What are the steps for an open appendectomy in a 70kg adult with acute appendicitis and no significant pre-existing renal or cardiac disease?

Open Appendectomy Technique

While laparoscopic appendectomy is strongly preferred over open appendectomy for acute appendicitis due to superior outcomes in pain, infection rates, hospital stay, and quality of life, open appendectomy remains necessary when laparoscopic expertise or equipment is unavailable, or when conversion is required. 1

Preoperative Preparation

• Administer broad-spectrum antibiotics 0-60 minutes before surgical incision covering facultative and aerobic gram-negative organisms plus anaerobes (e.g., ceftriaxone plus metronidazole, or cefotaxime plus metronidazole) 1, 2
• Ensure adequate resuscitation and hemodynamic stability before proceeding 3
• Obtain informed consent discussing risks including wound infection, intra-abdominal abscess, and potential for negative appendectomy 1

Surgical Steps

Incision and Exposure

• Make a McBurney's or Lanz incision (oblique or transverse) in the right lower quadrant, centered over McBurney's point (one-third the distance from anterior superior iliac spine to umbilicus) 1
• Divide subcutaneous tissue and identify the external oblique aponeurosis 1
• Split the external oblique, internal oblique, and transversus abdominis muscles in the direction of their fibers to minimize denervation 1
• Open the peritoneum carefully and extend the incision as needed for adequate exposure 1

Appendix Identification and Mobilization

• Identify the cecum by following the taeniae coli, which converge at the appendiceal base 1
• Deliver the cecum into the wound; if the appendix is retrocecal or difficult to locate, mobilize the cecum by incising the lateral peritoneal reflection 1
• Remove the appendix even if it appears macroscopically normal, as surgeon judgment is inaccurate and 27.8% of "normal-appearing" appendices show inflammation on histology 3

Appendix Removal

• Ligate the mesoappendix using clamps and ties, or divide with monopolar/bipolar energy for hemostasis 2
• Divide the mesoappendix close to the appendix to preserve blood supply to the cecum 1
• Ligate the appendiceal base with absorbable suture (simple ligation is recommended over stump inversion) 3
• Divide the appendix distal to the ligature and remove it 1
• Do not invert the stump routinely, as simple ligation is preferred in both open and laparoscopic approaches 3

Peritoneal Management

• Perform suction of any purulent material or fluid collections; irrigation does not prevent intra-abdominal abscess and may be avoided 1, 3
• Inspect the pelvis, paracolic gutters, and subhepatic space for additional pathology or fluid 1
• Do not place routine abdominal drains following appendectomy for complicated appendicitis, as they provide no benefit and prolong hospitalization 3

Closure

• Close the peritoneum if desired (not mandatory) 1
• Reapproximate the muscle layers anatomically 1
• Close the external oblique aponeurosis with absorbable suture 1
• Consider delayed primary closure or leaving the wound open in cases of perforated appendicitis with significant contamination to reduce wound infection risk 4
• Close skin with subcuticular suture or staples for uncomplicated cases 1

Postoperative Management

• Send the appendix for mandatory histopathological examination to identify unexpected findings including malignancy (incidence 0.3% to 24% in elderly patients) 1, 2
• For uncomplicated appendicitis with adequate source control, do not continue postoperative antibiotics 2, 3
• For complicated appendicitis (perforation, abscess, peritonitis), continue antibiotics for 3-5 days postoperatively when adequate source control is achieved 2, 3
• Monitor for complications including wound infection, intra-abdominal abscess, and prolonged ileus 4

Critical Pitfalls to Avoid

• Failing to remove a normal-appearing appendix in symptomatic patients—macroscopic judgment is unreliable and the appendix should be removed when no other pathology is found 2, 3
• Inverting the appendiceal stump, which is not recommended over simple ligation 3
• Placing routine drains, which increase hospital stay without reducing abscess formation 3
• Using peritoneal irrigation, which does not prevent complications and may be omitted 1, 3
• Omitting histopathology, which may miss unexpected malignancy or other pathology 2, 3
• Continuing antibiotics beyond 3-5 days in complicated appendicitis with adequate source control 2, 3

Special Considerations

• Maintain low threshold for conversion to open if laparoscopy was initially attempted and technical difficulties arise, particularly in complicated appendicitis with shock 3
• For patients ≥40 years old with complicated appendicitis, recommend colonoscopy and interval CT scan due to higher incidence of appendicular neoplasms (3-17%) 2
• In elderly patients, open appendectomy may be necessary when laparoscopic expertise is unavailable, though laparoscopy is preferred when available due to reduced morbidity and length of stay 1