What is the best course of treatment for a patient with suspected stump appendicitis, considering their past medical history of previous abdominal surgeries?

Stump Appendicitis: Diagnosis and Management

Immediate Surgical Treatment is Required

Stump appendicitis requires completion appendectomy—laparoscopic approach is preferred when CT imaging has been obtained to delineate anatomy, as it provides excellent visualization of the appendiceal remnant and surrounding structures. 1

Clinical Recognition and Diagnosis

Key Diagnostic Features

• Stump appendicitis presents with classic right lower quadrant pain, fever, and peritoneal signs in patients with prior appendectomy, occurring anywhere from 2 months to 20 years after the initial procedure 2, 1, 3
• The condition results from obstruction of the residual appendiceal stump (usually by fecalith), causing increased intraluminal pressure, impaired venous drainage, and subsequent bacterial infection 2
• The diagnosis is frequently delayed because clinicians incorrectly assume prior appendectomy rules out appendicitis—this delay increases morbidity and mortality 4, 3

Diagnostic Imaging

• CT abdomen/pelvis with IV contrast is the diagnostic modality of choice, showing a tubular inflammatory structure at the cecal base with surrounding inflammatory changes 1, 5, 3
• CT provides exquisite delineation of the appendiceal remnant length and surrounding anatomy, which is critical for surgical planning 1
• Ultrasound can be used if CT is unavailable, though CT remains superior for this specific indication 3

Surgical Management

Laparoscopic Completion Appendectomy

• Laparoscopic completion appendectomy should be performed unless other mitigating circumstances exist, guided by CT findings 1
• The laparoscopic approach has been demonstrated safe and effective in multiple case series, with successful outcomes and uneventful postoperative courses 1, 5, 4
• Laparoscopic surgery offers the standard advantages over open surgery: less pain, lower surgical site infection rates, shorter hospital stay, and faster recovery 6

Operative Technique Considerations

• Complete removal of the appendiceal base is essential—correct identification and removal without leaving residual stump tissue minimizes recurrence risk 1
• Simple ligation should be used for stump closure rather than stump inversion, as it provides shorter operative times and similar safety outcomes 6
• Endoloops, suture ligation, or polymeric clips are recommended for stump closure 6

Antibiotic Management

Perioperative Antibiotics

• Broad-spectrum antibiotics covering aerobic gram-negative organisms and anaerobes must be initiated immediately once stump appendicitis is diagnosed 6
• Preoperative antibiotic administration is strongly recommended before completion appendectomy 6
• Postoperative antibiotics should continue for 3-5 days in complicated cases (perforation, abscess, peritonitis), though discontinuation should be guided by clinical criteria including fever resolution and normalization of leukocytosis 6

Prevention During Initial Appendectomy

Technical Factors

• The original appendectomy must ensure complete removal of appendiceal tissue with proper identification of the appendiceal base—leaving a stump >0.5 cm increases stump appendicitis risk 1
• During laparoscopic appendectomy, surgeons should verify complete appendiceal removal and adequate stump closure 6

Critical Clinical Pitfalls

Common Diagnostic Errors

• Never dismiss appendicitis based solely on appendectomy history—stump appendicitis, though rare (estimated 1/50,000 lifetime risk), is a real and potentially dangerous entity 4, 3
• The McBurney scar or documented prior laparoscopic appendectomy often misleads emergency physicians into excluding appendicitis from the differential 3
• Delayed diagnosis leads to progression to complicated appendicitis with abscess formation and increased morbidity 2, 4

Imaging Interpretation

• CT findings showing a tubular structure posterior to the ileocecal junction with surrounding inflammation in a patient with prior appendectomy is diagnostic of stump appendicitis 5
• Free pelvic fluid and inflammatory mass in the right iliac fossa should raise suspicion 2, 5

Special Considerations for Patients with Prior Abdominal Surgery

• Patients with previous abdominal surgeries may have adhesions complicating laparoscopic access, but laparoscopy remains feasible and preferred when CT has defined the anatomy 1, 4
• Careful adhesiolysis may be required to access and dissect the appendiceal stump from surrounding adhesions 5
• The laparoscopic approach provides superior visualization in the presence of adhesions compared to limited open incisions 1