Appendectomy

Surgical Anatomy

Definition

Appendectomy refers to surgical removal of the vermiform appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy.

Embryology

A review of the development of the abdominal organs Development of the Abdominal organs The abdominal organs are derived primarily from endoderm, which forms the primitive gut tube. The gut tube is divided into 3 regions: foregut, midgut, and hindgut. Development of the Abdominal Organs is important in order to understand the location of the appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy within the abdominal cavity and its possible variants.

• The cecum Cecum The blind sac or outpouching area of the large intestine that is below the entrance of the small intestine. It has a worm-like extension, the vermiform appendix. Colon, Cecum, and Appendix: Anatomy and appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy are derived from the midgut Midgut Development of the Abdominal Organs.
• The cecum Cecum The blind sac or outpouching area of the large intestine that is below the entrance of the small intestine. It has a worm-like extension, the vermiform appendix. Colon, Cecum, and Appendix: Anatomy is visible during the 5th gestational week.
• The appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy appears as a cecal outpouching around the 8th week.
• The base of the appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy gradually moves toward the ileocecal valve Ileocecal valve The valve, at the junction of the cecum with the colon, that guards the opening where the ileum enters the large intestine. Small Intestine: Anatomy.
• During normal embryonic midgut Midgut Development of the Abdominal Organs rotation Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays, the cecum Cecum The blind sac or outpouching area of the large intestine that is below the entrance of the small intestine. It has a worm-like extension, the vermiform appendix. Colon, Cecum, and Appendix: Anatomy and appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy end up in the right lower abdominal quadrant. In congenital Congenital Chorioretinitis malrotation Malrotation Pediatric Gastrointestinal Abnormalities, they may be found in the middle upper abdomen.

Anatomy

A review of the anatomy of the colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix: Anatomy is important in order to more easily locate and recognize the cecum Cecum The blind sac or outpouching area of the large intestine that is below the entrance of the small intestine. It has a worm-like extension, the vermiform appendix. Colon, Cecum, and Appendix: Anatomy and appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy within the abdominal cavity during surgery.

• The appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy is a slender and hollow, blind-ended pouch attached to the proximal cecum Cecum The blind sac or outpouching area of the large intestine that is below the entrance of the small intestine. It has a worm-like extension, the vermiform appendix. Colon, Cecum, and Appendix: Anatomy.
• The appendiceal orifice is always located at the confluence of the taenia coli Taenia coli Colon, Cecum, and Appendix: Anatomy. 
• On average, the appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy is approximately 9 cm long but can vary from 2 to 22 cm.
• Mesentery Mesentery A layer of the peritoneum which attaches the abdominal viscera to the abdominal wall and conveys their blood vessels and nerves. Peritoneum: Anatomy of the appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy:
  • Called the mesoappendix
  • Attaches to the cecum Cecum The blind sac or outpouching area of the large intestine that is below the entrance of the small intestine. It has a worm-like extension, the vermiform appendix. Colon, Cecum, and Appendix: Anatomy and proximal appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy  
  • 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 Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy:
  • Retrocecal within the peritoneal cavity Peritoneal Cavity The space enclosed by the peritoneum. It is divided into two portions, the greater sac and the lesser sac or omental bursa, which lies behind the stomach. The two sacs are connected by the foramen of winslow, or epiploic foramen. Peritoneum: Anatomy (65%)
  • Pelvic (30%)
  • Subcecal
  • Ileocecal (preileal or postileal) 
  • Retroperitoneal Retroperitoneal Peritoneum: Anatomy
• McBurney’s point McBurney’s point Appendicitis:
  • The junction between the lateral and medial thirds of a line drawn from the anterior superior iliac spine Anterior Superior Iliac Spine Chronic Apophyseal Injury to the umbilicus
  • Localized tenderness at this point is a classic sign of appendicitis Appendicitis Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. Appendicitis.
  • Both McBurney’s and Rocky–Davis incisions for open appendectomy can be performed at this point.

Indications and Contraindications

Indications

• Acute appendicitis Appendicitis Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. Appendicitis:
  • Most common abdominal surgical emergency Surgical Emergency Acute Abdomen
  • Appendectomy is the first-line treatment.
• Appendiceal neoplasms Neoplasms New abnormal growth of tissue. Malignant neoplasms show a greater degree of anaplasia and have the properties of invasion and metastasis, compared to benign neoplasms. Benign Bone Tumors (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 Appendicitis Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. Appendicitis.
  • Most common appendiceal tumors:
    • Neuroendocrine tumor Tumor Inflammation or carcinoid 
    • Goblet cell Goblet cell A glandular epithelial cell or a unicellular gland. Goblet cells secrete mucus. They are scattered in the epithelial linings of many organs, especially the small intestine and the respiratory tract. Barrett Esophagus carcinoma
    • Lymphoma Lymphoma A general term for various neoplastic diseases of the lymphoid tissue. Imaging of the Mediastinum
    • Primary adenocarcinoma
    • Mucinous neoplasm
  • May require further surgery (right hemicolectomy), depending on the stage of the tumor Tumor Inflammation
• Prophylactic appendectomy:
  • Removal of a vermiform appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy 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 Malrotation Pediatric Gastrointestinal Abnormalities 
    • Surgery for Crohn’s disease, if cecum Cecum The blind sac or outpouching area of the large intestine that is below the entrance of the small intestine. It has a worm-like extension, the vermiform appendix. Colon, Cecum, and Appendix: Anatomy is not severely inflamed
    • “Chronic appendicitis Appendicitis Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. Appendicitis” (chronic lower abdominal pain Abdominal Pain Acute Abdomen): The appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy may appear grossly normal but have histologic abnormalities.
    • Grossly normal appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy during surgery for presumed appendicitis Appendicitis Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. Appendicitis

Contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation

• Most appendectomies are performed urgently for appendicitis Appendicitis Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. Appendicitis, and there are no absolute contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation.
• In select circumstances, when a patient has a high risk of complications, appendicitis Appendicitis Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. Appendicitis may be treated with antibiotics and the surgery delayed or avoided altogether.
• Some relative contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation include:
  • Perforated appendicitis Appendicitis Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. Appendicitis in a stable patient with large cecal phlegmon or abscess Abscess Accumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection. Chronic Granulomatous Disease
  • Anticoagulation Anticoagulation Pulmonary Hypertension Drugs therapy: Being treated with antiplatelet agents Antiplatelet agents Antiplatelet agents are medications that inhibit platelet aggregation, a critical step in the formation of the initial platelet plug. Abnormal, or inappropriate, platelet aggregation is a key step in the pathophysiology of arterial ischemic events. The primary categories of antiplatelet agents include aspirin, ADP inhibitors, phosphodiesterase/adenosine uptake inhibitors, and glycoprotein IIb/IIIa inhibitors. Antiplatelet Drugs (e.g., aspirin Aspirin The prototypical analgesic used in the treatment of mild to moderate pain. It has anti-inflammatory and antipyretic properties and acts as an inhibitor of cyclooxygenase which results in the inhibition of the biosynthesis of prostaglandins. Aspirin also inhibits platelet aggregation and is used in the prevention of arterial and venous thrombosis. Nonsteroidal Antiinflammatory Drugs (NSAIDs), Plavix Plavix A ticlopidine analog and platelet purinergic p2y receptor antagonist that inhibits adenosine diphosphate-mediated platelet aggregation. It is used to prevent thromboembolism in patients with arterial occlusive diseases; myocardial infarction; stroke; or atrial fibrillation. Antiplatelet Drugs) is not considered a contraindication. 
  • Severe cardiac disease:
    • Recent myocardial infarction Myocardial infarction MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction (within past 6 months)
    • Decompensated heart failure Heart Failure A heterogeneous condition in which the heart is unable to pump out sufficient blood to meet the metabolic need of the body. Heart failure can be caused by structural defects, functional abnormalities (ventricular dysfunction), or a sudden overload beyond its capacity. Chronic heart failure is more common than acute heart failure which results from sudden insult to cardiac function, such as myocardial infarction. Total Anomalous Pulmonary Venous Return (TAPVR)
    • Severe aortic stenosis Stenosis Hypoplastic Left Heart Syndrome (HLHS)
  • Severe pulmonary disease Pulmonary disease Diseases involving the respiratory system. Blastomyces/Blastomycosis: if there is a high risk of not being able to take the patient off the ventilator after surgery

Procedure

Preoperative preparation

• Initial supportive management:
  • Fluid resuscitation Resuscitation The restoration to life or consciousness of one apparently dead. . Neonatal Respiratory Distress Syndrome
  • Correct electrolytes Electrolytes Electrolytes are mineral salts that dissolve in water and dissociate into charged particles called ions, which can be either be positively (cations) or negatively (anions) charged. Electrolytes are distributed in the extracellular and intracellular compartments in different concentrations. Electrolytes are essential for various basic life-sustaining functions. Electrolytes.
  • Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways and nausea Nausea An unpleasant sensation in the stomach usually accompanied by the urge to vomit. Common causes are early pregnancy, sea and motion sickness, emotional stress, intense pain, food poisoning, and various enteroviruses. Antiemetics management
  • Bowel rest (nothing by mouth)
• Preoperative antibiotics:
  • Must be administered 30–60 minutes prior to incision 
  • Should cover skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions and intestinal flora
  • First-generation cephalosporin Cephalosporin Multidrug-resistant Organisms and Nosocomial Infections or fluoroquinolone + anaerobic coverage (e.g., cefazolin Cefazolin A semisynthetic cephalosporin analog with broad-spectrum antibiotic action due to inhibition of bacterial cell wall synthesis. It attains high serum levels and is excreted quickly via the urine. Cephalosporins– metronidazole Metronidazole A nitroimidazole used to treat amebiasis; vaginitis; trichomonas infections; giardiasis; anaerobic bacteria; and treponemal infections. Pyogenic Liver Abscess, ciprofloxacin Ciprofloxacin A broad-spectrum antimicrobial carboxyfluoroquinoline. Fluoroquinolones– metronidazole Metronidazole A nitroimidazole used to treat amebiasis; vaginitis; trichomonas infections; giardiasis; anaerobic bacteria; and treponemal infections. Pyogenic Liver Abscess)
• Anesthesia Anesthesia A state characterized by loss of feeling or sensation. This depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures. Anesthesiology: History and Basic Concepts:
  • General anesthesia General anesthesia Procedure in which patients are induced into an unconscious state through use of various medications so that they do not feel pain during surgery. Anesthesiology: History and Basic Concepts is most commonly used for both open and laparoscopic approaches.
  • Spinal or regional anesthesia Anesthesia A state characterized by loss of feeling or sensation. This depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures. Anesthesiology: History and Basic Concepts can be used for an uncomplicated open appendectomy.
• Foley catheter:
  • Optional
  • Often placed with a laparoscopic approach to prevent trocar injuries Trocar Injuries Laparotomy and Laparoscopy to the bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess

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 Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways scores.

Open appendectomy:

1. 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 Small intestine The small intestine is the longest part of the GI tract, extending from the pyloric orifice of the stomach to the ileocecal junction. The small intestine is the major organ responsible for chemical digestion and absorption of nutrients. It is divided into 3 segments: the duodenum, the jejunum, and the ileum. Small Intestine: Anatomy to separate from the right lower quadrant Right lower quadrant Anterior Abdominal Wall: Anatomy to provide better exposure of the cecum Cecum The blind sac or outpouching area of the large intestine that is below the entrance of the small intestine. It has a worm-like extension, the vermiform appendix. Colon, Cecum, and Appendix: Anatomy and appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy.
2. An incision is made through McBurney’s point McBurney’s point Appendicitis, which can be:
   • Oblique (McBurney’s incision)
   • Transverse (Rocky–Davis incision)
3. The peritoneal cavity Peritoneal Cavity The space enclosed by the peritoneum. It is divided into two portions, the greater sac and the lesser sac or omental bursa, which lies behind the stomach. The two sacs are connected by the foramen of winslow, or epiploic foramen. Peritoneum: Anatomy is entered by transecting the following abdominal wall Abdominal wall The outer margins of the abdomen, extending from the osteocartilaginous thoracic cage to the pelvis. Though its major part is muscular, the abdominal wall consists of at least seven layers: the skin, subcutaneous fat, deep fascia; abdominal muscles, transversalis fascia, extraperitoneal fat, and the parietal peritoneum. Surgical Anatomy of the Abdomen layers:
   • Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions
   • Camper’s fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis (subcutaneous fatty tissue)
   • Scarpa’s fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis (membranous layer of the anterior abdominal wall Abdominal wall The outer margins of the abdomen, extending from the osteocartilaginous thoracic cage to the pelvis. Though its major part is muscular, the abdominal wall consists of at least seven layers: the skin, subcutaneous fat, deep fascia; abdominal muscles, transversalis fascia, extraperitoneal fat, and the parietal peritoneum. Surgical Anatomy of the Abdomen)
   • External abdominal oblique fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis and muscle
   • Internal abdominal oblique muscle
   • Transversus abdominis Transversus abdominis Anterior Abdominal Wall: Anatomy muscle
   • Transversalis fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis
   • Preperitoneal fat
   • Peritoneum Peritoneum The peritoneum is a serous membrane lining the abdominopelvic cavity. This lining is formed by connective tissue and originates from the mesoderm. The membrane lines both the abdominal walls (as parietal peritoneum) and all of the visceral organs (as visceral peritoneum). Peritoneum: Anatomy
4. The mesoappendix is transected and the appendiceal vessels are ligated.
5. The appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy is transected at the base either with a stapler or with scissors and the stump is ligated/oversewn.
6. The appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy is removed from the abdominal cavity.
7. The abdominal wall Abdominal wall The outer margins of the abdomen, extending from the osteocartilaginous thoracic cage to the pelvis. Though its major part is muscular, the abdominal wall consists of at least seven layers: the skin, subcutaneous fat, deep fascia; abdominal muscles, transversalis fascia, extraperitoneal fat, and the parietal peritoneum. Surgical Anatomy of the Abdomen is closed in layers.

Laparoscopic appendectomy:

1. The patient is placed in the Trendelenburg position.
2. Most commonly, three trocars are placed:
   • One through the umbilicus, one in the left lower quadrant Left Lower quadrant Anterior Abdominal Wall: Anatomy, and one suprapubically
   • Other variations are possible, depending on the surgeon’s preference.
3. The mesoappendix is divided with energy devices or a stapler to control bleeding from the appendiceal vessels.
4. The appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy is transected at its base with a stapler or scissors and endoloop ligature.
5. The appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy is placed in a bag and removed from the abdominal cavity through one of the trocar sites, usually the umbilicus.

Special considerations

Peritoneal lavage or “toilet”: 

• If pus is seen in the abdomen, the peritoneal cavity Peritoneal Cavity The space enclosed by the peritoneum. It is divided into two portions, the greater sac and the lesser sac or omental bursa, which lies behind the stomach. The two sacs are connected by the foramen of winslow, or epiploic foramen. Peritoneum: Anatomy is washed out extensively with normal saline Normal saline A crystalloid solution that contains 9. 0g of sodium chloride per liter of water. It has a variety of uses, including: as a contact lens solution, in ophthalmic solutions and nasal lavage, in wound irrigation, and for fluid therapy. Intravenous Fluids.
• In the case of a localized abscess Abscess Accumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection. Chronic Granulomatous Disease cavity, a Jackson–Pratt drain is placed.

Exploratory laparotomy Exploratory Laparotomy Laparotomy and Laparoscopy:

• Usually performed through a vertical midline incision
• Preferred approach in a patient with a ruptured appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy and generalized peritonitis Peritonitis Inflammation of the peritoneum lining the abdominal cavity as the result of infectious, autoimmune, or chemical processes. Primary peritonitis is due to infection of the peritoneal cavity via hematogenous or lymphatic spread and without intra-abdominal source. Secondary peritonitis arises from the abdominal cavity itself through rupture or abscess of intra-abdominal organs. Penetrating Abdominal Injury 
• Allows better visualization, abdominal washout, and conversion to more extensive surgery if needed

Pregnant women:

• 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 Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy.
• During the late stages of pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care, an open approach may be more feasible, as a large uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy displaces the appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy and makes laparoscopic visualization and manipulation difficult.

Postoperative care Postoperative care After any procedure performed in the operating room, all patients must undergo close observation at least in the recovery room. After larger procedures and for patients who require hospitalization, observation must continue on the surgical ward. The primary intent of this practice is the early detection of postoperative complications. Postoperative Care

• Uncomplicated appendectomy with nonperforated appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy:
  • Antibiotics should be discontinued within 24 hours.
  • Diet is usually advanced rapidly.
  • The patient is commonly discharged home within 24 hours.
• Perforated appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy:
  • 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 Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways levels.

Complications

• Surgical site infection Surgical site infection Infection occurring at the site of a surgical incision. Surgical Complications (most common):
  • Wound infection:
    • Occurs in 3.3%–10.3% of appendectomies
    • More common with open appendectomies and perforated appendicitis Appendicitis Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. Appendicitis
    • Delayed primary wound closure does not lower the infection rate.
  • Pelvic abscess Abscess Accumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection. Chronic Granulomatous Disease:
    • Occurs in 9.4% of appendectomies
    • Slightly more common with the laparoscopic approach
    • More common with perforated appendicitis Appendicitis Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. Appendicitis
• Postoperative ileus Ileus A condition caused by the lack of intestinal peristalsis or intestinal motility without any mechanical obstruction. This interference of the flow of intestinal contents often leads to intestinal obstruction. Ileus may be classified into postoperative, inflammatory, metabolic, neurogenic, and drug-induced. Small Bowel Obstruction:
  • Transient slowing of bowel motility Motility The motor activity of the gastrointestinal tract. Gastrointestinal Motility
  • Especially common with perforated appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy
  • Treated with bowel rest, nasogastric tube Nasogastric tube Malnutrition in children in resource-limited countries decompression, and IV hydration Iv Hydration Crush Syndrome
• Small-bowel obstruction:
  • Secondary to adhesions/ inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation
  • More common after open approach and perforated appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy
  • Can happen in the early postoperative period Postoperative period The period following a surgical operation. Postoperative Care or years later
  • Nonoperative management is attempted first but sometimes may require surgical lysis of adhesions.
• Stump appendicitis Appendicitis Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. Appendicitis:
  • Can happen if the appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy 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.
• Infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility:
  • Very rare
  • Results from intraoperative damage to Fallopian tubes Fallopian tubes The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The fallopian tubes receive an ovum after ovulation and help move it and/or a fertilized embryo toward the uterus via ciliated cells lining the tubes and peristaltic movements of its smooth muscle. Uterus, Cervix, and Fallopian Tubes: Anatomy
• Mortality Mortality All deaths reported in a given population. Measures of Health Status:
  • Overall rate < 1%
  • Predictors of mortality Mortality All deaths reported in a given population. Measures of Health Status:
    • Age > 80 years
    • Immunosuppression
    • Severe cardiovascular disease
    • Perforated appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy
    • Previous antimicrobial therapy