Appendicectomy

Pre-op

• Ensure the bladder is empty

Laparoscopic appendicectomy

• Technique
  • Infra-umbilical Hasson
  • Decide on next two ports (usually supra-pubic and LIF)
  • Use a universal and a bowel grasper to identify appendix, find the TI, orient it
  • Decide how to take it out - antegrade vs retrograde
• Difficulty
  • Extra port
  • Mobilise caecum inferior to superior (watch out for ureter, stay in correct plane, anterior to Gerota's)
  • Retrograde appendicectomy
    • Divide appendix at base
    • Endoloops x2 to base
    • Dissect along appendix until you reach the tip and remove
  • Convert to open

Open appendicectomy

• Mark a line between ASIS and umbilicus, and mark Mcburney's point 1/3 of the way to umbilicus
• Make 5cm incision at McBurney's point along Langer's lines
  • Can also do Rockey-Davis (transverse) incision
• Carry incision down to aponeurosis of external oblique, and divide in direction of fibres to expose internal oblique
• Divide IO and expose transversus abdominis, which is split to expose peritoneum
• Elevate peritoneum and divide with Metz scissors
• Identify caecum and appendix
• Divide mesoappendix between two Kelly clamps and tie off
• Ligate appendix and divide
• No need to invert the stump
• Close in layers: first peritoneum and transversalis, then IO, then EO, then skin

Drains only necessary for abscess cavities

Complications:

• Wound infection 3-10%, mostly with perforated
• Abscess - 1%
  • If <4cm, can be safely managed non-op
  • Percutaneous drainage is the other option