Appendectomy

Definition
Appendectomy is the surgical removal of the appendix. The appendix is a worm-shaped hollow
pouch attached to the cecum, the beginning of the large intestine.

Purpose
Appendectomies are performed to treat appendicitis, an inflamed and infected appendix.

Description
After the patient is anesthetized, the surgeon can remove the appendix either by using the
traditional open procedure (in which a 2–3 in [5–7.6 cm] incision is made in the abdomen) or via
laparoscopy (in which four 1-in [2.5-cm] incisions are made in the abdomen).

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 performs a laparoscopic 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 on 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. The appendix is then 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.

To remove a diseased appendix, an incision is made in the patient's lower abdomen (A).
Layers of muscle and tissue are cut, and large intestine, or colon, is visualized (B). The
appendix is located (C), tied, and removed (D). The muscle and tissue layers are stitched
(E). (
Illustration by GGS Inc.
)

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, laparoscopic appendectomy (LA) always takes longer than traditional appendectomy
(TA). The increased time required to do a LA the greater the patient's exposure to anesthetics,
which increases the risk of complications. The increased time requirement also increases the 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 increase 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.

Insurance plans do cover the costs of appendectomy. Fees are charged independently by the
hospital and the physicians. Hospital charges include fees for operating and recovery room use,
diagnostic and laboratory testing, as well as the normal hospital room charges. Surgical fees vary
from region to region and range between $250–750. The anesthesiologist's fee depends on the
health of the patient and the length of the operation.

Preparation
Once the diagnosis of appendicitis is made and the decision has been made to perform an
appendectomy, the patient undergoes the standard preparation for an operation. This usually
takes only one to two hours and includes signing the operative consents, patient identification
procedures, evaluation by the anesthesiologist, and moving the patient to the operating area of
the hospital. Occasionally, if the patient has been ill for a prolonged period of time or has had
protracted vomiting, a delay of few to several hours may be necessary to give the patient fluids
and antibiotics .

Aftercare
Recovery from an appendectomy is similar to other operations. Patients are allowed to eat when
the stomach and intestines begin to function again. Usually the first meal is a clear liquid diet—
broth, juice, soda pop, and gelatin. If patients tolerate this meal, the next meal usually is a regular
diet. Patients are asked to walk and resume their normal physical activities as soon as possible. If
TA was done, work and physical education classes may be restricted for a full three weeks after
the operation. If a LA was done, most patients are able to return to work and strenuous activity
within one to three weeks after the operation.

Risks
Certain risks are present when any operation is performed under general anesthesia and the
abdominal cavity is opened. Pneumonia and collapse of the small airways (atelectasis) often
occurs. Patients who smoke are at a greater risk for developing these complications.
Thrombophlebitis, or inflammation of the veins, is rare but can occur if the patient requires
prolonged bed rest. Bleeding can occur but rarely is a blood transfusion required. Adhesions
(abnormal connections to abdominal organs by thin fibrous tissue) are a known complication of
any abdominal surgery such as appendectomy. These adhesions can lead to intestinal obstruction
that prevents the normal flow of intestinal contents. Hernia is a complication of any incision.
However, they are rarely seen after appendectomy because the abdominal wall is very strong in
the area of the standard appendectomy incision.

The overall complication rate of appendectomy depends upon the status of the appendix at the
time it is removed. If the appendix has not ruptured, the complication rate is only about 3%.
However, if the appendix has ruptured, the complication rate rises to almost 59%. Wound
infections do occur and are more common if the appendicitis was severe, far advanced, or
ruptured. An abscess may also form in the abdomen as a complication of appendicitis.

Occasionally, an appendix will rupture prior to its removal, spilling its contents into the
abdominal cavity. Peritonitis or a generalized infection in the abdomen will occur. Treatment of
peritonitis as a result of a ruptured appendix includes removal of what remains of the appendix,
insertion of drains (rubber tubes that promote the flow of infection inside the abdomen to outside
of the body), and antibiotics. Fistula formation (an abnormal connection between the cecum and
the skin) rarely occurs. It is only seen if the appendix has a broad attachment to the cecum and
the appendicitis is far advanced, causing destruction of the cecum itself.

The complications associated with undiagnosed, misdiagnosised, or delayed diagnosis of

appendicitis are very significant. This has led surgeons to perform an appendectomy any time
that they feel appendicitis is the diagnosis. Most surgeons feel that in approximately 20% of their
patients, a normal appendix will be removed. Rates much lower than this would seem to indicate
that the diagnosis of appendicitis was being frequently missed.

Normal results
Most patients feel better immediately after an operation for appendicitis. Many patients are
discharged from the hospital within 24 hours after the appendectomy. Others may require a
longer stay, from three to five days. Almost all patients are back to their normal activities within
three weeks.

Morbidity and mortality rates

The mortality rate of appendicitis has dramatically decreased over time. Currently, the mortality
rate is estimated at one to two per 1,000,000 cases of appendicitis. Death is usually due to
peritonitis, intra abdominal abscess, or severe infection following rupture.

Alternatives
Appendectomies are usually carried out on an emergency basis to treat appendicitis. There are no
alternatives, due to the serious consequence of not removing the inflamed appendix, which is a
ruptured appendix and peritonitis, a life-threatening emergency.

See also Laparoscopy .

Resources
BOOKS

Schwartz, Seymour I. "Appendix." In Principles of Surgery, edited by Seymour Schwartz, et al.

New York: McGraw-Hill, 1994.

Silen, William. "Acute Appendicitis." In Harrison's Principles of Internal Medicine , edited by

Anthony S. Fauci, et al. New York: McGraw-Hill, 1997.

PERIODICALS

Eypasch, E., S. Sauerland, R. Lefering, and E. A. Neugebauer. "Laparoscopic versus Open

Appendectomy: Between Evidence and Common Sense." Digestive Surgery 19 (2002): 518–522.

Peiser, J. G. and D. Greenberg. "Laparoscopic versus open appendectomy: results of a

retrospective comparison in an Israeli hospital." Israel Medical Association Journal 4 (February,
2002): 91–94.

Piskun, G., D. Kozik, S. Rajpal, G. Shaftan, and R. Fogler. "Comparison of laparoscopic, open,
and converted appendectomy for perforated appendicitis." Surgery and Endoscopy 15 (July
2001): 660–662.

Long, K. H., M. P. Bannon, S. P. Zietlow, E. R. Helgeson, et al. "A prospective randomized

comparison of laparoscopic appendectomy with open appendectomy: Clinical and economic
analyses." Pathology Case Reviews 129 (April, 2001): 390–400.

Selby, W. S., S. Griffin, N. Abraham, and M. J. Solomon. "Appendectomy protects against the
development of ulcerative colitis but does not affect its course." American Journal of
Gastroenterology 97 (November, 2002): 2834–2838.

ORGANIZATIONS

American College of Surgeons. 633 N. Saint Clair St., Chicago, IL 60611-3211. (312) 202-5000.
http://www.facs.org .

OTHER
"Appendectomy." MEDPLINE PLUS. [cited June 27, 2003].
http://www.nlm.nih.gov/medlineplus .

"The Appendix." Mayo Clinic Online. http://www.mayo health.org .

Mary Jeanne Krob, M.D., F.A.C.S.

Monique Laberge, Ph.D.

Surgeries and Procedures: Appendectomy

 Article
 Related Articles
 Related Resources

Article
Appendectomy is the surgical removal of the appendix when an infection has made it inflamed
and swollen. This infection, called appendicitis, is considered an emergency because it can be
life-threatening if it's not treated — the appendix occasionally bursts less than a day after
symptoms start. So it's very important to have it removed as soon as possible.

Fortunately, appendectomy is a routine procedure and complications are uncommon. And if

appendicitis is promptly diagnosed and an appendectomy is performed, most kids recover
quickly and with little difficulty.

Still, it helps to know some of the basics so you can feel confident about what is happening and
support your child. The more prepared, calm, and reassuring you are about the anesthesia and
surgery, the easier the experience will probably be for both of you.

About Appendicitis

Located in the abdomen, the appendix is a small organ that resembles a worm. One end of the
appendix is closed and the other opens into the large intestine, the organ that absorbs water from
waste (or stool) and moves it out of the body through the anus. Experts don't completely
understand what the appendix does, but most agree that it's not important to a person's health.
Causes

There's no way to prevent appendicitis. Because the appendix is so close to the large intestine, it
can sometimes become clogged with stool and bacteria. Other times mucus produced by the
appendix can thicken and cause a blockage. In both cases, once the opening to the appendix is
congested, it can become inflamed and swollen, causing appendicitis.

Signs and Symptoms

Appendicitis can cause sudden pain in the middle of the abdomen, usually concentrated around
the bellybutton. The pain often moves to the lower right part of the abdomen. At first, the pain
might come and go, but then it becomes persistent and sharp.

Appendicitis also can cause:

 loss of appetite
 fever
 nausea
 vomiting
 diarrhea

If the appendix bursts, a child can develop a fever as high as 104? Fahrenheit (40? Celsius), and
pain will move throughout the abdominal area.
Preparing for Surgery

Once it's determined that your child needs an appendectomy, he or she will be admitted to the
hospital. You'll have to fill out some paperwork and provide basic information, including:

 your child's health history

 name and phone number of your child's pediatrician
 your insurance provider
 any illnesses and medical conditions your child has
 any allergies your child has
 any medication, vitamin supplements, or herbal remedies your child is taking

You'll wait for surgery either in the emergency room or another room in the hospital, and your
child will be given an ID bracelet and asked to change into a hospital gown and remove any
jewelry. A nurse will check some of your child's vital signs and put in place these monitors:

 a blood pressure monitor, which periodically checks blood pressure throughout the procedure. It
is measured by a cuff that fits around the arm.
 a pulse oximeter, which measures the level of oxygen in the blood. A pulse oximeter resembles a
Band-Aid and is placed on a patient's fingertip.
  a heart monitor, which checks the rhythm and rate of the heart beat. A heart monitor is connected
to a series of small metal tabs (called electrodes) and records the activity of the heart. The
electrodes have adhesive backs that stick to the patient's skin and are placed on the chest.

Depending on the availability of a surgical room and how long it's been since your child ate or
drank, you and your child might have to wait for a little while for the surgery to begin.

Starting an IV Line

Before the surgery a nurse will begin an intravenous line (IV). After a needle punctures the
child's arm or hand, a tiny tube is attached to IV tubing, which connects to a bag containing the
mixture of medicines and fluids needed to keep the infection in check. The medicines and fluids
flow out of the bag, into the tubing, through the tiny tube in the skin, and into the bloodstream.

Since it involves a needle at first, starting an IV can cause a little bit of pain (kind of like a small
pinch). To ease discomfort, a nurse might put some numbing cream on your child's hand a little
while before inserting the needle.

Meeting the Surgeon

The surgeon will probably describe the procedure and answer any questions you and your child
might have. This is a good time to ask the surgeon to explain anything about the procedure you
don't understand.

Once you feel comfortable with the information, you'll be asked to sign an informed consent
form stating that you understand the procedure and its risks, and give your permission for the
surgery.

Anesthesia

Soon after, an anesthesiologist or a certified registered nurse anesthetist (CRNA) will come in to
talk to you and your child. Anesthesiologists and CRNAs specialize in giving and managing
anesthesia (medicines that prevent pain and sensation during the surgery). The anesthesiologist
or CRNA will explain the details about the type of anesthesia to be used.

General anesthesia, which is used for appendectomies, keeps the patient in a deep sleep-like state
throughout the procedure, so that he or she is completely unaware of what's happening and
doesn't feel any pain.

In addition to checking your child's breathing and heart rate, the anesthesiologist or CRNA will
ask about your child's medical history. You might have answered some of the questions already
when you filled out paperwork, but it's important to let the anesthesiologist or CRNA know the
following:

 your child's current and past health history

 your family's health history
 any medications, supplements, or herbal remedies your child is taking
  any previous reactions your child or any family member has had to anesthesia
 any allergies (especially to foods, medications, or latex) your child has had
 whether your child smokes, drinks alcohol, or takes recreational drugs or birth control pills

You'll also be asked how long it's been since your child has eaten or had anything to drink. It
may seem like an odd question, but this is important because the stomach must be empty at the
time of surgery so that food or liquid will not be aspirated (inhaled) into the lungs.

Anesthetic medications can suspend the body's normal reflexes, which could cause food to
become inhaled into the lungs. It can take up to 6 hours for a person to completely digest food,
so if your child has eaten recently, he or she may have to wait a little while for surgery.

To ensure your child's safety during the surgery, it's extremely important to answer all of these
questions as honestly and thoroughly as possible, so that the anesthesiologist or CRNA can give
the right amount of anesthetic medications and tailor them to your child's needs. After you've
provided all of this information and the anesthesiologist or CRNA has answered any questions,
you'll be asked to sign an informed consent form that authorizes the use of anesthesia.

Shortly before going into the operating room, your child will be given a sedative (a type of
medicine that helps patients relax before a procedure). The sedative is usually given through the
IV that is already in place.

Once your child is relaxed, the anesthesiologist or CRNA will start to administer the anesthesia.
Usually the medications are given through the IV or with gas given through a mask that covers
the mouth and nose. Often, the gas has a flavor like banana or bubblegum to make inhaling it
more pleasant.

Within a few minutes, your child will drift into a sleepy state. When your child is taken into
surgery, you'll be directed to a waiting area and a hospital staff member will update you during
the procedure and notify you when it is over.

During the Surgery

When your child is taken into surgery, a few devices will be used to prevent any complications,
including:

 a nasogastric tube, a slender soft tube that's inserted through the nose or mouth and down into the
stomach to suck out stomach fluids to make sure they don't interfere with the surgical procedure
 an endotracheal tube, a plastic tube inserted into the throat and the windpipe to help a patient
breathe during surgery. This tube is connected to a ventilator that pushes air in and out of the
lungs.
 a catheter, a long, thin tube that drains urine from the bladder and empties it. The catheter is
carefully inserted into the patient's urethra (which passes urine from the bladder to the outside of
the body), and then into the bladder. A catheter isn't used in all cases.

Once these monitors are in place, the surgery can begin. The two common types of
appendectomy are:
 1. Open Appendectomy
An open appendectomy is the "traditional" way of removing an infected appendix. Basically, a
surgeon makes an incision in the abdomen and locates the infected appendix. The appendix is cut
away from the large intestine and removed from the body. The incision is then closed with
stitches.
2. Laparoscopic Appendectomy
You've probably heard the word "laparoscopy," which is a type of surgery that uses a tiny video
camera called a laparoscope to help surgeons see inside the body. The thin tube of the
laparoscope is inserted into the body through a small incision and guided to the appendix to act as
the surgeon's "eyes." Other small incisions are made so medical instruments can be guided to the
area, and the entire operation is done while looking at a TV monitor.

Your child's surgical team will determine which method is appropriate.

During Open Procedure

For an open appendectomy, the surgeon first cleanses the skin of the abdomen with an antiseptic
solution. Then he or she makes an incision, about 2 inches long, through the skin of the
abdomen, past the abdominal muscles, and into the abdominal wall (layers of tissue that protect
the abdomen). The abdominal muscles are then separated and the appendix is located.

By using sutures (stitches) or a special stapling tool, the surgeon closes the open area of the
appendix connected to the large intestine to prevent it from tearing and spreading bacteria
through the abdomen while it's being removed. (The stapling tool uses stainless steel staples that
are slightly smaller than those used in a standard office stapler.)

The surgeon then cuts the appendix away from the large intestine and pulls it out of the body
through the incision.

Once the appendix is removed, the surgeon closes the abdominal wall and abdominal muscles
with dissolvable stitches. Then, the opening on the skin is closed with stitches and is covered
with a bandage.

During Laparoscopic Procedure

As with an open appendectomy, the surgeon first cleanses the skin with an antiseptic solution.
However, instead of making one large incision, the surgeon makes a small incision (about 1/2 to
1 inch long) in the crease of the bellybutton. This incision allows the laparoscope to be guided to
the appendix.

Two more small incisions are made to allow the surgeon to guide other special instruments to the
appendix area. These instruments are used to close off the appendix and remove it.

The small incisions are closed with dissolvable stitches and covered with small bandages.
Laparoscopic to Open Procedure

In some rare cases, a surgeon might start with the laparoscopic procedure but change to an open
procedure during surgery. This can happen for a variety of reasons: The surgeon might have
trouble finding the appendix with the laparoscope or the patient might have had previous
surgeries that have left scar tissue in the abdominal area, making it difficult to remove the
appendix through laparoscopy.

If the surgeon decides to switch from the laparoscopic procedure to the open procedure, he or she
will either close up the small incisions and immediately begin the open appendectomy or end the
surgery and reschedule the appendectomy for another time.

After the Surgery

After the surgery, your child will be taken to a recovery room, which is sometimes called the
"post-op" (post-operative) room or PACU (post-anesthesia care unit). Here, your child will
continue to be closely monitored by the medical team.

The surgeon will come out to talk to you about what happened during the surgery and let you
know how your child is doing, and in most cases you'll be able to join your child in the recovery
room.

It usually takes about an hour for a child to completely wake up from the anesthesia. People react
to anesthesia in a variety of ways, and while most feel fine afterwards, it's possible your child
may feel groggy, confused, chilly, nauseated, scared, alarmed, or even sad when waking up.

Also, your child might feel a little bit of pain near the incisions, but a doctor can prescribe
medication to help lessen it. Be sure to let doctors or nurses know if your child is uncomfortable
or in pain.

Recovery

Typically, a child stays in the hospital for 2 to 3 days after an appendectomy, a little longer if the
appendix burst before it was removed. Many hospitals allow at least one parent to stay with the
child throughout the day and overnight.

Once the doctors decide your child is ready to leave the hospital, you'll get instructions on home
care and when to come back for a follow-up visit with the doctor. This usually happens within a
few weeks.

In cases where the appendix has burst, doctors typically keep a child on antibiotics for a week or
more. Sometimes antibiotics are given through a portable IV that remains in place when the child
leaves the hospital. A nurse comes to the home in the following days to monitor the IV and
remove it.

Other things to think about as your child recovers at home:

  Eating and drinking: There probably won't be any food or drink restrictions after the surgery,
but it's likely that your child won't have much of an appetite at first.
 Caring for the incision: Be sure to keep the area clean and watch for signs of infection. Call
your doctor if you notice any redness or swelling around the incision, or your child develops pain
or a fever greater than 101? Fahrenheit (38.3? Celsius).
 Returning to school: The doctor will let you know when your child can return to school and get
back to normal activities. In most cases, kids can be back within a week of surgery, longer if the
appendix burst.
 Resuming physical activity: The doctor may recommend that your child stay out of gym class,
sports, and other physical activities for a few weeks.

With a little rest and care, most kids recover from appendicitis and an appendectomy with little
difficulty.

Risks of Surgery

Any surgery has some risks. The surgical team will discuss them with you before the surgery and
do everything possible to minimize them. If you have any questions or concerns, make sure
they're addressed before the surgery.

Anesthesia

Anesthesia is very safe. But in some cases it can cause complications in children (such as
irregular heart rhythms, breathing problems, allergic reactions to medications, and, in very rare
cases, death). These complications are not common, and usually involve patients who have other
medical problems.

Bleeding

In any surgery, there's a possibility of bleeding. Severe bleeding is rare during an appendectomy,
and almost all bleeding is controlled without the need for a blood transfusion.

Allergic reaction

It is possible that a patient can have an allergic reaction to the anesthesia or other medication
given during the surgery.

Symptoms of an allergic reaction can range from something minor, like a skin rash, to something
more serious, like dizziness, trouble breathing, or swollen lips or tongue. Allergic reactions
typically develop within a few minutes after the anesthesia is given. The doctors can provide
immediate medical attention if that happens.

Infection (internal)

Surgery is performed in a sterile environment, but any time the skin is cut and the internal body
is exposed, there's a risk of infection. Symptoms of an infection can develop in the first few days
after surgery and might include pain or a fever of about 101? Fahrenheit (38.3? Celsius).
In cases where the appendix has ruptured, an abscess can form. This is a pocket of pus that
collects in the abdomen. An abscess is usually detected and treated (often by draining the
infected fluid) before a child is discharged from the hospital, but in some cases additional
surgery may be needed.

Problems going to the bathroom

It is common for kids to have some trouble going to the bathroom after the surgery. That's
because the doctors operate near the digestive system when removing the appendix. Also, some
of the pain medication given for the surgery can lead to constipation. All of this can make it
difficult for a child to urinate, pass gas, and have bowel movements.

These problems usually develop in the first hours after the surgery and go away on their own
within a day or two. Your child will be monitored closely for any signs of problems in the
hospital.

Infected incision

Rarely, the incision becomes infected and will be treated with antibiotics. Signs of infection
include redness, pus, pain, and swelling around the incision, or a fever greater than 101?
Fahrenheit (38.3? Celsius). If you notice any of these signs, call the doctor.

Alternatives to Surgery

In nearly all cases of appendicitis, an appendectomy is the only option. If the appendix isn't
removed and it bursts, other organs can become infected. And if infections aren't treated, they
can continue to spread. So it's important to diagnose and treat appendicitis as soon as possible.

In some cases, doctors will perform what is known as an "interval appendectomy." This means
the operation is delayed because the appendix has ruptured. In the weeks leading up to the
surgery, the infection can be treated with antibiotics.

When your child is having any kind of procedure or surgery, it's understandable to be a little
uneasy. But it helps to know that in most cases, appendectomies are routine procedures and
complications are rare. Most kids who undergo an appendectomy recover from the surgery
without any difficulty or health problems. If you have any questions about appendectomies, talk
with your doctor.

Reviewed by: Kate M. Cronan, MD

Date reviewed: July 2008

http://www.thechildrenshospital.org/wellness/info/parents/62168.aspx