OPEN APPNDICECTOMY

DR.B.Selvaraj MS; Mch; FICS;Professor of SurgeryMelaka Manipal Medical CollegeMelaka 75150 Malaysia

OPERATIVE SURGERY

OPEN APPENDICECTOMY

• INDICATIONS: - Ac. Appendicitis - Subacute Appendicitis• ANESTHESIA: - GA/ SA or Epidural• POSITION: - Supine with slight left tilt

• Informed consent- risks of surgery: - Post-op adhesions < 4% - Intra abdominal abscess <5% - Fecal fistula < 2% - Wound infection high in perforation - Overall mortality from 0.2% for uncomplicated appendicitis to > 10% in perforated appendicitis

OPEN APPENDICECTOMY• INCISION: ACCESS - McBurney’s - Lanz or modified McBurney’s - Rocky- Davis - Fowler- Weir medial extension - Rutherford Morrison lateral extension• Division of External Oblique

Aponeurosis - Incise the aponeurosis of the external oblique along the line of its fibers

OPEN APPENDICECTOMY

• SPLITTING THE MUSCLES - Internal oblique & Transversus oblique muscles are bluntly spread apart with scissors - These muscles are held apart by 2 Richardson’s retractors

• INCISION OF PERITONEUM - Peritoneum is divided between 2 hemostats obliquely

OPEN APPENDICECTOMY

• Mobilisation of Cecal pole and delivering it into the wound

- Identify Cecum by tenia coli and mobilise it with Babcock’s forceps and gauze piece - 3 tenia coli converge at base of appendix

• Anatomy of Appendix - Mesoappendix extends behind the ileum - Skeletonisation of mesoappendix should proceed to posterior surface of ileum

OPEN APPENDICECTOMY

• Skeletonisation of Mesoappendix - clamp and divide mesoappendix serially

• Crushing the base of Appendix

- Crush the base of appendix with straight artery forceps for few minutes- Then remove and reapply few cms above

OPEN APPENDICECTOMY• Ligation and removal - Appendix is ligated in the crush mark - Transact 0.5cm distally with knife

• Alternate method of removal - Mesoappendix and base of appendix both divided with a linear stapler

OPEN APPENDICECTOMY• Appendiceal stump management - Appendix stump is inverted with purse string suture or Z stitch - I just cauterize the appendicular mucosa

OPEN APPENDICECTOMY• Retrocecal appendix - Make a window in meso appendix near the base, crush the base and apply ligature - Divide the appendix at the base first

• Retrograde Appendicectomy - Then serially clamp the mesoappendix and divide until you reach the tip of appendix

OPEN APPENDICECTOMY• Closure of peritoneum - Wash with povidone iodine - Close peritoneum with vicryl

• Closure of muscles and skin - Close muscles also with interrupted vicryl- Close External oblique aponeurosis

THANK YOU

Real open appendicectomy links: 1.https://www.youtube.com/watch?v=AGQ-PTm4-

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2. https://www.youtube.com/watch?v=4KHXgwFeG0E