Once a diagnosis of appendicitis is made, an appendectomy usually is performed. The operation may be performed through a standard small incision in the right lower part of the abdomen, or it may be performed using a laparoscope, which requires three to four smaller incisions. If other conditions are suspected in addition to appendicitis, they may be identified using laparoscopy. In some patients, laparoscopy is preferable to open surgery because the incision is smaller, recovery time is quicker, and less pain medication is required.
But if the appendix has perforated (ruptured), the surgery may be more complicated. In this situation, an abscess usually has formed, and the appendiceal perforation may have closed over. If the abscess is small, it initially can be treated with antibiotics; however, the abscess usually requires drainage. A drain usually is inserted with the aid of an ultrasound or CT scan that can determine the exact location of the abscess. The appendix is removed several weeks or months after the abscess has resolved. This is called an interval appendectomy and is done to prevent a second attack of appendicitis.
Before and after surgery, you will receive intravenous (IV) fluids and medications. Even if the appendix has not ruptured, your doctor may prescribe antibiotics because they can decrease the risk of infection after surgery.
Open appendectomy is still the most common approach because it is quick and cost effective. However, an increasing number of surgeons prefer laparoscopic appendectomy because of the diagnostic ability of laparoscopy, especially in female patients. The aesthetic results and an earlier return to normal activities may also be advantageous.
The Open Technique
In this operation, the surgeon makes a short incision through the skin and underlying fat. The muscles of the wall are then separated, revealing the peritoneum, which is the lining of the abdominal cavity. The peritoneum is cut to reveal the cecum, the section of the large intestine to which the appendix is attached. After the small intestine has been moved aside, the appendix is carefully freed from the surrounding structures. Blood vessels around the site are tied off.
At this point, the appendix is tied off and severed. The appendix is then sent to the pathology laboratory for examination. The stump of the appendix is positioned into the cecum. Finally, the peritoneum, the muscle wall, and the skin incision are closed. Closure of the skin is done either with sutures or tiny staples.
The Laparoscopic Technique
A laparoscope is used to view the inside of the abdominal cavity while the surgeon removes the appendix. A laparoscope is a long metal tube with a lens on which a TV camera is attached. The surgeon can then perform the appendectomy directly from the TV monitor. Surgical instruments called cannulas are inserted into other small openings and used to remove the appendix.
Laparoscopic appendectomy is a safe alternative to the open technique. Presently, there seems to be no difference between the two techniques in terms of hospital costs, length of the patient's hospital stay, or infection rate. It may, however, let patients resume normal activity more quickly than the open technique permits. This method is not for every patient, and it is up to you and your surgeon to decide whether it is right for you.