SURGICAL

MANAGEMENT

Appendectomy is the surgical removal of the

appendix, the small, finger-shaped pouch
that is located at the cecum (the junction
between the large and small intestines). The
surgery is the standard treatment for
appendicitis (inflammation and infection of
the appendix) and patients usually recover
from appendectomy without experiencing
complications. A ruptured appendix is
considered a medical emergency.
In this operation, the surgeon removes the
appendix and closes its connection to the
colon.The surgeon can perform an
appendectomy either laparoscopically or
through an open surgical procedure .

INSTRUMENT
Appendectomy Set
An appendectomy (appendisectomy or
appendicectomy) is the surgical removal of the
vermiform appendix. Medical Tools comprehensive 67
Pcs Appendectomy Set is designed for clinical needs
and practical challenges.Kit has all necessary tools
to perform Appendectomy Surgery. All tools are
made from high grade surgical stainless steel used
by professionals.
The Appendectomy Surgery instrument set includes:
01 Metzenbaum Scissors 18cm Curved
01 Metsenbaum Scissors 18cm Straight
01 Mayo Scissors14cm Curved
01 Mayo Scissors 14cm Straight

02 Scalpel Handle # 4
02 Allis Tissue Forceps
15cm
04 Kochers Tissue Forceps
1:2
01 Mcindoe Forceps 15cm
02 Babcocks Tissue
Forceps 16cm
02 Mayo Hagar Needle
Holder 16cm
02 Sponge Holding
Forceps
04 Backhaus Towel
Clamps 11cm

06 Spencer Wells
Straight 08 Spencer
Wells Curved 02 U S
Army Retractor 21cm
02 Adson Forceps
12cm
02 Adson Forceps 1:2
12cm
02 Lane Forceps 1:2
18cm
02 Forceps 16cm
04 Gallipots
02 Kidney Dish 8"

PERI-OPERATIVE CARE
An informed consent form must be signed
acknowledging that the patient understands the
procedure, the potential risks, and that they will
receive certain medications.
The anesthesiologist visits the patient to do a
brief physical examination and to obtain a
medical history.
Patients are required to refrain from eating or
drinking after midnight on the day before surgery.
Prior to surgery, an intravenous (IV) is started to
administer fluid and medications that have been
ordered.

 Place the patient supine, and tuck his or

her right arm for the duration of the
procedure. The surgeon should stand on
the patient's right, and the assistant
surgeon should stand on the patient's left.
General anesthesia is administered.
Before the start of the surgical procedure,
the anesthesiologist performs
endotracheal intubation to administer
volatile anesthetics and to assist
respiration.

INTRA-OPERATIVE CARE
Surgeons use one of two surgical techniques, open
appendectomy or laparoscopic appendectomy. The choice
of method is made by the surgeon on a case-by-case
basis.
Open appendectomy
On the basis of the anatomy of the anterior abdominal
wall, the following three distinct incisions can be employed
when performing an open appendectomy:
McBurney-McArthur incision
Lanz incision
Pararectus (Jalaguier, Battle, Kammerer, Lennander,
Senn) incision.

STEP 1: The position of the incision is based upon the

location of the McBurney point, which is a point one third
of the distance from the anterior superior iliac spine (ASIS)
to the umbilicus. Place the incision (1.5-5.0 cm in length,
depending on the patient's age) between the first third
and the second third of the distance from the ASIS to the
umbilicus, respecting the directions of the Langer skin
lines.

Skin incision is based on McBurney point,

which lies one third of distance between
anterior superior iliac spine (ASIS) and
umbilicus. Incision extends 3-5 cm along
skin creases (Lanz incision).

STEP 2: Make the incision with a No. 10 blade;

use a Bovie electrocautery to incise through
both the superficial (Camper) and thedeep
(Scarpa) fascia.

Dissection through both superficial

(Camper) and deep (Scarpa) fascia.
External oblique aponeurosis is
exposed and incised in direction of
fibers.

STEP 3: Expose the external oblique

aponeurosis, incising in the direction of fibers,
and split the external oblique muscle bluntly
with alternating Kelly clamps and Roux
retractors.

External oblique muscle is

split
bluntly byusing alternating
Kelly clamps and Roux
retractors.

STEP 4: This blunt muscle spreading, along with

appropriate retraction (again, the authors feel
that the Roux retractor is the best), allows
visualization of the transversalis fascia and the
peritoneum.

Sequence of muscle splitting and

retraction is repeated with fascia of
both internal oblique muscle and
transversus abdominis to expose
transversalis fascia and peritoneum.

STEP 5: Perform the incision on peritoneum in a

craniocaudal direction with Metzenbaum scissors, allowing
access to the peritoneal cavity; once the cavity is opened,
any fluid encountered should be sent for Gram stain and
culture.

Transversalis fascia and peritoneum are

grasped with 2 straight clamps, with palpation
between surgeon's fingers, and with care
taken to avoid entrapment of any underlying
structures. Incision is made with Metzenbaum
scissors, and per

STEP 6: The appendix can be removed through either an

antegrade or a retrograde technique. In performing the
antegrade approach, identify the ascending colon and its
taeniae coli, and use a series of Babcock surgical clamps to
follow them to their convergence, identifying the base of
the appendix. Free the appendix-mesoappendix complex
from its adjacent, often inflamed, tissue, and deliver it into
the wound. The mesoappendix, containing the appendiceal
artery, is then ligated and separated from the appendix

In antegrade approach, ascending colon and

its taeniae coli are identified and followed to
their convergence, identifying base of
appendix. Appendix-mesoappendix complex
is freed from its adjacent, often inflamed,
tissue and delivered into wound.
Mesoappendix, containing appendiceal
artery, is ligated (3-0 Vicryl 2 times) and

STEP 7. Once the mesoappendix is divided and the

appendiceal/cecal base is clearly exposed, perform
simple ligation with 2-0 plain polyglactin, tying off
the base; this ligation is performed twice. Place a
clamp just proximal to the distal ligature on the
appendix, avoiding any inadvertent contamination,
and divide sharply. Cauterize the exposed mucosa.

Completion of appendectomy by
dividing appendix between 2
ligatures, closer to cecum.

After the appendectomy is completed and the

wound is copiously irrigated with normal saline,
grasp the peritoneum with two straight clamps, and
close it with a continuous 3-0 polyglactin stitch.
Approximate all split muscle layers, using 3-0
polyglactin at each level. Close the external oblique
fascia with a continuous 2-0 polyglactin stitch.
Approximate the Scarpa fascia with 3-0 polyglactin,
and use 4-0 poliglecaprone subcuticular interrupted
sutures for skin closure.
If wound contamination is of concern in complicated
appendicitis, the wound may be closed at the
musculofascial level, left open and packed for 3-5
days, and secondarily closed. Another option is to
leave a Penrose drain in the wound and remove it 23 days later. If a phlegmon or abscess is
encountered, the abdomen should be thoroughly

LAPAROSCOPIC APPENDECTOMY

STEP 1. Port placement A 10-mm trocar is placed at the

umbilicus, and the abdominal cavity is insufflated to a
pressure of 15 mmHg.
The camera is also inserted through this larger trocar.
A 5-mm trocar is placed at the suprapubis, and a second
5-mm trocar is placed at the LLQ. (Placement of the third
port may vary by surgeon preference or as case dictates
but LLQ is standard placement).
STEP 2. Inspect abdominal cavity The area is inspected to
orient the surgeon to the position of the appendix.
Inspection will also alert surgeon to any anatomic variation
or pathological conditions that may be relevant (e.g.
peritonitis).

STEP 3. Expose appendix The bowel is gently

retracted rostrally using atraumatic graspers to
allow access to appendix.
STEP 4. Locate and separate appendicular artery
The mesoappendix is separated from the body of
the appendix, and the mesenteric fat is separated
to reveal the appendicular artery. This is best
done using the spreader action of a dissector.
STEP 5. Divide appendix from cecum Using an
endoloop, two loops are placed proximal to the
cecum, and a third loop is placed 1-2 cm distally
to these. The appendix is then divided between
the two proximal and 3rd distal loops using scissors
or cautery. Staples may be substituted for loops.

STEP 6. Divide appendicular artery The artery is

divided using the Endo GIA or the endoloop
method described above (two ligatures proximally,
one distally).
STEP 7. Extract appendix A fourth port (10 mm)
may be placed containing the extraction tube.
Alternately, the camera may be withdrawn and the
existing 10 mm port used for extraction (a 5 mm
camera is inserted into one of the smaller ports in
these cases).
In either case, an extraction tube is placed through
the appropriate 10 mm port, and the extraction.

STEP 8. Irrigate The abdominal cavity should be

irrigated thoroughly with sterile saline and
suctioned clean several times. In the event of a
rupture, great care should be taken to ensure all
pus or other infectious fluids have been removed.
STEP 9. Final inspection The abdominal and pelvic
cavities are inspected one final time for any signs
of infection, errors, or other potential complications
of which the surgeon might need to be aware. This
can often be done simultaneously with irrigation.

POST OPERATIVE CARE

Postoperative Medication
Administer intravenous antibiotics postoperatively. The
length of administration is based on the operative findings
and the recovery of the patient; in complicated
appendicitis, antibiotics may be required for many days or
weeks. Antiemetics and analgesics are administered to
patients experiencing nausea and wound pain.
Diet
When appendicitis is not complicated, the diet may be
advanced quickly postoperatively and the patient is
discharged from the hospital once a diet is tolerated. In
patients with complicated appendicitis, a clear liquid diet
may be started when bowel function returns. These
patients may be discharged after complete restitution of
infection.

Long-Term Monitoring
After hospital discharge following surgery,
patients must have a light diet and limit their
physical activity for a period of 2-6 weeks,
depending on the surgical approach (ie,
laparoscopic or open appendectomy). The
patient should be evaluated by the surgeon in
the clinic to determine improvement and to
detect any possible complications.

END