Appendictomy

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Appendectomy - Overview

An appendectomy is the surgical removal of the vermiform appendix. It is the definitive treatment for acute appendicitis, one of the most common causes of the acute surgical abdomen worldwide.

Anatomy of the Appendix

The appendix is approximately 9 cm long and 0.6 cm wide, originating from the terminal cecum where the three taenia coli converge. Its blood supply comes from the appendiceal artery, a branch of the ileocolic artery.

While the base always arises from the cecum, the tip position is variable - this is why presentations differ:

Position	Frequency	Clinical sign
Retrocecal	64%	Positive psoas sign
Subcecal	32%	RLQ pain
Pelvic	2%	Positive obturator sign
Preileal	1%	Variable
Postileal	0.5%	Variable

Indications

The primary indication is acute appendicitis, with a lifetime risk of 7-10% and ~400,000 US cases per year (16-40% perforated at presentation). Other indications include:

Interval appendectomy - after initial nonoperative management of a periappendiceal abscess/phlegmon
Incidental appendectomy - selectively considered in patients undergoing chemotherapy, those with Crohn's disease (if cecal base is uninflamed), or during cytoreductive ovarian surgery (though not routinely advocated due to adhesion risk)
Intraoperative finding of appendiceal pathology (Crohn's ileitis, Meckel's diverticulitis mimicking appendicitis)

Procedure Types

1. Laparoscopic Appendectomy (preferred)

The standard of care for uncomplicated appendicitis in both adults and children. Key steps:

Position: Supine, left arm tucked, consider Foley catheter
Access: Umbilical port via Veress needle (closed) or Hasson technique (open), insufflated to 12-15 mmHg CO₂
Port placement: Umbilical camera port + working ports in LLQ/RLQ (configuration varies by patient)
Steps: Four-quadrant exploration → Trendelenburg right-side-up → cecum identified by taenia coli → mesoappendix divided with a linear stapler (white load) or electrosurgical device (LigaSure) → appendix transected with blue load stapler or Endoloop → specimen placed in retrieval bag → wound closure
For a retrocecal appendix, the white line of Toldt must be divided to mobilize the cecum

Advantages: Lower wound infection rates, shorter hospital stay, faster return to work, better outcomes in children and obese patients.

2. Open Appendectomy

Still essential to know - used when laparoscopy is unavailable, contraindicated, or conversion is needed.

Incision: Oblique (muscle-splitting) incision at McBurney's point (one-third of the distance from the right ASIS to the umbilicus), within a skin crease
Layers: External oblique split along fiber direction → internal oblique bluntly spread → transversus abdominis split → peritoneum incised
Technique: Cecum elevated → appendix identified at taenia convergence → mesoappendix divided (stapler or Kelly clamps with 3-0 silk ties) → base crushed, ligated with 0 chromic, divided → stump cauterized or invaginated with purse-string/Z-stitch
Closure: Layers closed with absorbable suture; skin may be left open or loosely approximated in perforation cases

3. Interval Appendectomy

Performed 6-8 weeks after successful nonoperative management of a periappendiceal abscess or phlegmon. The rationale is to allow inflammation to resolve before operating in a technically hostile field. Its necessity is debated - recurrence rates after successful nonoperative management are ~20% over 5 years, and many patients never need surgery.

4. Single-Incision Laparoscopic Appendectomy (SILA)

A newer approach using a single umbilical port. A 2026 meta-analysis (PMID 40981423) found comparable operation time and postoperative pain versus standard three-port laparoscopy, with cosmetic advantage.

Management by Disease Stage

Stage	Management
Uncomplicated appendicitis	Laparoscopic appendectomy (preferred); antibiotics-only is an acceptable alternative in select patients
Perforated appendicitis with diffuse peritonitis	Resuscitate → urgent appendectomy (laparoscopic if feasible)
Periappendiceal abscess/phlegmon	IV antibiotics + percutaneous drainage (if drainable) → interval appendectomy

For perforated cases, IV antibiotics such as piperacillin-tazobactam or ceftriaxone + metronidazole are started immediately. Postoperative antibiotics continue for at least 3-5 days. A 2025 Cochrane review (PMID 40214287) examined the role of abdominal drainage after appendectomy for complicated appendicitis.

Nonoperative Management (Current Controversy)

Recent evidence supports antibiotics alone as a viable option for uncomplicated, non-perforated appendicitis in selected adult patients. The most common regimen is IV ertapenem or ceftriaxone + metronidazole, then oral amoxicillin-clavulanate. However, ~20-30% of patients treated nonoperatively will eventually require appendectomy, and appendicitis caused by an appendicolith carries higher failure rates.

Special Populations

Children: Infants have the highest perforation rates (51-100%). The Pediatric Appendicitis Score (PAS ≥7 = high probability) guides workup. Laparoscopic appendectomy is preferred; APSA guidelines recommend 3-5 days of postoperative antibiotics after perforation.
Pregnant patients: Appendicitis is the most common non-obstetric surgical emergency in pregnancy. Laparoscopy is safe in all trimesters with appropriate port adjustments.

Intraoperative Findings That Mimic Appendicitis

Finding	Action
Ovarian torsion	Detorsion + oophoropexy
Crohn's terminal ileitis	Appendectomy if cecal base is uninflamed
Meckel's diverticulitis	Segmental small bowel resection + primary anastomosis
Appendiceal mass	Laparoscopic appendectomy/ileocecectomy in a retrieval bag (no spillage)

Sources: Current Surgical Therapy 14e (Mahdi & Pegoli); Schwartz's Principles of Surgery 11e - Current Surgical Therapy, p. 324-332

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