Appendectomy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

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 recognised 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.

Appendicectomy may be performed laparoscopically 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 open appendicectomy is as follows.

Antibiotics are given immediately if there are signs of sepsis, otherwise a single dose of prophylactic intravenous antibiotics is given immediately prior to surgery.

General anaesthesia is induced, with endotracheal intubation and full muscle relaxation, and the patient is positioned supine.

The abdomen is prepared and draped and is examined under anaesthesia. 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).

The goal of therapy of acute appendicitis is early diagnosis and prompt operative intervention. However, this goal is not always easily accomplished since many patients do not seek medical attention in a timely manner and the diagnosis of appendicitis can be difficult . Many surgeons use an aggressive approach, accepting a certain number of negative appendectomies, traditionally 15 percent, although the use of imaging studies appears to have reduced the negative appendectomy rate to less than 10 percent.

Emergency appendicectomy

An inflamed appendix can be life-threatening, particularly if the patient is out of reach of medical care. Historical records show a number of appendicectomies carried out by unskilled ad hoc surgeons, communicating with a base hospital by telephone or even telegraph.

Prophylactic appendicectomy

To find the cause of unexplained abdominal pain, exploratory surgery is sometimes performed. If the appendix is NOT the cause of symptoms, the surgeon will thoroughly check the other abdominal organs and remove the appendix anyway, to prevent it from becoming a problem in the future.

When abdominal surgery is performed for an entirely different reason (e.g. hysterectomy or bowel resection), the surgeon sometimes decides to perform an appendicectomy in addition to the intended procedure, to eliminate the possible need of a future surgery just to remove the appendix. However, recent findings on the possible usefulness of the appendix has led to an abatement of this practice.

Pregnancy

If appendicitis develops in a pregnant woman, an appendicectomy is usually performed and should not harm the fetus.^[1]

Recovery

Recovery time from the operation can vary from person to person. Some will take up to 3 weeks before being completely active. Others it can be a matter of days. Roy Halladay of the Toronto Blue Jays baseball team, recovered from his appendicectomy in under 3 weeks, to return to the mound and win 3 straight games. In the case of a laparoscopic operation, the patient will have three stapled scars of about an inch in length, between the navel and pubic hair line. When a laparotomy has been performed, the patient will have a 2-4 inch scar, which will initially be heavily bruised.