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
Recovery time1-3 weeks
FrequencyCommon

An appendectomy (American English) or appendicectomy (British English) 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 complicated acute appendicitis. [1]

Contents

Appendectomy may be performed laparoscopically (as minimally invasive surgery) or as an open operation. [2] Over the 2010s, surgical practice has increasingly moved towards routinely offering laparoscopic appendicectomy; for example in the United Kingdom over 95% of adult appendicectomies are planned as laparoscopic procedures. [3] 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.

Complicated (perforated) appendicitis should undergo prompt surgical intervention. [1] There has been significant recent trial evidence that uncomplicated appendicitis can be treated with either antibiotics or appendicectomy. [4] [5] After appendicectomy the main difference in treatment is the length of time the antibiotics are administered. For uncomplicated appendicitis, antibiotics should be continued up to 24 hours post-operatively. For complicated appendicitis, antibiotics should be continued for anywhere between 3 and 7 days. [1] An interval appendectomy is generally performed 6–8 weeks after conservative management with antibiotics for special cases, such as perforated appendicitis. [6] Delay of appendectomy 24 hours after admission for symptoms of appendicitis has not shown to increase risk of perforation or other complications. [7]

Procedure

Young nurses assist at an appendectomy 8b07788v.jpg
Four incisions for an appendectomy, corresponding to the order listed. Appendectomy incision locations.jpg
Four incisions for an appendectomy, corresponding to the order listed.
Hasson Entry: The two red lines mark the sites of the 5mm laparoscopic ports. The blue line above the umbilicus marks the site of the camera port Laparoscopic Port Site.jpg
Hasson Entry: The two red lines mark the sites of the 5mm laparoscopic ports. The blue line above the umbilicus marks the site of the camera port
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. [8]
  2. General anaesthesia is induced, with endotracheal intubation and full muscle relaxation, and the patient is positioned supine. [8]
  3. The abdomen is prepared and draped and is examined under anesthesia. [8]
  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. [8]
  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. [8]
  6. On entering the peritoneum, the appendix is identified, mobilized, and then ligated and divided at its base. [8]
  7. Some surgeons choose to bury the stump of the appendix by inverting it so it points into the caecum. [8]
  8. Each layer of the abdominal wall is then closed in turn. [8]
  9. The skin may be closed with staples or stitches. [8]
  10. The wound is dressed.
  11. The patient is brought to the recovery room.

Incisions

The standardization of an incision is not best practice when performing an appendectomy given that the appendix is a mobile organ. [8] A physical exam should be performed prior to the operation and the incision should be chosen based on the point of maximal tenderness to palpation. [8]

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. [9] Recent research has led to the development of natural orifice transluminal endoscopic surgery (NOTES); 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. [10]

Many surgeons have attempted to reduce incisional morbidity and improve cosmetic outcomes in laparoscopic appendectomy 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. [10]

Also, a trend is increasing towards single-incision laparoscopic surgery (SILS), using a special multiport umbilical trocar. [11] 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; 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. [10] 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. [10]

Pediatric patients

Inflamed appendix removal Apendixexternalview.jpg
Inflamed appendix removal

Pediatric patients have a mobile cecum, which allows externalization of the cecal appendix through the umbilicus in most cases. This has led to the development of surgical techniques such as laparoscopic-assisted transumbilical appendectomy, which allows the entire surgery to be performed with a single umbilical incision and has significant advantages in terms of both recovery and aesthetic outcome. [12]

Laparoscopic-assisted transumbilical appendectomy scar on a pediatric patient. Anesthetic result one month after surgery. Scarlapappendix.jpg
Laparoscopic-assisted transumbilical appendectomy scar on a pediatric patient. Anesthetic result one month after surgery.

Pregnancy

Appendicitis is the most common emergent general surgery related problem to arise during pregnancy. There is a natural elevation in white blood cell count in addition to anatomical changes of the appendix that occur during pregnancy. [13] These findings, in addition to non-specific abdominal symptoms make appendicitis difficult to diagnose. Appendicitis develops most commonly in the second trimester. [2] If appendicitis develops in a pregnant woman, an appendectomy is usually performed and should not harm the fetus. [14] The risk of premature delivery is about 10%. [15] 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. [16]

There has been debate regarding which surgical approach is preferred during pregnancy. Overall, there is no increased risk of fetal loss or preterm delivery with the laparoscopic approach (LA) as compared to the open approach (OA). However, the LA was associated with shorter length of stay in the hospital as well as reduced risk of wound infection. [2]

Patient positioning is of utmost importance to ensure safety of the fetus during the procedure. This is especially important during the third trimester due to the potential of compression of the inferior vena cava leading by the enlarged uterus. Placing the patient in a 30-degree left lateral decubitus position alleviates this pressure and prevents fetal distress. [13]

One area of concern related to the LA during pregnancy is pneumoperitoneum. This causes an increase in the intra-abdominal pressure, leading to decreased venous return and therefore, decreased cardiac output. The decreased cardiac output may lead to fetal acidosis and cause distress. However, an animal pregnancy model demonstrated that a 10-12mmHg insufflation pressure demonstrated no adverse effects on the fetus. SAGES (Society of American Gastrointestinal and Endoscopic Surgeons) currently recommends an insufflation pressure of 10-15mmHg during pregnancy. [2]

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. [17]

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. [18]

Complications

One of the most common post-operative complications associated with an appendectomy is the development of a surgical site infection (SSI). [19] Signs and symptoms indicative of a superficial SSI are redness, swelling, and tenderness surrounding the incision and are most likely to arise on post-operative day 4 or 5. These symptoms oftentimes precede fluid drainage from the incision. Tenderness extending beyond the redness that surrounds the incision, in addition to the development of cutaneous vesicles or bullae may be indicative of a deep SSI. [19]

Patients with complicated appendicitis (perforated appendicitis) are more likely to develop a SSI, abdominal abscess, or pelvic abscess during the post-operative period. Placement of an abdominal drain was originally thought to reduce the risk of these post-operative complications. However, abdominal drains have not been found to play a significant role in reducing SSIs and have led to increased length of stay in the hospital in addition to increased cost of the operation. [20]

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. [21]

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 performed in September 1731 by English surgeon William Cookesley on Abraham Pike, a chimney sweep. [22] [23] The second 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. [7] 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. [24]

Harry Hancock performed the first abdominal surgery for appendicitis in 1848, but he did not remove the appendix. [25] 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 in 1961 had to perform the operation on himself as he was the only doctor on a remote Antarctic base. [26] [27]

On September 13, 1980, Kurt Semm performed the first laparoscopic appendectomy, opening up the path for a much wider application of minimally invasive surgery. [28] [29]

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, almost 120 times greater. The median charge was $33,611. [30] [31] 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. [32]

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. [17]

See also

Related Research Articles

The term abdominal surgery broadly covers surgical procedures that involve opening the abdomen (laparotomy). 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.

<span class="mw-page-title-main">Laparoscopy</span> Minimally invasive operations within the abdominal or pelvic cavities

Laparoscopy 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.

<span class="mw-page-title-main">Tubal ligation</span> Surgical clipping,removal or blocking of the fallopian tubes

Tubal ligation is a surgical procedure for female sterilization in which the fallopian tubes are permanently blocked, clipped or removed. This prevents the fertilization of eggs by sperm and thus the implantation of a fertilized egg. Tubal ligation is considered a permanent method of sterilization and birth control.

<span class="mw-page-title-main">Appendicitis</span> 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.

<span class="mw-page-title-main">Cholecystitis</span> Inflammation of the gallbladder

Cholecystitis is inflammation of the gallbladder. Symptoms include right upper abdominal pain, pain in the right shoulder, nausea, vomiting, and occasionally fever. Often gallbladder attacks precede acute cholecystitis. The pain lasts longer in cholecystitis than in a typical gallbladder attack. Without appropriate treatment, recurrent episodes of cholecystitis are common. Complications of acute cholecystitis include gallstone pancreatitis, common bile duct stones, or inflammation of the common bile duct.

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

<span class="mw-page-title-main">Hysterectomy</span> Surgical removal of the uterus

Hysterectomy is the partial or total surgical removal of the uterus. It may also involve removal of the cervix, ovaries (oophorectomy), fallopian tubes (salpingectomy), and other surrounding structures. Partial hysterectomies allow for hormone regulation while total hysterectomies do not.

<span class="mw-page-title-main">Cholecystectomy</span> 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 eighth most common operating room procedure performed in hospitals in the United States. Cholecystectomy can be performed either laparoscopically, or via an open surgical technique.

<span class="mw-page-title-main">Diverticulitis</span> Digestive disease of the large intestine

Diverticulitis, also called colonic diverticulitis, is a gastrointestinal disease characterized by inflammation of abnormal pouches—diverticula—that can develop in the wall of the large intestine. Symptoms typically include lower-abdominal pain of sudden onset, but the onset may also occur over a few days. There may also be nausea; and diarrhea or constipation. Fever or blood in the stool suggests a complication. Repeated attacks may occur.

<span class="mw-page-title-main">Adjustable gastric band</span> Inflatable silicone device

A laparoscopic adjustable gastric band, commonly called a lap-band, A band, or LAGB, is an inflatable silicone device placed around the top portion of the stomach to treat obesity, intended to decrease food consumption.

An incisional hernia is a type of hernia caused by an incompletely-healed surgical wound. Since median incisions in the abdomen are frequent for abdominal exploratory surgery, ventral incisional hernias are often also classified as ventral hernias due to their location. Not all ventral hernias are from incisions, as some may be caused by other trauma or congenital problems.

<span class="mw-page-title-main">Camran Nezhat</span>

Camran Nezhat, FACOG, FACS is an American 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, 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 re-implanted 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.

<span class="mw-page-title-main">Fallopian tube obstruction</span> Medical condition

Fallopian tube obstruction, also known as fallopian tube occlusion is a major cause of female infertility. Blocked fallopian tubes are unable to let the ovum and the sperm converge, thus making fertilization impossible. Fallopian tubes are also known as oviducts, uterine tubes, and salpinges.

Pyloromyotomy is a surgical procedure in which a portion of the muscle fibers of the pyloric muscle are cut. This is typically done in cases where the contents from the stomach are inappropriately stopped by the pyloric muscle, causing the stomach contents to build up in the stomach and unable to be appropriately digested. The procedure is typically performed in cases of "hypertrophic pyloric stenosis" in young children. In most cases, the procedure can be performed with either an open approach or a laparoscopic approach and the patients typically have good outcomes with minimal complications.

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.

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) is a 501c6 non-profit professional organization providing education on gastrointestinal minimally invasive surgery. It describes itself thus: The mission of the Society of American Gastrointestinal and Endoscopic Surgeons is to innovate, educate and collaborate to improve patient care.

<span class="mw-page-title-main">Kurt Semm</span> German gynecologist (1927–2003)

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 was a Dutch surgeon born in 1931. While working at the Beatrix Hospital in Gorinchem, the Netherlands, he pioneered surgical laparoscopy and was the first worldwide to perform an appendectomy assisted by laparoscopy in 1975. Henk died 25 December 2020.

References

  1. 1 2 3 Backbourne, Lorne. Surgical Recall. Wolters Kluwer. pp. 198–203.
  2. 1 2 3 4 Lee, Seung Hwan; Lee, Jin Young; Choi, Yoon Young; Lee, Jae Gil (2019-04-25). "Laparoscopic appendectomy versus open appendectomy for suspected appendicitis during pregnancy: a systematic review and updated meta-analysis". BMC Surgery. 19 (1): 41. doi: 10.1186/s12893-019-0505-9 . ISSN   1471-2482. PMC   6482586 . PMID   31023289.
  3. ↑ RIFT Study Group on behalf of the West Midlands Research Collaborative (3 December 2019). "Evaluation of appendicitis risk prediction models in adults with suspected appendicitis". British Journal of Surgery. 107 (1): 73–86. doi:10.1002/bjs.11440. ISSN   1365-2168. PMC   6972511 . PMID   31797357.
  4. ↑ Javanmard-Emamghissi, Hannah (Sep 3, 2021). "Antibiotics as first-line alternative to appendicectomy in adult appendicitis: 90-day follow-up from a prospective, multicentre cohort study". The British Journal of Surgery. 108 (11): 1351–1359. doi:10.1093/bjs/znab287. PMC   8499866 . PMID   34476484. Archived from the original on 8 September 2021. Retrieved 8 September 2021.
  5. ↑ CODA Collaborative (Oct 5, 2020). "A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis". The New England Journal of Medicine. 20 (383): 1907–1919. doi: 10.1056/NEJMoa2014320 . PMID   33017106. S2CID   222151141.
  6. ↑ Archived 2020-10-13 at the Wayback Machine , Sell N, O'Donnell T, Saillant N. Laparoscopic Appendectomy and Open Umbilical Hernia Repair. J Med Ins. 2019;2019(270) doi:https://jomi.com/article/270 Archived 2022-06-18 at the Wayback Machine
  7. 1 2 Yelon, Jay A.; Luchette, Fred A. (2013). Geriatric Trauma and Critical Care. Springer Science & Business Media. ISBN   9781461485018.
  8. 1 2 3 4 5 6 7 8 9 10 11 Zollinger, Robert (2016). Zollinger's Atlas of Surgical Operations. McGraw-Hill Education. p. 162. ISBN   978-0-07-179756-6.
  9. ↑ Zollinger, Robert (2016). Zollinger's Atlas of Surgical Operations. McGraw-Hill Education. p. 49. ISBN   978-0-07-179756-6.
  10. 1 2 3 4 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. 8 (4): 140–144. doi: 10.4103/0972-9941.103121 . PMC   3523451 . PMID   23248441. Archived from the original on 2018-06-01. Retrieved 2012-11-10.
  11. ↑ Far, Sasan Saeed; Miraj, Sepide (October 2016). "Single-incision laparoscopy surgery: a systematic review". Electronic Physician. 8 (10): 3088–3095. doi:10.19082/3088. ISSN   2008-5842. PMC   5133033 . PMID   27957308.
  12. ↑ Sekioka, Akinori; Takahashi, Toshiaki; Yamoto, Masaya; Miyake, Hiromu; Fukumoto, Koji; Nakaya, Kengo; Nomura, Akiyoshi; Yamada, Yutaka; Urushihara, Naoto (December 2018). "Outcomes of Transumbilical Laparoscopic-Assisted Appendectomy and Conventional Laparoscopic Appendectomy for Acute Pediatric Appendicitis in a Single Institution". Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A. 28 (12): 1548–1552. doi:10.1089/lap.2018.0306. ISSN   1557-9034. PMID   30088968. S2CID   51941735. Archived from the original on 2022-08-29. Retrieved 2022-08-29.
  13. 1 2 "Sign In | Health Library". lwwhealthlibrary.com. Retrieved 2020-01-11.
  14. ↑ Factors That Develop During Pregnancy at Merck Manual of Diagnosis and Therapy Home Edition
  15. ↑ Schwartz Book of General Surgery
  16. ↑ Sabiston Textbook of Surgery 2007.
  17. 1 2 Barrett M. L., Hines A. L., Andrews R. M. Trends in Rates of Perforated Appendix, 2001–2010 Archived 2018-08-02 at the Wayback Machine . HCUP Statistical Brief #159. Agency for Healthcare Research and Quality, Rockville, MD. July 2013.
  18. ↑ "Surgery 2 | PDF | Percutaneous Coronary Intervention | Mastectomy". Scribd. Archived from the original on 2015-06-20. Retrieved 2023-02-03.
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  20. ↑ Cheng, Yao; Zhou, Shiyi; Zhou, Rongxing; Lu, Jiong; Wu, Sijia; Xiong, Xianze; Ye, Hui; Lin, Yixin; Wu, Taixiang; Cheng, Nansheng (2015-02-07). "Abdominal drainage to prevent intra-peritoneal abscess after open appendectomy for complicated appendicitis". The Cochrane Database of Systematic Reviews (2): CD010168. doi:10.1002/14651858.CD010168.pub2. ISSN   1469-493X. PMID   25914903.
  21. ↑ 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. PMID   24716251. Archived from the original on 2014-03-28. Retrieved 2014-03-28.
  22. ↑ "A considerable share of the intestines cut off after a mortification in a hernia and cured". Medical Essays and Observations. Edinburgh: Society for the Improvement of Medical Knowledge. 5 (1): 427–31. 1742.
  23. ↑ Selley, Peter (2016). "William Cookesley, William Hunter and the first patient to survive removal of the appendix in 1731 – a case history with 31 years' follow up". Journal of Medical Biography. 24 (2): 180–3. doi:10.1177/0967772015591717. PMID   26758584. S2CID   1708483.
  24. ↑ 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 .
  25. ↑ Schwartz's principles of surgery (9 ed.). New York: McGraw-Hill, Medical Pub. Division. 2010. p. 1075. ISBN   9780071547697.
  26. ↑ Rogozov V.; Bermel N. (2009). "Auto-appendectomy in the Antarctic: case report". BMJ. 339: b4965. doi:10.1136/bmj.b4965. PMID   20008968. S2CID   12503748. Archived from the original on 2010-02-19. Retrieved 2010-06-29.
  27. ↑ Lentati, Sara (May 5, 2015). "The man who cut out his own appendix". BBC News. Archived from the original on July 28, 2019. Retrieved June 21, 2018.
  28. ↑ 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.
  29. ↑ Semm K (March 1983). "Endoscopic Appendectomy". Endoscopy. 15 (2): 59–64. doi:10.1055/s-2007-1021466. PMID   6221925. S2CID   45763958.
  30. ↑ "Health Care as a 'Market Good'? Appendicitis as a Case Study". Archived from the original on 2014-11-10. Retrieved 2012-04-27. JournalistsResource.org, retrieved April 25, 2012
  31. ↑ 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. Archived from the original on 2020-02-20. Retrieved 2012-04-27.
  32. ↑ Tanner, Lindsey (April 24, 2012). "Study finds appendectomy could cost as much as house". Florida Today . Melbourne, Florida. pp. 6A. Archived from the original on April 1, 2019. Retrieved April 25, 2012.
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