• Appendicitis is caused by an obstruction of the appendiceal lumen and can result in inflammation, edema, and the potential for rupture of the viscus.
• Appendectomy is a surgical procedure that can be performed, open or laparoscopically, to remove the appendix when infection and/or inflammation are suspected or present. Removal is undertaken to avoid the complication of a ruptured appendix with resultant peritonitis.
• Laparoscopic appendectomies are primarily performed today. Following trochar insertion and the establishment of a pneumoperitoneum, the cecum is identified and retracted in order to mobilize the appendix. An incision or window is made into the mesoappendix prior to clamping and ligating the base. The appendix may be removed through the trochar or placed into a bag depending on its size. Benefits over an open procedure include: Less postoperative pain, smaller incisions (better cosmetic result), and reduced length of stay. Drawbacks include: Greater cost, potentially longer operative time, and requirement of general anesthesia due to insufflation.
• Open appendectomy involves adequate exposure of the cecum, followed by pulling of the cecum through the incision site to expose the attached appendix. The base is clamped and cut and drains are inserted prior to wound closure.
  • Laparoscopic cases may be converted to open when operating conditions are suboptimal for laparoscopy.
  • It is commonly performed for complicated appendicitis or patients with extensive previous intra-abdominal surgeries.
  • May be performed under regional anesthesia for patients who are at high risk for complications of general anesthesia (e.g., pregnancy, pulmonary hypertension).

• Open: Supine with arms out or tucked
• Laparoscopy: Supine with arms tucked; surgeon stands on the left side of the patient. Rightward tilt of the bed and Trendelenburg position may facilitate surgical exposure.

• Laparoscopy: 1 cm incision at the umbilicus, and two to three 5 mm incisions in the lower abdomen for the insertion of trochars.
• Open: Transverse right lower quadrant incision (McBurney or Rockey-Davis)

15–60 minutes for either approach

Less than 75 mL

• 24 hours for uncomplicated appendicitis
• Ruptured or otherwise complicated appendicitis has an average length of stay of 5 days.

Laparoscopy equipment

Incidence

• In the US, ~250,000 cases of appendicitis annually
• Most common in 10–19 year olds

Prevalence

In the US, approximately 7% of people are affected at some point in their lives.

Varies from 5% to 11% and is related to the perforation of the appendix and degree of peritonitis

• Overall rate of 0.2–0.8% related to appendicitis, not surgical intervention
• Rate following appendectomy: 0–0.2%
• Elderly have the highest mortality rate.

History

Periumbilical pain that migrates to the right lower quadrant (RLQ) is present in approximately 50% of cases.

Signs/Physical Exam

• RLQ pain, tenderness
• Guarding, rebound on abdominal exam
• Pain with rectal exam
• Psoas sign; inflammation from retrocecal appendix
• Palpation of the mass in the RLQ

Labs/Studies

• KUB, ultrasound, and/or CT scan have reduced the incidence of "normal" appendixes mimicking appendicitis.
• WBC count with differential
• Beta-HCG, to rule out ectopic pregnancy as a cause of pain in females
• Concomitant organ dysfunction may necessitate additional preoperative assessment such as EKG, basic metabolic panel, etc.

Pregnancy Considerations

• GI prophylaxis including a H₂ blocker, non-particulate antacid, and possibly a pro-motility agent
• Preoperative hydration and electrolyte repletion, as needed

Patient should be consented for laparoscopic as well as open appendectomy.

• One dose is adequate for uncomplicated disease.
• Metronidazole plus a first-generation cephalosporin, aminoglycoside, or quinolone
• Common organisms are Escherichia coli, Bacteroides, Klebsiella, Enterococcus, and Pseudomonas.

• Laparoscopic appendectomy:
  • General endotracheal anesthesia (GETA)
• Open appendectomy:
  • GETA
  • Spinal or epidural anesthesia with a T10 level is also possible.

• Standard ASA monitors
• Foley, if patient has not voided in the immediate preoperative period, or per surgeon request to improve visualization

• Sequential compression devices should be placed prior to induction.
• Rapid-sequence induction with endotracheal intubation is often required unless a difficult airway is anticipated. If there is a potential for a difficult airway, consider an awake fiberoptic intubation.
• Muscle relaxants: The speed of onset of succinylcholine is favorable; however, it may be contraindicated in certain patients (e.g., children, stroke, etc.). Non-depolarizing muscle relaxants administered at induction doses may not be reversible by the end of the case.
• Place an orogastric tube after intubation for gastric emptying

• Choice of inhalation agent
• Muscle relaxation can enhance surgical exposure. If succinylcholine was used at induction, subsequent non-depolarizing administration may be needed.
• If a laparoscopic approach is used, the initial insufflation may lead to bradycardia from vagal stimulation, which should resolve with time. Desufflation may be necessary if the patient becomes hemodynamically unstable.
• As with other laparoscopic procedures, the pneumoperitoneum is created to enhance visualization. However, it can impair ventilation by decreasing lung compliance and functional residual capacity. Additionally, the Trendelenburg position is often implemented to displace bowel with gravity and can further impair ventilatory efforts.

The patient should be fully awake, fully reversed, and capable of protecting their airway to avoid aspiration.

Pediatric Considerations