Appendicular abscess surgery

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]

Following drain and antibiotics, an interval appendectomy is recommended for patients after six to eight weeks. The surgical approach can be either laparoscopic or open (laparotomic).

• Percutaneous drainage can be performed under ultrasound or CT guidance, using either the Seldinger or trocar technique.^[1]
• Ultrasound is limited if the abscess is small, obscured by other structures, or if precise placement is required because of nearby vessels or organs. In these cases, CT is the optimal imaging modality.^[2]
• When an abscess is deep in the pelvis, depending on the specific location of the fluid collection, access may be obtained via transgluteal, transvaginal, or transrectal approaches.^[3]
• If the fluid collection is sterile, a transgluteal approach is preferred because it allows for sterile technique.^[2]
• Depending on the location of abscess, patient is placed in prone or supine position on the CT table.
• Localization scan using CT allows in selecting a safe window of access into the collection.
• A coaxial micropuncture introducer set is advanced into the abscess under CT guidance.
• An Amplatz guidewire is advanced through the sheath and coiled within the abscess.
• After serial dilatation of the tract with a dilator, an pigtail drain is advanced over the guidewire and deployed.

Indications:

• When patients present with life-threatening signs of peritonitis
• Large appendiceal abscess
• Patients with an extraluminal appendicolith

Following drain and antibiotics, an interval appendectomy is recommended for patients after six to eight weeks. It may be performed to:

• Prevent recurrence of appendicitis^[4]
• Exclude neoplasms as a cause (such as carcinoid, adenocarcinoma, mucinous cystadenoma, and cystadenocarcinomas)

Complications of interval appendectomy may include:

• Wound infection (sepsis)
• Pelvic abscess
• Aspiration pneumonia

Late complications can include:

• Abdominal adhesions
• Fecal fistula^[5]

The following video demonstrates visualization of appendicular abscess: {{#ev:youtube|SRMOktFZim0}}