29 In the world of minimally-invasive surgery, is there still a place for an open approach for acute appendicitis?

Abstract Introduction Acute appendicitis is the most common cause of acute abdomen in the Emergency Department. Laparoscopic surgery has improved treatment for this condition, reducing surgical time, hospital stays, and postoperative complications. However, there are still a few scenarios where the approach must be open, that is: adhesions due to previous surgeries, generalized peritonitis with unstable patients, pregnancies in the last trimester or anesthetic contraindications. It should be noted that currently, during surgical residency, trainees see and perform very few or no open appendectomies. This lack of exposure means that junior surgeons and trainees are not comfortable with this type of approach, and when to opt for open surgery can be a challenge for them. We present a case of complicated acute appendicitis with peritonitis where open surgery had to be performed after a failed attempt at laparoscopy. Case Report A 36 y.o male, with no medical history of interest, arrived at the Emergency Department with tachycardia (123 bpm), hypotension (87 mmHg sBP) and generalized abdominal pain for the last 4 days, associated with nausea, vomiting, but no fever. On physical examination, pain was located in the right lower quadrant. Laboratory results showed leukocytosis of 14 000 and a CRP of 225.3 mg/l. After hemodynamic resuscitation and stabilization, an abdominopelvic CT scan was performed, which informed of perforated gangrenous acute appendicitis with an intra-abdominal abscess and signs of generalized peritonitis. Therefore, urgent surgical intervention was decided initially with a laparoscopic approach. Upon periumbilical incision for Hasson trocar insertion, a significant discharge of purulent content was observed, and intraabdominal inspection revealed purulent peritonitis in all four quadrants, with poor abdominal distension despite high C02 flow. As the laparoscopic approach was not feasible for the surgeon, an open approach was performed (infraumbilical midline laparotomy). During surgery, generalized purulent peritonitis was confirmed, cultures were obtained, and open appendicectomy for perforated appendicitis was performed, with generous lavage. The patient needed stabilization throughout the surgery. He required vasoactive drug administration to maintain blood pressure and admission to the Intensive Care Unit (ICU) for 2 days. In the postoperative period, the patient required empirical antibiotic therapy with Piperacillin/Tazobactam and had a slow but favorable recovery. He was discharged after thirteen days, uneventfully. Educational Highlights aparoscopic approach for acute appendicitis is the gold standard in high-income countries. Currently, this is how trainees are taught during their residency. However, a lack of surgical skill development and indications for the open approach is being established because of the few cases that are performed in this way. In our tertiary care university hospital, 297 appendicectomies in adult patients were performed last year. Only 1.34% of all appendicectomies were performed though an open approach, with the consequent deficit of surgical teaching. This represents a paradigm shift with respect to surgical training in recent years. In the case presented: was the initial laparoscopic approach adequate, or should exploratory laparotomy have been performed straight away? When laparoscopic (and now robotic) surgery was introduced, the operating theatres were full of surgeons wanting to watch and learn. Now it may have to be the other way around, and when open techniques are performed, all trainees should attend, to make sure they also learn these techniques, and the indications for when to perform them.