Appendectomy

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Updated: Oct 26, 2015
  • Author: Luigi Santacroce, MD; Chief Editor: John Geibel, MD, DSc, MSc, AGAF  more...
Overview

Background

In recent years, the incidence of appendicitis has markedly decreased. Nevertheless, appendicitis remains one of the more common surgical emergencies, and appendectomy remains the treatment of noncomplicated appendicitis.

The first report of an appendectomy came from Amyan, a surgeon of the English army. Amyan performed an appendectomy in 1735 without anesthesia to remove a perforated appendix. Fitz, an anatomopathologist at Harvard who advocated early surgical intervention, first described appendicitis in 1886; however, because he was not a surgeon, his advice was ignored for a time. Then, at the end of the 19th century, Hancock successfully performed the first appendectomy in a patient with acute appendicitis. Some years after this, McBurney published a series of reports that constituted the basis of the subsequent diagnostic and therapeutic management of acute appendicitis.

Thousands of classic appendectomies (ie, open procedure) have been performed in the past two centuries. Mortality and morbidity have gradually decreased, especially in the past few decades, because of antibiotics, early diagnosis, and improvements in anesthesiologic and surgical techniques.

For patient education information, see the Digestive Disorders Center, as well as Appendicitis and Abdominal Pain in Adults.

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Indications

Patients with appendicitis always need urgent referral and prompt treatment. Consider an appendectomy for patients with a history of persistent abdominal pain, fever, and clinical signs of localized or diffuse peritonitis, especially if leukocytosis is present.

If the clinical picture is unclear, a short period (4-6 hours) of watchful waiting and a computed tomography (CT) scan may improve diagnostic accuracy and help hasten the diagnosis. [1] However, if a patient is discharged from the medical center without a definite diagnosis at the end of the observation period, instruct him or her to return if symptoms continue or recur; a follow-up examination in 24 hours may be beneficial.

A retrospective study by Kim et al, designed to determine whether acute nonperforated appendicitis is a surgical emergency that necessitates immediate intervention or a condition that can be treated with a semielective approach, found that delaying appendectomy for 12-24 hours was safe for patients with acute nonperforated appendicitis. [2]

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Contraindications

No contraindications to appendectomy are known for patients with suspected appendicitis, except in the case of a patient with a long history of symptoms and signs of a large phlegmon. If a periappendiceal abscess or phlegmon exists secondary to appendiceal perforation or rupture, some clinicians may choose a conservative approach with broad-spectrum antibiotics and percutaneous drainage followed by appendectomy later (interval appendectomy).

Certain contraindications exist for laparoscopic appendectomy, including extensive adhesions, radiation or immunosuppressive therapy, severe portal hypertension, and coagulopathies. Laparoscopic appendectomy is contraindicated in the first trimester of pregnancy.

Rarely, an appendiceal mucocele (ie, a collection of mucus within the appendiceal lumen) may occur. Occasionally, patients may present with a low-grade carcinoma of the appendix or the cecum. In such cases, the surgeon must avoid perforation during dissection, because it may cause seeding of the peritoneum with viable cells, leading to pseudomyxoma peritonei.

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Technical Considerations

Procedural planning

Patients with appendicitis always need urgent referral and prompt treatment. An appendectomy is generally indicated for patients with a history of persistent abdominal pain, fever, and clinical signs of localized or diffuse peritonitis, especially if leukocytosis is present (see Indications).

For reasons of time and cost, open appendectomy is the most common approach. However, an increasing number of surgeons prefer laparoscopic appendectomy, especially in female patients, because of its diagnostic ability (see Technique).

If, on open appendectomy, the surgeon finds an apparently normal appendix, he or she is faced with a dilemma: remove the appendix or leave it in place? The argument for performing appendectomy is that even if the appendix is not removed, the patient will have a scar from a right-lower-quadrant incision. In the future, this may lead those who examine the patient to assume that an appendectomy has already been performed, in which case they will not include appendicitis in the differential diagnosis.

At the opposite extreme, in the past, appendicitis sometimes was so severe that the cecum appeared necrotic. Today, this finding is fortunately very rare. In such cases, perform an ileocecectomy or right hemicolectomy with a primary anastomosis.

Laparoscopic appendectomy has now been improved and standardized. [3]  It has some advantages over open appendectomy, including decreased postoperative pain, better aesthetic result, a shorter time to return to usual activities, and lower incidence of wound infections or dehiscence. Although cost-effective, it may require more operating than the corresponding open procedure. Kouhia et al found that by 2008, operating time was only 10 minutes longer with laparoscopic appendectomy than with the open approach; in addition, patients who underwent open appendectomy returned to work later and had more complications. [4]

The reported results of laparoscopic and open appendectomies seem to overlap. In fact, the average rates of abdominal abscesses, negative appendectomies, and hospital stays are very similar, according to an overview of 17 retrospective studies. [5]  In a study comparing laparoscopic and open appendectomy for complicated appendicitis in adult patients, Taguchi et al found that the minimally invasive approach was safe and feasible in this setting, though it did not significantly reduce complications. [6]

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Outcomes

Whether appendicitis is simple or complicated (ie, with gangrene or perforation), the prognosis is excellent and outcome is good, In fact, no mortality has been reported in patients with a nonperforated appendix. Mortality is lower than 1% if appendiceal perforation exists. An exception is elderly patients, who have a mortality that approaches 5%. An intermediate mortality (1-4%) is reported in infants because of the high frequency of perforation caused by delayed diagnosis due to the difficulties in distinguishing appendicitis from other conditions in the differential diagnosis.

Overall, patients may return to their activities soon after the operation. Once the patient has recovered, no changes in lifestyle (eg, diet, exercise) are required after appendectomy.

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