Este documento es un e-book que detalla el manejo quirúrgico de la apendicitis aguda, describiendo tanto la apendicectomía abierta como la laparoscópica en pasos detallados. Se incluye información sobre la etiología, síntomas, diagnóstico y complicaciones de la apendicitis, junto con algoritmos de tratamiento y recursos adicionales, como videos incrustados. Está dirigido a estudiantes de medicina y residentes quirúrgicos para ayudarles a adquirir confianza y habilidades en procedimientos quirúrgicos.

2. AcuteAppendicitis/Appendicectomy- Open And
Laparoscopic- Step By Step
Prof.Dr.Selvaraj
Surgical Educator

3. TABLE OF CONTENTS
1. Table of contents
2. Preface
3. Acute Appendicitis
4. Open Appendicectomy
5. Laparoscopic appendicectomy
6. References

4. PREFACE
In this series of E-books, I will be discussing the common surgical problems and
their operative management.
In this E-book I discuss about acute appendicitis and its management both open and
laparoscopic appendicectomy- a comprehensive review of Appendicular pathologies.
I discuss about acute appendicitis first and then will discuss about how to do both open
and laparoscopic appendicectomy step by step.
I will be using lot of pictures to demonstrate the various steps of the surgery and you will
have a feel as if watching an operative surgery atlas. You can also view my embedded
YouTube videos here in this book itself without leaving for YouTube.
I request all surgical trainees and medical students to mentally rehearse the various steps
of these operative procedures the day before you are going to do the surgery so that you
can develop the much-needed confidence to do the surgery successfully.
Prof.Dr.Selvaraj- (Surgical Educator)
WWW.surgicaleducator.com

5. Acute appendicitis- Learning Outcomes
✓Causes of RLQ Pain
✓Etiology
✓Pathology
✓Clinical features- Symptoms & Signs
✓Investigations
✓ Scoring system
✓ Treatment
✓ Complications
✓ Mind map
✓ Algorithm for RLQ Pain
✓ Treatment Algorithm for Acute
Appendicitis

6. Causes of Acute right lower quadrant pain
In adult females In adult males In Pediatric age
Acute appendicitis Acute appendicitis Acute appendicitis
Twisted ovarian cyst Right ureteric calculus Meckel’s diverticulitis
Ectopic pregnancy Crohn’s in terminal ileum Intussusception
Endometriosis Cecal diverticulitis Mesenteric lymphadenitis
Pelvic inflammatory
disease
Valentino appendicitis
Acute Cholecystitis
Acute Pancreatitis
Tubo-ovarian pathology Inferior wall MI

7. Acute Appendicitis- Etiology
1.Obstructive:
✓Fecolith
✓Worms- Enterobious Vermicularis
✓Lymphoid Hyperplasia in
Children
2.Non-Obstructive:
✓Catarrhal- infection

8. Acute Appendicitis- Pathology

9. Acute Appendicitis- Symptoms
Murphy’s Triad
✓ Pain in RLQ
✓ Vomiting/Nausea
✓ Fever- low graded

10. Acute Appendicitis- Signs
✓RIF Tenderness in McBurny’s point
✓RIF Rebound Tenderness, Release tenderness
or Blumberg’s Sign
✓Guarding/Rigidity/ Cope’s Psoas Test
✓Cope’s Obturator Test,
✓ Rovsing’s Sign,
✓ Hyperasthesia in Sherren’s Triangle

11. Acute appendicitis– Investigations
Lab investigations:
1. Total WBC and Differential counts
2. C-Reactive Protein- CRP
2. Urine- FEME if positive for C&S
3. B- HCG to R/O pregnancy
Imaging studies:
1. CXR- Erect or AXR including both side diaphragm to R/O
Pneumoperitoneum
2.USG-To R/O any other pathology in women of childbearing age group
3. USG-To confirm Appendicitis
4. CECT abdomen

12. Acute Appendicitis- USG Abdomen

13. Acute Appendicitis- CECT

14. Acute Appendicitis- Alvarado’s Scoring
✓Nemonic- MANTRELS
✓Score <4- discharge
patient
✓Score >8- Surgery
✓Score 4 to 7- Admit
and observe

15. Acute Appendicitis- Treatment
✓If simple Appendicitis→ Open/Lap
Appendicectomy
✓If Perforated Appendicitis→
Exploratory Laparotomy,
Appendicectomy & Peritoneal
toileting
✓If Appendicular Abscess < 5cms→ USG
guided Needle aspiration or
tube drain. If >5cms→ Open drain
✓If Appendicular Lump:
- Ochsner-Sherren Regimen of Conservative
treatment
- NPO & IVF
- IV broad spectrum Antibiotics
- Analgesics & Anti-inflammatory drugs
- Vital Signs Q2H

16. Acute Appendicitis- Treatment

17. Acute appendicitis- Complications

18. Acute appendicitis- Mind Map

19. Acute RLQ Pain- Treatment Algorithm

20. Acute Appendicitis- Treatment Algorithm

21. Acute Appendicitis- My Embedded YouTube Video
You can watch my YouTube video on Acute Appendicitis here.
https://www.youtube.com/watch?v=rut4xUmuVnM&t=2s

22. OPEN APPENDICECTOMY
STEP BY STEP

23. OPEN APPENDICECTOMY- STEP BY STEP
INDICATIONS:
Ac. Appendicitis
Subacute Appendicitis
ANESTHESIA:
GA/ SA or Epidural
POSITION:
Supine with slight left tilt
Informed consent- risks of surgery:
✓ Post-op adhesions < 4%
✓ Intra abdominal abscess <5%
✓ Fecal fistula < 2%
✓ Wound infection high in perforation
✓ Overall mortality from 0.2% for
uncomplicated appendicitis to > 10% in
perforated appendicitis

24. OPEN APPENDICECTOMY- STEP BY STEP
INCISION: ACCESS
- McBurney’s
- Lanz or modified McBurney’s
- Rocky- Davis
- Fowler- Weir medial extension
- Rutherford Morrison lateral
extension
Division of External Oblique
Aponeurosis
- Incise the aponeurosis of the
external oblique along the line of its
fibers

25. OPEN APPENDICECTOMY- STEP BY STEP
SPLITTING THE MUSCLES
- Internal oblique & Transversus
oblique muscles are bluntly spread
apart with scissors
- These muscles are held apart by 2
Richardson’s retractors
INCISION OF PERITONEUM
- Peritoneum is divided between
2 hemostats obliquely

26. OPEN APPENDICECTOMY- STEP BY STEP
Mobilisation of Cecal pole and
delivering it into the wound
- Identify Cecum by tenia coli and
mobilise it with Babcock’s forceps and
gauze piece
- 3 tenia coli converge at base of
appendix
Anatomy of Appendix
- Mesoappendix extends behind
the ileum
- Skeletonisation of mesoappendix
should proceed to posterior surface
of ileum

27. OPEN APPENDICECTOMY- STEP BY STEP
Skeletonisation of Mesoappendix
- Clamp and divide mesoappendix
serially
Crushing the base of Appendix
- Crush the base of appendix with
straight artery forceps for few minutes
- Then remove and reapply few cms
above

28. OPEN APPENDICECTOMY- STEP BY STEP
Ligation and removal
- Appendix is ligated in the crush
mark
- Transact 0.5cm distally with knife
Alternate method of removal
- Mesoappendix and base of
appendix both divided with a linear
stapler

29. OPEN APPENDICECTOMY- STEP BY STEP
Appendiceal stump management
- Appendix stump is inverted with purse
string suture or Z stitch
- I just cauterize the appendicular mucosa

30. OPEN APPENDICECTOMY- STEP BY STEP
Retrocecal appendix
- Make a window in meso appendix
near the base, crush the base and
apply ligature
- Divide the appendix at the base first
Retrograde Appendicectomy
- Then serially clamp the
mesoappendix and divide until you
reach the tip of appendix

31. OPEN APPENDICECTOMY- STEP BY STEP
Closure of peritoneum
- Wash with povidone iodine
- Close peritoneum with vicryl
Closure of muscles and skin
- Close muscles also with
interrupted vicryl
- Close External oblique aponeurosis

32. OPEN APPENDICECTOMY- STEP BY STEP
My Embedded YouTube Video
You can watch my YouTube video on Open Appendicectomy here.
https://youtu.be/CuGCjaUUCes

33. LAPAR0SCOPIC
APPENDICECTOMY
STEP BY STEP

34. LAPAROSCOPIC APPENDICECTOMY- STEP BY STEP
INDICATIONS:
- Ac. Appendicitis
- Subacute Appendicitis
- Diagnostic Laparoscopy in
doubtful cases
ANESTHESIA:
- GA (ET)
POSITION:
- Supine with slight left tilt
Informed consent- risks of surgery:
- Post-op adhesions < 1%
- Intra abdominal abscess <8%
- Fecal fistula < 2%
- Injury to hollow viscus & vascular
injury
- Hypercarbia
- Air embolism
- Conversion to open method if
dense adhesions

35. LAPAROSCOPIC APPENDICECTOMY- STEP BY STEP
Position of patient & surgeon
- Patient supine with Rt hand
extended on a board
- Surgeon & assistant on Lt side
Port Placement
-Primary 10mm camera port through umbilicus
-Two 5mms secondary ports through RIF and
hypogastrium

36. LAPAROSCOPIC APPENDICECTOMY- STEP BY STEP
Creating Pneumoperitoneum:
Closed or Veress needle method
Open or Hasson’s cannula method

37. LAPAROSCOPIC APPENDICECTOMY- STEP BY STEP
Identification of Appendix
- Appendix is identified by confluence
of 3 teniae coli in cecum
Skeletonisation of Appendix
-Appendix is serially clamped off it’s
blood supply in mesoappendix

38. LAPAROSCOPIC APPENDICECTOMY- STEP BY STEP
Ligation of appendix base
- 3 endoloops with vicryl or chromic
catgut are applied in the base of
appendix one above the other
Transaction of Appendix
- Transact the appendix in between
the 2nd & 3rd endo-loops.

39. LAPAROSCOPIC APPENDICECTOMY- STEP BY STEP
Alternate Method Stapler Method
- Create a window at base of appendix in
mesoappendix
- Divide both appendix and mesoappendix
with stapler

40. LAPAROSCOPIC APPENDICECTOMY- STEP BY STEP
Retrocecal Appendicitis
- Retrograde appendicectomy done
using stapler or multiple clips.
Retrograde Appendicectomy
- Here dissection method is shown
where cecum should be mobilised
by incising White line of Toldt.

41. LAPARASCOPIC APPENDICECTOMY- STEP BY STEP
Watch my embedded YouTube video here
You can watch my YouTube video on Laparoscopic Appendicectomy here.
https://www.youtube.com/watch?v=_WfviiQwPqk&t=18s

42. AcuteAppendicitis/Appendicectomy- Open And
Laparoscopic- Step By Step
References
1. Atlas of GI Surgery – 2nd Edition By
Cameron & Sandone
2. Atlas of General Surgery- 4th
Edition By David Carter & Russell
3. Atlas of General Surgery- 1st
Edition By Volker Schumpelick
4. Atlas of General Surgical
Techniques- 1st Edition By
Towensend & Evers
5. Chassin’s operative strategy in
General Surgery- 4th Edition By
Carol E. H. Scott & Conner
6. Mastery of Surgery – 7th Edition
By Josef E.Fischer
7. Maingot’s Abdominal Operations-
13th Edition By Zinner
8. Zollinger’s Atlas of Surgical
Operations- 11th Edition By Zollinger
& Ellison
9. Oxford Operative Surgery- 3rd
Edition By Anil Agarwal & McLatchie
10. Bailey & Love’s short practice of
surgery- 28th Edition, By Ronnan
Connell & Robert Mccaskie

43. USEFUL LINKS
Website:
WWW.surgicaleducator.com
YouTube Channel:
WWW.youtube.com/c/surgicaleduc
ator
Surgical Educator Podcast:
WWW.podcasters.spotify.com/pod/
show/surgical-educator-podcast
FB Fan Page:
WWW.facebook.com/surgicaltutor