Appendicitis surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Surgery is the mainstay of therapy for appendicitis. Either a laparoscopic approach or an open appendicectomy is recommended.

Surgery

Pre-Operative Preparations

• The treatment begins by keeping the patient from eating or drinking anything, even water, in preparation for surgery.
• An intravenous drip is used to hydrate the patient.

Surgical Procedure

• Both the laparoscopic approach or open appendicectomy is associated with low morbidity and mortality.
• If the stomach is empty (no food in the past six hours) general anesthesia is usually used. Otherwise, spinal anesthesia can also be used.
• There are two types of surgeries used to treat appendicitis: open and laparoscopic appendectomies.
• In 1983, when the first described minimally invasive laparoscopic appendectomy was completed, surgical procedures began to shift away from the open appendectomy towards laparoscopic procedures.

Open Appendectomy

• The open appendectomy is the conventional approach for removing the appendix during surgery.
• In open procedures, a 5 cm incision is made in the at the lateral border of the right rectus muscle in the abdomen, and the appendix is surgically removed.

Laparoscopic Surgery

• In the laparoscopic surgery, three small incisions are made in the abdomen with a small camera inserted to visualize the area of interest in the abdomen.
• Surgical tools are fed through trocars to minimize unnecessary surgical incisions in the patient. The appendix is surgically removed and taken out of the body through one of the small incisions.
  • If the findings reveal suppurative appendicitis with complications such as rupture, abscess, adhesions, etc., conversion to an open laparotomy may be necessary.
  • Open laparotomy incisions most often center on the area of maximum tenderness, McBurney's point, in the right lower quadrant of the abdomen.

Comparison of Surgical Treatments

• The open appendectomy is still considered the gold standard in complicated appendicitis because of increased intra-abdominal infectious complications during the post-operative period.

• According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic and open procedures, laparoscopic procedures seem to have various advantages over the open procedure.
• Wound infections were less likely after laparoscopic appendicectomy than after open appendicectomy (odds ratio 0.45; CI 0.35 to 0.58)
  • But the incidence of intraabdominal abscesses was increased (odds ratio 2.48; CI 1.45 to 4.21).
• The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic procedures.
• Pain on day 1 after surgery was reduced after laparoscopic procedures by 9 mm (CI 5 to 13 mm) on a 100 mm visual analogue scale.
• Hospital stay was shortened by 1.1 day (CI 0.6 to 1.5).
• Return to normal activity, work, and sport occurred earlier after laparoscopic procedures than after open procedures.
• While the operation costs of laparoscopic procedures were significantly higher, the costs outside of the hospital were reduced.
• Young female, obese, and employed patients seem to benefit from the laparoscopic procedure more than other groups.
• Advances in modern surgery, anesthesia, antibiotics, and imaging have lead to an improved outcome and a significant reduction in mortality.
• Laparoscopic surgery has lead to a decreased length of hospital stay, reduced risk of wound infection, reduced amount of post-operative pain, and a more rapid return to daily activities for the patient.