Treatment of acute appendicitis

Acute appendicitis is treated by surgery to remove the appendix (appendectomy). The operation may be performed through a standard small incision in the right lower part of the abdomen, or it may be performed using a laparoscopy, which requires three to four smaller incisions. In patients with diffuse or general peritonitis middle line laparotomy is preferred.

Do not administer analgesics and antipyretics to patients with suspected appendicitis who have not been evaluated by the surgeon.

Preparation of patients undergoing appendectomy is similar for both open and laparoscopic procedures. Perform complete routine laboratory and radiologic studies before intervention. Venous access must be obtained in all patients diagnosed with appendicitis. Venous access allows administration of isotonic fluids and broad-spectrum intravenous antibiotics prior to the operation. Prior to the start of the surgical procedure, the anaesthesiologist performs endotracheal intubation to administer volatile anaesthetics and to assist respiration. The abdomen is washed, antiseptically prepared, and then draped.

Open appendectomy

Surgical incisions for open appendectomy are:

– line oblique incision over the McBurney point (i.e., two thirds of the way between the umbilicus and the anterior superior iliac spine);

– vertical incisions (i.e., the Battle pararectal) are rarely performed because of the tendency for herniation;

– middle line laparotomy.

After cutting of peritoneum abdominal cavity is opened. Note the character of any peritoneal fluid to help confirm the diagnosis and then suction it from the field. If it is purulent, collect and culture the fluid.

The convergence of taenia coli is detected at the base of the appendix, beneath the Bauhin valve (i.e., the ileocaecal valve), and the appendix is then viewed. If the appendix is hidden, it can be detected medially by retracting the caecum and laterally by extending the peritoneal incision.

After exteriorization of the appendix, the mesoappendix is held between clamps, divided, and ligated. The appendix is clamped proximally about 5 mm above the caecum to avoid contamination of the peritoneal cavity and is cut above the clamp by a scalpel. The appendix must be ligated to prevent bleeding and leakage from the lumen. The appendix may be inverted into the caecum with the use of a purse-string suture or z-stitch.

The caecum is placed back into the abdomen. The abdomen is irrigated. When evidence of free perforation exists, peritoneal lavage with several liters of warm saline is recommended. After the lavage, the irrigation fluid must be completely aspirated to avoid the possibility of spreading infection to other regions of the peritoneal cavity. The use of a drain is not commonly required in patients with acute appendicitis, but obvious abscess with gross contamination requires drainage.

The wound closure begins by closing the peritoneum with a running suture. Then, the fibers of the muscular and fascial layers are reapproximated and closed with a continuous or interrupted absorbable suture. Lastly, the skin is closed with subcutaneous sutures or staples. In cases of perforated appendicitis, some surgeons leave the wound open, allowing for secondary closure or a delayed primary closure until the fourth or fifth day after operation. Other surgeons prefer immediate closure in these cases.

Laparoscopic appendectomy

According to the preferences of the surgeon, a short supraumbilical incision is made to allow the placement of a Hasson cannula or Veress needle. Pneumoperitoneum (10 – 14 mm Hg) is established and maintained by insufflating carbon dioxide. Through the access, a laparoscope is inserted to view the entire abdomen cavity. A 10-mm port is inserted through supraumbilical incision for camera. Another two 5-mm ports are placed in the right and left inguinal regions for manipulations. The appendix is grasped and retracted upward to expose the mesoappendix. The mesoappendix is divided, ligated or coagulated. The appendix may be transected with a linear endostapler, or, alternately, the base of the appendix may be suture ligated in a usual manner to that in an open procedure. The appendix is removed using a laparoscopic pouch to prevent wound contamination.

Postoperative treatment

Administer intravenous antibiotics postoperatively. The length of administration is based on the operative findings and the recovery of the patient. In complicated appendicitis, antibiotics may be required for many days or weeks.

Antiemetic’s and analgesics are administered to patients experiencing nausea and wound pain. The patient is encouraged to ambulate early.

In patients with complicated appendicitis, a clear liquid diet may be started when bowel function returns.

Follow-up care

After hospital discharge, patients must have a light diet and limit their physical activity for a period of 2–6 weeks based on the surgical approach (i.e., laparoscopic or open appendectomy). The patient should be evaluated by the surgeon in the clinic to determine improvement and to detect any possible complications:

– wound infection especially in patients with gangrenous or perforated appendicitis;ileus;

– caecal fistulas;

– pelvic or abdominal abscess.