Appendectomy Overview

Appendectomy is the surgical removal of the appendix, a small, finger-shaped pouch that is located at the cecum (the junction between the large and small intestines). The surgery is the standard treatment for appendicitis (inflammation and infection of the appendix) and patients usually recover from appendectomy without experiencing complications. A ruptured appendix is considered a medical emergency.

Surgical Procedures
Surgeons use one of two surgical techniques, open appendectomy or laparoscopic appendectomy. The choice of method is made by the surgeon on a case-by-case basis. General anesthesia (agent that renders the patient unconscious) is used in both procedures.

Open Appendectomy
Open appendectomy is the traditional method and the standard treatment for appendicitis. The surgeon makes an incision in the lower right abdomen, pulls the appendix through the incision, ties it off at its base, and removes it. Care is taken to avoid spilling purulent material (pus) from the appendix while it is being removed. The incision is then sutured. If the appendix has perforated (ruptured), the surgeon cleans the pus out of the abdomen with a warm saline solution to reduce the risk for infection. A drain may be inserted through the incision to allow the pus to drain from the abdomen. In this case, the skin is not sutured, but left open and packed with sterile gauze. The gauze and drain remain in place until the pus is completely drained and there is no sign of infection. If the abdomen is so inflamed that the surgeon cannot see the appendix, the infection is drained and treated with antibiotics, and then the appendix is removed.

Laparoscopic Appendectomy
Laparoscopic appendectomy has been used for several years and has become the standard of care. The procedure has several advantages including lower risk for postoperative infection, faster recovery time, a smaller scar, and a shorter hospital stay. The surgeon makes a very small incision right below the navel and inserts an instrument called a laparoscope. The laparoscope is a long tube with a lens at one end and a miniature video camera at the other. The laparoscope enables the doctor to see the appendix. Several more tiny incisions are made to allow for the passage of instruments, which are used to cut and clamp off the appendix.

The laparoscope is also used as a diagnostic tool. The doctor is able to see if the appendix is inflamed and, if the appendix is not the cause of the patient's symptoms, other organs can be seen in order to identify the source of the symptoms.

Preoperative Procedures for Appendectomy

A number of tests are ordered to assess the patient's health before surgery. Usually these tests are done a few days ahead, but because of the urgency of an appendectomy, the tests and surgery are frequently performed on the same day. Preoperative tests vary according to the patient's age and health, but a blood test, chest x-ray, and electrocardiogram (EKG) are standard. An informed consent form must be signed acknowledging that the patient understands the procedure, the potential risks, and that they will receive certain medications. Before surgery, the anesthesiologist visits the patient to do a brief physical examination and to obtain a medical history. He or she will want to know about any other medical conditions; if the patient is taking any medication (prescription or over-the-counter); if any dietary supplements or herbal products are being used; if there has been recent illicit drug use; if the patient smokes cigarettes or drinks alcohol; if the patient has a history of allergies, especially to medications; or has had a previous reaction to anesthesia, or a family history of problems with anesthesia. Patients are required to refrain from eating or drinking after midnight on the day before surgery; however, because an appendectomy is an emergency procedure, that may not be possible. As soon as the decision is made to operate, the patient must take nothing by mouth, including oral medications. Prior to surgery, an intravenous (IV) is started to administer fluid and medications that have been ordered, including antibiotics and pain medication. A sedative may be given to help the patient relax. Anesthesia is administered in the operating room.

Postoperative Care after Appendectomy

Following surgery, the patient is taken to the postanesthesia care unit (PACU) until the anesthesia wears off. During this time, the nursing staff checks temperature, heart rate, and breathing at frequent intervals. When the anesthesia wears off and vital signs stabilize, the patient is transferred to their hospital room.
Unruptured Appendix With an unruptured appendix, the patient's recovery time is relatively quick. The morning after surgery, clear liquids are offered. Once those are tolerated, the diet progresses to solid food. Once the patient is eating and drinking, the intravenous is removed. Physical activity, such as getting out of bed, begins on the same day as surgery or the next morning. Most patients need medication to relieve the pain in and

around the incision. The smaller incisions of a laparscopic procedure often cause less pain than the large incision made in open appendectomy.

The nursing staff continues to monitor the patient for signs of infection and checks that the incision is healing. Patients with uncomplicated surgeries usually leave the hospital 1 or 2 days following surgery. Once at home, the patient must check the incision site. It should be dry and the wound should be completely closed. If the incision drains blood or pus, or if the edges are pulling apart, the physician should be notified immediately. Fever and increasing pain at the incision site also should be reported to the physician. Normal activities can be resumed within a few days, but it takes 4 to 6 weeks for full recovery. Heavy lifting and strenuous activity should be avoided during recovery. If antibiotics and/or pain medication are prescribed, they should be taken as directed. The open procedure leaves a scar on the lower right side of the abdomen that is a few inches long and fades over time. Scarring from laparoscopic appendectomy is minimal.
Ruptured Appendix Recovery from surgery for a perforated appendix is longer, primarily because the infection must be treated. The hospital stay is at least 4 days and can be longer, if complications develop. The drain remains in place until the pus stops draining, and the nursing staff changes the gauze packing as needed. Intravenous antibiotics continue throughout the hospitalization.

When discharged, oral antibiotics are prescribed and should be taken as directed. The drain and gauze pack remain in place, and instructions are given on proper care of the area. It is important to inform the physician if the amount of drainage suddenly increases, or if the color and consistency changes. The drain is removed on an outpatient basis after the infection has resolved.

Postoperative Complications after Appendectomy

Paralytic ileus may occur following the operation. The bowel is normally in constant motion, digesting food and absorbing nutrients. Disturbing the bowel, even by the surgeon's just touching it, can cause the motion to come to a standstill. Fluid and gas may then cause the bowel to swell or distend. A nasogastric tube is passed through the nose and into the stomach to relieve the distension. When bowel function returns to normal (evident by passing gas or having a bowel movement), the tube is removed. Until that time, food and liquid are not permitted by mouth, and hydration is maintained intravenously. Paralytic ileus is more common when the appendix has perforated. Wound infection can cause the skin to become red and inflamed and pus to leak from the incision site. In this case, antibiotics are started and discharge from the hospital may be delayed,

depending on the severity of the infection. On rare occasions, the site must be reopened to allow the wound to drain.