Br. J. Surg. Vol. 64 (1977) 499-500
Appendicectomy : an assessment of the advisability of stump invagination A. P. S I N H A * SUMMARY
Seven hundred and thirty-two cases of appendicectomy performed over a period of 5 years are reviewed to compare the incidence of complications and the Iength of the postoperative stay in hospital, depending on whether the appendix stump was simply ligated or was invaginated by purse string suture following ligation. No detrimental effects are noted following simpre ligation, whereas patients who had stump invagination remained in hospital on average more than a day longer, mainly owing to a higher incidence of wound infection (16 per cent as against 6 per cent).
from our series but leaves 643 cases of appendicitis treated by one or other method for comparison.
Results Of the 643 patients, 210 (33 per cent) in group 1 had ligation and invagination and 433 (67 per cent) in group 2 had simple ligation alone. Group 1 patients stayed in hospital for 1.5 days longer than group 2 patients (8-6 days as opposed t o 7.1 days), and group 1 had a 16 per cent as opposed to a 6 per cent incidence of wound infection (Table Z). Other postoperative complications (Table I ) were infrequent in both groups. The one instance of stump abscess was OVERthe years, three main methods of dealing with found in a woman of 40 who, 15 months after the appendix stump have evolved. Probably the most appendicectomy with invagination, presented with common is to crush and ligate the stump and then pain in the right iliac fossa and abdominal fullness. invaginate it into the caecal wall by means of a purse Laparotomy disclosed a tumour-like mass in the string suture. However, some surgeons prefer to caecum adherent to the adenexas. A right hemiomit the step of invagination while others (Ochsner colectomy was performed and the caecum was found and Lilly, 1937) omit the ligature and merely invagi- to contain an abscess cavity in its wall, full of pus and vegetable foreign matter. There was a foreign body nate the unligated stump. Theoretical advantages of invagination of the ligated reaction on histological examination. stump are (a) better control of haemorrhage from the stump; (b) doubly secure closure of the caecal wall; Table I: POSTOPERATNE COMPLICATIONS IN THE (c) less chance of peritoneal contamination due to STUMP INVAGINATION AND SIMPLE burial of the infected stump; and ( d ) reduced risk of LIGATION GROUPS postoperative adhesions by minimizing the extent of Stumu Overall - ..... any raw surface. invagination Simple ligation average Nevertheless, those who practise simple ligation No. % No. % % Complications claim that burial of the stump is not only unnecessary, Wound infection 34 16.11 25 5.77 9.2 but occasionally leads to the formation of an intra- Pelvic abscess 2 0.94 1 0.23 0.5 mural abscess. Mayo (1934) warned very strongly of Portal pyaemia 1 0.47 0 0 0.2 1 0.47 1 0.23 0.3 this complication and Willis (1908) is quoted as Wound disruption 3 1.42 1 0.23 0.6 having held siniilar views. Cleland (1953) described Adhesions 1 0.47 0 0 0.2 an intussusception of the caecum following stump Stump abscess invagination in which an intramural abscess cavity constituted the apex of the intussusception. He also Discussion quoted two cases of peritonitis resulting from rupture In this survey the incidence of complications following of such an abscess. Jones (1974) has seen 3 such appendicectomy is low because, as already explained, cases. ln addition, a high incidence of adhesions has all the most severely infected cases were excluded to been suggested by Kohler (1926) in patients having allow a true comparison. Nevertheless, some potenstump invagination. Finally, Kingsley (1969) found, tially serious complications, such as portal pyaemia, on reviewing over lo00 cases of appendicitis, that in stump abscess and postoperative adhesions, were seen general there were fewer complications when invagi- and there was, overall, a significant wound infection nation was omitted. rate. The finding of comparable rates for the two techniques suggests that failure to invaginate is not Patients and methods The hospital records of patients undergoing appendicectomy at detrimental and, though a formal comparison cannot Stonehouse Hospital over a 5-year period from 1970 to 1974 be made, the different incidence of wound infection is inclusive have been examined. Over this period three surgeons interesting. The results confirm those of Kingsley and their respective assistants had been responsible for 732 (1969). appendicectomies. One surgeon and his staff carried out The theoretical danger of faecal discharge from simple ligation only, while the other two routinely invaginated insecure ligation of the appendicular stump among the stump, except where peritonitis causing local oedema and group 2 patients does not appear to have become friability made this inadvisable, i.e. even the latter two surgeons and their assistants practised simple ligation in badly inflamed, manifest in the present series. One can draw a similar gangrenous and perforated appendicitis. Thus, all cases with inference from a larger series published by Kingsley established local or general peritonitis were treated in a uniform (1969). The only case in the present series which manner by all these surgeons, i s . simple ligation. A true might be considered to have developed a stump -I
comparison of the techniques employed in appendicitis of similar severity is only possible if such advanced cases are excluded. This excludes 89 of the most severely ill patients
* Stonehouse Hospital, Stonehouse, Lanarkshire, Scotland. Correspondence to: Falkirk District and Royal Infirmary.
500
A. P.Sinha The one common complication in this, as in all similar studies of appendicectomy morbidity, was wound infection, the incidence in group 1 being approximately 16 per cent. There was a reduction in the incidence of this complication in the group 2 cases-6 per cent. It is suggested that there being less manipulation and a shorter operating time when invagination is omitted may lead to less contamination of the wound. The omission of invagination of the crushed and ligated appendix stump after appendicectomy simplifies and shortens the operation. In this and other series no added risk of complication has been found and indeed there is a lower risk of wound infection and a slightly shorter postoperative hospital stay when simple ligation of the appendix stump is practised.
Fig. 1. Microphotograph of an abscess in the caecal wall following appendicular stump invagination ( x 325).
abscess in the caecal wall at the site of stump invagination occurred, as anticipated, in group 1, which is in agreement with previous observations (Mayo, 1934; Cleland, 1953; Jones, 1974). Intraperitoneal adhesions were thought to have caused symptoms in 4 cases but, despite expectations to the contrary, 3 of them were in group 1 and of those, 2 had to have a laparotomy. These findings suggest that leaving the uninvaginated stump free in the peritoneal cavity does not increase the incidence of adhesions. Kohler (1926) made the same observation. A convincing explanation for this finding has not yet been offered, but it may be that burial of the stump in a closed space protects the organisms from exposure to the peritoneal defence mechanisms which could lead in the first instance to a stump abscess and could secondarily encourage adhesions. Intraperitoneal abscess was uncommon in both groups. There were only 2 cases of pelvic abscess and no instance of subphrenic abscess.
Acknowledgements The author is grateful to Mr T. G. Gray, Mr R. W. Irvine and Dr G. A. McEwan for permission to review their cases and for their constant guidance, help and encouragement during the preparation of this paper. He also wishes to acknowledge the invaluable help rendered by Dr K. Millar and Dr R. I. Shaw Dunn in the preparation of histopathological slides and to thank Mrs Jennifer Hare and Mrs Jean Howie for secretarial assistance.
References G . (1953) Caecocolic intussusception following appendicectomy. Br. J . Surg. 41, 108-109. JONES P. F. (1974) Acute appendicitis. In: Emergency Abdominal Surgery. Oxford, Blackwell Scientific, pp. 207-250. KINGSLEY D. P. E. (1969) Some observations on appendicectomy with particular reference to technique. Br. J. Surg. 56, 491-496. KOHLER B. (1926) Weber Stumpfversorgung bei der Wurmforsatzentferaung. Munch. Med. Wochens&hr.73, 1076. MAYO c. (1934) Appendicitis. Coll. Pap. Mayo Clin. 26,154-162. OCHSNER A. and LILLY G . (1937) The techniaue of appendicectomy. Surgery 2, 532-553. WILLIS M. (1908) The treatment of appendix stump after appendicectomy. Ann. Surg. 48, 74-79. CLELAND
Appendicectomy : an assessment of the advisability of stump invagination A. P. S I N H A * SUMMARY
Seven hundred and thirty-two cases of appendicectomy performed over a period of 5 years are reviewed to compare the incidence of complications and the Iength of the postoperative stay in hospital, depending on whether the appendix stump was simply ligated or was invaginated by purse string suture following ligation. No detrimental effects are noted following simpre ligation, whereas patients who had stump invagination remained in hospital on average more than a day longer, mainly owing to a higher incidence of wound infection (16 per cent as against 6 per cent).
from our series but leaves 643 cases of appendicitis treated by one or other method for comparison.
Results Of the 643 patients, 210 (33 per cent) in group 1 had ligation and invagination and 433 (67 per cent) in group 2 had simple ligation alone. Group 1 patients stayed in hospital for 1.5 days longer than group 2 patients (8-6 days as opposed t o 7.1 days), and group 1 had a 16 per cent as opposed to a 6 per cent incidence of wound infection (Table Z). Other postoperative complications (Table I ) were infrequent in both groups. The one instance of stump abscess was OVERthe years, three main methods of dealing with found in a woman of 40 who, 15 months after the appendix stump have evolved. Probably the most appendicectomy with invagination, presented with common is to crush and ligate the stump and then pain in the right iliac fossa and abdominal fullness. invaginate it into the caecal wall by means of a purse Laparotomy disclosed a tumour-like mass in the string suture. However, some surgeons prefer to caecum adherent to the adenexas. A right hemiomit the step of invagination while others (Ochsner colectomy was performed and the caecum was found and Lilly, 1937) omit the ligature and merely invagi- to contain an abscess cavity in its wall, full of pus and vegetable foreign matter. There was a foreign body nate the unligated stump. Theoretical advantages of invagination of the ligated reaction on histological examination. stump are (a) better control of haemorrhage from the stump; (b) doubly secure closure of the caecal wall; Table I: POSTOPERATNE COMPLICATIONS IN THE (c) less chance of peritoneal contamination due to STUMP INVAGINATION AND SIMPLE burial of the infected stump; and ( d ) reduced risk of LIGATION GROUPS postoperative adhesions by minimizing the extent of Stumu Overall - ..... any raw surface. invagination Simple ligation average Nevertheless, those who practise simple ligation No. % No. % % Complications claim that burial of the stump is not only unnecessary, Wound infection 34 16.11 25 5.77 9.2 but occasionally leads to the formation of an intra- Pelvic abscess 2 0.94 1 0.23 0.5 mural abscess. Mayo (1934) warned very strongly of Portal pyaemia 1 0.47 0 0 0.2 1 0.47 1 0.23 0.3 this complication and Willis (1908) is quoted as Wound disruption 3 1.42 1 0.23 0.6 having held siniilar views. Cleland (1953) described Adhesions 1 0.47 0 0 0.2 an intussusception of the caecum following stump Stump abscess invagination in which an intramural abscess cavity constituted the apex of the intussusception. He also Discussion quoted two cases of peritonitis resulting from rupture In this survey the incidence of complications following of such an abscess. Jones (1974) has seen 3 such appendicectomy is low because, as already explained, cases. ln addition, a high incidence of adhesions has all the most severely infected cases were excluded to been suggested by Kohler (1926) in patients having allow a true comparison. Nevertheless, some potenstump invagination. Finally, Kingsley (1969) found, tially serious complications, such as portal pyaemia, on reviewing over lo00 cases of appendicitis, that in stump abscess and postoperative adhesions, were seen general there were fewer complications when invagi- and there was, overall, a significant wound infection nation was omitted. rate. The finding of comparable rates for the two techniques suggests that failure to invaginate is not Patients and methods The hospital records of patients undergoing appendicectomy at detrimental and, though a formal comparison cannot Stonehouse Hospital over a 5-year period from 1970 to 1974 be made, the different incidence of wound infection is inclusive have been examined. Over this period three surgeons interesting. The results confirm those of Kingsley and their respective assistants had been responsible for 732 (1969). appendicectomies. One surgeon and his staff carried out The theoretical danger of faecal discharge from simple ligation only, while the other two routinely invaginated insecure ligation of the appendicular stump among the stump, except where peritonitis causing local oedema and group 2 patients does not appear to have become friability made this inadvisable, i.e. even the latter two surgeons and their assistants practised simple ligation in badly inflamed, manifest in the present series. One can draw a similar gangrenous and perforated appendicitis. Thus, all cases with inference from a larger series published by Kingsley established local or general peritonitis were treated in a uniform (1969). The only case in the present series which manner by all these surgeons, i s . simple ligation. A true might be considered to have developed a stump -I
comparison of the techniques employed in appendicitis of similar severity is only possible if such advanced cases are excluded. This excludes 89 of the most severely ill patients
* Stonehouse Hospital, Stonehouse, Lanarkshire, Scotland. Correspondence to: Falkirk District and Royal Infirmary.
500
A. P.Sinha The one common complication in this, as in all similar studies of appendicectomy morbidity, was wound infection, the incidence in group 1 being approximately 16 per cent. There was a reduction in the incidence of this complication in the group 2 cases-6 per cent. It is suggested that there being less manipulation and a shorter operating time when invagination is omitted may lead to less contamination of the wound. The omission of invagination of the crushed and ligated appendix stump after appendicectomy simplifies and shortens the operation. In this and other series no added risk of complication has been found and indeed there is a lower risk of wound infection and a slightly shorter postoperative hospital stay when simple ligation of the appendix stump is practised.
Fig. 1. Microphotograph of an abscess in the caecal wall following appendicular stump invagination ( x 325).
abscess in the caecal wall at the site of stump invagination occurred, as anticipated, in group 1, which is in agreement with previous observations (Mayo, 1934; Cleland, 1953; Jones, 1974). Intraperitoneal adhesions were thought to have caused symptoms in 4 cases but, despite expectations to the contrary, 3 of them were in group 1 and of those, 2 had to have a laparotomy. These findings suggest that leaving the uninvaginated stump free in the peritoneal cavity does not increase the incidence of adhesions. Kohler (1926) made the same observation. A convincing explanation for this finding has not yet been offered, but it may be that burial of the stump in a closed space protects the organisms from exposure to the peritoneal defence mechanisms which could lead in the first instance to a stump abscess and could secondarily encourage adhesions. Intraperitoneal abscess was uncommon in both groups. There were only 2 cases of pelvic abscess and no instance of subphrenic abscess.
Acknowledgements The author is grateful to Mr T. G. Gray, Mr R. W. Irvine and Dr G. A. McEwan for permission to review their cases and for their constant guidance, help and encouragement during the preparation of this paper. He also wishes to acknowledge the invaluable help rendered by Dr K. Millar and Dr R. I. Shaw Dunn in the preparation of histopathological slides and to thank Mrs Jennifer Hare and Mrs Jean Howie for secretarial assistance.
References G . (1953) Caecocolic intussusception following appendicectomy. Br. J . Surg. 41, 108-109. JONES P. F. (1974) Acute appendicitis. In: Emergency Abdominal Surgery. Oxford, Blackwell Scientific, pp. 207-250. KINGSLEY D. P. E. (1969) Some observations on appendicectomy with particular reference to technique. Br. J. Surg. 56, 491-496. KOHLER B. (1926) Weber Stumpfversorgung bei der Wurmforsatzentferaung. Munch. Med. Wochens&hr.73, 1076. MAYO c. (1934) Appendicitis. Coll. Pap. Mayo Clin. 26,154-162. OCHSNER A. and LILLY G . (1937) The techniaue of appendicectomy. Surgery 2, 532-553. WILLIS M. (1908) The treatment of appendix stump after appendicectomy. Ann. Surg. 48, 74-79. CLELAND
