What is the procedure for an open appendectomy?

Open Appendectomy Procedure

For open appendectomy, use a McBurney or Lanz incision, perform simple ligation of the appendiceal stump without inversion, employ wound ring protectors to reduce surgical site infections, and close the skin primarily with absorbable intradermal sutures. 1

Preoperative Preparation

• Administer a single dose of broad-spectrum intravenous antibiotics 0-60 minutes before skin incision (amoxicillin/clavulanate 1.2g is commonly used) 2
• Fluoroquinolones and vancomycin require 1-2 hours for administration, so begin within 120 minutes of incision if using these agents 1
• Perform surgery within 24 hours of hospital admission to minimize complications 3

Surgical Technique

Incision and Access

• Make a McBurney or Lanz incision in the right lower quadrant 4
• Insert a wound ring protector at the time of incision, particularly for complicated appendicitis with contaminated/dirty wounds, as this significantly reduces surgical site infection rates 1

Appendix Mobilization and Mesoappendix Division

• Use monopolar electrocoagulation or bipolar energy for mesoappendix dissection, as these are the most cost-effective techniques with equivalent outcomes 1, 3
• Other energy devices may be used based on intraoperative judgment and available resources 3

Stump Management

• Perform simple ligation of the appendiceal stump rather than stump inversion, as simple ligation is associated with shorter operative times, less postoperative ileus, quicker recovery, and similar morbidity rates 1
• Use standard suture ligation for stump closure 1
• Remove the appendix even if it appears macroscopically normal, as 27.8% of "normal-appearing" appendices show inflammation on histopathology 5

Peritoneal Management

• Perform suction of any intra-abdominal collections present 1
• Avoid routine peritoneal irrigation, as it does not prevent intra-abdominal abscess formation or wound infections 1
• Do not place prophylactic intra-abdominal drains after appendectomy for complicated appendicitis, as drains provide no benefit in preventing abscess formation and lead to longer hospitalization 1

Wound Closure

• Close the skin primarily with a unique absorbable intradermal (subcuticular) suture, as this technique is associated with lower rates of surgical site infection, abscess, and seroma formation compared to traditional non-absorbable separated stitches 1
• Delayed primary closure increases hospital stay and costs without reducing surgical site infection risk 1
• Consider using triclosan-coated sutures, though evidence for additional benefit is limited 2

Postoperative Antibiotic Management

• For uncomplicated appendicitis with adequate source control, discontinue antibiotics postoperatively 5
• For complicated appendicitis (perforation, abscess, or peritonitis), continue antibiotics for 3-5 days postoperatively when adequate source control is achieved 5

Specimen Handling

• Send all appendectomy specimens for routine histopathological examination to identify unexpected findings, as the incidence of unexpected disease (including neoplasms) is significant, particularly in patients ≥40 years old 1, 5

Common Pitfalls to Avoid

• Do not invert the appendiceal stump, as this increases operative time and postoperative ileus without reducing complications 1
• Do not use drains routinely, as they increase morbidity and hospital stay 1
• Do not perform delayed primary closure of contaminated wounds, as primary closure with subcuticular sutures is superior 1
• Do not skip histopathology, even when the appendix appears grossly normal, as macroscopic assessment is unreliable 5
• Ensure the appendiceal stump is adequately long (avoid leaving excessive stump length) to prevent stump appendicitis, though this complication remains rare 6