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Acute appendicitis is a bacterial process that is usually progressive, but many locations of the appendix allow this organ to mimic many other retrocecal, intra-abdominal, or pelvic diseases. While multiple ongoing studies seek to investigate nonoperative management of acute appendicitis, surgical intervention remains the standard of care. 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 is 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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Preoperative preparation is devoted chiefly to the restoration of fluid balance, especially in very young and aged patients. The patient should be well hydrated, as indicated by a good urine output. A nasogastric/orogastric 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 because hyperpyrexia complicates general anesthesia. Preoperative broad-spectrum antibiotics are routinely administered prior to incision and are continued in the postoperative period in patients with signs of systemic sepsis or if a phlegmon or an abscess is encountered during the operation.
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Inhalation anesthesia is preferred, but spinal anesthesia is satisfactory.
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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. Sterile drapes are applied according to the surgeon's specifications. Then a time-out is performed.
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INCISION AND EXPOSURE
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Historically, a McBurney's or gridiron incision has been described as the preferred access for appendectomy. This incision is oriented in the direction of external oblique fibers and is placed at the junction of the medial two-thirds and lateral one-third of an imaginary line connecting the right anterosuperior iliac spine to the umbilicus. In no surgical procedure has the practice of standardizing the incision proved more harmful than appendectomy. There can be no incision that always should be used because 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 (FIGURE 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 ...