Appendectomy



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 * Associate Editor-in-Chief: Mohammed A. Sbeih, M.D. [mailto:msbeih@perfuse.org]

Overview
An Appendicectomy (or appendectomy) is the surgical removal of the vermiform appendix. This procedure is normally performed as an emergency procedure, when the patient is suffering from acute appendicitis. In the absence of surgical facilities, intravenous antibiotics are used to delay or avoid the onset of sepsis; it is now recognised that many cases will resolve when treated non-operatively. In some cases the appendicitis resolves completely; more often, an inflammatory mass forms around the appendix. This is a relative contraindication to surgery.

Many patients do not seek medical attention early when they have symptoms, this delays the diagnosis of appendicitis ,and some cases could be missed. Some surgeons accepts negative appendectomies up to 15 percent of cases, so they intervene aggressively with suspicious cases. The use of imaging studies before going through the surgery reduces the rate of negative appendictomy to less than 10 percent according to some studies.

Anatomy and pathophysiology
The appendix is a part of small intestine, it is a small, finger-like projection located in the right lower quadrant of abdomen. It is attached to the large intestine through a small opening, which allow fluids and other materials to flow in and out of the appendix, When this opening becomes blocked, there is a buildup of secretions and fluids in the appendix. It becomes swollen and may be infected (Appendicitis), also it can ruptures, resulting in peritonitis, perforation is a major concern when evaluating a patient with more than 24 hours of symptoms, even perforation can develop more rapidly and should always be considered.

An Appendectomy is done for Appendicitis. The condition can be hard to be diagnosed, especially in children, older people, and women of childbearing age, since there are some medical conditions that mimics Appendicitis in their symptoms. Most often, the first symptom is vague abdominal pain around the umbilicus. The pain may be mild at first, but it becomes sharp and severe. The pain often moves into the right lower abdomen and becomes more focused in this area.

Other symptoms include:


 * Diarrhea or constipation.
 * Fever (usually not very high).
 * Nausea and vomiting.
 * Reduced appetite.

Signs of Appendicitis include:
 * Guarding: Guarding occurs when a person subconsciously tenses the abdominal muscles during an examination. Voluntary guarding occurs the moment the doctor's hand touches the abdomen. Involuntary guarding occurs before the doctor actually makes contact.
 * Rebound tenderness: A doctor tests for rebound tenderness by applying hand pressure to a patient's abdomen and then letting go. Pain felt upon the release of the pressure indicates rebound tenderness.
 * Rovsing's sign: A doctor tests for Rovsing's sign by applying hand pressure to the lower left side of the abdomen. Pain felt on the lower right side of the abdomen upon the release of pressure on the left side indicates the presence of Rovsing's sign.
 * Psoas sign: The right psoas muscle runs over the pelvis near the appendix. Flexing this muscle will cause abdominal pain if the appendix is inflamed. A doctor can check for the psoas sign by applying resistance to the right knee as the patient tries to lift the right thigh while lying down.
 * Obturator sign: The right obturator muscle also runs near the appendix. A doctor tests for the obturator sign by asking the patient to lie down with the right leg bent at the knee. Moving the bent knee left and right requires flexing the obturator muscle and will cause abdominal pain if the appendix is inflamed.
 * Rectal tenderness.
 * Increase in white blood cells (WBC).

Treatment of Appendicitis
Most of the appendicitis cases are treated surgically and an appendectomy remains the gold standard of care. some studies showed that some patients may respond to medical therapy alone if a person is not well enough to undergo surgery or the diagnosis is unclear. Nonsurgical treatment includes antibiotics to treat infection and a liquid or soft diet until the infection subsides, but these patients are at risk for recurrent disease, that is why appendectomy is the only effective treatment for appendicitis.

There are two types of operations used to remove the appendix: the traditional open procedure and a laparoscopic procedure. Laparoscopic surgery is often used if the diagnosis is in doubt, or if it is desirable to hide the scars in the umbilicus or in the pubic hair line. Recovery may be a little quicker with laparoscopic surgery; the procedure is more expensive and resource-intensive than open surgery and generally takes a little longer, with the (low in most patients) additional risks associated with pneumoperitoneum (inflating the abdomen with gas). Advanced pelvic sepsis occasionally requires a lower midline laparotomy.

Even when the surgeon finds that the appendix is not infected during the surgery, it will be removed to prevent future problems.

Indications for Appendectomy
Appendicitis (infected appendix) must be surgically removed (emergency appendectomy) before a hole develops in the appendix (perforation) and spreads the infection to the entire abdominal space (peritonitis).

Preoperative preparation
Before the operation, the health care provider should take a full history from the patient and examine the abdomen and rectum. Women of childbearing age may be asked to undergo a pelvic exam to rule out gynecological conditions, which sometimes cause abdominal pain similar to appendicitis. The patient's vital signs should be monitored.

Other tests should be done:


 * Laboratory tests
 * Blood tests are used to check for signs of infection, such as a high white blood cell count. Blood tests may also show dehydration or fluid and electrolyte imbalances. Any electrolytes disturbances should be corrected before the surgery. The patient should be adequetly hidrated with intravenous fluid, a Foley catheter may be required in severely dehydrated patients to measure the urine output.
 * Urinalysis is used to rule out a urinary tract infection.
 * Pregnancy test may also be ordered for women to rule out pregnancy.

If the doctors are uncertain about the diagnosis, they can perform some imaging studies to make sure the appendix is the cause of the problem, but there are no actual tests to confirm the diagnosis of appendicitis.
 * Imaging tests


 * Computerized tomography (CT) scans, which create cross-sectional images of the body, can help diagnose appendicitis and other sources of abdominal pain.
 * Ultrasound is sometimes used to look for signs of appendicitis, especially in people who are thin or young.
 * An abdominal x-ray is rarely helpful in diagnosing appendicitis but can be used to look for other sources of abdominal pain.

Women of childbearing age should have a pregnancy test before undergoing x-rays or CT scanning. Both use radiation and can be harmful to a developing fetus. Ultrasound does not use radiation and is not harmful to a fetus.

Before the operation, the following should be done also:
 * Reviewing the anesthetic history of the patient.
 * Making sure that the procedure's trocars, staplers and drains are available.
 * Ordering a deep venous thrombosis (DVT) prophylaxis if applicable.
 * Making sure that prophylactic antibiotics have been ordered. Prophylactic antibiotics help to prevent wound infection and abscess formation following the procedure .The patients should receive prophylactic antibiotics within one hour before the initial incision as follows :
 * In non complicated case of acute appendicitis, only a single dose of prophilactic antibiotic against surgical wound infection is adeqeuet.


 * In complicated cases of appendicitis (Perforated), the patient should be given an empiric broad-spectrum prophylactic antibiotics that cover both gram-negative rods and anaerobs until receive the culture results.

Once the diagnosis of appendicitis has been made and the surgeon decides to perform an operation, the patient should proceed to the OR (operating room) as early as possible in order to avoid the progression to perforation and peritonitis.

The procedure
The choice of laparoscopic or traditional (open) appendectomy is decided by the surgeon. This decision depends on many factors such as personal experience of the surgeon, hospital capabilities, the severity of the case, body habitus of the patient, and other factors. Laparoscopic surgery may be the preferred if the diagnosis is not clear   ,also it is preferred in obese patients to avoid large morbidity-prone incision in order to expose the right lower quadrant) and elderly patients to decrease the hospital stay.

In general terms, the procedure for an Appendicectomy is as follows:


 * Antibiotics are given immediately if there are signs of sepsis, otherwise a single dose of prophylactic intravenous antibiotics is given immediately prior to surgery.
 * General anaesthesia is induced, with endotracheal intubation and full muscle relaxation, and the patient is positioned supine.
 * In the laparoscopic approach, the stomach should be decompressed by orogastric tube. A foley catheter may be inserted to decompress the bladder.
 * The abdomen is prepared and draped and is examined under anaesthesia. A single larger incision for a traditional open appendectomy, or several tiny keyhole incisions for a laparoscopic appendectomy should be made by the surgeon, locations of these incisions will vary depending on the preferences of the surgeon.
 * In case of open appendicectomy', if a mass is present, the incision is made over the mass; otherwise, the incision is made over McBurney's point, one third of the way from the anterior superior iliac spine (ASIS) and the umbilicus; this represents the position of the base of the appendix (the position of the tip is variable).
 * In laparoscopic appendectomy, the surgeon will use a tool called a trocar to create an opening or keyhole near the umbulicus. Carbon dioxide gas will be pumped through this port to puff up your abdomen so its contents can be viewed more easily. The surgeon will create other openings through which surgical instruments may be passed. Next, the surgeon will insert the laparoscope through the first opening. Images from its camera will be projected onto a video monitor in the operating room.


 * The basic method of removing the appendix is the same for both traditional (open) and laparoscopic appendectomies. The surgeon will tie off blood vessels in the area to prevent bleeding. Any adhesions to surrounding structures can be lysed with a combination of blunt and sharp dissection. The surgeon should take care not to injure the retroperitoneal structures such as the right ureter and iliac vessels. He or she will then use surgical instruments to grasp the appendix, isolate it from its surroundings, separate it from the intestine, and remove it from the abdomen. In the Laparoscopic approach The appendix is removed using a specimen bag through the umbilical port, this decrease the risk of wound infection.


 * The surgeon should inspect the operative field for bleeding, he or she may irrigate the field with saline.
 * At the end of the procedure, the traditional or keyhole incisions will be closed with sutures and dressed with bandages. In open appendicectomy, the incision is closed in layers with running 2-0 absorbable suture, from inside to outside the layers that should be closed are: Peritoneum, transversus abdominus, internal oblique, and external oblique. Irrigation is performed at each layer. Scarpa's fascia is closed with interrupted 3-0 absorbable suture, followed by a subcuticular closure or staples for the skin.

If the appendix has ruptured, the surgeon will use large amounts of warm, sterile salt solution to rinse out the abdominal cavity. A drain will often be left in place to allow fluid to escape even some recent studies showed that drains are not necessary, as they do not reduce the incidence of wound infection or abscess formation after appendectomy for perforated appendicitis, the patient will be given antibiotics through an IV line. In this case, the surgeon may leave the incision open to heal on its own over 5-10 days. The recovery period will be substantially longer than for an uncomplicated appendectomy.

If appendicitis develops in a pregnant woman, an Appendicectomy is usually performed and should not harm the fetus.

Prophylactic Appendectomy
To find the cause of unexplained abdominal pain, exploratory surgery is sometimes performed. If the appendix is not the cause of symptoms, the surgeon will thoroughly check the other abdominal organs and remove the appendix anyway, to prevent it from becoming a problem in the future.

When abdominal surgery is performed for an entirely different reason (e.g. hysterectomy or bowel resection), the surgeon sometimes decides to perform an Appendicectomy in addition to the intended procedure, to eliminate the possible need of a future surgery just to remove the appendix. However, recent findings on the possible usefulness of the appendix has led to an abatement of this practice.

Recovery
Recovery time from the operation can vary from person to person, and varies with the type of the operation (open or laparoscopic). Most patients are discharged within 24 to 48 hours of surgery.

Patients may be started on a clear liquid diet post-operatively and advanced to regular diet as tolerated. Antibiotics are not required after the operation except in perforated cases. Full recovery from surgery takes about 4 to 6 weeks. Limiting physical activity during this time allows tissues to heal. In the case of a laparoscopic operation, the patient will have three stapled scars of about an inch in length, between the navel and pubic hair line. When a laparotomy has been performed, the patient will have a 2-4 inch scar, which will initially be heavily bruised. Any drainage tubes left in place will usually be removed within a few days of the surgery.

After an uncomplicated appendectomy, the surgeon will usually advise the patient to: The same advice often applies in the case of a ruptured appendix, but over a longer time period.
 * Get up and walk around the day of the surgery.
 * Keep the incision clean and dry.
 * Avoid lifting.
 * Avoid constipation and straining during bowel movements by drinking plenty of fluids and eating high-fiber foods such as fruits, vegetables, beans, and whole grains; move bowels as soon as the patient feel the urge.

Surgical outcome
Patients who have the appendix removed through small surgical cuts (Laparoscopic appendicectomy) tend to recover and get back to their daily activities faster. Recovery is slower and more complicated if the appendix has broken open or an abscess has formed. Living without an appendix causes no known health problems.

Possible complications
Risks from any anesthesia include the following:

Risks from any surgery include the following:
 * Reactions to medications.
 * Problems breathing.

Other risks with an appendectomy after a ruptured appendix include the following:
 * Bleeding.
 * infection of the wound (the most common complication). Studies showed that delayed primary closure of the wound does not dicrease the incidence of post-operative infections.


 * Buildup of pus (abscess), which may need draining and antibiotics, this is more common in perforated appendicitis.
 * Pylephlebitis (thrombosis and infection within the portal venous system) although it is rare.
 * Longer hospital stays.
 * Side effects from medications.

Videos

 * Laparoscopic Appendectomy video.