The document provides an outline for performing an open appendectomy surgery. It discusses the relevant anatomy of the appendix, causes of appendicitis, pre-operative care including investigations and antibiotic treatment. It describes the surgical technique including common incisions used, identifying and ligating the appendix and closing the wound. Post-operative care involves monitoring for complications and managing patients depending on whether the case was complicated or uncomplicated.

1. OPEN APPENDECTOMY
Dr Eretare C. Odjugo

2. OUTLINE
• Introduction
• Relevant anatomy
• Aetiopathogenesis
• Epidemiology
• Peri-procedural care
• Anaesthesia and positioning
• Technique (Steps)
• Antegrade appendectomy
• Retrograde appendectomy

3. OUTLINE
• Post operative care
• Follow-up
• Conclusion
• References

4. INTRODUCTION
• Appendectomy also called appendicectomy is a common surgical
procedure.
• Acute appendicitis is the most common indication for an
appendectomy.
• An appendectomy is the surgical removal of the appendix.
• Appendectomy can be either open or laparoscopic

5. RELEVANT ANATOMY
• The vermiform appendix is a vestigial
organ
• Usually located at the right iliac fossa
• Variable location
• Abnormalities though rare exist and
must be considered if the appendix is
difficult to locate

6. RELEVANT ANATOMY

7. AETIOPATHOGENESIS
• The most common etiological factor
is obstruction of the lumen that
leads to increased intra luminal
pressure.
• This presses upon the blood vessels
producing ischemic injury which in
turn favours the bacterial
proliferation and hence acute
appendicitis
• Obstructive causes:
• Faecolith
• Calculi
• Foreign body
• Tumor
• Worms
• Diffuse lymphoid hyperplasia
• Non obstructive causes:
• Haematogenous spread of generalized
infection
• Vascular occlusion
• Inappropriate diet lacking roughage

8. INDICATION
• Acute appendicitis
• Recurrent appendicitis
• Chronic appendicitis
• As Interval appendectomy after drainage of abcess or in appendicial
mass
• Carcinoid tumour : at the tip. <2cm
• Mucocele of the appendix

9. PRE-PROCEDURAL CARE
• Investigations
• Full blood count
• Serum electrolyte, urea and creatinine
• Retroviral screening
• Chest x-ray
• Electrocardiography
• CT scan

10. PRE-PROCEDURAL CARE
• Fluid resuscitation and correction of any electrolyte deficits
• Antibiotic cover
• Counselling and consent
• Surgeons
• Anaesthesiologist
• Nasogastric Intubation
• Urethral catheterisation

11. ANAESTHESIA
• General anaesthesia
• GA + endotracheal intubation
• Inhalational
• Rarely Total intravenous anaesthesia
• Spinal
• Epidural
• Local or regional in very sick patients

12. PREPARATION
• After the patient has been anaesthesized, the surgeon palpates the abdomen again
to identify the presence of an appendix mass.
• This is more reliable as the sedated patient has complete muscle relaxation
• The surgical team the scrubs, gowns and masks.
• The skin prep is performed using an anti-septic solution (Betadine, Hibitane,
Chlorhexidene and Centrimide) with a swab on stick from the nipples to the mid
thigh.
• After the initial sponge appears clean, the area is dried off and then cleaned with
surgical alcohol.
• Square draping is then done exposing the right iliac fossa

13. POSITIONING
• Patient
• Supine and in the anatomical position
• Surgical team
• Surgeon at the right hand side of the patient
• Assistant opposite the patient
• Scrub nurse faces the surgeon and to the left of the assistant
• Anaesthetist at the head of the patient

14. SKIN INCISIONS
• There are various skin incisions
• McBurney’s (Gridiron): An incision made perpendicular to an imaginary line
joining the umbilicus to the anterior superior iliac spine at the junction of the
middle third and lateral third.
• Lanz: A skin crease incision 2cm blow the level of the umbilicus centred on the
mid-clavicular line.
• Rocky Davis Incision: This is a transverse incision centred on McBurney’s point.
• Midline infra-umbilical.
• The skin incisions may also be made over the area of maximal
tenderness or over a mass palpated after initiation of anaesthesia

15. STEPS
• Skin incision is made with the belly of a Size 10, 20 or 23 blade.
• The Campers and Scarpas fascia are divided with the aid of electrocautery between
two haemostats holding the inferior surface of the skin in the direction of the skin
incision exposing the external oblique.
• The small haemostats are reapplied to the external oblique forming a tent. A nick is
made between the haemostats using a Metzenbaum scissors along the direction of
the fibres of the external oblique and lengthened in both directions.
• The assistant now retracts the external oblique exposing the internal oblique.
• The internal oblique and transversus abdominis are split in the direction of their
fibres by blunt dissection and then retracted to the deep surface of the transversus
abdominis.

16. STEPS
• Rutherford Morrison extension is a lateral extension of the incision in the
internal oblique and transversus abdominis when more access is required
• Fowler-Weir extension: This is a medial extension of the incision on the internal
oblique and transversus abdominis to the semilunar line.
• The transversalis fascia and the peritoneum are usually closely
applied and are incised as one layer.
• The surgeon grasps the peritoneum with a haemostat, a second
haemostat is applied and the first reapplied after carefully verifying
that intra-abdominal viscera is not inadvertently grasped,
• A small incision is made on the peritoneum with a Metzenbaum.

17. STEPS
• Aspirate taken for microscopy, culture and sensitivity and the secretions
suctioned
• Edges of the peritoneum grasped with artery forceps and extended carefully
• The Langenbeck retractor is placed within the peritoneal cavity to elevate
the anterior abdominal wall.
• The table may be given a slight left tilt to displace the small bowel from the
operative field.
• The caecum is delivered into the wound and the taenia coli is followed to
identify the appendix

18. STEPS (ANTEGRADE)
• 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 this
allow application of artery forceps the clamped and ligated with 2-0
suture and divided
• However, it is advisable to divide the mesentry in separate bites if the
artery has divided early into individual branches.

19. STEPS (ANTEGRADE)
• The base of the appendix is then gently crushed twice with a right angled
haemostat. This is to reduce swelling of the tissue to be ligated and reduce likelihood
of suture cutting through the edematous tissue.
• The base is then doubly ligated with 2-0 absorbable sutures. A haemostat is placed
on the ligatures.
• A right angle haemostat is placed on the appendix approximately 1 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. STEPS (RETROGRADE)
• The retrograde technique is used under the following circumstances:
• The appendix is very inflamed, and manipulation may cause perforation
• The appendix is in a retroperitoneal position
• The appendix is surrounded by inflammatory tissue, omentum, or both, which makes
identification difficult
• In the retrograde technique, the base of the appendix is found first, exposed, ligated,
and transected.
• Attention is then turned to the mesoappendix, which is ligated last and then
transected.
• The appendix and other contaminated instruments are now removed from the
operating field..

22. STEPS
• Using the haemostat at the stump ligature, it is inspected for bleeding
or leakage.
• The stump mat then be cleaned with gauze soaked in Betadine or
methylated spirit. It may also be cauterized.
• Though no longer popular, the stump may be inverted with a purse
string made at the base of the caecum
• Purse stringing is not performed if the caecum is inflamed.

23. STEPS (CLOSURE)
• After the appendectomy is completed, the wound is copiously irrigated with
normal saline
• The peritoneum is grasped with two straight clamps, and closed it with a
continuous 3-0 polyglactin stitch.
• Approximate all split muscle layers, using 3-0 polyglactin at each level.
• Close the external oblique aponeurosis with a continuous 2-0 polyglactin
stitch.
• Approximate the Scarpa fascia with 3-0 polyglactin.
• A narrow gauge absorbable subcuticular interrupted sutures for skin
closure.

24. STEPS (CLOSURE)
• If wound contamination is a concern in complicated appendicitis, the
wound may be closed at the musculofascial level, left open and packed
for 3-5 days, and closed secondarily.
• Conversely, a drain may be left in place if there was copious peritoneal
abscess that had been suctioned off.
• Leaving a drain though is not commonly practiced.

25. POST OPERATIVE CARE
• In uncomplicated cases
• Nil per os for about 12 hours then fluid diet.
• Semi solid diet is commenced at 24 hours
• Antibiotics are not always indicated
• In complicated cases
• Nil per os until bowel sounds return and/or bowel opening is attained
• IV antibiotics are given until fever abates
• Bowel rest through nasogastric intubation and decompression

26. COMPLICATIONS
• Wound infection: Most common, 5-10% of patient, seen on 4-5th day
• Intra- abdominal abscess -8%
• Haemorrhage
• Ileus
• Generalised peritonitis
• Respiratory infections
• UTI
• Venous thrombosis and embolism
• Faecal fistula
• Adhesive intestinal obstruction

27. REFERENCES
• Farquharson M, Hollingshead J, Moran B. Farquharsons Textbook of operative General
Surgery. 10th edition.
• Bailey & Love’s Short Practice of Surgery. 25th edition.
• Zollinger’s Atlas of Surgical Operations
• Bruncardi FC et al: Schwartz Principles of surgery. 10th edition
• Fischer’s Mastery of Surgery
• https://emedicine.medscape.com/article/1582203-technique accessed 12/01/19
• https://www.slideshare.net/bashirbnyunus/appendectomy-46728589 accessed 12/01/19

28. REFERENCES
• https://www.slideshare.net/levouge777/appendectomy-presentation accessed
12/01/19
• Lawrence PF. Essentials of General Surgery. 5th edition.

29. THANK YOU