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

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Absolute

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  • None.

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Relative

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  • 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.

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Expected Benefits

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  • Treatment of acute appendicitis.

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Potential Risks

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  • 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.

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  • 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.

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  • No oral intake; maintenance intravenous fluids.
  • Preoperative antibiotics to cover enteric flora.

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Open Appendectomy

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  • 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).

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Laparoscopic Appendectomy

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  • 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.

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Open Appendectomy

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  • 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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