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An inversion-ligation technique for incidental appendectomy
By Harry
C. Bishop
and Howard
C. Filston
I
NCIDENTAL REMOVAL ot‘ the appendi\- in inl‘ants and cl~ildren undergoing abdominal surgery has been advisable. unless the surgeon feared possible C‘OIItamination resulting from amputation of the appendix. In 1968 Lilly and Randolph reported 108 children who had a sterile incidental appendectomy by invel-sion ot‘the appendix after removal of its mesentary and a pursestring closure 01‘ the cecal wail after inversion.’ Their description and drawings suggested that the intramural blood supply of the appendix could be eliminated by a figure-eight loop made with the pursestring suture that would obliterate tile main submucosal arterial supply tioupllly 50 infants and children underwent incidental appendectomy using thts teckniquz at The Children’s Hospital of Philadelphia. Unt‘ortunately two youngsters d~eloped intussusception due to a retention ot‘ part ot‘ the apprnd~s whicll acted :IS the Icad point. CASE
HISTORIES
A transver% loop coIostom\1 W%IL performed in the neonatal period on a \+hlte mal? ~ntant WI~II imperforate anus and a rectourethral fistula. At the age of 6 mo the fistula was divided ‘md .I Rehbein colorectal pull-through procedure was performed. Appendlccal inversion 1%~ performed by the Lilly-Randolph technique. The infant developed a recurrent rectourethrul t’tstual 5 mo after colostomy closure. A rtght transverse colostomy was reestablished. Two months later in mtussusception prolapsed through the colostomy with the prcvlously Inverted intact .tppendi\ ;I\ the lead point (Fig. 1A). The appendix was amputated was reduced. and there was no recurrence.
through
the colostomy.
the intus~u\i,cptiol,
A lo-yr-old black female underwent laparotomy for lower abdommal pam. A leit o~;tr~n teratomd with infarction secondary to volvulus of the tube Jnd ovary pedicle was found. -\ Ict’l salpingooophorectomy was done. and the appendix was totally Inverted by the LIIIy-Randolph technique. She returned 5 mo later with right lower quadrant pain and .j palpable m:~. A har~um enema encountered an mtussusception which wa\; reduced. Po~trcdu~tion films \ho\\ed ‘1 persistent polypoid mass in the cecum (Fig. IB). .At .I second exploration ;I 3-cm viable remnant ot the appendix was found and was removed through a cecotomy. ‘I hc child made in une\rntl~ul
recover! Since the “f‘igure of eight loop suture” cannot guarantee devasculsriLation and sloughing of the entire inverted appendix and because there is great merit to ridding the pa-__-
Journal of Pedfatm Surgery VOI 8 No 6
(December)
1973
889
BISHOP AND
FILSTON
Fig. 1. (A) Case 1. Retained segment of inverted appendix, the lead point of an intussusception prolapsing through an abdominal colostomy. (6) Case 2. Barium enema showing retained inverted appendix after hydrostatic reduction of an intussusception.
tient of an appendix during other surgical procedures,’ used since late 1969. SURGICAL
the following method has been
TECHNIQUE
As in the Lilly-Randolph total inversion technique, the mesentery is divided, the vessels tied proximally, and the mesoappendix is then stripped by sharp dissection from the length of the appendix. skeletonizing it along the serosal surface without injury to the muscular coat (Fig. ?A). The tip of the appendix is then softened by gently pinching it several times with a partially closing hemostat (Fig. 2B), and a standard blunt-ended silver probe is used to begin intussuscepting the tip into the lumen of the appendix (Fig. 2C). The inversion is continued until only 3-4 mm of the base of the appendix still protrudes beyond the cecal wall, the major portion of the organ now being intussuscepted into itself and into the cecum. At this point a plain 3-O catgut suture is tied tightly in place around the remaining appendix (Fig. 2D), creating essentially a ligated stump, as the silver probe is withdrawn. A nonabsorbable seromuscular pursestring suture is then placed in the cecum around the base of the appendix. making no effort to specifically ligate submucosal vessels (Fig. 2E) and the stump is further inverted as in a routine amputation appendectomy (Fig. 2F). This not only completes the total inversion but provides a necrosing ligature assuring that no blood supply will remain to the appendix and hence assuring that it will slough leaving only a short inverted stump. The above method has now been used in over 200 patients without apparent complications. INDICATIONS
We are now willing to use this inversion-ligation method of incidental appendectomy during all laparotomies in our pediatric patients when the appendix is readily available and the cecum and ascending colon can be held in a straightened position to accept the metal probe during inversion. We have found no technical difficulties in performing it in any age group. The thin appendix can be inverted easily into the colon of the newborn, even if the, as yet, unused colon appears small.
INVERSION~LIGATION
TECHNIQUE
is removed by sharp dissection without damaging the Fig. 2. (A) The entire mesoappendix muscular coats of the appendix. (6) The tip of the appendix is softened by squeezing but not clamping a hemostat, (CI Silver probe has started inversion of the appendiceal tip into the appendiceal lumen. (D) 3-O plain catgut ties the base of the appendix as the probe is withdrawn, assuring necrosis and sloughing of the appendix. (E) Silk pursestring suture placed in the cecum at the base of appendiceal stump. (F) Appendiceal stump inverted and pursestring suture tied.
Incidental many
appendectomy
procedures
where
by inversion-ligation previously
we have been
technique reluctant
is now to
performed
during
do a classical, potentially contaminating amputation appendectomy. It is routinely used during a Ladd’s procedure for malrotation. during omphalocele repair if the omphalocele sac has been opened, during abdominal tumor surgery and other urinary tract procedures, and
BISHOP
892
AND
FILSTON
during surgical exploration for abdominal trauma including youngsters who have a hemoperitoneum. It has been used during the repair of diaphragmatic hernias whether approached abdominally or transthoracically. This “clean” method of incidental appendectomy has been performed during splenectomy, lobar hepatectomy, pancreatectomy. pyloromyotomy, retroperitoneal node dissection, pelvic exenterations, and other extensive abdominal procedures. CONTRAINDICATIONS
There are contraindications to inversion-ligation incidental appendectomy. It should not be used when operating for acute appendicitis or when operating on an appendix previously scarred by an inflammatory process, where there might be fibrosis of the wall or stenosis of the lumen. It should not be used in the presence of an appendiceal fecalith unless the fecalith can be easily milked back into the cecum. It should not be used in patients who are explored for abdominal pain of unknown etiology since such appendices should be submitted for histological examination. It obviously makes little sense to invert an appendix if colonic surgery is being performed at the same time, since potential contamination of the operative site has already occurred. SUMMARY
Inversion of the appendix does not guarantee that it will slough and a remnant has led to intussusception in two patients. Incidental elimination of the appendix by inversion plus ligation of the base and inversion of the stump appears to be safe, simple, and uncomplicated. This method eliminates the appendix without contamination of the operative field. Such appendectomies are now done in all age groups if the surgical exposure allows ready access to the appendix and cecum. REFERENCES 1. Lilly JR, Randolph JG: Total inversion of the appendix: experiences with incidental appendectomy in children. J Pediatr Surg 3:357, 196X
2. Ludbrook J, Spears GFS: The risk of developing appendicitis. Br J Surg 52:856, 1965
C. Bishop
and Howard
C. Filston
I
NCIDENTAL REMOVAL ot‘ the appendi\- in inl‘ants and cl~ildren undergoing abdominal surgery has been advisable. unless the surgeon feared possible C‘OIItamination resulting from amputation of the appendix. In 1968 Lilly and Randolph reported 108 children who had a sterile incidental appendectomy by invel-sion ot‘the appendix after removal of its mesentary and a pursestring closure 01‘ the cecal wail after inversion.’ Their description and drawings suggested that the intramural blood supply of the appendix could be eliminated by a figure-eight loop made with the pursestring suture that would obliterate tile main submucosal arterial supply tioupllly 50 infants and children underwent incidental appendectomy using thts teckniquz at The Children’s Hospital of Philadelphia. Unt‘ortunately two youngsters d~eloped intussusception due to a retention ot‘ part ot‘ the apprnd~s whicll acted :IS the Icad point. CASE
HISTORIES
A transver% loop coIostom\1 W%IL performed in the neonatal period on a \+hlte mal? ~ntant WI~II imperforate anus and a rectourethral fistula. At the age of 6 mo the fistula was divided ‘md .I Rehbein colorectal pull-through procedure was performed. Appendlccal inversion 1%~ performed by the Lilly-Randolph technique. The infant developed a recurrent rectourethrul t’tstual 5 mo after colostomy closure. A rtght transverse colostomy was reestablished. Two months later in mtussusception prolapsed through the colostomy with the prcvlously Inverted intact .tppendi\ ;I\ the lead point (Fig. 1A). The appendix was amputated was reduced. and there was no recurrence.
through
the colostomy.
the intus~u\i,cptiol,
A lo-yr-old black female underwent laparotomy for lower abdommal pam. A leit o~;tr~n teratomd with infarction secondary to volvulus of the tube Jnd ovary pedicle was found. -\ Ict’l salpingooophorectomy was done. and the appendix was totally Inverted by the LIIIy-Randolph technique. She returned 5 mo later with right lower quadrant pain and .j palpable m:~. A har~um enema encountered an mtussusception which wa\; reduced. Po~trcdu~tion films \ho\\ed ‘1 persistent polypoid mass in the cecum (Fig. IB). .At .I second exploration ;I 3-cm viable remnant ot the appendix was found and was removed through a cecotomy. ‘I hc child made in une\rntl~ul
recover! Since the “f‘igure of eight loop suture” cannot guarantee devasculsriLation and sloughing of the entire inverted appendix and because there is great merit to ridding the pa-__-
Journal of Pedfatm Surgery VOI 8 No 6
(December)
1973
889
BISHOP AND
FILSTON
Fig. 1. (A) Case 1. Retained segment of inverted appendix, the lead point of an intussusception prolapsing through an abdominal colostomy. (6) Case 2. Barium enema showing retained inverted appendix after hydrostatic reduction of an intussusception.
tient of an appendix during other surgical procedures,’ used since late 1969. SURGICAL
the following method has been
TECHNIQUE
As in the Lilly-Randolph total inversion technique, the mesentery is divided, the vessels tied proximally, and the mesoappendix is then stripped by sharp dissection from the length of the appendix. skeletonizing it along the serosal surface without injury to the muscular coat (Fig. ?A). The tip of the appendix is then softened by gently pinching it several times with a partially closing hemostat (Fig. 2B), and a standard blunt-ended silver probe is used to begin intussuscepting the tip into the lumen of the appendix (Fig. 2C). The inversion is continued until only 3-4 mm of the base of the appendix still protrudes beyond the cecal wall, the major portion of the organ now being intussuscepted into itself and into the cecum. At this point a plain 3-O catgut suture is tied tightly in place around the remaining appendix (Fig. 2D), creating essentially a ligated stump, as the silver probe is withdrawn. A nonabsorbable seromuscular pursestring suture is then placed in the cecum around the base of the appendix. making no effort to specifically ligate submucosal vessels (Fig. 2E) and the stump is further inverted as in a routine amputation appendectomy (Fig. 2F). This not only completes the total inversion but provides a necrosing ligature assuring that no blood supply will remain to the appendix and hence assuring that it will slough leaving only a short inverted stump. The above method has now been used in over 200 patients without apparent complications. INDICATIONS
We are now willing to use this inversion-ligation method of incidental appendectomy during all laparotomies in our pediatric patients when the appendix is readily available and the cecum and ascending colon can be held in a straightened position to accept the metal probe during inversion. We have found no technical difficulties in performing it in any age group. The thin appendix can be inverted easily into the colon of the newborn, even if the, as yet, unused colon appears small.
INVERSION~LIGATION
TECHNIQUE
is removed by sharp dissection without damaging the Fig. 2. (A) The entire mesoappendix muscular coats of the appendix. (6) The tip of the appendix is softened by squeezing but not clamping a hemostat, (CI Silver probe has started inversion of the appendiceal tip into the appendiceal lumen. (D) 3-O plain catgut ties the base of the appendix as the probe is withdrawn, assuring necrosis and sloughing of the appendix. (E) Silk pursestring suture placed in the cecum at the base of appendiceal stump. (F) Appendiceal stump inverted and pursestring suture tied.
Incidental many
appendectomy
procedures
where
by inversion-ligation previously
we have been
technique reluctant
is now to
performed
during
do a classical, potentially contaminating amputation appendectomy. It is routinely used during a Ladd’s procedure for malrotation. during omphalocele repair if the omphalocele sac has been opened, during abdominal tumor surgery and other urinary tract procedures, and
BISHOP
892
AND
FILSTON
during surgical exploration for abdominal trauma including youngsters who have a hemoperitoneum. It has been used during the repair of diaphragmatic hernias whether approached abdominally or transthoracically. This “clean” method of incidental appendectomy has been performed during splenectomy, lobar hepatectomy, pancreatectomy. pyloromyotomy, retroperitoneal node dissection, pelvic exenterations, and other extensive abdominal procedures. CONTRAINDICATIONS
There are contraindications to inversion-ligation incidental appendectomy. It should not be used when operating for acute appendicitis or when operating on an appendix previously scarred by an inflammatory process, where there might be fibrosis of the wall or stenosis of the lumen. It should not be used in the presence of an appendiceal fecalith unless the fecalith can be easily milked back into the cecum. It should not be used in patients who are explored for abdominal pain of unknown etiology since such appendices should be submitted for histological examination. It obviously makes little sense to invert an appendix if colonic surgery is being performed at the same time, since potential contamination of the operative site has already occurred. SUMMARY
Inversion of the appendix does not guarantee that it will slough and a remnant has led to intussusception in two patients. Incidental elimination of the appendix by inversion plus ligation of the base and inversion of the stump appears to be safe, simple, and uncomplicated. This method eliminates the appendix without contamination of the operative field. Such appendectomies are now done in all age groups if the surgical exposure allows ready access to the appendix and cecum. REFERENCES 1. Lilly JR, Randolph JG: Total inversion of the appendix: experiences with incidental appendectomy in children. J Pediatr Surg 3:357, 196X
2. Ludbrook J, Spears GFS: The risk of developing appendicitis. Br J Surg 52:856, 1965