The patient is sedated and anaesthetized using General anesthesia, sometimes regional anesthesia like spinal or epidural maybe

used. A small incision (about 2-3 inches) is made in the right lower quadrant of the abdomen, and the appendix is removed. If the surgeon feels the appendix has ruptured or infection has spread, then he would thoroughly wash the abdomen. The surgeon will also leave a small tube to drain fluids and pus. Sometimes when the diagnosis is in doubt, frequently in women, the procedure is done by Exploratory Laparotomy. This can mean a bigger incision. Laparoscopic Appendectomy: In this procedure, a small camera with a thin telescope is used to view the inside of the abdominal cavity. Laparoscopy is now replacing most of the open surgical procedures. Preference of open or Laparoscopic surgery may also depend on the experience of the Surgeon and his or her preference. Sometimes the general condition of the patient may not be good enough for this keyhole surgery.

Read more: Appendectomy / Appendecetomy Surgery http://www.medindia.net/surgicalprocedures/Appendectomy-Surgery.htm#i

Appendectomy

From Wikipedia, the free encyclopedia

An appendectomy in progress

An appendectomy (sometimes called appendisectomy or appendicectomy) is the surgical removalof the vermiform appendix. This procedure is normally performed as an emergency procedure, when the patient is suffering from acute appendicitis. In the absence of surgical facilities, intravenous antibiotics are used to delay or avoid the onset of sepsis; it is now recognized that many cases will resolve when treated non-operatively. In some cases the appendicitis resolves completely; more often, an inflammatory mass forms around the appendix. This is a relative contraindication to surgery. Appendectomy may be performed laparoscopically (this is called minimally invasive surgery) or as an open operation. Laparoscopy is often used if the diagnosis is in doubt, or if it is desirable to hide the scarsin the umbilicus or in the pubic hair line. Recovery may be a little quicker with laparoscopic surgery; the procedure is more expensive and resource-intensive than open surgery and generally takes a little longer, with the (low in most patients) additional risks associated with pneumoperitoneum (inflating the abdomen with gas). Advanced pelvic sepsis occasionally requires a lower midline laparotomy.

There have been some cases of auto-appendectomies, i.e. operating on yourself. One was performed by Dr Kane in 1921, but the operation was completed by his assistants. Another case is Leonid Rogozovwho had to perform the operation on himself as he was the only surgeon on a remote Arctic base.[1] In general terms, the procedure for an open appendectomy is as follows.

1.

Antibiotics are given immediately if there are signs of sepsis, otherwise a single dose of prophylactic intravenous antibiotics is given immediately prior to surgery.

2. 3. 4.

General anaesthesia is induced, with endotracheal intubation and full muscle relaxation, and the patient is positioned supine. The abdomen is prepared and draped and is examined under anesthesia. 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 (ASIS) and the umbilicus; this represents the position of the base of the appendix (the position of the tip is variable).

5. 6.

The various layers of the abdominal wall are then opened. The effort is always to preserve the integrity of abdominal wall. Therefore, the External Oblique Aponeurosis is slitted along its fiber, and the internal oblique muscleis split along its length, not cut. As the two run at right angles to each other, this prevents later Incisional hernia.

7. 8. 9.

On entering the peritoneum, the appendix is identified, mobilized and then ligated and divided at its base. Some surgeons choose to bury the stump of the appendix by inverting it so it points into the caecum. Each layer of the abdominal wall is then closed in turn.

10. The skin may be closed with staples or stitches. 11. The wound is dressed. 12. The patient will be brought to the recovery room. Contents [hide]

1 Prophylactic appendectomy 2 Pregnancy 3 Recovery 4 References 5 External links

[edit]Prophylactic

appendectomy
This section does not cite any references or sources.
Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed. (November 2010)

[edit]Pregnancy

If appendicitis develops in a pregnant woman, an appendectomy is usually performed and should not harm the fetus.[2] 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.
[3]

[edit]Recovery

Scar and Bruise 2 days after operation.

Recovery time from the operation varies from person to person. Some will 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 will have three stapled scars of about an inch in length, between the navel and pubic hair line. When a laparotomy has been performed the patient will have a 2-3 inch scar, which will initially be heavily bruised.[4]

[edit]References

1. 2. 3. 4.

^ Auto-appendectomy in the Antarctic: case report, BMJ 2009;339:b4965 ^ Risk Factors That Develop During Pregnancy ^ Sabiston Textbook of Surgery 2007 ^ http://www.scribd.com/doc/17692145/Surgery-2

[edit]External

links

   

Open appendectomy, appendectomy Part of the operative howto series, explaining the steps in carrying out an open appendectomy Open & Laparoscopic appendectomy, appendectomy Open and Laparoscopic appendectomy A video of the procedure Another video of the procedure (Either Requires Windows Media Player and will not load in Firefox 1.5; or use this direct link with any player that can play .wmv files.)

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Appendicitis is a condition characterized by inflammation of the appendix. It is classified as a medical emergency and many cases require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of peritonitis and shock. Reginald Fitz first described acute and chronic appendicitis in 1886,
[1] [2]

and it has been recognized as one

of the most common causes of severe acute abdominal pain worldwide. A correctly diagnosed non-acute form of appendicitis is known as "rumbling appendicitis". The term "pseudoappendicitis" is used to describe a condition mimicking appendicitis. It can be associated with Yersinia enterocolitica.
[4] [3]

Signs & Symptoms

Location of the appendix in thedigestive system

For the most part symptoms relate to disturbed function of bowels. Pain first, vomiting next and fever last has been described as classic presentation of acute appendicitis. Pain starts mid abdomen, and except in children below 3 years, tends to localize in right iliac fossa in a few hours. This pain can be elicited through various signs. Signs include localized findings in the right iliac fossa. The abdominal wall becomes very sensitive to gentle pressure (palpation). Also, there is severe pain on suddenly releasing a deep pressure in lower abdomen rebound tenderness. In case of a retrocecal appendix, however, even deep pressure in the right lower quadrant may fail to elicit tenderness (silent appendix), the reason being that the cecum, distended with gas, prevents the pressure exerted by the palpating hand from reaching the inflamed appendix. Similarly, if the appendix lies entirely within the pelvis, there is usually complete absence of the abdominal rigidity. In such cases, a digital rectal examinationelicits tenderness in the rectovesical pouch. Coughing causes point tenderness in this area (McBurney's point) and this is the least painful way to localize the inflamed appendix. If the abdomen on palpation is also involuntarily guarded (rigid), there should be a strong suspicion of peritonitis requiring urgent surgical intervention.

[edit]Rovsing's

sign

Continuous deep palpation starting from the left iliac fossa upwards (anti clockwise along the colon) may cause pain in the right iliac fossa, by pushing bowel contents towards the ileocaecal valve and thus increasing pressure around the appendix. This is the Rovsing's sign. Laughing too hard can result in great pain when dealing with appendicitis. [edit]Psoas
[5]

sign

Main article: Psoas sign Psoas sign or "Obraztsova's sign" is right lower-quadrant pain that is produced with the patient extending the hip due to inflammation of the peritoneum overlying the iliopsoas muscles and inflammation of the psoas muscles themselves. Straightening out the leg causes the pain because it stretches the muscles, and flexing the hip into the "fetal position" relieves the pain. [edit]Obturator

sign

If an inflamed appendix is in contact with the obturator internus, spasm of the muscle can be demonstrated by flexing and internal rotation of the hip. This maneuver will cause pain in the hypogastrium. [edit]Dunphy's

sign
[6]

Increased pain in the right lower quadrant with coughing. [edit]Volkovich-Kocher

(Kosher)'s sign

During anamnesis, the appearance of pain in the epigastric region or around the stomach at the beginning of disease with a subsequent shift to the right iliac region. [edit]Sitkovskiy

(Rosenstein)'s sign

Increased pain in the right iliac region as patient lies on his/her left side. [edit]Bartomier-Michelson's

sign

Increased pain on palpation at the right iliac region as patient lies on his/her left side compared to when patient was on supine position. [edit]Aure-Rozanova's

sign

Increase pain on palpation with finger in right Petit triangle (can be a positive Shchetkin-Bloomberg's sign) - typical in retroceacal position of the appendix. [edit]Blumberg
[7]

sign

Also referred as rebound tenderness. Deep palpation of the viscera over the suspected inflamed appendix followed by sudden release of the pressure causes the severe pain on the site indicating positive Blumberg's sign and peritonitis. [edit]Causes
[8]

On the basis of experimental evidence, acute appendicitis seems to be the end result of a primary obstruction of the appendix lumen (the inside space of a tubular structure).
[9][10]

Once this obstruction occurs the appendix subsequently becomes filled

with mucus and swells, increasing pressures within the lumen and the walls of the appendix, resulting in thrombosis and occlusion of the small vessels, and stasis of lymphatic flow. Rarely, spontaneous recovery can occur at this point.

As the former progresses, the appendix becomes ischemic and then necrotic. As bacteria begin to leak out through the dying walls, pus forms within and around the appendix (suppuration). The end result of this cascade is appendiceal rupture (a 'burst appendix') causing peritonitis, which may lead to septicemia and eventually death. Among the causative agents, such as foreign bodies, trauma, intestinal worms, lymphadenitis, and calcified deposits known as appendicoliths,
[11]

the occurrence of anobstructing fecalith has attracted attention. The prevalence of fecaliths in patients with
[12]

appendicitis is significantly higher in developed than in developing countries with complicated appendicitis
[13]

, and an appendiceal fecalith is commonly associated

. Also, fecal stasis and arrest may play a role, as demonstrated by a significantly lower number of
[14]

bowel movements per week in patients with acute appendicitis compared with healthy controls

. The occurrence of a fecalith in the

[15]

appendix seems to be attributed to a right sided fecal retention reservoir in the colon and a prolonged transit time

. From

epidemiological data it has been stated that diverticular disease and adenomatous polyps were unknown and colon cancer exceedingly rare in communities exempt for appendicitis cancer in the colon and rectum appendicitis transit time
[19] [20][21] [18] [16][17]

. Also, acute appendicitis has been shown to occur antecedent to

. Several studies offer evidence that a low fiber intake is involved in the pathogenesis of

. This is in accordance with the occurrence of a right sided fecal reservoir and the fact that dietary fiber reduces

[22]

[edit]Diagnosis

Diagnosis is based on patient history (symptoms) and physical examination backed by an elevation of neutrophilic white blood cells. Histories fall into two categories, typical and atypical. Typical appendicitis usually includes abdominal pain beginning in the region of the umbilicus for several hours, associated with anorexia, nausea or vomiting. The pain then "settles" into the right lower quadrant, where tenderness develops. Atypical histories lack this typical progression and may include pain in the right lower quadrant as an initial symptom. Atypical histories often require imaging with ultrasound and/or CT scanning.
[23]

A pregnancy test is vital in all women

of child bearing age, as ectopic pregnancies and appendicitis present with similar symptoms. The consequences of missing an ectopic pregnancy are serious, and potentially life threatening. Furthermore the general principles of approaching abdominal pain in women (in so much that it is different from the approach in men) should be appreciated. Blood Test Most patients suspected of having appendicitis would be asked to do a blood test. 50% of the times, the blood test may be normal. So it is not fool proof in diagnosing appendicitis. Two form of blood tests commonly done: FBC (Full blood count) or CBC (Complete blood count), depending on which side of the Atlantic you live on) is an inexpensive and commonly requested blood test. It involves the blood measured for its richness in red blood cells as well as the number of the various white blood cell constituents in it. The number of white cells in the blood is a usually less than 10,000cells per cubic millimetre. An abnormal rise in the number of white blood cells in the blood is a crude indicator of infection or inflammation going on in the body. Such rise is not specific to appendicitis alone. If it is abnormally elevated, with a good history and examination findings pointing towards appendicitis, the likelihood of having the disease is higher. In pregnancy, there may be a normal elevation of white blood cells, without any infection present. CRP is an acronym for Cryo-Reactive Proteins. It is an acute phase response protein produced by the liver in response to any infection or inflammatory process in the body. Again, like the FBC, it is not a specific test. It is another crude marker of infection or

inflammation. Inflammation at ANY site can lead to the CRP to rise. A significant rise in CRP with corresponding signs and symptoms of appendicitis is a useful indicator in the diagnosis of appendicitis.It is said that if CRP continues to be normal after 72 hours of the onset of pain, it is likely that the appendicitis will resolve on its own without intervention. A worsening CRP with good history is a sure signal fire of impending perforation or rupture and abscess formation Urine Test: Urine test in appendicitis is usually normal. It may however show blood if the appendix is rubbing on the bladder, causing irritation A urine test or urinalysis is compulsory in women, to rule out pregnancy in appendicitis, as well to help ensure that the abdominal pain felt and thought to be acute appendicitis is not in fact, due to ectopic pregnancy. X Ray In 10% of patients with appendicitis, plain abdominal x-ray may demonstrate hard formed faeces in the lumen of the appendix (Faecolith). It is agreed that the finding of Faecolith in the appendix on X ray alone is a reason to operate to remove the appendix, because of the potential to cause worsening symptoms. In this respect, a plain abdominal X-ray may be useful in the diagnosis of appendicitis, though plain abdominal x- ray is no longer requested routinely in suspected cases of appendicitis. An abdominal X ray may be done with a barium enema contrast to diagnose appendicitis. Barium enema is whitish toothpaste like material that is passed up into the rectum to act as a contrast. It will usually fill the whole of the large bowel. In normal appendix, the lumen will be present and the barium fills it up and is seen when the x-ray film is shot. In appendicitis, the lumen of the appendix will not be visible on the barium film. [edit]Ultrasound

Ultrasound image of an acute appendicitis.

Ultrasonography and Doppler sonography provide useful means to detect appendicitis, especially in children and shows free fluid collection in right iliac fossa along with a visible appendix without blood flow in color Doppler. In some cases (15% approximately), however, ultrasonography of the iliac fossa does not reveal any abnormalities despite the presence of appendicitis. This is especially true of early appendicitis before the appendix has become significantly distended and in adults where larger amounts of fat and bowel gas make actually seeing the appendix technically difficult. Despite these limitations, in experienced hands sonographic imaging can often distinguish between appendicitis and other diseases with very similar symptoms such as inflammation of lymph nodes near the appendix or pain originating from other pelvic organs such as the ovaries or fallopian tubes.

[edit]Computed

tomography

A cat scan demonstrating acute appendicitis (note the appendix has a diameter of 17.1mm and there is surrounding fat stranding.)

A fecalith marked by the arrow which has resulted in acute appendicitis.

In places where it is readily available, CT scan has become frequently used, especially in adults whose diagnosis is not obvious on history and physical. Concerns about radiation, however, tend to limit use of CT in pregnant women and children. A properly performed CT scan with modern equipment has a detection rate (sensitivity) of over 95% and a similar specificity. Signs of appendicitis on CT scan include lack of oral contrast (oral dye) in the appendix, direct visualization of appendiceal enlargement (greater than 6 mm in cross sectional diameter), and appendiceal wall enhancement with IV contrast (IV dye). The inflammation caused by appendicitis in the surrounding peritoneal fat (so called "fat stranding") can also be observed on CT, providing a mechanism to detect early appendicitis and a clue that appendicitis may be present even when the appendix is not well seen. Thus, diagnosis of appendicitis by CT is made more difficult in very thin patients and in children, both of whom tend to lack significant fat within the abdomen. The utility of CT scanning is made clear, however, by the impact it has had on negative appendectomy rates. For example, use of CT for diagnosis of appendicitis in Boston, MA has decreased the chance of finding a normal appendix at surgery from 20% in the pre-CT era to only 3% according to data from the Massachusetts General Hospital. [edit]Ultrasound

and CT compared

According to a systematic review from UC-San Francisco comparing ultrasound vs. CT scan, CT scan is more accurate than ultrasound for the diagnosis of appendicitis in adults and adolescents. CT scan has a sensitivity of 94%, specificity of 95%, a

positive likelihood ratio of 13.3 (CI, 9.9 to 17.9), and a negative likelihood ratio of 0.09 (CI, 0.07 to 0.12). Ultrasonography had an overall sensitivity of 86%, a specificity of 81%, a positive likelihood ratio of 5.8 (CI, 3.5 to 9.5), and a negative likelihood ratio of 0.19 (CI, 0.13 to 0.27). [edit]Alvarado
[24]

score

A number of clinical and laboratory based scoring systems have been devised to assist diagnosis. The most widely used isAlvarado score.

Symptoms

Migratory right iliac fossa pain

1 point

Anorexia

1 point

Nausea and vomiting

1 point

Signs

Right iliac fossa tenderness

2 points

Rebound tenderness

1 point

Fever

1 point

Laboratory

Leucocytosis

2 points

Shift to left (segmented neutrophils) 1 point

Total score

10 points

A score below 5 is strongly against a diagnosis of appendicitis

[25]

, while a score of 7 or more is strongly predictive of acute

appendicitis. In patients with an equivocal score of 5-6, CT scan is used in the USA to further reduce the rate of negative appendicectomy. [edit]Other

Data

Tzanakis Scoring. Tzanakis and colleagues, in 2005 published a simplified system, now called the Tzanakis scoring system for appendicitis, to aid the diagnosis of appendicitis. It incorporates the presence 4 variables made up of specific signs and symptoms (presence of right lower abdominal tenderness = 4points and rebound tenderness = 3), laboratory findings (presence of white blood cells greater than 12,000 in the blood = 2) as well as ultrasound findings (presence of positive ultrasound scan findings of appendicitis = 6), to which scores are allocated, in the computing of a scoring to predict the presence of appendicitis. A total score of 15 is the maximum that can be scored. Where a patient scores 8 or more points, there is greater than 96 percent chance that appendicitis exists. Matrix metalloproteinase (MMP) levels can be used as biomarkers of increased risk of appendiceal rupture among patients with acute appendicitis according to a cohort study.
[26]

MMP-1 was higher in gangrenous (p<0.05) and perforated appendicitis

(p<0.01) compared with controls. MMP-9 was most abundantly expressed in inflamed appendix and reached a tenfold higher expression in all groups with appendicitis compared with controls (p<0.001). [edit]Differential In children:

diagnosis

Gastroenteritis, mesenteric adenitis, Meckel's diverticulitis, intussusception, Henoch-Schnlein purpura, lobar pneumonia, urinary tract infection (abdominal pain in the absence of other symptoms can occur in children with UTI), new-onset Crohn's disease or ulcerative colitis, pancreatitis, and abdominal trauma from child abuse; distal intestinal obstruction syndrome in children with cystic fibrosis; typhlitis in children with leukemia; in girls: menarche, dysmenorrhea, severe menstrual cramps,Mittelschmerz, pelvic inflammatory disease, ectopic pregnancy

In adults:

regional enteritis, renal colic, perforated peptic ulcer, pancreatitis, rectus sheath hematoma; in men: testicular torsion, newonset Crohn's disease or ulcerative colitis; in women: pelvic inflammatory disease, ectopic pregnancy, endometriosis, torsion/rupture of ovarian cyst, Mittelschmerz (the passing of an egg in the ovaries approximately two weeks before an expected menstruation cycle)

In elderly:

diverticulitis, intestinal obstruction, colonic carcinoma, mesenteric ischemia, leaking aortic aneurysm.

[edit]Management

Largely surgical, any conservative management is done at the threshold of operation theater as the acutely inflamed appendix is liable to rupture during such treatment.

Inflamed appendix removal by open surgery

[edit]Before

surgery

The treatment begins by keeping the patient from eating or drinking in preparation for surgery. An intravenous drip is used to hydrate the patient. Antibiotics given intravenously such as cefuroxime and metronidazole may be administered early to help kill bacteria and thus reduce the spread of infection in the abdomen and postoperative complications in the abdomen or wound. Equivocal cases may become more difficult to assess with antibiotic treatment and benefit from serial examinations. If the stomach is empty (no food in the past six hours) general anaesthesia is usually used. Otherwise, spinal anaesthesia may be used. Once the decision to perform an appendectomy has been made, the preparation procedure takes more or less one to two hours. Meanwhile, the surgeon will explain the surgery procedure and will present the risks that must be considered when performing an appendectomy. With all surgeries there are certain risks that must be evaluated before performing the procedures. However, the risks are different depending on the state of the appendix. If the appendix has not ruptured, the complication rate is only about 3% but if the appendix has ruptured, the complication rate rises to almost 59%.
[27]

The most usual complications that can occur are

pneumonia, hernia of the incision,thrombophlebitis, bleeding or adhesions. Recent evidence indicates that a delay in obtaining surgery after admission results in no measurable difference in patient outcomes
[28]

The surgeon will also explain how long the recovery process should take. Abdomen hair is usually removed in order to avoid complications that may appear regarding the incision. In most of the cases patients experience nausea or vomiting which requires specific medication before surgery. Antibiotics along with pain medication may also be administrated prior to appendectomies. [edit]Pain

management

Pain from appendicitis can be severe. Strong pain medications (i.e., narcotic pain medications) are recommended for pain management prior to surgery. Morphine is generally the standard of care in adults and children in the treatment of pain from appendicitis prior to surgery. In the past (and in some medical textbooks that are still published today), it has been commonly accepted that pain medication not be given until the surgeon has the chance to evaluate the patient, so as to not "corrupt" the findings of the physical

examination. This line of practice, combined with the fact that surgeons may sometimes take hours to come to evaluate the patient, especially if he or she is in the middle of surgery or has to drive in from home, often leads to a situation that is ethically questionable at best. More recently, due to better understanding of the importance of pain control in patients, it has been shown that the physical examination is actually not that dramatically disturbed when pain medication is given prior to medical evaluation. Individual hospitals and clinics have adapted to this new approach of pain management of appendicitis by developing a compromise of allowing the surgeon a maximum time to arrive for evaluation, such as 20 to 30 minutes, before active pain management is initiated. Many surgeons also advocate this new approach of providing pain management immediately rather than only after surgical evaluation. [edit]Surgery

Laparoscopic appendectomy.

The surgical procedure for the removal of the appendix is called an appendicectomy (also known as an appendectomy). Often now the operation can be performed via a laparoscopic approach, or via three small incisions with a camera to visualize the area of interest in the abdomen. If the findings reveal suppurative appendicitis with complications such as rupture, abscess, adhesions, etc., conversion to open laparotomy may be necessary. An open laparotomy incision if required most often centers on the area of maximum tenderness, McBurney's point, in the right lower quadrant. A transverse or a gridiron diagonal incision is used most commonly. In March 2008, an Indian woman had her appendix removed via her vagina, in a medical first by the NOTES (Natural Orifice Transluminal Endoscopic Surgery) method in Coimbatore, India.
[29]

According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic and open procedures, laparoscopic procedures seem to have various advantages over the open procedure. Wound infections were less likely after laparoscopic appendicectomy than after open appendicectomy (odds ratio (OR) 0.45; confidence interval (CI) 0.35 to 0.58), but the incidence of intraabdominal abscesses was increased (OR 2.48; CI 1.45 to 4.21). The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic procedures. Pain on day 1 after surgery was reduced after laparoscopic procedures by 9 mm (CI 5 to 13 mm) on a 100 millimeter visual analogue scale. Hospital stay was shortened by 1.1 day (CI 0.6 to 1.5). Return to normal activity, work, and sport occurred earlier after laparoscopic procedures than after open procedures. While the operation costs of laparoscopic procedures

were significantly higher, the costs outside hospital were reduced. Young female, obese, and employed patients seem to benefit from the laparoscopic procedure more than other groups.
[30]

There is debate whether emergency appendicectomy (within 6 hours of admission) reduces the risk of perforation or complication versus urgent appendicectomy (greater than 6 hours after admission). According to a retrospective case review study
[31]

no

significant differences in perforation rate among the two groups were noted (P=.397). Various complications (abscess formation, readmission) showed no significant differences (P=0.667, 0.999). According to this study, beginning antibiotic therapy and delaying appendicectomy from the middle of the night to the next day does not significantly increase the risk of perforation or other complications. This finding is important not simply for the convenience of the surgeons and staff involved but for the fact that there have been other studies that have shown that surgeries taking place during the night, when people may be more tired and there are fewer staff available, have higher rates of surgical complications. Findings at the time of surgery are less severe in typical appendicitis. With atypical histories, perforation is more common and findings suggest perforation occurs at the beginning of symptoms. These observations may fit a theory that acute (typical) appendicitis and suppurative (atypical) appendicitis are two distinct disease processes. (1) Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours in complicated cases. [edit]Laparotomy

explained

Laparotomy is the traditional type of surgery used for treating appendicitis. This procedure consists in the removal of the infected appendix through a single larger incision in the lower right area of the abdomen.
[32]

The incision in a laparotomy is usually 2-3 inches

long. This type of surgery is used also for visualizing and examining structures inside the abdominal cavity and it is called exploratory laparotomy. During a traditional appendectomy procedure, the patient is placed under general anesthesia in order to keep his/her muscles completely relaxed and to keep the patient unconscious. The incision is two to three inches long and it is made in the right lower abdomen, several inches above the hip bone.
[33]

Once the incision opens the abdomen cavity and the appendix is identified,

the surgeon removes the infected tissue and cuts the appendix from the surrounding tissue. After the surgeon inspects carefully and closely the infected area and there are no signs that surrounding tissues are damaged or infected, he will start closing the incision. This means sewing the muscles and using surgical staples or stitches to close the skin up. In order to prevent infections the incision is covered with a sterile bandage. The entire procedure does not last longer than an hour if complications do not occur. [edit]Laparoscopic

surgery

The newer method to treat appendicitis is the laparoscopic surgery. This surgical procedure consists of making three to four incisions in the abdomen, each 0.25 inches to 0.5 inches long. This type of appendectomy is made by inserting a special surgical tool called laparoscope into one of the incisions. The laparoscope is connected to a monitor outside the patient's body and it is designed to help the surgeon to inspect the infected area in the abdomen. The other two incisions are made for the specific removal of the appendix by using surgical instruments. Laparoscopic surgery also requires general anesthesia and it can last up to two hours. The latest methods areNOTES appendectomy pioneered in Coimbatore ,India where there is no incision on the external skin
[34]

and SILS( Single incision laparoscopic Surgery)where a single 2.5 cm incision is made to perform the surgery.

[edit]After

surgery

The stitches the day after having his appendix removed by surgery.

Hospital lengths of stay typically range from a few hours to a few days, but can be a few weeks if complications occur. The recovery process may vary depending on the severity of the condition, if the appendix had ruptured or not before surgery. Appendix surgery recovery is generally a lot faster if the appendix did not rupture.
[35]

It is important that patients respect their doctor's advice and limit

their physical activity so the tissues can heal faster. Recovery after an appendectomy may not require diet changes or a lifestyle change. After surgery occurs, the patient will be transferred to an intensive-care unit so his or her vital signs can be closely monitored in order to avoid complications. Pain medication may also be administrated if necessary. After patients are completely awake, they are moved into a hospital room to recover. Most individuals will be offered clear liquids the day after the surgery and then progress to a regular diet when the intestines start to function properly. It is highly recommended that patients sit up on the edge of the bed and walk short distances for several times a day. Moving is mandatory and pain medication may be given if necessary. Full recovery from appendectomies takes about 4 to 6 weeks but it can prolong to up to 8 weeks if the appendix had ruptured. [edit]Prognosis

Most appendicitis patients recover easily with surgical treatment, but complications can occur if treatment is delayed or if peritonitis occurs. Recovery time depends on age, condition, complications, and other circumstances, including the amount of alcohol consumption, but usually is between 10 and 28 days. For young children (around 10 years old), the recovery takes three weeks. The real possibility of life-threatening peritonitis is the reason why acute appendicitis warrants speedy evaluation and treatment. The patient may have to undergo amedical evacuation. Appendectomies have occasionally been performed in emergency conditions (i.e., outside of a proper hospital), when a timely medical evaluation was impossible. Typical acute appendicitis responds quickly to appendectomy and occasionally will resolve spontaneously. If appendicitis resolves spontaneously, it remains controversial whether an elective interval appendectomy should be performed to prevent a recurrent episode of appendicitis. Atypical appendicitis (associated with suppurative appendicitis) is more difficult to diagnose and is more apt to be complicated even when operated early. In either condition, prompt diagnosis and appendectomy yield the best results with full

recovery in two to four weeks usually. Mortality and severe complications are unusual but do occur, especially if peritonitis persists and is untreated. Another entity known as appendicular lump is talked about quite often. It happens when appendix is not removed early during infection and omentum and intestine get adherent to it forming a palpable lump. During this period, operation is risky unless there is pus formation evident by fever and toxicity or by USG. Medical management treats the condition. An unusual complication of an appendectomy is "stump appendicitis": inflammation occurs in the remnant appendiceal stump left after a prior incomplete appendectomy.
[36]