as effective as traditional triple-anti$iotic therapy with cost $enefits.%% )his was confirmed in a prospec- tive, randomi4ed trial.%1 )herefore, c rrent $est evi- dence s ggests once-a-day dosing with ceftria*one at -0 mg@kg@day and with metronida4ole at (0 mg@kg@day provides the simplest and least e*pensive regimen. )he length of time re. ired for anti$iotic treatment or the mode of delivery for perforated appendicitis has yet to $e delineated. # m lticenter case-control st dy s ggests that the patient who is clinically well $y post- operative day ( is nlikely to develop an a$scess.10 # retrospective comparative series fo nd early transition to oral anti$iotics as effective as a prolonged co rse of intraveno s anti$iotics.1! /owever, prospec- tive trials will $e re. ired to clarify this iss e.

S&r$!ca" Ma#a$e%e#t
# disc ssion of the s rgical management of appendici- tis m st $e separated into the three distinct categories of disease at presentation. )hese categories are those with appendicitis with no evidence of perforation, those with perforated appendicitis, and those with a well-defined a$scess.

TREATMEN T Me !ca" Ma#a$e%e#t

)he treatment of appendicitis $egins with intraveno s fl ids and anti$iotics. )he anti$iotic regimen m st pro- vide $road-spectr m coverage of enteric organisms.

Acute Appendicitis
#c te, nonperforated appendicitis is c red with prompt appendectomy, which is the rationale for why an early operation has always $een the standard of

care. 6e now nderstand that, as a version of divertic litis, ac te appendicitis can $e treated effectively to the point of disease resol tion and hospital discharge with anti$iotics alone.1"-1+ )his fact has $een proven $y large prospective, randomi4ed trials in ad lts compar- ing anti$iotics alone to appendectomy for appendici- tis. 1+,1)herefore, once anti$iotics have $een initiated, the operation is not an emergency or even necessary in the immediate setting. #ppendectomy in the middle of the night is no longer 9 stified. 1"-1+,1'-1% 3ot only is the operation elective once anti$iotic therapy has $een initiated, this information may $e sef l in eas- ing family an*iety d ring the time they await s rgical intervention.

Perforated Appendicitis
#ppendectomy for perforated appendicitis is c rrently a topic of de$ate. )here are three general strategies possi$le for this sit ationC anti$iotics only, anti$iotics followed $y interval appendectomy, and appendec- tomy on presentation. )he logic of treating initially with anti$iotics is to avoid a diffic lt operation in the presence of severe inflammation that o$literates the normal anatomy and creates dense adherence of the s rro nding str ct res. once the infection is controlled with anti$iotics, allow- ing an operation to $e more simple and safe, the deci- sion $ecomes whether to perform the appendectomy. )hose who do not perform appendectomy $elieve there is a low risk of rec rrent appendicitis, which short-term data s ggest are %& to !+&.11,!00 /owever, not only is there short-term follow- p in these st d- ies, these are retrospective reviews of patients already treated, meaning they were specifically selected for this management. ,t wo ld $e e*pected that a prospective application of anti$iotics alone to all patients with evi- dence of perforation on 8) wo ld yield a m ch higher fail re rate. A rthermore, all pediatric follow- p data, even to age !%, is relatively short term considering the c rrent life e*pectancy is nearly %0 years. )herefore, it is impossi$le to estimate the lifetime risk of leaving the appendi* in sit as these patients mat re thro gh ad lthood $eca se we do not know what the rec r- rence c rves wo ld look like decade $y decade. /ow- ever, ass ming a sta$le rate, and ass ming the c rrent series are acc rate in estimating the short-term risk of rec rrence at !& to (& per year, this is an nfavor- a$le prognosis when the typical pediatric patient has '0 to %0 years of e*pected life remaining. Some a thors have noted a high rate of pathologic findings in interval appendectomy specimens.!0!,!0" )hese cases a gment the concern over the lifetime risk of not performing the appendectomy. ,n addition, most pediatric s rgeons perform the interval appendectomy in patients who were initially managed medically. # s rvey of the #merican Pediatric S rgical #ssocia- tion >#PS#? fo nd that %'& of the responders perform interval appendectomy ro tinely after nonoperative management of perforated appendicitis.!0( Begarding nonoperative management of perforated appendicitis, one gro p fo nd a high fail re rate in

patients with more than !-& $and forms in the dif- ferential white cell co nt on presentation. !0+ #nother gro p fo nd fail re was more common when an appendicolith was present on imaging. !0- others have fo nd that evidence of disease or contamina- tion $eyond the right lower . adrant on imaging is a predictor of fail re. !0' Ainally, when choosing among treatment options, the s rgeon sho ld remem$er that some cases are diffic lt to categori4e acc rately as per- forated or nonperforated preoperatively. #ltho gh the logic of anti$iotic therapy first is to avoid a diffic lt and potentially dangero s operation, most e*perienced s rgeons can perform this operation safely thro gh a minimally invasive approach. :apa- roscopic appendectomy has $een shown to $e reli- a$ly feasi$le and safe in $oth children and ad lts who present with a phlegmono s mass in the right lower . adrant.!07,!0% ,n the disc ssion a$o t whether to perform an operation, the most important factor is deciding if the patient has a perforation. )he presence or a$sence of perforation cannot $e acc rately predicted $y preoperative imaging, $ t not all patients will have preop- erative imaging performed. ,n these cases, perforation is diagnosed intraoperatively. )his is another so rce of controversy. S rgeons polled with photographs have e*treme incongr ence on which patients wo ld $e considered to have a perforation.!01 A rthermore, a s rvey of #PS# mem$ers demonstrated the ma9or- ity of mem$ers reported that they $ased their practice approaches on their individ al preferences.!!0 0eca se s rgeons do not agree on what constit tes perfora- tion, and $eca se each s rgeon holds his or her own opinion, this means almost all of the data p $lished on the topic of perforated appendicitis m st $e viewed with ca tion $eca se we do not know the composi- tion of the st dy pop lations. ,n reality, a definition of perforation is not as important as the a$ility to iden- tify which patients possess a high risk of developing a postoperative a$scess. 5merging prospective evidence s ggests defining perforation as an identifia$le hole in the appendi* or as a fecalith in the a$domen clearly separates high-risk from low-risk patients.!!! More- over, this distinction prevents overtreating patients with p r lent disease who act ally have a good prog- nosis from the o tset.

Abscess on Presentation
Patients presenting with a well-defined a$scess that is identified on imaging are clinically challenging. /istorically, the operations were diffic lt and re. ired large incisions with high mor$idity. )reatment of the a$scess with perc taneo s drainage with or with- o t drain placement >Aig. +(-!?, followed $y interval appendectomy when the inflammation has resolved, allows for a less mor$id operation. )his approach was initially descri$ed over "- years ago and has $ecome an important part of contemporary practice.!0(,!!"-!!' /owever, the advancement of laparoscopic skills has also allowed the operation to $e performed with mini- mal mor$idity. )here are no conc rrent comparative

*
A B C

F!$&re 43'() )his patient presented with perforated appendicitis and a well-defined a$scess. She nderwent initial nonoperative man- agement >a$scess drainage, anti$iotics? followed $y a laparoscopic interval appendectomy !0 weeks later. )hese 8) scans show the large pelvic a$scess > asterisk, A? followed $y needle placement >arrow, *?, and drainage with a perc taneo s drain >arrow, C?. )he drainage res lted in resol tion of the a$scess.

data availa$le descri$ing how the patients with perc taneo s drainage fare in comparison to a cohort ndergoing early operation. )he practice of perc taneo s drainage with interval appendectomy also car- ries the risk of complications and employs considera$le medical reso rces.!!7 A rthermore, there are no data availa$le on the stress of the medical $ rden placed on the families treated with a long medical co rse involving anti$iotics, drainage, and a long wait for the interval operation. )his topic is an important one to address with a prospective trial, which is c rrently nderway. !!% Begardless of whether the a$scess is drained nder radiologic g idance or is opened at operation, c lt re of the fl id has not $een shown to $e helpf l. !!1,!"0 one st dy demonstrated that children whose treat- ment followed the c lt res did somewhat worse than those whose fl id was not c lt red.!"0 ,n addition, peritoneal lavage with saline or anti$iotic sol tion has never $een shown to red ce the incidence of post- operative a$scess. !"! Similarly, the se of drains has not proved sef l e*cept in cases of walled-off a$scess cavities.!"",!"( ,n9ection of $ pivacaine into the wo nd

has $een shown to red ce postoperative pain signifi- cantly in a randomi4ed controlled trial in children.!"+

The Lapar+,c+p!c Appr+ach

)he traditional method of appendectomy was a m sclesplitting, right lower . adrant incision. :aparoscopic appendectomy typically involves a camera site at the m$ilic s with two additional working ports >Aig. +(-"?. D ring the initial e*perience with laparoscopy for perforated appendicitis, some a thors fo nd a higher postoperative a$scess rate than had $een seen with the open operation.!"--!"7 /owever, this litera- t re also s ffers from the lack of a s $stantative defi- nition of perforation. #lternatively, this finding may have $een the res lt of the early e*perience with laparoscopy. Since the last edition of this $ook, there has $een a plethora of evidence from aro nd the world doc menting no difference in intra-a$dominal a$scess risk $etween the open and laparoscopic approaches.!"%!+' )his evidence incl des a m ltit de of level !, ", and ( st dies, incl ding m ltiple prospective trials,

F!$&re 43'-) A. Port positions for a laparoscopic appendectomy. )ypically three cann las are sed, with the endoscopic stapler intro- d ced thro gh the !"-mm m$ilical port. )he appendi* is removed thro gh this site as well. *. Postoperative appearance.

meta-analyses, and large m lti-instit tional comparative series from several co ntries. )his is important $eca se the risk of postoperative a$scess was the potential 9 stification for the open approach. :aparoscopy possesses several advantages. )his approach effectively removes the concern for wo nd infections, which has $een a formida$le pro$lem in some patients with the open operation. )he wo nd infection rate is s $stantially lower with laparoscopy owing to the small incisions and protection of the tiss es $y the cann las.!"%-!(",!(-,!(',!+"-!++,!+',!+7 6hen a wo nd infection occ rs with laparoscopy, the mor$idity is . ite minimal owing to the si4e of the incision.%1 )his effect is amplified in o$ese patients in whom the lapa- roscopic incision si4e remains the same $ t the open operation re. ires a m ch larger incision that res lts in the contamination of an a$ ndance of poorly vas- c lari4ed s $c taneo s tiss es.!+%,!+1 #lso, the length of hospitali4ation has $een repeatedly shown to $e shorter with laparoscopy. !"1,!(0,!("-!(7,!+0-!+-,!+7 :apa- roscopy has $een shown to allow for an earlier ret rn to f ll activity in several st dies, incl ding an earlier ret rn to sports and work.!+!,!+",!++,!+-,!+7 one prospective, randomi4ed trial doc mented a s perior . ality of life at " weeks after laparoscopic appendectomy compared with the open operation.!(7 # large data$ase st dy involving +(,7-7 patients fo nd a lower rate of gastrointestinal complications and overall complications with laparoscopy. !+( Similarly, the laparoscopic operation has also $een shown to red ce the rate of postoperative adhesive small $owel o$str ction.!-0 M ltiple a thors have e*pressed the point that laparoscopy offers the s $stantial advan- tage of allowing e*cellent vis ali4ation of the entire a$dominal cavity, removing therape tic concerns of an alternative diagnosis.!("-!(+,!+!,!++,!+7,!-! )he most recent 8ochrane review concl ded that laparoscopy sho ld $e the primary approach for s spected appen- dicitis, if availa$le.!+7 )he concern a$o t laparoscopy re. iring longer operative time is $ecoming dated. #s with the early e*perience of all laparoscopic operations, it is likely that a longer operating time was the res lt of s rgeons comparing an approach they were $eginning to apply against one they had practiced for decades. Several recent comparative st dies, incl ding two prospective, randomi4ed trials, have failed to show laparoscopy as

taking longer.!(0,!(',!(%,!(1,!+! )he most recent metaanalysis fo nd no difference in operative time. !(' one prospective trial in patients with ac te appendi- citis and another large comparative series in patients with perforated appendicitis fo nd the laparoscopic approach to have a shorter operating time.!(0,!(% Most of the early st dies doc menting longer operating times for laparoscopy were reporting operating times of over ! ho r. )he recent st dies report times of less than -0 min tes. ,n the most recent prospective, ran- domi4ed trial in children with perforated appendicitis, who all nderwent laparoscopic appendectomy, the mean operating time was ++ min tes, with many cases re. iring (0 min tes or less. %1 ,f these times are fo nd in the setting of perforation, a straightforward appen- dectomy can easily $e done in "0 min tes with good laparoscopic e*perience. ,n spite of the fact that appendicitis is the most common ac te s rgical condition in children, there are many nresolved management iss es that will re. ire prospective st dies to delineate.

Technique
)he patient is placed s pine on the operating ta$le, and the a$domen is prepped widely. # !"-mm can- n la is introd ced thro gh an m$ilical incision, and pne moperitone m is esta$lished. Diagnostic laparoscopy is then performed. )wo --mm ports are then placed, one in the left mida$domen and one in the left s prap $ic area >see Aig. +(-"?. # --mm +--degree telescope is introd ced thro gh the m$ilical port, and the two --mm ports are the working ports ntil intro- d ction of the stapler. once the appendi* is identi- fied, a window is made in the mesoappendi*. #t this point, the telescope is rotated from the m$ilical port to the left mida$dominal port and an endoscopic sta- pler is inserted thro gh the !"-mm m$ilical cann la. Us ally, the appendi* is ligated and divided first >Aig. +(-(?, followed $y ligation and division of the mesoappendi*. on occasion, however, it may $e more e*pedi- ent to ligate the mesoappendi* first. ,f the appendi* can $e delivered thro gh the can- n la, an endoscopic $ag is not sed. /owever, so as not to drag the appendi* thro gh the m$ilical inci- sion, an endoscopic $ag is tili4ed if the appendi* is too large for the cann la.

F!$&re 43'3) A. ,nitially, a window is made in the mesoappendi*. *. Us ally, the appendi* is ligated and divided with the stapler first, followed $y ligation@division of the A mesoappendi*.

Aor perforated appendicitis, the port positions remain the same. /owever, the p r lent material is evac ated in the pelvis and s prahepatic areas. ,nterloop a$scesses are also lysed and opened if they have developed. Drains are not ro tinely tili4ed for advanced disease. o r e*perience with laparoscopic appendec- tomy over the past % years has $een previo sly

reported.%%,%1,!!!,!-0,!-",!-( o r conversion rate is less than !&. 6e have fo nd a less than !& postopera- tive a$scess rate in patients with ac te appendicitis and a "0& postoperative a$scess rate if perforation has occ rred.%1,!!!