Appendectomy 

Introduction

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.

History of the procedure

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. Reginald H. 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, the English surgeon H. Hancock successfully performed the first appendectomy in a patient with acute appendicitis. Some years after this, the American C. 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 last 2 centuries. Mortality and morbidity have gradually decreased, especially in the last few decades because of antibiotics, early diagnosis, and improvements in anesthesiologic and surgical techniques.

Open versus laparoscopic appendectomy

Open appendectomy remains the most common approach due to operative time and cost. Since 1987, however, an increasing number of surgeons have come to prefer laparoscopic appendectomy (see Technique). Laparoscopic appendectomy has now been improved and standardized.^[1]

Laparoscopic appendectomy has some advantages, including decreased postoperative pain, better aesthetic result, a shorter time to return to usual activities, and lower incidence of wound infections or dehiscence. This procedure is cost-effective but may require more operative time compared with open appendectomy. Kouhia et al found that by 2008, operative time with laparoscopic appendectomy was only 10 minutes longer than with the open approach. In addition, patients who underwent open appendectomy returned to work later and had more complications.^[9]

The reported results of laparoscopic and open-procedure appendectomies seem to overlap. In fact, the average rate of abdominal abscesses, negative appendectomies, and hospital stays are very similar, according to an overview of 17 retrospective studies.^[2]

Key Considerations

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).

Open appendectomy is the most common approach due to time and cost. However, an increasing number of surgeons prefer laparoscopic appendectomy, especially in female patients, due to 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 been performed and 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.

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 h) of watchful waiting and a computed tomography (CT) scan may improve diagnostic accuracy and help to hasten the diagnosis. However, if a patient is discharged from the medical center without a definite diagnosis at the end of the observation period, instruct the patient to return if symptoms continue or recur, and the patient may benefit from a follow-up examination in 24 hours.

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. These contraindications are 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.

Anesthesia

Appendectomy requires general anesthesia. Before the start of the surgical procedure, the anesthesiologist performs endotracheal intubation to administer volatile anesthetics and to assist respiration.

Preoperative Medications

Because they may mask the underlying disease, do not administer analgesics and antipyretics to patients with suspected appendicitis who have not been evaluated by the surgeon.

Venous Access

Venous access must be obtained in all patients diagnosed with appendicitis. Venous access allows administration of isotonic fluids and broad-spectrum intravenous antibiotics before the operation

Open Versus Laparoscopic Appendectomy

Controversy continues over the operative approach to appendectomy. Open appendectomy is still the most common approach, because it is quick and cost-effective. However, an increasing number of surgeons prefer laparoscopic appendectomy because of the diagnostic ability of laparoscopy, especially in female patients.^[3] The aesthetic results and an earlier return to normal activities may also be advantageous.

Some authors have criticized the cost of a laparoscopic procedure. Nevertheless, evidence indicates that in the future, laparoscopic appendectomy will be the standard treatment for patients with appendicitis and undiagnosed abdominal pain.

Open Appendectomy

Before incision, the surgeon should carefully perform a physical examination of the abdomen to detect any mass and to determine the site of the incision.

Open appendectomy requires a transverse incision in the right lower quadrant over the McBurney point (ie, two thirds of the way between the umbilicus and the anterior superior iliac spine [ASIS]). Vertical incisions (ie, the Battle pararectal) are rarely performed because of the tendency for dehiscence and herniation.

The abdominal wall fascia (ie, Scarpa fascia) and the underlying muscular layers are sharply dissected or split in the direction of their fibers to gain access to the peritoneum. If necessary (eg, because of concomitant pelvic pathologies), the incision may be extended medially, with the surgeon dissecting some fibers of the oblique muscle and retracting the lateral part of the rectus abdominis. The peritoneum is opened transversely and entered.

Note the character of any peritoneal fluid to help confirm the diagnosis and then suction it from the field. If the fluid is purulent, collect and culture it.

Retractors are gently placed into the peritoneum. The cecum is identified and medially retracted. It is then exteriorized, using a moist gauze sponge or Babcock clamp, and the taeniae coli are followed to their convergence. The convergence of the taeniae coli is detected at the base of the appendix, beneath the Bauhin valve (ie, the ileocecal valve), and the appendix is then viewed. If the appendix is hidden, it can be detected medially by retracting the cecum and laterally by extending the peritoneal incision.

If the appendix appears normal, other causes of the patient's condition should be sought. These include ovarian pathology, Meckel diverticulum, and sigmoid disease.

After exteriorization of the appendix, the mesoappendix is held between clamps, divided, and ligated. The appendix is clamped proximally about 5 mm above the cecum to avoid contamination of the peritoneal cavity, and the cut is made above the clamp by a scalpel. Fecaliths within the lumen of the appendix may be detected. The appendix must be ligated to prevent bleeding and leakage from the lumen.

The residual mucosa of the appendix is gently cauterized to avoid a future mucocele. The appendix may be inverted into the cecum with the use of a purse-string suture or z-stitch. Appendiceal stump inversion is not mandatory, however.

The cecum is placed back into the abdomen, and the abdomen is irrigated. When evidence of free perforation exists, peritoneal lavage with several liters of warm saline is recommended. After the lavage, the irrigation fluid must be completely aspirated to avoid the possibility of spreading infection to other areas of the peritoneal cavity. The use of a drain is not commonly required in patients with acute appendicitis, but obvious abscess with gross contamination requires drainage.

Wound closure begins with closing of the peritoneum with a running suture. Then, the fibers of the muscular and fascial layers are reapproximated and closed with a continuous or interrupted absorbable suture. Lastly, the skin is closed with subcutaneous sutures or staples.

In cases of a perforated appendicitis, some surgeons leave the wound open, allowing for secondary closure or a delayed primary closure until the fourth or fifth day after operation. Other surgeons prefer immediate closure in these cases.

Laparoscopic Appendectomy

The surgeon typically stands on the left of the patient, and the assistant stands on the right. The anesthesiologist and the anesthesia equipment are placed at the patient's head, and the video monitor and the instrument table are placed at the feet.

Although some variations are possible, the standard approach is to place 3 cannulae during the procedure. Two of these have a fixed position (ie, umbilical, suprapubic); the position of the third, which is placed in the right periumbilical region, may vary greatly depending on the patient's anatomy.

According to the preferences of the surgeon, a short umbilical incision is made to allow the placement of a Hasson cannula or Veress needle that is secured with 2 absorbable sutures. Pneumoperitoneum (10-14 mm Hg) is established and maintained by insufflating carbon dioxide. Through the access, a laparoscope is inserted to view the entire abdomen cavity.

A 12-mm trocar is inserted above the pubic symphysis to allow the introduction of instruments (eg, incisors, forceps, stapler). Another 5-mm trocar is placed in the right periumbilical region, usually between the right costal margin and the umbilicus, to allow the insertion of an atraumatic grasper to expose the appendix.

The appendix is grasped and retracted upward to expose the mesoappendix. The mesoappendix is divided using a dissector inserted through the suprapubic trocar. Then, a linear endostapler, endoclip, or suture ligature is passed through the suprapubic cannula to ligate the mesoappendix. The mesoappendix is transected using a scissor or electrocautery; to avoid perforation of the appendix and iatrogenic peritonitis, the tip of the appendix should not be grasped.

The appendix may now be transected with a linear endostapler, or, alternately, the base of the appendix may be suture ligated in a similar manner to that in an open procedure (see Open Appendectomy). The appendix is now free and may be removed through the umbilical or the suprapubic cannula using a laparoscopic pouch to prevent wound contamination. Peritoneal irrigation is performed with antibiotic or saline solution. Completely aspirate the irrigant. The cannulae are then removed and the pneumoperitoneum is reduced.

The fascial layers at the cannula sites are closed with absorbable suture. The cutaneous incisions are closed with interrupted subcuticular sutures or sterile adhesive strips.

Single-port appendectomy

Recently, the efficacy of another laparoscopic technique, single-port appendectomy, has been investigated.^{[4, 5]} In comparing results from 35 patients who underwent the procedure with those from 37 patients who were treated with the 3-port laparoscopic method, Lee et al determined that there were no statistically significant differences between the 2 groups with regard to surgery time, length of hospital stay, or number of times the patients received analgesic injection.^[6]

The complication rate was 8.6% for the single-port patients, versus 2.7% for those who underwent 3-port surgery; complications included 2 cases of wound infection in the single-port group and 1 case in the 3-port group, as well as 1 case of intra-abdominal fluid accumulation in a single-port patient with perforated appendicitis. The investigators concluded that the single-port procedure is a feasible technique that, in addition to leaving a nearly inconspicuous scar, has outcomes comparable with those of 3-port appendectomy.^[6]

Outcome

The prognosis is excellent, and outcome is good, whether appendicitis is simple or complicated (ie, with gangrene or perforation). In fact, no mortality has been reported in patients with a nonperforated appendix. The mortality rate is less than 1% if appendiceal perforation exists. An exception is elderly patients, who have a mortality rate that approaches 5%. An intermediate mortality rate (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.

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.^[7]

Complications

Complications may occur in patents with appendicitis, accounting for an average morbidity near 10%. Death is rare but can occur in patients who have profound peritonitis and sepsis. If a complication occurs, further diagnostic and therapeutic procedures may be required, leading to additional cost and prolonged hospitalization.

Infection

Severe infection may result in adynamic ileus. Postoperatively, wound infection or dehiscence may occur, especially in patients with gangrenous or perforated appendicitis, persistent ileus, cecal fistulas, and pelvic or abdominal abscess. Patients with these conditions present with wound tenderness or soreness, drainage of fluid from the incision, or swelling and redness at the incision site.

Patients with postoperative infections usually present with a mild fever, abdominal pain, and disorders of bowel transit (ie, diarrhea, constipation). Persistent nausea, vomiting, difficulty with micturition, and persistent pain in the lower limbs may also occur.

Cardiovascular and pulmonary complications

Cardiovascular complications (eg, myocardial infarction) and pulmonary complications (eg, pneumonia, pulmonary embolism) have been reported.

Stump appendicitis

A rare complication after appendectomy, stump appendicitis, is a special concern. This condition is an acute inflammation of the residual appendix and may occur from a few months to up to 20 years after the appendix resection, as reported by Uludag et al.^[8]

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.

Patient Education

For patient education information, see eMedicine's Esophagus, Stomach, and Intestine Center, as well as Appendicitis and Abdominal Pain in Adults.