I feel sorry for the OR team that got stuck working the same night with me. We had a case of perforated appendicitis, the kind where you start regretting the decision to operate the minute pus starts oozing out of the first incision. (Note to ER doctors: unless the patient has a creatinine of 3 [indicating real renal failure] never ever ever do a CT scan without iv contrast (ok, unless you’re looking for kidney stones); and there is literally no excuse in the world for not giving oral contrast to a patient over the age of reason – appropriate use of antiemetics should enable the patient to get at least a modicum of the contrast down, and some is better than none. For the non-medical readers, iv contrast is invaluable for demarcating abscesses, which are characterized by a vascularized wall, and no blood flow inside. It also helps to diagnose dozens of other surgical conditions, including mesenteric ischemia, ischemic gut, and small bowel obstructions which need an urgent operation (as opposed to the ones that can wait). Oral contrast is necessary to show which round objects are intestine, and which could be something else, like an inflamed appendix or an abscess. Not having contrast is like trying to peel potatoes in the dark – a waste of time and radiation.) (Note to self: next time, when the patient has diffuse peritonitis on exam, you should ignore the worthless noncontrast CT scan which may or may not show an abscess, and go with your clinical diagnosis of a perforation that’s had time to spread.)
(Appendicitis complicated by perforation and an abscess ought to be treated nonoperatively, because surgery is too difficult and risky in that setting. Like many other medical pearls, I didn’t quite believe that one until I proved it for myself. Someday, I’ll stop reinventing the wheel.)
It’s not that I did the case badly, just very very slowly. I’m doing better at getting the laparoscopic instruments where I want them to go, but things take twice as long when I drop everything I pick up, and have to grab it again and again before I get a grasp that works. However, as the attending observed, since there was already pus everywhere, things could hardly get any worse. . .
Better luck the next night, I guess.
Cut On The Dotted Line 
December 18, 2008 at 10:34 pm
When to drain an appendiceal abscess (and by which method: surgical vs radiological) and when to treat non-operatively is a matter of judgment. It’s not inarguable that it must be treated non-operatively, as you imply. Nor would every anesthetist agree with the idea of forcing oral contrast with anti-emetics in someone destined, or possibly destined, to the OR. It’s one of those things that, in my opinion, ought to be discussed with the surgeon in advance. But nowadays, ER docs order CTs without any discussion with the surgeon, often because (I think I already ranted about this) the surgeons like it that way, abdicating their role in the diagnostic phase.
And, if I may further repeat myself, draining an abscess laparoscopically is REALLY a waste of resources: a well-placed incision, and intelligent and appropriately delicate finger, and you’re done in a couple of minutes.
Another underused modality, for a pelvic abscess, usually appendiceal: transrectal drainage. Works great!
December 18, 2008 at 10:36 pm
I should add: in the case you describe, if there was free pus in the abdomen, of course you had to operate. If it was an abscess you entered with the first incision, you were done. Unless I misunderstand.
December 19, 2008 at 6:15 am
One of the few times I agree with Sid, Contrast + Lungs = Lawyers
but with a surgical abdomen you gotta do a Rapid Sequence Intubation anyway….
stories like yours make me glad my appendixes at the bottom of a Nebraska land fillll
December 20, 2008 at 1:12 pm
Local radiologists ancy about Cr>1.4 or BUN>20 with contrast. Pediatric surgeons
at the TCH in Bham don’t use po and not much
IV contrast according to the pundits at the
APLS course last year. Surgeons at the hospital I work at won’t see a pt with out a CT report in their hands, said CT with IV + PO contrast usually
adding 2 to 5 hrs (best/worse case) to the time frame. I dx 2/3 of my appendicitis with
“Renal stone search CT” something I can get in 30-45 min. Then there is the oceanic swell from radiology: do we really need to do so many CT scans? They are really on the warpath over thoracic CT (R/O PTE). The
hospitalists want one on every chest pain with the slightest drop in O2 sat or hint of risk factor.
December 23, 2008 at 1:49 pm
I think we’re moving away from non-operative treatment of appendicitis. Abscess or not, I operate, as long as the symptoms have been present for less than three days. More than that and “it depends”. Laparoscopically I can wash out the pelvis, evacuate the abscess, and of course do the appendectomy. All in one session. the textbooks stating “percutaneous drainage if there is an abscess” are outdated. Save your patient the extended hospitalization and multiple procedures. Operate. I have a series of 50 perforated appies (some with abscess/some not) done laparoscopoically. No post op infections or complications….
December 23, 2008 at 7:27 pm
Thanks, Dr. Schwab, and Buckeye. I wasn’t thinking quite clearly when writing there, more reflecting the attending’s comments during the case than a practical across-the-board approach.