Irrigation during Laparoscopic Appendectomy for Complicated Appendicitis: Time to Review Current Guidelines

This article is referred to by:

Copious Irrigation Versus Suction Alone During Laparoscopic Appendectomy for Complicated Appendicitis in Adults

INTRODUCTION

It could be asserted that the advent of evidence-based medicine and minimally invasive approaches are among the most remarkable revolutions that general surgeons had to face with during the second half of the 20th century. Still being one of the most common diseases leading to emergency surgery procedures, with a lifetime risk of 8.6% for males and 6.7% for females [1], acute appendicitis (AA) seems to be a paradigm of the challenging changes of current surgical practice. A recent meta-analysis [2] could not demonstrate the superiority of laparoscopic appendectomy (LA) compared with open appendectomy for what concerns the incidence of intra-abdominal abscess (IAA) (odds ratio (OR) 0.79; 95% confidence interval (CI) 0.45–1.37).

One of the most reliable tools for surgeons facing with acute appendicitis is represented in the World Society of Emergency Surgery (WSES) Jerusalem guidelines [1] issued after a Consensus Conference held in 2015. Giving Level of Evidence (LoE) and Grade of Recommendation (GoR) for a wide number of questions about diagnosis and therapy of acute appendicitis, these guidelines include a section about peritoneal irrigation in complicated appendicitis treated with LA. Their statement about laparoscopic lavage affirms that it does not add any advantage if compared with suction alone (LoE 2, GoR B), the main outcome considered by WSES recommendations being IAA. The studies cited to get to this conclusion are low-powered or conducted in children and the attention of the authors seems to shift to the use of drains and the operative time, stating that irrigation leads to a prolongation of operative time and a lower trend in drain placement [1, 3]. In details, Moore et al. [4] in 2011 were among the first who stated that LA with irrigation was of no use against IAA, and moreover could lead to a higher risk of IAA if compared with suction alone in cases in which perforated acute appendicitis is treated laparoscopically, even if this last consideration was supported by a small sub-cohort in a retrospective study. One year later, in a randomized controlled trial (RCT), St Peter et al. showed in children that irrigation compared with suction alone does not influence the incidence of IIA [3]. Another recent RCT conducted in adults by Snow et al. could not demonstrate any difference between irrigation and suction alone for what concerns the incidence of IAA [5].

The RCT by Sun et al. [6] concludes that irrigation during LA for complicated appendectomy, using at least 2-L normal saline in all four quadrants until no grossly purulent remnants are visible, implying that all the injected fluid is aspirated, reduces IAA incidence, shortens time to first anal exufflation and post-operative stay, and reduces hospital charge. This study has the potential of giving a LoE IB and GoR A, enhancing the process to further meta-analysis, and hopefully new guidelines.

A good rule to keep in mind when designing studies like this is to pay great attention in standardizing inclusion criteria, such as complicated appendicitis definition, and operative details, such as minimum amount of normal saline used and extent of removal of purulent residues. It could be argued that acute appendicitis still represents a challenging disease, in which the attention to particulars of no apparent importance actually can positively impact patients' health. It is not visionary to suppose that the extent of peritoneal infection, as well as the grade of cleanliness reached after irrigation, plays a primary role in determining the usefulness or detriment of peritoneal irrigation.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.