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INDICATIONS

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Acute appendicitis is a bacterial process that is usually progressive; however, many locations of the appendix allow this organ to mimic many other retrocecal, intra-abdominal, or pelvic diseases. When the diagnosis of acute appendicitis is made, prompt operation is almost always indicated. Delay for administration of parenteral fluids and antibiotics may be advisable in toxic patients, children, or elderly patients.

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If the patient has a mass in the right lower quadrant when first seen, several hours of preparation may be indicated. Often a phlegmon is present and appendectomy can be accomplished. When an abscess is found, it is drained and appendectomy performed concurrently, if this can be done easily. Otherwise, the abscess is drained and an interval appendectomy is carried out at a later date.

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If the diagnosis is chronic appendicitis, then other causes of pain and sources of pathology should be ruled out.

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PREOPERATIVE PREPARATION

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The preoperative preparation is devoted chiefly to the restoration of fluid balance, especially in the very young and in aged patients. The patient should be well hydrated, as manifest by a good urine output. A nasogastric tube is passed for decompression of the stomach so as to minimize vomiting during induction of anesthesia. Antipyretic medication and external cooling may be needed since hyperpyrexia complicates general anesthesia. If peritonitis or an abscess is suspected, antibiotics are given.

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ANESTHESIA

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Inhalation anesthesia is preferred; however, spinal anesthesia is satisfactory. Local anesthesia may be indicated in the very ill patient.

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POSITION

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The patient is placed in a comfortable supine position.

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OPERATIVE PREPARATION

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The skin is prepared in the usual manner.

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INCISION AND EXPOSURE

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In no surgical procedure has the practice of standardizing the incision proved more harmful. There can be no incision that should always be utilized, since the appendix is a mobile part of the body and may be found anyplace in the right lower quadrant, in the pelvis, up under the ascending colon, and even, rarely, on the left side of the peritoneal cavity (figures 1 and 3). The surgeon determines the location of the appendix, chiefly from the point of maximum tenderness by physical examination, and makes the incision best adapted for exposing this particular area. The great majority of appendices are reached satisfactorily through the right lower muscle-splitting incision, which is a variation of the original McBurney procedure (figure 1, incision A). If the patient is a woman and laparoscopic evaluation is not available, many surgeons prefer a midline incision to permit exposure of the pelvis. If there is evidence of abscess formation, the incision should be made directly over the site of the abscess.

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Wherever the incision is, it is deepened first to the aponeurosis of the ...

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