Appendectomy: operative steps

Pre-operative

1. Confirm the diagnosis (clinical assessment plus imaging as needed).
2. Give pre-operative IV antibiotics.
3. Obtain consent and give general anaesthesia.
4. Have the patient void, or place a Foley catheter or straight catheter, so the bladder is empty.

Laparoscopic appendectomy

1. Position. Place the patient supine with the left arm tucked. Prep from the chest to the pubis.
2. Access. Enter the abdomen at the umbilicus with an open (Hasson), Veress, or optical trocar technique. Insufflate CO2 to 12-15 mm Hg. Inspect under the entry site to exclude injury to underlying viscera.
3. Ports. Place two more ports under direct vision. Usual sites are the suprapubic area and the left lower quadrant. The surgeon and assistant stand on the patient's left.
4. Explore. Examine all four quadrants to exclude other pathology (for example tubo-ovarian abscess or diverticulitis). Then tilt the patient reverse Trendelenburg with the right side up.
5. Find the appendix. Sweep the small bowel away and follow the taeniae coli to where they converge on the caecum. This is the base of the appendix. The ileal "sail" and the ligament of Treves also help.
6. Mobilise.
   • Lyse any adhesions.
   • Grasp and elevate the appendix tip with an atraumatic grasper.
   • For a retrocaecal appendix, divide the white line of Toldt to mobilise the caecum.
7. Divide the mesoappendix. Create a window at the base between the appendix and mesoappendix. Divide the mesoappendix with a stapler (white load), LigaSure, harmonic scalpel, or clips with cautery. Do this under direct vision to avoid injuring the caecum.
8. Divide the appendix. Use a stapler (blue load) or two Endoloops at the base. Divide the appendix distal to the secured base.
9. Retrieve. Put the specimen in a retrieval bag and remove it through a port. Do not pull an inflamed appendix through the abdominal wall unprotected.
10. Finish.
    • Inspect the stump and staple line for haemostasis.
    • Suction the pelvis, and irrigate if there is pus or turbid fluid.
    • Send a culture if the fluid is cloudy.
    • Remove the ports under vision and deflate the abdomen.
    • Close the fascia of the 10-12 mm sites and the skin.

Open appendectomy

1. Incision. Mark McBurney's point, one-third of the way along the line from the anterior superior iliac spine to the umbilicus. Make an oblique (McBurney) or transverse (Rockey-Davis) skin incision in a skin crease.
2. Muscle-splitting approach. Go down to the external oblique aponeurosis. Split the external oblique, internal oblique, and transversus abdominis along the direction of their fibres. Do not cut them.
3. Enter the peritoneum. Lift it and incise it sharply, taking care not to injure the bowel underneath.
4. Deliver the appendix. Identify the caecum and follow the taeniae to the appendiceal base. Deliver the caecum and appendix into the wound.
5. Mesoappendix. Clamp, divide, and ligate it with 3-0 silk, or use a stapler. Ligate the appendicular artery securely.
6. Appendiceal base.
   • Crush the base with a Kelly clamp.
   • Move the clamp 1 cm distally.
   • Tie an absorbable ligature (0 chromic) at the crushed zone.
   • Divide the appendix just proximal to the clamp.
7. Stump. Cauterise it or invert it with a purse-string or Z-stitch. Sabiston says simple ligation is preferred.
8. Closure. Return the caecum to the abdomen. Close the peritoneum and transversus abdominis with a running absorbable suture. Appose the internal and external obliques. Close the skin with a subcuticular suture. If the appendix was perforated, leave the skin open or loosely approximated.

Points to remember

• Laparoscopy is associated with fewer wound complications, less pain, and shorter recovery. It also allows examination of the whole peritoneal cavity. Sabiston supports it even in complicated appendicitis, elderly patients, and pregnancy.
• If the appendix looks normal, look for other causes such as the terminal ileum (Meckel's, Crohn's), ovarian or tubal disease, and mesenteric adenitis.
• Leave no appendiceal stump, because a long stump can cause stump appendicitis.
• Perforation with abscess or phlegmon may be treated with antibiotics and drainage, followed by an interval appendectomy.

• Current Surgical Therapy 14e, "Laparoscopic Appendectomy" and "Open Appendectomy"
• Sabiston Textbook of Surgery, "Laparoscopic Versus Open Appendectomy," Ch. 94
• Fischer's Mastery of Surgery 8e, "Laparoscopic Appendectomy," Ch. 288

Appendix ka operation (Appendectomy): asan bhasa mai

Pehle basic samjho

1. Laparoscopic: chhote-chhote cuts aur camera se. Aajkal ye zyada hota hai.
2. Open: right neeche pet par ek cut lagake.

1. Laparoscopic (camera wala) operation

• Patient ko behosh karte hain (general anaesthesia).
• Bladder khali karwate hain ya catheter lagate hain, taaki operation mai chot na lage.
• Antibiotic de dete hain.

• Naabhi (umbilicus) par chhota cut lagate hain.
• Pet mai CO2 gas bharte hain, jisse pet phool jata hai aur andar dekhne ke liye jagah ban jati hai.
• Camera andar daalte hain.
• Do aur chhote cuts lagate hain (left neeche aur pubic area ke upar). Inse instruments jate hain.

• Pehle poora pet check karte hain ki koi aur problem to nahi hai.
• Phir appendix dhoondhte hain. Trick: badi aant (caecum) par 3 lambi patti jaisi cheezein hoti hain, jinhe taenia coli kehte hain. Ye teeno jahan milti hain, wahin appendix ka base hota hai.

• Mesoappendix ek patli jhilli hai jisme appendix ki blood vessels hoti hain.
• Isko pehle kaatte aur seal karte hain, taaki khoon na bahe.

• Appendix ke base ko stapler se ya Endoloop (phanda) se baandh dete hain.
• Phir uske upar se appendix kaat dete hain.

• Appendix ko ek plastic bag mai daalke bahar nikalte hain, taaki infection pet mai na phaile.

• Dekhte hain ki khoon to nahi beh raha.
• Agar pus ya ganda paani ho to pet dhoke saaf karte hain.
• Gas nikalke cuts ko silai karke band kar dete hain.

2. Open operation (seedha cut wala)

• External oblique
• Internal oblique
• Transversus abdominis

Exam ke liye yaad rakhne wali baatein

• Laparoscopic mai dard kam hota hai, wound ka infection kam hota hai aur recovery jaldi hoti hai. Isliye ye zyada pasand kiya jata hai.
• Muscle-splitting ka matlab hai muscles kaatna nahi, sirf alag karna.
• Open mai pehle mesoappendix (blood vessels), phir appendix ka base.
• Appendix ka stump chhota rakho, nahi to baad mai stump appendicitis ho sakta hai.
• Agar operation mai appendix normal dikhe, to baaki cheezein dekho, jaise terminal ileum, ovary aur tube.
• Retrocaecal appendix mai caecum ko free karna padta hai (white line of Toldt kaatke).