Overview of Appendectomy
An appendectomy, or surgery to remove the appendix, is one of the most typical operations performed today. It’s usually needed when someone has a condition known as acute appendicitis, which is an infection of the appendix. You have a 9% to 10% chance of experiencing acute appendicitis in your lifetime. It’s the most common in individuals between the ages of 10 and 20, but it can occur at any age.
Appendicitis has a notable place in American medical history, often being referred to as the first American surgical disease. A doctor named Charles McBurney published a significant report about how to surgically treat appendicitis in 1895. He talked about the potential dangers of not properly draining an infected appendix, the downsides to the traditional way of opening up the abdomen (known as a midline laparotomy), and a procedure where a needle is used to explore the area. He also introduced a new way to approach the surgery by making a series of cuts through the different layers of muscle in the abdomen, instead of the traditional midline laparotomy.
The appendectomy was the first surgery of its kind, designed to remove an infection from the body. Since it was first described over one hundred years ago, removing the appendix is still considered the best treatment for appendicitis. Today, the infected appendix can be removed with either an open surgery, where a large cut is made in the abdomen, or a laparoscopic appendectomy, which is a less invasive method where smaller cuts are made and a special camera is used. This laparoscopic method was first described by a doctor named Semm in 1983.
Even though there have been significant changes in how we manage appendicitis, such as using antibiotics, surgery is still the primary treatment option. In a large study of patients with appendicitis, it was found that while treating with antibiotics might have similar short-term results as surgery, one in four of the people treated with antibiotics still needed to have their appendix removed within a year.
Anatomy and Physiology of Appendectomy
The appendix is a small, tube-shaped part that hangs off the large intestine. It’s usually found right where the small and large intestines meet. Even though the appendix doesn’t seem to play a major role in the body, it’s considered a useful marker during surgery.
It’s positioned in front of the lower back nerves and a muscle called the iliopsoas. It’s at the back of a fatty tissue called the omentum. The appendix is linked to the lowest part of the small intestine using a triangular flap of tissue. This link is shorter than the appendix itself, giving the appendix a curled and twisted look.
Typically, the appendix is located in the lower right area of your belly. But sometimes, it could be positioned in different parts or orientations of your body such as the upper left part, the center, or even near your pelvic bone.
The flow of blood to your appendix happens through a small artery that comes from a larger one in about 35% of people. But it can sometimes originate from other nearby arteries.
Why do People Need Appendectomy
When a doctor suspects that a patient might have acute appendicitis, they will look at a few different things to verify this. They will consider the individual’s medical history, do a physical examination, have a look at laboratory test results, and analyze any relevant images from scans. There are several methods developed to help doctors make quick decisions and identify which patients might need an appendectomy or removal of the appendix. One of these methods is the Alvarado scoring system, which helps to diagnose acute appendicitis and can help to avoid unnecessary surgery. However, it’s not always accurate and shouldn’t be used on its own. A score of 7 or higher on this system suggests a high chance of acute appendicitis, ranging from a 78% to 96% probability.
Surgery to remove the appendix is required in several situations. Let’s discuss a few of the common situations briefly.
Uncomplicated Appendicitis
Surgery is recommended for patients showing signs of acute uncomplicated appendicitis. Here, the appendix is inflamed but there are no signs of tissue death or rupture. In most cases, the appendix is not ruptured at the time the patient is diagnosed.
Medical experts have extensively studied the effectiveness of using antibiotics as the primary treatment for acute uncomplicated appendicitis, but results are mixed. Some studies found that the risk of infection after intervention was higher for patients who received antibiotic treatment. However, others found that antibiotic treatment was feasible despite a recurring risk of appendicitis.
While some studies, like the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial, suggest managing acute appendicitis with antibiotics alone, this approach should be closely monitored. There are several unclear outcomes, such as possible missed cancers, repeat appendicitis, and long-term effectiveness.
Scientific study from around the world – the Prospective Observational Study on Acute Appendicitis Worldwide – confirms that surgery is still the most effective treatment for appendicitis. Despite the possibility of using antibiotics, appendectomy is the standard treatment protocol for acute uncomplicated appendicitis.
Complicated Appendicitis
Complicated appendicitis is recognized by the existence of an abscess or inflammation around the appendix. This can be treated by two methods, either through immediate surgery or through initial conservative management followed by the surgical procedure.
There’s no clear judgement as to whether immediately removing the appendix or delaying the surgery is a better approach to handling complicated appendicitis. The evidence available suggests that immediate surgeries might cause longer hospital stays and more down-time; the strength of this evidence is considered very low.
For patients with significant inflammation, abscesses, or prolonged symptoms, immediate surgery should be avoided as this might increase complications. In these cases, doctors usually follow a standard management protocol, which includes giving the patient antibiotics through an IV drip, stabilizing the patient, and for those with continued infection, performing a procedure that allows for drainage of the infection. This approach has a success rate of 79%, particularly for those with lower-grade abscesses or those who receive drainage guided by CT scans. If these methods fail or there is a rupture inside the body cavity, immediate surgery is chosen.
Emergency surgery might be required in cases like a ruptured appendix causing severe infection or instability, failed initial management with antibiotics or drainage, or if an abscess in the appendix is either too small or too large and inaccessible for removal through drainage.
For decision-making purposes, appendicitis is often divided into categories: non-ruptured appendix with gangrene, ruptured appendix with localized contamination, ruptured appendix with inflammation or abscess, and ruptured appendix with widespread infection in the body cavity.
Surgery via a laparoscope is indicated in non-ruptured appendicitis with gangrene and ruptured appendicitis with localized contamination. If possible, this type of surgery is also suitable for those with a ruptured appendix with widespread infection in the body cavity. Initial treatment without surgery is indicated for patients with a ruptured appendix with regional inflammation or abscess.
Acute Appendicitis in Patients with Crohn Disease
Patients diagnosed with Crohn’s disease may end up developing entero-enteric fistulas, connections between different parts of the intestines formed abnormally. However, only a small percentage of all patients diagnosed with acute appendicitis are further diagnosed with Crohn’s disease. Therefore, in cases where a patient has a confirmed diagnosis of Crohn’s disease without any complication in the cecum or the beginning of the large intestine and shows signs of acute appendicitis, surgery to remove the appendix is recommended.
Appendiceal Neoplasms
Around 1% of all removed appendixes contain what are known as appendiceal neoplasms, or tumors in the appendix. However, the actual incidence of these tumors is still not clear.
These tumors can be complex to classify, but they are typically divided into four different subtypes: colonic-type adenocarcinoma, mucinous neoplasm, goblet cell carcinoma, and neuroendocrine neoplasms.
It is worth noting that any type of tumor in the appendix can appear as acute appendicitis, which could make pre-surgery diagnosis not very certain. Therefore, it is only after the surgical removal of the appendix that a definitive diagnosis based on the analysis of the tissue can be made and further treatment decided. The decision for surgery, in such cases, is made on the basis of physical examination, laboratory testing, and imaging results presented during the initial diagnosis.
When a Person Should Avoid Appendectomy
An appendectomy, which is surgery to remove the appendix, can’t be done for everyone. Here are some reasons why someone might not be able to have this surgery:
- If someone is not strong enough or too unwell to be given general anesthesia, which is the medication they use to put you to sleep during an operation, they may not be able to have an appendectomy.
- Laparoscopic surgery, which is performed using small incisions and filling the abdomen with gas for better visibility, might not be tolerated by some due to underlying health issues.
- For those who have a blood clotting disorder, known as uncorrectable coagulopathy, that makes it difficult to stop bleeding, surgery may pose too much risk.
On the other hand, an appendectomy done incidentally (or without an emergency) may not be suitable in certain situations:
- Patients with unstable hemodynamics, which means their blood pressure, pulse, and other vital signs are not stable.
- Patients who have been diagnosed with Crohn disease, an inflammatory bowel disease that affects parts of the digestive system.
- Patients who are set for a radiation treatment plan, a common therapy for cancer, should also not have an appendectomy.
Equipment used for Appendectomy
When a doctor carries out an open appendectomy, which is surgery to remove an inflamed appendix, they use various tools. These can include:
- A scalpel, which is a very sharp knife used in surgeries, and forceps which are like tweezers used to pick up or hold tissue during the operation.
- Non-damaging graspers, tools used to gently hold organs or tissues, and electrocautery, a device that uses heat to stop bleeding or cut tissue.
- A type of stitch that’ll dissolve in the body over time (absorbable sutures) and needle drivers, tools to handle those stitches.
For a laparoscopic appendectomy, which is the same operation but done with a camera and small incisions, the doctor typically uses:
- A monitor to see what’s happening inside the patient’s body, projected from a laparoscope, which is a thin tube with a camera on the end that’s inserted into the abdomen through a small cut.
- A Veress needle or Hasson trocar, these instruments are used to create a path for the laparoscope and other tools to enter the body. Also, a source of carbon dioxide gas and tubing are used to gently inflate the abdomen, making it easier for the doctor to see and work.
- The standard tray of laparoscopic instruments and a small bag (endoscopic retrieval bag) for collecting and removing the appendix.
- Trocars, which are devices inserted into the body as a pathway for surgical instruments. The doctor would use two smaller trocars (5 mm) for working and one larger one (10 to 12 mm) for the laparoscope.
- The same scalpel, needle driver, forceps, and absorbable stitches as in the open procedure.
- An open major abdominal tray, which includes needed instruments if the doctor decides mid-operation to switch to an open appendectomy (using larger incisions).
Who is needed to perform Appendectomy?
There are two types of procedures used by doctors to perform surgeries; open and laparoscopic surgeries.
For either kind of surgery, several trained medical professionals are involved to make sure everything goes as planned.
The main person on this team is the operating surgeon. This is a doctor who has been specially educated and trained to do surgeries. Surgeons are experts at safely removing or fixing parts of the body that are causing problems.
Helping the surgeon is a surgical first assistant. Like the name suggests, this person assists the surgeon throughout the procedure. They’re right there helping out with important tasks during the operation.
A surgical technician or operating room nurse also plays an important role. They prepare the operating room and help the surgeon and first assistant during the surgery.
The Circulator or operating room nurse is the one who doesn’t directly take part in the surgery but manages the broader issues in the operating room. They make sure conditions in the room are safe and everything is in order for the surgery.
Finally, there are the general anesthesia personnel. They’re responsible for putting you to sleep during the surgery. They make sure you don’t feel pain or discomfort during the procedure.
Each of these professionals plays a key role in ensuring your surgery goes well and that you’re safe before, during and after the procedure.
Preparing for Appendectomy
Before undergoing an appendix surgery, patients need to take antibiotics. These antibiotics keep harmful bacteria at bay, ensuring you don’t get an infection after the surgery. For the best results, these antibiotics should be taken within the hour leading up to the surgery.
Antibiotics play a crucial role in preventing you from developing infections at the operation site or ‘pockets’ of pus inside your abdomen. The antibiotics tackle a wide variety of bacteria, including some difficult to treat ones. However, medical tests may later be done to see how sensitive these bacteria are to different antibiotics. Based on these test results, your doctor might adjust your antibiotics.
There are specific guidelines for antibiotics before surgery developed by the Surgical Care Improvement Project. If you don’t have a known allergy to certain classes of antibiotics like penicillins or cephalosporins, you could have a single dose of either cefotetan or cefoxitin, or a combination of metronidazole and a dosage of cefazolin adjusted for your weight. However, if you do have an allergy, the recommendation changes. In this case, you may be given a combined dose of clindamycin and either levofloxacin, ciprofloxacin, gentamycin, or aztreonam.
How is Appendectomy performed
To explain the procedure in simpler terms, let’s break it down:
For the laparoscopic appendectomy (a method of removing your appendix using a camera and specialized tools), you will lie on your back and your left arm will be tucked by your side. After this position is set, your body will be slightly tilted with your right side up to ensure the doctor can easily see and reach the appendix.
The area we are working on will be cleaned and will stretch from just above your ribcage to your pubic bone, and across your stomach from the right to the left side. It’s a wide and sterile area, made in case we need to switch to an open procedure.
We get access to your abdomen through a technique that involves making a small incision near your belly button. To help visualize these areas and conduct the procedure, we make minor incisions or ‘ports’ above your pubic bone and in your lower left side. These ports will be used for the camera and the tools needed for the operation.
We then examine your abdomen thoroughly. The small bowels and a part of the fat in your stomach are moved upward to access lower parts of your belly. We then identify the appendix, which if it’s located behind the cecum (a part of large intestine), we may need to slightly move your cecum and ascending colon. After correctly adjusting your position, the tools help to expose the cecum ensuring optimal visibility.
Once the appendix is seen clearly, careful judgment is used considering the state of your appendix. We ‘dissect’ it from the base to the tip using a surgical method that avoids damage to the nearby bowels. If the appendix is inflamed and adhesive, blunt or sharp separation might be necessary.
After the appendix is completely visible, it is lifted off the cecum in the front and a small ‘window’ is created at its base to access it. The cutting of the appendix is performed using a surgical stapler which seals blood vessels. It is then placed in a retrieval bag and taken out through the belly button. After making sure the area is stable and not bleeding, your bowels and the fatty tissue are returned to their original position.
In case of an open appendectomy (a conventional method to remove your appendix where a larger incision is made), the same cleaning and preparation procedure is followed. We will make an incision either obliquely across or vertically down your right lower abdomen. We then separate the muscle layers and reach the peritoneum (a membrane that lines your abdominal cavity). We then inspect the cecum, and after identifying the appendix, cut it at the base and seal the blood vessels with sutures. The stump of the appendix is then closed off and the incision site is checked for any bleeding before sewing it closed.
In both these procedures, our main aim is to safely remove your appendix causing minimum discomfort and ensuring a speedy recovery for you.
Possible Complications of Appendectomy
After an appendectomy, which is the removal of the appendix, some people might experience problems. The most common issue is an infection at the surgical site. This could be an infection of the wound itself or an infection inside the abdomen. It’s quite rare in cases when the appendix was removed without any complications. But when the appendix has burst, which we call a perforated appendix, up to 10% of patients might get this kind of infection.
There are two kinds of wound infections to watch out for – superficial and deep. A superficial infection happens within a month of the operation and affects the skin and the layer of tissue beneath it. To check for this, doctors study your surgical history and conduct a physical examination where they will look for pain, swelling and redness around the cut. Other signs like pus-drainage from the wound, a positive wound culture, or having to re-open the surgical cut, support the diagnosis of a superficial wound infection.
Deep wound infections show up within one to three months after the surgery. These can involve not just the skin and underlying tissues, but also the muscles and the tissue deep underneath your skin. Similar to a superficial infection, a detailed past surgical history and a physical exam will be performed. You might have a deep wound infection if you have pain and tenderness around the wound, and overall symptoms like a fever. If there is pus-drainage from the wound or wound dehiscence (a fancy term for the surgical cut re-opening), and a positive wound test, this helps confirm a deep infection.
To lower your risk of getting these infections after surgery, doctors usually give antibiotics before the surgery, clean the surgical area thoroughly, use specific tools during surgery, and clean inside your abdomen. The order and timing of closing your surgical cut doesn’t really matter when it comes to infection rates. A laparoscopic appendectomy, which is a surgery method using small cuts and a camera, reduces the risk of wound infection but can increase the chances of getting an infection inside your abdomen and pelvis.
About 9.4% of people who had a complicated appendectomy might develop a pelvic abscess, a pocket of pus in the pelvic area, after their surgery. Doctors recommend several measures to reduce this, including cleaning inside your abdomen during the surgery. However, no single method has shown to be more effective than the others.
A rare issue called stump appendicitis can happen when not enough of the appendix is removed and a long “stump” remains in the body. This is most common in cases of a burst appendix. Removing enough of the appendix so that less than 5 mm is left behind can help prevent this.
On the whole, the risk of death due to an appendectomy is quite low. It’s considered a generally safe surgery. However, death rates can change based on where you live, with developed countries having a lower rate (0.09% to 0.24%) compared to developing countries (1% to 4%).
What Else Should I Know About Appendectomy?
Your appendix could rupture or “perforate” within 36 hours from when it starts to get inflamed or swollen, typically known as appendicitis. This risk increases by 5% every 12 hours. That’s why it’s so vital to get a speedy diagnosis and removal (appendectomy) of your appendix if you have appendicitis.
If you have an appendectomy due to appendicitis (that wasn’t complicated or perforated), it’s important to follow a diet of clear liquids, before gradually going back to your usual diet after the surgery. Usually, you won’t need antibiotics after the surgery. Most people are ready to leave the hospital one to two days after their surgery. It’s also possible that you could leave the hospital the same day you have your surgery if you had it done laparoscopically – a type of surgery that uses small cuts instead of one large one.
Now, if your appendicitis was complicated, meaning if your appendix ruptured or there were other complications, you would need to stay in the hospital for around 5 to 7 days after your appendectomy. This period allows you to fully handle a regular diet again, which is a good measure of your recovery. Usually, you will also take antibiotics for 3 to 5 days after your operation.
Laparoscopic appendectomy is considered better than open appendectomy (which involves a larger incision), as it often results in fewer infections and a shorter hospital stay. Converting a laparoscopic procedure to an open one depends on several factors, like the surgeon’s judgement and skills, equipment availability, and your fitness for the surgery. This method is safe and effective for uncomplicated appendicitis and can also be done if your appendix has ruptured.
Even if your appendix looks normal during the operation, the surgeon may decide to remove it based on your specific case. This is because an appendix that looks normal can still show signs of disease under a microscope – this is observed in about 40% of people suspected to have acute appendicitis.
Importantly, laparoscopic appendectomy is generally the preferred method for older patients (those over 65), where it has been shown to have fewer complications and deaths than an open appendectomy. It can also be safely performed in children and pregnant women. In fact, many consider it to be the standard procedure for pregnant women with suspected appendicitis.