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Appendix

Chapter · April 2016

DOI: 10.1007/978-3-319-21338-5_18

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1 Appendix
18
2 Luca Ansaloni, Marco Lotti, Michele Pisano,
3 and Elia Poiasina

4 Contents 18.1 Appendectomy 32

5 18.1      Appendectomy   173
6 18.2      Open Appendectomy   173
Objectives: To Describe
7 18.2.1   Positioning and Personnel   173
8 18.2.2   Exploration   174 • The most common technique
9 18.2.3   Mesoappendix Division and • Technique for ectopic (retrocecal)
10 Appendectomy   174 appendicitis
11 18.2.4   Search for Meckel’s Diverticulum   175
• Management of pelvic abscesses and
12 18.2.5   Drainage   175
13 18.2.6   Abdominal Closure   175 peritonitis
14 18.2.7   Variations   175 • Indications for conversion
15 18.3      Summary of Open Appendectomy   176 • Open questions: treatment of the appen-
dicular stump, drainage, optimal port
16 18.4      Laparoscopic Appendectomy   176
17 18.4.1   Equipment and Instruments   176
sites, treatment of associated Meckel’s
18 18.4.2   Positioning, Personnel, and Port Sites   176 diverticulum, resection of a normal
19 18.4.3   Port Site Placement   176 appendix
20 18.4.4   Exploration   177
21 18.4.5   Mesoappendix Exposure and Division   177
22 18.4.6   Appendectomy   178
23 18.4.7   Drainage   178
24 18.4.8   Retrocecal Appendicitis   178
25 18.4.9   Pelvic Abscess   179 18.2 Open Appendectomy 33
26 18.4.10  Retrograde Appendectomy   179
27 18.4.11  Normal Appendix   179
28 18.4.12  Conversion   180 18.2.1  Positioning and Personnel 34
29 18.4.13  Search for Meckel’s Diverticulum
30 (Via Laparoscopy and Laparotomy)   180 • The patient is placed supine and right arm 35
31 Selected Reading   180 tucked to the patient’s side. 36
–– Urinary catheter insertion is optional (may 37
be omitted if the patient has voided imme- 38
L. Ansaloni, MD (*) • M. Lotti, MD diately before anesthesia). 39
M. Pisano, MD • E. Poiasina, MD • The surgeon stands to the right of the patient, 40
1st General Surgery Unit, Department of Emergency,
Papa Giovanni XXIII Hospital, Piazza OMS 1,
the assistant on the left, and if available 41

Bergamo 24127, Italy scrub nurse (second assistant) on right, close 42

e-mail: mlotti@hpg23.it to the legs. 43

© Springer International Publishing Switzerland 2016 173

A. Fingerhut et al. (eds.), Emergency Surgery Course (ESC®) Manual:
The Official ESTES/AAST Guide, DOI 10.1007/978-3-319-21338-5_18
 174 L. Ansaloni et al.

[AU1] Fig. 18.1 

44 Draping: Fig. 18.2 

45 • Should allow extension of the incision (right
46 iliac fossa or midline) as well as insertion of
47 drain (laterally) 18.2.2  Exploration 75
48 Skin protection.
49 Adhesive skin protector is ideal but not mandatory. • Withdrawal of free fluid for bacterial 76
50 Antibiotic prophylaxis. identification. 77
51 • As per local protocol • The wound is protected with moist gauze. 78
52 Access to the abdominal cavity • The appendix is located, following the taenia 79
53 • 2–5 cm skin incision over McBurney’s point, coli toward the cecal base. 80
54 perpendicular to the line between the right • Adhesions can usually be freed with blunt 81
55 anterior superior iliac spine and the umbilicus dissection. 82
56 (junction one-third lateral, two-­third from the • The cecum and the appendix are then exteriorized. 83
57 umbilicus (Fig. 18.1))
58 • Some authors prefer a shorter incision, parallel
59 to Langer’s lines, located two fingerbreadths 18.2.3  Mesoappendix Division 84
60 medial to the anterosuperior iliac spine. and Appendectomy 85
61 –– Muscle splitting
62 The external oblique fascia is sharply • Division of the mesoappendix near the base of 86
63 incised lateral to the rectus sheath accord- the appendix, either between clamps and liga- 87
64 ing to the direction of its fibers. tion, or directly ligated with 2-0 absorbable 88
65 The internal oblique and the transversus suture 89
66 abdominis muscles are bluntly separated, • Placement of two wide jaw clamps parallel to 90
67 according to the direction of their fibers each other at the appendicular base 91
68 (Fig. 18.2). • Removal of the clamp close to the cecum 92
69 • Opening the peritoneum • Double ligation of the base of the appendix 93
70 –– The peritoneum is grasped with forceps (cau- with 0 absorbable suture (Fig. 18.3) 94
71 tion being exercised not to pinch internal • Division of the appendix with scalpel 95
72 organs); a small incision is ­performed with scis- • Treatment of the stump 96
73 sors and then enlarged with finger guidance. –– Several possibilities: 97
74 –– Retractors (handheld or autostatic) are placed. Some electrocoagulate the mucosa. 98
 18 Appendix 175

Fig. 18.3 

99 Others consider that this is dangerous and

100 prefer to strip it with a scalpel or use bipo-
101 lar cautery. Fig. 18.4 
102 Still others prefer to invert the stump using
103 a 3-0 absorbable purse string suture (but • In case of abscess or peritonitis, the utility of 126

104 there is no evidence to show that this pre- drainage is controversial type; open or closed 127

105 vents secondary blowout) may be used. 128

106 –– Any pus or blood collection is aspirated.

107 –– Irrigate only when needed, to reduce the
18.2.6  Abdominal Closure 129
108 risk of abdominal abscess.
109 –– Aspiration of fluid in the pelvis is ­advisable
• The peritoneum is grasped with four clamps 130
110 to avoid early postoperative development
and closed with 2-0 absorbable running suture. 131
111 of fluid collections/abscesses.
• The transverse and the internal oblique mus- 132
cles are approximated with two 2-0 absorb- 133
able stitches (figure of eight stitches should be 134
112 18.2.4  Search for Meckel’s avoided to limit muscle ischemia). 135
113 Diverticulum • The external oblique fascia is grasped with 136
four clamps and then closed with 0 absorbable 137
114 • Resection of an uninflamed Meckel’s diver-
running suture. 138
115 ticulum should be avoided in case of appendi-
• The skin is closed with interrupted sutures. 139
116 citis complicated with peritoneal abscess or
–– The incision may be left open in case of 140
117 peritonitis (see chapter on small intestinal
frank contamination. 141
118 pathology for more details).
119 • The decision for resection of an incidental
120 Meckel’s diverticulum should be discussed 18.2.7  Variations 142
121 with the patient before the operation and
122 informed consent obtained. 18.2.7.1  Appendicitis in Ectopic Appendix 143
• In case of appendicitis in a long retrocecal 144
appendix or in case of a difficult exteriorization 145
123 18.2.5  Drainage of the appendix, retrograde appendectomy 146
should be preferred (steps 7 and 6 are reversed; 147
124 • Drainage is unnecessary in case of limited mobilization of the appendix is better done 148
125 phlegmonous or gangrenous appendicitis. close to the appendicular wall (Fig. 18.4)). 149
 176 L. Ansaloni et al.

150 • If needed, McBurney’s incision can be scissors, 10-mm curved dissecting forceps, 191
151 enlarged. 10-mm laparoscopic palpator, and 5-mm suc- 192
152 –– However, especially in case of diffuse tion irrigator cannula 193
153 peritonitis, pelvic disease, or unusual • For ligation and retrieval: two absorbable 194
154 position of the cecum, some prefer to con- Endoloops, extraction bag, and 10-mm extrac- 195
155 tinue with a midline incision, while others tion tube 196
156 convert to laparoscopy (“reversed • Optional: one more 5-mm trocar, one 5-mm 197
157 conversion”). alligator grasper, 5-mm needle holder, laparo- 198
158 –– The McBurney’s incision can be closed or scopic 45-mm flexible endocutter with 199
159 used for drainage. reloads, 10-mm clip applier, and 10-mm suc- 200
tion irrigator cannula 201
160 18.2.7.2  Acute Perforated Appendicitis
161 • The inflamed appendix can usually be peeled
162 off from adjacent adhering organs, but care 18.4.2  Positioning, Personnel, 202
163 must be taken not to disrupt the serosa. and Port Sites 203
164 • In case of localized abscess, the cavity must
165 be washed abundantly and drained. • The patient is placed supine, secured by straps 204
166 • Careful inspection of the abdominal cavity is to prevent slippage during table position 205
167 required to search for and remove all contami- changes. 206
168 nated material and/or fecalith. –– Left arm is tucked along the patient’s side. 207
–– Urinary catheter insertion is optional (may 208
be omitted if the patient has voided imme- 209
169 18.3 S
 ummary of Open diately before anesthesia). 210
170 Appendectomy • The surgeon stands on the patient’s left; the 211
assistant stands initially on the patient’s right 212
171 Open appendectomy is performed via McBurney’s and then moves to the left of the surgeon once 213
172 incision; the anterograde procedure is preferred all the trocars are in place. 214
173 (ligation of the mesoappendix, then division of the • The nurse is on the patient’s left, toward the 215
174 appendix at its base), except in long retrocecal feet. 216
175 appendicitis or fixed appendix where a retrograde • The monitor is on the patient’s right, facing 217
176 approach may be preferred. No guidelines exist on the surgeon. 218
177 the treatment of the appendix stump, drainage or
178 skin closure when contamination is likely. In case
179 of difficulty at any step, the McBurney’s incision 18.4.3  Port Site Placement 219
180 can be enlarged or access to the peritoneal cavity
181 through a midline incision is also an option. • For access: several setups are possible. 220
Triangulation with the manipulation angle 221
focused in the right lower quadrant is ideal. 222
182 18.4 Laparoscopic • The open technique or visual-assisted tech- 223
183 Appendectomy nique for the first trocar should be preferred, 224
especially in complicated appendicitis, where 225
184 18.4.1  Equipment and Instruments there is always some degree of ileus. 226
–– The first port is usually supraumbilical. 227
185 • A 10-mm Hasson trocar (or Veress needle and –– Alternatively, a Veress needle is placed 228
186 one 11-mm bladeless optical tip trocar), one supraumbilical in Palmer’s point. 229
187 10-mm trocar, and one 5-mm trocar –– Or an 11-mm optical tip bladeless trocar is 230
188 • For dissection: 30-degree angled laparoscope, placed on the left side of the umbilicus. 231
189 two 5-mm graspers, 5-mm hook ­electrocautery, • 12 mmHg pneumoperitoneum is established; 232
190 bipolar coagulating forceps, 5-mm curved then, the abdominal cavity is explored. 233
 18 Appendix 177

Fig. 18.5  Fig. 18.6 

234 • A second 10-mm trocar is placed under vision, • The appendix should be pursued only after 264
235 two fingerbreadths medial to the left anterosu- clear identification of the cecum and the ter- 265
236 perior iliac spine, avoiding the epigastric ves- minal ileus, completely freeing them from 266
237 sels; a 5-mm trocar is placed in the suprapubic adhesions with adjacent viscera. 267
238 midline (Fig. 18.5). • During adhesiolysis, periappendicular abscesses 268
239 • The gas tube is placed in the 10-mm trocar, are eventually opened and evacuated with the 269
240 coming straight from the column; the light and suction irrigator cannula. 270
241 camera cables are fixed by Velcro straps on the
242 left side of the operating field, to prevent
243 tangling. 18.4.5  Mesoappendix Exposure 271
244 • The laparoscope is placed in the 10-mm trocar and Division 272
245 between the two manipulation trocars and
246 held by the assistant. • The patient is positioned in Trendelenburg 273
with table tilt to the left (right side up). 274
• The appendix is grasped with 5-mm grasper 275
247 18.4.4  Exploration introduced through the periumbilical tro- 276
car and pulled upward to expose the 277
248 • In the presence of peritonitis, complete mesoappendix. 278
249 removal of pus before attempting isolation –– The mesoappendix is then electrocoagu- 279
250 of the appendix should help avoid further lated with the bipolar forceps, introduced 280
251 contamination during patient’s position in the suprapubic trocar (Fig. 18.6), and 281
252 changes. then divided with scissors, proceeding 282
253 • The abdominal cavity should be irrigated from the free edge of the mesoappendix 283
254 abundantly with saline and aspirated only if toward the base of the appendix. Accurate 284
255 peritonitis is generalized; otherwise, local bipolar electrocoagulation is sufficient 285
256 aspiration is usually sufficient (all fluids for control of the appendicular artery: 286
257 should be evacuated by suction). caution should be paid not to injure the 287
258 • Inflammatory adhesions between the bowel cecum or the terminal ileus during 288
259 and the peritoneal surface are best divided coagulation. 289
260 with the aid of the 10-mm palpator, also –– Alternatively, some surgeons prefer elec- 290
261 used to access intermesenteric spaces trocoagulation and dividing the mesoap- 291
262 between the bowel loops, avoiding injury of pendix close to the appendicular wall, 292
263 the bowel. where only small vessels are encountered. 293
 178 L. Ansaloni et al.

tion should be paid, however, to avoid heat 325

transmission to the stump sutures and the 326
cecum. 327

Any collection of fluid or blood is then aspi- 328

rated, and the base of the mesoappendix is checked 329
for adequate hemostasis. Irrigation with saline is 330
performed only when gross contamination is evi- 331
dent, quickly followed by aspiration to avoid fluid 332
spreading to the abdominal cavity, due to gravity. 333

Fig. 18.7  18.4.7  Drainage (As Above) 334

18.4.7.1  Wound Closure 335

294 • The base of the appendix is squeezed gently • Trocars are removed under vision and pneu- 336
295 with an atraumatic grasper to ensure easy liga- moperitoneum is released. 337
296 tion of the stump. • Hemostasis on the port sites can be ensured by 338
bipolar coagulation. 339
• Some surgeons advise to close only those port 340
297 18.4.6  Appendectomy sites greater than 5 mm, and others do not 341
close any. 342
298 • Simple or double ligation is performed at the
299 base of the appendix using absorbable
300 Endoloops (Fig. 18.7). 18.4.8  Retrocecal Appendicitis 343
301 –– Endoloops are introduced in the perium-
302 bilical trocar, while the appendix is held • Failure to identify the appendix should sug- 344
303 with a grasper introduced through the gest a retrocecal position of the appendix. 345
304 suprapubic trocar. Conversion is not always necessary (to the 346
305 • Ligation should be performed close to the contrary, the parietal insult is minimized by 347
306 cecum: leaving a long stump is a risk factor for continuing via laparoscopy). 348
307 developing stump appendicitis (as in open). • Adequate cecal mobilization is mandatory to 349
308 • After ligation, the appendix is grasped close to ensure correct identification of the appendix 350
309 the point of division (using a grasper intro- and treatment of a retrocecal abscess. 351
310 duced in the suprapubic trocar), divided with –– The parietal peritoneum is divided with 352
311 scissors, and then placed in an extraction bag sharp dissection in preference to hook 353
312 retrieved from the periumbilical trocar or ­electrocautery, while the cecum is pulled 354
313 extracted through one of the 10–12-mm tro- toward the midline. 355
314 cars (without the need of an extraction bag). –– Occasionally, mobilization of the terminal 356
315 –– Some surgeons favor closing the distal ileum is necessary to expose a retroperito- 357
316 stump with a stapler (dilated, fragile appen- neal appendix: caution should be exercised 358
317 dix, inflammatory involvement of the not to injury the right ureter. 359
318 base). Sutures should be used with caution, • An inflamed retroperitoneal appendix, adher- 360
319 especially in case of local inflammation. ent to the cecum and ascending colon, is better 361
320 –– Others prefer to electrocoagulate the isolated via blunt dissection, with the aid of 362
321 mucosa of the proximal stump with bipolar the suction irrigation cannula and a 10-mm 363
322 forceps (avoid monopolar) with the intent palpator: in this case, another 5-mm trocar, 364
323 to prevent mucocele and the development inserted in the epigastrium, and a 5-mm atrau- 365
324 of a postoperative pericecal abscess: cau- matic grasper inserted by the assistant to help 366
 18 Appendix 179

Fig. 18.8 

Fig. 18.9 
367 hold the cecum toward the midline may be
368 necessary. Alternatively, a 5-mm trocar is
369 inserted at the point of McBurney and used by 18.4.10  Retrograde Appendectomy 398
370 the surgeon: in this case, the assistant uses the
371 suprapubic port site to hold the cecum or the • In case of a long retrocecal appendix adhering to 399
372 terminal ileum (Fig. 18.8). the posterior wall of the ascending colon, where 400
the apex of the appendix can reach the liver and 401
is difficult to identify, the retrograde technique is 402
373 18.4.9  Pelvic Abscess safer. Again, it is not usually necessary to con- 403
vert, and the identification and management of 404
374 • In this case, a change of trocar placement may retrocecal appendicitis is perfectly adapted to 405
375 be necessary: one supraumbilical 11-mm blade- laparoscopy with adequate expertise. 406
376 less trocar (for first access), one 10-mm trocar –– The base of the appendix is dissected first 407
377 placed where the transverse umbilical line and then divided either with sutures as 408
378 crosses the right midclavicular line, and one above, or a linear stapler. 409
379 10-mm trocar placed where the intra-iliac line –– Dissection then proceeds close to the appen- 410
380 crosses the left midclavicular line (Fig. 18.9) dicular wall, where only small ­vessels are 411
381 • Pelvic abscesses are usually covered by the sig- encountered, using bipolar coagulation in 412
382 moid colon and small bowel adhering to the pari- preference to hook electrocautery. 413
383 etal peritoneum. Access is gained to the abscess
384 via gentle blunt dissection with the 10-mm pal-
385 pator to detach the sigmoid colon and the bowel 18.4.11  Normal Appendix 414
386 loops without injuring the intestinal wall.
387 • Complete aspiration of pus and abscess is bet- • Finding an apparently normal appendix should 415
388 ter achieved with the aid of a 10-mm suction prompt the surgeon to carefully inspect the 416
389 irrigation cannula used in combination with abdominal cavity for other causes of disease: 417
390 the 10-mm palpator. clearly one of the advantages of laparoscopy. 418
391 • The appendix often is found to adhere to the –– Salpingitis, ruptured ovarian follicle, endo- 419
392 bowel or the pelvic peritoneum, and its metriosis, Meckel’s diverticulitis, ­diverticulitis 420
393 removal follows the same steps as above. of the sigmoid colon, Crohn’s disease, omen- 421
394 • Before ending the operation, the surgeon must tal infarction, cholecystitis, and perforated 422
395 inspect the small bowel, to ensure that it is free gastroduodenal ulcer are the most frequent 423
396 of adhesions, not twisted, and that the serosa causes of pain mimicking acute appendicitis: 424
397 is not torn. accurate diagnosis is possible, and in most 425
 180 L. Ansaloni et al.

426 cases, adequate treatment can be performed Selected Reading 467

427 through laparoscopy.
428 • The decision to remove a normal appendix should Allemann P, Probst H, Demartines N, Schäfer M. 468
Prevention of infectious complications after laparo- 469
429 be discussed with the patient before operation. scopic appendectomy for complicated acute appendi- 470
430 –– When the cause of the acute abdomen is citis—the role of routine abdominal drainage. 471
431 clear, removal of a normal appendix is Langenbecks Arch Surg. 2011;396(1):63–8. 472
432 questionable. When accurate laparoscopic Beldi G, Vorburger SA, Bruegger LE, Kocher T, Inderbitzin 473
D, Candinas D. Analysis of stapling versus endoloops 474
433 exploration of the abdominal cavity reveals in appendiceal stump closure. Br J Surg. 2006; 475
434 no cause for acute pain, removal of a nor- 93:1390–3. 476
435 mal appearing appendix could be consid- Chu T, Chandhoke RA, Smith PC, Schwaitzberg SD. The 477
436 ered, especially in subjects with recurrent impact of surgeon choice on the cost of performing 478
laparoscopic appendectomy. Surg Endosc. 479
437 episodes of pain in the right iliac fossa. 2011;25(4):1187–91. 480
Fingerhut A. Conversion from open to laparoscopic treat- 481
ment of peritonitis: “Reversed Conversion” revisited. 482
438 18.4.12  Conversion Surg Innov. 2011;18:5–7. 483
Guidelines for laparoscopic appendectomy. Practice/ 484
clinical guidelines published on 04/2009 by the 485
439 • Most frequently needed when a chronically Society of American Gastrointestinal and Endoscopic 486
440 inflamed appendix is tenaciously adherent to Surgeons (SAGES). http://www.sages.org/publica- 487
441 the cecum or is embedded in a retroperitoneal tion/id/05/. 488
Hussain A, Mahmood H, Singhal T, Balakrishnan S, 489
442 abscess and the surgeon lacks the necessary El-Hasani S. What is positive appendicitis? A new 490
443 experience to accomplish the operation answer to an old question. Clinical, macroscopical and 491
444 laparoscopically. microscopical findings in 200 consecutive appendec- 492
445 • Some surgeons prefer to convert to a large tomies. Singap Med J. 2009;50:1145–9. 493
Ingraham AM, Cohen ME, Bilimoria KY, Pritts TA, Ko 494
446 McBurney, or if needed, pararectal incision or CY, Esposito TJ. Comparison of outcomes after lapa- 495
447 median laparotomy. roscopic versus open appendectomy for acute appen- 496
dicitis at 222 ACS NSQIP hospitals. Surgery. 497
2010;148:625–35; discussion 635–7. 498
Khanna S, Khurana S, Vij S. No clip, no ligature laparo- 499
448 18.4.13  Search for Meckel’s scopic appendectomy. Surg Laparosc Endosc Percutan 500
449 Diverticulum (Via Tech. 2004;14:201–3. 501
450 Laparoscopy Sahm M, Kube R, Schmidt S, Ritter C, Pross M, Lippert 502
451 and Laparotomy) H. Current analysis of endoloops in appendiceal stump 503
closure. Surg Endosc. 2011;25(1):124–9. 504
Sauerland S, Jaschinski T, Neugebauer EA. Laparoscopic 505
452 Resection of an uninflamed Meckel’s diverticu- versus open surgery for suspected appendicitis. 506
453 lum does not seem to be associated with increased Cochrane Database Syst Rev. 2010;10:CD001546. 507
454 perioperative morbidity, but there is no evidence Schein M. Acute appendicitis. In: Schein, Rogers, editors. 508
Scheins’s common sense emergency abdominal sur- 509
455 of any benefit in routine removal. Resection of an gery. 2nd ed. Berlin: Springer; 2005. p. 245–54. 510
456 uninflamed Meckel’s diverticulum should be Shapiro R, Eldar S, Sadot E, Venturero M, Papa MZ, 511
457 avoided in case of appendicitis complicated with Zippel DB. The significance of occult carcinoids in the 512
458 peritoneal abscess or peritonitis. The decision to era of laparoscopic appendectomies. Surg Endosc. 513
2010;24(9):2197–9. 514
459 resect an incidental Meckel’s diverticulum should Skandalakis JE, Skandalakis PN, Scandalakis LJ. 515
460 be discussed with the patient before the operation Appendix. Surgical anatomy and technique, A pocket 516
461 and informed consent obtained. manual. New York: Springer; 1995. p. 389–99. 517
462 Whether via laparoscopy or laparotomy, it is Smink DS, Soybel DI. Acute appendicitis. In: Cameron JL, 518
editor. Current surgical therapy. 8th ed. Pennsylvania: 519
463 important to resect the base of the diverticulum as Lippincott Williams & Wilkins; 2004. p. 241–4. 520
464 ectopic gastric or pancreatic tissue may be har-
465 bored there: simple diverticulectomy by mass
466 ligation should be avoided.
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