Open appendectomy

A basic description of the appendectomy procedure with a little background information such as anatomy.

1. Open appendectomy Dr Eretare C. Odjugo

2. Outline Introduction Relevant anatomy Aetiopathogenesis Epidemiology Peri-procedural care Anaesthesia and positioning Technique (Steps) Antegrade appendectomy Retrograde appendectomy

3. Outline Post operative care Follow-up Conclusion References

4. introduction Appendectomy also called appendicectomy is a common surgical procedure. Acute appendicitis is the most common indication for an appendectomy. An appendectomy is the surgical removal of the appendix. Appendectomy can be either open or laparoscopic

5. Relevant anatomy The vermiform appendix is a vestigial organ Usually located at the right iliac fossa Variable location Abnormalities though rare exist and must be considered if the appendix is difficult to locate

6. Relevant anatomy

7. aetiopathogenesis The most common etiological factor is obstruction of the lumen that leads to increased intra luminal pressure. This presses upon the blood vessels producing ischemic injury which in turn favours the bacterial proliferation and hence acute appendicitis Obstructive causes: Faecolith Calculi Foreign body Tumor Worms Diffuse lymphoid hyperplasia Non obstructive causes: Haematogenous spread of generalized infection Vascular occlusion Inappropriate diet lacking roughage

8. indication Acute appendicitis Recurrent appendicitis Chronic appendicitis As Interval appendectomy after drainage of abcess or in appendicial mass Carcinoid tumour : at the tip. <2cm Mucocele of the appendix

9. Pre-procedural care Investigations Full blood count Serum electrolyte, urea and creatinine Retroviral screening Chest x-ray Electrocardiography CT scan

10. Pre-procedural care Fluid resuscitation and correction of any electrolyte deficits Antibiotic cover Counselling and consent Surgeons Anaesthesiologist Nasogastric Intubation Urethral catheterisation

11. anaesthesia General anaesthesia GA + endotracheal intubation Inhalational Rarely Total intravenous anaesthesia Spinal Epidural Local or regional in very sick patients

12. Preparation After the patient has been anaesthesized , the surgeon palpates the abdomen again to identify the presence of an appendix mass. This is more reliable as the sedated patient has complete muscle relaxation The surgical team the scrubs, gowns and masks. The skin prep is performed using an anti-septic solution (Betadine, Hibitane , Chlorhexidene and Centrimide ) with a swab on stick from the nipples to the mid thigh. After the initial sponge appears clean, the area is dried off and then cleaned with surgical alcohol. Square draping is then done exposing the right iliac fossa

13. Positioning Patient Supine and in the anatomical position Surgical team Surgeon at the right hand side of the patient Assistant opposite the patient Scrub nurse faces the surgeon and to the left of the assistant Anaesthetist at the head of the patient

14. Skin incisions There are various skin incisions McBurney’s (Gridiron): An incision made perpendicular to an imaginary line joining the umbilicus to the anterior superior iliac spine at the junction of the middle third and lateral third. Lanz : A skin crease incision 2cm blow the level of the umbilicus centred on the mid-clavicular line. Rocky Davis Incision: This is a transverse incision centred on McBurney’s point. Midline infra-umbilical. The skin incisions may also be made over the area of maximal tenderness or over a mass palpated after initiation of anaesthesia

15. Steps Skin incision is made with the belly of a Size 10, 20 or 23 blade. The Campers and Scarpas fascia are divided with the aid of electrocautery between two haemostats holding the inferior surface of the skin in the direction of the skin incision exposing the external oblique. The small haemostats are reapplied to the external oblique forming a tent. A nick is made between the haemostats using a Metzenbaum scissors along the direction of the fibres of the external oblique and lengthened in both directions. The assistant now retracts the external oblique exposing the internal oblique. The internal oblique and transversus abdominis are split in the direction of their fibres by blunt dissection and then retracted to the deep surface of the transversus abdominis.

16. steps Rutherford Morrison extension is a lateral extension of the incision in the internal oblique and transversus abdominis when more access is required Fowler-Weir extension: This is a medial extension of the incision on the internal oblique and transversus abdominis to the semilunar line. The transversalis fascia and the peritoneum are usually closely applied and are incised as one layer. The surgeon grasps the peritoneum with a haemostat, a second haemostat is applied and the first reapplied after carefully verifying that intra-abdominal viscera is not inadvertently grasped, A small incision is made on the peritoneum with a Metzenbaum.

17. Steps Aspirate taken for microscopy, culture and sensitivity and the secretions suctioned Edges of the peritoneum grasped with artery forceps and extended carefully The Langenbeck retractor is placed within the peritoneal cavity to elevate the anterior abdominal wall. The table may be given a slight left tilt to displace the small bowel from the operative field. The caecum is delivered into the wound and the taenia coli is followed to identify the appendix

18. Steps (Antegrade) Once the appendix is delivered, it is held in a Babcock's forceps, while the mesentry is viewed against light to identify the anatomy of the appendicular vessels. A small window in the mesoappendix near the base is created this allow application of artery forceps the clamped and ligated with 2-0 suture and divided However, it is advisable to divide the mesentry in separate bites if the artery has divided early into individual branches.

19. Steps (antegrade) The base of the appendix is then gently crushed twice with a right angled haemostat. This is to reduce swelling of the tissue to be ligated and reduce likelihood of suture cutting through the edematous tissue. The base is then doubly ligated with 2-0 absorbable sutures. A haemostat is placed on the ligatures. A right angle haemostat is placed on the appendix approximately 1 cm distal to the ligature, and the appendix is transected with a scalpel (between the suture and the forceps). The specimen and the contaminated instruments are removed from the operative field.

20. Steps (retrograde) The retrograde technique is used under the following circumstances: The appendix is very inflamed, and manipulation may cause perforation The appendix is in a retroperitoneal position The appendix is surrounded by inflammatory tissue, omentum , or both, which makes identification difficult In the retrograde technique, the base of the appendix is found first, exposed, ligated, and transected . Attention is then turned to the mesoappendix, which is ligated last and then transected . The appendix and other contaminated instruments are now removed from the operating field..

21. Steps Using the haemostat at the stump ligature, it is inspected for bleeding or leakage. The stump mat then be cleaned with gauze soaked in Betadine or methylated spirit. It may also be cauterized. Though no longer popular, the stump may be inverted with a purse string made at the base of the caecum Purse stringing is not performed if the caecum is inflamed.

22. Steps (closure) After the appendectomy is completed, the wound is copiously irrigated with normal saline The peritoneum is grasped with two straight clamps, and closed it with a continuous 3-0 polyglactin stitch. Approximate all split muscle layers, using 3-0 polyglactin at each level. Close the external oblique aponeurosis with a continuous 2-0 polyglactin stitch. Approximate the Scarpa fascia with 3-0 polyglactin. A narrow gauge absorbable subcuticular interrupted sutures for skin closure.

23. Steps (closure) If wound contamination is a concern in complicated appendicitis, the wound may be closed at the musculofascial level, left open and packed for 3-5 days, and closed secondarily. Conversely, a drain may be left in place if there was copious peritoneal abscess that had been suctioned off. Leaving a drain though is not commonly practiced.

24. Post operative care In uncomplicated cases Nil per os for about 12 hours then fluid diet. Semi solid diet is commenced at 24 hours Antibiotics are not always indicated In complicated cases Nil per os until bowel sounds return and/or bowel opening is attained IV antibiotics are given until fever abates Bowel rest through nasogastric intubation and decompression

25. complications Wound infection: Most common, 5-10% of patient, seen on 4-5th day Intra- abdominal abscess -8% Haemorrhage Ileus Generalised peritonitis Respiratory infections UTI Venous thrombosis and embolism Faecal fistula Adhesive intestinal obstruction

26. References Farquharson M, Hollingshead J, Moran B. Farquharsons Textbook of operative General Surgery. 10 th edition. Bailey & Love’s Short Practice of Surgery. 25 th edition. Zollinger’s Atlas of Surgical Operations Bruncardi FC et al: Schwartz Principles of surgery. 10 th edition Fischer’s Mastery of Surgery https://emedicine.medscape.com/article/1582203-technique accessed 12/01/19 https://www.slideshare.net/bashirbnyunus/appendectomy-46728589 accessed 12/01/19

27. references https://www.slideshare.net/levouge777/appendectomy-presentation accessed 12/01/19 Lawrence PF. Essentials of General Surgery. 5 th edition.

28. Thank you