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.
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.