Appendectomy, open - general and visceral surgery

3–4cm long muscle splitting incision in right lower quadrant (at the lateral third of a virtual line from the anterior superior spine of the ilium to the umbilicus)
Follow this by transecting the subcutis and Scarpa fascia with electrocautery.

Note: Routine approach should be the muscle splitting incision, and not the pararectal incision, since the stacked muscles of the lateral abdominal wall virtually prevent incisional hernia. The often cited criticism that a muscle splitting incision cannot be extended if the surgical approach requires this is not correct: The muscle splitting incision may easily be extended superiad as “hockey-stick” incision and medially as modified Pfannenstiel incision.

Split the external aponeurosis from laterocephalad to mediocaudad with scissors.

Bluntly split the internal oblique and transversalis abdominis with scissors and retract with Roux retractors.

Expose the peritoneum and open it with scissors.

Take a swab of the intraperitoneal cavity.

Grasp the cecum and the appendix with a wet pad and with gentle traction coax it out through the wound.

Dissect the appendix between Overholt clamps (close to its base, Overholt 19 or 14) by ligating and transecting the mesoappendiceal vessels in small bites.

Place the Vicrly 3/0 SH purse string suture, needed later on for stump inversion, around the base at a distance of about 10mm.

Tip: In challenging local situations it may be helpful to leave the purse string suture somewhat longer opposite its entry and exit. By lifting the cecum with both ends of the suture and the loop this facilitates stump inversion.

Ligate the appendix at its base (Vicrly 3/0) and resect it on a PVP iodine swab with the scalpel (discard).

Invert the appendiceal stump with forceps (assistant) while tightening the purse string suture (discard forceps and scissors after cutting the tails of the suture).
Then clean the pouch of Douglas first with moist and then dry swabs.

Note: No routine drainage if focus has been cleared and peritonitis is localized!

Note: Only check for Meckel diverticulum in case of bland appendix.

• • Meckel diverticulum:
    Clamp the diverticulum sufficiently far from its base, resect and close it transversely with extramucosal single-layered suture (monofilament 4/0) or resect it with a linear cutter. (e.g,. ILA 52)