Home Terms of Use Agreement Privacy Policy Bio Contact

Appendix Removal (Appendectomy)

April 1, 2006 | Posted in Appendix Surgery Open Technique Indications Appendicitis acute or subacute process that causes the lumen of the appendix (which is a blind sac) to become obstructed with buildup of pressure and eventual rupture. Mass rarely an appendiceal mass is found on CT scan or during intra-abdominal surgery (laparotomy) Abscess if found secondary to appendicitis it must be drained. If it is diagnosed preoperatively care currently is to have an interventional radiologist (a radiologist who does procedures) drain the abscess via a percutaneously (through the skin) placed catheter that is left in place to decompress the cavity and allow it to heal from the inside out. The appendix is then removed at about 6 weeks. If it is found during surgery it must be decompressed and a drain left in place in the abcess cavity by the surgeon.

Contraindications Existing appendiceal rupture with defined abscess cavity. Appendicitis in setting of adjacent inflammatory bowel disease (e.g., a Crohns disease flare-up in the contiguous terminal ileum or cecum. Diagnosis Clinical diagnosis appendicitis remains a clinical diagnosis primarily. There is no set of invariably ocurring signs and symptoms. The two most common are anorexia (loss of appetite) and pain, although there are many cases of appendicitis that have neither of these. Other signs and symptoms included pain around the umbilicus that moves to the right lower quadrant, fever, nausea, vomiting, diarrhea, rigid and board-like abdomen, and worsening pain on walking.

Appendicitis is most difficult to clinically diagnose in the very young and very old and in patients who are diabetic or on steroids. Radiographic diagnosis there are three radiographic studies that are commonly used to help diagnose appendicits, although in clear-cut clinical cases none is absolutely required. The most widely used is computed tomography (CT) of the abdomen and pelvis with 5 mm cuts. For best results this should be performed with intravenous dye, dye given by mouth (or PO), and dye given per rectum (although this is often not done as it is uncomfortable for the patient and radiology technician both.) Findings consistent with appendicitis are stranding in the mesentery, non-visualization of the appendix lumen, fluid in the pelvis, and an enlarged and thickened appendix, especially if it is seen in cross-section. It must be noted that a normal CT does not rule appendicitis. Studies have shown that a CT can miss appendicitis, especially in the early stages, in up to 10% of cases. Although less widely used today, plain-film radiography (aka a flat plate) can be helpful in showing an opacity in the right lower quadrant that could be suggestive of an fecolith (insissipated stool in the mouth of the appendix). The third radiology test that is sometimes used in children is an ultrasound of the right lower abdomen. This test is easy to perform, non-invasive, and has no radiation exposure, but it is of limited help as it is sometimes difficult to visualize the appendix (either normal or inflamed). It is almost never used in adults due to the larger body habitus. Preoperative Workup and Preparation Fluid Resuscitation this usually consists of crystalloid fluids intravenously to restore any intravascular fluid depletion that might be present due to inflammation of the peritoneum (peritonitis) and fluid sequestration in the intraabdominal tissues (third spacing). The fluid given is usually normal saline solution or lactated Ringers solution. Antibiotics uniformly given. Since the appendix comes off the terminal ileum at the juncture of the colon, rupture leads to spillage into the peritoneal cavity of gram negative and anaerobic bacteria. The type antibiotics given are Unasyn and Flagyl (metronidazole) or Zosyn (pipercillintazobactam) or in the case of a person with a penicillin allergy ciprofloxacin and Flagyl Incision McBurney incision- small incision that runs diagonally on the abdominal wall in the right lower quadrant (i.e., parallel to the edge of the external oblique muscle or in the direction running from the hip bone to the pubic bone.) Rocky-Davis incision- small incision that runs horizontally on the abdominal wall in the right lower quadrant

Midline incision- this is sometimes done is the patient is obese or if the surgeon is anticipating the need for a formal resection of the terminal ileum and cecum (i.e., if the appendix has ruptured at the base) Surgical Details of Procedure 1. Skin incision is made with a knife. 2. Bovie electrocautery is used to dissect through subcutaneous tissue and control small skin bleeding. 3. The aponeurosis (muscle sheath) of the outer layer of the external oblique muscle is visualized and split by a small incision with a knife and then further opened along the direction of the fibers with a scissors or the Bovie. 4. The muscle belly of the external oblique is then bluntly retracted (but not cut) using the classic muscle splitting technique via a hemostat or Kelly clamp until the aponeurosis of the internal oblique is visualized. 5. The aponeurosis of the internal oblique is split in a similar manner as the external oblique. 6. The muscle belly of the internal oblique is bluntly retracted in a similar manner as the external oblique until the peritoneum is visualized. 7. The peritoneum is grasped on either side by two forceps, pulled up and into the wound, and palpated to insure there is no bowel caught in the fold of the peritoneum. 8. The peritoneum is opened with a small incision using either a knife or scissors. 9. The peritoneal fluid is immediately inspected for amount and prurulence and cultures are taken. 10. The opening in the peritoneum is widened and two hand-held retractors are placed to expose the cecal area. 11. Manual and visual exploration for the appendix is performed by locating the convergence of the cecum and the terminal ileum. 12. The appendix is delivered up into the wound either by digitally flipping it up or be grasping the base with a Alice or Babcock and applying traction to allow dissection of any adhesions holding it in the abdominal cavity. 13. The entire appendix is inspected with close attention to the base to insure that the area of rupture is sufficiently distant from the base to allow a margin of healthy tissue.

14. If the base of the appendix is involved in the rupture a limited right hemicolectomy is done (see right hemicolectomy). 15. If the base of the appendix is not involved, the mesoappendix or mesentery of the appendix is divided, cross-clamped with Kelly clamps or hemostats and tied with 2-0 or 3-0 silk usually. 16. When the appendix has been isolated from the mesoappendix, the appendix proximal to the rupture is crushed with a straight clamp. 17. Two chromic ties are then placed on the area of crushed appendix. 18. The appendix is then resected off the stump distal to the ties using a knife. 19. The exposed mucosa is then ablated by the Bovie cautery. 20. Some surgeons then prefer to dunk the tied-off appendiceal stump by placing a running pursestring suture around the stump. 21. The intraabdominal area is inspected for bleeding and pockets of remaining infection. 22. Most surgeons will irrigate the abdominal cavity with saline solution or antibiotic-containing saline solution. 23. The edges of the peritoeum are reapproximated using a running 3-0 or 4-0 Vicryl suture. 24. The edges of the internal oblique aponeurosis are reapproximated using a 1-0 or 2-0 Vicryl suture. 25. The edges of the external oblique aponeurosis are likewise reapproximated. 26. The superficial wound is irrigated. 27. If the appendix has ruptured and there was frank pus, many surgeons will leave the subcutaneous tissue and skin open to heal by secondary intention. 28. If the appendicitis was in the early stages or was normal the subcutaneous tissue can be closed at the level of Scarpas fascia with interrupted or running 2-0 Vicryl suture. 29. The skin is closed with staples, interrupted Nylon sutures, or a subcuticular absorbably suture such as Monocryl Postoperative Course Non-ruptured appendicitis if the procedure was done through a relatively small right lower incision, recovery is usually rapid with patients starting oral feeds and being discharged from the

hospital in 1-2 2 days. If the incision is a larger right lower quadrant incision or a midline incision, recovery is delayed and the hospital course is lengthened by several seve days. Ruptured appendicitis even in the age of modern antibiotics a ruptured appendix is associated with increased morbidity and mortality. If peritonitis is present, it may take the bowel several days to have a return of function and a 2-3 2 day stay is not unusual, although many patients recover quickly and can be discharged sooner. Complications Superficial wound infection this is a risk with all surgical incisions and is increased if the skin edges are closed in the setting of late appendicitis or rupture. Intraperitoneal abscess this is fortunately unusual but can complicate up to 10% of cases of ruptured appendicitis. Other as with all surgeries there is always a risk of blood clots, pulmonary embolism, stroke, heart attack, and death. Related Posts Where Does the Appendix Actually Rupture?

10 Responses to Appendix Removal (Appendectomy) (Appendectomy)

Sid Schwab, MD: July 18, 2006 at 2:24 pm Couple of tricks: at the base of the appendix, the mesoappendix is nearly always ve very thin. A Kelly can be pass through, a tie brought back and tied as the mesoappendix is cut. It gets it done in a semi-single single motion. Unless the mesoappendix is very fat. Also: making the incision too medial is the most common thing that makes the operati operation hard. Lateral enough, and youre likely to come right upon the cecum, thus saving the need for the retractors and the hunting. And, much as I think laparoscopy has changed many operation for the excellent, in my opinion appy aint one of them. Especiall Especially in the middle of the night with a crew less familiar with it. Give me a small single incision, a 15 or 20 minute operation, a discharge within a day (in the routine cases).

Sid Schwab, MD:

July 18, 2006 at 2:25 pm Oh yeah; one more thing: if you sweep your finger over the peritoneum before opening it, in such a way as to mobilize it from the overlying fascia, closure on the way out is WAY easier.

Hoang: August 29, 2006 at 9:59 am Two week ago my mothers appendix was removed. Her doctor said her case has ruptured appendicitis. My question is as to why the tube for drainage still put in place until now? Initially, her some of her bowel moment was mixed in liquid and visible through bag as it drains out. At present, only small amount of yellowish liquid is visible. Can you please comment on her particular case? Thanks

Amber: November 10, 2006 at 7:41 am I am in Surgical Technology school and this site was the only one I could find that helped me with my appendectomy project!! The step by step listing was very helpful. Thanks for your help!! Hopefully I will get a good grade!!:)

Sherrie: November 20, 2006 at 2:02 pm I just had a Laparoscopic Appendectomy last Wed that went very well (surgery at 8pm, went home at noon the next day). I go in tomorrow to have the staples removed. The surgeon was great in explaining everything, but it was very interesting to see what was done during the surgery! Thank you!

arjun kumar budhathoki: December 1, 2006 at 10:00 am

it was awesome.reading .reading through the text i visualised what i had seen in the theatre.this time around when i try my hand on appendectomy this reading must make me go swiftly.

arjun kumar budhathoki: December 1, 2006 at 10:00 am it was awesome.reading through the text i visualised what i had seen in the theatre.this time around when i try my hand on appendectomy this reading must make me go swiftly.

arjun kumar budhathoki: December 1, 2006 at 10:03 am it was awesome.reading through the text i visualised what i had seen in the theatre.this time around when i try my hand on appendectomy this reading must make me go swiftly.

Delay in Removing emoving Appendix In Specific Circumstances Does Not Affect Overall Mortality | InsideSurgery Medical Information Blog: Blog September 20, 2010 at 6:27 pm [...] Appendix Surgery (Appendectomy) // Share| Posted in Medical News Wire Tags: abscess appendicitis appendix rupture phlegmon [...]

Pyloromyotomy Open Technique (Fredet-Ramstedt (Fredet Ramstedt Operation) | InsideSurgery Medical Information Blog: December 19, 2010 at 11:40 11:4 pm [...] Appendectomy // Share| Posted in Pediatric Surgery [...]

Subscribe Today Enter your email address:

Subscribe

Search This Site

Search

Categories

Amputation Surgery Appendix Surgery Articles Bird Flu BP Oil Spill Health Risks Brain Surgery Breast Surgery Cancer Cardiac Surgery Case Reports Clinical Trials Published Colon Surgery Complementary and Alternative Medicine Dental and Oral Surgery Devices and Technology Drug-Drug Interactions Eye Surgery Foot and Ankle Surgery For Professionals Gallbladder Surgery General Glossaries and Lists Grand Rounds Gray's Anatomy 1918 Hand Surgery Head and Neck Surgery Healthcare Law Hernia Surgery Hip Surgery History of Surgery and Medicine Interviews Journal News Knee Surgery Medical Eponym Bios Medical Eponyms Medical Malpractice Medical Mnemonics Medical News Wire

Medical Trivia Medical Words and Abbreviations Musings Nanomedicine Neck Surgery Nutrition ObGyn Surgery Pancreas Surgery Pediatric Surgery People Rectal Surgery Small Bowel Surgery Spleen Surgery Stomach Surgery Surgery and Medicine Quotations Surgical Procedure Videos Surgpedia Thoracic Surgery Tip of the Day Transplant Surgery Trauma Surgery Triumph Over Illness and Injury Uncategorized Urology Surgery USMLE Vascular Surgery

Medical Links

Daily Interview Daily JFK LymeHealth

Follow Online Count per Day

The link ed image cannot be display ed. The file may hav e been mov ed, renamed, or deleted. Verify that the link points to the correct file and location.