I don´t use drains, they are unnecessary. Just a good wash and IV antibiotics.

Diogo-Filho, Augusto. The use of drain after appendectomy appendicitis, even if perforated, is unnecessary. Exceptionally, in cases of severe inflammation ilio-cecal, in which a resection ilio-cecal-colic was necessary, proceed with prophylactic abdominal drainage to exteriorize a probable lekage anastomosis.

Personally I didn't use any drain after appendectomy if good irrigation by Normal saline done . Some surgeons think the peritoneum is able to absorb everything even pus ,so the current trend to disuse the drains .

Intraperitoneal drains for ruptured appendix are necessary if abscess but not typically for peritonitis. On the other hand, a skin incisional drain could minimize the potential for wound infection.

The surgeon can decide the need for drain accordingly

Lawson Tait's dictum "When in doubt, drain" is always rewarding in surgery and open appendicectomy for a perforated appendicitis can not be an exception. One who does not leave a drain, will invariably have regrets.

A drain is needed only when an abscess cavity exists. You cannot drain the entire peritoneal cavity effectively. Regarding irrigation, you should read this http://www.ncbi.nlm.nih.gov/pubmed/22964730. It is an randomized trial that found irrigation does not improve outcomes in perforated appendicitis.

There is almost never needed to irrigate the abdominal cavity when only local fluide collection found at operation; it is better to perform the fluid aspiration or dry it out by gause pellets. The exceptions are an abcess cavity existance that should be washed out and dried carefully off many times, and be drained, and "frankly" faecal diffuse peritonitis in case of caecal disruption which I have never seen in case of the acute appendicitis, but that rarely occured due to the neglected large bowel obstruction or trauma.

About drains:

History of Surgery lists many fashions about the peritonitis treatment. In the beginning of the last centuary it was fashionable not to drain the abdominal cavity too. They said: "The abdominal cavity will cure itself better'. Sad experience followed, and that method was abandoned for long years till its oblivience have thoroughly completed.

The correctly placed drain tube is far less harmful comparing with the second-look operation or US-guided evacuation of fluid collection after the first operation.

By the way, taking in mind that more than 99% of the appendix lumen microflora is the obligate anaerobs, a light oxygene irrigation through the drain tube would be more effective than dozen of the most modern antibiotics in store.

One more fact: the abdominal cavity fluide bacterial count in case of the perforated appendicitis levels about 10,000,000/g presented by the very dangerous spp; the skin bacterial count is about 100-500/g presented with complaisant enough coagulase-negative staphylococci; the ICU air bacterial count is about 10-100/g (same staff). Make your choice, dear colleagues!

About Sophistry in general:

The arrow paradox

If everything when it occupies an equal space is at rest, and if that which is in locomotion is always occupying such a space at any moment, the flying arrow is therefore motionless as recounted by Aristotle, Physics VI:9, 239b5

If during appendectomy we find a fair quantity of pus diffused in the abdominal cavity it's mandatory a prolonged (> 10 min.) washing with a great quantity of saline (liters!!!) with aspiration until the washing liquid is completly clear. Sometimes, if it's a really diffused peritonitis, it helps to put the patient in Trendelemburg and anti-Trendelemburg position, Dx and Sx sides (this is the best procedure to avoid late post-operative abscesses). If the washing is done correctly and with great patience, the drains are not useful at all. In cases of severe diffuse peritonitis in order to prevent wound infections we always take into consideration the delayed closure of the wound (closure of the fascia but subcutaneous tissue and skin open). The wound will be closed on the 4th-5th post-operative day.

I forgot, usually antibiotics in the washing liquid are not necessary since by this way most of them are not active and effective. The quantity of saline makes the difference, since what we want to achieve is a mechanical cleaning.

Currently, there is no а a strict consensus on the use of peritoneal drains after perforated appendicitis (that confirmed by our discussion). Opinions on the practice are divided: some surgeons believe that peritoneal drains are useless, sometimes - harmful (wound infections, intrabdominal abscesses or postoperative ileus) and always do not work, while others collegues routinely use peritoneal drains as "therapeutic drains" (for evacuating an established collection of pus) or sometimes as "prophylactic drains" (for prevention of further collections or for early verification of leakages or hemorrhage). The experience of our clinic suggests that, unless an abscess or diffuse peritonitis are present, transperitoneal drainage must be abandoned for all patients with perforated appendicitis (after intraoperative peritoneal lavage without antibiotics). Similarly as in the clinic of Professor Renzo Dionigi, in all cases of perforated appendicitis with diffuse peritonitis we use delayed wound closure. In general, the question of drainage after open surgery with perforated appendicitis requires prospective study.

I must add the following sentences to this topic also:

I am agreed completely with thesis about abundant, lavish irrigation of the abdominal cavity at the perforated appendicitis complicated with the diffuse peritonitis and ileus, and the same irrigation of the abcess cavity. However, I have several more questins on the topic:

1) as far as I learned, the human peritonitis animal modelling is not possible till nowadays that makes difficult to achieve process complete understanding on the matter;

2) the inflamed peritoneum cannot stop to produce liquid at once so that the liquid would collect in the peritoneal cavity for a while after surgery without drains and may ... no, it really CAN produce ileus, pain, etc;

3) the acute appendicitis complicated with perforation is a relatively rare clinical entity 'dispersed' among patients of different age, comorbidity, time of arrival, and other properties, so that it is difficult to produce general strategy of their treatment;

4) I could not find in literature on the matter what kind of oxygene environment takes place in the abdominal cavity under normal and under pathological conditions, namely, is the normal abdominal cavity environment aerobic one, when a distance between serosal surfaces is less than 10 micrones, and whether it remains the same, to be arobic one, under pathologic conditions, when the distance becomes 1000-fold as larger, so that the oxigene diffuse process becomes by far more difficult. To leave such a anaerobic and contaminated with obligate anaerobs (as the bacteroid spp., fusobacterium spp, etc) fluid collection in the abdominal cavity would be more dangerous comparing with draining.

5) evidently enough, that the perforated appendicitis group is inhomogeneous, and should be futher devided into homogeneous subgroups, so that to achive more appriate data about the immediate post-surgery period

6) I could not find as well in this very topic anything about the drain-related complications which is dangerous enough to not permit the drain useness in clinical practice. Dear colleagues, would you speak up what are you afraid of, please? Have any tube-related complication?

Recalling the forgotten:

The questions of drainage of cases of acute peritonitis is still one of the

problems of surgery concerning which there is a diversity of opinion. There

is as yet no general agreement not only regarding when and when not to

drain, but also concerning the type of drain to be used.

[W. M. WEEDEN, M.D. / THE GIBSON-MIKULICZ DRAIN IN ACUTE APPENDICITIS

WITH REPORT OF 1588 CASES // Ann Surg. 1928 July; 88(1): 76–79]

This small randomized study in children (in 1993) found no advantage to use of drains:

http://link.springer.com/article/10.1007%2FBF00176728?LI=true

Conclusion: "The evidence suggests that, unless an abscess is present, drainage may be abandoned for children with perforated appendicitis."

A more recent randomized study came to the same conclusion. The title is misleading becasue only patients with "generalized peritonitis" and abscess were excluded - the study population was localized peritonitis (from perforated appendix).

http://www.ajol.info/index.php/ecajs/article/view/72508

However, an Abstract from SAGES 2011 reported a retrospective study that found increased postop abscess after laparoscopic appendectomy for perforated appendicitis in those patients where a drain was not used.

http://www.sages2011.org/routine-pelvic-drainage-reduces-pelvic-abscess-formation-after-laparoscopic-appendectomy-for-gangrenous-or-perforated-appendicitis/

So peritoneal drainage might be useful for laparoscopic approach to perforated appendicitis without abscess.

Thank you vary much for these items, Dr.Bowman! Unfortunately, I am not sure, what penrose drain looks like? Is it the same thing that a simple silicone tube?

No, a Penrose drain looks like a flimsy rubber "tapeworm" about 2cm wide, collapsible internal "luman" that acts primarily like a wick to allow fluid to "drain" by capillary action to the outside. This is considered "open" drain type vs "closed-suction" drains that are usually silicone and more stiff configured as single lumen connected to a suction chamber (such as Hemovac) or double lumen (one for fluid and one for "sump" air intake) connected to suction device (such as a flat Jackson-Pratt drain).

Thank you for this exhaustive explanation about drains! Now I understood.

At first, both D.A.Johnson et al, 1993; and P.G. Jani & P.N.Nyaga, 2011, studies are devoted to the Penrose drain use for the treatment of the perforated appendicitis. As far as I know at any rate, drains of this kind have not been used since the1970s in Russia for the abdominal cavity draining in the peritonitis patients. Moreover, I have has sad personal experience not use drains of such a type for other cases, because their essential feature is to really produce wound sepsis due to mechanism beyond my knowlidge and a matter of current discussion. Perhaps, they induce a rapid and abundunt mucous-like substance production of the adjacent tissue that may serve as a conductor for the abdominal microflora into the abdominal wall, or vice versa, for the cutaneous flora from surface to inside, or something of the kind. The Penrose may be good for oozing soft tissue superficial wound, and not for longer than 6-8 hours, but I think that careful hemostasis and light compression bandage (pelote, or pad, if I remember correctly its name) may be preferable due to its non-invasiveness.

So, a transperitoneal drain tube MUST be as much elastic and firm to not collapse, and as far gentle to avoid damage of the abdominal wall and neighbouring structures. A silicone tube is a quite appropriate one.

At second, the colleagues from Nairobi 'exteriozide' drain THROUGH the main wound that MUST NOT be done. When I was young and distrustful, I doubted everything that was not explained. So, I concluded two consequtive operations for the gangrenous appendicitis with lavish purulent exudate and the similar cholecystitis by insertion the drainage tube through the main wound (so that 'to avoid additional holes in the abdominal wall'). The both wounds became septic rapidly and in full their lengths. Those cases struck me so, that I have never use such a manoevre since that time. The drain tube MUST be inserted through the stab wound for its own (so that it should not connect with the main wound nor on surface, neither in depth on the abdominal wall) and it will NEVER become septic for sure, even in case of (keep away!) the peritonitis progression.

These are not all my doubts. The remain are concern the highly specific pattern of the perforated appendicitis in the cited articles, for example, the very high rate of the perforated appencitis among all cases of the acute appendicitis (from 30% to 50%), much higher prevalence of the acute appendicitis (428:10,000), and, perhaps, special pattern of the appendix microflora, relatively late admission, etc., peculiarities that make these studies hardly representative ones for north countries.

So, I daresay that further inverstigations are really needed, etc, etc...

Agree entirely!

I agree with these authors. If the rind that enclosed the abscess can be completely removed/peeled from the surfaces of bowel, omentum, and peritoneum (such as in the pelvis or gutter) then a drain is superfluous and thorough irrigation will suffice. Removing this rind is probably more difficult using the laparoscopic approach. I have used simple round silastic perforated drains in recesses (as in the pelvis or gutter) where removal of the rind was incomplete, dissection was difficult, and there was oozing of raw surfaces - a situation inviting a postoperative abscess to form.

It is imperative to completely remove any fecalith(s) that may have escaped from a perforated appendix!