Appendicitis with Dr. Whit Holcomb

For classic appendicitis presentation without prior imaging, patient should go directly to OR for laparoscopic appendectomy without imaging study

Symptom duration >24-36 hours raises concern for perforation and warrants imaging starting with ultrasound

If ultrasound is not diagnostic or shows concern, proceed to CT scan

Non-visualization of appendix on CT at 4 days should show secondary signs of appendicitis and likely perforation; if neither present, likelihood of appendicitis is low but not zero

Limited CT scan protocol is used to minimize radiation exposure while focusing on appendicitis diagnosis

Ceftriaxone 50mg/kg and metronidazole 30mg/kg given once daily has similar efficacy to triple antibiotic regimen (ampicillin, gentamicin, clindamycin) for appendicitis

Single preoperative dose of antibiotics is given for non-perforated appendicitis; no additional doses needed postoperatively

Once-daily dosing of ceftriaxone and metronidazole is more cost-effective than triple antibiotics and does not require serum level monitoring

Prospective randomized trial of 100 patients showed no difference in abscess rate or wound infections between ceftriaxone/metronidazole and ampicillin/gentamicin/clindamycin, published Journal of Pediatric Surgery 2008

Single-incision laparoscopic approach uses 5mm port through upper umbilical fascia with stab incision below for Maryland dissector or grasper

Locking grasper is important when exteriorizing appendix to prevent dropping it during removal

10-12mm fascial incision is needed to safely exteriorize appendix without dropping it, as grasper creates U-shaped configuration

Perforation is defined as stool in the abdomen (fecalith in abdominal cavity) or a visible hole in the appendix

Non-perforated appendicitis patients are discharged home within 6 hours of surgery without additional antibiotics

Perforated appendicitis patients require 4-5 days of antibiotic therapy

Randomized trial of 360 patients (August 2009-November 2010) comparing single-site to three-port laparoscopy showed no difference in wound infection rate, time to regular diet, length of hospitalization, or return to activity, published Annals of Surgery October 2011

Mean operative time for single-site approach was 5 minutes longer than three-port, which was statistically significant but not clinically relevant

Single-site laparoscopic appendectomy had 3.3% wound infection rate vs 1.7% for three-port approach (p=0.5, not statistically significant)

Study comparing irrigation plus suction vs suction alone in perforated appendicitis showed no difference in abscess rate or location, both groups had approximately 20% postoperative abscess development

In all appendectomy studies for perforated disease (6-7 studies), abscess rate has consistently been between 15-20%

Retrospective study of over 700 cases using electrocautery for mesoappendix showed almost no bleeding except one patient with factor 8 deficiency

Early 1990s experience at Vanderbilt showed 3 children with adjacent small bowel injuries from cautery during laparoscopic appendectomy requiring reoperation

Standard protocol for perforated appendicitis is 5 days of IV antibiotics postoperatively

Discharge criteria for perforated appendicitis: normal white blood cell count on day 5, afebrile, tolerating regular diet

If WBC elevated on day 5, patient receives 2 additional days of antibiotics and repeat WBC; if still elevated, receives 3 more days and CT scan to look for abscess

Almost all patients who develop postoperative abscess develop it in the hospital, very few go home and return with abscess

Study of 50 patients randomized to mandatory 5 days IV vs early discharge on oral Augmentin showed no difference in abscess rate; 40% of early discharge group went home before day 5

For well-defined abscess from perforated appendicitis, randomized trial showed no difference in total hospitalization length, recurrent abscess rates, or overall charges between immediate appendectomy vs non-operative management with interval appendectomy, published Journal of Pediatric Surgery 2010

Initial appendectomy for abscess takes longer than interval appendectomy (61 minutes vs 42 minutes)

Symptom duration of 3-4 days warrants immediate operation; 6-7 days suggests well-defined abscess suitable for non-operative management; 5 days is transition zone

Estimated 50-60% of pediatric appendicitis patients could be managed non-operatively with antibiotics based on emerging data