Laparoscopic Lavage Versus Suction Only in Complicated Acute Appendicitis: A Prospective Randomized Control Trial

Abstract

Background: Laparoscopic appendectomy for complicated appendicitis presents a challenge with concerns about pelvic collections. It is unclear whether lavage or if simple suctioning of pus influences complications. Methods: A prospective, single,-blinded, randomized control trial was conducted. Patients with suspected acute appendicitis were consented. Those found to have complicated appendicitis (perforation, localized pus, or four-quadrant pus) at laparoscopy were randomized to suction or lavage. Exclusions included conversions and drainage of abscess only. Lavage consisted of 3 liters of lavage. Intra-abdominal abscess that required reintervention (i.e., relook, percutaneous drainage) was the primary outcome. Hospital stay and return of bowel function were also recorded. Results: A total of 213 patients were assessed for eligibility. We excluded 157 patients, as they had simple appendicitis; 7 patients were converted to laparotomies; 5 had abscesses but the appendix was not removed. We analyzed 86 patients. The mean age was 26.6 years (14–74). We lavaged 42 (48.8%) patients and 44 (51.2%) were suctioned. Four-quadrant pus was present in 26 (30.2%) of the patients overall. Complications developed in 20 (47.5%) of the patients that were lavaged versus 12 patients (27.1%) with suction only. The difference did not reach significance due to sample size ( P = 0.0739). Operative time was longer in the lavage group by 30 minutes ( P = 0.086). If a complication developed, then the hospital stay was significantly prolonged 13.5 days versus 5 days ( P < 0.001). The study was stopped by the internal review board due to the excess risk with lavage. Conclusions: This exploratory study into lavage versus suction only in complicated appendicitis revealed potential harm with lavage. The study was stopped prematurely by the internal review due to the excess risk experienced by the lavage group, thus the study did not reach statistical power. If a patient with complicated appendicitis developed any complication, hospital stay was longer.

Effectiveness of intraoperative peritoneal lavage with saline in patient with intra-abdominal infections: a systematic review and meta-analysis

“…No studies focused on infectious pancreatitis or fecal peritonitis. Eight RCTs involved adults [ 31 , 32 , 34 – 37 , 39 , 40 ] and two involved children [ 33 , 38 ]. The majority of the patients with peritonitis involved in two RCTs [ 31 , 32 ] were diffuse infections, and the patients with appendicitis involved in eight RCTs were localized infections [ 33 – 40 ].…”

“…Nine RCTs with 1232 patients reported on IAA, seven included patients with appendicitis and two included patients with peritonitis [ 31 – 35 , 37 – 40 ]. IAA occurred in 67 patients with appendicitis (12.3%) in the IOPL group and 72 patients with appendicitis (11.8%) in the non-IOPL group.…”

“…Six RCTs with 1019 patients reported on reoperation, in which all included patients were appendicitis [ 33 – 35 , 37 , 38 , 40 ]. Reoperation occurred in 14 patients with appendicitis (2.9%) in the IOPL group and 9 patients with appendicitis (1.7%) in the non-IOPL group.…”

Laparoscopic appendectomy for complicated appendicitis in children: does the post-operative peritoneal drain make any difference? A pilot prospective randomised controlled trial

“…This, however, has been challenged by St Peter et al and a more recent meta-analysis, showing no benefit in preventing post-operative IAC in adults and children [ 12 , 13 ]. In a randomised prospective study conducted at our institution on adults, potential harm was indicated with irrigation [ 14 ]. Based on this evidence, “suction only” was performed in all the patients in the study group.…”

Laparoscopic versus Open Appendectomy

“…However, efforts to reduce intra-abdominal collections in complicated appendicitis were addressed by departmental practice of avoiding irrigation in these cases supported by a prospective randomised controlled trial which was performed by the General Surgery Department at Sefako Makgatho Health Sciences University on adult patients with complicated appendicitis, which revealed potential harm with irrigation. [ 16 ]…”