Necrotising fasciitis is a serious postoperative complication with a reported mortality of 29–76%.2
This case documents the successful management of this condition following laparoscopic appendicectomy in a young fit male patient.
Contamination of the port site seems the most probable source of infection in our case as the necrotising fasciitis was centred on the LIF port site. Other probable sources could be either direct spread to the abdominal wall from the inflamed or exogenous pathogens invading the wound perioperatively. Haematogenous spread from distant infection has also been reported.3
Laparoscopic appendicectomy for acute appendicitis has been shown to be of benefit by reducing postoperative recovery time in a prospective randomised trial4
and some studies show it is associated with fewer wound infections than open appendicectomy.5
Perioperative systemic antibiotics have also been beneficial in reducing postoperative septic complications in non-perforated6
appendicitis, are recommended in both open and laparoscopic appendicectomy7
and were used in our case.
An endoscopic non-porous retrieval bag, for extraction of gallbladders and appendices, is considered good practice in reducing port site infections.8
In this case, although such a bag was used, contamination of the outside was inevitable due to the presence of free pus.
In this case, the diagnosis of necrotising fasciitis was made promptly thanks to a high level of clinical suspicion. The disproportionate pyrexia, tachycardia and pain were sufficient to suggest the diagnosis and the palpable crepitus mandated surgical exploration. Prompt surgical intervention with debridement, together with multi-disciplinary management by the surgical, HDU, microbiology and tissue viability teams, contributed to a successful outcome.
Necrotising fasciitis should be considered as a diagnosis in patients whose condition deteriorates after apparently straight forward emergency surgery even if laparoscopic.
- Necrotising fasciitis can complicate laparoscopic surgery.
- It is an uncommon condition but potentially fatal without prompt recognition.
- All staff should be aware of the characteristic symptoms and signs, maintain a high index of suspicion and request early senior review if the diagnosis is suspected.