Preprocedural Planning
The various locations and attachments of the appendix may make for a difficult dissection. Occasionally, either the most proximal or distal portion of the appendix may be concealed and, if not properly identified, may be inadvertently left behind. One must constantly inspect and evaluate both the surgical specimen (for its completeness) and the suture line and cecum (for any remaining appendiceal stump).
When an open appendectomy is performed for presumed acute appendicitis (AA), Crohn disease may incidentally be encountered. Thorough evaluation of the cecum allows one to utilize the appropriate algorithm of surgical treatment. As long as a normal cecal base is identified, appendectomy should be performed, even if the appendix is normal, to exclude appendicitis from future right-lower-quadrant (RLQ) pain evaluation.
The gravid uterus causes alterations in the position of the appendix and obligatory changes in the localization of abdominal tenderness, which must be understood. Additionally, hyperemesis and the physiologic leukocytosis of pregnancy may obscure the diagnosis of AA. In cases of perforated AA, maternal and fetal mortality are 0-4% and 20-35%, respectively. There is no role for conservative management. [24]
The incidence of appendicitis during pregnancy ranges from 0.05% to 0.13%; it usually occurs in the second or third trimesters. Appendicitis occurs at the same rate in pregnant and nonpregnant women, but pregnant women have a higher rate of perforation. Complications of appendicitis, including perforation, increase by trimester, and a ruptured appendix results in increased fetal morbidity and mortality. Computed tomography (CT) is generally considered safe during the second and third trimesters.
The second trimester has been reported to be the safest for performing laparoscopy. During pregnancy, laparoscopic appendectomy can be as safe as open appendectomy. Laparoscopic surgery has the advantage of allowing reduced narcotic use (hence, less fetal depression), better intraoperative visualization and exposure, less postoperative pain, early return of bowel function, early ambulation, and shorter postoperative stays.
Equipment
All equipment must be present in the surgical arena and checked for proper working capacity before the procedure begins. A standard laparotomy set with customary clamps and retractors (Richardson, Regnel, and Roux) is used, along with appropriate sutures and ties. The authors prefer to use their institution's predefined minor instrument tray and retractor set.
Patient Preparation
Anesthesia
Open appendectomy can be performed with various anesthetic techniques, including general, regional, and local. Routinely, general anesthesia is the first choice, especially in the pediatric population. Studies show that local anesthesia, with anesthetic infiltrated into the subcutaneous and deep tissue layers (including the peritoneum), is a safe and cost-effective practice. [25, 26]
The operative procedure must always start with the surgical time-out. The importance of reviewing the patient identification, surgical team, procedure to be performed, and completion of all preoperative requirements prior to proceeding cannot be overstated. At this point, the patient is ready to be prepared and draped in a sterile fashion.
Positioning
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.
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Open appendectomy. Skin incision is based on McBurney point, which lies one third of distance along imaginary line between right anterior superior iliac spine (ASIS) and umbilicus. Incision is made through this point perpendicular to this line (McBurney-McArthur) or horizontally (Lanz). Incision extends 3-5 cm along skin creases.
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Open appendectomy. Dissection through both superficial (Camper) and deep (Scarpa) fascia. External oblique aponeurosis is exposed and incised in direction of fibers.
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Open appendectomy. External oblique muscle is split bluntly by using alternating Kelly clamps and Roux retractors.
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Open appendectomy. Sequence of muscle splitting and retraction is repeated with fascia of both internal oblique muscle and transversus abdominis to expose transversalis fascia and peritoneum.
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Open appendectomy. 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 peritoneal cavity is entered.
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Open appendectomy. 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 separated from appendix.
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Open appendectomy. Completion of appendectomy by division of appendix between 2 ligatures, closer to cecum.
