Management of an appendix mass
If an appendix mass is present and the
condition of the patient is satisfactory, the standard treatment is the
conservative
Ochsner—Sherren regimen. This strategy is based on the premise that the
inflammatory process is already localised and that inadvertent surgery is
difficult and may be dangerous. It may be impossible to find the appendix and,
occasionally, a faecal fistula may form. For these reasons it is wise to observe
a nonoperative programme, but to be prepared to operate should clinical
deterioration occur (Table 59.7).
Careful
record of the patient’s condition and the extent of the mass should be made,
and the abdomen regularly reexamined. It is helpful to mark the limits of mass
on the abdominal wall using a skin pencil. A nasogastric tube should be passed
and intravenous fluid and antibiotic therapy instigated. Temperature and pulse
rate should be recorded 4-hourly and a fluid balance record maintained. Clinical
deterioration or evidence of peritonitis is indication for early laparotomy.
Clinical improvement is usually evident within 24—48 hours at which time the
nasogastric tube can be removed and oral fluids introduced. Failure of the mass
to resolve should raise suspicion of a carcinoma or Crohn’s disease. Using
this regime approximately 90 per cent of cases resolve without incident. It is
advisable to remove the appendix usually after an interval of 6—8 weeks.
Postoperative
complications
Postoperative complications following
appendicectomy are relatively uncommon and reflect the degree of peritonitis
that was present at the time of operation and intercurrent diseases that may
predispose to complications (Table 59.8).
Wound infection
This is the most common postoperative
complication which occurs in 5—10 per cent of all cases. This usually presents
with pain and erythema of the wound on the fourth or fifth postoperative day,
often soon after hospital discharge.
Intra-abdominal abscess
Intra-abdominal abscess has become a
relatively rare complication after appendicectomy with the use of
perioperative antibiotics. Postoperative spiking fever, malaise and anorexia,
developing 5—7 days after operation, suggest an intraperitoneal collection.
Interloop, paracolic, pelvic and subphrenic sites should be considered.
Abdominal ultrasonography and CT scanning greatly facilitate diagnosis and allow
percutaneous drainage. Laparotomy should be considered in patients suspected
to have intrabdominal sepsis in whom imaging fails to show a collection,
particularly those with continuing ileus.
Ileus
A period of adynamic ileus is to be expected
after appendicectomy, and may last for a number of days following removal of a
gangrenous appendix. Ileus persisting for more than 4—5 days, particularly in the presence of a fever, is indicative
of continuing intra-abdominal sepsis and should prompt further investigation
(see above).
Respiratory
In the absence of concurrent pulmonary
disease, respiratory complications are rare following appendicectomy. Adequate
postoperative analgesia and physiotherapy, when appropriate, reduce the
incidence.
Venous thrombosis and embolism
These are rare after appendicectomy except in
the elderly and women taking the oral contraceptive pill. Appropriate
prophylactic measures should be taken in such cases.
Portal pyaemia (Pylephlebitis)
Pylephlebitis is a rare but very serious
complication of gangrenous appendicitis associated with high fever, rigors
Faecal fistula
Leakage from the appendicular stump rarely
occurs, but may follow if the encircling stitch has been put in too deeply or if
the caecal wall was involved by oedema or inflammation. Occasionally, a fistula
may result following appendicectomy in Crohn’s disease.
Adhesive intestinal obstruction
Adhesive intestinal obstruction is the most
common late complication of appendicectomy. At operation often a single band
adhesion is responsible. Occasionally, chronic pain in the right iliac fossa is
attributed to adhesion formation after appendicectomy. In such cases
laparoscopy is of value in confirming the presence of adhesions and allowing
division.
Right inguinal hernia
This is said to be more common following a
grid-iron incision for appendicitis due to injury to the iliohypogastric nerve.