Chapter 20

• Clinical suspicion of appendicitis in an ill-appearing patient.

• None.

### Relative

• 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.

### Expected Benefits

• Treatment of acute appendicitis.

### Potential Risks

• 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.

### Open Appendectomy

• 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).

### Laparoscopic Appendectomy

• 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.

### Open Appendectomy

• 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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