MRCS Appendicectomy 1

 
Open Appendicectomy
Start: Full history, examination and appropriate investigations.
Pre-operative measures
After diagnosis of appendicitis:

• Nil by mouth 6 hours before operation.

• Ensure adequate IV hydration using, for example, Hartmann’s solution
(lactated Ringer’s).
• If the decision to proceed to appendicectomy has been made then
antibiotics can be commenced (check local policy). Particularly
recommended if suspicion of perforation but there is evidence of
preventing wound infection in non-perforated.1 (Note: The only
treatment of appendicitis is surgery, antibiotics are an adjunct)
• Perform without delay.

Consent Form
• Name of surgery – Open Appendicectomy
• Brief account of proposed surgery – i.e. area of incision, removal of
appendix, closure of wound, dressing.
• General surgical risks:
§ Bleeding – may need transfusion
§ Infection
§ Anaesthetic complications – nausea, vomiting and, very
rarely, death.
• Specific risks:
§ Pain
§ Local haematoma
§ Abscess
§ Fistula
§ Hernia
§ Damage to adjacent structures – organs, nerves
• May need to proceed to laparotomy and further surgery if other
diagnosis made on the table or if complications.
MRCS Appendicectomy 2

 
Set-up
• Anaesthesia: General anaesthetic.
• Position: Supine
• Drape: Expose the right lower abdominal quadrant; allow identification
of the right anterior superior iliac spine (ASIS) and the umbilicus.

Incision
• Location: McBurney’s point (Charles
McBurney US surgeon described Red = Lanz
incision
1884) – 1 third away from the ASIS
to the umbilicus. Supposedly Green = Gridiron
demarcates the base of the incision
appendix. Image courtesy of
• Classical Gridiron – muscle splitting Wikimedia
oblique incision. commons
• Lanz – transverse incision, better
cosmesis.  

Layers traversed:
• Skin
• Subcutaneous fat
• Scarpa’s fascia
• External oblique aponeurosis
• Internal oblique muscle
• Transversus abdominus muscle
• Transversalis fascia
• Pre-peritonieal fat
• Parietal peritoneum

Procedure
i. Commence incision 2cm medial to the ASIS and continue transversely.
ii. Divide the subcutaneous fat and fascia down to the external oblique
aponeurosis.
iii. Use wound retractors to fully expose the external oblique aponeurosis
and then make a small incision with the scalpel into the external
oblique aponeurosis along the line of fibres – extend this with tissue
scissors.
MRCS Appendicectomy 3

 
iv. The internal oblique muscle has now been exposed. Bluntly split this
and the underlying transversus abdominus with scissors (large curved
work well) to reveal the peritoneum.
v. Using artery forceps hold the peritoneal layer up, tenting it off
underlying structures. Open the peritoneum at the apex of this tent
by gently stroking the belly of the scalpel across. Take care not to
damage bowel beneath. Extend the incision with scissors.
vi. Adjust your assistant’s retractors to create good exposure. Swab
peritoneal fluid for culturing. Then inspect for other pathology – such
as Meckel’s diverticulum, caecal tumours, PID, ectopic pregnancy etc.
vii. Identify and gently mobilize the caecum (following back from small
bowel can help). Follow the taenia coli of the caecum to lead to the
appendix.
viii. Attempt to deliver the appendix through the wound. If heavily
inflamed and adherent to underlying structures - gently using a finger
bluntly dissect the appendix away.
ix. Inspect the appendix and confirm your diagnosis.
x. Clamp and divide the mesoappendix. Ligating the vessels with braided
absorbable ties such as Vicryl.
xi. Using Dunhill forceps clamp just above the base of the appendix and
then apply a surgical tie below at the base.
xii. Using a scalpel blade divide the appendix under the attached forceps
and above the suture tie. Send the appendix for histology.
xiii. Diathermy can be used on the exposed mucosa of the appendix stump
(may reduce mucocele formation).
xiv. Apply a purse string suture to the caecum and around the appendix
stump to bury the stump within the caecum.
xv. Discard the instruments and suture material used to divide the
appendix, as these are now dirty.
xvi. Aspirate any free peritoneal fluid. Some advocate peritoneal lavage at
this stage but there is the increasing consensus that this may spread
contaminated fluid. If there is free pus or a perforated appendix an
abdominal drain is usually be warranted.

Closure
Close in layers:
i. Pick up the free edges of the peritoneum and close with continuous
absorbable sutures (such as Vicryl 3.0).
ii. Internal oblique and transversus abdominus can be closed using
interrupted absorbable sutures.
iii. Close external oblique securely with continuous absorbable sutures
(such as Vicryl 3.0).
MRCS Appendicectomy 4

 
iv. If desired local anaesthetic can be infiltrated for post-operative
analgesia.
v. Close the skin with either clips or subcuticular absorbable sutures.
Clips are preferable in a highly contaminated wound.

Postoperative care
• Routine observation of vital signs.
• Free fluids orally when fully awake change to full diet next day if no
complications.
• DVT prophylaxis.
• Complete course of antibiotics (oral if eating and drinking) if appendix
was highly inflamed, perforated or abscess present.
• If no immediate or early complications and patient tolerating oral diet
consider discharge the afternoon of next day or day after.

Top tips
• Note: When presenting common surgical procedures talk as if you
were performing the surgery yourself i.e. “When I’ve performed this
operation”, “I would perform a Lanz incision by..” Etc.
• Palpate the abdomen after patient is anaesthetised. The abdomen will
be more relaxed and identification of an appendix mass may be easier.
• Always remove the appendix even if the appearance is normal.
Approximately 15-20% of macroscopically normal appendixes are
inflamed microscopically. Furthermore the subsequent RIF scar is
assumed to be from a previous appendicectomy.
• If appendix mass/abscess is found but the appendix itself is unable to
be located, then treat acutely with an abdominal drain and antibiotics
(check local policy) with a view to perform an interval appendicectomy
once patient has recovered.
• If an unexpected pathology is found e.g. colon carcinoma, terminal
ileitis then re-assess appropriate surgery i.e. hemicolectomy.
• Appendix has variable anatomical positions generally:
§ 75% are retrocaecal
§ 20% subcaecal and pelvic
§ 5% pre-ileal and retro-ileal

References:
1. Liberman MA, Greason KL, Frame S, Ragland JJJ Single-dose cefotetan or cefoxitin
versus multiple-dose cefoxitin as prophylaxis in patients undergoing appendectomy
for acute nonperforated appendicitis Am Coll Surg. 1995 Jan;180(1):77-80.