Perforated appendicitis: The solution to pollution is not dilution

Published:November 15, 2022DOI:


      • Withholding irrigation decreased abscess formation from 19.6% to 9.9%, though this did not reach statistical significance.
      • Odds of abscess formation in non-irrigated patients multiplicatively increased 67% for each 6-min increase in operative time.
      • Odds of postoperative abscess formation in non-irrigated patients was 13.4 times greater with operative time ≥60 min.



      Surgical dogma states that the “solution to pollution is dilution.” We hypothesized that withholding irrigation during pediatric Single Incision Laparoscopic Surgery (SILS) appendectomies for perforated appendicitis would decrease postoperative abscess rate.


      From May 2011 to 5/2015, during SILS appendectomies, saline irrigation and suctioning was performed. From June 2015 to 8/2021, only suctioning was performed. The operations and peri-operative management were otherwise identical. We retrospectively reviewed 46 patients in the Irrigation (I) Group and 91 patients in the Non-Irrigation (NI) Group.


      Abscess rate decreased from 19.6% in Group I to 9.9% in Group NI, but this did not reach statistical significance (p = 0.12). Operative duration was significantly longer in patients who developed postoperative abscesses in Group NI (odds ratio 1.67, p = 0.002) and overall (odds ratio 1.45, p = 0.0002).


      Withholding irrigation during SILS appendectomies trended toward a decreased postoperative abscess rate. Increased operative times were associated with postoperative abscess formation.


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        • Bhangu A.
        • Søreide K.
        • Di Saverio S.
        • Assarsson J.H.
        • Drake F.T.
        Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management.
        Lancet. 2015; 386: 1278-1287
        • Wei B.
        • Qi C.L.
        • Chen T.F.
        • et al.
        Laparoscopic versus open appendectomy for acute appendicitis: a metaanalysis.
        Surg Endosc. 2011; 25: 1199-1208
        • Esparaz J.R.
        • Jeziorczak P.M.
        • Mowrer A.R.
        • et al.
        Adopting single-incision laparoscopic appendectomy in children: is it safe during the learning curve?.
        J Laparoendosc Adv Surg Tech. 2019; 29: 1306-1310
        • Emil S.
        • Elkady S.
        • Shbat L.
        • et al.
        Determinants of postoperative abscess occurrence and percutaneous drainage in children with perforated appendicitis.
        Pediatr Surg Int. 2014; 30: 1265-1271
        • Henry M.C.W.
        • Walker A.
        • Silverman B.L.
        • et al.
        Risk factors for the development of abdominal abscess following operation for perforated appendicitis in children.
        Arch Surg. 2007; 142: 236-241
        • Fike F.B.
        • Mortellaro V.E.
        • Juang D.
        • Sharp S.W.
        • Ostlie D.J.
        • St Peter S.
        The impact of postoperative abscess formation in perforated appendicitis.
        J Surg Res. 2011; 170: 24-26
        • Fraser J.D.
        • Aguayo P.
        • Sharp S.W.
        • et al.
        Physiologic predictors of postoperative abscess in children with perforated appendicitis: subset analysis from a prospective randomized trial.
        Surgery. 2010; 147: 729-732
        • Kimbrell A.R.
        • Novosel T.J.
        • Collins J.N.
        • et al.
        Do postoperative antibiotics prevent abscess formation in complicated appendicitis?.
        Am Surg. 2014; 80: 878-883
        • Coakley B.A.
        • Sussman E.S.
        • Wolfson T.S.
        • et al.
        Postoperative antibiotics correlate with worse outcomes after appendectomy for nonperforated appendicitis.
        J Am Coll Surg. 2011; 213: 778-783
        • Siotos C.
        • Stergios K.
        • Prasath V.
        • et al.
        Irrigation versus suction in laparoscopic appendectomy for complicated appendicitis: a meta-analysis.
        J Surg Res. 2019; 235: 237-243
        • Bi L.W.
        • Yan B.L.
        • Yang Q.Y.
        • Cui H.L.
        Peritoneal irrigation vs suction alone during pediatric appendectomy for perforated appendicitis: a meta-analysis.
        Medicine. 2019; 98
        • Anandalwar S.P.
        • Cameron D.B.
        • Graham D.A.
        • et al.
        Association of intraoperative findings with outcomes and resource use in children with complicated appendicitis.
        JAMA Surg. 2018; 153: 1021-1027