“Love is like the human appendix. You take it for granted while it's there, but when it's suddenly gone you're forced to endure horrible pain that can only be alleviated through drugs.” ― Reverend Jen,

1. OPEN APPENDECTOMY
DR. MOHSIN KHAN,
General Surgery Resident,
Surgical Unit IV, CHK.

2. Introduction:
An appendectomy is the surgical removal of the
appendix.
 TYPES
 Open
 Laparoscopic

3. Indications:
 Acute appendicitis
 Recurrent appendicitis
 As Interval appendectomy after drainage of abscess or in
appendicial mass
 Carcinoid tumor : at the tip (<2cm)
 Mucocele of the appendix
 Appendicular graft; ileal conduit

4. Pre-Operative Preparations:
 INVESTIGATIONS
 Urinalysis : exclude infection
 Full blood count : leukocytosis
 Ultrasound scan : non-compressible diameter of > 6mm
 Rehydrate patient with IV fluids
 Pass Urethral catheter and Nasogastric tube
 IV antibiotics prophylaxis : broad spectrum

5. Anesthesia:
 General anesthesia with endotracheal intubation
and muscle relaxation
 Local anesthesia may be indicated in the very ill
patient

6. Position:
 Routine scrubbing and gowning
 The skin is cleaned from the nipple line to the mid-thigh
and draped exposing the operation field
Patient is placed in supine position

7. Procedure:
 The surgeon stand on the right side of the
patient.
 The assistant on the left side of the patient.
 The nurse on the left side of the assistant.

8. Incision:
 The incision is placed at the point
of maximum tenderness.
 APPROACHES :
 Mc Burney’s/Grid iron: An
incision placed perpendicular to
the Mc Burney’s point i.e an
lateral 1/3 and medial 2/3 of an
imaginary line joining the ASIS
and the umbilicus.

9. Incision:
 Lanz: A variation of the traditional Mc
Burney's incision, made at the same point
along the transverse plane and deemed
cosmetically better. Variations exist on the
method used to locate the incision. Some
surgeons advocate that the incision is made
approximately 2 cm below the umbilicus
centered on mid clavicular - mid inguinal
line. Others imply use of Mc Burney's
point to center the incision.

10. Incision:
 Rocky-Davis: This incision is usually
made parallel with the course of the
fibers of the external oblique fascia, one
or two inches cephalad to the anterior
superior spine of the ilium.
 Rutherford Morison’s; muscle cutting.
The muscles are cut upwards and
laterally- cutting the internal oblique and
transversus abdominis - extension of Mc
Burney.
 Fowler weir incision; by cutting the
muscle medially over the rectus

11. Incision
 Lower mid-line; when in
doubt of peritonitis, pelvic
appendix.

12. Opening the Abdomen:
 Skin incision is deepened through the subcutaneous tissue to expose
the external oblique aponeurosis, while securing the hemostasis.
Edges are retracted.
 A small incision is made on the external oblique aponeurosis along
the line of its fibers.
 The superior and the inferior edges are grasp and the incision are
extended with a Scissor (McIndoe or Metzenbaum) to expose the
internal oblique muscle.

13. Opening the Abdomen:
 The fibers are splited along the fibers with curved artery forceps
and retracted with langenberg.
 This exposes the transversus abdominis muscles which is also
splited and retractor adjusted, the peritoeum is exposed.
 The surgeon grasps the peritoneum with an artery forceps, carefully
verifying that intra-abdominal viscera is not inadvertently grasped.

14. Opening the Abdomen:
 A small incision is made on the peritoneum. Allow air to enter the
peritoneal cavity so that the viscera fall away.
 Edges of the peritoneum grasped with artery forceps and extended.
 The langenbarg retractor is placed within the peritoneal cavity to
elevate the anterior abdominal wall and the wound edges are
protected with moist laparotomy pads.

15. Assessment:
 Aspirate taken for microscopy and culture, the secretions suctioned.
 The caecum is delivered into the wound and the taenia coli is
followed to identify the appendix.
 If difficulty is encountered in delivering the cecum, the peritoneal
lining along the lateral paracolic area may need to be divided to
mobilize the cecum, especially if the appendix is adherent retro-
caecally.

16. Assessment:
 Confirm the diagnosis: the appendix or more usually its tip, is
swollen, congested, inflamed or even gangrenous often with fibrin
deposition, turbid fluid or frank pus.
 If the appendix is not inflamed, examine its tip to exclude a
neuroendocrine (carcinoid) tumor, which usually manifests as a
yellowish swelling at the tip; such tumors are common, with low
malignant potential, and appendectomy may well be curative.
Adenocarcinoma of the appendix, however, demands a right
hemicolectomy.

17. Assessment:
 Examine the caecum, since an ulcer, inflammation or cancer may
present as appendicitis. Pass the distal 1.5 m of the ileum and its
mesentery through your fingers to exclude mesenteric adenitis,
Crohn’s disease or Meckel’s diverticulum. Palpate the posterior
abdominal wall, ascending colon, liver edge and gallbladder fundus
and the lower pole of the right kidney. Now feel below into the right
rim of the pelvis, the bladder fundus, right iliac vessels and right
inguinal region. In females, examine the right ovary and fallopian
tube and attempt to feel the uterus, left ovary and tube.

18. Actions:
 Once the appendix is delivered, it is held in a Babcock's forceps,
while the mesentry is viewed against light to identify the anatomy of
the appendicular vessels.
 A small window in the mesoappendix near the base is created that
allows application of artery forceps then clamped and ligated with 2-
0 suture (usually vicryl) and divided.
 However, it is advisable to divide the mesentry in separate bites
particularly if the artery has divided early into individual branches,
fat-laden, inflammed, oedematous.

19. Actions:
 While addressing the mesoappendix, it is advisable to wrap the
inflamed appendix in a gauze sponge to avoid direct contact with the
wound margins and thus prevent wound infections.
 The base of the appendix is then gently crushed with a straight
artery forceps.(this is to reduce swelling of the tissue to be ligated
and reduce likelihood of suture cutting through the edematous
tissue, however if the base of the appendix is inflamed, it should not
be crushed but ligated just tight enough to occlude the lumen)
 The base is then doubly ligated with 2-0 absorbable sutures.

20. Actions:
 A straight hemostat is placed on the appendix approximately 1.5 cm
distal to the ligature, and the appendix is transected with a scalpel
(between the suture and the forceps).
 The specimen and the contaminated instruments are removed from
the operative field.

21. Actions:
The stump
 One way of managing the stump is to cleanse it with Betadine or
spirit and then electro-coagulate its mucosa.
 Alternatively, some surgeons prefer placing a purse-string suture
(sero-muscular) on the caecum 1.25cm from the base of the
appendix using 3-0 absorbable sutures and then inverting the
appendiceal stump. This is contra-indicated if the caecum is
inflamed.

22. Actions:
 If an acutely inflamed appendix had been found and removed, the
rest of the abdomen does not need to be explored.
 However, if the appendix is not inflamed, the surgeon needs to
exclude other pathologic processes;
 Terminal ileitis
 Meckel’s diverticulum
 Tubal or ovarian cause in female
 Crohn’s disease

23. Closure:
 The edges of the peritoneum around the entire incision are picked up
with fine hemostats to allow easy and safe suturing of the opening
with continuous 2/0 Vicryl or similar material.
 Insert interrupted stitches of the same material into the internal
oblique muscle with just enough tension to appose but not
strangulate the muscle fibers. Now close the external oblique
aponeurosis with a continuous Vicryl stitch.
 Appose the subcuticular tissues with fine sutures in an obese patient
and close the skin with a continuous absorbable subcuticular suture
or clips.

24. Postoperative:
 In the absence of general peritonitis, start oral fluids and a light diet
as tolerated when the patient is fully awake.
 If the appendix was perforated, and particularly in a high-risk
patient, continue antibiotics for 5 days. These should be given
intravenously until gut function returns.
 Remove any drain after 2–3 days unless there is still profuse
discharge.
 Monitor the wound if pyrexia develops, and exclude chest and
urinary infection.

25. Complications:
 Wound infection develops occasionally in patients with mild
appendicitis but has a higher incidence in those who have had a
gangrenous or perforated appendix removed. Anaerobic
Bacteroides and aerobic coliform organisms are usually
responsible. Examine the wound regularly and remove some of the
skin suture or clips if there is evidence of infection, to allow any pus
to drain. Check the results of any microbiological investigations
taken at the time of surgery and tailor antibiotic therapy accordingly.

26. Complications:
 If pyrexia develops, always carry out a rectal examination. Pelvic
infection produces localized heat, ‘bogginess’ and tenderness.
Repeat the examination at intervals to detect if an abscess develops
and ‘points’: be willing to aspirate it using a needle inserted through
the vagina or rectum. If needle aspiration confirms the presence of
an abscess gently thrust, closed, long-handled forceps into the cavity
to drain it into the rectum. Ultrasound or radiological imaging may
help if you are uncertain and may allow percutaneous drainage of a
collection.

27. Complications:
 Faecal fistula develops in two circumstances. Either the patient has
unsuspected Crohn's disease or in florid appendicitis, the
appendicular stump or adjacent caecum has undergone necrosis. In
the presence of necrosis do not over-optimistically rely on suturing
the defect. Prefer to insert a large tube in the hole and suture the
margins of the hole to the anterior abdominal wall where the tube
emerges. The tube can be removed after 2 weeks and the fistula will
heal spontaneously.

28. Complications:
 Reactive hemorrhage is infrequent, but occasionally the ligature
falls off the appendicular artery. Return the patient to the operating
theatre and re-open the wound to catch and re-ligate the artery.

29. Reference: Kirk's General Surgical Operations ( 6th Edition )
Thank You