Perforated appendicitis


PREOPERATIVE DIAGNOSIS: Perforated appendicitis.

POSTOPERATIVE DIAGNOSIS: Phlegmonous appendicitis with interloop / intramesenteric abscess.

PROCEDURE: 1. Diagnostic laparoscopy. 2. Interloop abscess.

INDICATIONS: is a 52-year-old male with a history of abdominal pain consistent with
appendicitis and CT scan demonstrating the same. I offered him laparoscopic appendectomy explained to him
the risks, benefits, complications of the procedure as noted in my consult note including potential for
bleeding, infection, abscess, pain, hernia, scarring, entry injury and cardiopulmonary risk and he opted
for the above.

OPERATIVE REPORT: was taken to the operating room and was placed in the normal supine position.
He was treated by anesthesia with general endotracheal anesthetic. He was straight catheterized x1 and was
prepped and draped in normal sterile fashion. A 17 mm incision was then performed with a knife in the
cephalocaudad manner in the umbilicus. Using clips this was everted. Varus needle was placed in the
abdomen and saline drop test was passed and the abdomen was inflated to15 mmHg with carbon dioxide gas. 10
mm trocar port was then placed through the same without incident.

Camera was placed through the above and then hypogastric and left lateral abdominal 5 mL trocar ports were
then placed under direct visualization.

The patient was placed in appropriate positioning and evaluation was then begun. It appeared the patient
had retrocecal appendicitis which was phlegmonous and had resulted in perforation into the mesentery of the
ileum posterior to the bloodless fold of Treves. In exploring this we immediately drained a well walled
off abscess which was very mature I would estimate several days old. I did encounter the tip the appendix
however this was phlegmonous and I felt it to high risk to try to dissect this out for fear of significant
bleeding as well as potential for colostomy and enterotomy as a result of the phlegmonous development. At
this point we therefore terminated the operation after irrigation and drainage by placing a 19 Blake drain
through the hypogastric the trocar port. This was cut and then placed directly in the abscess cavity
itself and then sewn in appropriate position. Prior to this we replaced the camera in this port and removed
the 10 mm trocar port and placed in 0 Vicryl suture using Gore type suture passer. This port was then
replaced and then again after placing the drain as noted we removed the left lateral abdominal trocar port
under direct visualization without significant bleeding. Procedure was then terminated.

Plan will be to treat the patient with IV antibiotics until white blood cell count normalizes and pain
improves with the potential for interval appendectomy, although I recommended to his wife that in fact
current literature is suggesting that in fact this is probably not necessary.