Management of Ruptured Appendix During Laparoscopic Appendectomy
For a ruptured appendix discovered during laparoscopic appendectomy, perform thorough suction alone without irrigation, avoid routine drainage, and continue appropriate antibiotic therapy postoperatively. 1
Immediate Intraoperative Management
- Perform thorough suction of purulent material and contaminated fluid without peritoneal irrigation, as irrigation provides no additional benefits and may prolong operative time 1
- Complete the appendectomy using standard techniques with careful attention to the appendiceal stump 1
- For mesoappendix dissection, use monopolar electrocoagulation or bipolar energy as these are the most cost-effective techniques 1
- For stump closure, use endoloops/suture ligation or polymeric clips; endostaplers may be considered for complicated cases based on surgeon judgment 1
- Perform simple ligation of the appendiceal stump rather than stump inversion, as this is associated with shorter operative times and quicker recovery 1
Drainage Considerations
- Avoid routine placement of abdominal drains as they provide no benefit in preventing intra-abdominal abscess formation 1
- Drains are associated with longer hospital stays (5.2 vs 2.9 days) and do not reduce postoperative abscess rates 2
- In adults, drains may even be associated with increased 30-day morbidity and mortality rates 1
- For pediatric patients, prophylactic drainage should also be avoided as it does not prevent complications and may lead to negative outcomes 1, 3
Postoperative Management
- Continue appropriate antibiotic therapy based on the severity of contamination 4
- For complicated appendicitis with adequate source control, limit postoperative antibiotics to 3-5 days in adults 4
- Monitor for signs of postoperative complications, including surgical site infections and intra-abdominal abscess formation 5
- If surgical site infection develops postoperatively, open the wound, evacuate infected material, and continue dressing changes until healing occurs by secondary intention 5
Special Considerations
- For open appendectomy cases, use wound ring protectors to decrease the risk of surgical site infection 4
- Primary skin closure with absorbable intradermal suture is recommended over delayed closure, as it reduces hospital stay without increasing infection risk 1, 4
- Routine histopathology of the appendix specimen is recommended to identify any unexpected findings 1
Common Pitfalls to Avoid
- Avoid excessive irrigation which does not reduce intra-abdominal abscess rates but prolongs operative time 1, 6
- Do not routinely place drains based solely on the presence of perforation, as evidence shows this practice extends hospital stays without clinical benefit 2, 7
- Recognize that conversion to open procedure may be necessary in select cases with extensive abscess formation 8