Inversion-Ligation Appendectomy
Appendectomy
Guy R. Voeller, MD, Timothy C. Fabian,
Inversion-ligation appendectomy involves the fol-
lowing steps: ( 1) skeletonizing the appendix from
its mesentery; (2) inverting the appendix via a
blunt probe into the cecal lumen; (3) ligating the
remaining nubbin of tissue; and (4) inverting the
nubbin with a purse-string stitch. This procedure
allows the surgeon to perform incidental appendec-
tomy while avoiding transection of the appendiceal
lumen with its attendant risk of enteric bacterial
contamination.
B 0th retrospective and prospective studies have shown
that incidental appendectomy can be done in con-
junction with other abdominal operations without adding
to the morbidity and mortality of the primary surgical
procedure [Z-3]. However, those opposed to incidental
appendectomy can cite several studies to support their
view that exposing the surgical wound to bacterial con-
tamination from the append&al lumen leads to in-
creased morbidity and mortality [4-q. Inversion-ligation
appendectomy is a surgical technique that avoids cutting
the appendix and thus eliminates the risk of contamina-
tion of the peritoneal cavity and surgical wound.
From the Department of Surgery, University of Tennessee, Memphis,
Memphis, Tennessee.
Requests for reprints should be addressed to Guy R. Voeller, MD,
Department of Surgery, University of Tennessee, Memphis, 956 Court
Avenue, Suite G218, Memphis, Tennessee 38163.
Manuscript submitted November 7, 1989, and accepted in revised
form February 15, 1990.
THE AMERICAN JOURNAL OF SURGERY
for Incidental
MD, Memphis. TWI~SS~~
TECHNIQUE
Inversion-ligation appendectomy is accomplished in
the following manner (Figure 1): the appendix is skele-
tonized by ligation and division of the mesoappendix flush
with the appendiceal serosa (top left); the appendix is
intussuscepted into the cecal lumen by means of a blunt
probe beginning at the append&al tip (top right); a %- to
l-cm nubbin of intussusceptum is left and ligated at the
junction with the cecum (middle left); the ligated nubbin
is then inverted into the cecal lumen with a purse-string
suture (bottom right); the purse-string is then tied, com-
pletely inverting the entire appendix (bottom left).
When performing this procedure, it is important to
begin the inversion of the tip with the blunt probe gradu-
ally. Gently intussuscepting with the pressure of the
probe placed at the sides rather than the tip of the appen-
dix after inversion has begun avoids perforation into the
lumen. Inversion is also aided by gently squeezing the tip
of the intussusceptum between the fingers with a gauze
sponge as inversion of the appendix proceeds. Without
gentle technique, the tip of the appendix can be perforat-
ed, thus eliminating the advantage of this procedure. Fi-
brous obliteration of the appendix or a fecalith may make
inversion difficult, and this technique is obviously con-
traindicated for acute appendicitis.
COMMENTS
The technique of inversion appendectomy was de-
scribed by Edebohls [7] in 1895. It has been rediscovered
in recent years by the pediatric surgery community, many
of whom regard it highly because it is quick, clean, and
uncomplicated [8,9].
There are some potential concerns with this proce-
dure. Intussusception of the cecum with the inverted ap-
pendix as the lead point has been reported in the pediatric
population [9]. There might also be a concern with a
cecal filling defect on barium enema examination. Both
of these could occur if the appendix was not completely
devascularized, and, in fact, division of the mesoappendix
does not always completely eliminate blood supply. A
sufficient amount of blood can be delivered from small
cecal vessels at the appendiceal base. For these reasons,
pediatric surgeons added the important step of ligation of
the appendiceal nubbin as in Figure 1. When the nubbin
of appendiceal intussusceptum is ligated, strangulation is
ensured. The inverted appendix sloughs into the cecal
lumen within a week and is passed in the fecal mass.
Are the benefits derived from elimination of the po-
tential for future appendicitis greater than the risks of the
potential development of infectious morbidity caused by
incidental appendectomy? The procedure of inversion-
ligation appendectomy seems to solve the problem of that
benetit:risk ratio.
VOLUME 161 APRIL 1991 483
VOELLERANDFABIAN

1. Technique of inverslon-ligstlon appendectomy. Topleft,

Figure
skeletonizing the appendix. Top right, initiation of inversion. Mld-
die left, ligation of km nubbin of Intussusceptum. Bottom dght,
placement of pwssstring in cecum. Boitom Id& inversion corn
pleted and purse-string tied.

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4B4 THE AMERICAN JOURNAL OF SURGERY VOLUME 161 APRIL 1991