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Since appendicitis was first described over a century ago, appendectomy has been the gold standard of treatment. It is among the most commonly performed surgeries in the United States and globally. Appendectomy is a relatively safe procedure, with a mortality rate ranging from 0.09% to 0.24 %, and serves as the definitive treatment for appendicitis. Open and laparoscopic surgery are the two approaches used to perform appendectomies. In recent years, rates of laparoscopic surgery have surpassed that of open surgery in both nonperforated and perforated appendicitis. Laparoscopic appendectomy is the preferred treatment for specific populations with unique considerations, such as pregnant women, pediatric patients, older adults, and individuals with obesity. Laparoscopic appendectomy is associated with decreased wound infection rates, length of hospital stay, and morbidity and mortality rates. This activity reviews appendectomies and highlights the role of the interprofessional team in evaluating and treating patients who undergo appendectomy. Objectives: Correlate the anatomy of the appendix with common presenting signs and symptoms of acute appendicitis. Outline the indications for and contraindications to open and laparoscopic appendectomy. Implement correct techniques of open and laparoscopic appendectomy. Identify the most common complications of appendectomy. Access free multiple choice questions on this topic.

Appendectomy is among the most commonly performed surgical procedures.[1] The most common indication for appendectomy is acute appendicitis. The lifetime risk of acute appendicitis ranges from 9% to 10%.[2] Acute appendicitis most commonly occurs between the ages of 10 and 20 years.[3] Appendicitis is called the first American surgical disease, and appendectomy holds a prominent and storied position in surgical history. Charles McBurney published his report on the surgical management of appendicitis in 1895. He described the potential consequences of undrained purulent appendicitis, the disadvantages of the classical midline laparotomy, and exploratory needle puncture. Finally, he described a novel surgical approach and exposure, introducing consecutive lateral incisions through the external oblique aponeurosis, internal oblique, and transversus abdominis muscles rather than midline laparotomy.[4] Appendectomy was the first laparotomy performed with a source control approach to eradicate an infectious threat.[5] Since appendicitis was first described over a century ago, appendectomy remains the gold standard of treatment.[6] Today, the inflamed appendix can be surgically removed using either an open approach or the laparoscopic appendectomy method first described by Semm in 1983. Despite a significant change in managing acute appendicitis with primary antibiotic therapy, the primary option for treating acute appendicitis remains a surgical approach. A large, randomized trial of antibiotic therapy for the primary management of acute appendicitis showed that while antibiotic therapy might have comparable results with appendectomy in the short term, 1 of 4 participants in the antibiotic therapy arm required appendectomy within one year.[7]

The most common complication following appendectomy is surgical site infection, including wound infections and intraabdominal abscesses. Surgical site infections are relatively rare in cases of uncomplicated appendicitis but may occur in up to 10% of patients with a perforated appendix. Wound Infection Superficial wound infections occur within the 30 days following an appendectomy and involve the skin and subcutaneous tissues. Diagnosis is based primarily on history and physical examination. Examination findings consistent with superficial wound infection include peri-incisional pain, swelling, and erythema. The diagnosis is supported by purulent drainage from the incision, a positive wound culture, or the need to open a surgical incision. Deep wound infections occur in the 30 to 90 days following an appendectomy and include the muscles and fascia deep to the subcutaneous tissue. Again, a thorough medical history and physical examination should be performed. Examination findings consistent with a deep wound infection include per-incisional pain, tenderness, and systemic findings such as fever. The diagnosis is supported by purulent drainage from the incision site, a positive wound culture, or wound dehiscence.[55] Preoperative antibiotics, appropriate wound scrubbing, specific intraoperative retractors, and intraoperative irrigation may be used to minimize the risk of postoperative wound infections. There is no difference in the rate of wound infection between primary and delayed primary incision closure.[56] Compared to open appendectomy, laparoscopic appendectomy is associated with a lower risk of incision site infection but a higher risk of intra-abdominal and pelvic infection.[57] Pelvic Abscess Approximately 9.4% of patients who undergo appendectomy for complicated appendicitis will develop a postoperative pelvic abscess. Several measures have been recommended to reduce the risk of postoperative pelvic abscesses, including intraoperative peritoneal irrigation. Outcomes of the measures conflict, and no intervention has been proven more effective than another.[58] Stump Appendicitis

Approximately 9.4% of patients who undergo appendectomy for complicated appendicitis will develop a postoperative pelvic abscess. Several measures have been recommended to reduce the risk of postoperative pelvic abscesses, including intraoperative peritoneal irrigation. Outcomes of the measures conflict, and no intervention has been proven more effective than another.[58] Stump Appendicitis Stump appendicitis, a form of recurrent appendicitis, may occur when an inadequate amount of appendiceal tissue is resected, and a long stump is left behind.[59] Post-appendectomy stump appendicitis most commonly occurs in cases of perforated appendicitis. Resection of adequate appendiceal tissue with less than 5 mm of stump preservation is recommended to minimize risk.[60] Mortality The mortality associated with appendectomy is low; it is considered a relatively safe procedure. Morbidity and mortality after appendiceal perforation are 5.1 per 1000. However, the mortality rate can differ depending on the geographic location, as evidenced by more developed countries having a rate of 0.09% to 0.24% and developing countries having a rate of 1% to 4%.

Patients with appendicitis typically present with abdominal pain localizing to the right lower quadrant. Emergency department triage staff should be familiar with the presenting signs and symptoms of acute appendicitis to facilitate urgent admission and treatment. While the patient is undergoing further clinical evaluation, IV access should be obtained, and fluids, pain medication, and antibiotics administered as ordered. Imaging study orders should indicate the possibility of acute appendicitis. In addition, a pregnancy test should be performed in patients of childbearing age with a uterus. After a presumptive diagnosis of appendicitis, the surgeon should coordinate with the patient and interprofessional team to determine the preferred surgical approach. The pharmacist should evaluate potential drug interaction allergies and report any concerns to the interprofessional team. Before surgery, the anesthesiologist and surgical assistant should be notified of the patient’s scenario and surgical plan. The operating room staff should ensure all necessary instruments and materials are available. Postoperatively, the nurse should monitor for acute changes in vital signs or symptoms and report findings to the team. Early recognition of the signs and symptoms of appendicitis lowers rates of complications to improve outcomes. Laparoscopic appendectomy is an effective and safe method for treating uncomplicated appendicitis and may also be performed safely in patients with perforated appendicitis. [Level 1, 2] The laparoscopic approach is associated with lower morbidity and mortality rates and shorter stays regardless of whether abscesses developed or perforations occurred. [Level 2] Developing consistent operative methods decreases operating time, costs, and complications.[59] [Level 2]