Laparoscopic treatment of generalized peritonitis caused by perforated appendicitis.

Juan D Hernandez, MD, Anwar Medellin, MD, Maria I Rizo, MD, Fernando Arias, MD, Roosevelt Fajardo, MD, Eduardo Londono, MD, FACS, Ricardo Nassar, MD, Felipe Perdomo, MD, Roberto Rueda, Angela Ospina, Manuel Cadena, MD, FACS

Hospital Universitario Fundacion Santa Fe de Bogota and Universidad de los Andes

Introduction: Peritonitis is one of the most feared complications of the progression of acute appendicitis, with a high rate of complications and an estimated mortality rate of up to 47%. A thorough surgical technique with systematic revision of the abdominal cavity and complete eradication of purulent fluid is mandatory for a good outcome. With a higher penetration of laparoscopy in acute abdomen cases, appendiceal peritonitis is now being treated with a minimal access surgery approach. There is scarce data on the outcomes of this approach

Objective: to present the outcome of a series of patients with peritonitis secondary to acute appendicitis undergoing laparoscopic appendectomy, peritonitis removal and lavage.

Materials and Methods: All patients during the period of study with surgical findings of perforated appendicitis and generalized peritonitis were included. Generalized peritonitis was defined as the presence of contamination in two or more quadrants. Patients with localized peritonitis, abscess or perforation were not included. Laparoscopy was performed using three-port technique or a single port approach and 30- degree lens. Mesoappendix was sectioned using a bipolar energy device without clip application. Depending on the site of the perforation and the condition of the caecum, the appendix stump was closed using mechanical sutures, suture ligation or vascular locking clip application. Surgical technique included determined search and retrieval of fecaliths, complete removal of all purulent fluid and saline solution irrigation and suction of the whole cavity including subphrenic spaces, paracolic gutters, pelvis and between bowel loops. The peritoneal cavity is left as dry as possible and an active closed drain is left in the right iliac fossa.

Results: Between January 2011 and June 31 2012, seven surgeons carried out the operation on 22 consecutive patients who were found to have generalized peritonitis secondary to perforated appendicitis. Of them, 10 (45%) were male and 12 (55%) female, age ranged between 18 and 84 years with a mean of 45,7. Patients remained in hospital between 8 and 25 days with a mean of 8,1 days. Conversion was required in 1 (4,5%); because the surgeon suspected necrosis of the caecum. Seven patients required Intensive Care. Two patients (9%) developed intraabdominal abscesses, one of them three simultaneous, and required percutaneous drainage. There was no mortality.

Conclusions: in 18 months a team of seven surgeons carried out 22 successful laparoscopic operations demonstrating that minimal access surgery is safe and effective in the treatment of generalized peritonitis caused by perforated appendicitis. Most publications refer to complicated appendicitis but do not report on the frequency of generalized peritonitis, a more morbid presentation than just perforation or localized abscess. Since laparoscopy is the preferred approach at the authors’ institution, the comparison with open surgery in a single institution was not possible.Therefore, this series is presented since there is little published information on the management of peritonitis following appendiceal perforation as opposed to perforated peptic ulcer or complicated diverticulitis, were good results have already been reported.

Session: Poster Presentation

Program Number: P562