Introduction

Appendicitis remains one of the most common diseases faced by the surgeon in practice. Despite improving diagnostic technology, there is still no single test or clinical finding that is 100% reliable. The cause of acute appendicitis is unknown but is probably multifactorial; luminal obstruction with an appendicolith is quite common. Lymphoid hyperplasia, parasitic infections, and neoplasm are less common causes

In 1886, Reginald Fitz's seminal publication, ‘Perforating Inflammation of the Vermiform Appendix’ advocated early appendectomy for appendicitis. Appendicectomy is traditionally the treatment of choice and is increasingly done as a laparoscopic procedure.

Classification: Classified as uncomplicated or complicated based on clinical, radiologic, intra-operative, and/or histologic findings

Uncomplicated appendicitis (simple or non-perforated appendicitis) Inflamed appendix without any evidence of gangrene, perforation, purulent intraperitoneal fluid, appendicular phlegmon, or intra-abdominal abscess.

Complicated appendicitis (includes perforated appendicitis) Gangrenous inflamed appendix, formation of appendicular phlegmon, perforation, purulent- intraperitoneal fluid, , or intra-abdominal abscess. The appendiceal wall has been compromised due to pressure and inflammation and the intraluminal contents have leaked out into the peritoneal cavity.

Incidence

Western data estimates that as much as 6% to 7% of the general population will develop appendicitis during their lifetime, with the incidence peaking in the second decade of life. Indian data is lacking.

Symptoms

1.       Patients typically complain of anorexia followed by epigastric or periumbilical abdominal pain. Usually, the pain localizes to its classic location in the right lower quadrant, so referred to as ‘migrating pain’.

2.   Pain gets worse after oral ingestion or movements

3.   Feeling of nausea and vomiting (usually after onset of pain)

4.   Low grade fever (absence of fever does not rule out appendicitis)

5.   Weakness

Signs

1.   Typical appendicitis patient appears ill and prefer to lie still because of the presence of localized peritonitis, which makes any movement painful.

2.   Mild to moderate tachycardia.

3.   Normal to low grade elevation of temperature.

4.     Abdominal examination typically reveals tenderness and guarding on palpation of the right lower quadrant. The location of the tenderness is classically over Mc Burney’s point (located one-third the distance between the anterior superior iliac spine and the umbilicus)

5.   Rebound tenderness is also commonly elicited.

6.   Occasionally if perforation occurs, diffuse peritonitis is seen.

A number of clinical tests and signs have been described to help in the diagnosis of acute appendicitis, however they are all indicators of peritoneal irritation and may differ depending on the location of the appendix.

Investigations

The diagnosis of acute appendicitis is predominantly a clinical one; many patients present with a typical history and examination findings. However, in atypical presentation diagnosis may be clinched with the help of imaging modalities like ultrasound scan and / or CT scan. The diagnosis of acute appendicitis can be challenging. Scoring systems devised are not definitive. A high index of suspicion– clinical, biochemical and radiological findings put together, may help a better decision making in the management of the patient with suspected appendicitis.

Diagnostic aides:

Laboratory tests are non-specific and need to be correlated clinically.

•    White cell count - usually elevated

•    C-Reactive Protein - usually elevated

•      Urine examination including pregnancy test (for female patient in child bearing age) – to be done to rule out ectopic pregnancy in atypical presentation.

Imaging aides

1.   USG abdomen/pelvis –

·       preferred initial test in most patients

·       risk of radiation – Nil

·       usually seen is a distended, non-compressible appendix with an at least

6 mm diameter

2.   CT scan abdomen /pelvis:

·       for selected patients especially with diagnostic dilemma, perforation and obese patients

·       Risk of radiation exposure – present

·       Plain or with IV contrast is recommended (Oral and rectal administration of contrast material is not routinely required)

·       Appearance of a thickened, inflamed appendix with surrounding fat

“stranding” indicative of inflammation, is usually suggestive

·       High sensitivity and high negative predictive value –may help reduce the rate of negative appendicectomy

·       Not preferred as first line modality during pregnancy

3.   MRI abdomen/pelvis

·       Reserved for suspected appendicitis during pregnancy

·       Recommended without use of contrast agents

·       Risk of radiation exposure– Nil

·       Appendiceal enlargement (>7 mm), thickening (>2 mm), and the presence of inflammation are usually suggestive of appendicitis

·       Low availability and expertise during non-working hours

For fitness for Surgery & Anaesthesia

•    Complete Hemogram

•    Blood sugar – if diabetic

•    Serum Electrolytes – in selected patients with profound vomiting

•    Blood Urea, Serum creatinine – in selected patients

•    Bleeding time, clotting time and /or prothrombin time

•    X-ray chest – in elderly and with history of pulmonary diseases

•    ECG & 2D echo – in selected patients when cardiac compromise is suspected or evident

•    PFT/ ABG –optional in high-risk cases

•    Other patient profile specific tests – as per pre-anaesthetic check up

Management of Acute appendicitis:

The following comorbidities are associated with poorer outcomes following treatment of appendicitis:

•    Diabetes

•    Immunocompromised state

•    Obesity

•    Crohn’s disease

•    HIV infection

•    End-stage renal disease

I.   Management of Acute Uncomplicated Appendicitis

A.     Operative management of Uncomplicated appendicitis The appropriate treatment of acute uncomplicated appendicitis is prompt appendectomy.

1.    Timing of Surgery: (Urgent, not emergent) The timing of surgery has been categorized as urgent intervention and not as emergent and can be performed within 6-24 hours of diagnosis without any statistically significant difference in length of hospital stay, operative time or rates of complications.

2.   Resuscitation, optimization & Antibiotics: Patient should be fluid resuscitated as many presents with mild dehydration. Appendicitis is considered polymicrobial infections and IV broad spectrum antibiotics need to be administered to cover Gram- ve bacteria and anaerobes (as per institutional policy).

3.  Surgical approach

Open Appendicectomy: Traditional approach

Position: supine

Anaesthesia: Spinal/General / Regional / Even local

Incision: The choice of incision is surgeon's preference, Commonly used incisions are:

·  Oblique muscle-splitting (Grid iron) incision (Mc Burney),

·  Transverse incision (Rockey-Davis),

·  Conservative midline incision, as indicated

·  Lane’s crease incision

Common Steps:

·  The cecum is grasped by the taeniae and delivered into the wound

·   Allows delivery of the appendiceal tip & visualization of the base of the appendix.

·  The mesoappendix is divided sequentially.

·  Appendix is crushed just above the base, ligated with an absorbable ligature at the site of crush, and divided.

·  The stump is then either cauterized or inverted by a purse-string or Z suture technique.

·   Abdomen is thoroughly irrigated if indicated, haemostasis noted and the wound closed in layers

Laparoscopic Appendicectomy

Laparoscopic appendicectomy is to be offered only when facilities and expertise is available and only when the charges are acceptable to the patient and not a procedure to be recommended as the only option to the patient.

Position: supine (The bladder is emptied by a straight catheter or by having the patient void immediately before the procedure). Both the surgeon and assistant stand to the left side of the patient with the left arm tucked. Patient strapped to table to prevent sliding off during table tilts.

Anaesthesia: General

Access & Port placements:

·  Open or Veress needle access

·    Ports: Supra/infra/trans umbilical camera port and 2 working ports (5mm) typically in the left / right lower quadrant and one in either suprapubic, supra umbilical or right upper quadrant as per surgeons preference to allow optimum triangulation. Common Steps:

·     30 degree telescope is used routinely used, a four-quadrant exploration is performed quickly and diagnosis confirmed.

·  The patient is placed in reverse Trendelenburg position with right side up to gain exposure to the appendix and caecum.

·   In a retrocecal appendix, sometimes the lateral peritoneal attachments, the white line of Toldt, must be divided to mobilize the cecum and expose the appendix.

·  Atraumatic bowel graspers are used to elevate the appendix and inspect the base.

·    Mesoappendix is carefully divided using the cautery (preferably bipolar) or harmonic scalpel and scissors after clipping or ligation.

·  The base is then secured with Endoloops and the appendix divided.

·   Alternatively, the appendix may be divided with an endoscopic stapler (prefer to use a blue loadstapler in cases in which the entire appendix is friable to get a healthy base stapled close to the caecum)

·  Appendix is usually retrieved in an endo-bag.

·   The pelvis is irrigated, haemostasis noted, trocars are removed under vision, and the wounds are closed.

·   Laparoscopic appendectomy may also be performed with single-site laparoscopic surgical techniques as well in expert hands.

Although the laparoscopic approach is increasingly becoming the procedure of choice in most patients, open appendectomy still remains the choice of treatment on a global basis.

Post Operative Care: No further need for antibiotics. Patient is usually discharged after passage of flatus and tolerating oral diet.

Common Complications of Appendicectomy

•    Bleeding • Ileus • Bowel obstruction • Stump leakage • Stump appendicitis

•    Intra-abdominal abscess • Wound infection

B.  Nonoperative Management of Uncomplicated Appendicitis

•       Current best practice at this time for uncomplicated appendicitis is prompt appendectomy either by open or by laparoscopic approach. This concept has been challenged with non-operative management of acute appendicitis and is evolving.

•    If non-operative management is chosen for some reason, the surgeon must remain extremely vigilant.

•     Serial examinations and imaging are necessary to monitor for treatment failure especially if there’s an appendicolith.

•    The rate of recurrence of appendicitis treated with antibiotics alone is shown to be 7% to 14% at 1 year from the indexed episode especially in children.

•    Treatment is by IV antibiotics, analgesics, fluids and serially initiating enteral feeds depending on abdominal findings.

•    In future, the algorithm may move towards less invasive approaches, however, at this time appendicitis is still a surgical disease

II.   Management of Acute Complicated appendicitis:

•    Delayed Presentation with septicemia

•    Appendicular perforation

•    Appendicular phlegmon or Mass

•    Appendicular abscess

Patients with diffuse peritonitis are challenging to manage with a high morbidity and sometimes mortality as well. These patients can be managed with multidisciplinary approach

e.g: • interventional radiologists inserting a percutaneous drain for an abscess or collection

•    may require ICU admission

•     In these cases, the treatment should be individualized on the basis of the

nature of the presentation.

•       In general, treatment for these patients is initially accomplished non- operatively. Fluid resuscitation is initiated, and broad-spectrum antibiotic therapy is initiated. A CT scan is obtained, and perforated appendicitis with a localized abscess or phlegmon is confirmed.

•       Due to the extreme induration and friability of the involved tissues, Immediate exploration and attempted appendectomy in these patients may result in substantial morbidity, including

·  failure to identify the appendix,

·  postoperative abscess or fistula, and

·  unnecessary extension of the operation to include ileocecectomy.

If a localized abscess is identified,

·       Antibiotic therapy for 5-7 days

·       Drainage of abscess

·       CT-guided percutaneous drainage is performed for source control. The drainage catheter is typically left in place for 4 to 7 days

·       Laparoscopic drainage is another option that can be exceptionally useful. This technique is performed by visualizing the inflammatory mass with the laparoscope and then entering the abscess with a laparoscopic suction tip, evacuating the purulent material, and placing a drain within the residual abscess cavity.

·       Postoperative management is identical to that of patients who are successfully drained percutaneously.

•    If an appendiceal phlegmon is present or if the amount of fluid present is not sufficient to drain, the patient may be treated with antibiotics alone, typically for 4 to 7 days also, as recommended by institutional guidelines for treatment of intra-abdominal infection.

•   Interval appendicectomy can be performed based on risk assessment and for patients harbouring appendicolith. The current data is inclined towards an interval appendicectomy in children, however in adults the evidence in favour of interval appendicectomy is declining.

Referral Criteria:

·     All patients with suspected appendicitis need to be referred for a Surgical Consultant and be managed by him. ICU admission criteria: o usually for complicated appendicitis

o  ICU care may be needed in patients who present late with shock, septicemia or with perforation peritonitis and / or have other systemic illnesses.

o     Patients with appendicitis who are not improving in-spite of intra-venous antibiotics and/or require tertiary care including ventilator support.

MDT approach: · Patients with complicated appendicitis requiring interventional radiologists support for abscess drainage or fecal fistula, intensivists for nutrition and sepsis management or experienced surgical team for further management.

·    Pregnancy related management of acute appendicitis including need for MRI abdomen/pelvis.

Who does what?

Doctor: Surgeon: - (Surgical team –PG’s, Registrar’s, Consultants)

·  Diagnosis & work up

·  Pre operative planning

·  Operative procedure

·  Peri operative care in conjunction with Anaesthetist / Intensivist

·  Post operative follow up

Anaesthetist: - Pre-Anaesthesia Check-up Part of resuscitation and stabilization Performing anaesthesia Post op ICU management in conjunction with Surgeon

Nurse:-(OT, ICU, ward & OPD) Pre/Intra/Postop comprehensive care Dressing of the wound

OT Technician: - Pre op equipment and drugs to be checked and kept ready Assist anaesthetist in the OT Assist the surgeon, positioning of the patient Resources required for one patient / procedure (Patient weight -approx. 60 Kgs)

Human Resources Drugs/Consumables Equipment

1.   Surgeon – 1

2.   Medical Officer / Assistant Surgeon – 1

3.   Anaesthetist – 1

4.   Pathologist – 1------ Services from outside can be availed

5.   Staff Nurse – 1

6.   Technician – 1

7.   Nursing Orderly – 1

8.   Cleaning staff-1

Investigations

1. Haemogram 2. Blood Sugar 3. Renal Function Test in selected cases 4. LFT in selected cases 5. S. Electrolytes in selected cases 6. USG in selected cases 7. ECG-if justifiable clinically 8. X- Ray – Chest- if justifiable clinically 9. Histopathology

Drugs & Consumables 1. OT Table & lights 2. Instrument trolley 3. Anesthetic Machine, instruments including endotracheal tubes & drugs 4. Monitor 5. Set of surgical Instruments (open and/or Laparoscopic) 6. Suction (open and/or laparoscopic) 7. Sutures / endoloops / stapler 8. Drains 9. Catheters 10. Cautery – a basic set (monopolar and/or bipolar) or harmonic shears 11. Antibiotics 12. Analgesics 13. I.V. Fluids 14. Dressings.

If the centre has facilities for Laparoscopic Surgery, the procedure can be done laparoscopically or open surgery as deemed appropriate by the Surgeon.