Appendectomy

Appendectomy is an invasive surgical procedure performed with the goal of resecting and extracting the vermiform appendix through either an open or a laparoscopic approach. The most common indication is 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, which is why appendectomies are usually carried out in an urgent fashion. It is one of the most commonly performed emergent abdominal procedures. It can be associated with a number of postoperative complications; however, the majority of patients do very well and recover quickly.

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Surgical Anatomy

Definition

Appendectomy refers to surgical removal of the vermiform appendix.

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 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.

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 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 Taenia Taenia belong to the Cestoda class of helminths. Humans are infected with these tapeworms by eating undercooked beef (T. saginata) or pork (T. solium and T. asiatica). Taeniasis is often asymptomatic, but the ingestion of larvae can cause abdominal discomfort, nausea, and constipation or diarrhea. Taenia/Taeniasis 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%)
    • Subcecal
    • Ileocecal (preileal or postileal) 
    • Retroperitoneal
  • 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 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
    • 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 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 or carcinoid 
      • Goblet cell carcinoma
      • Lymphoma
      • 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 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 Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain): The appendix may appear grossly normal but have histologic abnormalities.
      • Grossly normal appendix 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

  • 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.
  • 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 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
    • Anticoagulation 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 Agents (e.g., aspirin, Plavix) 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 congestive heart failure Congestive heart failure Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure
      • Severe aortic stenosis Aortic stenosis Aortic stenosis (AS), or the narrowing of the aortic valve aperture, is the most common valvular heart disease. Aortic stenosis gradually progresses to heart failure, producing exertional dyspnea, angina, and/or syncope. A crescendo-decrescendo systolic murmur is audible in the right upper sternal border. Aortic Stenosis
    • Severe pulmonary disease: 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
    • 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 and nausea 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. Structure and Function of the Skin and intestinal flora
    • First-generation cephalosporin or fluoroquinolone + anaerobic coverage (e.g., cefazolin–metronidazole, ciprofloxacin–metronidazole)
  • Anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts:
    • 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:
    • Optional
    • 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 Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain 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 to separate from the right lower quadrant to provide better exposure of the cecum and appendix.
  2. An incision is made through McBurney’s point, which can be:
    • Oblique (McBurney’s incision)
    • Transverse (Rocky–Davis incision)
  3. The peritoneal cavity is entered by transecting the following abdominal wall layers:
    • Skin
    • Camper’s fascia (subcutaneous fatty tissue)
    • Scarpa’s fascia (membranous layer of the anterior abdominal wall Anterior abdominal wall The anterior abdominal wall is anatomically delineated as a hexagonal area defined superiorly by the xiphoid process, laterally by the midaxillary lines, and inferiorly by the pubic symphysis. Anterior Abdominal Wall)
    • External abdominal oblique fascia and muscle
    • Internal abdominal oblique muscle
    • Transversus abdominis muscle
    • Transversalis fascia
    • 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 and Retroperitoneum
  4. The mesoappendix is transected and the appendiceal vessels are ligated.
  5. The appendix is transected at the base either with a stapler or with scissors and the stump is ligated/oversewn.
  6. The appendix is removed from the abdominal cavity.
  7. The abdominal wall is closed in layers.
Mcburney’s and rocky–davis incision

McBurney’s and Rocky–Davis incisions

Image by Lecturio. License: CC BY-NC-SA 4.0

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, 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 is transected at its base with a stapler or scissors and endoloop ligature.
  5. The appendix is placed in a bag and removed from the abdominal cavity through one of the trocar sites, usually the umbilicus.
Appendix-entfernung

Laparoscopic appendectomy

Image: “Appendix-Entfernung” by Life-of-hannes.de. License: Public Domain

Special considerations

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.

Exploratory laparotomy Laparotomy Laparotomy is an open surgical exploration of the abdomen, usually through a single large incision. Laparotomy and Laparoscopy:

  • 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

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.
  • During the late stages of pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care, an open approach may be more feasible, as a large uterus displaces the appendix 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:
    • 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 Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain levels.

Complications

  • Surgical site infection (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:
      • 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:
    • 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 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
    • 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 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 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
  • Mortality:
    • Overall rate < 1%
    • Predictors of mortality:
      • Age > 80 years
      • Immunosuppression
      • Severe cardiovascular disease
      • Perforated appendix
      • Previous antimicrobial therapy

References

  1. Dahdaleh FS, Heidt D, Turaga KK. (2019). The appendix. Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Kao LS, Hunter JG, Matthews JB, Pollock RE (Eds.), Schwartz’s Principles of Surgery, 11th ed. New York: McGraw-Hill. https://accessmedicine-mhmedical-com.ezproxy.unbosque.edu.co/content.aspx?bookid=2576&sectionid=216215350
  2. Quick CRG, Biers SM, Arulampalam THA. (2020). Appendicitis. In: Quick CRG, Biers SM, Arulampalam THA, Tan HA (Eds.), Essential surgery: Problems, diagnosis and management (pp. 366–373). https://www.clinicalkey.es/#!/content/3-s2.0-B9780702076312000262
  3. Richmond B. (2018). Apéndice. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL (Eds.), Sabiston. tratado de cirugía (pp. 1296–1311). https://www.clinicalkey.es/#!/content/3-s2.0-B9788491131328000500
  4. Valente MA. (2021). Appendectomy. In Delaney CP (Ed.), Netter’s Surgical Anatomy and Approaches (pp. 263–274). https://www.clinicalkey.es/#!/content/3-s2.0-B9780323673464000256

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