Appendectomy refers to surgical removal of the vermiform appendix.
A review of the development of the abdominal organs is important in order to understand the location of the appendix within the abdominal cavity and its possible variants.
- The cecum and appendix are derived from the midgut.
- The cecum is visible during the 5th gestational week.
- The appendix appears as a cecal outpouching around the 8th week.
- The base of the appendix gradually moves toward the ileocecal valve.
- During normal embryonic midgut rotation, the cecum and appendix end up in the right lower abdominal quadrant. In congenital malrotation, they may be found in the middle upper abdomen.
A review of the anatomy of the colon is important in order to more easily locate and recognize the cecum and appendix within the abdominal cavity during surgery.
- The appendix is a slender and hollow, blind-ended pouch attached to the proximal cecum.
- The appendiceal orifice is always located at the confluence of the taenia coli.
- On average, the appendix is approximately 9 cm long but can vary from 2 to 22 cm.
- Mesentery of the appendix:
- Called the mesoappendix
- Attaches to the cecum and proximal appendix
- Contains the appendiceal artery and vein
- Blood supply:
- The appendiceal artery is a branch of the ileocolic artery.
- The appendiceal vein is a tributary of the ileocolic vein.
- Positions of the appendix:
- Retrocecal within the peritoneal cavity (65%)
- Pelvic (30%)
- Ileocecal (preileal or postileal)
- McBurney’s point:
- The junction between the lateral and medial thirds of a line drawn from the anterior superior iliac spine to the umbilicus
- Localized tenderness at this point is a classic sign of appendicitis.
- Both McBurney’s and Rocky–Davis incisions for open appendectomy can be performed at this point.
Indications and Contraindications
- Acute appendicitis:
- Most common abdominal surgical emergency
- Appendectomy is the first-line treatment.
- Appendiceal neoplasms (0.5%–0.9% of appendectomies):
- Most often, these are discovered intraoperatively or postoperatively on a pathology report after appendectomy is performed for presumed appendicitis.
- Most common appendiceal tumors:
- Neuroendocrine tumor or carcinoid
- Goblet cell carcinoma
- Primary adenocarcinoma
- Mucinous neoplasm
- May require further surgery (right hemicolectomy), depending on the stage of the tumor
- Prophylactic appendectomy:
- Removal of a vermiform appendix that is macroscopically normal, usually during surgery, for another indication
- Prophylactic appendectomy is controversial and is not routinely recommended.
- Sometimes this procedure is performed to avoid future diagnostic uncertainty.
- Some conditions in which a prophylactic appendectomy is warranted:
- During Ladd’s procedure for malrotation
- Surgery for Crohn’s disease, if cecum is not severely inflamed
- “Chronic appendicitis” (chronic lower abdominal pain): The appendix may appear grossly normal but have histologic abnormalities.
- Grossly normal appendix during surgery for presumed appendicitis
- Most appendectomies are performed urgently for appendicitis, and there are no absolute contraindications.
- In select circumstances, when a patient has a high risk of complications, appendicitis may be treated with antibiotics and the surgery delayed or avoided altogether.
- Some relative contraindications include:
- Perforated appendicitis in a stable patient with large cecal phlegmon or abscess
- Anticoagulation therapy: Being treated with antiplatelet agents (e.g., aspirin, Plavix) is not considered a contraindication.
- Severe cardiac disease:
- Recent myocardial infarction (within past 6 months)
- Decompensated congestive heart failure
- Severe aortic stenosis
- Severe pulmonary disease: if there is a high risk of not being able to take the patient off the ventilator after surgery
- Initial supportive management:
- Fluid resuscitation
- Correct electrolytes.
- Pain and nausea management
- Bowel rest (nothing by mouth)
- Preoperative antibiotics:
- Must be administered 30–60 minutes prior to incision
- Should cover skin and intestinal flora
- First-generation cephalosporin or fluoroquinolone + anaerobic coverage (e.g., cefazolin–metronidazole, ciprofloxacin–metronidazole)
- General anesthesia is most commonly used for both open and laparoscopic approaches.
- Spinal or regional anesthesia can be used for an uncomplicated open appendectomy.
- Foley catheter:
- Often placed with a laparoscopic approach to prevent trocar injuries to the bladder
Types and steps of the procedures
Both open and laparoscopic approaches are considered acceptable. The choice should be made on the basis of the surgeon’s expertise and the patient’s preference. Laparoscopic appendectomies are associated with slightly shorter hospital stays and better pain scores.
- The patient is placed in the supine position, with at least a 15 degree head-down tilt (Trendelenburg position).
- This position allows the small intestine to separate from the right lower quadrant to provide better exposure of the cecum and appendix.
- An incision is made through McBurney’s point, which can be:
- Oblique (McBurney’s incision)
- Transverse (Rocky–Davis incision)
- The peritoneal cavity is entered by transecting the following abdominal wall layers:
- Camper’s fascia (subcutaneous fatty tissue)
- Scarpa’s fascia (membranous layer of the anterior abdominal wall)
- External abdominal oblique fascia and muscle
- Internal abdominal oblique muscle
- Transversus abdominis muscle
- Transversalis fascia
- Preperitoneal fat
- The mesoappendix is transected and the appendiceal vessels are ligated.
- The appendix is transected at the base either with a stapler or with scissors and the stump is ligated/oversewn.
- The appendix is removed from the abdominal cavity.
- The abdominal wall is closed in layers.
- The patient is placed in the Trendelenburg position.
- Most commonly, three trocars are placed:
- One through the umbilicus, one in the left lower quadrant, and one suprapubically
- Other variations are possible, depending on the surgeon’s preference.
- The mesoappendix is divided with energy devices or a stapler to control bleeding from the appendiceal vessels.
- The appendix is transected at its base with a stapler or scissors and endoloop ligature.
- The appendix is placed in a bag and removed from the abdominal cavity through one of the trocar sites, usually the umbilicus.
Peritoneal lavage or “toilet”:
- If pus is seen in the abdomen, the peritoneal cavity is washed out extensively with normal saline.
- In the case of a localized abscess cavity, a Jackson–Pratt drain is placed.
- Usually performed through a vertical midline incision
- Preferred approach in a patient with a ruptured appendix and generalized peritonitis
- Allows better visualization, abdominal washout, and conversion to more extensive surgery if needed
- The laparoscopic approach is generally safe.
- Lower intraabdominal pressure should be used.
- Trocar placement needs to be modified to avoid injury to a gravid uterus.
- During the late stages of pregnancy, an open approach may be more feasible, as a large uterus displaces the appendix and makes laparoscopic visualization and manipulation difficult.
- Uncomplicated appendectomy with nonperforated appendix:
- Antibiotics should be discontinued within 24 hours.
- Diet is usually advanced rapidly.
- The patient is commonly discharged home within 24 hours.
- Perforated appendix:
- Usually 3–5 days of postoperative antibiotics
- Diet is advanced as tolerated, depending on the patient’s recovery.
- Discharge home occurs when the patient is afebrile, is tolerating the diet, and has acceptable pain levels.
- Surgical site infection (most common):
- Wound infection:
- Occurs in 3.3%–10.3% of appendectomies
- More common with open appendectomies and perforated appendicitis
- Delayed primary wound closure does not lower the infection rate.
- Pelvic abscess:
- Occurs in 9.4% of appendectomies
- Slightly more common with the laparoscopic approach
- More common with perforated appendicitis
- Wound infection:
- Postoperative ileus:
- Transient slowing of bowel motility
- Especially common with perforated appendix
- Treated with bowel rest, nasogastric tube decompression, and IV hydration
- Small-bowel obstruction:
- Secondary to adhesions/inflammation
- More common after open approach and perforated appendix
- Can happen in the early postoperative period or years later
- Nonoperative management is attempted first but sometimes may require surgical lysis of adhesions.
- Stump appendicitis:
- Can happen if the appendix is not completely resected (appendiceal stump > 0.5 cm)
- Stump resection needs to be performed (laparoscopic or open).
- The perforated appendiceal stump may require more extensive bowel resection.
- Very rare
- Results from intraoperative damage to Fallopian tubes
- Overall rate < 1%
- Predictors of mortality:
- Age > 80 years
- Severe cardiovascular disease
- Perforated appendix
- Previous antimicrobial therapy
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