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Total inversion of the appendix: Experience with incidental appendectomy in children
Total Inversion
of the Appendix : Experience
Incidental Appendectomy B~JOHNR.LILLY
with
in Children
ANDJUDSONG.RANDOLPH
I
INCIDENTAL APPENDECTOMY is regarded by many as a worthwhile complementary procedure during laparotomy. Since the majority of cases of appendicitis occur in the childhood years,1 incidental appendectomy seems especially desirable in pediatric patients. The fear of unnecessary contamination and possible infection has generated reluctance on the part of some surgeons to carry out complementary appendectomy. It is undoubtedly true that some bacterial contamination occurs with transection of the appendix. An ideal technic for elective appendectomy would completely eliminate contamination without increasing the dissection or prolonging the operative time. Total inversion of the appendix satisfies these criteria. Once denuded of its mesoappendix, the appendix can be turned inside out into the lumen of the cecum. If the blood supply is interrupted, the entire appendix will subsequently slough innocuously into the cecum. At no time is the lumen of the intestinal tract opened. During the past three years, 108 patients at the Children’s Hospital in Washington, D. C. undergoing abdominal surgery for a variety of conditions, had incidental appendectomy by inversion of the appendix. The purpose of this paper is to report the application, technic, and results of this method of appendectomy. HISTORY In 1895, Edebohls2 described and illustrated total inversion of the appendix and advocated this technic “whenever, for any reasons, the abdomen is opened . , . .” In these earlier days, this seemed a bold approach, yet further recommendations were given by Filho3 in 1923 and again by Christitch in 1938. These surgeons performed total inversion of the appendix in over 600 patients without mortality and with minimal morbidity. More recently, Hallatts attested to the safety of the technic having carried out this form of appendectomy in 713 patients of all ages. He reported no instances of wound or pelvic infection or postoperative intestinal obstruction. In the majority of cases described previously, total inversion of the appendix has been a complementary __
~~ ~. __
-__
From the Surgical Seroice of the Children’s Hospital of the District of Columbia and the l?c,partmcnt of SllTgeTy, George Washington University School of Medicine, Washington: 1). c. Jolr\- R. I.II.LY, M.D.: Attending Surgeon, The Children’s Hospital: Assistant Professor of Srrrgw~, George Washington Uniuersity School of Medicine. JUDSON G. RANDOLPH, M.D.: Szrrccorl-in-Chief, The Children’s Hospital; Associate Professor of Surgery, George Washington Unicprsity School of Medicine. JOCRXAL OF PEDIATRIC SURGERY, VOL. 3, No. 3 (JUNE),
1968
357
358
LILLY AND RANDOLPH
Fig. L-A, The initial steps in total appendiceal inversion are similar to other forms of appendectomy. The mesoappendix is ligated and divided in the conventional manner. B, The fragments of mesoappendix remaining along the length of the appendix are sharply excised. C, A purse-string suture of nonabsorbable material is placed in the wall of the cecum at the base of the appendix. The figureeight loop must be placed at the start of this suture. D, The end of the skeletonized appendix is gently compressed emptying the lumen at the tip. A probe is placed at the tip of the appendix and the organ is intussuscepted on itself. E, Intussusception of the appendix on itself is continued until the entire organ is inverted into the cecum. F, The probe is withdrawn and the purse-string suture is tied completing the operation.
procedure to gynecologic surgery. Warden” appendectomy for patients of any age.
has advocated
this technic
of
TECHNIC
The initial maneuvers in appendiceal
inversion are similar to other forms of
TOTAL
INVERSION
OF THE APPENDIX
359
Fig. Z-Barium paste outlines the inverted appendix on a radiograph taken 24 hours after surgery. An abdominal radiograph 10 davs later showed no barium on the abdominal film.
appendectomy. The mesoappendix is ligated and divided in the conventional manner (Fig. 1A). The fragments of mesoappendix remaining along the length of the appendix are cleaned away sharply. A purse-string suture of nonabsorbable material is placed in the wall of the cecum at the base of the appendix (Fig. 1D). A fig ure of eight loop must be placed at the start of this purse-string at the base of the mesoappendix (Fig. 1C). This suture encompasses the major portion of the submucosal blood supply to the base of the appendix. The very tip of the appendix is gently compressed between finger and thumb to empty
360
LILLY
AND RANDOLPH
Fig. 3.- The infarcted, but still partially intact, inverted appendix appeared at the colostomy on the eighth postoperative day. the lumen here and thereby allow intussusception at the tip of the appendix. A probe is placed at the tip and then the entire organ is intussuscepted on itself and inverted into the lumen of the cecum (Fig. 1E). The probe is withdrawn, and the purse-string suture is tied and cut (Fig. 1F).
361
TOTALINVERSION OFTHEAPPENDIX KE~ULTS The 108 children undergoing
laparotomy for unrelated conditions who have had appendectomy by total inversion of the appendix are recorded in Table 1. We have found the procedure to be safe and effective in removing the appendix. The technic is mechanically pleasing and has an elegant simplicity. There have been no complications which might be attributed to the removal of the appendix in this manner. There were no wound or pelvic infections, no cases of postoperative intestinal obstruction in the three-year follow up period, and no instances of intussusception. Postoperative studies, including the injection of the inverted appendix with sterile barium paste, show that it promptly undergoes necrosis and is discharged into the cecum about the tenth postoperative day (Fig. 2). At the time of reoperation in some of these patients, the site of total appendiceal inversion was inspected. There was a striking lack of adhesions in the cecal area. No appendiceal remnant, either intralumenal or extralumenal was found. DISCUSSION
The two most familiar forms of elective appendectomy today are ( 1) amputation of the appendix after ligation of its base and (2) amputation of the appendix and inversion of its stump. In the former, the surgeon leaves a mucosal-covered appendiceal stump exposed in the coelomic cavity. In no other surgical procedure is such a situation considered. In the latter, a partially infarcted appendiceal stump is buried in the wall of the cecum with the rather disturbing plan that this intramural stump will form an abscess and rupture into the lumen of the cecum. One of these choices or a modification thereof is mandatory for an acute suppurative appendicitis. The surgeon is released from such restrictions in elective appendectomy. Transection of a segment of colon (appendix) flourishing with bowel organisms obviously increases the likelihood of wound and peritoneal infections. Although data on the incidence of infection from elective appendectomy are not available, most surgeons easily recall one or two wound infections (from a bowel organism) in which an incidental appendectomy was the only possible source of contamination, Similarly, the peritoneum may become infected. Peritoneal contamination at the time of elective appendectomy, however slight, increases the likelihood of postoperative adhesions in the region7 Furthermore. contamination with subclinical infection may well be responsible for some cases of intratubal stenosis and subsequent ectopic tubal pregnancy. Hallatts has reported the only common denominator in the increased incidence of rightsided tubal pregnancy was a previous appendectomy. Such postoperative complications would appear to be lessened by the complete elimination of contamination with total appendiceal inversion. The operative time necessary to carry out this procedure is no longer than that needed for amputation with inversion of the stump of the appendix. It usually takes less time to sharply excise the appendiceal side of the mesoappendix and invert the entire appendix than it does to crush the base of the appendix, ligate it, amputate the organand then apply the varied popular
362
LILLY
Table I.-Complementary _~ Primary Operative Diagnosis/Procedure
Intussusception Hiatal hernia Hirschsprung’s
Appendectomy
disease
Liver biopsy Intersex Malrotation of the colon Peptic ulcer Ureteral reimplantation Bladder neck obstruction Ovarian cyst
10 9 8 6 5 5 4 4
in 108 Children
Primary Operative Diagnosis/Procedure
Number of cases
13 11
AND RANDOLPH
Number of cases
Urinary diversion (Bricker procedure) Diaphragmatic hernia (not in newborn) Mesenteric adenitis Intestinal foreign body Intestinal anomalies (stenosis, duplication, Meckel’s diverannular pancreas, internal ticulum, hernia, mesenteric and retroperitoneal cysts) Other
3 3 3* 2 17
5 TOTAL
108
*Three cases of mesenteric adenitis had total appendiceal inversion carried out at the start of this series. We now believe the appendix should be removed in children with abdominal pain in order to submit the organ for pathologic study.
ablutions to the stump before inversion. Prior to such maneuvers, of course, the procedures are identical. Careful attention to the blood supply of the base of the totally inverted appendix is necessary to assure total necrosis of the organ after it is inverted. The figure of eight portion of the purse-string suture obliterates the major submucosal vascular supply to the base of the appendix. If this is not carried out, total appendiceal infarction may not occur and an intracecal remnant may persist. Although of no clinical significance, the remnant would result in a cecal filling defect if, for any reason, barium enema studies were subsequently done. Once devoid of its blood supply, the infarcted appendix promptly undergoes disintegration with separation of its attachments and passes harmlessly into the cecal lumen and the fecal stream. Remnants of the organ may be seen in the stool of some patients in about 10 days and are occasionally observed and reported by the child’s parents. In one child having had a prior transverse colostomy for Hirschsprung’s disease, the infarcted, but still partially intact, appendix was recoved from the colostomy on the eighth postoperative day (Fig. 3). The possibility of intussusception might appear a theoretical objection to appendiceal inversion. This has not been true in our series of patients, and indeed we have used this method of appendectomy when operating on patients with intussusception (Table 1). Although ceco-cecal intussusception has been reported,sJO such case reports are unique and infrequent. No instances of cecocecal intussusception have been reported following total appendiceal inversion, although Hallatta reported a right lower quadrant mass with discomfort which subsided spontaneously. The child’s propensity for intussusception is at the ileocecal valve and not at the base of the cecum. There has been no age restriction to this form of appendectomy. This procedure has been carried out in children ranging in age from 24 hours to 15 years.
363
TOTAL INVERSION OF THE APPENDIX
The technic is particularly suitable in such pediatric surgical problems as malrotation of the colon and small bowel stenosis. On the other hand, we feel a definite contraindication exists in cases of an “unused” colon as is seen, for example, in meconium ileus or intestinal atresia. The miniature colon in these instances would be almost occluded by the inverted appendix. Nor, do we believe appendiceal inversion should be carried out when operating on children for abdominal pain when no explanation for such symptoms are found at the time of laparotomy. In these patients, “amputation” appendectomy should he accomplished so that the organ may be submitted for pathologic study. CONCLUSIONS
Total inversion of the vermiform appendix is a safe and effective method of appendectomy. By elimination of contamination by this technic, potential postoperative complications of wound and pelvic infection, adhesive bands, and possibly subsequent ectopic tubal pregnancy should be minimal. The avoidance of such complications in younger subjects with a full life expectancy is especially advantageous. SUMMARIO IN INTERLINGUA Quando le provision de sanguine de1 appendice es interrumpite, le integre organ” potr esser intussuscipite super se mesme e-subsequentemente-invertite ad in le ceco ubi illo es promptemente disintegrate, con separation de su attachamentos. A nulle tempore es il necessari aperir le lumine de1 intestino, de maniera que omne contamination es evitate. Iste forma de appendicectomia elective esseva effectuate in 108 juveniles, sin complication. In juvene subjectos con plen superviventia probabile, evitar omne potential complicationes postchirurgic per infection intravulneral e intrapelvic, per bandas de adhesion. e possibilemente per le occurrentia subsequente de ectopic pregnantias tubal es particularmente desirabile. REFERENCES 1. Ludbrook, J., and Spears, G. F. S.: The risk of developing appendicitis. Brit. J. Surg. 52:856, 1965. 2. Edebohls, George M.: Inversion of the vermiform appendix. Am. J. Med. Science 109:650, 1895. 3. Filho, Brandao: Invagination de l’appendice. Presse Med. 31:6, 1923. 4. Christitch, Stavra: Invagination de l’appendice ileo-caecal comme operation complementair de la laparotomie gynecologigue. Gynec. et Obst. 37:194, 1938. 5. Hallntt, J. G.: Inversion of the entire
appendix as an incidental procedure. Amer. J. Obstet. Gynec. 75:1043, 1958. 6. Warden, M. Jas.: Personal communication. 7. Welch, Claude E.: Intestinal Obstruction, Chicago, Year Book Publishers, 1958. 8. Hallatt, J. G.: Personal communication. 9. Hood, P. A.: Intussusception in infants and children. J. Irish Med. Ass. LX:l3, 1967. 10. Gross, Robert IX.: The Surgery of Infancy and Childhood. Philadelphia, Saunders. 1953.
of the Appendix : Experience
Incidental Appendectomy B~JOHNR.LILLY
with
in Children
ANDJUDSONG.RANDOLPH
I
INCIDENTAL APPENDECTOMY is regarded by many as a worthwhile complementary procedure during laparotomy. Since the majority of cases of appendicitis occur in the childhood years,1 incidental appendectomy seems especially desirable in pediatric patients. The fear of unnecessary contamination and possible infection has generated reluctance on the part of some surgeons to carry out complementary appendectomy. It is undoubtedly true that some bacterial contamination occurs with transection of the appendix. An ideal technic for elective appendectomy would completely eliminate contamination without increasing the dissection or prolonging the operative time. Total inversion of the appendix satisfies these criteria. Once denuded of its mesoappendix, the appendix can be turned inside out into the lumen of the cecum. If the blood supply is interrupted, the entire appendix will subsequently slough innocuously into the cecum. At no time is the lumen of the intestinal tract opened. During the past three years, 108 patients at the Children’s Hospital in Washington, D. C. undergoing abdominal surgery for a variety of conditions, had incidental appendectomy by inversion of the appendix. The purpose of this paper is to report the application, technic, and results of this method of appendectomy. HISTORY In 1895, Edebohls2 described and illustrated total inversion of the appendix and advocated this technic “whenever, for any reasons, the abdomen is opened . , . .” In these earlier days, this seemed a bold approach, yet further recommendations were given by Filho3 in 1923 and again by Christitch in 1938. These surgeons performed total inversion of the appendix in over 600 patients without mortality and with minimal morbidity. More recently, Hallatts attested to the safety of the technic having carried out this form of appendectomy in 713 patients of all ages. He reported no instances of wound or pelvic infection or postoperative intestinal obstruction. In the majority of cases described previously, total inversion of the appendix has been a complementary __
~~ ~. __
-__
From the Surgical Seroice of the Children’s Hospital of the District of Columbia and the l?c,partmcnt of SllTgeTy, George Washington University School of Medicine, Washington: 1). c. Jolr\- R. I.II.LY, M.D.: Attending Surgeon, The Children’s Hospital: Assistant Professor of Srrrgw~, George Washington Uniuersity School of Medicine. JUDSON G. RANDOLPH, M.D.: Szrrccorl-in-Chief, The Children’s Hospital; Associate Professor of Surgery, George Washington Unicprsity School of Medicine. JOCRXAL OF PEDIATRIC SURGERY, VOL. 3, No. 3 (JUNE),
1968
357
358
LILLY AND RANDOLPH
Fig. L-A, The initial steps in total appendiceal inversion are similar to other forms of appendectomy. The mesoappendix is ligated and divided in the conventional manner. B, The fragments of mesoappendix remaining along the length of the appendix are sharply excised. C, A purse-string suture of nonabsorbable material is placed in the wall of the cecum at the base of the appendix. The figureeight loop must be placed at the start of this suture. D, The end of the skeletonized appendix is gently compressed emptying the lumen at the tip. A probe is placed at the tip of the appendix and the organ is intussuscepted on itself. E, Intussusception of the appendix on itself is continued until the entire organ is inverted into the cecum. F, The probe is withdrawn and the purse-string suture is tied completing the operation.
procedure to gynecologic surgery. Warden” appendectomy for patients of any age.
has advocated
this technic
of
TECHNIC
The initial maneuvers in appendiceal
inversion are similar to other forms of
TOTAL
INVERSION
OF THE APPENDIX
359
Fig. Z-Barium paste outlines the inverted appendix on a radiograph taken 24 hours after surgery. An abdominal radiograph 10 davs later showed no barium on the abdominal film.
appendectomy. The mesoappendix is ligated and divided in the conventional manner (Fig. 1A). The fragments of mesoappendix remaining along the length of the appendix are cleaned away sharply. A purse-string suture of nonabsorbable material is placed in the wall of the cecum at the base of the appendix (Fig. 1D). A fig ure of eight loop must be placed at the start of this purse-string at the base of the mesoappendix (Fig. 1C). This suture encompasses the major portion of the submucosal blood supply to the base of the appendix. The very tip of the appendix is gently compressed between finger and thumb to empty
360
LILLY
AND RANDOLPH
Fig. 3.- The infarcted, but still partially intact, inverted appendix appeared at the colostomy on the eighth postoperative day. the lumen here and thereby allow intussusception at the tip of the appendix. A probe is placed at the tip and then the entire organ is intussuscepted on itself and inverted into the lumen of the cecum (Fig. 1E). The probe is withdrawn, and the purse-string suture is tied and cut (Fig. 1F).
361
TOTALINVERSION OFTHEAPPENDIX KE~ULTS The 108 children undergoing
laparotomy for unrelated conditions who have had appendectomy by total inversion of the appendix are recorded in Table 1. We have found the procedure to be safe and effective in removing the appendix. The technic is mechanically pleasing and has an elegant simplicity. There have been no complications which might be attributed to the removal of the appendix in this manner. There were no wound or pelvic infections, no cases of postoperative intestinal obstruction in the three-year follow up period, and no instances of intussusception. Postoperative studies, including the injection of the inverted appendix with sterile barium paste, show that it promptly undergoes necrosis and is discharged into the cecum about the tenth postoperative day (Fig. 2). At the time of reoperation in some of these patients, the site of total appendiceal inversion was inspected. There was a striking lack of adhesions in the cecal area. No appendiceal remnant, either intralumenal or extralumenal was found. DISCUSSION
The two most familiar forms of elective appendectomy today are ( 1) amputation of the appendix after ligation of its base and (2) amputation of the appendix and inversion of its stump. In the former, the surgeon leaves a mucosal-covered appendiceal stump exposed in the coelomic cavity. In no other surgical procedure is such a situation considered. In the latter, a partially infarcted appendiceal stump is buried in the wall of the cecum with the rather disturbing plan that this intramural stump will form an abscess and rupture into the lumen of the cecum. One of these choices or a modification thereof is mandatory for an acute suppurative appendicitis. The surgeon is released from such restrictions in elective appendectomy. Transection of a segment of colon (appendix) flourishing with bowel organisms obviously increases the likelihood of wound and peritoneal infections. Although data on the incidence of infection from elective appendectomy are not available, most surgeons easily recall one or two wound infections (from a bowel organism) in which an incidental appendectomy was the only possible source of contamination, Similarly, the peritoneum may become infected. Peritoneal contamination at the time of elective appendectomy, however slight, increases the likelihood of postoperative adhesions in the region7 Furthermore. contamination with subclinical infection may well be responsible for some cases of intratubal stenosis and subsequent ectopic tubal pregnancy. Hallatts has reported the only common denominator in the increased incidence of rightsided tubal pregnancy was a previous appendectomy. Such postoperative complications would appear to be lessened by the complete elimination of contamination with total appendiceal inversion. The operative time necessary to carry out this procedure is no longer than that needed for amputation with inversion of the stump of the appendix. It usually takes less time to sharply excise the appendiceal side of the mesoappendix and invert the entire appendix than it does to crush the base of the appendix, ligate it, amputate the organand then apply the varied popular
362
LILLY
Table I.-Complementary _~ Primary Operative Diagnosis/Procedure
Intussusception Hiatal hernia Hirschsprung’s
Appendectomy
disease
Liver biopsy Intersex Malrotation of the colon Peptic ulcer Ureteral reimplantation Bladder neck obstruction Ovarian cyst
10 9 8 6 5 5 4 4
in 108 Children
Primary Operative Diagnosis/Procedure
Number of cases
13 11
AND RANDOLPH
Number of cases
Urinary diversion (Bricker procedure) Diaphragmatic hernia (not in newborn) Mesenteric adenitis Intestinal foreign body Intestinal anomalies (stenosis, duplication, Meckel’s diverannular pancreas, internal ticulum, hernia, mesenteric and retroperitoneal cysts) Other
3 3 3* 2 17
5 TOTAL
108
*Three cases of mesenteric adenitis had total appendiceal inversion carried out at the start of this series. We now believe the appendix should be removed in children with abdominal pain in order to submit the organ for pathologic study.
ablutions to the stump before inversion. Prior to such maneuvers, of course, the procedures are identical. Careful attention to the blood supply of the base of the totally inverted appendix is necessary to assure total necrosis of the organ after it is inverted. The figure of eight portion of the purse-string suture obliterates the major submucosal vascular supply to the base of the appendix. If this is not carried out, total appendiceal infarction may not occur and an intracecal remnant may persist. Although of no clinical significance, the remnant would result in a cecal filling defect if, for any reason, barium enema studies were subsequently done. Once devoid of its blood supply, the infarcted appendix promptly undergoes disintegration with separation of its attachments and passes harmlessly into the cecal lumen and the fecal stream. Remnants of the organ may be seen in the stool of some patients in about 10 days and are occasionally observed and reported by the child’s parents. In one child having had a prior transverse colostomy for Hirschsprung’s disease, the infarcted, but still partially intact, appendix was recoved from the colostomy on the eighth postoperative day (Fig. 3). The possibility of intussusception might appear a theoretical objection to appendiceal inversion. This has not been true in our series of patients, and indeed we have used this method of appendectomy when operating on patients with intussusception (Table 1). Although ceco-cecal intussusception has been reported,sJO such case reports are unique and infrequent. No instances of cecocecal intussusception have been reported following total appendiceal inversion, although Hallatta reported a right lower quadrant mass with discomfort which subsided spontaneously. The child’s propensity for intussusception is at the ileocecal valve and not at the base of the cecum. There has been no age restriction to this form of appendectomy. This procedure has been carried out in children ranging in age from 24 hours to 15 years.
363
TOTAL INVERSION OF THE APPENDIX
The technic is particularly suitable in such pediatric surgical problems as malrotation of the colon and small bowel stenosis. On the other hand, we feel a definite contraindication exists in cases of an “unused” colon as is seen, for example, in meconium ileus or intestinal atresia. The miniature colon in these instances would be almost occluded by the inverted appendix. Nor, do we believe appendiceal inversion should be carried out when operating on children for abdominal pain when no explanation for such symptoms are found at the time of laparotomy. In these patients, “amputation” appendectomy should he accomplished so that the organ may be submitted for pathologic study. CONCLUSIONS
Total inversion of the vermiform appendix is a safe and effective method of appendectomy. By elimination of contamination by this technic, potential postoperative complications of wound and pelvic infection, adhesive bands, and possibly subsequent ectopic tubal pregnancy should be minimal. The avoidance of such complications in younger subjects with a full life expectancy is especially advantageous. SUMMARIO IN INTERLINGUA Quando le provision de sanguine de1 appendice es interrumpite, le integre organ” potr esser intussuscipite super se mesme e-subsequentemente-invertite ad in le ceco ubi illo es promptemente disintegrate, con separation de su attachamentos. A nulle tempore es il necessari aperir le lumine de1 intestino, de maniera que omne contamination es evitate. Iste forma de appendicectomia elective esseva effectuate in 108 juveniles, sin complication. In juvene subjectos con plen superviventia probabile, evitar omne potential complicationes postchirurgic per infection intravulneral e intrapelvic, per bandas de adhesion. e possibilemente per le occurrentia subsequente de ectopic pregnantias tubal es particularmente desirabile. REFERENCES 1. Ludbrook, J., and Spears, G. F. S.: The risk of developing appendicitis. Brit. J. Surg. 52:856, 1965. 2. Edebohls, George M.: Inversion of the vermiform appendix. Am. J. Med. Science 109:650, 1895. 3. Filho, Brandao: Invagination de l’appendice. Presse Med. 31:6, 1923. 4. Christitch, Stavra: Invagination de l’appendice ileo-caecal comme operation complementair de la laparotomie gynecologigue. Gynec. et Obst. 37:194, 1938. 5. Hallntt, J. G.: Inversion of the entire
appendix as an incidental procedure. Amer. J. Obstet. Gynec. 75:1043, 1958. 6. Warden, M. Jas.: Personal communication. 7. Welch, Claude E.: Intestinal Obstruction, Chicago, Year Book Publishers, 1958. 8. Hallatt, J. G.: Personal communication. 9. Hood, P. A.: Intussusception in infants and children. J. Irish Med. Ass. LX:l3, 1967. 10. Gross, Robert IX.: The Surgery of Infancy and Childhood. Philadelphia, Saunders. 1953.