Chapter 53 - Appendectomy

Summary

Appendectomy is performed for acute appendicitis (simple, suppurative, gangrenous, gangrenous with perforation); chronic or recurrent appendicitis; as an interval procedure after recovery from an appendiceal abscess; for small (< 2 cm) carcinoid tumors or benign mucoceles not involving the appendiceal orifice; and prophylactically during laparotomy for other conditions. The accuracy of diagnosis in acute appendicitis has increased to over 90% in several series using diagnostic adjuncts such as graded-compression ultrasound and special CT protocols. With graded compression ultrasound, a uniform pressure is applied to the right lower quadrant of the abdomen by a hand-held transducer. Normal loops of intestine are either displaced or compressed between the anterior and posterior abdominal walls. An inflamed appendix, however, is aperistaltic and non-compressible. In addition, percutaneous drainage of periappendiceal abscesses may allow for a subsequent single laparoscopic operation to remove the remnant of the perforated appendix (interval appendectomy). Interval appendectomy is generally performed 6–8 weeks after the initial abscess drainage.

With the patient under general anesthesia, appendectomy may be performed through a right lower quadrant muscle-splitting incision or by a laparoscopic approach using three ports. The laparoscopic operation affords an operative advantage in morbidly obese patients and patients with a retrocecal appendix, allowing for anatomy to be more easily visualized by virtue of the laparoscope. With simple, suppurative, or gangrenous appendicitis, the stress of operation is minimal. For patients with perforated gangrenous appendicitis and diffuse peritonitis or with a large intra-abdominal abscess, stress can be moderate or major. The duration of a simple appendectomy is 45 minutes, but this increases to 60 to 75 minutes in obese patients with retrocecal appendicitis and rupture. In some of these patients, the usual 6- to 7-cm incision must be extended to gain exposure of the posterior cecum and ascending colon. Blood transfusion is generally not required.