Appendectomy

An appendectomy is a surgical removal of the vermiform appendix. Surgery remains the mainstay of therapy for acute appendicitis, although many appendectomies are now performed laparascopically rather than through an open incision. Although appendicitis is a common disorder, there still can be difficulty in diagnosing it.

The procedure was first performed, as open surgery, by a non-surgeon in 1735, identified only as "Amyan"; H. Hancock, an English surgeon, formally performed the procedure at the end of the 19th century.

For a surgical procedure, it is relatively simple, although anatomical abnormalities and infection can make the procedure a challenge to an experienced surgeon. Still, there are many examples of having a nonsurgeon guided through the procedure, as in a number of cases in the Second World War, where a medical corpsman aboard a U.S. Navy submarine at sea performed it under radio direction.

Open surgery

McBurney's incision is classic; in general terms, this is on the right lower quadrant of the abdomen. Specifically, the incision is made at right angles to a line drawn between the anteriorsuperior spine of the ilium and the umbilicus. Two-thirds of the incision should be above the umbilicus.

The surgeon then incises the external oblique, internal oblique and transversus abdominis muscle, and then displaces fascia and peritoneal fat to expose the peritoneum. Next, the peritoneum is opened and retracted.

Cultures of free peritoneal fluid should be taken, and the cecum mobilized and pulled through the incision. This maneuver will either pull the appendix through the incision, or make it visible. A pair of clamps is then used to divide the mesoappendix, and suture material is applied to ligate the area; this can require additional suturing if the appendix is difficult to access, or the mesoappendix is easily damaged.

With blood supply to the appendix now controlled, the appendix is lifted straight up, and two clamps are applied to its base. Two lines of sutures are then put through the base; the surgeon chooses whether or not to invert the stump of the appendix. Using a scalpel with phenol solution, or an electrocautery, the appendix is now cut away, and a purse-string suture tied around the stump.

After the appendix is removed, the operator irrigates the area, and then closes the muscle in the reverse order of their opening. If no peritonitis is present, the skin is also closed. If there is peritonitis, the wound is packed with iodoform gauze retained by suture material.