APPENDECTOMY

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, intravenous antibiotics 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 appendicectomy is as follows.

1. Antibiotics are given immediately if there are signs of sepsis, otherwise a single dose of

prophylactic intravenous antibiotics is given immediately prior to surgery.

2. General anaesthesia is induced, with endotracheal intubation and full muscle relaxation, and
the patient is positioned supine.
3. The abdomen is prepared and draped and is examined under anesthesia.

4. 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).
5. The various layers of the abdominal wall are then opened.
6. The effort is always to preserve the integrity of abdominal wall. Therefore, the External

Oblique Aponeurosis is slitted along its fiber, and the internal oblique muscle is split along its
 length, not cut. As the two run at right angles to each other, this prevents later Incisional
hernia.
7. On entering the peritoneum, the appendix is identified, mobilized and then ligated and
divided at its base.
8. Some surgeons choose to bury the stump of the appendix by inverting it so it points into the
caecum.
9. Each layer of the abdominal wall is then closed in turn.
10. The skin may be closed with staples or stitches.
11. The wound is dressed.
12. The patient will be brought to the recovery room.

APPENDICITIS

Appendicitis is inflammation of the appendix. It is thought that appendicitis begins when the
opening from the appendix into the cecum becomes blocked. The blockage may be due to a build-up
of thick mucus within the appendix or to stool that enters the appendix from the cecum. The mucus
or stool hardens, becomes rock-like, and blocks the opening. This rock is called a fecalith (literally, a
rock of stool). At other times, the lymphatic tissue in the appendix may swell and block the appendix.
Bacteria which normally are found within the appendix then begin to invade (infect) the wall of the
appendix. The body responds to the invasion by mounting an attack on the bacteria, an attack called
inflammation. (An alternative theory for the cause of appendicitis is an initial rupture of the appendix
followed by spread of bacteria outside the appendix.. The cause of such a rupture is unclear, but it
may relate to changes that occur in the lymphatic tissue that line the wall of the appendix.)
If the inflammation and infection spread through the wall of the appendix, the appendix can
rupture. After rupture, infection can spread throughout the abdomen; however, it usually is confined
to a small area surrounding the appendix (forming a peri-appendiceal abscess).
Sometimes, the body is successful in containing ("healing") the appendicitis without surgical
treatment if the infection and accompanying inflammation do not spread throughout the abdomen.
The inflammation, pain and symptoms may disappear. This is particularly true in elderly patients and
when antibiotics are used. The patients then may come to the doctor long after the episode of
appendicitis with a lump or a mass in the right lower abdomen that is due to the scarring that occurs
during healing. This lump might raise the suspicion of cancer.

SIGNS AND SYMPTOMS

The main symptom of appendicitis is abdominal pain. The pain is at first diffuse and poorly
localized, that is, not confined to one spot. (Poorly localized pain is typical whenever a problem is
confined to the small intestine or colon, including the appendix.) The pain is so difficult to pinpoint
that when asked to point to the area of the pain, most people indicate the location of the pain with a
circular motion of their hand around the central part of their abdomen. A second, common, early
symptom of appendicitis is loss of appetite which may progress to nausea and even vomiting. Nausea
and vomiting also may occur later due to intestinal obstruction.
As appendiceal inflammation increases, it extends through the appendix to its outer covering and
then to the lining of the abdomen, a thin membrane called the peritoneum. Once the peritoneum
becomes inflamed, the pain changes and then can be localized clearly to one small area. Generally,
this area is between the front of the right hip bone and the belly button. The exact point is named
after Dr. Charles McBurney--McBurney's point. If the appendix ruptures and infection spreads
throughout the abdomen, the pain becomes diffuse again as the entire lining of the abdomen
becomes inflamed.

DIAGNOSTIC PROCEDURES

The diagnosis begins with a thorough history and physical examination. Patients often have an
elevated temperature, and there usually will be moderate to severe tenderness in the right lower
abdomen when the doctor pushes there. If inflammation has spread to the peritoneum, there is
frequently rebound tenderness. This means that when the doctor pushes on the abdomen and then
quickly releases his hand, the pain becomes suddenly but transiently worse.

White Blood Cell Count

The white blood cell count in the blood usually becomes elevated with infection. In early
appendicitis, before infection sets in, it can be normal, but most often there is at least a mild
elevation even early. Unfortunately, appendicitis is not the only condition that causes elevated white
blood cell counts. Almost any infection or inflammation can cause this count to be abnormally high.
Therefore, an elevated white blood cell count alone cannot be used as a sign of appendicitis.

Urinalysis
Urinalysis is a microscopic examination of the urine that detects red blood cells, white blood
cells and bacteria in the urine. Urinalysis usually is abnormal when there is inflammation or stones in
the kidneys or bladder which sometimes can be confused with appendicitis. Therefore, an abnormal
urinalysis suggests that there is a kidney or bladder problem while a normal urinalysis is more
characteristic of appendicitis.

Abdominal X-Ray
An abdominal x-ray may detect the fecalith (the hardened and calcified, pea-sized piece of
stool that blocks the appendiceal opening) that may be the cause of appendicitis. This is especially
true in children.

Ultrasound
An ultrasound is a painless procedure that uses sound waves to identify organs within the
body. Ultrasound can identify an enlarged appendix or an abscess. Nevertheless, during appendicitis,
the appendix can be seen in only 50% of patients. Therefore, not seeing the appendix during an
ultrasound does not exclude appendicitis. Ultrasound also is helpful in women because it can exclude
the presence of conditions involving the ovaries, fallopian tubes and uterus that can mimic
appendicitis.
Barium Enema
A barium enema is an x-ray test where liquid barium is inserted into the colon from the anus
to fill the colon. This test can, at times, show an impression on the colon in the area of the appendix
where the inflammation from the adjacent inflammation impinges on the colon. Barium enema also
can exclude other intestinal problems that mimic appendicitis, for example Crohn's disease.
CT Scan
In patients who are not pregnant, a CT Scan of the area of the appendix is useful in diagnosing
appendicitis and peri-appendiceal abscesses as well as in excluding other diseases inside the
abdomen and pelvis that can mimic appendicitis.

Laparoscopy
Laparoscopy is a surgical procedure wherein a small fiberoptic tube with a camera is inserted
into the abdomen through a small puncture made on the abdominal wall. Laparoscopy allows a direct
view of the appendix as well as other abdominal and pelvic organs. If appendicitis is found, the
inflamed appendix can be removed at the same time. The disadvantage of laparoscopy compared to
ultrasound and CT scanning is that it requires a general anesthetic.
There is no one test that will diagnose appendicitis with certainty. Therefore, the approach to
suspected appendicitis may include a period of observation, tests as previously discussed, or surgery.

HOW APPENDECTOMY IS DONE?

During an appendectomy, an incision two to three inches in length is made through the skin
and the layers of the abdominal wall in the area of the appendix. The surgeon enters the abdomen
and looks for the appendix, usually located in the right lower abdomen. After examining the area
around the appendix to be certain that no additional problem is present, the appendix is removed.
This is done by freeing the appendix from its attachment to the abdomen and to the colon, cutting
the appendix from the colon, and sewing the over the hole in the colon. If an abscess is present, the
pus can be drained with drains (rubber tubes) that go from the abscess and out through the skin. The
abdominal incision then is closed.
Newer techniques for removing the appendix involve the use of the laparoscope. The
laparoscope is a thin telescope attached to a video camera that allows the surgeon to inspect the
inside of the abdomen through a small puncture wound (instead of a larger incision). If appendicitis is
found, the appendix can be removed with special instruments that can be passed into the abdomen,
just like the laparoscope, through small puncture wounds. The benefits of the laparoscopic technique
include less post-operative pain (since much of the post-surgery pain comes from incisions) and a
speedier recovery. An additional advantage of laparoscopy is that it allows the surgeon to look inside
the abdomen to make a clear diagnosis in cases in which the diagnosis of appendicitis is in doubt. For
example, laparoscopy is especially helpful in menstruating women in whom a rupture of an ovarian
cysts may mimic appendicitis.
If the appendix is not ruptured (perforated) at the time of surgery, the patient generally is
sent home from the hospital in one or two days. Patients whose appendix has perforated generally
are sicker than patients without perforation. After surgery, their hospital stay often is prolonged (four
to seven days), particularly if peritonitis has occurred. Intravenous antibiotics are given in the hospital
to fight infection and assist in resolving any abscess.
Occasionally, the surgeon may find a normal-appearing appendix and no other cause for the
patient's problem. In this situation, the surgeon may remove the appendix. The reasoning in these
cases is that it is better to remove a normal-appearing appendix than to miss and not treat
appropriately an early or mild case of appendicitis.

COMPLICATIONS

The most common complication of appendectomy is infection of the wound, that is, of the
surgical incision. Such infections vary in severity from mild, with only redness and perhaps some
tenderness over the incision, to moderate, requiring only antibiotics, to severe, requiring antibiotics
and surgical treatment. Occasionally, the inflammation and infection of appendicitis are so severe
that the surgeon will not close the incision at the end of the surgery because of concern that the
wound is already infected. Instead, the surgical closing is postponed for several days to allow the
infection to subside with antibiotic therapy and make it less likely for infection to occur within the
incision. Another complication of appendectomy is an abscess, a collection of pus in the area of the
appendix.

TYPES OF APPENDECTOMY

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 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.
RISKS

Risks for any anesthesia include the following:

 Reactions to medications
 Problems breathing
Risks for any surgery include the following:
 Bleeding
 Infection

Additional risks with an appendectomy with ruptured appendix include the following:
 Longer hospital stays
 Side effects from medications

AFTER THE PROCEDURE

Patients tend to recover quickly after a simple appendectomy. Most patients leave the
hospital in 1 - 3 days after the operation. Normal activities can be resumed within 1 - 3 weeks after
leaving the hospital.
Recovery is slower and more complicated if the appendix has ruptured or an abscess has
formed.
Living without an appendix causes no known health problems.
ANATOMY AND PHYSIOLOGY

the appendix (or vermiform appendix; also cecal (or caecal) appendix; also vermix) is a blind-
ended tube connected to the cecum (or caecum), from which it develops embryologically. The cecum
is a pouchlike structure of the colon. The appendix is located near the junction of the small intestine
and the large intestine.
The term "vermiform" comes from Latin and means "worm-shaped".

Size and location

The appendix averages 10 cm in length, but can range from 2 to 20 cm. The diameter of the
appendix is usually between 7 and 8 mm. The longest appendix ever removed measured 26 cm in
Zagreb, Croatia. The appendix is located in the lower quadrant of the abdomen, or more specifically,
the right iliac fossa. 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
ileocaecal valve, the location of the tip of the appendix can vary from being retrocaecal (74%) to
being in the pelvis to being extraperitoneal. In rare individuals with situs inversus, the appendix may
be located in the lower left side.

Function

Given the appendix's propensity to cause death by infection, and general good health of
people who have had their appendix removed or who have a congenital absence of an appendix, the
appendix is traditionally thought to have no function in the human body.There have been no reports
of impaired immune or gastrointestinal function in people without an appendix.

Vermiform appendix

The most common explanation is that the human appendix is a vestigial structure which has
lost its original function. (There has been little study of its function in the other animals in which it
occurs—apes, wombats and some rodents—or comparison with animals in which it does not occur.)
In The Story of Evolution, Joseph McCabe argued:
The vermiform appendage—in which some recent medical writers have vainly endeavoured to find a
utility—is the shrunken remainder of a large and normal intestine of a remote ancestor. This
interpretation would stand even if it were found to have a certain use in the human body. Vestigial
organs are sometimes pressed into a secondary use when their original function has been lost.
One potential ancestral purpose put forth by Charles Darwin was that the appendix was used
for digesting leaves as primates. It may be a vestigial organ of ancient humans that has degraded
down to nearly nothing over the course of evolution. Evidence can be seen in herbivorous animals
such as the koala. The cecum of the koala is very long, enabling it to host bacteria specific for
cellulose breakdown. Human ancestors may have also relied upon this system and lived on a diet rich
in foliage. As people began to eat more easily digested foods, they became less reliant on cellulose-
rich plants for energy. The cecum became less necessary for digestion and mutations that previously
had been deleterious were no longer selected against. These alleles became more frequent and the
cecum continued to shrink. After thousands of years, the once-necessary cecum has degraded to
what we see today, with the appendix. Evolutionary theorists have suggested that natural selection
selects for larger appendices because smaller and thinner appendices would be more susceptible to
inflammation and disease.

Immune function

New studies propose that the appendix may harbor and protect bacteria that are beneficial in
the function of the human colon. Loren G. Martin, a professor of physiology at Oklahoma State
University, argues that the appendix has a function in fetuses and adults. Endocrine cells have been
found in the appendix of 11 week old fetuses that contribute to "biological control (homeostatic)
mechanisms." In adults, Martin argues that the appendix acts as a lymphatic organ. The appendix is
experimentally verified as being rich in infection-fighting lymphoid cells, suggesting that it might play
a role in the immune system. Zahid suggests that it plays a role in both manufacturing hormones in
fetal development as well as functioning to "train" the immune system, exposing the body to
antigens so that it can produce antibodies. He notes that doctors in the last decade have stopped
removing the appendix during other surgical procedures as a routine precaution, because it can be
successfully transplanted into the urinary tract to rebuild a sphincter muscle and reconstruct a
functional bladder.

Maintaining gut flora

Although it was long accepted that the immune tissue, called gut associated lymphoid tissue,
surrounding the appendix and elsewhere in the gut carries out a number of important functions,
explanations were lacking for the distinctive shape of the appendix and its apparent lack of
importance as judged by an absence of side-effects following appendectomy. William Parker, Randy
Bollinger, and colleagues at Duke University proposed that the appendix serves as a haven for useful
bacteria when illness flushes those bacteria from the rest of the intestines. This proposal is based on
a new understanding of how the immune system supports the growth of beneficial intestinal
bacteria, in combination with many well-known features of the appendix, including its architecture
and its association with copious amounts of immune tissue. Such a function is expected to be useful
in a culture lacking modern sanitation and healthcare practice, where diarrhea may be prevalent.