Appendectomy

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Appendectomy
Blinddarm-01.jpg
An appendectomy in progress
Other namesAppendisectomy, appendicectomy
Specialty General surgery
Uses Appendicitis
ComplicationsInfection, bleeding
Approach Laparoscopic, open

An appendectomy is a surgical operation in which the vermiform appendix (a portion of the intestine) is removed. Appendectomy is normally performed as an urgent or emergency procedure to treat acute appendicitis.

Surgery Medical specialty

Surgery is a medical specialty that uses operative manual and instrumental techniques on a patient to investigate or treat a pathological condition such as a disease or injury, to help improve bodily function or appearance or to repair unwanted ruptured areas.

Appendicitis Inflammation of the appendix

Appendicitis is inflammation of the appendix. Symptoms commonly include right lower abdominal pain, nausea, vomiting, and decreased appetite. However, approximately 40% of people do not have these typical symptoms. Severe complications of a ruptured appendix include widespread, painful inflammation of the inner lining of the abdominal wall and sepsis.

Contents

Appendectomy may be performed laparoscopically (as minimally invasive surgery) or as an open operation. Laparoscopy is often used if the diagnosis is in doubt, or in order to leave a less visible surgical scar. Recovery may be slightly faster after laparoscopic surgery, although the laparoscopic procedure itself is more expensive and resource-intensive than open surgery and generally takes longer. Advanced pelvic sepsis occasionally requires a lower midline laparotomy. In US adults, the 30-day mortality after appendectomy was 1.8%. [1]

A laparotomy is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity. It is also known as a celiotomy.

Procedure

Young nurses assist at an appendectomy 8b07788v.jpg
Surgeons perform a laparoscopic appendectomy. US Navy 060227-N-9742R-004 The Ship's Surgeon Lt. Cmdr. Michael Barker, center, and Senior Medical Officer Commander David Gibson, left, perform an urgent laparoscopic appendectomy.jpg
Surgeons perform a laparoscopic appendectomy.

In general terms, the procedure for an open appendectomy is:

  1. Antibiotics are given immediately if signs of actual sepsis are seen (in appendicitis, sepsis and bacteremia usually only occurs at some point after rupture, once peritonitis has begun), or if there is reasonable suspicion that the appendix has ruptured (e.g., on imaging) or if the onset of peritonitis- which will lead to full sepsis if not quickly treated- is suspected; otherwise, a single dose of prophylactic intravenous antibiotics is given immediately before surgery.
  2. General anaesthesia is induced, with endotracheal intubation and full muscle relaxation, and the patient is positioned supine.
  3. The abdomen is prepared and draped and is examined under anesthesia.
  4. If a mass is present, the incision is made over the mass. Otherwise, the incision is made over McBurney's point (one-third of the way from the anterior superior iliac spine to the umbilicus), which represents the most common position of the base of the appendix.
  5. The various layers of the abdominal wall are opened. In order to preserve the integrity of abdominal wall, the external oblique aponeurosis is split along the line of its fibers, as is the internal oblique muscle. As the two run at right angles to each other, this reduces the risk of later incisional hernia.
  6. On entering the peritoneum, the appendix is identified, mobilized, and then ligated and divided at its base.
  7. Some surgeons choose to bury the stump of the appendix by inverting it so it points into the caecum.
  8. Each layer of the abdominal wall is then closed in turn.
  9. The skin may be closed with staples or stitches.
  10. The wound is dressed.
  11. The patient is brought to the recovery room.

Incisions

These incisions are placed for appendectomy:

  1. McBurney's incision, also known as grid iron incision
  2. Lanz incision
  3. Rutherford Morison incision
  4. Paramedian incision
Wound healing - ten days after a laparoscopic appendectomy Appendectomy plus 10 days.png
Wound healing - ten days after a laparoscopic appendectomy

Over the past decade, the outcomes of laparoscopic appendectomies have compared favorably to those for open appendectomies because of decreased pain, fewer postoperative complications, shorter hospitalization, earlier mobilization, earlier return to work, and better cosmesis. However, despite these advantages, efforts are still being made to decrease abdominal incision and visible scars after laparoscopy. Recent research has led to the development of natural orifice transluminal endoscopic surgery (NOTES). [2] However, numerous difficulties need to be overcome before a wider clinical application of NOTES is adopted, including complications such as the opening of hollow viscera, failed sutures, a lack of fully developed instrumentation, and the necessity of reliable cost-benefit analyses. [2]

Cosmesis is the preservation, restoration, or bestowing of bodily beauty. In the medical context, it usually refers to the surgical correction of a disfiguring defect, or the cosmetic improvements made by a surgeon following incisions. Its use is generally limited to the additional, usually minor, steps that the surgeon takes to improve the aesthetic appearance of the scars associated with the operation. Typical actions include removal of damaged tissue, mitigation of tension on the wound, and/or using fine (thin) sutures to close the outer layer of skin.

Many surgeons have attempted to reduce incisional morbidity and improve cosmetic outcomes in laparoscopic appendicectomy by using fewer and smaller ports. Kollmar et al. described moving laparoscopic incisions to hide them in the natural camouflages like the suprapubic hairline to improve cosmesis. Additionally, reports in the literature indicate that minilaparoscopic appendectomy using 2– or 3-mm or even smaller instruments along with one 12-mm port minimizes pain and improves cosmesis. More recently, studies by Ates et al. and Roberts et al. have described variants of an intracorporeal sling-based single-port laparoscopic appendectomy with good clinical results. [2]

Also, a trend is increasing towards single-incision laparoscopic surgery (SILS), using a special multiport umbilical trocar. With SILS, a more conventional view of the field of surgery is seen compared to NOTES. The equipment used for SILS is familiar to surgeons already doing laparoscopic surgery. Most importantly, it is easy to convert SILS to conventional laparoscopy by adding a few trocars; this conversion to conventional laparoscopy is called 'port rescue'. SILS has been shown to be feasible, reasonably safe, and cosmetically advantageous, compared to standard laparoscopy. [2] However, this newer technique involves specialized instruments and is more difficult to learn because of a loss of triangulation, clashing of instruments, crossing of instruments (cross triangulation), and a lack of maneuverability. Also, the additional problem of decreased exposure and the added financial burden of procuring special articulating or curved coaxial instruments exist. SILS is still evolving, being used successfully in many centres, but with some way to go before it becomes mainstream. This limits its widespread use, especially in rural or peripheral centres with limited resources. [2]

Pregnancy

If appendicitis develops in a pregnant woman, an appendectomy is usually performed and should not harm the fetus. [3] The risk of premature delivery is about 10% [4] The risk of fetal death in the perioperative period after an appendectomy for early acute appendicitis is 3 to 5%. The risk of fetal death is 20% in perforated appendicitis. [5]

Pregnancy time when children develop inside the mothers body before birth

Pregnancy, also known as gestation, is the time during which one or more offspring develops inside a woman. A multiple pregnancy involves more than one offspring, such as with twins. Pregnancy can occur by sexual intercourse or assisted reproductive technology. Childbirth typically occurs around 40 weeks from the start of the last menstrual period (LMP). This is just over nine months, where each month averages 31 days. When measured from fertilization it is about 38 weeks. An embryo is the developing offspring during the first eight weeks following fertilization, after which, the term fetus is used until birth. Symptoms of early pregnancy may include missed periods, tender breasts, nausea and vomiting, hunger, and frequent urination. Pregnancy may be confirmed with a pregnancy test.

A fetus or foetus is the unborn offspring of an animal that develops from an embryo. Following embryonic development the fetal stage of development takes place. In human prenatal development, fetal development begins from the ninth week after fertilisation and continues until birth. Prenatal development is a continuum, with no clear defining feature distinguishing an embryo from a fetus. However, a fetus is characterized by the presence of all the major body organs, though they will not yet be fully developed and functional and some not yet situated in their final anatomical location.

Recovery

Scar and bruise 2 days after operation SCAR.jpg
Scar and bruise 2 days after operation
Scar 10 days after operation 2011-08-03 Cicatriz posterior apendicectomia paciente masculino.jpg
Scar 10 days after operation

A study from 2010 found that the average hospital stay for people with appendicitis in the United States was 1.8 days. For people with a perforated (ruptured) appendix, the average length of stay was 5.2 days. [6]

Recovery time from the operation varies from person to person. Some take up to three weeks before being completely active; for others, it can be a matter of days. In the case of a laparoscopic operation, the patient has three stapled scars of about an inch (2.5 cm) in length, between the navel and pubic hair line. When an open appendectomy has been performed, the patient has a 2– to 3-inch (5–7.5 cm) scar, which will initially be heavily bruised. [7]

Frequency

About 327,000 appendectomies were performed during U.S. hospital stays in 2011, a rate of 10.5 procedures per 10,000 population. Appendectomies accounted for 2.1% of all operating-room procedures in 2011. [8]

History

An appendectomy at the French Hospital in Tbilisi, Georgia, 1919 Appendectomy at the French Hospital in Tiflis (Dartigues 1919).JPG
An appendectomy at the French Hospital in Tbilisi, Georgia, 1919

The first recorded successful appendectomy was on December 6, 1735, at St. George's Hospital in London, when French surgeon Claudius Amyand described the presence of a perforated appendix within the inguinal hernial sac of an 11-year-old boy. [9] The organ had apparently been perforated by a pin the boy had swallowed. The patient, Hanvil Andersen, made a recovery and was discharged a month later. [10]

Harry Hancock performed the first abdominal surgery for appendicitis in 1848, but he did not remove the appendix. [11] In 1889 in New York City, Charles McBurney described the presentation and pathogenesis of appendicitis accurately and developed the teaching that an early appendectomy was the best treatment to avoid perforation and peritonitis.

Some cases of autoappendectomies have occurred. One was attempted by Evan O'Neill Kane in 1921, but the operation was completed by his assistants. Another was Leonid Rogozov, who had to perform the operation on himself as he was the only doctor on a remote Antarctic base. [12] [13]

On September 13, 1980, Kurt Semm performed the first laparoscopic appendectomy opening up the path for a much wider application of minimally invasive surgery. [14] [15]

Cost

United States

While appendectomy is a standard surgical procedure, its cost has been found to vary considerably in the United States. A 2012 study analyzed 2009 data from nearly 20,000 adult patients treated for appendicitis in California hospitals. Researchers examined “only uncomplicated episodes of acute appendicitis” that involved “visits for patients 18 to 59 years old with hospitalization that lasted fewer than four days with routine discharges to home.” The lowest charge for removal of an appendix was $1,529 and the highest $182,955, more than 120 times greater. The median charge was $33,611. [16] [17] While the study was limited to California, the researchers indicated that the results were applicable anywhere in the United States. Many, but not all, patients are covered by some sort of medical insurance. [18]

A study by the Agency for Healthcare Research and Quality found that in 2010, the average cost for a stay in the United States involving appendicitis was $7,800. For stays where the appendix had ruptured, the average cost was $12,800. The majority of patients seen in the hospital were covered by private insurance. [6]

See also

Related Research Articles

The term abdominal surgery broadly covers surgical procedures that involve opening the abdomen. Surgery of each abdominal organ is dealt with separately in connection with the description of that organ Diseases affecting the abdominal cavity are dealt with generally under their own names.

General surgery medical specialty

General surgery is a surgical specialty that focuses on abdominal contents including esophagus, stomach, small bowel, colon, liver, pancreas, gallbladder, appendix and bile ducts, and often the thyroid gland. They also deal with diseases involving the skin, breast, soft tissue, trauma, peripheral vascular surgery and hernias and perform endoscopic procedures such as gastroscopy and colonoscopy.

Laparoscopy

Laparoscopy invented by George Kelling in 1901, in Germany, is an operation performed in the abdomen or pelvis using small incisions with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.

Peritonitis inflammation of the peritoneum, the lining of the inner wall of the abdomen

Peritonitis is inflammation of the peritoneum, the lining of the inner wall of the abdomen and cover of the abdominal organs. Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss. One part or the entire abdomen may be tender. Complications may include shock and acute respiratory distress syndrome.

Cholecystectomy surgical removal of the gallbladder

Cholecystectomy is the surgical removal of the gallbladder. Cholecystectomy is a common treatment of symptomatic gallstones and other gallbladder conditions. In 2011, cholecystectomy was the 8th most common operating room procedure performed in hospitals in the United States. Cholecystectomy can be performed either laparoscopically, using a video camera, or via an open surgical technique.

Gastric bypass surgery bariatric surgery

Gastric bypass surgery refers to a surgical procedure in which the stomach is divided into a small upper pouch and a much larger lower "remnant" pouch and then the small intestine is rearranged to connect to both. Surgeons have developed several different ways to reconnect the intestine, thus leading to several different gastric bypass (GBP) procedures. Any GBP leads to a marked reduction in the functional volume of the stomach, accompanied by an altered physiological and physical response to food.

Common bile duct stone Human disease

Common bile duct stone, also known as choledocholithiasis, is the presence of gallstones in the common bile duct (CBD). This condition can cause jaundice and liver cell damage. Treatment is by cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP).

Pneumoperitoneum pneumatosis (abnormal presence of air or other gas) in the peritoneal cavity, a potential space within the abdominal cavity.

Pneumoperitoneum is pneumatosis in the peritoneal cavity, a potential space within the abdominal cavity. The most common cause is a perforated abdominal viscus, generally a perforated peptic ulcer, although any part of the bowel may perforate from a benign ulcer, tumor or abdominal trauma. A perforated appendix seldom causes a pneumoperitoneum.

Marc Bessler, M.D. is an American surgeon known for his innovations in bariatrics. He is currently the United States Surgical Professor of Surgery at Columbia University Medical Center and also serves as a content contributor for Bariatric Surgery Source. Dr. Bessler specializes in surgical management of morbid obesity and laparoscopic surgery of the stomach, among other specialties.

Natural orifice transluminal endoscopic surgery

Natural orifice transluminal endoscopic surgery (NOTES) is an experimental surgical technique whereby "scarless" abdominal operations can be performed with an endoscope passed through a natural orifice then through an internal incision in the stomach, vagina, bladder or colon, thus avoiding any external incisions or scars.

Camran Nezhat American surgeon

Camran Nezhat, FACOG, FACS is a laparoscopic surgeon, reproductive endocrinology and infertility sub-specialist who has been teaching and practicing medicine and surgery as an adjunct clinical professor of surgery, and obstetrics and gynecology at Stanford University Medical Center in Palo Alto, California since 1993. Nezhat is also Chair of the Association of the Adjunct Clinical Faculty, Stanford University School of Medicine, and a Clinical Professor of OB/GYN at the University of California, San Francisco.

"Tubal Reversal," also called "Tubal Sterilization Reversal," or "Tubal Ligation Reversal," or "Microsurgical Tubal Reanastomosis," is a surgical procedure that can restore fertility to women after a tubal ligation. By rejoining the separated segments of the fallopian tube, tubal reversal can give women the chance to become pregnant again. In some cases, however, the separated segments cannot actually be reattached to each other. In some cases the remaining segment of tube needs to be reimplanted into the uterus. In other cases, when the end of the tube has been removed, a procedure called a neofimbrioplasty must be performed to recreate a functional end of the tube which can then act like the missing fimbria and retrieve the egg that has been released during ovulation.

Single-port laparoscopy (SPL), is a recently developed technique in laparoscopic surgery. It is a minimally invasive surgical procedure in which the surgeon operates almost exclusively through a single entry point, typically the patient's navel. Unlike a traditional multi-port laparoscopic approach, SPL leaves only a single small scar.

Single-incision laparoscopic surgery (SILS) is an advanced, minimally invasive (keyhole) procedure in which the surgeon operates almost exclusively through a single entry point, typically the patient’s umbilicus (navel). Special articulating instruments and access ports eliminate the need to place trochars externally for triangulation, thus allowing the creation of a small, solitary portal of entry into the abdomen.

Mark A. Talamini is professor and chairman of surgery and chief of surgical services at Stony Brook Medicine; editor-in-chief of Surgical Endoscopy, the official journal of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and European Association for Endoscopic Surgery; and former president of SAGES.

Kurt Karl Stephan Semm was a German gynecologist and pioneer in minimally invasive surgery. He has been called "the father of modern laparoscopy".

Henk de Kok is a Dutch surgeon born in 1931. While working at the Beatrix Hospital in Gorinchem, the Netherlands, he pioneered surgical laparoscopy and was the first world wide to perform an appendectomy assisted by laparoscopy in 1975.

Erich Mühe was a German surgeon known for performing the first laparoscopic cholecystectomy in 1985.

References

  1. Margenthaler JA, Longo WE, Virgo KS, et al. (Jul 2003). "Risk Factors for Adverse Outcomes After the Surgical Treatment of Appendicitis in Adults". Ann. Surg. 238 (1): 59–66. doi:10.1097/01.SLA.0000074961.50020.f8. PMC   1422654 . PMID   12832966.
  2. 1 2 3 4 5 Ashwin, Rammohan; Paramaguru, Jothishankar; Manimaran, A. B.; Naidu, R. M. (2012). "Two-port vs. three-port laparoscopic appendicectomy: A bridge to least invasive surgery". Journal of Minimal Access Surgery.
  3. Factors That Develop During Pregnancy at Merck Manual of Diagnosis and Therapy Home Edition
  4. Schwartz Book of General Surgery
  5. Sabiston Textbook of Surgery 2007.
  6. 1 2 Barrett M. L., Hines A. L., Andrews R. M. Trends in Rates of Perforated Appendix, 2001–2010. HCUP Statistical Brief #159. Agency for Healthcare Research and Quality, Rockville, MD. July 2013.
  7. Surgery 2
  8. Weiss A. J.; Elixhauser A.; Andrews R. M. (February 2014). "Characteristics of Operating Room Procedures in U.S. Hospitals, 2011". HCUP Statistical Brief #170. Rockville, MD: Agency for Healthcare Research and Quality.
  9. Yelon, Jay A.; Luchette, Fred A. (2013). Geriatric Trauma and Critical Care. Springer Science & Business Media. ISBN   9781461485018.
  10. Amyand, Claudius (1735). "Of an inguinal rupture, with a pin in the appendix caeci, incrusted with stone; and some observations on wounds in the guts". Philosophical Transactions of the Royal Society of London. 39 (443): 329–336. doi:10.1098/rstl.1735.0071. Archived from the original on 2017-05-15. Retrieved 2016-10-12.
  11. Schwartz's principles of surgery (9 ed.). New York: McGraw-Hill, Medical Pub. Division. 2010. p. 1075. ISBN   9780071547697.
  12. Rogozov V.; Bermel N. (2009). "Auto-appendectomy in the Antarctic: case report". BMJ. 339: b4965. doi:10.1136/bmj.b4965. PMID   20008968.
  13. Lentati, Sara (May 5, 2015). "The man who cut out his own appendix". BBC News.
  14. Grzegorz S. Litynski (1998). "Kurt Semm and the Fight against Skepticism: Endoscopic Hemostasis, Laparoscopic Appendectomy, and Semm's Impact on the "Laparoscopic Revolution"". JSLS. 2 (3): 309–13. PMC   3015306 . PMID   9876762.
  15. Semm K (March 1983). "Endoscopic Appendectomy". Endoscopy. 15 (2): 59–64. doi:10.1055/s-2007-1021466. PMID   6221925.
  16. "Health Care as a 'Market Good'? Appendicitis as a Case Study". JournalistsResource.org, retrieved April 25, 2012
  17. Hsia, Renee Y.; Kothari, Abbas H.; Srebotnjak, Tanja; Maselli, Judy (2012). "Health Care as a 'Market Good'? Appendicitis as a Case Study". Archives of Internal Medicine. 172 (10): 818–9. doi:10.1001/archinternmed.2012.1173. PMC   3624019 . PMID   22529183.
  18. Tanner, Lindsey (April 24, 2012). "Study finds appendectomy could cost as much as house". Florida Today . Melbourne, Florida. pp. 6A.
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