Summary Recommendations - ESRA
×
ESRA Members Login
Forgot Password?
Renew Membership | Register
View all Procedures

New: Appendicectomy

Translate

Summary Recommendations

PROSPECT provides clinicians with supporting arguments for and against the use of various interventions in postoperative pain based on published evidence and expert opinion. Clinicians must make judgements based upon the clinical circumstances and local regulations. At all times, local prescribing information for the drugs referred to must be consulted.

Appendicectomies are frequently performed laparoscopic and open procedures. Despite this, peri-operative pain is inadequately treated due to limited evidence on the most effective treatment options. Furthermore, appendicectomies are often viewed as minor or less invasive procedures, leading to pain being underestimated and undertreated. Effective postoperative pain management shortens hospital stays, reduces risk of chronic pain, and reduces morbidity and mortality (Kehlet 2006; Pöpping 2008; Beattie 2003; Rodgers 2000; van Boekel 2019).

This PROSPECT review (Freys 2024) aimed to develop evidence-based, procedure-specific recommendations for pain management following appendicectomies. Recommendations were made by systematically evaluating available literature on the impact of analgesics, anaesthetics, and surgical interventions on pain. All recommendations apply to both children and adults.

The unique PROSPECT methodology is available at https://esraeurope.org/prospect-methodology/. The methodology reflects on clinical practice, efficacy, and adverse effects of analgesic techniques. This has been updated now for future reviews (Joshi 2023).

Literature databases were searched from January 1999 to October 2022.

Summary of recommendations and key evidence for procedure-specific pain management in patients undergoing appendicectomy (children and adults)  

Surgical intervention
Three-port laparoscopic appendicectomy is recommended over open appendicectomy due to lower pain scores and reduced complications

Pharmacological treatment
Systemic analgesia should include paracetamol and NSAIDs (or selective COX-2 inhibitors in adults), administered pre-operatively or intra-operatively and continued postoperatively for basic analgesia

  • Despite limited evidence for systemic non-opioid analgesics in appendicectomy, these are fundamental in all peri-operative pain control protocols, with their analgesic effects being well established (Joshi 2014; Martinez 2017; Ong 2010)
  • There is debate regarding the use of NSAIDs during gastrointestinal operations, particularly with digestive anastomoses. However, appendicectomy typically involves a closing suture, and recent studies showed a well-documented safety profile, even in the context of colonic anastomoses (Gustafsson 2019; Arron 2020; Morris 2020)
Opioids should be reserved for rescue analgesia

Laparoscopic appendicectomy – Regional analgesic strategies

Instillation of intraperitoneal local anaesthetic is recommended pre-/intra-operatively

  • Several studies demonstrated mostly positive results, leading to it being recommended despite limitations present in adult studies. Limitations included heterogeneity in study designs with variability in placement of local anaesthetic, and not reporting complications and basic analgesia (Thanapal 2014; Sevensma 2019; Kang 2010; Kim 2011; Čustovic 2019; Hamill 2017; Elnabtity 2018)
  • This technique does not have relevant side effects and has a rapid and straightforward application
  • Regional analgesia spares opioid use during and after surgery

Open appendicectomy – Regional analgesic strategies
Pre-operative unilateral TAP block is recommended

  • Several studies showed a significant and clinically-relevant analgesic benefit of a TAP block as a component of multimodal analgesia with no increase in complications (Patel 2018; Niraj 2009; Abdul 2014; Carney 2010; Ramzy 2014)
  • Regional analgesia spares opioid use during and after surgery
Pre-incisional infiltration with local anaesthetics into the skin and external oblique is recommended if TAP block is not possible

  • Studies showed a relevant reduction in pain severity with little to no side effects compared with no infiltration or subcutaneous infiltration alone (Refaat 2015; Lohsiriwat 2004; Randall 2010)

COX, cyclooxygenase; NSAID, non-steroidal anti-inflammatory drug; TAP, transverse abdominis plane.

Analgesic interventions that are not recommended for pain management in patients undergoing appendicectomy

Intervention

Reason for not recommending

Laparoscopic appendicectomy

Pre-operative
Dexamethasone/corticosteroids Limited procedure-specific evidence
Local wound infiltration with local anaesthetics in single incision technique Lack of procedure-specific evidence
Intravenous lidocaine Lack of procedure-specific evidence
Combined spinal + epidural block Limited procedure-specific evidence
Pentoxifylline Limited procedure-specific evidence
Interfascial plane blocks Limited procedure-specific evidence
Bilateral TAP-block Lack of procedure-specific evidence
Bilateral quadratus lumborum block Lack of procedure-specific evidence
Intra-operative
Single-port incision Inconsistent evidence and risk of

postoperative complications
Needlescopic technique Lack of procedure-specific evidence
Double-incision, three-port technique Lack of procedure-specific evidence
Hem-o-Lok clips to close stump Lack of procedure-specific evidence
Intraperitoneal nebulised ropivacaine Lack of procedure-specific evidence
Warm humidified carbon dioxide insufflation Lack of procedure-specific evidence
Post-operative
Topical lidocaine patch on trocar site Lack of procedure-specific evidence

Open appendicectomy
Pre-operative
Ketamine Limited procedure-specific evidence (and no basic analgesia in the positive study)
Intra-operative
New right groin incision vs McBurney’s incision Lack of procedure-specific evidence
Cutting diathermy vs scalpel skin incisions Lack of procedure-specific evidence
Peritoneal closure vs non-closure Lack of procedure-specific evidence
Subcuticular vs transdermal or interrupted suturing Lack of procedure-specific evidence
Post-operative
Morphine added to bupivacaine for TAP block Lack of procedure-specific evidence
Continuous wound infiltration with local anaesthetics Conflicting procedure-specific evidence
Aromatherapy Limited procedure-specific evidence

TAP, transverse abdominis plane.

COX, cyclooxygenase; NSAIDs, non-steroidal anti-inflammatory drugs; TAP, transverse abdominis plane.

PROSPECT recommendations for appendicectomy – infographic