Appendicectomy : Open

See appendicitis.

GA, pt supine, bladder empty.
Prep entire abdomen, drape taking into account changes in plan eg lap --> open.
Palpate RIF for mass.

Conventional Technique

Small incision in skin crease just above McBurney's pt.
- centred on midclavicular line.
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Divide aponeurosis of external oblique in course of fibres.
Seprate with spreaders.
Separate int oblique with spreaders.
Separated transversus with spreaders.
Lift peritoneum and cut.
Find appendix.
Deliver appendix into wound by rotation of caecum, holding teniae with Babcock's.
- avoid too-extensive a blind dissection to achieve this.
Make window at base of mesoappendix.
Clamp across vessels, cut, transfix with 2-0 vicryl tie.
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Apply crushing clamp to appendix base.
Then move a little distal with crushers.
Transfix or tie with 2-0 vicryl in first crush groove.
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Invert stump with 3-0 vicryl ligature
- unless feel need at the time.
Close peritoneum with 3-0 vicryl.
Close internal oblique with a few interrupted sutures.
Close ext oblique aponeurosis well - this is where strength of wound comes from.
Close skin with subcuticular 4-0 monocryl.

Appendicitis not found:
There is a low probability of an occult appendicitis.
Methodic search for other causes.
- terminal ileum and ascending colon for IBD
- examine mesentry for nodes (take 2 if enlarged: one culture, one histo)
- run the small bowel in retrograde fashion for Meckel's.
- ?peritoneal fluid / exudate.
- examine pelvic organs.
- examine gall bladder & gastroduodenum.
- omentum for infarction / torsion
- occasionally sigmoid diverticulitis may be noted.
- etc etc.
Sometimes may need a new incision to treat the pathology found.
Remove appendix; it may be the cause and they have an appendicectomy scar now.
- there are vague reports about an increased risk of crohn's disease following appendicectomy.

The appendix was perforated.
Antibiotics
Wash
Drain if abscess cavity present.

The patient is pregnant, where is the appendix?
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