A Comparative Study between closure and non-closure of peritoneum during appendicectomy

Introduction

The clinical diagnosis of appendicitis is controversial, and appendicitis continues to present challenges for surgeons even today.^1-3 Appendicitis is a common surgical emergency and appendectomy is the common abdominal surgical procedure performed for the same.^1,4,5 Re-approximation of peritoneum after appendicectomy has been widely performed on a routine basis. On the contrary, theoretical considerations and animal experiments support that suture peritonisation tends to cause ischemia, necrosis, inflammation and foreign body reactions to suture material. These factors may slowdown the healing process and are considered important precursors of adhesion formation. On the other hand, clean excision of peritoneal surface without suturing the cut edges provides more rapid peritoneal repair and does not lead to tissue ischemia and inflammation, thus decreasing the risk of adhesion formation.^1,6 Due to the presence of mesothelial cells in the peritoneum, spontaneous reperitonealization will be initiated within 48 to 72 hours after injury with complete healing in 5 to 6 days.⁷

Closure of peritoneum after lower abdominal surgeriessuch as appendicectomy does not provide additional advantage but is associated with more complications.Moreover, non-closure of peritoneum at lower abdominal surgery and appendectomy is associated with reduced use of analgesics and shorter hospital stay.⁸

Much of the experience on non-closure of peritoneum in the literature comes from obstetric and gynaecological surgeries. The post-operative pain still remains a controversial issue.9This study was undertaken to compare the outcome and safety of peritoneal non-closure and closure in regard to operative time, post-operative pain, wound infections, duration of hospital stay and post-operative hernia in 6 months follow up.

Material and methods

This was a hospital based randomized controlled study conducted after approval of the institutional ethical committee in Mahadevappa Rampure Medical College, Kalaburgi. Total 200 patients with the diagnosis of acute appendicitis were recruited. Follow up was done after 15 days, 1 month and 3 months till August 2019.

Inclusion criteria:

All patients of age between 15-65 years with clinical diagnosis of acute appendicitis undergoing open appendicectomy.

Exclusion criteria:

Intra-operatively diagnosed free purulent fluid in abdominal cavity, preoperatively diagnosed intra-abdominal abscess, appendicular mass and perforated appendix, pregnancy, immune-compromised patients, patients with history of malignancy, mental retardation/ addicted to drugs/ psychiatric illness, chronic liver failure, diabetes mellitus andpatients denial to participate to study.

Using a proforma, details of patient demography, clinical findings at admission and parameters relevant to study were recorded.

Patients were divided in two groups:

Group A:

Patients subjected for open appendicectomy who underwent closure of peritoneum.

Group B:

Patients subjected for open appendicectomy who underwent non-closure of peritoneum.

Patients were randomly allotted to either of the groups based on surgeons individual preference. All patients underwent open appendicectomy and follow up was done till August 2019.

To assess immediate post-operative pain patients were divided into two groups:

•  Standard analgesics requirement.

• High analgesic requirement.

All patients were given same analgesics (inj. Diclofenac) in recommended doses as per weight for 3 days. Patients who required analgesics for more than 3 days or patients who required more than one analgesics (inj. Tramadol) were said to be in high analgesics requirement group. Post -operative pain is assessed by Visual Analog Scale (VAS) for pain.

Study parameters

Operative time (minute):

The time required for surgery was noted from skin incision to skin closure.Post-operative pain: Perception of postoperative pain by VAS scale among the subjects.

Analgesic requirements:

After surgery the patients requiring analgesics were grouped in two categories as those requiring standard analgesics and those who require high analgesics.

Post-operative complications:

Like development of surgical site infection, wound gaping and delayed wound healing.Post-operative hospital stay:Duration of hospital stay following surgery.

Pain persistence during follow-up:

Patients were followed up on 15 days, 1 month and 3 months.

Statistical analysis:

All the data collected were entered into the Statistical Package for Social Sciences (SPSS). Mean and standard deviation is used for quantitative data, while frequency and percentage were calculated for qualitative data. For independent samples t-test/student t-test/ chi-square test was used for comparison p-value of <0.05 was considered as significant.

Results

Among the subjects, all of them (100%) had right iliac fossa pain, followed by pulse rate of more than 100 among 97%, nausea (20.5%), fever (16.5%), vomiting (12%). (table 1).

Among the study subjects most  (40.5%) were operated between 61-90 minutes, some (30.5%) were operated less than 60 minutes, and few (29%) were operated more than 90 minutes. (Table 2)

Among the study subjects, 41.5% perceived mild post-operative pain, 35.5% did not perceive any pain and 23% perceived moderate pain. (table 3).

Analgesic requirements, Post-operative complications:

Among the total subjects, 134(67% )required standard analgesics following surgery and 66 (33%) showed higher requirement of analgesics., 2.5% subjects developed post-operative complications like surgical site infection and wound gaping. Among the subjects,51( 25.5%) were discharged in less than 3 days.132 (66%) were discharged between 3-6 days and  17 (8.5%) after 6 days. Persistence of  pain lasted in 161(80.5%) subjects for 15 days during follow-up. Pain persisted in 17 (8.5%) subjects during 1 month follow-up and 3  (1.5%) subjects showed persistence of pain for a period 3 months.

Discussion

Simplified surgical technique requiring less foreign material is beneficial to the patient. Reapproximation of peritoneal edges even with suture material considered to be minimally reactive results in increased tissue ischemia, necrosis and foreign body reactions leading to adhesion formation.^10-12 So suturing the peritoneum may actually increase the risk of adhesion formation.

Histological studies in animals have revealed that the peritoneum regenerates de novo and not from cut edges of the defect as in skin wounds, because the entire surface becomes mesothelialized simultaneously. Therefore, peritoneal defects even large when left undisturbed demonstrate mesothelial integrity by 48 hours and complete indistinguishable healing by 5 days.^11,12

In this study an attempt is made to evaluate the effect of non-closure of peritoneum in open appendicectomy, in terms of intra operative and post-operative course and to compare the two surgical techniques-closure and non-closure of peritoneum at open appendicectomy in various aspects described.

In the present study, in relation to operative time, all (100%) the subjects with operating time less than 60 minutes had non-closure of peritoneum.  The mean time required for surgery in group A was 100 minutes. In group B mean duration was 87.5 minutes. This was statistically significant (table 4) .

In present study, in relation to perception of postoperative pain, among the subjects with no pain, majority (57.5%) had non- closure of peritoneum. However, this association was not statistically significant (Table 9).  The results comparing the occurrence of post-operative pain with the results of Esha Trivedi and coworkers showed no difference.¹⁴

In this study, in relation to post-operative analgesic requirement, among the subjects who required only standard analgesics, majority (56%) of them had non-closure of peritoneum. Those who required high analgesic requirement, majority (41%) are closure of peritoneum. This association was statistically significant Table 10: association between analgesic requirement in closure and non-closure group and was statistically significant (table 5 and 6).

In this study, in relation to post-operative complications, among the subjects who did not develop any complications, majority (50.8%) had no-closure of peritoneum. However, this association was statistically not significant (Table 7).

In this study, in relation to post-operative hospital stay, among the subjects who were admitted for more than 6 days, majority (82.3%) had closure of peritoneum. This association was statistically significant and was comparable with the results of Esha Trivedi et al¹⁴.

Persistence of pain and complications during follow up of 15 days, 1 month and 3 months of closure vsnon-closure of appendicectomy.

In present study, in relation to persistence of pain and complications like incisional hernia, wound dehiscence was observed during follow up of 15 days, 1 month and 3 months. Among those subjects who had pain during 15 days follow up are patients of closure of peritoneum (56.4%). However, this was not statistically not significant. Follow up after 1 month shows subject who did have pain, majority (82.4%) had closure of peritoneum. This association was statistically significant. Follow up of 3 months, among those subjects who did have any pain, majority (66.7%) had closure of peritoneum. This association was statistically not significant.

Conclusion

Non-closure of peritoneum in open appendicectomy is associated with lesser operating period, shorter duration of stay in the hospital and low requirement of postoperative analgesia. No difference in perception of post-operative pain and the incidence of post-operative complications when compared to closure of peritoneum in open appendicectomy. Hence, non-closure of peritoneum in open appendicectomies can be recommended.