Treatment

• Open Appendectomy
• Laparoscopic Appendectomy
• Natural Orifice Transluminal Endoscopic Surgery
• Antibiotics as Definitive Therapy
• Interval Appendectomy
Open Appendectomy
• most surgeons use :
1. McBurney (oblique) right lower quadrant
musclesplitting incision
2. Rocky-Davis (transverse)
• The incision should be centered over either the point of maximal
tenderness or a palpable mass
• If an abscess is suspected, a laterally placed incision is imperative to
allow retroperitoneal drainage and to avoid generalized
contamination of the peritoneal cavity
• If the diagnosis is in doubt, a lower midline incision is recommended
to allow a more extensive examination of the peritoneal cavity
• limited mobilization of the cecum is needed to aid in adequate
visualization
• The appendiceal stump can be managed by simple ligation or by
ligation and inversion with either a purse-string or Z stitch (as long the
stump viable and doesn’t inflamation)
• If perforation or gangrene is found in adults, the skin and
subcutaneous tissue should be left open and allowed to heal by
secondary intent or closed in 4 to 5 days as a delayed primary closure.
• If purulent fluid is encountered, it is imperative that the source be
identified. (peritoneal fluid taken for Gram’s staining and culture)
Laparoscopic Appendectomy
• Laparoscopic appendectomy is performed under general anesthesia
& usually requires the use of three ports.
• One assistant is required to operate the camera.
• One trocar is placed in the umbilicus (10 mm), a second trocar (10 or
12 mm, depending on whether or not a linear stapler will be used) is
placed in the suprapubic position (some in left lower quadrant) and
the third trocar (5 mm) is variable (left lower quadrant, epigastrium,
or right upper quadrant).
The appendix is identified by following the anterior taeniae to its base.
Dissection at the base of the appendix enables the surgeon to create a
window between the mesentery and the base of the appendix.

• Base appendix and

mesoappendix is
evaluated for
hemostasis.
• The right lower
quadrant should be
irrigated.
• Trocars are removed
under direct vision.
Advantages & disadvantages
- pain on the first postoperative
day is significantly less after
laparoscopic appendectomy
- Hospital length of stay also is
statistically significantly less after
laparoscopic appendectomy
- laparoscopic appendectomy is
associated with a shorter period
before return to normal activity,
return to work, and return to
sports
- laparoscopic appendectomy in
the management of acute
appendicitis remains controversial
(open appendictomy still more
effective)
- the duration of surgery and costs
of operation were higher for
laparoscopic appendectomy than
for open appendectomy
Natural Orifice Transluminal Endoscopic
Surgery
• a new surgical procedure using flexible endoscopes in the abdominal
cavity
• access is gained by way of organs that are reached through a natural,
already-existing external orifice
• The hoped-for advantages : the reduction of postoperative wound
pain, shorter convalescence, avoidance of wound infection and
abdominal-wall hernias, and the absence of scars
Antibiotics as Definitive Therapy
• If symptoms did not improve within the first 24 hours, an
appendectomy was performed
• patients receiving only antibiotic therapy may still be at risk for the
development of appendicitis
• when patients are treated with antibiotics alone it is possible that
diagnoses of significant pathology such as carcinoid or carcinoma may
be delayed
• surgery still remains the gold standard of care for patients with acute
appendicitis
Interval Appendectomy
• a palpable or radiographically documented mass (abscess or
phlegmon) is conservative therapy with interval appendectomy 6 to
10 weeks later.
• This technique has been quite successful and produces much lower
morbidity and mortality rates than immediate appendectomy.
• Unfortunately, this treatment is associated with greater expense and
longer hospitalization time (8 to 13 days).
• initial treatment consists of IV antibiotics and bowel rest (9 to 15%
failure rate, with operative intervention required at 3 to 5 days after
presentation)
• second stage of this treatment plan, interval appendectomy, has
usually been carried out, the need for subsequent operation has been
questioned.
• major argument against interval appendectomy is that approximately
50% of patients treated conservatively never develop manifestations
of appendicitis, and those who do generally can be treated
nonoperatively