Appendicectomy
Encyclopedia
An appendectomy is the surgical removal
of the vermiform appendix
. This procedure is normally performed as an emergency procedure
, when the patient is suffering from acute appendicitis
. In the absence of surgical facilities, intravenous antibiotics are used to delay or avoid the onset of sepsis
; it is now recognized that many cases will resolve when treated perioperatively. In some cases the appendicitis resolves completely; more often, an inflammatory mass forms around the appendix, causing transruptural flotation. This is a relative contraindication
to surgery
.
Appendectomy may be performed laparoscopic
ally (this is called minimally invasive surgery) or as an open operation. Laparoscopy is often used if the diagnosis
is in doubt, or if it is desirable to hide the scar
s in the umbilicus
or in the pubic hair line. Recovery may be a little quicker with laparoscopic surgery; the procedure is more expensive and resource-intensive than open surgery and generally takes a little longer, with the (low in most patients) additional risks associated with pneumoperitoneum
(inflating the abdomen with gas). Advanced pelvic sepsis occasionally requires a lower midline laparotomy
.
There have been some cases of auto-appendectomies, i.e. operating on yourself. One was performed by Dr Kane in 1921, but the operation was completed by his assistants. Another case is Leonid Rogozov
who had to perform the operation on himself as he was the only surgeon on a remote Antarctic base.
woman, an appendectomy is usually performed and should not harm the fetus
. 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.
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.
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
of the vermiform appendix
Vermiform appendix
The appendix is a blind-ended tube connected to the cecum , from which it develops embryologically. The cecum is a pouchlike structure of the colon...
. This procedure is normally performed as an emergency procedure
Emergency medicine
Emergency medicine is a medical specialty in which physicians care for patients with acute illnesses or injuries which require immediate medical attention. While not usually providing long-term or continuing care, emergency medicine physicians diagnose a variety of illnesses and undertake acute...
, when the patient is suffering from acute appendicitis
Appendicitis
Appendicitis is a condition characterized by inflammation of the appendix. It is classified as a medical emergency and many cases require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of the risk of rupture leading to...
. In the absence of surgical facilities, intravenous antibiotics are used to delay or avoid the onset of sepsis
Sepsis
Sepsis is a potentially deadly medical condition that is characterized by a whole-body inflammatory state and the presence of a known or suspected infection. The body may develop this inflammatory response by the immune system to microbes in the blood, urine, lungs, skin, or other tissues...
; it is now recognized that many cases will resolve when treated perioperatively. In some cases the appendicitis resolves completely; more often, an inflammatory mass forms around the appendix, causing transruptural flotation. This is a relative contraindication
Contraindication
In medicine, a contraindication is a condition or factor that serves as a reason to withhold a certain medical treatment.Some contraindications are absolute, meaning that there are no reasonable circumstances for undertaking a course of action...
to surgery
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
.
Appendectomy may be performed laparoscopic
Laparoscopic surgery
Laparoscopic surgery, also called minimally invasive surgery , bandaid surgery, or keyhole surgery, is a modern surgical technique in which operations in the abdomen are performed through small incisions as opposed to the larger incisions needed in laparotomy.Keyhole surgery makes use of images...
ally (this is called minimally invasive surgery) or as an open operation. Laparoscopy is often used if the diagnosis
Medical diagnosis
Medical diagnosis refers both to the process of attempting to determine or identify a possible disease or disorder , and to the opinion reached by this process...
is in doubt, or if it is desirable to hide the scar
Scar
Scars are areas of fibrous tissue that replace normal skin after injury. A scar results from the biological process of wound repair in the skin and other tissues of the body. Thus, scarring is a natural part of the healing process. With the exception of very minor lesions, every wound results in...
s in the umbilicus
Navel
The navel is a scar on the abdomen caused when the umbilical cord is removed from a newborn baby...
or in the pubic hair line. Recovery may be a little quicker with laparoscopic surgery; the procedure is more expensive and resource-intensive than open surgery and generally takes a little longer, with the (low in most patients) additional risks associated with pneumoperitoneum
Pneumoperitoneum
Pneumoperitoneum is air or gas in the abdominal cavity. It is often seen on X-ray, but small amounts are often missed, and CT is nowadays regarded as a criterion standard in the assessment of a pneumoperitoneum. CT can visualize quantities as small as 5 cm³ of air or gas...
(inflating the abdomen with gas). Advanced pelvic sepsis occasionally requires a lower midline laparotomy
Laparotomy
A laparotomy is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity. It is also known as coeliotomy.- Terminology :...
.
There have been some cases of auto-appendectomies, i.e. operating on yourself. One was performed by Dr Kane in 1921, but the operation was completed by his assistants. Another case is Leonid Rogozov
Leonid Rogozov
Leonid Ivanovich Rogozov was a Russian general practitioner who took part in the sixth Soviet Antarctic Expedition in 1960-1961. He was the only doctor stationed at the Novolazarevskaya Station and, while there, developed peritonitis, which meant he had to perform an appendectomy on himself, a...
who had to perform the operation on himself as he was the only surgeon on a remote Antarctic base.
Procedure
In general terms, the procedure for an open appendectomy is as follows.- Antibiotics are given immediately if there are signs of sepsisSepsisSepsis is a potentially deadly medical condition that is characterized by a whole-body inflammatory state and the presence of a known or suspected infection. The body may develop this inflammatory response by the immune system to microbes in the blood, urine, lungs, skin, or other tissues...
, otherwise a single dose of prophylactic intravenous antibiotics is given immediately prior to surgery. - General anaesthesiaGeneral anaesthesiaGeneral anaesthesia is a state of unconsciousness and loss of protective reflexes resulting from the administration of one or more general anaesthetic agents...
is induced, with endotracheal intubation and full muscle relaxationMuscle relaxantA muscle relaxant is a drug which affects skeletal muscle function and decreases the muscle tone. It may be used to alleviate symptoms such as muscle spasms, pain, and hyperreflexia. The term "muscle relaxant" is used to refer to two major therapeutic groups: neuromuscular blockers and spasmolytics...
, and the patient is positioned supineSupine positionThe supine position is a position of the body: lying down with the face up, as opposed to the prone position, which is face down, sometimes with the hands behind the head or neck. When used in surgical procedures, it allows access to the peritoneal, thoracic and pericardial regions; as well as the...
. - The abdomenAbdomenIn vertebrates such as mammals the abdomen constitutes the part of the body between the thorax and pelvis. The region enclosed by the abdomen is termed the abdominal cavity...
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 pointMcBurney's pointMcBurney's point is the name given to the point over the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the navel...
, one third of the way from the anterior superior iliac spineAnterior superior iliac spineThe anterior superior iliac spine is an important landmark of surface anatomy. It refers to the anterior extremity of the iliac crest of the pelvis, which provides attachment for the inguinal ligament, and the sartorius muscle...
(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 AponeurosisAponeurosisAponeuroses are layers of flat broad tendons. They have a shiny, whitish-silvery color, are histologically similar to tendons, and are very sparingly supplied with blood vessels and nerves. When dissected, aponeuroses are papery, and peel off by sections...
is slitted along its fiber, and the internal oblique muscleMuscleMuscle is a contractile tissue of animals and is derived from the mesodermal layer of embryonic germ cells. Muscle cells contain contractile filaments that move past each other and change the size of the cell. They are classified as skeletal, cardiac, or smooth muscles. Their function is to...
is split along its length, not cut. As the two run at right angles to each other, this prevents later Incisional herniaIncisional herniaAn incisional hernia occurs in an area of weakness caused by an incompletely-healed surgical wound. Since median incisions in the abdomen are frequent for abdominal exploratory surgery, ventral incisional hernias are termed ventral hernias. If it is not caused by an incision, then it is a...
. - On entering the peritoneumPeritoneumThe peritoneum is the serous membrane that forms the lining of the abdominal cavity or the coelom — it covers most of the intra-abdominal organs — in amniotes and some invertebrates...
, the appendix is identified, mobilized and then ligated and divided at its base. - Some surgeons choose to bury the stump of the appendix by inverting it so it points into the caecum.
- 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.
Pregnancy
If appendicitis develops in a pregnantPregnancy
Pregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...
woman, an appendectomy is usually performed and should not harm the fetus
Fetus
A fetus is a developing mammal or other viviparous vertebrate after the embryonic stage and before birth.In humans, the fetal stage of prenatal development starts at the beginning of the 11th week in gestational age, which is the 9th week after fertilization.-Etymology and spelling variations:The...
. 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.
Recovery
External links
- Laproscopic Appendectomy Video (includes case presentation)
- Open appendectomy, appendectomy Part of the operative howto series, explaining the steps in carrying out an open appendectomy
- Open & Laparoscopic appendectomy, appendectomy Open and Laparoscopic appendectomy
- A video of the procedure
- Another video of the procedure (Either Requires Windows Media Player and will not load in Firefox 1.5; or use this direct link with any player that can play .wmv files.)