Appendectomy

• Appendectomy is the
surgical removal of the
appendix, a small,
finger-shaped pouch
that is located at the
cecum (the junction
between the large and
small intestines).
• The surgery is the standard treatment for
appendicitis (inflammation and infection of
the appendix) and patients usually recover
from appendectomy without experiencing
complications. A ruptured appendix is
considered a medical emergency.
 Surgical Procedures

• Surgeons use one of two surgical techniques,

open appendectomy or
laparoscopic appendectomy. The choice of
method is made by the surgeon on a case-by-
case basis. General anesthesia (agent that
renders the patient unconscious) is used in
both procedures.
•
• Open Appendectomy
• Open appendectomy is the traditional method
and the standard treatment for appendicitis.
The surgeon makes an incision in the lower
right abdomen, pulls the appendix through
the incision, ties it off at its base, and removes
it. Care is taken to avoid spilling purulent
material (pus) from the appendix while it is
being removed. The incision is then sutured.
• If the appendix has perforated (ruptured), the
surgeon cleans the pus out of the abdomen
with a warm saline solution to reduce the risk
for infection. A drain may be inserted through
the incision to allow the pus to drain from the
abdomen. In this case, the skin is not sutured,
but left open and packed with sterile gauze.
The gauze and drain remain in place until the
pus is completely drained and there is no sign
of infection.
 Laparoscopic Appendectomy

• Laparoscopic appendectomy has been used

for several years and has become the
standard of care. The procedure has several
advantages including lower risk for
postoperative infection, faster recovery time,
a smaller scar, and a shorter hospital stay.
• The surgeon makes a very small incision right
below the navel and inserts an instrument
called a laparoscope. The laparoscope is a long
tube with a lens at one end and a miniature
video camera at the other. The laparoscope
enables the doctor to see the appendix.
Several more tiny incisions are made to allow
for the passage of instruments, which are used
to cut and clamp off the appendix.
• The laparoscope is also used as a diagnostic
tool. The doctor is able to see if the appendix
is inflamed and, if the appendix is not the
cause of the patient's symptoms, other organs
can be seen in order to identify the source of
the symptoms.
•
 Preoperative Procedures for
Appendectomy
• A number of tests are ordered to assess the
patient's health before surgery. Usually these
tests are done a few days ahead, but because
of the urgency of an appendectomy, the tests
and surgery are frequently performed on the
same day. Preoperative tests vary according
to the patient's age and health, but a blood
test, chest x-ray, and electrocardiogram (EKG)
are standard.
• An informed consent form must be signed
acknowledging that the patient understands
the procedure, the potential risks, and that
they will receive certain medications.
• Before surgery, the anesthesiologist visits the patient
to do a brief physical examination and to obtain a
medical history. He or she will want to know about any
other medical conditions; if the patient is taking any
medication (prescription or over-the-counter);
• if any dietary supplements or herbal products are
being used; if the patient smokes cigarettes or drinks
alcohol; if the patient has a history of allergies,
especially to medications; or has had a previous
reaction to anesthesia, or a family history of problems
with anesthesia.
• Patients are required to refrain from eating or
drinking after midnight on the day before
surgery; however, because an appendectomy
is an emergency procedure, that may not be
possible. As soon as the decision is made to
operate, the patient must take nothing by
mouth, including oral medications.
•
• Prior to surgery, an intravenous (IV) is started
to administer fluid and medications that have
been ordered, including antibiotics and pain
medication. A sedative may be given to help
the patient relax. Anesthesia is administered
in the operating room.
 Postoperative Care after
Appendectomy
• Following surgery, the patient is taken to the
postanesthesia care unit (PACU) until the
anesthesia wears off. During this time, the
nursing staff checks temperature, heart rate,
and breathing at frequent intervals. When the
anesthesia wears off and vital signs stabilize,
the patient is transferred to their hospital
room.
 Unruptured Appendix

• With an unruptured appendix, the patient's

recovery time is relatively quick. The morning
after surgery, clear liquids are offered. Once
those are tolerated, the diet progresses to
solid food. Once the patient is eating and
drinking, the intravenous is removed.
• Physical activity, such as getting out of bed,
begins on the same day as surgery or the next
morning. Most patients need medication to
relieve the pain in and around the incision.
The smaller incisions of a laparscopic
procedure often cause less pain than the large
incision made in open appendectomy.
• The nursing staff continues to monitor the
patient for signs of infection and checks that
the incision is healing. Patients with
uncomplicated surgeries usually leave the
hospital 1 or 2 days following surgery.
• Once at home, the patient must check the
incision site. It should be dry and the wound
should be completely closed. If the incision
drains blood or pus, or if the edges are pulling
apart, the physician should be notified
immediately. Fever and increasing pain at the
incision site also should be reported to the
physician.
• Normal activities can be resumed within a few
days, but it takes 4 to 6 weeks for full recovery.
Heavy lifting and strenuous activity should be
avoided during recovery. If antibiotics and/or
pain medication are prescribed, they should be
taken as directed.
• The open procedure leaves a scar on the lower
right side of the abdomen that is a few inches
long and fades over time. Scarring from
laparoscopic appendectomy is minimal.
• The abdomen is prepared and draped and is
examined under anesthesia.
• If a mass is present, the incision is made over
the mass; otherwise, the incision is made over
McBurney's point, one third of the way from
the anterior superior iliac spine (ASIS) and the
umbilicus; this represents the position of the
base of the appendix (the position of the tip is
variable).
• The various layers of the abdominal wall are
then opened.
• The effort is always to preserve the integrity
of abdominal wall. Therefore, the
External Oblique Aponeurosis is slitted along
its fiber, and the internal oblique muscle is
split along its length, not cut. As the two run
at right angles to each other, this prevents
later Incisional hernia.
• Muscle
– Rectus abdominis
– External oblique muscle
– Internal oblique muscle
– Transverse abdominal muscle
• Fascia transversalis
• Peritoneum
• On entering the peritoneum, the appendix is
identified, mobilized and then ligated and
divided at its base.
• Each layer of the abdominal wall is then
closed in turn.
• The skin may be closed with staples or
stitches.
• The wound is dressed.
• The patient will be brought to the recovery
room.
• Postoperative Fever

The most common complication of appendectomy is infection of the

surgical wound.

•
Intra-abdominal abscess (fluid), needing drainage.

•
• Postoperative Fever

The most common complication of appendectomy is infection of the

surgical wound.

•
Intra-abdominal abscess (fluid), needing drainage.

•
• Paralytic ileus where the gut stops
functioning. This usually happens if the
appendix ruptures and causes diffuse
inflammation.

Deep Vein Thrombosis is rare complication

and required further tests.
• Anesthesia Related:  

Risks for any anesthesia include the following:

Problems with breathing

Chest infection

Reactions to medications
 Prophylactic appendectomy
• To find the cause of unexplained abdominal
pain, exploratory surgery is sometimes
performed. If the appendix is not the cause of
symptoms, the surgeon will thoroughly check
the other abdominal organs and remove the
appendix anyway, to prevent it from
becoming a problem in the future.
• When abdominal surgery is performed for an
entirely different reason (e.g. hysterectomy or
bowel resection), the surgeon sometimes
decides to perform an appendectomy in
addition to the intended procedure, to
eliminate the possible need of a future
surgery just to remove the appendix.
However, recent findings on the possible
usefulness of the appendix has led to an
abatement of this practice.
• Pregnancy
• If appendicitis develops in a pregnant woman,
an appendectomy is usually performed and
should not harm the fetus.[1] The risk of fetal
death in the perioperative period after an
appendectomy for early acute appendicitis is
3% to 5%. The risk of fetal death is 20% in
perforated appendicitis. [2]
• Recovery
• Scar and Bruise 2 days after operation.
• Recovery time from the operation varies from person
to person. Some will take up to three weeks before
being completely active; for others it can be a matter
of days. In the case of a laparoscopic operation, the
patient will have three stapled scars of about an inch in
length, between the navel and pubic hair line. When a
laparotomy has been performed the patient will have a
2-3 inch scar, which will initially be heavily bruised.