Appendectomy is the surgical removal of the appendix. The appendix is a worm-shaped hollow pouch attached to the cecum, the beginning of the large intestine.
Description
Appendectomy is considered a major surgical operation. Therefore, a general surgeon must perform this operation in the operating room of a hospital. An anesthesiologist is also present during the operation to administer an anesthetic. Most often the anesthesiologist uses a general anesthetic technique whereby patients are put to sleep and made pain free by administering drugs in the vein or by agents inhaled through a tube placed in the windpipe. Occasionally a spinal anesthetic may be used.
After the patient is anesthetized, the general surgeon can remove the appendix either by using the traditional open procedure (in which a 2-3 [5-7.6 cm] in incision is made in the abdomen) or via laparoscopy (in which four 1 in [2.5 cm] incisions are made in the abdomen).
Traditional open appendectomy
When the surgeon uses the open approach, he makes an incision in the lower right section of the abdomen. Most incisions are less than 3 in (7.6 cm) in length. The surgeon then identifies all of the organs in the abdomen and examines them for other disease or abnormalities. The appendix is located and brought up into the wounds. The surgeon separates the appendix from all the surrounding tissue and its attachment to the cecum and then removes it. The site where the appendix was previously attached, the cecum, is closed and returned to the abdomen. The muscle layers and then the skin are sewn together.
Laproscopic appendectomy
When the surgeon conducts a laproscopic appendectomy, four incisions, each about 1 in (2.5 cm) in length, are made. One incision is near the umbilicus, or navel, and one is between the umbilicus and the pubis. Two other incisions are smaller and are in the right side of the lower abdomen. The surgeon then passes a camera and special instruments through these incisions. With the aid of this equipment, the surgeon visually examines the abdominal organs and identifies the appendix. Similarly, the appendix is freed from all of its attachments and removed. The place where the appendix was formerly attached, the cecum, is stitched. The appendix is removed through one of the incisions. The instruments are removed and then all of the incisions are closed.
Studies and opinions about the relative advantages and disadvantages of each method are divided. A skilled surgeon can perform either one of these procedures in
less than one hour. However, laproscopic appendectomy (LA) always takes longer than traditional appendectomy (TA). The increased time required to do a LA increases the patient's exposure to anesthetics, which increases the risk of complications. The increased time requirement also escalates fees charged by the hospital for operating room time and by the anesthesiologist. Since LA also requires specialized equipment, the fees for its use also increases the hospital charges. Patients with either operation have similar pain medication needs, begin eating diets at comparable times, and stay in the hospital equivalent amounts of time. LA is of special benefit in women in whom the diagnosis is difficult and gynecological disease (such as endometriosis, pelvic inflammatory disease, ruptured ovarian follicles, ruptured ovarian cysts, and tubal pregnancies) may be the source of pain and not appendicitis. If LA is done in these patients, the pelvic organs can be more thoroughly examined and a definitive diagnosis made prior to removal of the appendix. Most surgeons select either TA or LA based on the individual needs and circumstances of the patient.
Insurance plans do cover the costs of appendectomy. Fees are charged independently by the hospital and the physicians. Hospital charges include fees for operating and recovery room use, diagnostic and laboratory testing, as well as the normal hospital room charges. Surgical fees vary from region to region and range between $250-$750. The anesthesiologist's fee depends upon the health of the patient and the length of the operation.
Who Performs the Procedure and Where Is It Performed?
An appendectomy is performed by a fully trained surgeon who, after medical school, has gone through years of training in an accredited residency program to learn the specialized skills of a surgeon. A sign of a surgeon's competence is certification by a national surgical board approved by the American Board of Medical Specialties (ABMS). All board-certified surgeons have completed an approved training program and have passed a rigorous specialty examination. The letters F.A.C.S. (Fellow of the American College of Surgeons) after a surgeon's name are a further indication of a surgeon's qualifications.
Appendectomy is considered a major surgical operation. Therefore, the surgeon must perform this operation in the operating room of a hospital. An anesthesiologist is also present during the operation to administer an anesthetic.
Questions to Ask the Doctor
What are the possible risks involved with this surgery?
What are the expected results after having a laparoscopic appendectomy versus having an open abdominal appendectomy?
Will I have a scar?
Which procedure will you use to perform the appendectomy?
Must I do anything special after the operation?
How long does it take to recover?
How many appendectomies do you perform each year?
Definition
Appendectomy is the surgical removal of the appendix. The appendix is a worm-shaped hollow pouch attached to the cecum, the beginning of the large intestine.
Purpose
Appendectomies are performed to treat appendicitis, an inflamed and infected appendix.
Description
After the patient is anesthetized, the surgeon can remove the appendix either by using the traditional open procedure (in which a 2–3 in [5–7.6 cm] incision is made in the abdomen) or via laparoscopy (in which four 1-in [2.5-cm] incisions are made in the abdomen).
Traditional Open Appendectomy
When the surgeon uses the open approach, he makes an incision in the lower right section of the abdomen. Most incisions are less than 3 in (7.6 cm) in length. The surgeon then identifies all of the organs in the abdomen and examines them for other disease or abnormalities. The appendix is located and brought up into the wounds. The surgeon separates the appendix from all the surrounding tissue and its attachment to the cecum, and then removes it. The site where the appendix was previously attached, the cecum, is closed and returned to the abdomen. The muscle layers and then the skin are sewn together.
Laparoscopic Appendectomy
When the surgeon performs a laparoscopic appendectomy, four incisions, each about 1 in (2.5 cm) in length, are made. One incision is near the umbilicus, or navel, and one is between the umbilicus and the pubis. Two other incisions are smaller and are on the right side of the lower abdomen. The surgeon then passes a camera and special instruments through these incisions. With the aid of this equipment, the surgeon visually examines the abdominal organs and identifies the appendix. The appendix is then freed from all of its attachments and removed. The place where the appendix was formerly attached, the cecum, is stitched. The appendix is removed through one of the incisions. The instruments are removed and then all of the incisions are closed.
To remove a diseased appendix, an incision is made in the patient's lower abdomen (A). Layers of muscle and tissue are cut, and large intestine, or colon, is visualized (B). The appendix is located (C), tied, and removed (D). The muscle and tissue layers are stitched (E). (Illustration by GGS Inc.)
Studies and opinions about the relative advantages and disadvantages of each method are divided. A skilled surgeon can perform either one of these procedures in less than one hour. However, laparoscopic appendectomy (LA) always takes longer than traditional appendectomy (TA). The increased time required to do a LA the greater the patient's exposure to anesthetics, which increases the risk of complications. The increased time requirement also increases the fees charged by the hospital for operating room time and by the anesthesiologist. Since LA also requires specialized equipment, the fees for its use also increase the hospital charges. Patients with either operation have similar pain medication needs, begin eating diets at comparable times, and stay in the hospital equivalent amounts of time. LA is of special benefit in women in whom the diagnosis is difficult and gynecological disease (such as endometriosis, pelvic inflammatory disease, ruptured ovarian follicles, ruptured ovarian cysts, and tubal pregnancies) may be the source of pain and not appendicitis. If LA is done in these patients, the pelvic organs can be more thoroughly examined and a definitive diagnosis made prior to removal of the appendix. Most surgeons select either TA or LA based on the individual needs and circumstances of the patient.
Insurance plans do cover the costs of appendectomy. Fees are charged independently by the hospital and the physicians. Hospital charges include fees for operating and recovery room use, diagnostic and laboratory testing, as well as the normal hospital room charges. Surgical fees vary from region to region and range between $250–750. The anesthesiologist's fee depends on the health of the patient and the length of the operation.
Preparation
Once the diagnosis of appendicitis is made and the decision has been made to perform an appendectomy, the patient undergoes the standard preparation for an operation. This usually takes only one to two hours and includes signing the operative consents, patient identification procedures, evaluation by the anesthesiologist, and moving the patient to the operating area of the hospital. Occasionally, if the patient has been ill for a prolonged period of time or has had protracted vomiting, a delay of few to several hours may be necessary to give the patient fluids and antibiotics.
Aftercare
Recovery from an appendectomy is similar to other operations. Patients are allowed to eat when the stomach and intestines begin to function again. Usually the first meal is a clear liquid diet—broth, juice, soda pop, and gelatin. If patients tolerate this meal, the next meal usually is a regular diet. Patients are asked to walk and resume their normal physical activities as soon as possible. If TA was done, work and physical education classes may be restricted for a full three weeks after the operation. If a LA was done, most patients are able to return to work and strenuous activity within one to three weeks after the operation.
Risks
Certain risks are present when any operation is performed under general anesthesia and the abdominal cavity is opened. Pneumonia and collapse of the small airways (atelectasis) often occurs. Patients who smoke are at a greater risk for developing these complications. Thrombophlebitis, or inflammation of the veins, is rare but can occur if the patient requires prolonged bed rest. Bleeding can occur but rarely is a blood transfusion required. Adhesions (abnormal connections to abdominal organs by thin fibrous tissue) are a known complication of any abdominal surgery such as appendectomy. These adhesions can lead to intestinal obstruction that prevents the normal flow of intestinal contents. Hernia is a complication of any incision. However, they are rarely seen after appendectomy because the abdominal wall is very strong in the area of the standard appendectomy incision.
The overall complication rate of appendectomy depends upon the status of the appendix at the time it is removed. If the appendix has not ruptured, the complication rate is only about 3%. However, if the appendix has ruptured, the complication rate rises to almost 59%. Wound infections do occur and are more common if the appendicitis was severe, far advanced, or ruptured. An abscess may also form in the abdomen as a complication of appendicitis.
Occasionally, an appendix will rupture prior to its removal, spilling its contents into the abdominal cavity. Peritonitis or a generalized infection in the abdomen will occur. Treatment of peritonitis as a result of a ruptured appendix includes removal of what remains of the appendix, insertion of drains (rubber tubes that promote the flow of infection inside the abdomen to outside of the body), and antibiotics. Fistula formation (an abnormal connection between the cecum and the skin) rarely occurs. It is only seen if the appendix has a broad attachment to the cecum and the appendicitis is far advanced, causing destruction of the cecum itself.
The complications associated with undiagnosed, misdiagnosised, or delayed diagnosis of appendicitis are very significant. This has led surgeons to perform an appendectomy any time that they feel appendicitis is the diagnosis. Most surgeons feel that in approximately 20% of their patients, a normal appendix will be removed. Rates much lower than this would seem to indicate that the diagnosis of appendicitis was being frequently missed.
Normal Results
Most patients feel better immediately after an operation for appendicitis. Many patients are discharged from the hospital within 24 hours after the appendectomy. Others may require a longer stay, from three to five days. Almost all patients are back to their normal activities within three weeks.
Morbidity and Mortality Rates
The mortality rate of appendicitis has dramatically decreased over time. Currently, the mortality rate is estimated at one to two per 1,000,000 cases of appendicitis. Death is usually due to peritonitis, intra abdominal abscess, or severe infection following rupture.
Alternatives
Appendectomies are usually carried out on an emergency basis to treat appendicitis. There are no alternatives, due to the serious consequence of not removing the inflamed appendix, which is a ruptured appendix and peritonitis, a life-threatening emergency.
Schwartz, Seymour I. "Appendix." In Principles of Surgery, edited by Seymour Schwartz, et al. New York: McGraw-Hill, 1994.
Silen, William. "Acute Appendicitis." In Harrison's Principles of Internal Medicine, edited by Anthony S. Fauci, et al. New York: McGraw-Hill, 1997.
Periodicals
Eypasch, E., S. Sauerland, R. Lefering, and E. A. Neugebauer. "Laparoscopic versus Open Appendectomy: Between Evidence and Common Sense." Digestive Surgery 19 (2002): 518–522.
Peiser, J. G. and D. Greenberg. "Laparoscopic versus open appendectomy: results of a retrospective comparison in an Israeli hospital." Israel Medical Association Journal 4 (February, 2002): 91–94.
Piskun, G., D. Kozik, S. Rajpal, G. Shaftan, and R. Fogler. "Comparison of laparoscopic, open, and converted appendectomy for perforated appendicitis." Surgery and Endoscopy 15 (July 2001): 660–662.
Long, K. H., M. P. Bannon, S. P. Zietlow, E. R. Helgeson, et al. "A prospective randomized comparison of laparoscopic appendectomy with open appendectomy: Clinical and economic analyses." Pathology Case Reviews 129 (April, 2001): 390–400.
Selby, W. S., S. Griffin, N. Abraham, and M. J. Solomon. "Appendectomy protects against the development of ulcerative colitis but does not affect its course." American Journal of Gastroenterology 97 (November, 2002): 2834–2838.
Organizations
American College of Surgeons. 633 N. Saint Clair St., Chicago, IL 60611-3211. (312) 202-5000. www.facs.org.
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, intravenousantibiotics are used to delay or avoid the onset of sepsis; it is now recognized 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.
Appendectomy may be performed laparoscopically (this is called minimally invasive surgery) or as an open operation. Laparoscopy 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.
In general terms, the procedure for an open 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.
The abdomen is prepared and draped and is examined under anesthesia.
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).
The various layers of the abdominal wall are then opened.
The effort is always to preserve the integrity of abdominal wall. Therefore, the External ObliqueAponeurosis is slitted along its fiber, and the internal obliquemuscle is split along its length, not cut. As the two run at right angles to each other, this prevents later Incisional hernia.
On entering the peritoneum, the appendix is identified, mobilized and then ligated and divided at its base.
Some surgeons choose to bury the stump of the appendix by inverting it so it points into the caecum.
Each layer of the abdominal wall is then closed in turn.
The skin may be closed with staples or stitches.
A bandage is stuck on.
In America, a lengthy dictation is done but in the UK and Finland, only a few handwritten sentences are mentioned in the notes because lawyers are not as much a problem.
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.
Pregnancy
If appendicitis develops in a pregnant woman, an appendicectomy is usually performed and should not harm the fetus.[1] The risk of fetal death in the perioperative period after an appendectomy for early acute appendicitis is 3% to 5%. The risk of fetal death is 20% in perforated appendicitis. [2]
Recovery time from the operation varies from person to person. Some will take up to three weeks before being completely active; for others it can be a matter of days. 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 2-3 inch scar, which will initially be heavily bruised.
