Appendectomy Technique

Updated: Jul 11, 2017
  • Author: Luigi Santacroce, MD; Chief Editor: John Geibel, MD, DSc, MSc, AGAF  more...
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Technique

Approach Considerations

Controversy continues over the operative approach to appendectomy. Open appendectomy has traditionally been 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. [8, 1] 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.

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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 (eg, 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.

The character of any peritoneal fluid should be noted to help confirm the diagnosis, and the fluid should then be suctioned from the field. If the fluid is purulent, it should be collected and cultured.

Retractors are gently placed into the peritoneum. The cecum is identified and medially retracted. It is then exteriorized by 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, such as 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 minimize 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 calls for drainage.

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

In cases of perforated appendicitis, some surgeons leave the wound open, allowing for secondary closure or a delayed primary closure until postoperative day 4 or 5. Other surgeons prefer immediate closure in these cases.

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Laparoscopic Appendectomy

Standard laparoscopic appendectomy

An example of a laparoscopic appendectomy is provided in the video below.

Laparoscopic appendectomy. Procedure perfomed by Spencer Armory, MD, and James Lee, MD, Columbia University Medical Center, New York, NY. Video courtesy of ColumbiaDoctors (https://www.columbiadoctors.org).

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, a standard approach is to place three 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. It should be noted that these are suggested port sites and that it is acceptable to adjust port placement according to the characteristics of the patient, the type of ports used, and the experience of the surgeon.

According to the preferences of the surgeon, a short umbilical incision is made to allow placement of a Hasson cannula or Veress needle that is secured with two 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, or stapler). Another 5-mm trocar is placed in the right periumbilical region, usually between the right costal margin and the umbilicus, to allow insertion of an atraumatic grasper to expose the appendix.

The appendix is grasped and retracted upward to expose the mesoappendix. The mesoappendix is divided with 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 with scissors 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. The appendix is now free and may be removed through the umbilical or the suprapubic cannula in a laparoscopic pouch to prevent wound contamination. Peritoneal irrigation is performed with antibiotic or saline solution. The irrigant must be completely aspirated. Peritoneal irrigation appears to be a risk factor for intra-abdominal abscess after laparoscopic appendectomy. [9]

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

Single-port appendectomy has been investigated as an alternative to conventional laparoscopic appendectomy. [10, 11, 12] In comparing results from 35 patients who underwent the procedure with those from 37 patients who were treated with the three-port laparoscopic method, Lee et al found no statistically significant differences between the two groups with regard to surgery time, length of hospital stay, or number of times the patients received analgesic injection. [13]

In this study, the complication rate was 8.6% for the single-port patients, versus 2.7% for those who underwent three-port surgery; complications included two cases of wound infection in the single-port group and one case in the three-port group, as well as one case of intra-abdominal fluid accumulation in a single-port patient with perforated appendicitis. [13] 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 three-port appendectomy.

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NOTES Appendectomy

Natural orifice transluminal endoscopic surgery (NOTES) appendectomy, including transvaginal appendectomy and transgastric appendectomy, has also been the subject of some study. A hybrid approach, in which auxiliary precutaneous trocars are used, is common. A study of the first 217 data sets from the German NOTES registry (the largest NOTES registry worldwide), almost all of which were done with a hybrid technique, found that hybrid NOTES appendectomy was safe and that the transvaginal technique had advantages in terms of procedural time and conversion rate. [14]

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Postoperative Care

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.

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. [15]

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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.

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

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. [16]

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