An appendectomy (American English) or appendicectomy (British English) is a surgical operation in which the vermiform appendix (a portion of the intestine) is removed. Appendectomy is normally performed as an urgent or emergency procedure to treat complicated acute appendicitis.
Appendectomy may be performed laparoscopically (as minimally invasive surgery) or as an open operation. Laparoscopy is often used if the diagnosis is in doubt, or to leave a less visible surgical scar. Recovery may be slightly faster after laparoscopic surgery, although the laparoscopic procedure itself is more expensive and resource-intensive than open surgery and generally takes longer. Advanced pelvic sepsis occasionally requires a lower midline laparotomy.
Complicated (perforated) appendicitis should undergo prompt surgical intervention. with 51% of those treated with antibiotics avoiding an appendectomy after 3 years. After appendicectomy, the main difference in treatment is the length of time the antibiotics are administered. For uncomplicated appendicitis, antibiotics should be continued up to 24 hours postoperatively. For complicated appendicitis, antibiotics should be continued for anywhere between 3 and 7 days. Delay of appendectomy 24 hours after admission for symptoms of appendicitis has not been shown to increase the risk of perforation or other complications.
- General anaesthesia is induced, with endotracheal intubation and full muscle relaxation, and the patient is positioned supine. because of decreased pain, fewer postoperative complications, shorter hospitalization, earlier mobilization, earlier return to work, and better cosmesis; however, despite these advantages, efforts are still being made to decrease abdominal incision and visible scars after laparoscopy. Recent research has led to the development of natural orifice transluminal endoscopic surgery (NOTES); however, numerous difficulties need to be overcome before a wider clinical application of NOTES is adopted, including complications such as the opening of hollow viscera, failed sutures, a lack of fully developed instrumentation, and the necessity of reliable cost-benefit analyses.
Many surgeons have attempted to reduce incisional morbidity and improve cosmetic outcomes in laparoscopic appendectomy by using fewer and smaller ports. Kollmar et al. described moving laparoscopic incisions to hide them in the natural camouflages, like the suprapubic hairline, to improve cosmesis. Additionally, reports in the literature indicate that minilaparoscopic appendectomy using 2– or 3-mm or even smaller instruments along with one 12-mm port minimizes pain and improves cosmesis. More recently, studies by Ates et al. and Roberts et al. have described variants of an sling-based single-port laparoscopic appendectomy with good clinical results. With SILS, a more conventional view of the field of surgery is seen compared to NOTES. The equipment used for SILS is familiar to surgeons already doing laparoscopic surgery. Most importantly, it is easy to convert SILS to conventional laparoscopy by adding a few trocars; this conversion to conventional laparoscopy is called 'port rescue'. SILS is feasible, reasonably safe, and cosmetically advantageous, compared to standard laparoscopy; however, this newer technique involves specialized instruments and is more difficult to learn because of a loss of triangulation, clashing of instruments, crossing of instruments (cross triangulation), and a lack of maneuverability.
thumb|Laparoscopic-assisted transumbilical appendectomy scar on a pediatric patient. Anesthetic result one month after surgery.
Pregnancy
Appendicitis is the most common emergent general surgery-related problem to arise during pregnancy. There is a natural elevation in white blood cell count in addition to anatomical changes of the appendix that occur during pregnancy. These findings, in addition to non-specific abdominal symptoms, make appendicitis difficult to diagnose. Appendicitis develops most commonly in the second trimester. If appendicitis develops in a pregnant woman, an appendectomy is usually performed and should not harm the fetus. The risk of premature delivery is about 10%. The risk of fetal death in the perioperative period after an appendectomy for early acute appendicitis is 3 to 5%. The risk of fetal death is 20% in perforated appendicitis.
There has been debate regarding which surgical approach is preferred during pregnancy. Overall, there is no increased risk of fetal loss or preterm delivery with the laparoscopic approach (LA) as compared to the open approach (OA). However, the LA was associated with shorter length of stay in the hospital as well as reduced risk of wound infection.
Recovery time from the operation varies from person to person. Some take up to three weeks before being completely active; for others, it can be a matter of days. In the case of a laparoscopic operation, the patient has three stapled scars of about an inch (2.5 cm) in length, between the navel and pubic hair line. When an open appendectomy has been performed, the patient has a 2- to 3-inch (5–7.5 cm) scar, which will initially be heavily bruised.
Complications
One of the most common post-operative complications associated with an appendectomy is the development of a surgical site infection (SSI).
Patients with complicated appendicitis (perforated appendicitis) are more likely to develop an SSI, abdominal abscess, or pelvic abscess during the post-operative period. Placement of an abdominal drain was originally thought to reduce the risk of these post-operative complications. However, abdominal drains have not been found to play a significant role in reducing SSIs and have led to increased length of stay in the hospital, in addition to increased cost of the operation.
Frequency
Approximately 327,000 appendectomies were performed during U.S. hospital stays in 2011, a rate of 10.5 procedures per 10,000 population. Appendectomies accounted for 2.1% of all operating-room procedures in 2011.
History
thumb|An appendectomy at the French Hospital in [[Tbilisi, Georgia, 1919]]
The first recorded successful appendectomy was performed in September 1731 by English surgeon William Cookesley on Abraham Pike, a chimney sweep. The second was on December 6, 1735, at St. George's Hospital in London, when French surgeon Claudius Amyand described the presence of a perforated appendix within the inguinal hernial sac of an 11-year-old boy. The organ had apparently been perforated by a pin the boy had swallowed. The patient, Hanvil Andersen, made a recovery and was discharged a month later.
Harry Hancock performed the first abdominal surgery for appendicitis in 1848, but he did not remove the appendix. In 1889, in New York City, Charles McBurney described the presentation and pathogenesis of appendicitis accurately and developed the teaching that an early appendectomy was the best treatment to avoid perforation and peritonitis.
Some cases of autoappendectomies have occurred. One was attempted by Evan O'Neill Kane in 1921, but the operation was completed by his assistants. Another was Leonid Rogozov, who in 1961 had to operate on himself as he was the only doctor on a remote Antarctic base.
On September 13, 1980, Kurt Semm performed the first laparoscopic appendectomy, opening up the path for a much wider application of minimally invasive surgery.
Cost
United States
While appendectomy is a standard surgical procedure, its cost has been found to vary considerably in the United States. A 2012 study <!-- from the University of California, San Francisco, published in the Archives of Internal Medicine --> analyzed 2009 data from nearly 20,000 adult patients treated for appendicitis in California hospitals. Researchers examined "only uncomplicated episodes of acute appendicitis" that involved "visits for patients 18 to 59 years old with hospitalization that lasted fewer than four days with routine discharges to home." The lowest charge for removal of an appendix was $1,529 and the highest $182,955, almost 120 times greater. The median charge was $33,611. While the study was limited to California, the researchers indicated that the results were applicable anywhere in the United States. Many, but not all, patients are covered by some form of medical insurance.<!---the hard copy and soft copy sources are different. They are, however, the same article-->
A study by the Agency for Healthcare Research and Quality found that in 2010, the average cost for a stay in the United States involving appendicitis was $7,800. For stays where the appendix had ruptured, the average cost was $12,800. The majority of patients seen in the hospital were covered by private insurance.