APPENDECTOMY

Surgical Details of Procedure for Appendix Removal 1. To start an appendix removal, the skin incision is made with a knife. 2. Bovie electrocautery is used to dissect through subcutaneous tissue and control small skin bleeding. 3. The aponeurosis (muscle sheath) of the outer layer of the external oblique muscle is visualized and split by a small incision with a knife and then further opened along the direction of the fibers with a scissors or the Bovie. 4. The muscle belly of the external oblique is then bluntly retracted (but not cut) using the classic muscle splitting technique via a hemostat or Kelly clamp until the aponeurosis of the internal oblique is visualized. 5. The aponeurosis of the internal oblique is split in a similar manner as the external oblique. 6. The muscle belly of the internal oblique is bluntly retracted in a similar manner as the external oblique until the peritoneum is visualized. 7. The peritoneum is grasped on either side by two forceps, pulled up and into the wound, and palpated to insure there is no bowel caught in the fold of the peritoneum. 8. The peritoneum is opened with a small incision using either a knife or scissors. 9. The peritoneal fluid is immediately inspected for amount and purulence and cultures are taken. 10. The opening in the peritoneum is widened and two hand-held retractors are placed to expose the cecal area. 11. Manual and visual exploration for the appendix is performed by locating the convergence of the cecum and the terminal ileum. 12. The appendix is delivered up into the wound either by digitally flipping it up or be grasping the base with a Alice or Babcock and applying traction to allow dissection of any adhesions holding it in the abdominal cavity. 13. The entire appendix is inspected with close attention to the base to insure that the area of rupture is sufficiently distant from the base to allow a margin of healthy tissue. 14. If the base of the appendix is involved in the rupture a limited right hemicolectomy is done 15. If the base of the appendix is not involved, the mesoappendix or mesentery of the appendix is divided, cross-clamped with Kelly clamps or hemostats and tied with 2-0 or 3-0 silk usually. 16. When the appendix has been isolated from the mesoappendix, the appendix proximal to the rupture is crushed with a straight clamp. 17. Two chromic ties are then placed on the area of crushed appendix. 18. The appendix is then resected off the stump distal to the ties using a knife. 19. The exposed mucosa is then ablated by the Bovie cautery. 20. Some surgeons then prefer to dunk the tied-off appendiceal stump by placing a running pursestring suture around the stump. 21. The intraabdominal area is inspected for bleeding and pockets of remaining infection. 22. Most surgeons will irrigate the abdominal cavity with saline solution or antibiotic-containing saline solution. 23. The edges of the peristeum are reapproximated using a running 3-0 or 4-0 Vicryl suture. 24. The edges of the internal oblique aponeurosis are reapproximated using a 1-0 or 2-0 Vicryl suture. 25. The edges of the external oblique aponeurosis are likewise reapproximated. 26. The superficial wound is irrigated. 27. If the appendix has ruptured before the appendix removal surgery and there was frank pus, many surgeons will leave the subcutaneous tissue and skin open to heal by secondary intention. 28. If the appendicitis was in the early stages or was normal the subcutaneous tissue can be closed at the level of Scarpas fascia with interrupted or running 2-0 Vicryl suture. 29. The skin is closed with staples, interrupted Nylon sutures, or a subcuticular absorbably suture such as Monocryl

Instruments used 01 Metzenbaum Scissors 20cm TC Curved 01 Metsenbaum Scissors 20cm TC Straight 01 Mayo Scissors 14cm Curved TC 01 Mayo Scissors 14cm Straight TC 02 Scalpel Handle # 4 02 Allis Tissue Forceps 15cm 04 Kochers Tissue Forceps 1:2 01 Mcindoe Forceps 15cm 02 Babcocks Tissue Forceps 16cm 02 Mayo Hagar Needle Holder 16cm 02 Sponge Holding Forceps 04 Backhaus Towel Clamps 11cm 08 Criles Forceps 14cm curved 06 Criles Forceps14cm Straight 06 Spencer Wells Straight 18cm 08 Spencer Wells Curved 18cm 02 U S Army Retractor 21cm 02 Adson Forceps 12cm 02 Adson Forceps 1:2 12cm 02 Lane Forceps 1:2 18cm 02 Forceps 16cm 04 Gallipots 02 Kidney Dish 8" Electrocautery Indications for Appendix Removal (Appendectomy) Appendicitis acute or subacute process that causes the lumen of the appendix (which is a blind sac) to become obstructed with buildup of pressure and eventual rupture. This is the most common indication for appendix removal (appendectomy). Mass rarely an appendiceal mass is found on CT scan or during intra-abdominal surgery (laparotomy) Abscess if found secondary to appendicitis it must be drained. If it is diagnosed preoperatively care currently is to have an interventional radiologist (a radiologist who does procedures) drain the abscess via a percutaneously (through the skin) placed catheter that is left in place to decompress the cavity and allow it to heal from the inside out. The appendix is then removed with the techniques described below for appendix removal at about 6 weeks. If it is found during surgery it must be decompressed and a drain left in place in the abscess cavity by the surgeon. The classic symptoms of appendicitis include: -Dull pain near the navel or the upper abdomen that becomes sharp as it moves to the lower right abdomen. This is usually the first sign. -Loss of appetite -Nausea and/or vomiting soon after abdominal pain begins -Abdominal swelling -Fever of 99-102 degrees Fahrenheit -Inability to pass gas Almost half the time, other symptoms of appendicitis appear, including: -Dull or sharp pain anywhere in the upper or lower abdomen, back, or rectum -Painful urination -Vomiting that precedes the abdominal pain -Severe cramps -Constipation or diarrhea with gas

Contraindications -cardiovascular problems -respiratory problems -ascites -long history of symptoms and signs of a large phlegmon -extensive adhesions -radiation or immunosuppressive therapy -severe portal hypertension. -first trimester of pregnancy Review of system The appendix (or vermiform appendix; also cecal appendix; also vermix) is a blind-ended tube connected to the cecum, from which it develops embryologically. The cecum is a pouch like structure of the colon. The appendix is located near the junction of the small intestine and the large intestine. The human appendix averages 11 cm in length but can range from 2 to 20 cm. The diameter of the appendix is usually between 7 and 8 mm. The appendix is located in the right lower quadrant of the abdomen, near the right hip bone. Its position within the abdomen corresponds to a point on the surface known as McBurney's point. While the base of the appendix is at a fairly constant location, 2 cm below the ileocecal valve, the location of the tip of the appendix can vary from being retrocecal (behind the cecum) to being in the pelvis to being extraperitoneal.