Appendicitis with Dr. Whit Holcomb

Classic appendicitis presentation (umbilical pain migrating to right lower quadrant, nausea, vomiting, WBC 14, low-grade fever, McBurney's point tenderness) can be taken directly to OR without imaging study

Symptom duration of 24-36 hours generally does not indicate perforation, but duration longer than 36 hours likely indicates perforation if appendicitis is present

Ultrasound may not be completely accurate for appendicitis diagnosis; if any concern on ultrasound, proceed to CT scan

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

Children's Mercy uses IV contrast and limited CT scan focused on appendicitis to minimize radiation exposure

Ceftriaxone (50 mg/kg) and metronidazole (30 mg/kg) once-daily dosing is the most cost-effective antibiotic combination for appendicitis and has similar efficacy to triple-antibiotic regimens

Non-perforated appendicitis patients receive only single preoperative dose of antibiotics; no postoperative antibiotics needed

Prospective randomized trial (Journal of Pediatric Surgery 2008, 100 patients) found no difference in abscess rate or wound infections between ceftriaxone/metronidazole and ampicillin/gentamicin/clindamycin, with lower antibiotic charges for ceftriaxone/metronidazole

Single-incision or double-incision laparoscopic approach used for thin patients with non-perforated appendicitis; three-port approach used for perforated cases

Locking grasper is important when exteriorizing appendix to prevent dropping it; non-locking graspers have resulted in several instances of appendix slipping off

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

Non-perforated appendicitis patients are discharged home same day (within 6 hours) if surgery completed by 7-8 PM; over 100 patients managed this way with minimal returns

Annals of Surgery 2011 randomized trial (360 patients, non-perforated appendicitis): no difference in wound infection rate (3.3% single-incision vs 1.7% three-port, p=0.5), time to regular diet, length of stay, or return to activity between single-incision and three-port laparoscopy

Single-incision laparoscopic appendectomy had 5 minutes longer operative time than three-port (statistically significant but not clinically relevant), higher surgical difficulty scores, and greater hospital charges

Prospective study comparing irrigation plus suctioning versus suctioning alone in perforated appendicitis found no difference in abscess rate (both approximately 20%) or abscess location

Abscess rate for perforated appendicitis has been consistently 15-20% across 6-7 prospective studies at Children's Mercy

Surgeons who report lower abscess rates for perforation may be including gangrenous or necrotic appendicitis (not truly perforated) in their perforated group, which lowers the abscess rate

At Children's Mercy, staplers are cost-effective for appendectomy when OR billing is $225/minute; if stapler costs $600 and saves 3 minutes, it is cost-effective

Retrospective study of over 700 cases using electrocautery for mesoappendix showed minimal bleeding complications (one patient with factor 8 deficiency)

Early 1990s at Vanderbilt: 3 children had adjacent small bowel injuries from cautery during laparoscopic appendectomy, requiring reoperation

Standard protocol for perforated appendicitis: 5 days IV antibiotics (ceftriaxone and metronidazole once daily); discharge criteria are afebrile, normal WBC on day 5, tolerating regular diet

Almost all postoperative abscesses in perforated appendicitis develop in-hospital, not after discharge

Randomized trial comparing 5 days IV antibiotics versus early discharge with oral Augmentin (to complete 7 total days) found no difference in abscess rates; 40% of early-discharge group went home before day 5

Journal of Pediatric Surgery 2010 study (40 patients): immediate laparoscopic appendectomy versus initial non-operative management with interval appendectomy for well-defined abscess showed no difference in total hospitalization, recurrent abscess rates, or overall charges

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

For well-defined abscess at 5-7 days, prefer initial non-operative management with interval appendectomy at 8-10 weeks; for 3-4 day presentations, still operate acutely

Current data on non-operative appendicitis management is not mature enough to change practice; same-day surgery remains standard until more data available in 5 years

Current practice at Children's Mercy: proceed with interval laparoscopic appendectomy at 8-10 weeks after non-operative management of perforated appendicitis; families prefer this to avoid future appendicitis episodes