- Clinical suspicion of appendicitis in an ill-appearing patient.
- Presence of large periappendiceal abscess, which may be treated best with initial drainage and interval appendectomy.
- Suspicion of Crohn's disease involving the cecum at the base of the appendix.
- Treatment of acute appendicitis.
- Bleeding requiring reoperation.
- Surgical site infection (deep or superficial).
- Fecal fistula.
- Conversion to open appendectomy.
- Need for midline laparotomy.
- Open wound.
- Need for additional tests or procedures.
- The open procedure requires no special equipment.
- The laparoscopic procedure requires the following equipment:
- 5-mm angled laparoscope.
- Veress needle or Hasson trocar.
- Endoscopic stapler.
- Endoscopic retrieval bag for removal of the appendix.
- No oral intake; maintenance intravenous fluids.
- Preoperative antibiotics to cover enteric flora.
- The patient should be supine with both arms extended.
- The entire abdomen is prepared and draped in case a midline incision is needed (eg, unexpected disease is encountered or the operative course dictates it).
- Figure 20–1: The patient is supine with both arms tucked at the sides. The operating surgeon and assistant stand on the patient's left.
- A Foley catheter is placed to decompress the bladder.
- The patient's entire abdomen is prepared and draped.
- The classic transverse incision can be made with two thirds of the incision lateral to McBurney's point.
- Alternatively, the point of maximal tenderness or the location of the appendix based on preoperative imaging can be used to determine the location of the incision.
- Figure 20–2: A scalpel is used to incise the epidermis and the dermis. Bovie electrocautery is used to dissect down to the external oblique aponeurosis.
- The aponeurosis is opened in a superolateral to inferomedial direction along the direction of its fibers to expose the internal oblique muscle.
- The internal oblique muscle is bluntly divided perpendicular to the direction of its fibers.
- The transverse abdominal muscle is similarly divided and the peritoneum is identified.
- Figure 20–3: The peritoneum is grasped with forceps and incised with a 15-blade knife.
- Attention is now focused on locating the appendix.
- If the cecum is visualized, it can be used as a guide to help identify the appendix.
- Babcock forceps can be used to grasp the taeniae coli and advanced until the appendix is externalized.
- Alternatively, a finger can be swept around the cecum, beginning superolaterally and continuing inferomedially to locate the appendix.
- Figure 20–4: Once identified, the mesoappendix is dissected and the appendiceal vessels are divided between clamps and ligated with silk sutures.
- Figure 20–5: A silk purse-string suture is placed around ...
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