APENDICECTOMIA

Current Procedures: Surgery > Chapter 20. Appendectomy > Indications Clinical suspicion of appendicitis in an ill-appearing patient. Contraindications Absolute None. Relative Presence of large periappendiceal abscess, which may be treated best with initial drainage and interval appendectomy. Suspicion of Crohn's disease involving the cecum at the base of the appendix. Informed Consent Expected Benefits Treatment of acute appendicitis. Potential Risks Bleeding requiring reoperation. Surgical site infection (deep or superficial). Fecal fistula. Conversion to open appendectomy. Need for midline laparotomy. Open wound. Need for additional tests or procedures. Equipment The open procedure requires no special equipment. The laparoscopic procedure requires the following equipment: 5-mm angled laparoscope. Veress needle or Hasson trocar. Endoscopic stapler. Endoscopic retrieval bag for removal of the appendix. Patient Preparation No oral intake; maintenance intravenous fluids. Preoperative antibiotics to cover enteric flora. Patient Positioning Open Appendectomy The patient should be supine with both arms extended. The entire abdomen is prepared and draped in case a midline incision is needed (eg, unexpected disease is encountered or the operative course dictates it). Laparoscopic Appendectomy Figure 20–1: The patient is supine with both arms tucked at the sides. The operating surgeon and assistant stand on the patient's left. A Foley catheter is placed to decompress the bladder. The patient's entire abdomen is prepared and draped. Figure 20–1 Procedure Open Appendectomy The classic transverse incision can be made with two thirds of the incision lateral to McBurney's point. Alternatively, the point of maximal tenderness or the location of the appendix based on preoperative imaging can be used to determine the location of the incision. Figure 20–2: A scalpel is used to incise the epidermis and the dermis. Bovie electrocautery is used to dissect down to the external oblique aponeurosis. The aponeurosis is opened in a superolateral to inferomedial direction along the direction of its fibers to expose the internal oblique muscle. The internal oblique muscle is bluntly divided perpendicular to the direction of its fibers. The transverse abdominal muscle is similarly divided and the peritoneum is identified. Figure 20–3: The peritoneum is grasped with forceps and incised with a 15-blade knife. Attention is now focused on locating the appendix. If the cecum is visualized, it can be used as a guide to help identify the appendix. Babcock forceps can be used to grasp the taeniae coli and advanced until the appendix is externalized. Alternatively, a finger can be swept around the cecum, beginning superolaterally and continuing inferomedially to locate the appendix. Figure 20–4: Once identified, the mesoappendix is dissected and the appendiceal vessels are divided between clamps and ligated with silk sutures. Figure 20–5: A silk purse-string suture is placed around the base of the appendix. A right-angle clamp is applied to the base of the appendix and used to crush the tissue. The clamp is moved distally and an absorbable suture is used to ligate the appendix at the base at the site of the crushed tissue. A 15-blade is used to excise the appendix proximal to the level of the clamp. Figure 20–6A, B: The mucosa of the appendiceal stump may then be obliterated with electrocautery (Figure 20–6A). The purse-string suture is then used to invert the stump (Figure 20–6B). The wound is irrigated with warm saline to remove any inflammatory debris and hemostasis is achieved. Figures 20–7 and 20–8. The peritoneum and fascial layers are closed with running absorbable sutures. The skin is closed with monofilament absorbable suture. Figure 20–2 Figure 20–3 Figure 20–4 Figure 20–5 Figure 20–6A–B Figure 20–7 Figure 20–8 Laparoscopic Appendectomy A 12-mm infraumbilical incision is made and access to the abdomen is achieved using either a Veress needle or Hasson technique (see Figure 20–1). The peritoneal cavity is then insufflated with carbon dioxide gas and a 5-mm angled laparoscope is inserted. A 5-mm port is placed in the midline above the pubic bone and a second 5-mm port is placed laterally in the left lower quadrant (see Figure 20–1). The laparoscope is inserted through this lateral port, while the surgeon operates through the midline ports. Exploration of the abdomen is performed to rule out other disease. Attention then turns to the right lower quadrant. The patient is placed into steep Trendelenburg position with right side up to facilitate exposure. The omentum and small bowel are swept cephalad. The terminal ileum is identified by its antimesenteric fat (fold of Treves). The terminal ileum is then followed to the cecum. The appendix can usually be identified by following the teniae of the cecum. In the case of a retrocecal appendix, the cecum and ascending colon may need to be mobilized by division of the lateral retroperitoneal attachments. Inflammatory adhesions between small bowel, cecum, and appendix are often encountered and can usually be divided using blunt dissection, although sharp dissection may be required. Cautery should be avoided near the bowel. Once visualized, the tip of the appendix is grasped and elevated anteriorly off of the cecum. A Maryland dissector is used to create a window between the base of the appendix and the mesoappendix as shown in Figure 20–4. The safest orientation of dissection is to place the appendix and its mesoappendix parallel to the lateral abdominal wall, thus minimizing the risk of bowel injury. The mesoappendix is divided with an endoscopic stapler using a vascular staple load. The appendix is divided at its base using a second load of the endoscopic stapler, making sure that the stapler is apposed to the cecum so that an appendiceal stump is not left in place. The appendix is placed into an endoscopic retrieval bag and removed through the supraumbilical port. The appendiceal and mesoappendiceal staple lines are assessed for integrity and hemostasis. The abdomen is irrigated in all quadrants to prevent abscess formation. The small bowel is returned to the lower abdomen and the omentum is draped over the appendiceal stump. The laparoscope is placed back into one of the midline ports, and the remaining ports are removed under direct visualization to ensure hemostasis at the anterior abdominal wall. The 5-mm ports do not require fascial closure, but the fascia of the supraumbilical port should be closed with absorbable sutures. The skin is closed with monofilament suture or skin adhesive. Postoperative Care Patients should be advanced to a regular diet as tolerated and discharged home when they can tolerate oral intake and manage pain with oral medication only. Potential Complications Injury to bowel or other adjacent structures. Intra-abdominal abscess. Superficial wound infection (more common with open appendectomy). Colonic fistula. Pearls and Tips It is useful to place the incision where the patient's pain is the greatest or where preoperative imaging has identified the appendix. This is particularly important in pregnant patients, as the appendix may be in an atypical location. Conversion to an open procedure should be considered if visualization or dissection is difficult during laparoscopic appendectomy. References Andersen BR, Kallehave FL, Andersen HK. Antibiotics versus placebo for prevention of postoperative infection after appendicectomy. Cochrane Database Syst Rev. 2005;3: CD001439. Doria AS, Moineddin R, Kellenberger CJ, et al. US or CT for diagnosis of appendicitis in children and adults? A meta-analysis. Radiology. 2006;241:83–94.[PubMed: 16928974] [Full Text] Jones PF. Suspected acute appendicitis: trends in management over 30 years. Br J Surg. 2001;88:1570–1577.[PubMed: 11736966] [Full Text] Sauerland S, Lefering R, Neugebauer EA. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev. 2004;4:CD001546.