Plate 54

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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