SURGICAL MANAGEMENT

Appendectomy is the surgical removal of the appendix, the 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.In this operation, the surgeon removes the appendix and closes its connection to the colon.  The surgeon can perform an appendectomy either laparoscopically or through an open surgical procedure.   

INSTRUMENT Appendectomy Set 

An appendectomy  (appendisectomy or appendicectomy) is the surgical removal of the vermiform appendix. Medical Tools comprehensive 67 Pcs Appendectomy Set is designed for clinical needs and practical challenges.Kit has all necessary tools to perform Appendectomy Surgery. All tools are made from high grade surgical stainless steel used by professionals.

The Appendectomy Surgery instrument set includes:01 Metzenbaum Scissors 18cm Curved01 Metsenbaum Scissors 18cm Straight01 Mayo Scissors14cm Curved 01 Mayo Scissors 14cm Straight

02 Scalpel Handle # 402 Allis Tissue Forceps 15cm04 Kochers Tissue Forceps 1:201 Mcindoe Forceps 15cm02 Babcocks Tissue Forceps 16cm02 Mayo Hagar Needle Holder 16cm02 Sponge Holding Forceps04 Backhaus Towel Clamps 11cm08 Criles Forceps 14cm curved06 Criles Forceps 14cm Straight

06 Spencer Wells  Straight 08 Spencer Wells Curved 02 U S Army Retractor 21cm02 Adson Forceps 12cm02 Adson Forceps 1:2 12cm02 Lane Forceps 1:2 18cm 02 Forceps 16cm04 Gallipots02 Kidney Dish 8" 

PERI-OPERATIVE CARE

• An informed consent form must be signed acknowledging that the patient understands the procedure, the potential risks, and that they will receive certain medications.

• The anesthesiologist visits the patient to do a brief physical examination and to obtain a medical history.

• Patients are required to refrain from eating or drinking after midnight on the day before surgery.

• Prior to surgery, an intravenous (IV) is started to administer fluid and medications that have been ordered.

• Place the patient supine, and tuck his or her right arm for the duration of the procedure. The surgeon should stand on the patient's right, and the assistant surgeon should stand on the patient's left.

• General anesthesia is administered. Before the start of the surgical procedure, the anesthesiologist performs endotracheal intubation to administer volatile anesthetics and to assist respiration.

INTRA-OPERATIVE CARE

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.

Open appendectomyOn the basis of the anatomy of the anterior abdominal wall, the following three distinct incisions can be employed when performing an open appendectomy:

• McBurney-McArthur incision• Lanz incision• Pararectus (Jalaguier, Battle, Kammerer, Lennander,

Senn) incision.

STEP 1: The position of the incision is based upon the location of the McBurney point, which is a point one third of the distance from the anterior superior iliac spine (ASIS) to the umbilicus. Place the incision (1.5-5.0 cm in length, depending on the patient's age) between the first third and the second third of the distance from the ASIS to the umbilicus, respecting the directions of the Langer skin lines.     

Skin incision is based on McBurney point, which lies one third of distance between

anterior superior iliac spine (ASIS) and umbilicus. Incision extends 3-5 cm along

skin creases (Lanz incision).

STEP 2: Make the incision with a No. 10 blade; use a Bovie electrocautery to incise through both the superficial (Camper) and the deep (Scarpa) fascia.    

Dissection through both superficial (Camper) and deep (Scarpa) fascia.

External oblique aponeurosis is exposed and incised in direction of

fibers.

STEP 3: Expose the external oblique aponeurosis, incising in the direction of fibers, and split the external oblique muscle bluntly with alternating Kelly clamps and Roux retractors.   

External oblique muscle is split

bluntly byusing alternating Kelly clamps and Roux

retractors.

STEP 4: This blunt muscle spreading, along with appropriate retraction (again, the authors feel that the Roux retractor is the best), allows visualization of the transversalis fascia and the peritoneum.    

Sequence of muscle splitting and retraction is repeated with fascia of

both internal oblique muscle and transversus abdominis to expose

transversalis fascia and peritoneum.

STEP 5: Perform the incision on peritoneum in a craniocaudal direction with Metzenbaum scissors, allowing access to the peritoneal cavity; once the cavity is opened, any fluid encountered should be sent for Gram stain and culture.   

Transversalis fascia and peritoneum are grasped with 2 straight clamps, with palpation

between surgeon's fingers, and with care taken to avoid entrapment of any underlying

structures. Incision is made with Metzenbaum scissors, and per

STEP 6: The appendix can be removed through either an antegrade or a retrograde technique. In performing the antegrade approach, identify the ascending colon and its taeniae coli, and use a series of Babcock surgical clamps to follow them to their convergence, identifying the base of the appendix. Free the appendix-mesoappendix complex from its adjacent, often inflamed, tissue, and deliver it into the wound. The mesoappendix, containing the appendiceal artery, is then ligated and separated from the appendix

In antegrade approach, ascending colon and its taeniae coli are identified and followed to

their convergence, identifying base of appendix. Appendix-mesoappendix complex

is freed from its adjacent, often inflamed, tissue and delivered into wound.

Mesoappendix, containing appendiceal artery, is ligated (3-0 Vicryl 2 times) and

separated from appendix.

STEP 7. Once the mesoappendix is divided and the appendiceal/cecal base is clearly exposed, perform simple ligation with 2-0 plain polyglactin, tying off the base; this ligation is performed twice. Place a clamp just proximal to the distal ligature on the appendix, avoiding any inadvertent contamination, and divide sharply. Cauterize the exposed mucosa.   

Completion of appendectomy by dividing appendix between 2 ligatures, closer to cecum.

After the appendectomy is completed and the wound is copiously irrigated with normal saline, grasp the peritoneum with two straight clamps, and close it with a continuous 3-0 polyglactin stitch. Approximate all split muscle layers, using 3-0 polyglactin at each level. Close the external oblique fascia with a continuous 2-0 polyglactin stitch. Approximate the Scarpa fascia with 3-0 polyglactin, and use 4-0 poliglecaprone subcuticular interrupted sutures for skin closure.If wound contamination is of concern in complicated appendicitis, the wound may be closed at the musculofascial level, left open and packed for 3-5 days, and secondarily closed. Another option is to leave a Penrose drain in the wound and remove it 2-3 days later. If a phlegmon or abscess is encountered, the abdomen should be thoroughly irrigated with normal saline. Closed suction drainage may be used in these circumstances or if the adequacy of appendiceal stump closure is of concern.

LAPAROSCOPIC APPENDECTOMY STEP 1. Port placement A 10-mm trocar is placed at the umbilicus, and the abdominal cavity is insufflated to a pressure of 15 mmHg. The camera is also inserted through this larger trocar. A 5-mm trocar is placed at the suprapubis, and a second 5-mm trocar is placed at the LLQ. (Placement of the third port may vary by surgeon preference or as case dictates but LLQ is standard placement).STEP 2. Inspect abdominal cavity The area is inspected to orient the surgeon to the position of the appendix. Inspection will also alert surgeon to any anatomic variation or pathological conditions that may be relevant (e.g. peritonitis).

STEP 3. Expose appendix The bowel is gently retracted rostrally using atraumatic graspers to allow access to appendix.STEP 4. Locate and separate appendicular artery The mesoappendix is separated from the body of the appendix, and the mesenteric fat is separated to reveal the appendicular artery. This is best done using the “spreader” action of a dissector.STEP 5. Divide appendix from cecum Using an endoloop, two loops are placed proximal to the cecum, and a third loop is placed 1-2 cm distally to these. The appendix is then divided between the two proximal and 3rd distal loops using scissors or cautery. Staples may be substituted for loops.

STEP 6. Divide appendicular artery The artery is divided using the Endo GIA or the endoloop method described above (two ligatures proximally, one distally).STEP 7. Extract appendix A fourth port (10 mm) may be placed containing the extraction tube. Alternately, the camera may be withdrawn and the existing 10 mm port used for extraction (a 5 mm camera is inserted into one of the smaller ports in these cases). In either case, an extraction tube is placed through the appropriate 10 mm port, and the extraction.

STEP 8. Irrigate The abdominal cavity should be irrigated thoroughly with sterile saline and suctioned clean several times. In the event of a rupture, great care should be taken to ensure all pus or other infectious fluids have been removed.

STEP 9. Final inspection The abdominal and pelvic cavities are inspected one final time for any signs of infection, errors, or other potential complications of which the surgeon might need to be aware. This can often be done simultaneously with irrigation.   

POST OPERATIVE CAREPostoperative MedicationAdminister intravenous antibiotics postoperatively. The length of administration is based on the operative findings and the recovery of the patient; in complicated appendicitis, antibiotics may be required for many days or weeks. Antiemetics and analgesics are administered to patients experiencing nausea and wound pain.DietWhen appendicitis is not complicated, the diet may be advanced quickly postoperatively and the patient is discharged from the hospital once a diet is tolerated. In patients with complicated appendicitis, a clear liquid diet may be started when bowel function returns. These patients may be discharged after complete restitution of infection.

Long-Term MonitoringAfter hospital discharge following surgery, patients must have a light diet and limit their physical activity for a period of 2-6 weeks, depending on the surgical approach (ie, laparoscopic or open appendectomy). The patient should be evaluated by the surgeon in the clinic to determine improvement and to detect any possible complications. 

END