Appendectomy

Indications

Appendectomy is the definitive treatment for acute appendicitis. Preoperative broad-spectrum intravenous antibiotics (covering Gram-negative and anaerobic organisms) should be administered before surgery. Two approaches exist: laparoscopic and open.

Laparoscopic Appendectomy

The preferred and most commonly used approach.

Patient setup:

Supine position, left arm or both arms tucked
Foley catheter considered if not voided pre-op
Prepped from the xiphoid to the pubis

Abdominal access:

Umbilical port placed via Veress needle (closed technique) or Hasson open technique
Abdomen insufflated with CO₂ to 12–15 mmHg
Typical port configuration: umbilical camera port (12 mm) + two working ports (RLQ and LLQ)

Operative steps:

Four-quadrant exploration performed first
Patient placed in reverse Trendelenburg with right side up
Cecum identified by tracing the taeniae coli to the appendiceal base
Appendix elevated toward the LUQ; peritoneal and omental attachments lysed
For a retrocecal appendix: the white line of Toldt is divided to mobilize the cecum
A window is created through the mesoappendix
Mesoappendix divided with a linear GI stapler (white load) or energy device (cautery/LigaSure)
Appendiceal base divided with a blue load stapler (or Endoloop ligature)
Specimen placed in retrieval bag and removed through the umbilical port
Staple line inspected; hemostasis achieved
If turbid/murky peritoneal fluid is found, a sample should be sent for gram stain, culture, and sensitivities

Open Appendectomy

Essential skill despite the laparoscopic approach being standard.

Patient setup:

Supine, standard sterile prep

Incision:

McBurney's point identified (1/3 of the way along a line from the ASIS to the umbilicus)
Skin incision made within a natural skin crease (oblique/Rocky-Davis)
Muscle-splitting dissection through:
- External oblique aponeurosis (split along fibers)
- Internal oblique (split bluntly)
- Transversus abdominis (split)
- Peritoneum (elevated and sharply entered)

Operative steps:

Cecum identified and delivered into the wound
Appendix located at confluence of the taeniae
Mesoappendix divided between Kelly clamps and ligated with 3-0 silk
Appendiceal base crushed with a Kelly clamp
Clamp relocated 1 cm distal to the crushed zone; base ligated with 0-chromic suture
Appendix divided just proximal to the clamp
Stump may be cauterized or invaginated with a purse-string or Z-stitch
Abdomen closed in layers (peritoneum + transversus abdominis → internal + external oblique → skin)
In perforation: skin may be left open or loosely approximated

Perforated (Complicated) Appendicitis

Occurs in up to 40% of appendicitis cases, usually with longer symptom duration
Resuscitate with IV fluids + immediate IV antibiotics: piperacillin-tazobactam or ceftriaxone + metronidazole
Diffuse peritonitis / hemodynamic instability → urgent OR after resuscitation
Phlegmon or abscess → nonoperative management with antibiotics ± percutaneous drainage; transition to oral amoxicillin-clavulanate (5-day course proven equivalent to 7 days)

Interval Appendectomy

Performed after successful nonoperative management of complicated appendicitis, typically ≥6 weeks after the acute episode.

Controversial in adults: low recurrence rate, but surgery carries ~11% complication rate
Adults ≥40 years: interval CT + colonoscopy recommended to exclude malignancy
Children: more commonly indicated; a 2017 multicenter RCT found 23% recurrence within 1 year with nonoperative management

Nonoperative Management (Uncomplicated Appendicitis)

A viable alternative to surgery, particularly for uncomplicated cases. Antibiotics alone carry a failure rate, with a portion requiring appendectomy within 1 year. Appendectomy remains the gold standard, but nonoperative management is accepted in select patients.

Sources: Current Surgical Therapy 14e; Mulholland and Greenfield's Surgery 7e

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