Appendicectomy Pre-operative Preparation

Surgeon: Infection control: o Antibiotic prophylaxis e.g 1g metronidazole pr o The patient should be instructed to take an anti-bacterial cleansing bath, e.g. Chlorhexidine Gluconate 2%, 1 hour before the operation. Make sure you inspect the area for any infected hair follicles, especially in females.

Operation Surgeon
Positioning:
1. The patient is placed in the supine position 2. Surgeon stands on the right side of the patient

Operative Preparation:
1. The patient is exposed from the nipples to knees. 2. The abdomen is shaved with electric clippers 3. The abdominal skin from the xiphisternum to groin crease is prepared with an appropriate anti-septic solution, e.g. povidone-iodine, Chlorhexidine 0.5%, and allowed to dry for 3mins. 4. Occlusive drapes are applied to square off the Right Iliac fossa. Make sure you can feel your landmarks, Anterior superior Iliac Spine and umbilicus

Intra-Operative Instruction Incision:

There are numerous incisions that can be employed (lanz, gridiron etc) The base of the appendix is traditionally located at McBurneys point (junction of middle ant outer third of a line joining the anterior superior iliac spine to the umbilicus). A safe and cosmetically acceptable incision is 2cm a transverse incision 2cm above and medial to the ASIS extending 4cm medially. This gives you the opportunity of extending

it laterally and medially should you need. However centre your incision over any palpable appendix mass.

Procedure: 1. Entering the peritoneal cavity

Incise the skin with a scalpel and extend incision through subcutaneous fat and Scarpas fascia to expose the external oblique aponeurosis (white fibres running infero-medially) o Insert a self-retaining retractor (West/Travers) Incise the External oblique aponeurosis with a scalpel and then open the aponeurosis in the line of its fibres with mayo scissors o Reposition the self-retainer The internal oblique muscle fibres should now be evident Split the muscle fibres (travelling supero-medially) by inserting the mayo scissors into the muscle and opening them up. In the created defect now place two Langenbecks and pull the muscle open o Reposition the self-retainer The transversalis fascia is now evident with fused peritoneum on its underside Pick up the facia with artery forceps and then pick up the facsia with another pair of forceps next to the original. Replace the original forceps. o = three clip technique o This prevents any structures within the peritoneal cavity from being picked up.

Incise the fasci/peritoneum with a scalpel and extend the opening with Mayo scissors in the line of the skin incision o Reposition your Langenbecks within the peritoneum and remove selfretainer

2. Assess
Send a microbiologcal sample of any free intra-peritoneal fluid/pus

3. Locate the appendix

Identify the caecum

Follow the taenia coli proximally to the base of the appendix o This is made easier by grasping the taenia with a pair of Babcocks and moving them proximally to the base as you follow the taenia. o Place a Babcocks around the base of the appendix

If the appendix is still not evident you can: o Place you index finger on the right inferior margin of the peritoneal cavity and move it superiorly along Iliacus muscle until you reach the caecum o Deliver the caecum into the wound You may need to mobilise the caecum by dividing the parietal peritoneum in the lateral paracolic gutter

o Identify the base of the appendix

4. Assess
Ask is the appendix swollen, engorged, gangrenous, perforated, covered in fibrin? Is there any other obvious pathology?

5. Removal of Appendix
The appendicular artery enters the appendix mesentry (mesoappendix) medially Identify and divide the artery and mesoappendix between two artery forceps. o If the mesoappendix is particularly thickened divide the structures in two or more bites antegrade or retrogradely Ligate the artery/mesentry with 2/0 vicryl Crush the base of the appendix with an artery forcep and then reposition the forcep just distal to the crushed segement

Transfix the base of the appendix with 2/0 vicryl, but hold onto the ends of the suture Divide the base with a sharp scalpel by running it along the proximal surface of the artery forcep Remove the appendix, artery forcep, scalpel (they are dirty as you have entered bowel)

Cut the ends of your ligature to the base of your appendix Some surgeons advocate burying the base of the appendix utilising a purse string suture there is no evidence for this!

6. Normal Appendix
If the appendix appears normal or you are unsure remove the appendix unless you have diagnosed crohns then: a. Examine the small bowel is there an inflamed Meckels? b. Examine he Small bowel mesentry is there any enlarged lymph nodes? If yes obtain a biopsy c. Examine the caecum is there a tumour? Diverticulitis? d. Gallbladder? Bile-stained fluid? e. Sigmoid colon? If you still cannot identify a cause you have two options: a. Close and serially assess the patient over the next 24-48hrs b. Proceed to laparaotomy These decisions are based upon your pre-operative and intra-operative findings. Discuss with a colleague/consultant in any doubt exists!

7. Washout
We utilise a thorough peritoneal cavity washout with 2L warm water. However some surgeons believe this converts a localised infection into generalised peritonitis.

8. Closure
Do not close the peritoneum unless the bowel is preventing safe closure of the proceeding layers. Closing the peritoneum increases the risk of adhesions! 2-3 loose tacking sutures 2/0Vicryl to the internal oblique muscle Close external oblique with 2/0 Vicryl continous 2/0 Vicryl to Scarpas interrupted 4/0 biosyn suncuticular to skin If the appendix was perforated or there was a large abscess then place a running subcuticular suture in the skin but pack the wound with betadine soaked gauze for 24hours and then pull the suture tight to close skin. Local anaesthetic into the incision

9. Anaesthetic:

7. Dressing:

Mepore

Postoperative instructions
Surgeon: 1. Change Mepore for water proof dressing 6 hours post-op. 2. Antibiotics: a. If appendix inflamed 3 post-op doses b. If appendix perforeated for 5 days post-op 3. Can go in shower after 24 hours and home 2days post-op if well 4. Be aware of post-op collections and wound infections in particular 5. No heavy (>5kg) lifting for 6 weeks

Tips
Surgeon If you cannot locate the appendix despite the above techniques, extend your incision laterally and medially The Caecum can be located quite superiorly under the liver When delivering the appendix do not pull on it as this may fracture a gangrenous appendix. Be aware of vessels in the right iliac fossa Recognise that although appendicectom is still considered an SHO operation they can still be extremely difficult as you are operating through a small incision