European Journal of Cardiovascular Medicine

The treatment of acute appendicitis was non-operative up till a hundred years ago then it turned totally surgical in less than 20 years. Appendectomies per 100,000 populations peaked at mid century and have since steadily declined in western countries. It seems that surgeons are returning to the core of knowledge about appendicitis held in the late 1800s. ^[1] The mortality was relatively low as most appendicitis resolves spontaneously but there was a significant recurrence of the appendicitis. The surgical pioneers of appendectomy feared that the operative mortality exceeded that of conservative treatment at the time and hence they avoided the acute operation. ^[2] They were familiar with and feared the recurrence and therefore did interval appendectomy to prevent the relapse. When emergency appendectomy exploded in the first years of the last century the mortality in appendicitis did not decline. ^[3] Indeed, vital statistics from Sweden show that the death rate from appendicitis in the population was unchanged or higher at least up till 1930. ^[4]

Appendectomy is among the most commonly performed surgical procedures. The most common indication for appendectomy is acute appendicitis. The lifetime risk of acute appendicitis ranges from 9% to 10%. Acute appendicitis most commonly occurs between the ages of 10 and 20 years. ^[5]

Appendicitis is called the first American surgical disease, and appendectomy holds a prominent and storied position in surgical history. Charles McBurney published his report on the surgical management of appendicitis in 1895. He described the potential consequences of undrained purulent appendicitis, the disadvantages of the classical midline laparotomy, and exploratory needle puncture. Finally, he described a novel surgical approach and exposure, introducing consecutive lateral incisions through the external oblique aponeurosis, internal oblique, and transversus abdominis muscles rather than midline laparotomy. ^[6]

Appendectomy was the first laparotomy performed with a source control approach to eradicate an infectious threat. Since appendicitis was first described over a century ago, appendectomy remains the gold standard of treatment. ^[7] Today, the inflamed appendix can be surgically removed using either an open approach or the laparoscopic appendectomy method first described by Semm in 1983. ^[8]

Despite a significant change in managing acute appendicitis with primary antibiotic therapy, the primary option for treating acute appendicitis remains a surgical approach. A large, randomized trial of antibiotic therapy for the primary management of acute appendicitis showed that while antibiotic therapy might have comparable results with appendectomy in the short term, 1 of 4 participants in the antibiotic therapy arm required appendectomy within one year. ^[9]

This is a prospective study was conducted in the Department of Surgery, Tertiary Care Teaching Hospital over a period of 1 year. Inclusion criteria include patients diagnosed to have acute appendicitis which is complicated by appendicular mass (diagnosed by clinical examination, abdominal ultrasound examination or accidentally encountered during appendectomy). Patients either come to our hospital directly or referred from other hospitals.

The symptoms of the patients were right lower abdominal pain and anorexia in all patients while vomiting, fever, abdominal distension and constipation were present but not in all patients. These symptoms ranged from 4 to 12 days in duration. On admission, all of patients were clinically evaluated and a palpable mass was detected in 35 from 46 [76%] patients. Subsequent investigation with blood chemistry and abdominal ultrasound.

Diagnosis of appendicular mass was either clinical [35 from 46 (76%) patients], ultrasound of abdomen which confirmed the clinical examination and detected appendicular mass in another 6(13%) patients and appendicular abscess in 4 patients from patients diagnosed with appendicular mass. In the remaining 5(11%) patients, the mass was detected intra-operative.

Patients underwent operation within 24 h of admission after preliminary investigations. The operation was explained to every patient and informed consent was taken from each patient.

Open or laparoscopic approach was used. The laparoscopic approach was used in patients in who mass was detected by ultrasonographic examination only or the procedure was planned from the start for laparoscopic appendectomy and the mass was detected intra-operative. The peritoneal cavity was accessed using the open technique, with sub umbilical insertion of a 10 mm trocar. Two additional 5 mm trocars are inserted in the supra-pubic and left iliac fossa regions. A careful dissection is employed to release the appendix from adherent omentum or loops of bowel, using a blunt non traumatic instrument and ultrasonic dissector which was also used to divide the mesoappendix. The appendix was divided at the base after two endoloop application and extracted through the umbilical port with removal of the trocar itself with the appendix to avoid direct contact with subcutaneous tissue and umbilical skin. Copious irrigation with warm saline and adequate suction was then undertaken.

The open procedure through McBurney incision was used for patients diagnosed with appendicular mass both by clinical and by ultrasonographic examination. Dissection of the inflammatory mass from the surrounding healthy tissues and appendicectomy was done. If pus was detected, a copious lavage and irrigation of the peritoneum was performed.

A drain was inserted around the area of the mass and into the pouch of Douglas in all patients. Patients started oral fluids after 24 h and discharged from the hospital after 2–4 days. The drain was removed during the hospital stay in all patients except 4 patients with appendicular abscess in whom the drain removed during the period of follow up in the outpatient clinic. Antibiotics were given IV during the hospital stay (third generation cephalosporins 1g m BD and metronidazole 500 mg was added if pus was found) and then oral continuation of the antibiotics till the time of stitch removal. After 2 months patients were seen in follow up.

A total of 90 patients with diagnosis of appendicitis and its complication were managed in our unit over this period. Around 60 patients (66.7%) were males and 30 patients (33.3%) were females. The average age for a male was 34.65 years with range of 17 -74 years whereas the average age in females was 37.6 years with a range of 17-75 years. 49 patients (54.4%) had only acute appendicitis whereas 47.83% of patients had some form of complications of appendicitis. Appendicular mass (13.3%) was the most common complication in our study (Table 1)

Table 1: Distribution of Appendicitis and its complications

Table 2 Surgical management of appendicitis and its complications

A total 78 patients (86.7%) required operative surgical intervention whereas 12 patients (13.3%) who  had appendicular mass were managed conservatively. 35 patients (85.37%) underwent emergency surgeries whereas 5 patient had undergone elective procedure. Open Appendicectomy (33.4%) was the most common surgery done followed by laparoscopic appendicectomy (28.9%). 4.4% of patients required conversion from laparoscopic surgery to open appendicectomy (Table2).

One patient had undergone right hemicolectomy due to a large perforation at the junction of appendix and caecum. The ascending colon was very short, unhealthy and edematous and thus we preferred to this procedure instead of limited resection.

In 08 patients (8.9%) had complications. 6 patients had surgical site infections and one patient had an iatrogenic bladder perforation during the laparotomy of a patient with extensive intra-abdominal abscess due to appendicular perforation. There was no mortality.  

Patients with hematologic disorders often exhibit abnormal CBCs. Historically, surgical interventions in these patients with unusual CBC results have been linked to increased postoperative complications. For instance, thrombocytopenia frequently requires transfusions and is associated with higher 30-day mortality and a range of complications, from pulmonary to thromboembolic events. ^[9] Neutropenia has been connected to increased postoperative mortality and a rise in major morbidities, especially infections. ^[10] Similarly, anemia elevates 30-day mortality, often necessitating transfusion interventions. ^[11] Hematologic disorders inherently raise surgical risks, including increased mortality, multiorgan complications, and reduced long-term survival. ^[12]

For patients diagnosed with appendicitis who also have underlying hematologic conditions, careful preoperative laboratory adjustments and choosing a minimally invasive appendectomy seem to be safe options. These approaches do not increase the incidence of severe complications when compared to conservative treatments.

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