Overview
Definition:
Open appendectomy is a surgical procedure involving the removal of the vermiform appendix, typically performed under general or spinal anesthesia
It is indicated for the treatment of acute appendicitis and other less common conditions affecting the appendix.
Epidemiology:
Appendicitis is the most common surgical emergency worldwide, with an incidence of approximately 7-8% in Western populations and slightly lower in India
It can occur at any age but is most common in adolescents and young adults (10-30 years).
Clinical Significance:
Open appendectomy remains a cornerstone in the management of acute appendicitis, especially in resource-limited settings or when laparoscopic surgery is not feasible or contraindicated
Understanding its indications, technique, and potential complications is crucial for surgical residents preparing for DNB and NEET SS examinations.
Indications
Acute Appendicitis:
The primary indication
Suspected or confirmed diagnosis based on clinical presentation, laboratory findings, and imaging
Includes uncomplicated and complicated appendicitis (perforation, abscess, peritonitis).
Chronic Appendicitis:
Less common, characterized by recurrent, intermittent right lower quadrant pain with histopathological confirmation
Surgical removal is curative.
Appendiceal Neoplasms:
Rarely, appendectomy may be performed for benign or malignant tumors of the appendix, such as carcinoid tumors or adenocarcinomas, often discovered incidentally or during surgery for appendicitis.
Other Conditions:
Conditions like mucocele of the appendix, appendicular abscess not amenable to percutaneous drainage, or certain parasitic infestations of the appendix.
Preoperative Preparation
Patient Assessment:
Thorough history and physical examination to confirm diagnosis and assess for comorbidities
Assess for signs of peritonitis, sepsis, or hemodynamic instability.
Laboratory Investigations:
Complete blood count (leukocytosis, shift to the left)
Electrolytes, renal function tests, liver function tests, coagulation profile
Urinalysis to rule out urinary tract pathology
Blood grouping and cross-matching.
Imaging:
Ultrasound (especially in children and pregnant women) and CT scan of the abdomen and pelvis are highly sensitive and specific for diagnosing appendicitis, identifying complications like abscess or perforation, and guiding surgical approach.
Antibiotic Prophylaxis:
Broad-spectrum intravenous antibiotics are crucial, especially in suspected complicated appendicitis
Common regimens include cefotetan, cefoxitin, or ceftriaxone with metronidazole
Administer within 1 hour of incision.
Anesthesia Considerations:
General anesthesia with endotracheal intubation is most common
Spinal anesthesia may be used in select cases
Adequate analgesia and fluid management are essential.
Procedure Steps
Incision:
Typically a right lower quadrant (RLQ) incision, often a McBurney incision (oblique muscle-splitting) or a modified Rocky-Davis incision (transverse)
The choice depends on surgeon preference, suspected pathology, and patient factors.
Exploration And Identification:
The abdominal cavity is explored
The cecum is identified, and the appendix is traced to its base
Care is taken to avoid injury to the ileocecal junction and surrounding structures.
Appendiceal Dissection:
The mesoappendix is divided, ligating its vessels
The base of the appendix is ligated with sutures or a stapler
The appendix is then divided distal to the ligature.
Inversion Or Exteriorization:
The appendiceal stump can be inverted into the cecum (invaginated) using Lembert sutures or ligated and left exteriorized
The peritoneal coat of the stump is often sutured over it
Some surgeons perform cauterization of the stump.
Irrigation And Drainage:
The peritoneal cavity is thoroughly irrigated with normal saline, especially in cases of perforation or gross contamination
Drains are typically not required unless there is a significant abscess or gross contamination, but their use is debated.
Closure:
The abdominal wall layers are closed in anatomical order
The skin is closed with sutures or staples
A sterile dressing is applied.
Postoperative Care
Pain Management:
Adequate analgesia is vital, often using intravenous opioids initially, followed by oral analgesics
Patient-controlled analgesia (PCA) can be useful.
Fluid And Electrolyte Balance:
Intravenous fluids are maintained until oral intake is established
Monitor for fluid overload or dehydration.
Antibiotic Therapy:
Continued intravenous antibiotics are usually given for 24-48 hours or longer in complicated appendicitis (perforation, abscess)
Oral antibiotics may follow if indicated.
Ambulation And Diet:
Early ambulation is encouraged to prevent deep vein thrombosis and pneumonia
Patients are typically advanced to a clear liquid diet as tolerated, progressing to regular diet.
Monitoring For Complications:
Close observation for signs of wound infection, intra-abdominal abscess, ileus, or anastomotic leak (if applicable)
Monitor vital signs, abdominal exam, and laboratory parameters.
Complications
Early Complications:
Wound infection (most common)
Intra-abdominal abscess (may require re-operation or percutaneous drainage)
Bleeding (from mesoappendix or stump)
Ileus
Peritonitis
Sepsis.
Late Complications:
Incisional hernia
Chronic incisional pain
Bowel obstruction due to adhesions
Stump appendicitis (rare).
Prevention Strategies:
Meticulous surgical technique, proper ligation of mesoappendix and stump, adequate wound irrigation, appropriate antibiotic use, and early mobilization
Careful patient selection and adherence to surgical protocols are key.
Prognosis
Factors Affecting Prognosis:
The stage of appendicitis at presentation (uncomplicated vs
complicated)
Presence of comorbidities
Development of complications like peritonitis or abscess
Promptness of diagnosis and treatment.
Outcomes:
In uncomplicated appendicitis, outcomes are excellent with prompt surgical intervention, leading to full recovery within a few weeks
Complicated appendicitis has a higher morbidity and mortality risk.
Follow Up:
Routine follow-up is usually not required for uncomplicated appendicitis
Patients with complicated appendicitis or those who developed complications may require more structured follow-up to monitor for long-term sequelae.
Key Points
Exam Focus:
DNB/NEET SS exams will test your knowledge on classic presentation, diagnostic modalities (USG vs CT), antibiotic regimens, surgical anatomy, common complications, and management of complicated appendicitis
Understand the differences in management between uncomplicated and complicated cases.
Clinical Pearls:
Palpate the entire abdomen, not just the RLQ
Rebound tenderness and guarding are key signs of peritoneal irritation
Consider differential diagnoses in specific populations (e.g., gynecological causes in women, mesenteric adenitis in children).
Common Mistakes:
Delayed diagnosis due to atypical presentations or misinterpretation of imaging
Inadequate antibiotic coverage, especially for gram-negative and anaerobic organisms in complicated cases
Failure to consider appendiceal rupture or abscess formation
Rushing closure of abdominal layers in obese patients.