Appendectomy : How I do It

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appendix Leonardo Da Vinci 1492 1886

Reginald Heber Fitz abscess right iliac fossa ruptured appendicitis

early recognition condition 1894 Charles McBurney

appendectomy incision acute appendicitis
(Acute abdomen)

Indication
1. Clinically diagnosed acute appenditis
2. After subsided from appendiceal phlegmon abscess controversy rate recurrent
appendicitis 7-45% 8-12 operation interval appendectomy
fecalith appendectomy routine
risk appendicitis prophylaxis
complication

2
1. Uncomplicated cases

ruptured

appendicitis
2. Complicated cases
ruptured appendicitis sign peritonitis 2 quadrants
Choice of anesthesia
1. General anesthesia with endotracheal intubation
2. Spinal anesthesia alternative option
ruptured
Preoperative talks

based on clinical diagnosis accuracy 80-

90%


negative
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finding
postoperative morbidity

x-ray CT scan

CT scan

film acute abdomen series free air peptic ulcer

perforation CT scan right-sided diverticulitis right-sided

colonic cancer confirm

ruptured appendicitis

reasonable risk

100%

100%

Laparoscopic diagnosis unnecessary appendectomy

Preoperative preparation
Uncomplicated cases order
- NPO
- CBC, UA, anti HIV
- BUN, Cr, Electrolytes ( > 40 )
- CXR, EKG ( > 40 )
- IV fluid hydration
- Preparation of abdomen and perineum
- Antibiotics (Cefoxitin 1 gm IV or Metronidazole 500 mg. IV + Gentamicin 160-240 mg. IV)
- OR on call
complicated cases fluid resuscitation monitor urine output
Foley catheter NG tube decompress stomach

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Surgical Approach
2

Open appendectomy
2. Laparoscopic appendectomy alternative option
female with child-bearing age, obese patient, equivocal diagnosis
intra-abdominal abscess open (7.4% vs 4.6%)
1.

Surgical Technique in open appendectomy

Position
Supine position
Preparation of operative site
Scrub paint antiseptics mid-thigh ( explore lap)
Choice of incision
1. Gridiron incision
2. Lanzs incision (Transverse incision)
3. Rutherford Morrison incision ( muscle extend skin incision)
4. Right paramedian incision
5. Lower midline incision

case clinical complicated appendicitis retrocecal appendicitis or

paracecal type incision Gridiron Lanzs incision

case ruptured lower midline incision\
case retrocecal or paracecal type Gridiron incision or Rutherford Morrison incision (
muscle incision)
approach peritoneal cavity

a. subcutaneous tissue scarpa fascia external oblique aponeurosis

tooth forceps incision skin skin
b. internal oblique muscle transversalis fascia clamp 2
transversalis fascia peritoneum
c. Army-navy retractor muscle fiber incision skin
d. Stop bleeding muscle
e. peritoneum inflamed
f. clamp peritoneum 2 1-2 mm.
g. bowel omentum clamp
h. peritoneum swab drape field contamination
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i. peritoneum
i.
ii. Omentum inflammation
j. retractor peritoneum skin incision
Appendix

Fact
1. cecum
2. Appendix taenia 3 cecum constant anatomy
3. Type retrocecal type 35-75%
Technique cecum
i. sponge 1-2 lateral abdominal wall bowel medical cecum
structure lateral
ii. taenia babcock
iii. cecum cecum fat epiploaca sigmoid colon fat epiploaca
transverse colon sigmoid fat epiploaca
iv. taenia base of appendix
v. retrocecal paracecal type mobilize cecum white line right lateral
cecum expose appendix
Appendectomy

1. Simple case ( omentum ruptured)

mesoappendix appendix tension mesoappendix Babcock
appendix forcep clamp mesoappendix clamp
2 clamp ( appendix) silk 2-0 3-0
base of appendix
Clamp appendix 2 0.5-0.8 cms.
mucosa phenol cautery
2. Ruptured case
control contamination rupture gauze
spillage midline incision control contamination
3. Omental walled off
simple case omentum omentum appendix
4. Paracecal type or retrocecal type
white line mobilize cecum
mesoappendix base appendectomy control appendiceal stump
mesoappendix (Retrograde appendectomy)
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Management of appendiceal stump

3

1. Inversion alone
2. Ligation alone ligation, double ligation, sutured ligation cecal abscess
contamination
3. Ligation and inversion cecal abscess

cecum

cecum tissue 2 3
cecum tissue inflamed suture materials cut through 2
(ligation alone)
suture materials
2 (ligation alone) nonabsorbable sutures silk 2-0 prolene 2-0
3 (ligation and inversion) absorbable sutures (chromic 2-0) ligation
nonabsorbable sutures (silk 3-0) inversion pursestring suture
Technique pursestring sutures
appendix (B) appendiceal stump (A) B > A
stump appendix
seromuscular suture lumen bowel
Cleansing
1. Right paracolic gutter
2. Pelvis (Cul de sac)
3. Options contamination interloop small bowel subhepatic space
tip appendix tissue debris slough
Closure
1.
2.
3.
4.

Peritonization chromic catgut 2-0 3-0

Muscle transversalis internal oblique chromic 2-0 approximate
External oblique aponeurosis vicryl 2-0 interrupted
Subcutaneous tissue skin Nylon 3-0 4-0 approximate
cover base

Postoperative care
antibiotics
1. Uncomplicated cases ruptured gangrene inflamed
antibiotic immunocompromised host
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2. Complicated cases
a. Ruptured appendicitis antibiotics treatment 7-14
24-48
b. Gangrene appendicitis antibiotics 24-48 off treat bacteremia

Special considerations
grossly normal appendix
diagnosis (TOA, PID, Ovarian tumor, Endometriosis) Terminal ileitis
gangrene perforation , Meckels diverticulitis diverticulectomy, Cecal diverticulitis
complication abscess antibiotics, Mesenteric adenitis smear fluid ,
Peptic perforation fluid right paracolic gutter acute appendicitis clue
fluid fibrin incision midline explore
remove appendix grossly normal appendix focal
microscopic inflammation 25%
appendix

Mobilize cecum taenia confluence 3 taenia

absence of appendix rare sigmoid transverse colon cecum
appendix
appendiceal mass
appendiceal phlegmon inflammation appendectomy
injury antibiotic

Appendiceal tumor primary carcinoid tumor adenocarcinoma Secondary metastatic

adenocarcinoma colorectal ovary general surgeon . refer
finding
appendiceal abscess
drainage priority drain close system (silastic or tube drain) abdominal wall
appendix appendectomy drain
ruptured base appendix
appendectomy base necrotic tissue ruptured clear serosa
debride base cecum bleed 2 figure of eight Z-stitches
base 0.5 cm all layers serosa mucosa Vicryl 3-0 Dexon 3-0 2
seromuscular suture silk 3-0 interrupted tube drain detect leakage 1
stump Post-up feces tube drain ( leakage) off tube

drain
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 drain drain
ruptured appendicitis collection pus loculated drain
close system drainage silastic or tube drain
drain

loculated pus contamination

drain appendiceal stump burst cecal

tissue ruptured base Z-stitches close drainage

Mortality acute appendicitis
ruptured 2-8.5% ruptured 35%
Mesoappendix gangrene cut through
inflammation silk 3-0 tissue friable
tissue bleed
ligate
Observe
6-12

References
1. Jaffe BM, Berger DH. The Appendix In: Brunicardi FC, Anderson DK, Biliar TR, Dunn DL, Hunter JG, Pollock RE.,
editors. Swartzs Principle of Surgery. 8th ed. Mcgraw-Hill Inc.;2005. p119-37.
2. Ho HS. Appendectomy. In:Souba WW, Fink MP, Jurkovich GJ, Kaiser LR, Pearce WH, Pembertom JH, Soper NJ.,
editors. ACS Surgery Principles & Practice. WebMD Inc.;2004. p.598-606.

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 1 incision appendectomy

2 purse-string suture

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