Appendectomy, the surgical removal of the appendix, is the standard treatment for acute appendicitis. The procedure can be performed via open or laparoscopic techniques, with the choice depending on the patient’s condition, surgeon expertise, and available resources. Below is a detailed overview of both approaches, including historical context, procedural steps, and special considerations.
Historical Context
The first successful appendectomy was performed by Claudius Amyand in 1736, when he removed an inflamed appendix from a hernial sac. Lawson Tait performed the first deliberate appendectomy for acute appendicitis in 1880, though the case was not reported until 1890. Thomas Morton was the first to diagnose appendicitis, drain an abscess, and remove the appendix with a successful recovery, publishing his findings in 1887.
Laparoscopic Appendectomy
Laparoscopic appendectomy is the preferred approach in most cases due to its minimally invasive nature, faster recovery, and lower complication rates. It is performed under general anesthesia with the patient in a supine position.
- Port Placement:
- A 10-mm port is placed at the umbilicus for the camera.
- Two 5-mm ports are placed in the left lower quadrant and suprapubic midline for instruments.
- Procedure:
- The abdomen is insufflated with carbon dioxide to create a pneumoperitoneum.
- The appendix is identified by tracing the taeniae coli of the cecum.
- Adhesions to the appendix are divided, and the appendix is elevated.
- The mesoappendix is dissected using an energy device, stapler, or cautery, and the appendicular artery is ligated.
- The base of the appendix is stapled or ligated, and the appendix is amputated.
- The appendix is removed through the largest port, often using a containment bag to prevent contamination.
- The surgical site is irrigated if necessary, and drains may be placed in cases of significant perforation or purulence.
- The pneumoperitoneum is reduced, and port sites are closed with absorbable sutures.
Open Appendectomy
Open appendectomy is typically reserved for complicated cases (e.g., perforation, abscess) or when laparoscopic equipment or expertise is unavailable.
- Incision:
- A gridiron incision is made at right angles to a line joining the anterior superior iliac spine and the umbilicus, centered on McBurney’s point.
- Alternatively, a transverse (Lanz) incision may be used, placed 2 cm below the umbilicus and centered on the mid-clavicular–mid-inguinal line.
- Procedure:
- The external and internal oblique muscles and transversus abdominis are split in the direction of their fibers.
- The cecum is identified by tracing the taeniae coli, and the appendix is delivered into the wound.
- The mesoappendix is divided between clamps and ligated.
- The base of the appendix is crushed, ligated, and amputated.
- The appendiceal stump may be inverted using a purse-string or “Z” suture, though this step is considered optional by many surgeons.
- The abdomen is closed in layers, with the skin left open in cases of significant contamination.
Special Circumstances
- Retrocecal Appendix:
- If the appendix is retrocecal and adherent, a retrograde appendectomy may be performed. The base of the appendix is divided first, and the mesoappendix is ligated before delivering the appendix.
- Gangrenous or Perforated Appendix:
- In cases of gangrenous or perforated appendicitis, the base of the appendix may be too inflamed to ligate safely. Instead, the appendix is amputated flush with the cecal wall, and the stump is closed with interrupted sutures.
- Appendiceal Abscess:
- If an abscess is encountered and the appendix cannot be safely removed, percutaneous drainage and intravenous antibiotics are preferred. Rarely, a caecectomy or partial right hemicolectomy may be required.
- Normal Appendix Found:
- If a normal appendix is found during surgery, other causes of abdominal pain (e.g., terminal ileitis, Meckel’s diverticulitis, or gynecological conditions) should be considered. The appendix is usually removed to avoid future diagnostic confusion.
- Appendiceal Tumor:
- Small tumors (<2 cm) can be treated with appendectomy, while larger tumors may require a right hemicolectomy.
- Crohn’s Disease:
- If Crohn’s disease is discovered during surgery, appendectomy can be performed if the cecal wall is healthy. However, if the appendix is involved, a conservative approach with corticosteroids and antibiotics may be warranted.
Postoperative Considerations
- Complications:
- Potential complications include wound infection, intra-abdominal abscess, and postoperative ileus.
- Recovery:
- Patients undergoing laparoscopic appendectomy typically experience faster recovery and shorter hospital stays compared to open appendectomy.
- Follow-Up:
- Patients with complicated appendicitis (e.g., perforation or abscess) may require prolonged antibiotic therapy and close follow-up to monitor for complications.
Summary
Appendectomy remains the gold standard for treating acute appendicitis, with laparoscopic appendectomy being the preferred approach due to its minimally invasive nature and faster recovery times. Open appendectomy is reserved for complicated cases or when laparoscopy is not feasible. Special techniques are employed for retrocecal, gangrenous, or perforated appendices, and careful consideration is given to incidental findings such as tumors or Crohn’s disease. Advances in surgical techniques and imaging have significantly improved outcomes, making appendectomy one of the most commonly performed and successful emergency surgeries.