Appendectomy - Indications, Procedure, and Risks

Introduction:

The human body has various organs that perform different functions. Every organ is unique in its shape, structure, and function. The appendix is a small hollow organ present in the lower part of the abdomen. Interestingly, the exact role and function of this organ are still unknown.

When the appendix becomes dysfunctional due to infection or any other abnormality, then removing the organ from the body is preferred. This procedure is called an appendectomy. In most patients, appendectomy is performed as an emergency elective surgery. Depending on the technique used to perform an appendectomy, the recovery time, hospital stay, etc., vary.

What Is an Appendectomy?

It is the surgical removal of the appendix after appendicitis.

What Is Appendicitis?

It is the inflammation or infection of the appendix.

What Is an Appendix?

It is a small, hollow organ present in the right lower quadrant of the abdomen. It is located at the tip or end of the large intestine or cecum.

What Is the Role of the Appendix?

The role of the appendix in the human body is still unknown. It is believed to provide immunity by creating a unique immune system in the body, especially in young people.

What Is the Location of the Appendix?

The appendix is located at the tip of the cecum (the first part of the large intestine) or the small and large intestine junction. The direction of its location may vary depending on the position of its tail. The different positions are:

• Retrocecal - Most commonly, it is positioned behind the cecum.

• Subcecal - Under the cecum.

• Pre Ileal - Distal part of the appendix is positioned in front of the ileum.

• Post Ileal - At the back of the ileum.

• Pelvic - The direction of the appendix is downwards, crossing the edge of the pelvis.

What Causes Appendicitis?

Appendicitis occurs because of the following:

• Infection from bacteria or viruses present in the digestive tract.

• Blockage of the tube or duct that connects the large intestine with the appendix.

• Accumulation of the stool in the tube.

• Presence of tumor.

What Is the Pathophysiology of Appendicitis?

The infection of the appendix begins with the obstruction or blockage of the appendiceal orifice (a landmark in the cecum). When there is a bacterial infection in the appendix, the number of normal cells present in the lymph nodes increases (lymphoid hyperplasia). This may also occur because of local ischemia, perforation, or the formation of an abscess or pus. All these factors lead to the development of obstruction, increasing abdominal pressure (intraluminal), and an increase in pressure within the appendix. Thus, increasing the size of the appendix (intramural pressure). This leads to the blockage of blood flow in the blood vessels (vessel occlusion), and abnormal lymphatic circulation leads to swelling. The appendix becomes swollen from the inside, and the walls become necrotic and ischemic because of compromised blood and lymph supply. The swollen appendix provides a favorable environment for bacterial growth. If the condition worsens, then it leads to abscess formation.

What Are the Appendicitis Symptoms?

The patient is represented with the following:

• Pain in the lower right quadrant of the abdomen. Rarely may the patient feel pain during coughing or walking.

• Nausea and vomiting.

• Fever.

• An eating disorder or obsession with maintaining body weight below normal - anorexia.

• Feeling of being sick or unwell - malaise.

• Increased frequency of urination.

• Pain on extending the right leg - psoas sign.

How to Diagnose Appendicitis?

1. Physical Examination: There are various signs that the doctor will look for upon physical examination, such as -

• The tenderness is present in the right lower quadrant. Upon gentle pressure, the skin of the affected area will bounce back.

• Rovsing’s Sign - When the lower left quadrant is palpated or touched with gentle pressure, the patient will feel pain in the lower right quadrant.

• Dunphy’s Sign - When the patient coughs, the pain in the abdomen increases.

• Psoas Sign - Pain on extending the right leg.

• Obturator Sign - Pain on rotating right hip, suggesting pelvic appendicitis.

1. Duration of Onset of Symptoms: Generally, patients give a history of onset of pain and other symptoms within 12 to 14 hours. This indicates acute appendicitis.

2. Lab Tests: Complete blood count (CBC) will show increased white blood cells, which is the classical sign of appendicitis. Sometimes, normal levels of white blood cells are reported. The urine test will show the presence of ketone and high c-reactive protein.

3. Imaging Test: The computed tomography of the abdomen shows an enlarged appendix, a thickened wall of the appendix of more than 2 mm; an abnormal increase in the fat near the appendix; and calcifications in the appendix. Magnetic resonance imaging is helpful in pregnant women.

What Is the Appendectomy Treatment?

Appendectomy is the gold standard approach for appendicitis. In order to remove the appendix surgically, there are two options:

Open Appendectomy: This approach is functional when there is an abscess formation in the appendix. In this technique:

• An incision or cut of 2 to 4 cm is made on the lower right side of the abdomen.

• Access to the internal organs and appendix is gained.

• The appendix is removed and taken out.

• The incision is closed with sutures.

Laparoscopic Appendectomy: It is a less invasive method and causes less scar formation but takes longer surgical time. In this technique:

• An incision of 1 to 3 cm is made on the lower right side of the abdomen.

• Carbon dioxide gas is used to blow up the abdomen for better visualization.

• A laparoscope is inserted - a thin tube with a video camera and tools.

• The video camera shows images of the internal structures on a screen.

• The doctor removes the appendix by visualizing it through the screen.

• The incision is closed with sutures.

• Sometimes, during the procedure, if the appendix bursts and infection spread to the nearby organs, then an open appendectomy is performed.

Medications:

1. Antibiotic therapy is given to the patient to subside the infection. Sometimes, antibiotic therapy is started a few weeks before performing the surgery.

2. Analgesics help to relieve pain and discomfort after surgery.

What Are Appendectomy Complications?

• Infection after surgery.

• Abscess or pus formation.

• Blood clot formation - hematoma.

• Recurrent appendicitis.

• Injury to surrounding tissues and organs.

• Bowel problem or obstruction leads to disturbed bowel movement and indigestion.

What Is Appendectomy Recovery Time?

After surgery, the patient can carry out daily life activities within four to six weeks. If sutures are placed, then these may take seven to ten days to heal. In general, quick recovery within 48 hours is possible if appendicitis is treated early.

What Should Be the Diet After Appendectomy?

The patient should take a low-fat diet with fewer spices, such as mashed potatoes, rice, plain pasta, and low-fat milk, and increase the intake of water.

What Should Be the Sleeping Position After Appendectomy?

The patient should sleep on the side or back - in a supine position.

Conclusion:

Appendicitis is a commonly occurring condition that requires emergency elective surgery. For this purpose, the complete removal of the appendix is the gold standard approach - appendectomy. The patient is usually presented with a severe onset of pain in the lower right abdomen within 24 hours. Appendectomy can be done through open surgery or with a laparoscope. More commonly, laparoscopic appendectomy is preferred because it is less invasive, has lesser recovery time, and shortens the hospital stay of the patient. Early diagnosis and prompt treatment can result in recovery within 48 hours.