Appendectomies are performed to treat appendicitis, an inflamed and infected appendix.
Since appendicitis occurs most commonly in males between the ages of 10-14 and in females between the ages of 15-19, appendectomy is most often performed during this time. The diagnosis of appendicitis is most difficult in the very young (less than two years of age) and in the elderly.
Appendectomy is considered a major surgical operation. Therefore, a general surgeon must perform this operation in the operating room of a hospital. An anesthesiologist is also present during the operation to administer an anesthetic. Most often the anesthesiologist uses a general anesthetic technique whereby patients are put to sleep and made pain free by administering drugs in the vein or by agents inhaled through a tube placed in the windpipe. Occasionally a spinal anesthetic may be used.
After the patient is anesthetized, the general surgeon can remove the appendix either by using the traditional open procedure (in which a 2-3 [5-7.6 cm] in incision is made in the abdomen) or via laparoscopy (in which four 1 in [2.5 cm] incisions are made in the abdomen).
Traditional open appendectomy
When the surgeon uses the open approach, he makes an incision in the lower right section of the abdomen. Most incisions are less than 3 in (7.6 cm) in length. The surgeon then identifies all of the organs in the abdomen and examines them for other disease or abnormalities. The appendix is located and brought up into the wounds. The surgeon separates the appendix from all the surrounding tissue and its attachment to the cecum and then removes it. The site where the appendix was previously attached, the cecum, is closed and returned to the abdomen. The muscle layers and then the skin are sewn together.
When the surgeon conducts a laproscopic appendectomy, four incisions, each about 1 in (2.5 cm) in length, are made. One incision is near the umbilicus, or navel, and one is between the umbilicus and the pubis. Two other incisions are smaller and are in the right side of the lower abdomen. The surgeon then passes a camera and special instruments through these incisions. With the aid of this equipment, the surgeon visually examines the abdominal organs and identifies the appendix. Similarly, the appendix is freed from all of its attachments and removed. The place where the appendix was formerly attached, the cecum, is stitched. The appendix is removed through one of the incisions. The instruments are removed and then all of the incisions are closed.
Studies and opinions about the relative advantages and disadvantages of each method are divided. A skilled surgeon can perform either one of these procedures in
less than one hour. However, laproscopic appendectomy (LA) always takes longer than traditional appendectomy (TA). The increased time required to do a LA increases the patient's exposure to anesthetics, which increases the risk of complications. The increased time requirement also escalates fees charged by the hospital for operating room time and by the anesthesiologist. Since LA also requires specialized equipment, the fees for its use also increases the hospital charges. Patients with either operation have similar pain medication needs, begin eating diets at comparable times, and stay in the hospital equivalent amounts of time. LA is of special benefit in women in whom the diagnosis is difficult and gynecological disease (such as endometriosis, pelvic inflammatory disease, ruptured ovarian follicles, ruptured ovarian cysts, and tubal pregnancies) may be the source of pain and not appendicitis. If LA is done in these patients, the pelvic organs can be more thoroughly examined and a definitive diagnosis made prior to removal of the appendix. Most surgeons select either TA or LA based on the individual needs and circumstances of the patient.
Insurance plans do cover the costs of appendectomy. Fees are charged independently by the hospital and the physicians. Hospital charges include fees for operating and recovery room use, diagnostic and laboratory testing, as well as the normal hospital room charges. Surgical fees vary from region to region and range between $250-$750. The anesthesiologist's fee depends upon the health of the patient and the length of the operation.
Once the diagnosis of appendicitis is made and the decision has been made to perform an appendectomy, the patient undergoes the standard preparation for an operation. This usually takes only one to two hours and includes signing the operative consents, patient identification procedures, evaluation by the anesthesiologist, and moving the patient to the operating suites of the hospital. Occasionally, if the patient has been ill for a prolonged period of time or has had protracted vomiting, a delay of few to several hours may be necessary to give the patient fluids and antibiotics.
Recovery from an appendectomy is similar to other operations. Patients are allowed to eat when the stomach
Certain risks are present when any operation requires a general anesthetic and the abdominal cavity is opened. Pneumonia and collapse of the small airways (atelectasis) often occurs. Patients who smoke are at a greater risk for developing these complications. Thrombophlebitis, or inflammation of the veins, is rare but can occur if the patient requires prolonged bed rest. Bleeding can occur but rarely is a blood transfusion required. Adhesions (abnormal connections to abdominal organs by thin fibrous tissue) is a known complication of any abdominal procedure such as appendectomy. These adhesions can lead to intestinal obstruction which prevents the normal flow of intestinal contents. Hernia is a complication of any incision, However, they are rarely seen after appendectomy because the abdominal wall is very strong in the area of the standard appendectomy incision.
The overall complication rate of appendectomy depends upon the status of the appendix at the time it is removed. If the appendix has not ruptured the complication rate is only about 3%. However, if the appendix has ruptured the complication rate rises to almost 59%. Wound infections do occur and are more common if the appendicitis was severe, far advanced, or ruptured. An abscess may form in the abdomen as a complication of appendicitis.
Occasionally, an appendix will rupture prior to its removal, spilling its contents into the abdominal cavity. Peritonitis or a generalized infection in the abdomen will occur. Treatment of peritonitis as a result of a ruptured appendix includes removal of what remains of the appendix, insertion of drains (rubber tubes that promote the flow of infection inside the abdomen to outside of the body), and antibiotics. Fistula formation (an abnormal connection between the cecum and the skin) rarely occurs. It is only seen if the appendix has a broad attachment to the cecum and the appendicitis is far advanced causing destruction of the cecum itself.
Others may require a longer stay—three to five days. Almost all patients are back to their normal activities within three weeks.
The mortality rate of appendicitis has dramatically decreased over time. Currently, the mortality rate is estimated at one to two per 1,000,000 cases of appendicitis. Death is usually due to peritonitis, intra abdominal abscess or severe infection following rupture.
The complications associated with undiagnosed, misdiagnosised, or delayed diagnosis of appendectomy are very significant. The diagnosis is of appendicitis is difficult and never certain. This has led surgeons to perform an appendectomy any time that they feel appendicitis is the diagnosis. Most surgeons feel that in approximately 20% of their patients, a normal appendix will be removed. Rates much lower than this would seem to indicate that the diagnosis of appendicitis was being frequently missed.
Schwartz, Seymour I. "Appendix." In Principles of Surgery,ed. Seymour Schwartz, et al. New York: McGraw-Hill, 1994.
Silen, William. "Acute Appendicitis." In Harrison's Principles of Internal Medicine, ed. Anthony S. Fauci, et al. New York: McGraw-Hill, 1997.
McCall, J. L., K. Sharples, and F. Jafallah. "Systematic Review of Randomized Controlled Trial Comparing Laproscopic with Open Appendectomy." British Journal of Surgery 84, no. 8 (Aug. 1997): 1045-1950.
Minne, L., et al. "Laproscopic Vs Open Appendectomy. Prospective Randomized Study of Outcomes." Archives of Surgery 132 (July 1997): 708-711.
"Appendectomy." ThriveOnline. <http://thriveonline.oxygen.com>.
"The Appendix." Mayo Clinic Online. <http://www.mayohealth.org>.
Mary Jeanne Krob, MD, FACS
Abscess—A collection of pus buried deep in the tissues or in a body cavity.
Anesthesiologist—A physician who has special training and expertise in the delivery of anesthetics.
Anesthetics—Drugs or methodologies used to make a body area free of sensation or pain.
Cecum—The beginning of the large intestine and the place where the appendix attaches to the intestinal tract.
General surgeon—A physician who has special training and expertise in performing a variety of operations.
Pelvic organs—The organs inside of the body that are located within the confines of the pelvis. This includes the bladder and rectum in both sexes and the uterus, ovaries, and fallopian tubes in females.
Pubis—The anterior portion of the pelvis located in the anterior abdomen.
Thrombophlebitis—Inflammation of the veins, usually in the legs, which causes swelling and tenderness in the affected area.