What are the steps involved in an appendectomy procedure?

Step by Step of Appendectomy Procedure

Laparoscopic appendectomy is strongly recommended over open appendectomy for both adults and children due to its advantages including less pain, lower surgical site infection rates, shorter hospital stays, earlier return to work, and better quality of life. 1

Preoperative Management

• Appendectomy should be performed within 24 hours of admission to minimize complications, with early appendectomy (within 8 hours) recommended for complicated appendicitis 1, 2
• Preoperative antibiotic therapy is recommended for all patients with suspected appendicitis 3

Surgical Approach Selection

• Conventional three-port laparoscopic technique is preferred over single-incision laparoscopic appendectomy due to shorter operative times, less postoperative pain, and lower incidence of wound infection 1, 2
• Laparoscopic approach is particularly beneficial for obese patients, older patients, patients with comorbidities, and pregnant patients 1
• In pediatric patients with favorable anatomy, single incision/transumbilical extracorporeal laparoscopic-assisted appendectomy may be considered as an alternative 2

Laparoscopic Appendectomy Steps

1. Patient Positioning and Setup

   • Position patient supine with left arm tucked 4
   • Surgeon stands on patient's left side with monitors positioned on patient's right side 4

2. Port Placement

   • Insert primary port (10-12mm) at umbilicus using open (Hasson) technique or closed technique 1
   • Place secondary ports (5mm) in suprapubic region and left lower quadrant under direct visualization 1

3. Abdominal Exploration

   • Perform systematic exploration of abdomen to confirm diagnosis and rule out other pathology 4
   • Identify appendix by following taenia coli to base of cecum 4

4. Mesoappendix Dissection

   • For mesoappendix dissection, use monopolar electrocoagulation or bipolar energy as cost-effective techniques 1
   • Dissect mesoappendix from tip to base, identifying and controlling appendicular artery 4

5. Appendix Base Management

   • For stump closure, use endoloops/suture ligation or polymeric clips for both uncomplicated and complicated appendicitis 1
   • Simple ligation is preferred over stump inversion in both open and laparoscopic appendectomy 1, 2
   • Ensure adequate stump length (<5mm) to prevent stump appendicitis 5

6. Appendix Removal

   • Place appendix in specimen retrieval bag before removal through port site to prevent wound contamination 4
   • In complicated appendicitis with intra-abdominal collections, use suction alone rather than irrigation 1

7. Final Steps

   • Inspect hemostasis and ensure no active bleeding 4
   • Remove instruments and ports under direct visualization 4
   • Close fascial defects at port sites ≥10mm to prevent hernia formation 4

Open Appendectomy (When Laparoscopic Approach Not Feasible)

1. Incision

   • Make McBurney (oblique) or Rocky-Davis (transverse) incision at McBurney's point 4
   • Use wound ring protectors to decrease risk of surgical site infection 2

2. Appendix Identification and Removal

   • Identify cecum and trace taenia coli to appendix 4
   • Ligate and divide mesoappendix 4
   • Ligate base of appendix, transect, and remove 4
   • Simple ligation of appendicular stump is recommended over stump inversion 2

3. Closure

   • Primary skin closure with absorbable intradermal suture is recommended for open appendectomy wounds 3

Postoperative Management

• Abdominal drains are not recommended following appendectomy for complicated appendicitis in adults or children 1, 2
• Outpatient laparoscopic appendectomy can be considered for uncomplicated appendicitis when an ambulatory setting with well-defined protocols is available 1, 6
• Postoperative antibiotics are indicated for complicated appendicitis but may not be necessary for uncomplicated cases 1

Special Considerations

• The normal-appearing appendix should be removed during surgery in symptomatic patients when no other pathology is found 1
• Routine histopathological examination of the appendix is necessary to identify unexpected findings 1, 3
• In perforated appendicitis with periappendiceal abscess, percutaneous image-guided drainage may be considered when available 1

Common Pitfalls to Avoid

• Inadequate stump closure can lead to stump appendicitis, a rare but serious complication requiring reoperation 5
• Failure to identify the true base of the appendix may result in incomplete appendectomy 5
• Delaying appendectomy beyond 24 hours from admission increases risk of adverse outcomes 1, 3
• Macroscopic judgment of early appendicitis is often inaccurate, so appendectomy should be performed even if the appendix appears normal during surgery in symptomatic patients 1