Peritonitis secondary to appendicitis

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摘要

The description of peritonitis secondary to appendicitis covers all aspects of the surgical procedure used for the management of peritonitis secondary to appendicitis.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration, exposure, dissection, ligature and division, extraction, end of procedure.
Consequently, this operating technique is well standardized for the management of this condition.

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刊物

2002-01

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音訊

數位出版

WeBSurg.com, Jan 2002;2(01).
URL: http://www.websurg.com/doi-ot02en216.htm

Peritonitis secondary to appendicitis

1. Introduction

Peritonitis secondary to appendicitis is traditionally treated either by an enlarged McBurney’s incision to the flank and the right lower quadrant (in case of local peritonitis) or by a median incision (in case of general peritonitis). The laparoscopic approach makes it possible to avoid a large incision in the abdominal wall and almost eliminates the risk of wound infection.
For peritonitis, laparoscopy is an excellent approach with both diagnostic and therapeutic benefits.
Laparoscopic exploration leads to an accurate diagnosis of the origin of the peritonitis in 85% of cases, and permits a precise assessment of the pathologies (perforated appendix, location of purulent collections).
More than 80% of the cases of peritonitis from perforated appendices can be treated via laparoscopy. When conversion to laparotomy proves necessary, it is often possible to limit the size of the incision and to place it more accurately.
There are no complications specific to laparoscopy. However, caution must be exercised and certain technical rules must be observed.
There are 2 risks related to the creation of a pneumoperitoneum in the context of intra-abdominal sepsis:
- hypercapnia: carbon dioxide absorption is increased by peritoneal inflammation,
- bacteremia: bacterial dissemination through the blood may occur either via bacterial translocation or direct bacterial passage through the lymphatics of the diaphragm and the thoracic duct.

2. Anatomy

• Anatomy

• Generalities

1. Cecum
2. Ileum
3. Vermiform appendix
The appendix is situated in the right lower quadrant of the abdomen in a region commonly called the right iliac fossa. The appendicular ostium is normally situated in the middle of a line joining the anterior and superior iliac spine to the umbilicus (McBurney’s point). In this position, the tip of the appendix extends to the junction of the right and middle thirds of a line joining both anterior and superior iliac spines.
The serosal junction of the appendix is found at the internal part of the cecal fundus where it joins the free tenia.

• Arteries

The ileocolic artery is a branch of the superior mesenteric artery. It divides into the:
1. Ileocolic artery
2. Posterior cecal artery
3. Anterior cecal artery
4. Appendicular artery

• Lymphatics

The ileocecal lymphatics are situated along the anterior and posterior cecal arteries. They are drained by a large lymph node chain situated in the ileocecal flexure.

• Peritoneum

1. Mesentery
2. Superior ileocecal recess
3. Inferior ileocecal recess
4. Mesoappendix
The cecal mesenteric fold demarcates the anterior or superior ileocecal recess. The ileoappendicular peritoneal fold, along with the mesoappendix, demarcates the inferior or posterior ileocecal recess.

• Variations

• Appendix position

The position of the appendix in the lesser pelvis in relation to its neighboring organs is variable. The following are common locations:
1. Retrocecal appendix
2. Mesoceliac appendix
3. Normal appendix
4. Pelvic appendix

• Cecum position

Variations in cecum position are as follows:
1. Right iliac fossa (classic position)
2. Pelvic cecum
3. Subhepatic cecum
4. Redundant cecum
In case of redundant cecum, the appendix comes up behind the ascending colon in a subhepatic position.

• Pathophysiology

The usual anatomical landmarks (cecal teniae, antimesenteric part of the small intestine, ileocecal junction, etc) are altered by inflammation-induced changes and adhesions.
An adhesive phlegmon made up of intestinal loops and omentum can form a periappendicular mass.
Generalized peritonitis occurs when the entire peritoneal cavity becomes infected following the perforation of the appendix. Peritonitis is first identified by visualization of a periappendicular abscess or a purulent collection at the level of the right paracolic gutter and the rectouterine pouch (pouch of Douglas).
From the right paracolic gutter, the purulent liquid follows 2 paths:
- it flows towards the pelvis, crosses to the left in front of the sigmoid colon, and spreads to the left gutter and left subphrenic region,
- it flows up the right gutter towards the right subphrenic and subhepatic regions.

3. Indications

Indications
All occurrences of peritonitis secondary to appendicitis, irrespective of the patient’s age and morphology, can be indications for laparoscopic surgery. The patient’s hemodynamic status should be stable. Peritonitis is diagnosed when purulent infected fluid is found in the peritoneal cavity.

Contraindications
- patient in ASA classification type IV or in a non-reversible state of shock;
- massive ileus;
- limited laparoscopic experience;
- the formation of an adhesive phlegmon because of appendicitis that cannot be dissected.
Severe generalized peritonitis is not a contraindication. The feasibility of laparoscopy depends on the extent of the intestinal distention and of the inflammatory adhesions between the loops of the small bowel.

Limitations
Laparoscopy is contraindicated for patients with high operative risk (ASA classification type IV, in a non-reversible state of shock), due to the decrease in cardiac output induced by the pneumoperitoneum.
Massive distention of the intestinal loops (ileus) greatly reduces the operative field in laparoscopy, making the access to the ileocecal junction difficult and preventing proper peritoneal lavage.

4. Operating room set-up

• Patient

The patient, surgeon, assistants and the laparoscopic video unit are positioned as for a standard appendectomy. The tilt of the operating table depends on the operative dissection. The patient is in supine position, legs together and stretched out.
In a female patient, in case of diagnostic uncertainty, (ie gynecological pathology such as salpingitis or tubo-ovarian abscess), the best position is low lithotomy; a uterine cannula allows for better exposure of the uterus and its adnexa.
A left lateral decubitus position may be useful during cecoappendicular dissection to help shift the intestinal loops towards the left. The Trendelenburg position is used during pelvic lavage and the reverse Trendelenburg position during supramesocolic lavage.

• Team

The surgeon stands on the patient’s left opposite the monitor. The assistant stands on the surgeon’s right.
1. Surgeon
2. Assistant

• Equipment

1. Anesthetic equipment
2. Laparoscopic unit
3. Electrocautery
4. Operating table

5. Trocar placement

• Optical trocar

The trocar (10/11 mm, 0°) is placed in periumbilical position (subumbilical, supraumbilical or lateroumbilical).

• Operating trocars

Two operating trocars (5 or 10/11 mm and 5 mm) are placed in median suprapubic and left iliac fossa position.
The appendix is grasped with an atraumatic grasper and pulled upwards to expose the mesoappendix. Identification of the various anatomical structures (cecum, appendix, small intestine) is sometimes difficult due to the extent of the anatomical alterations caused by the inflammation.

• Optional

A fourth trocar (5 mm) placed in the right subcostal region at the level of the midclavicular line is often necessary to retract the intestinal loops, to aspirate liquids in the area of the operative field or to perform peritoneal lavage (notably in the supramesocolic region).

6. Instrumentation

• Optical device

1. 0° laparoscope, 10 mm

• Operating devices

1. Scissors
2. Hook
3. Bipolar grasper
4. Extraction bag
5. Clip applier
6. Atraumatic grasper

• Retracting devices

1. Suction-irrigation device
2. Retractor

• Optional devices

1. Needle holder
2. 30° laparoscope
A sterile hypoallergenic surgical glove may be used as an extraction bag.
A transfixing suture is placed above the fingers of the glove, which are then cut. A cone-shaped receptacle is thus formed into which the appendicular specimen is inserted. In case of a small appendix, one finger of the glove is enough.

7. Major principles

- anesthetic monitoring (cardiac monitor, capnograph, arterial blood pressure, assisted ventilation);
- intravenous antibiotic therapy before insufflation;
- pneumoperitoneum: intra-abdominal pressure between 8 and 12 mm Hg;
- precise localization of purulent collections (bacteriologic samples and assessment of the peritonitis as either local or generalized);
- aspiration of the pus and peritoneal lavage with saline;
- freeing of the periappendicular adhesions (ileum, omentum);
- identification of the source of the peritoneal contamination (perforated appendix);
- appendectomy;
- extraction bag;
- drainage of the peritoneal cavity.

8. Exploration

• Exploration

Two operating trocars are required, along with the optical trocar, to perform the abdominal exploration. Proper muscular relaxation of the abdominal wall is necessary to obtain an adequate operative field. By tilting the operating table in various directions, it is possible to search for and evacuate the collections of pus that may be present throughout the abdomen. These collections may be found deep in between the intestinal loops, which should be manipulated with care (due to distention and fragility caused by inflammation).

• Tilt of operating table

Left lateral decubitus
Exploration of the right paracolic gutter and appendix

Reverse Trendelenburg
Exploration of the right subphrenic and right subhepatic regions

Trendelenburg
Exploration of the pelvis and the rectouterine pouch, and in between the intestinal loops

Right lateral decubitus
Exploration of the left paracolic gutter and the left subphrenic region.

9. Exposure

• Freeing of the mass

Freeing of the periappendicular mass is done with the atraumatic grasper and the suction-irrigation device. These instruments should perform the same gestures as would be performed by the fingers of the surgeon in an open case. Pus is taken for bacteriologic sampling.

• Exposure

Retraction from the right subcostal trocar is done by pushing the intestinal loops and omentum towards the left. A left decubitus position and a Trendelenburg position may be useful.
The appendix is grasped with an atraumatic grasper and pulled upwards to expose the mesoappendix. Identification of the various anatomical structures (cecum, appendix, small intestine) can be difficult due to the extent of the anatomical alterations caused by the inflammation.

10. Dissection

Control of the mesoappendix can be accomplished in 2 ways:
- electrocoagulation is carried out as close as possible to the appendicular wall. All branches of the appendicular artery are coagulated, starting from the apex and working towards the base (monopolar or bipolar hook). This technique has the advantage of reducing the appendicular volume, thus making extraction easier.
- dissection of the mesoappendix starts at its base and the appendicular artery is controlled using clips or ligatures.
In case of bleeding at the level of the mesoappendix (obese patient, inflammation of the mesoappendix), bipolar coagulation is very useful.

11. Ligature and division

1. Base of the appendix
2. Clip
Control of the appendicular stump is an essential step that may prove tricky due to the edema of the bowel wall.
Ligature of the base of the appendix is performed using slowly absorbable sutures with either a surgical loop, or with intracorporeal or extracorporeal knots. Two ligatures are generally placed.
A clip or a ligature can be applied across the base of the appendix once its contents have been pushed towards the distal end of the appendix. This manipulation, which prevents fecal contamination during the division of the base of the appendix, can be done either by moving the partially closed clip applier transversally or with atraumatic graspers.
The appendix is divided at its base and a peanut swab soaked with an antiseptic (iodine, for example) is applied to the appendicular stump.
In cases of necrosis of the base of the appendix, the use of a mechanical stapling device or a suture of the cecum may prove necessary.

12. Extraction

The extraction of the appendix must always be performed with protection so there is no direct contact between the appendix and the abdominal wall.
The techniques used depend on the size of the appendix:
- removal of the appendix through the 10/11 mm trocar (left iliac fossa) or the use of a 10/5 mm reducer sleeve through the same trocar if the diameter of the specimen does not exceed 10 mm;
- placing the appendix in an extraction bag or in a finger of a surgical glove (less expensive method), and their extraction after removing the 10/11 mm trocar from the left iliac fossa.

13. End of procedure

Abdominal lavage is an essential part of the procedure. It begins right after the general exploration and aims to rapidly eliminate as much contaminated fluid as possible. It is continued after suturing the appendix.
Peritoneal lavage is performed with warm saline (4 to 6 L) using a pressured suction-irrigation device until a clear effluent is obtained. It is often necessary to change the tilt of the operating table and to moderately shake the patient to ensure good distribution of the saline throughout the entire peritoneal cavity. All residual fluids must be aspirated.
Routine drainage of the peritoneal cavity is performed with silicone drains (from 12 to 18 French). Generally, the drains are removed through the suprapubic and right subcostal trocar sites and are placed at the level of the rectouterine pouch and the right paracolic gutter.
Trocars are removed one by one and hemostasis of the trocar sites is carefully checked. The musculo-aponeurotic plane is closed only at the 10/11 mm trocar sites. The skin is closed using staples or sutures.
The drains are removed when flow is less than 100 mL per day, provided they are not draining feculent, bloody or purulent material.
Intravenous antibiotic therapy is maintained depending on the severity of the peritonitis and at least until a culture of the pus taken during the procedure is obtained. If the culture is positive, antibiotic therapy is continued either intravenously or orally for 10 days.

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