What is an appendectomy

An appendectomy also known as an appendicectomy, is an operation to remove the appendix, which is a small, tube-like part of the bowel. An appendectomy often needs to be performed urgently when someone has an infected and inflamed appendix (appendicitis) or the appendix has burst (perforated appendix). The appendix is a small, finger-shaped organ that branches off from the first part of the large intestine. When your appendix becomes swollen (inflamed) or infected, the condition is called appendicitis. When you have appendicitis, your appendix may need to be removed. An appendix that has a hole in it can leak and infect the entire abdomen area. This can be life threatening.

If the appendix becomes infected it must be surgically removed before it ruptures and spreads infection to the entire abdominal space. Symptoms of acute appendicitis include pain in the lower right side of the abdomen, fever, reduced appetite, nausea or vomiting.

• There is no test to confirm appendicitis and the symptoms may be caused by other illnesses. The doctor must diagnose from the information you report and what he sees. During appendectomy surgery, even if the surgeon finds that the appendix is not infected (which can happen up to 25% of the time), he will thoroughly check the other abdominal organs and remove the appendix anyway.

Appendectomies are one of the most commonly performed operations, with approximately 1 in 2000 persons requiring an appendectomy during his or her lifetime ¹⁾.

Depending upon the circumstances of the individual patient, an appendectomy can be performed in one of two ways, through an open incision or with a laparoscope.

Types of appendectomy:

• Open appendectomy, the traditional method of operation for appendicitis, requires a medium-sized incision (about 2 to 4 inches long) in the lower right part of the abdomen. The appendix is removed through this incision after surgically separating it from the base of the colon. Open appendectomy usually requires general anesthesia but in some cases may be performed with spinal anesthesia.
• Laparoscopic appendectomy (key hole surgery) is performed using 1 to 3 small (often less than an inch long) incisions and a port (nozzle) is inserted into one of the slits, and carbon dioxide gas inflates the abdomen. A laparoscope is inserted through another port. It looks like a telescope with a light and camera on the end so the surgeon can see inside the abdomen. Surgical instruments are placed in the other small openings and used to remove the appendix. The area is washed with sterile fluid to decrease the risk of further infection. The carbon dioxide comes out through the slits, and then the sites are closed with sutures or staples or covered with glue-like bandage and Steri-Strips. Your surgeon may start with a laparoscopic technique and need to change to an open technique. This change is done for your safety. This technique is most often used for early appendicitis and has an overall shorter recovery time than open appendectomy. If the appendix has ruptured (burst) or if there is scar tissue from previous operations, the laparoscopic approach may not be possible and an open appendectomy is necessary. Laparoscopic appendectomy requires general anesthesia for the operation.

Some cases of appendicitis may be handled in a non-emergency manner if antibiotics are given while waiting. Operations may safely be delayed for certain individuals. Surgeons make that decision on a case-by-case basis.

Most studies have shown that there is minimal differences between open and laparoscopic appendectomy for appendicitis in terms of infection, pain control after surgery, hospitalization time and recovery. It is generally the surgeons preference as to whether an open or laparoscopic appendectomy is performed.

Appendectomy is done using either:

• Spinal anesthesia. — Medicine is put into your back to make you numb below your waist. You will also get medicine to make you sleepy.
• General anesthesia — You will be asleep and not feel any pain during the surgery.

If the appendix broke open or a pocket of infection (abscess) formed, your abdomen will be thoroughly washed out during surgery. The surgeon may then leave the skin open and allow it to heal together on its own, to allow the infection to drain, or less frequently, put in a small drainage tube

Living without an appendix causes no known health problems.

As for all surgical procedures, appendectomy contains risks.

Possible risks from appendectomy include wound infection, infection inside your abdomen, bleeding, damage to the intestine or bladder, and needing to change from a keyhole to an open procedure partway through the surgery and risks of the anaesthetic

However, these risks are considered to be minimal, especially when appendicitis can be fatal if it leads to peritonitis.

What is the appendix?

The appendix is a small, finger shaped pouch of intestine that extends from the cecum, which is the first part of the large intestine. It is found in the right lower quadrant of the abdomen. The purpose of the appendix is unknown, however it is not believed to have any significant function.

What is appendicitis?

Appendicitis is an infection of the appendix. The infection and swelling can decrease the blood supply to the wall of the appendix. This leads to tissue death, and the appendix can rupture or burst, causing bacteria and stool to release into the abdomen. This is called a ruptured appendix. A ruptured appendix can lead to peritonitis, which is an infection of your entire abdomen. Appendicitis most often affects people between the ages of 10 and 30 years old. It is a common reason for an operation in children, and it is the most common surgical emergency in pregnancy ²⁾.

Figure 1. Laparoscopic appendectomy

Figure 2. Appendectomy scar (open appendectomy)

Why is appendectomy performed?

An appendectomy is done for appendicitis. The condition can be hard to diagnose, especially in children, older people, and women of childbearing age.

Most often, the first symptom is pain around your belly button:

• The pain may be mild at first, but it becomes sharp and severe.
• The pain often moves into your right lower abdomen and becomes more focused in this area.

Other symptoms include:

• Diarrhea or constipation
• Fever (usually not very high)
• Nausea and vomiting
• Reduced appetite

There are many reasons for abdominal pain besides appendicitis. These include gastroenteritis, indigestion, constipation, diverticulitis, gallbladder disease, hernias, ulcer disease, female reproductive system disease (including ovarian torsion [a twisted ovary], pelvic inflammatory disease, miscarriage of a pregnancy, and ruptured ovarian cysts), male reproductive system disease, bladder infection, kidney or bladder stones, and other less common problems. The abdominal pain usually associated with appendicitis often starts around the umbilicus (belly button), then concentrates in the lower right part of the abdomen. It is made worse by movement or by pressing on the abdomen and quickly releasing that pressure (rebound tenderness).

If you have symptoms of appendicitis, seek medical help right away. DO NOT use heating pads, enemas, laxatives, or other home treatments to try to relieve symptoms.

Your health care provider will examine your abdomen and rectum. Other tests may be done:

• Blood tests, including a white blood cell count, may be done to check for infection.
• When the diagnosis is not clear, the doctor may order a CT scan or ultrasound to make sure the appendix is the cause of the problem.

There are no actual tests to confirm that you have appendicitis. Other illnesses can cause the same or similar symptoms.

The goal is to remove an infected appendix before it breaks open (ruptures). After reviewing your symptoms and the results of the physical exam and medical tests, your surgeon will decide whether you need surgery.

How to prepare for an appendectomy

You will need to fast (have nothing to eat or drink) for at least 6 hours before the operation. You might be given fluids through a drip (intravenously, directly into a vein) so you don’t get dehydrated.

Your doctors and nurses will explain the operation. Ask questions if you’re not sure about something.

What happens during an appendectomy?

A general anaesthetic is needed for this kind of surgery.

The surgeon might do the appendectomy laparoscopically, through several tiny cuts. Sometimes a larger cut is needed – this is known as an open appendectomy.

During and after the surgery you will be carefully monitored.

You are likely to be given antibiotics and pain relief.

Appendectomy recovery

Most people leave the hospital in 1 to 2 days after appendectomy surgery. You can go back to your normal activities within 2 to 4 weeks after leaving the hospital.

If you had laparoscopic appendectomy, you will likely recover quickly. Recovery is slower and more complicated if your appendix has broken open or an abscess has formed.

After your appendectomy surgery, it is normal to feel weak and tired for several days after you return home. Your abdomen may be swollen and may be painful. If you had laparoscopic appendectomy, you may have pain in your shoulder for about 24 hours. This is due to the gas inserted into your abdomen during the procedure. Moving and walking helps to decrease the gas and the right shoulder pain.

You may also feel sick to your stomach and have diarrhea, constipation, gas, or a headache. This usually goes away in a few days.

Your recovery time depends on the type of appendectomy surgery you had. If you had laparoscopic appendectomy, you will probably be able to return to work or a normal routine 1 to 3 weeks after surgery. If you had an open appendectomy surgery, it may take 2 to 4 weeks. If your appendix ruptured, you may have a drain in your incision.

Your body will work fine without an appendix. You will not have to make any changes in your diet or lifestyle.

Each person recovers at a different pace. Follow the steps below to get better as quickly as possible.

Call your healthcare provider if you have:

• A fever higher than 100.4°F (38°C), or as directed by the healthcare provider
• Abdominal swelling
• Green or yellow drainage from any incision
• Pain that gets worse as hours or days pass
• Redness or swelling around the incision
• Sluggishness
• Vomiting

Appendectomy recovery tips

Activity

• Rest when you feel tired. Getting enough sleep will help you recover.
• Try to walk each day. Start by walking a little more than you did the day before. Bit by bit, increase the amount you walk. Walking boosts blood flow and helps prevent pneumonia and constipation.
• When you have an operation, you are at risk of getting blood clots because of not moving during anesthesia. The longer and more complicated your surgery, the greater the risk. This risk is decreased by getting up and walking 5 to 6 times per day, wearing special support stockings or compression boots on your legs, and for high-risk patients, taking a medication that thins your blood.
• For about 2 weeks, avoid lifting anything that would make you strain. This may include a child, heavy grocery bags and milk containers, a heavy briefcase or backpack, cat litter or dog food bags, or a vacuum cleaner.
• Avoid strenuous activities, such as bicycle riding, jogging, weight lifting, or aerobic exercise, until your doctor says it is okay.
• You may be able to take showers (unless you have a drain near your incision) 24 to 48 hours after surgery. Pat the incision dry. Do not take a bath for the first 2 weeks, or until your doctor tells you it is okay. If you have a drain near your incision, follow your doctor’s instructions.
• You may drive when you are no longer taking pain medicine and can quickly move your foot from the gas pedal to the brake. You must also be able to sit comfortably for a long period of time, even if you do not plan on going far. You might get caught in traffic.
• You will probably be able to go back to work in 1 to 3 weeks. If you had an open surgery, it may take 3 to 4 weeks.
• Do not lift or participate in strenuous activity for 3 to 5 days for laparoscopic appendectomy and 10 to 14 days for open procedure.
• Your doctor will tell you when you can have sex again.
• Children can usually go to school 1 week or less after an operation for an unruptured appendix and up to 2 weeks after a ruptured appendix.
• Most children will not return to gym class, sports, and climbing games for 2 to 4 weeks after the operation.

Diet

• You can eat your normal diet. If your stomach is upset, try bland, low-fat foods like plain rice, broiled chicken, toast, and yogurt.
• Drink plenty of fluids (unless your doctor tells you not to). Continue to drink lots of fluids, usually about 8 to 10 glasses per day.
• After intestinal surgery, you may have loose watery stools for several days. If watery diarrhea lasts longer than 3 days, contact your surgeon.
• Pain medication (narcotics) can cause constipation. Increase the fiber in your diet with high-fiber foods if you are constipated. Your surgeon may also give you a prescription for a stool softener.
• Foods high in fiber include beans, bran cereals and whole-grain breads, peas, dried fruit (figs, apricots, and dates), raspberries, blackberries, strawberries, sweet corn, broccoli, baked potatoes with skin, plums, pears, apples, greens, and nuts.
• You may notice that your bowel movements are not regular right after your surgery. This is common. Try to avoid constipation and straining with bowel movements. You may want to take a fiber supplement every day. If you have not had a bowel movement after a couple of days, ask your doctor about taking a mild laxative.

Medicines

• Your doctor will tell you if and when you can restart your medicines. He or she will also give you instructionsabout taking any new medicines.
• If you take blood thinners, such as warfarin (Coumadin), clopidogrel (Plavix), or aspirin, be sure to talk to your doctor. He or she will tell you if and when to start taking those medicines again. Make sure that you understandexactly what your doctor wants you to do.
• If your appendix ruptured, you will need to take antibiotics. Take them as directed. Do not stop taking them just because you feel better. You need to take the full course of antibiotics.
• Take pain medicines exactly as directed.
• If the doctor gave you a prescription medicine for pain, take it as prescribed.
• If you are not taking a prescription pain medicine, take an over-the-counter medicine such as acetaminophen (Tylenol), ibuprofen (Advil, Motrin), or naproxen (Aleve). Read and follow all instructions on the label.
• Do not take two or more pain medicines at the same time unless the doctor told you to. Many pain medicines have acetaminophen, which is Tylenol. Too much Tylenol can be harmful.
• If you think your pain medicine is making you sick to your stomach:
• Take your medicine after meals (unless your doctor has told you not to).
• Ask your doctor for a different pain medicine.

Surgical wound care

• If you had an open appendectomy surgery, you may have staples in your incision. The doctor will take these out in 7 to 10 days.
• If you have strips of tape on the incision, leave the tape on for a week or until it falls off.
• If you have a glue-like covering over the incision, allow the glue to fl ake off on its own.
• You may wash the area with warm, soapy water 24 to 48 hours after your surgery, unless your doctor tells you not to. Pat the area dry.
• Keep the area clean and dry. You may cover it with a gauze bandage if it weeps or rubs against clothing. Change the bandage every day.
• If your appendix ruptured, you may have an incision with packing in it. Change the packing as often as your doctor tells you to.
• Packing changes may hurt at first. Taking pain medicine about half an hour before you change the dressing can help.
• If your dressing sticks to your wound, try soaking it with warm water for about 10 minutes before you remove it. You can do this in the shower or by placing a wet face cloth over the dressing.
• Remove the old packing and flush the incision with water. Gently pat the top area dry.
• The size of the incision determines how much gauze you need to put inside. Fold the gauze over once, but do not wad it up so that it hurts. Put it in the wound carefully. You want to keep the sides of the wound from touching. A cotton swab may help you push the gauze in as needed.
• Put a gauze pad over the wound, and tape it down.
• You may notice greenish grey fluid seeping from your wound as you start to heal. This is normal. It is a sign that your wound is healing.

Appendectomy scar

• Avoid wearing tight or rough clothing. It may rub your incisions and make it harder for them to heal.
• Protect the new skin, especially from the sun. The sun can burn and cause darker scarring.
• Your scar will heal in about 4 to 6 weeks and will become softer and continue to fade over the next year.
• Sensation around your incision will return in a few weeks or months.

Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments, and call your doctor or nurse call line if you are having problems. It’s also a good idea to know your test results and keep a list of the medicines you take.

When should you call for medical help?

Call your local emergency services anytime you think you may need emergency care. For example, call if:

• You passed out (lost consciousness).
• You are short of breath..
• You are sick to your stomach or cannot drink fluids.
• You cannot pass stools or gas.
• You have pain that does not get better when you take your pain medicine.
• You have signs of infection, such as:
• Increased pain, swelling, warmth, or redness.
• Red streaks leading from the wound.
• Pus draining from the wound.
• A fever.
• You have loose stitches, or your incision comes open.
• Bright red blood has soaked through the bandage over your incision.
• You have signs of a blood clot in your leg (called a deep vein thrombosis), such as:
• Pain in your calf, back of knee, thigh, or groin.
• Redness and swelling in your leg or groin.

Appendectomy complications

Complications are higher in smokers, obese patients, and those with other diseases such as diabetes, heart failure, renal failure and lung disease. Wound healing may also be decreased in smokers.

Any complication, including: Surgical infections, breathing difficulties, blood clots, renal (kidney) complications, cardiac complications, and return to the operating room

• Laparoscopic appendectomy 3.4%
• Open appendectomy 6.4%

Children have less than 1% for all complications. Children with perforated appendix have increased wound infection rates and abdominal infections. There are no deaths reported with simple appendectomy.

Intestinal obstruction 3%: Short-term blockage of stool or fluids. Swelling of the tissue around the intestine can stop stool and fluid from passing. You will be asked if you are passing gas, and bowel sounds will be checked. If you have a temporary block, a tube may be placed through your nose into your stomach for 1 or 2 days to remove fluid from your stomach.

Pregnancy risks: Premature labor 8 to 10% and fetal loss 2%. The risk of fetal loss increases to 10% when the appendix ruptures and there is peritonitis (infection of the abdominal cavity) ³⁾.

Wound Infection (laparoscopic 1.9% and open 4.3%): Infection at the area of the incision or near the organ where the surgery was performed. Antibiotics are typically given before the operation. Smoking can increase the risk of infection.

Return to the operating room 1.8%: Significant pain and bleeding may cause a return to surgery.

Pneumonia (less than 1%): Infection in the lungs. Stopping smoking, walking and deep breathing after your operation can help prevent lung infections.

Urinary tract infection (less than 1%): Infection of the bladder or kidneys. A urinary catheter (small thin tube) that drains urine from the bladder is sometimes inserted. Signs of a urinary tract infection include pain with urination, fever, and cloudy urine.

Blood clot (less than 1%): A clot in the legs that can travel to the lung Less than 1% Longer surgery and bed rest increase the risk. Getting up, walking 5 to 6 times per day, and wearing support stockings reduce the risk.

Heart complication (less than 1%): Includes heart attack or sudden stopping of the heart. Problems with your heart or lungs can be sometimes be worsened by general anesthesia. Your anesthesia provider will take your history and suggest the best option for you.

Risks of anesthesia and surgery in general include:

• Reactions to medicines
• Problems breathing
• Bleeding, blood clots, or infection

Risks of an appendectomy after a ruptured appendix include:

• Buildup of pus, which may need draining and antibiotics
• Longer hospital stays.

Death: Less than 1%. Death is extremely rare in healthy people.