PROCEDURE 14-7 – APPENDECTOMY
SURGICAL ANATOMY AND PATHOLOGY
• Attached to cecum by the mesoappendix, which contains the appendiceal artery
• Frequently located upward and inward, behind the cecum called retrocecal
• Inflamed, infected appendix called appendicitis; often due to impacted feces
PREOPERATIVE DIAGNOSTIC TESTS AND PROCEDURES
• Physical exam
• CT scan
• Laboratory tests
EQUIPMENT AND INSTRUMENTS UNIQUE TO PROCEDURE
• Major instrument set
• Richardson appendiceal retractors
SUPPLIES UNIQUE TO PROCEDURE
• Aerobic and anaerobic culture tubes (do not open until requested by surgeon)
• ¼” and ½” Penrose drain (do not open until requested by surgeon)
• Antibiotic irrigation solution
PREOPERATIVE PREPARATION
• Position: Supine
• Anesthesia: General
• Skin prep: Umbilicus to symphysis pubis and bilaterally as far as possible
• Draping: Square off RLQ with four towels; laparotomy drape
PRACTICAL CONSIDERATIONS
• For female patient, a laparoscopy may be first performed to rule out ovarian cyst or ectopic
pregnancy.
• If the appendix is ruptured, or ruptures/leaks during the procedure, the surgical technologist
should anticipate the use of antibiotic irrigation; amount and antibiotic according to surgeon’s
preference.
SURGICAL PROCEDURE
1. The McBurney’s incision is typically used.
Procedural Consideration: Small retractors (e.g., U.S. Army) are placed and may be redirected
several times as the incision proceeds through the muscle layers. Richardson appendiceal
retractors may be used as the design allows for better visualization in dissection of muscle
layers.
2. The appendix is identified by following the cecal taenia to the appendiceal base. This may
require the gentle mobilization of the cecum into the wound (see Figure 14-13A and 14-13B).
the appendix is identified, brought out of the wound, and grasped with a Babcock.
Procedural Consideration: Be prepared to culture fluid, if present, as soon as the peritoneum is
entered and have suction ready.
3. The mesoappendix is transected from the free end tip of the appendix toward the base, by a
series of double clamping, cutting, and ligation with 3-0 absorbable ties (Figure 14-13C).
Procedural Consideration: This step of the procedure may be reversed if the appendix is
severely adhered or retrocecal.
4. A clamp is placed across the appendix near the base, crushing the appendix, and is then
removed and reapplied slightly distally.
Procedural Consideration: prepare pursestring suture if surgeon uses that technique. Replace
Babcock with Crile hemostat to grasp the tip of the appendix.
5. A 3-0 absorbable suture on a small taper needle may be passed through the cecum, around the
base of the appendix, in a pursestring manner (see Figure 14-13D).
Procedural Consideration: Suture and needle are contaminated and must be isolated after use;
try to avoid touching them or change glove(s) if necessary.
6. The crushed base is then ligated with an 0 absorbable tie and the appendix is amputated
electrosurgically or with scissors or a scalpel. The appendiceal stump is inverted within the
lumen of the cecum and the pursestring suture is tightened and tied. The STSR gently pushes the
stump into the lumen with the Crile hemostat and as the pursestring suture is tightened, he or
she unclamps the hemostat and gently removes it.
Procedural Consideration: have a kidney basin on the sterile field for placement of the appendix
and contaminated instruments and pass off to the circulator. Sterile team members should
change gloves at the minimum upon passing off contaminated instruments.
A Penrose drain may be placed if the appendix was perforated, size according to surgeon’s
choice. Antibiotic irrigation solution may be used, especially in presence of wound
contamination; have a small basin ready on the back table for the circulator to pour the saline
and antibiotic in order to mix.
7. The incision is closed in layers.
Procedural Consideration: The incision is small; be prepared to perform the counts quickly.
POSTOPERATIVE CONSIDERATIONS
Immediate Postoperative Care
• Transport to PACU.
Prognosis
• No complications: Return to normal activities in 4 to 6 weeks.
• Complications: Hemorrhage; SSI; intestinal obstruction due to postoperative adhesions forming;
appendiceal stump rupture; sepsis
Wound Classification
• Class II: Clean-contaminated
• Class III: Contaminated; ruptured appendix
