What is the recommended management for a patient presenting with symptoms necessitating a Lanz incision, likely due to appendicitis or another acute abdominal condition?

Lanz Incision: Clinical Context and Management

Understanding the Lanz Incision

The Lanz incision is a transverse skin incision in the right lower quadrant, typically used for open appendectomy. While laparoscopic appendectomy should be the preferred surgical approach for acute appendicitis due to lower postoperative pain, reduced surgical site infections, shorter hospital stays, and improved quality of life 1, 2, the Lanz incision remains relevant when open surgery is necessary.

When Open Appendectomy (Lanz Incision) Is Indicated

Laparoscopic appendectomy is the gold standard and should be performed whenever feasible 3. However, open appendectomy via Lanz incision may be considered in:

• Hemodynamically unstable patients requiring immediate source control 3
• Complicated appendicitis with perforation and diffuse peritonitis when laparoscopic expertise is unavailable 3
• Pregnant patients when laparoscopic expertise is not available 2
• Immunocompromised or transplanted patients when laparoscopic approach is contraindicated 3
• Settings where concerns exist about viral dissemination in pneumoperitoneum (e.g., COVID-19 pandemic) and laparoscopic safety measures are unavailable 3

Surgical Timing

Surgery should not be delayed beyond 24 hours from diagnosis for uncomplicated appendicitis 1, 2. For complicated appendicitis with perforation or peritonitis, urgent intervention within 8 hours is recommended to provide adequate source control 3, 1.

Antibiotic Management

Preoperative Antibiotics

Administer a single dose of broad-spectrum antibiotics 0-60 minutes before surgical incision 1, 2. Appropriate regimens must cover facultative gram-negative organisms and anaerobes 3:

• Piperacillin-tazobactam monotherapy 4
• Ceftriaxone + metronidazole 1, 4
• Ampicillin-sulbactam 1

Postoperative Antibiotics

• For uncomplicated appendicitis: No postoperative antibiotics are needed 1
• For complicated appendicitis: Continue IV antibiotics for 48 hours if clinically improving, then switch to oral antibiotics 1
• Total antibiotic duration should be less than 7 days postoperatively 1

Critical Pitfalls to Avoid

• Do not delay surgery beyond 24 hours in uncomplicated cases or 8 hours in complicated cases 1, 2
• Do not continue postoperative antibiotics beyond 3-5 days for complicated appendicitis with adequate source control 1
• Do not use extended-spectrum antibiotics routinely (carbapenems) as they offer no advantage over narrower-spectrum agents 1
• Do not perform routine intra-operative irrigation as it does not prevent intra-abdominal abscess formation 3

Special Populations

Immunocompromised/Transplanted Patients

These patients should undergo appendectomy as soon as possible, usually within 24 hours from diagnosis 3. Laparoscopic approach should be preferred when feasible 3. Conservative treatment is not recommended given the high rate of complicated appendicitis and good outcomes after surgical intervention 3.

Pregnant Patients

Laparoscopic appendectomy is preferred when expertise is available 2. If imaging is needed in first trimester, ultrasound or MRI should be used instead of CT to avoid ionizing radiation 3.

Alternative to Open Surgery: Nonoperative Management

For uncomplicated appendicitis without appendicolith on CT, antibiotic therapy alone may be considered 3, 4. However, this approach has a 30.7% failure rate requiring appendectomy within one year 5. CT findings of appendicolith, mass effect, or appendiceal diameter >13mm predict 40% failure rate and warrant surgical management 4.

For periappendiceal abscess, percutaneous drainage plus antibiotics is appropriate when advanced laparoscopic expertise is unavailable 3, 1.