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Surrey Vascular Surgeon

Expert vascular care from a Vascular Surgeon covering Surrey, Berkshire and Hampshire. Treating Varicose Veins, aneurysms, carotid disease.

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Open Appendicectomy

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Written by Neville Dastur   
Friday, 26 January 2007 16:32

Preparation for open appendicectomy

Setup for open appendicectomy

  • The patient will require a general anaesthetic and be positioned supine

  • Prophylactic antibiotics are given to reduce the incidence of wound infection

  • The patient should be draped to expose the right lower abdominal quadrant and allowing identification of the umbilicus and right anterior superior iliac spine (ASIS)

Incision for open appendicectomy

Open appendicectomy incisionClassically the incision lies over McBurney's point; which is a surface marking 1/3rd of way along an imaginary line joining the right ASIS and the umbilicus. An incision is made perpendicular to this line. This is also known as a gridiron or McBurney's incision.

The Lanz incision is more commonly used now as it has a better cosmetic result. This incision is made horizontally over McBurney's point.

A lower midline incision should be considered in the middle aged or elderly patient or if the diagnosis is in doubt.

Tip: It is useful and also good practise to palpate the abdomen once the patient is anaesthetised and relaxed. This allows you to possibly identify an appendix mass and often the caecum can be palpated which aids the location of your incision.

Tip: For the exams - remember that McBurney's point is supposed to mark the base of the appendix, as the tip can lie in many places.

Procedure for open appendicectomy

After the skin incision the subcutaneous fat is divided down to the external oblique aponeurosis. And it is useful to clear the fat of the aponeurosis with a small swab at this stage.

An incision is made in the line of the fibres into the external oblique aponeurosis with a scalpel and extended with tissue scissors. Beneath this you will find the internal oblique muscle which is split with a pair of curved heavy scissors. The split can be enlarged with either your fingers or a pair of retractors. Peritoneum should now be visible. It can be picked by and tented by two small clips. The peritoneum is then opened by stroking with the belly of a scalpel blade. Ensure there is nothing adherent to the underlying peritoneum and extend the incision with scissors.

Made a note of any fluid released from the peritoneal cavity and if turbid then consider sending a culture swab.

In acute appendicitis it is very likely that the omentum will have migrated down to the right iliac fossa. This can be gently pushed away medially.

Appendix Delivered Through WoundProbably the easiest method of finding the appendix is to first identify the caecum. If the caecum is not readily identifiable then find some small bowel and follow it back to the caecum. The taeniae on the caecum can then be followed down to the appendix. Attempted to deliver the caecum and appendix through the wound. If the appendix is very inflammed it will be adherent to surrounding structures. Pass your index finger down from the base of the appendix clearing and adhesions with gentle blunt dissection.

If at this stage you are unable to deliver the appendix then enlarge your incision by dividing the fibres of internal oblique. If necessary rectus can be divided too.


Tied meso-appendix

Once the appendix is delivered it should be held with a tissue holding forcep such as a babcock. The mesoappendix is then clipped and divided and the pedicles tied with an braided absorbable tie such as vicryl.

The base of the appendix is crushed with a heavy clip and the clip is placed slightly higher on the appendix. The safest method of dealing with the base is to suture ligate it. The appendix is then divided under the attached clip with a scalpel blade and the suture cut. The remaining suture can then be used to bury the stump with either a purse string or a 'Z' stitch. Now ensure that both the remaining suture and blade used are discarded as they are dirty.

The ceacum is gently placed back into the peritoneal cavity and any fluid sucked out. A washout can be performed although some argue that it just spreads the contaminated fluid around the whole abdomen.

Appendix base tied

Closure following appendicectomy

The edges of the peritoneum are identified and picked up with up to four clips. The peritoneum is then closed using a continuous 3/0 absorbable suture. The muscle fibres can be loosely approximated with some interrupted stitches. The external oblique defect must be securely repaired. This is done with a continuous 3/0 absorbable suture.

A local anaesthetic agent can now be infiltrated to provide postoperative pain relief.

Skin can be closed with a continuous subcuticular absorbable suture. If the wound has been highly contaminated then consider closing with an interrupted suture or skin clips.

Postoperative Care

  • Routine observation of heart rate, blood pressure and temperature

  • Allow free fluids orally and full diet the next day

  • DVT prophylaxis should be commenced immediately

  • Two further doses of the antibiotic used on induction can be given postoperatively

Other points to note

  • If the appendix looks macroscopically normal it should still be removed. Patients with a right iliac fossa scar will be assumed to have had a appendicectomy by other medical staff. Additionally, 15% of macroscopically normal appendixes prove to be acute appendicitis under microscopy.

  • If macroscopically normal, then do remember to check for other causes, such as mesenteric adenitis, Meckel's diverticulitis, ovario-tibular pathology or a sigmoid diverticulitis.

  • If an appendix mass (abscess) is present and the appendix can not be found then place an abdominal drain to the mass and close. An interval appendicectomy can be performed at a later date.

  • Occasionally you will find a right colon carcinoma or terminal ileitis. This require a right hemi-colectomy to be performed and senior help should be obtained if required.

 

Comments  

 
+1 # ayman nazim 2008-04-14 07:10
:-) thanks 4 your effort
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-15 # Hiba Rabei 2008-10-03 20:28
Thank you!
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-1 # Ricardo Mendoza 2009-01-21 02:17
very kool!! nice description of the procedure. :woohoo:
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+1 # mohd diab 2009-01-22 15:53
thaks, please do ultrasound pelvis in +/- all females with ?appendicitis.
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+3 # elena gamborino 2009-01-24 23:34
:-) very nice. thanks.
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+2 # Azhar Bukhari 2009-02-08 22:08
Nice, goodand knowledgable effort. I routinely close peritoneum but some recommend not to close peritonium so as to prevent adhesions. Is it true for appendicectomy also or only midline or other incisions incisions
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+2 # mohd diab 2009-02-09 07:33
thanks (Peritoneal closure): regarding adhesion it is not proved,but no difference in the other outcome.
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0 # Tashfeen Imtiaz 2009-03-05 14:33
nice effort.
there is evidence in some literature where closure of peritoneum is condemned as it hampers the blood supply of the divided edges of the peritoneum therefore delaying its healing process which is very rapid (in hours) the other way around.
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+1 # Amin Rahman 2009-04-09 13:13
nice coverage...
however some key notes for improvements
regarding Postoperative Care

\"DVT prophylaxis should be commenced immediately\" - this statement, i thinks it is not necessary and only useful for high risk patient

\"Two further doses of the antibiotic used on induction can be given postoperatively\" - this also controversial, some studies said as if it is clean-contaminated surgery -appendix only inflamed antibiotic is recommended only at the time of induction, no need another dose post-operatively...but if it is perforated/suppurative then antibiotic can be continued as a theraputic dose 3-5 days...

i just wanna ask you...how long do you take to do an appendicectomy?(an average)

keep-up with good works
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+2 # Neville Dastur 2009-04-14 21:46
Thanks for the comments.

My point about DVT prophylaxis is that there is no need to delay starting it.

With regards antibiotics you are right.

And a straight forward appendicectomy should take about 20-40 mins. Most juniors ought to be calling for help if it is more than an hour.
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0 # Abdellatif El Alwany 2009-04-17 16:08
thanks I hope to know more about peritoneal closure
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+3 # kyaw kyawsoe 2009-04-26 17:08
thank you for very clear discription.
i would like to ask you some questions.
1. type of anesthesia - what about regional anesthesia for appendicectomy.
2.in delivering the appendix, i prefer to hook the tenia with left index finger and pull it downward and medially through the wound - what about your opinion.
3. in case of retrocaecal type, if it is not possible to deliver the appendix through the wuoud, i push the caecum medially with deep retractors, and appendectomy is done inside the cavity, usually retrogradely. what about your opinion?
4. i am not agree with the procedure of crushing of base of appendix before ligation, instead of that i prefer to ligate with force just enough to occlude the lumen.
but,i agrees with your suture ligation method.
5. i am also on the side of not bury the stump - my opinion is it is not avandageous and may even be harmful.
6.i am also on the side of not closing the peritoneum and a little more time will be saved and is also safe.
7.how about interval appendicectomy?
in my opinion, only a small more % of appendicitis ( let\'s say 4 % ) occur in patients with resloved
appendiculat mass in comparison to normal population, i would like to perform appendicectomy in these patients only if next attack occur especially if they live near the
porper health care centre.

thanks, with respect -
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+1 # mahmoud khashashneh 2009-05-24 22:46
waw thats nice....
thanks
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0 # hossam shoaib 2009-11-10 19:17
Thank You
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+1 # Dr. Tint Swe 2010-02-24 05:08
Thanks! Clear and practical.
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0 # Ahmed Adam 2010-05-28 17:28
That is nice dear kyaw kyawsoe
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0 # abishek banota 2010-06-09 11:29
:P :P :P i liked it .
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0 # ezdehar 2010-07-06 20:25
thaaaaaaanks so mush
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0 # Administrator 2010-07-06 21:04
Thanks for all the good comments. Glad it helps
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0 # akhil chauhan 2010-07-10 16:29
great job man thanks for describing it in so easy way....
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0 # Dr.Ali Ben Omran 2010-07-23 16:27
thank tou :-) :-)
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-1 # Ramadan shaker 2010-08-11 22:41
i prefer to take alook on opened peritoneum opened up by retractors before any manipulations and disruption of anatomy i may see caecum or even the appendix to deliver
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-2 # Administrator 2010-08-12 12:14
Yes, true. Sometimes the appendix is just sitting there waiting for you!
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0 # Dr.Sara 2010-10-23 00:20
Thanks.
Very nice.
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0 # Dr.Sara 2010-10-23 00:22
Thanks for you.
Very nice.
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0 # obasanmi victor 2010-10-23 20:56
very precise.just one question;how safe is this procedure in a gravid woman with acute appendicitis?say about 19 wks gestation
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0 # Neville Dastur 2010-10-23 22:25
Quoting obasanmi victor:
very precise.just one question;how safe is this procedure in a gravid woman with acute appendicitis?say about 19 wks gestation

As I understand it the risk of miscarriage is just as high from leaving the sepsis as operating and of course you have to treat the mother first. So it is not safe but a matter of weighting risk and benefit.
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0 # obasanmi victor 2010-10-23 21:00
thanks alot. i remember when i just started operating,i spent almost an hour and half looking for it.had to close up.surprisingly when i opened up the next day,it was right there waiting for me,
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0 # Shwe Sin Win 2010-10-31 12:47
Thanks.Its really nice. But it will be better if we can watch movie while reading step by step procedure. :-)
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0 # Dr.Badar Muneer 2010-11-01 15:27
Thanks a lot.
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0 # C.Elliott 2010-11-02 03:21
A recent xray shows what looks like surgical pins and staples near the area of an old appendix scar. This operation was done at 3yrs of age in 1953. This came as a complete surprise, as the only other operation i have had was a caesarian section in 1969. The position/presence of the pins/staples is a mystery. Could they have been put there in 1953?
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0 # Ahmed.M 2010-12-04 14:37
thanks>>>>>>> good work!! ;-)
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+1 # Dr.Ibrahim M Sallam 2011-03-19 16:34
Thank you . I'm really grateful . It's a nice brief practical review with good notes . . . .
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-1 # dr prem 2011-06-19 12:05
thank you very nice work D V T not necessary for young
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# yusuf Olatunde 2017-01-21 10:23
Thanks for the nice piece. please can you share your experience with us on appendicectomy in a highly muscular patient?
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