CHAPTER 19 Appendectomy
♦ The appendix is a finger-like evagination of the proximal wall of the cecum. There has been extensive debate as to its evolutionary significance, with many considering it a vestigial organ in humans. More recent thought suggests an immune regulatory role involving immune-mediated maintenance of the normal gut flora.
♦ The appendix is about 10 cm long and 8 mm wide and has a luminal diameter of 1 to 3 mm. The three taenia coli merge at its base. Its sole blood supply is from the appendiceal artery, which originates as a branch of the ileocecal artery. The artery runs in the mesoappendix, the mesentery attaching the organ to the wall of the cecum. The position of the appendix can vary considerably and may be retrocecal in up to 65% of adults. The terminal ileum is an adjacent anatomic landmark.
♦ Because of its position in the right lower quadrant, pain in this area is usually suspicious for appendicitis. Variations in anatomic location, because of such conditions as advanced pregnancy or intestinal malrotation, are infrequent but should be suspected in the appropriate clinical context.
♦ Patients should be consented for appendectomy and both laparoscopic and open approaches should be discussed with the patient, as well as the usual complications including bleeding, infection, and damage to intra-abdominal structures.
♦ Expedient operation is advised, although the urgency of the operation is usually dictated by patient symptoms, laboratory results, availability of the operating room or anesthesia resources, and results of imaging studies.
♦ Placement of an orogastric (OG) tube will facilitate decompression of the stomach if there is evidence of significant gastric content based on recent oral intake or evidence from computed tomography (CT) scan.
♦ A Foley catheter is required in order to decompress the bladder and decrease the risk of bladder injury. In uncircumcised males, make sure to pull the foreskin back over the glans penis after inserting the catheter.
♦ The main display monitor is positioned off the patient’s right leg directly in line with the appendix and operating surgeon’s line of sight. If an additional display monitor is available, it should be positioned off the patient’s left leg in line with the assistant surgeon. An additional monitor will reduce the assistant’s neck strain but may increase difficulty in using the laparoscope because of the viewing angle and fulcrum effect.