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Appendectomy, open
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Relevant surgical anatomy
Surgical anatomy of the right lower quadrant
The colon is about 1.5m long and originates at the confluence of the small intestine into the cecum. The cecum is located inferior to the ileocecal valve, has its own mesentery (→ mobility) with the appendicular artery and vein (← ileocolic artery← superior mesenteric artery) and is approx. 7cm long. The vermiform appendix originates on the dorsomedial wall of the cecum directly caudad of the ileocecal valve in the taenia libera. It is intraperitoneal, its length is 2–20cm and its diameter between 0.5cm and 1cm. Usually, the appendix extends from the posterior middle of the cecum to the center of the body, but its position can be quite variable, and thus also the location and severity of tenderness. This surgical condition is incorrectly referred to as "appendicitis", although from an anatomical point of view the affected organ is merely the vermiform appendix of the cecum.
Anatomical variants of the appendix:
- Descending type: Appendix extending into the lesser pelvis. In women it may be closely adjacent to the ovary.
- Medial position: Appendix between loops of the small intestine.
- Lateral position: Appendix between the lateral abdominal wall and cecum.
- Retrocecal position: Appendix turned craniad posterior to the cecum (65%)
- Anterocecal position: Appendix turned craniad anterior to the cecum.
- Subhepatic position: Appendix turned toward the liver and in contact with it.
Histologically, the mucous membrane of the appendix demonstrates the same makeup as in the large bowel. However, it has a large number of lymphatic cells and thus becomes part of the human immune system. In addition, in the wall of the appendix the 3 individual strips of longitudinal muscles (taenia) characteristic of the colon conjoin to a complete layer once again.
Follow this link for further information on the anterior abdominal wall.
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Indication
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Contraindication
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Preoperative diagnostic work-up
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Special preparation
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Informed consent
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Anesthesia
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Positioning
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Operating room setup
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Special instruments and fixation systems
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Postoperative management
date of publication: 14.09.2009
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Skin incision
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.
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Splitting the external aponeurosis
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Splitting the abominal muscles
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Peritoneal incision
Expose the peritoneum and open it with scissors.
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Swabbing
Take a swab of the intraperitoneal cavity.
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Coaxing out the cecum
Grasp the cecum and the appendix with a wet pad and with gentle traction coax it out through the wound.
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Dissectring the appendix
Dissect the appendix between Overholt clamps (close to its base, Overholt 19 or 14) by ligating and transecting the mesoappendiceal vessels in small bites.
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Placing the purse string suture
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.
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Ligating and resecting the appendiceal base
Ligate the appendix at its base (Vicrly 3/0) and resect it on a PVP iodine swab with the scalpel (discard).
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Inverting the stump
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)
- Meckel diverticulum:
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Peritoneal and fascial suture
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End of procedure
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Intraoperative complications
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Postoperative complications
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Literature summary
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Ongoing trials on this topic
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References on this topic
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literature search
Literature search under: http://www.pubmed.com