|Year : 2012 | Volume
| Issue : 2 | Page : 106-109
Management of appendix stump: The technique
Gurjit Singh, Apoorva Pandey
Department of Surgery, Padmashree Dr. D.Y. Patil Medical College, Sant Tukaram Nagar, Pimpri, Pune, Maharashtra, India
|Date of Web Publication||10-Nov-2012|
Department of Surgery, Padmashree Dr. D.Y. Patil Medical College, Sant Tukaram Nagar, Pimpri, Pune - 411018, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Time and again the technique of appendectomy for acute appendicitis has been debated, and optimal management of the stump is still a matter of discussion. Thus, a study was proposed to compare two techniques of management of the stump i.e., simple ligation alone vs. ligation and invagination of the stump with purse string sutures. Aim: To compare and evaluate simple ligation alone with ligation and invagination of the stump during appendectomy. Materials and Methods: A total of 102 patients were included in this study. Each patient was alternately divided under two groups (Group A: Simple ligation of the stump and Group B: Ligation and invagination of the stump with purse string sutures). The two techniques were compared with respect to duration, intra-operative and post-operative complications. Results: It was observed that simple ligation is not only an equally safe a procedure, but is also better in terms of duration of the procedure, which was seen to be less in the case of simple ligation alone. Post-operative course as well as duration of hospital stay was similar in both the groups. Conclusion: Simple ligation is as good a technique as ligation and stump invagination with purse string sutures with respect to the results of the procedure.
Keywords: Appendicectomy, appendicitis, appendicular stump
|How to cite this article:|
Singh G, Pandey A. Management of appendix stump: The technique. Med J DY Patil Univ 2012;5:106-9
| Introduction|| |
Appendicitis is a clinical emergency; if left untreated, it has the potential for severe complications, including perforation or sepsis, and may even cause death.
Based on the high rate of failure with antibiotics alone, non-operative management of acute appendicitis cannot be recommended. Antibiotic treatment may be a useful temporizing measure, in environments with no surgical capabilities. 
Appendicectomy has been the definitive treatment for acute appendicitis. Open appendectomy is still the most common approach because it is quick and cost-effective.
A traditional method of dealing with the appendix stump is to crush it, ligate it and then invaginate it, as described by Miles and Wilkie, carbolisation of the stump prior to invagination was included as an added safeguard method against infection. 
After ligation or transfixation of the appendix stump, some surgeons invaginate the stump by the means of a purse string stitch or a Z-stitch or doubly invaginate the stump. 
On the other hand, those who do only simple ligation, found it simpler, less time-consuming and without interfering with anatomy of cecal wall. 
Therefore, it was proposed to undertake a study to compare the two methods of dealing with amputated appendicular stump in cases presented in our hospital.
| Materials and Methods|| |
The study was of prospective type, conducted from April 2008 to September 2010.
In all, 102 patients were included during the above period for this study. They were divided alternately into Group A and Group B.
Group A: Simple ligation - 51 cases.
Group B: Ligation with invagination of appendix stump - 51 cases.
All the patients above 12 years of age were included in the study and patients who underwent interval appendectomy or diagnosed with perforated appendix and appendicular lump were excluded.
All the patients were evaluated as per the proforma, which included pre-operative workup of the time taken to complete each procedure from skin to skin, intra-operative complications if any (cecal wall puncture, serosal tear etc.) culture from the cut surface of the appendix all the specimens were sent for histopathological examination. Post-operatively, all the patients were given the same antibiotics. Post-operative complications (post-operative pain, vomiting, wound infection, etc.) were recorded. Wound inspection was done on post-operative day three and five, incidence of wound infection in the two groups was recorded and the discharge was sent for culture and sensitivity. Duration of hospital stay was noted in the two groups and after discharge the patients were followed-up for six months.
Wound infection was defined as:
Infection occurring within 30 days of surgery involving only the skin and subcutaneous tissue with one of the following features:
Clinically at least one of the following signs of infection should be present:
- Purulent discharge from a superficial infection
- Organisms isolated from aseptically obtained wound culture
Sutures were removed on day 8 post-operatively.
- Pain or tenderness
- Localized swelling
- Redness or raised temperature
Once the patient was discharged, pain during follow-up was measured using a visual analog scale [Figure 1].
| Results|| |
All the 102 patients included in the study underwent appendectomy. Both the groups had 51 patients each. Group A (who underwent simple ligation) as well as Group B (underwent ligation and inversion) patients had the highest incidence of appendicitis in the age group of 21 to 30 years and was more commonly seen in males. Migratory right iliac fossa pain was the most common symptom present in all the patients (100%) and tenderness in right iliac fossa was the most common sign elicited (98%). The most common position recorded in this study was retrocecal (35%).
Intra-operative complications like cecal wall puncture and serosal wall tear [Table 1] were more common in Group B. Slipping of ligature, where another ligature was required to tie the stump of the appendix, was more commonly seen in Group A.
The mean duration of the procedure from incision to skin closure was less in Group A (48.2 minutes) in this study when compared to Group B (60.9 minutes). [Figure 2]
The rate of wound infection as well as the duration of hospital stay was not of much difference in the two groups. The most common organism cultured from the cut surface of the appendix was Klebsiella and the most common organism cultured from the post-operative infected wounds was Staphylococcus.
The post-operative course of the patients in both the groups was similar. The difference between the post-operative complications like ileus and wound infection was of no significance in either of the groups [Table 2].
Post-operative wound infection increased the duration of hospital stay in both the groups by an average of one week.
All the patients were followed-up for six months, out of which 76 patients completed the follow-up period. During the follow-up, the most common complaint of the patients was persisting dull aching pain over the operated site, which was measured using visual analog scale.
| Discussion|| |
Acute appendicitis is one of the most common surgical emergencies, which is common in the second and third decades of life.  During appendectomy, some surgeons do simple ligation [Figure 3] alone of the appendix stump while others prefer to invaginate the stump using purse string sutures [Figure 4]. This study was aimed to evaluate the two methods of dealing with the stump. The reasons given for the invagination of the stump are safety against the slipping of the ligature from the stump, less chances of peritonitis from spillage of pathogens from the remaining stump, and less incidence of post-operative wound infection.  On the other hand, those who had simple ligation of the stump found it to be simpler and less time-consuming, leaving the anatomy of the cecal wall intact, with no difference in the incidence of post-operative paralytic ileus and wound infection.  In our study, it was also seen that with purse string sutures there are more chances of intra-operative complications like cecal wall puncture and serosal tear. The duration of the procedure was seen to be less in case of simple ligation alone. There was no significant difference in the incidence of wound infection in the two groups in our study. This was also observed by Engstrom, Watter and Dass. ,, Follow-up of the patients for six months revealed no serious complications like residual abscess or any type of peritoneal adhesions following simple ligation, which have been stated in the literature. The only problem reported was prolonged dull aching pain over the operated site, which was equal in both the groups.
| Conclusion|| |
It can be concluded that simple ligation of the appendix stump is an equally safe and shorter procedure for managing the stump during appendectomy with no difference in the outcome in comparison with invagination of the stump with purse string sutures.
| References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]