What are the surgical approaches to a ruptured base of the appendix?

From the Guidelines

Laparoscopic surgery is a safe and feasible first-line treatment for a ruptured base of the appendix, associated with fewer readmissions and fewer additional interventions than conservative treatment, with a comparable hospital stay 1.

Surgical Approach

The surgical approach to a ruptured base of the appendix involves several key considerations to minimize morbidity, mortality, and improve quality of life.

• The procedure may begin with a laparoscopic approach, which has been shown to be safe and effective in experienced hands 1.
• If the laparoscopic approach is not feasible, a right lower quadrant incision (McBurney's or Rocky-Davis) or midline laparotomy may be necessary, especially if diffuse peritonitis is suspected.
• After entering the peritoneal cavity, the surgeon should carefully isolate the operative field with moist laparotomy pads to prevent further contamination.
• The appendiceal stump must be securely closed, typically using a purse-string suture or stapler on the cecum since the base is compromised.

Postoperative Management

Postoperatively, patients require:

• Broad-spectrum antibiotics, such as piperacillin-tazobactam or ceftriaxone plus metronidazole, for 5-7 days depending on clinical response 1.
• Early enteral nutrition should be initiated when bowel function returns.
• Closed-suction drains may be placed near the operative site to manage potential postoperative collections.

Evidence-Based Decision

The decision to perform laparoscopic surgery as the first-line treatment is based on the high-quality RCT by Mentula et al., which demonstrated that laparoscopic appendectomy (LA) is a safe and feasible first-line treatment for appendiceal abscess, associated with fewer readmissions and fewer additional interventions than conservative treatment, with a comparable hospital stay 1.

Key Considerations

• The proximity of the ruptured base to the cecum can lead to more extensive contamination of the peritoneal cavity, highlighting the importance of thorough peritoneal lavage with several liters of warm saline to remove purulent material and reduce bacterial load.
• The use of percutaneous drainage as an adjunct to antibiotics may be beneficial in certain cases, although there is a lack of evidence for its use on a routine basis 1.

From the Research

Surgical Approaches for Ruptured Base of the Appendix

The surgical approaches for a ruptured base of the appendix include:

• Laparoscopic appendectomy (LA) 2, 3, 4
• Open appendectomy (OA) 5, 6, 3, 4
• Interval appendectomy after initial conservative management with antibiotics and drainage of accessible abscesses 2

Comparison of Laparoscopic and Open Appendectomy

Studies have compared the outcomes of laparoscopic and open appendectomy:

• Laparoscopic appendectomy is associated with a shorter hospital stay, lower wound infection rate, and faster recovery 2, 3, 4
• Open appendectomy may have a higher risk of wound infection, especially in cases of complicated appendicitis 5, 3
• The use of abdominal drainage in open appendectomy is controversial, with some studies suggesting it may not reduce the risk of intra-peritoneal abscess or wound infection 6

Specific Considerations for Ruptured Appendicitis

In cases of ruptured appendicitis:

• Aggressive medical management with antibiotics may be used initially, followed by interval appendectomy 2
• Laparoscopic appendectomy may be preferred due to its lower risk of surgical site infection and faster recovery 3, 4
• Open appendectomy may still be necessary in some cases, especially if the patient has a high risk of complications or the surgeon is not experienced in laparoscopic techniques 5, 6