Appendectomy

Acute appendicitis is a bacterial process that is usually progressive; however, the 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.

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.

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

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.

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

The patient is placed in a comfortable supine position.

The skin is prepared in the usual manner.

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 2 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.

Wherever the incision is, it is deepened first to the aponeurosis of the outer layer of muscle. In the muscle-splitting incision the aponeurosis of the external oblique is split from the edge of the rectus sheath out into the flank parallel to its fibers (Figure 4). With the external oblique held aside by retractors, the internal oblique muscle is split parallel to its fibers up to the rectus sheath (Figure 5) and laterally toward the iliac crest (Figure 6). Sometimes the transversalis fascia and muscle are divided with the internal oblique, but a stouter structure for repair results if the transversalis fascia is opened with the peritoneum. The rectus sheath may be opened for 1 or 2 cm to give additional exposure (Figure 7). The peritoneum is picked up between forceps, first by the operator and then by the assistant (Figure 8). The operator drops the original bite, picks it up again close to the forceps of the first assistant, and compresses the peritoneum between the forceps with the handle of the scalpel to free the underlying intestine. This maneuver to safeguard the bowel is important and should always be carried out before opening the peritoneum. As soon as the peritoneum is opened (Figure 8), its edges are clamped to the moist gauze sponges already surrounding the wound (Figure 9). Cultures are taken of the peritoneal fluid.

As a rule, if the cecum presents almost immediately, it is better to pull it into the wound, to hold it in a piece of moist gauze, and to deliver the appendix without feeling around blindly in the abdomen (Figure 10). The peritoneal attachments of the cecum may require division to facilitate the removal of the appendix. Once the appendix is delivered, its mesentery near the tip may be seized in a clamp, and the cecum may be returned to the abdominal cavity. Following this, the peritoneal cavity is walled off with moist gauze sponges (Figure 11). The mesentery of the appendix is divided between clamps, and the vessels are carefully ligated (Figure 12). It is better to apply a transfixing suture rather than a tie to the contents of the clamps, for when structures are under tension, the vessels not infrequently retract from the clamp and bleed later into the mesentery. With the vessels of the mesentery tied off, the stump of the appendix is crushed in a right-angle clamp (Figure 13).

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The right-angle clamp is moved 1 cm toward the tip of the appendix. Just at the proximal edge of the crushed portion, the appendix is ligated (Figure 14) and a straight clamp is placed on the knot. A purse-string suture is laid in the wall of the cecum at the base of the appendix, care being taken not to perforate blood vessels where the mesentery of the appendix was attached (Figure 15). The appendix is held upward; the cecum is walled off with moist gauze to prevent contamination; and the appendix is divided between the ligature and clamp (Figure 16). The suture on the base of the appendix is cut and pushed inward with the straight clamp on the ligature of the stump to invaginate the stump into the cecal wall. The jaws of the clamp are separated, and the clamp is removed as the purse-string suture is tied. The wall of the cecum may be fixed with tissue forceps to aid in inverting the appendiceal stump (Figure 17). The cecum then appears as shown in Figure 18. The area is lavaged with warm saline and the omentum is placed over the site of operation (Figure 19). If there has been a localized abscess or a perforation near the base, so that a secure closure of the cecum is not possible, or if hemostasis has been poor, drainage may be advisable. Drains should be soft and smooth, preferably a silastic sump one. On no occasion should dry gauze or heavy rubber tubing be used, since these may cause bowel injury. Some surgeons do not drain the peritoneal cavity in the presence of obvious peritonitis that is not localized, relying upon peritoneal irrigation, parenteral antibiotic, and systemic antibiotic therapy to control it.

If the appendix is not obviously involved with acute inflammation, a more extensive exploration is mandatory. In the presence of peritonitis without involvement of the appendix, the possibility of a ruptured peptic ulcer or sigmoid diverticulitis must be ruled out. Acute cholecystitis, regional ileitis, and involvement of the cecum by carcinoma are not uncommon possibilities. In the female, the possibility of bleeding from a ruptured graafian follicle, ectopic pregnancy, or pelvic infection is ever present. Inspection of the pelvic organs under these circumstances cannot be omitted. On occasion a Meckel's diverticulum will be found. Closure of the abdomen, with subsequent study and adequate preparation for bowel resection at a later date, may be indicated.

The muscle layers are held apart while the peritoneum is closed with a running or interrupted absorbable suture (Figure 19). Transversalis fascia incorporated with the peritoneum offers a better foundation for the suture. Interrupted sutures are placed in the internal oblique muscle and in the small opening at the outer border of the rectus sheath (Figure 20). The external oblique aponeurosis is closed but not constricted with interrupted sutures (Figure 21). The subcutaneous tissue and skin are closed in layers. The skin may be left open for a delayed secondary closure if pus is found about the appendix.

In some instances, in order to avoid rupturing a distended acute appendix, it is safe to ligate and divide the base of the appendix before attempting to deliver the appendix into the wound. For example, if the appendix is adherent to the lateral wall of the cecum (Figure 22), it is occasionally simpler to pass a curved clamp beneath the base of the appendix in order that it may be doubly clamped and ligated (Figure 23). Following ligation of the base of the appendix, which is often quite indurated, it is divided with a knife (Figure 24). The base of the appendix is then inverted with a purse-string suture (Figures 25 and 26). The attachments of the appendix are divided with long, curved scissors until the blood supply can be clearly identified (Figure 27). Curved clamps are then applied to the mesentery of the appendix, and the contents of these clamps are subsequently ligated with 00 sutures (Figure 28).

When the appendix is not readily found, the search should follow the anterior taenia of the cecum, which will lead directly to the base of the appendix regardless of its position. When the appendix is found in the retrocecal position, it becomes necessary to incise the parietal peritoneum parallel to the lateral border of the appendix as it is seen through the peritoneum (Figure 29). This allows the appendix to be dissected free from its position behind the cecum and on the peritoneal covering of the iliopsoas muscle (Figure 30).

On occasion the cecum may be in the upper quadrant or indeed on the left side of the abdomen when failure of rotation has occurred. A liberal increase in the size of the incision and even a second incision may be, on occasion, good judgment.

Postoperative Care

The fluid balance is maintained by the intravenous administration of Ringer's lactate. The patient is permitted to sit up for eating on the day of operation, and he may get out of bed on the first postoperative day. Sips of water may be given as soon as nausea subsides. The diet is gradually increased.

If there has been evidence of peritoneal sepsis, frequent doses of antibiotics are administered. Constant gastric suction is advisable until all evidence of peritonitis and abdominal distention has subsided. Accurate estimate of the fluid intake and output must be made.

Pelvic localization of pus is enhanced by placing the patient in a semisitting position. The patient is allowed out of bed as soon as his general condition warrants. Prophylaxis against deep venous thrombosis is instituted. In the presence of persistent signs of sepsis, wound infection and pelvic or subphrenic abscess should be considered. In the presence of prolonged sepsis, serial computed tomography (CT) imaging scans beginning about 7 days after surgery may reveal the causative site.