What is the management for a patient with crepitus near the postoperative site after an appendectomy?

Management of Crepitus Near Postoperative Site After Appendectomy

Crepitus near the postoperative site after appendectomy requires immediate evaluation and management as it likely indicates subcutaneous emphysema, which may be a sign of wound infection or anastomotic leak requiring prompt intervention. 1

Initial Assessment

• Crepitus (subcutaneous emphysema) after appendectomy is an abnormal finding that warrants immediate clinical evaluation 1
• Physical examination should focus on:
  • Extent of crepitus (localized vs. spreading)
  • Signs of systemic infection (fever, tachycardia)
  • Wound appearance (erythema, drainage, dehiscence)
  • Abdominal examination for signs of peritonitis 1

Diagnostic Workup

• Laboratory tests:
  • Complete blood count with differential to assess for leukocytosis
  • C-reactive protein to evaluate inflammatory response 1
• Imaging:
  • CT scan with contrast is recommended to:
    • Identify potential intra-abdominal abscess
    • Evaluate for anastomotic leak or stump dehiscence
    • Determine extent of subcutaneous emphysema 1

Management Algorithm

For Localized Crepitus Without Systemic Signs:

1. Close monitoring with frequent reassessment
2. Broad-spectrum antibiotics (if not already administered)
   • For adults: combination therapy with either cephalosporins or fluoroquinolones with metronidazole 1, 2
   • For children: early switch (after 48h) to oral antibiotics if responding well 1
3. Wound care with possible opening of superficial layers to allow drainage if indicated 1

For Extensive Crepitus or Signs of Systemic Infection:

1. Immediate surgical consultation for potential reoperation
2. Broad-spectrum IV antibiotics
   • Continue for 3-5 days with adequate source control 1
3. Wound exploration and possible debridement
4. Consider CT-guided percutaneous drainage if localized abscess is identified 1

Specific Considerations

• Against routine drainage: The World Society of Emergency Surgery strongly recommends against the routine use of drains following appendectomy for complicated appendicitis in adults, as drains provide no benefit in preventing intra-abdominal abscess and may lead to longer hospitalization 1
• Antibiotic duration: If crepitus is associated with complicated appendicitis, antibiotics should not be prolonged beyond 3-5 days with adequate source control 1
• Wound closure: If the wound requires reopening, primary skin closure with absorbable intradermal sutures is recommended once infection is controlled 1

Complications to Monitor

• Surgical site infections (most common complication, occurring in approximately 5.5% of appendectomy cases) 3
• Intra-abdominal abscess formation (occurs in approximately 3% of cases) 3
• Anastomotic leak or stump dehiscence 1
• Progression to necrotizing soft tissue infection (rare but serious) 1

Prevention of Further Complications

• Wound ring protectors during the initial surgery have shown evidence of surgical site infection reduction in open appendectomy 1
• Single preoperative dose of broad-spectrum antibiotics is effective in decreasing wound infection and postoperative intra-abdominal abscess 1, 4
• Early mobilization and adequate nutritional support to promote wound healing 1

The presence of crepitus after appendectomy should never be dismissed as it may indicate a serious complication requiring prompt intervention to prevent morbidity and mortality 1.