Appendectomy is the surgical removal of the vermiform appendix (appendix for short). Nowadays, the procedure is almost always performed minimally invasively, i.e., by laparoscopy (laparoscopy).Appendicitis (synonym: appendicitis) is the inflammation of the appendix vermiformis. It usually occurs in individuals in the second and third decades of life and in childhood. The incidence (number of new cases) is about 100 cases per 100,000 inhabitants per year. The lethality (mortality in relation to the total number of people suffering from the disease) is approximately 0.1% in uncomplicated appendicitis. In a complicated course with perforation (breakthrough), it ranges from three to 15%.
Indications (areas of application)
- Appendectomy is indicated even when appendicitis is suspected (see Diseases/Symptoms: Appendicitis), otherwise severe complications such as peritonitis may occur.
- Furthermore, surgery is also used for tumors such as appendiceal carcinoid (AC; most common neuroendocrine tumor; found as an incidental finding in 0.3% of all appendectomies).
Contraindications
- Cardiopulmonary decompensated patient (in laparoscopic surgery due to necessary creation of pneumoperitoneum/peritoneal cavity filled with air or gas/peritoneal cavity).
- Contraindications to proceeding with laparoscopic surgery:
- Laparoscopic inaccurate visualization of the appendiceal base.
- Tumors of the appendix vermiformis
- Phlegmon (bacterial inflammation of the connective tissue) of the coecum wall (appendix wall) or appendix perforation near the base (“appendix perforation”).
- Insufficient possibility of sanitation in the case of perforation or abscess (formation of a pus cavity).
The surgical procedure
Appendectomy is divided into open surgery and laparoscopy (laparoscopy).In open surgery, an incision is made in the right lower abdomen and the abdominal cavity is opened to expose the intestine with the appendix vermiformis. Then, the blood supply to the appendix vermiformis via the so-called mesenteriolum (tissue fold that contains the blood vessels supplying the appendix vermiformis in addition to fat and connective tissue) is interrupted and cut through by ligature or electrocoagulation. The appendix is then ligated at the base, that is, at the junction of the appendix and the caecum (appendix), and set apart. In the conventional procedure, the ligation is performed using absorbable suture; in the laparoscopic procedure (see below), this is inserted as a so-called “Röder snare” (pre-knotted snare). The stump can be inserted into the caecum by a tobacco bag suture or left in place after disinfection.Laparoscopic appendectomy is performed in the following manner:
- Infraumbilical incision (surgical incision below the belly button (umbilicus)) and insertion of the camera trocar under visualization Note: A trocar is an instrument used in minimally invasive surgery to create sharp or blunt access to a body cavity (e.g., abdominal cavity, chest cavity) and to keep it open by means of a tube (= tube).
- Creating the pneumoperitoneum (gas-filled peritoneal cavity / peritoneal cavity) and subsequent exploration of the abdomen (“exploration / examination of the abdomen).
- Placement of working trocars under visualization (13.5 mm trocar in the left lower abdomen and 5 mm trocar in the right lower abdomen)
- Skeletonization and deposition of the appendix
- Settling of the mesoterioum, irrigation of the situs especially in the Douglas space (woman) or excavatio rectovesicalis (man) and suction.
- Salvage of the appendix
- Removal of the salvage bag and trocars.
- Fascia closure, skin suture and dressing.
Laparoscopic appendectomy can cause increased intestinal suture insufficiency and vascular injury in addition to the complications mentioned below. However, with great experience of the surgeon, these mentioned risks are hardly increased. Which form of surgery is chosen depends on the patient’s condition, exact findings and secondary diseases. The operation is mainly performed under general anesthesia. The average duration of the conventional, i.e. open, operation is approx.40 (± 18) minutes.The mean operative time of laparoscopic appendectomy is approximately 45 (± 15) minutes.
Potential complications
- Insufficiency of the appendiceal stump with subsequent abscess (encapsulated collection of pus) or peritonitis (inflammation of the peritoneum)
- Wound infection (especially in the case of perforation of the appendix due to intraoperative spread of bacteria into the abdominal wall).
- Infections
- (Post) bleeding
- Nerve and vascular damage
- Injury to the bowel, ureter, or other adjacent organs
- Ileus (intestinal obstruction)
- Adhesions in the abdominal cavity (adhesions in the abdominal cavity).
- Incisional hernia (incisional hernia)
Other notes
- Recurrent appendicitis after appendectomy (appendectomy) (due to stump appendicitis).
