Open Appendectomy Technique

Updated: Aug 18, 2017
  • Author: Umashankar K Ballehaninna, MD, MS; Chief Editor: Kurt E Roberts, MD  more...
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Technique

Surgical Removal of Appendix

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

Whether any of these incisions is superior to the others has not been decided in the medical literature; the final determining factor is the individual surgeon's preference. The technique described below uses the McBurney-McArthur incision.

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. (See the image below.)

Open appendectomy. Skin incision is based on McBur 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.

Make the incision with a No. 10 blade; use a Bovie electrocautery to incise through both the superficial (Camper) and the deep (Scarpa) fascia. (See the image below.)

Open appendectomy. Dissection through both superfi Open appendectomy. Dissection through both superficial (Camper) and deep (Scarpa) fascia. External oblique aponeurosis is exposed and incised in direction of fibers.

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. (See the image below.)

Open appendectomy. External oblique muscle is spli Open appendectomy. External oblique muscle is split bluntly by using alternating Kelly clamps and Roux retractors.

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. (See the image below.)

Open appendectomy. Sequence of muscle splitting an 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.

Perform the incision on peritoneum in a craniocaudal direction with Metzenbaum scissors, thereby gaining access to the peritoneal cavity. Once the cavity is opened, any fluid encountered should be sent for Gram stain and culture. (See the image below.)

Open appendectomy. Transversalis fascia and perito 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.

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. (See the image below.)

Open appendectomy. In antegrade approach, ascendin 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.

The appendix can be removed in various ways, including simple ligation (the authors' preference), purse-stringing, and inversion appendectomy. The actual method of resection has not been shown to make a significant difference with respect to wound infection, length of hospital stay, postoperative fever, and intra-abdominal abscess formation. [27, 28]

The authors' preference is as follows. 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. (See the image below.)

Open appendectomy. Completion of appendectomy by d Open appendectomy. Completion of appendectomy by division of appendix between 2 ligatures, closer to cecum.

The retrograde technique is used under the following circumstances:

  • The appendix is very inflamed, and manipulation may cause perforation
  • The appendix is in a retroperitoneal position
  • The appendix is surrounded by inflammatory tissue, omentum, or both, which makes identification difficult

In the retrograde technique, the base of the appendix is found first, exposed, ligated, and transected. Attention is then turned to the mesoappendix, which is ligated last.

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 a concern in complicated appendicitis, the wound may be closed at the musculofascial level, left open and packed for 3-5 days, and closed secondarily.

Another option is to leave a Penrose drain in the wound and remove it 2-3 days later. If a phlegmon or abscess is encountered, the abdomen should be thoroughly irrigated with normal saline. Closed suction drainage may be used in these circumstances or if the adequacy of appendiceal stump closure is of concern. According to a 2015 Cochrane review, it is unclear whether routine abdominal drainage is effective in preventing intraperitoneal abscesses after open appendectomy for complicated appendicitis. [29]

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Postoperative Care

After completion of the surgical procedure, the patient should be encouraged to ambulate, with appropriate pain control. The diet is advanced as tolerated with plans for discharge on postoperative day 1 for noncomplicated appendicitis. Discharge instructions consist of pain management, instructions on indications for urgent return to the emergency department, and an office appointment in 1 week's time. Same-day discharge protocols have been studied in pediatric patients undergoing appendectomy for acute nonperforated appendicitis and appear to be safe and efficient with appropriate patient selection. [30]

The postoperative outpatient office visit evaluates the patient's continued progression with a detailed history and physical examination, discussion of the final pathology, and evaluation of the surgical wound. Resumption of normal activity occurs within 1 day following the procedure; adequate analgesia allows safe return to daily duty.

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Complications

The morbidity and mortality of acute appendicitis (AA) are related to the stage of the disease at presentation, and both are notably higher in cases of perforation. The mortality figures for nonperforated and perforated appendicitis are 0.8 and 5.1 per 1000 cases, respectively. [31]  The average rate of perforation at presentation is 16-30%, but in elderly and young patients, it is significantly increased because of delays in diagnosis. [32]

Early

Common early complications associated with any technique include bleeding, surgical-site infection (SSI), intra-abdominal abscess, unrecognized enteric injury, and fistula formation.

SSIs are determined by the level of intraoperative wound contamination, with rates of infection ranging from less than 5% in simple appendicitis to 20% in patients with perforation. In a meta-analysis of 54 randomized clinical trials comparing laparoscopic with open appendectomy, SSIs were less likely after laparoscopic appendectomy than after open appendectomy. [8]  Whatever surgical approach is chosen, preoperative intravenous (IV) antibiotics have been shown to decrease the postoperative rate of SSI. [33]

In the postoperative period, fluctuating pyrexia, along with worsening diarrhea, may give clues to the formation of intra-abdominal or pelvic abscesses, specifically after gross contamination of the peritoneal cavity. The incidence of intra-abdominal abscesses is increased nearly threefold after laparoscopic appendectomy. [8]

The diagnosis can be confirmed by means of either ultrasonography or computed tomography (CT); treatment consists of radiologic drainage and continued IV antibiotics. Other early complications primarily include anterior abdominal wall vessel injury, enteric leaks from unrecognized injuries, and postoperative ileus and fistula formation.

Late

Late complications consist of incisional hernia, stump appendicitis (recurrent infections from a retained appendiceal stump), and small-bowel obstruction. Small-bowel obstruction occurs in fewer than 1% of patients after appendectomy for uncomplicated appendicitis and in 3% of patients with perforated appendicitis who are monitored for 30 years. [34]  About one half of these patients present with bowel obstruction during the first year.

Complicated appendicitis

Complicated appendicitis includes gangrenous or perforated appendicitis or the presence of an appendicular abscess or phlegmon. The white blood cell (WBC) count, the granulocyte count, and the C-reactive protein (CRP) level have stronger discriminatory capacity for perforated appendicitis. High WBC and granulocyte counts and an increased CRP concentration are relatively strong predictors of perforated appendicitis, with a likelihood ratio as high as 7.20.

These cases are traditionally managed conservatively by administering IV antibiotics and draining an evolving abscess, if indicated; however, this approach, again, has been questioned in the medical literature. [35]  An important caveat in this treatment algorithm is the absence of peritoneal signs.

Because of the delay in seeking diagnosis and treatment, the recovery time and the corresponding length of hospital stay are found to be significantly longer with this approach than with appendectomy performed at the time of presentation. [35]  An interval appendectomy in the presence of a diagnosed fecalith is the surgical approach that is currently en vogue. Patients aged 40 years and older may benefit from further investigations (eg, colonoscopy) and close follow-up to rule out the possibility of coexisting disease (eg, carcinoma).

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