APPENDICECTOMY (Appendectomy)

What is the Appendix?

Vermiform appendix is small tube-shaped pouch attached to the lower end of the large intestine (caecum), the junction between the large and small intestine on the right side of the abdomen. It is variable in length (2-20cm) and its function is unknown.

What is appendicitis?

Appendicitis is the inflammation of the appendix (worm shaped appendage to the caecum). It can affect any age but more commonly between the age of 8 to 25 years old. Although there is no specific reason for the inflammation of the appendix, it can sometimes be blocked with hardened pieces of stool resulting in appendicitis. Appendicitis is often the most common cause of abdominal pain in young adult requiring emergency surgery.

Symptoms

The first sign is usually pain and discomfort in the centre of the abdomen, although this can often be mistaken for simple stomach upset or vice versa. This pain can be intermittent and radiates from the navel to the right side of the lower abdomen. Eventually the pain increases and becomes constant in the right region of the lower abdomen.

There is a raised in temperature and the patient's complexion becomes flushed. This is associated with nausea, vomiting and loss of appetite.

Diagnosis

A medical history is taken and several tests can be done to ascertain the patient's health before any surgery. Usually these tests can be done a few days ahead, but because of the urgency of a possible perforated appendix, the tests and surgery are frequently performed on the same day. Body temperature, urine sampling and blood test are taken to look for infection. A chest x-ray and ECG (Electrocardiogram) are standard prior to surgery.

The patient is examined by checking tenderness on the lower right part of the abdomen. A manual examination of the anal canal (back passage) is sometimes done to exclude other causes of pain and for women a vaginal examination is also given.

Treatment
There are two surgical techniques that are frequently used, open appendicectomy or laparoscopic appendicectomy. The choice is normally on a case-by-case basis and the surgeon's preference or experience. In both these procedures, general anaesthesia is used to relax the abdominal muscles.

Open appendicectomy

The traditional and standard method of treating appendicitis is the open appendicectomy (appendectomy). General anaesthesia is used to put the patient to sleep and to relax the abdominal muscles. An incision of 3-6cm is made in the lower right side of the abdomen, through which the caecum is located. Once the appendix is freed from the caecum, it is tied off at its base and removed. Precaution is taken to prevent any spillage of purulent material (pus) in the process of removing the appendix. After the excision of the appendix, the caecum is pushed back in the abdominal cavity and the wound is sutured.

In case of perforated (ruptured) appendix, the abdomen is washed out with warm saline solution to reduce the risk of spreading the infection. Sometimes a drain is left in the patient to allow for the pus to drain from the abdomen. The drain is removed within a day or two and the patient is treated with antibiotic.

Laparoscopic Appendicectomy

Well over the past ten years laparoscopic surgery has been gaining momentum, and laparoscopic appendicectomy is becoming a routine in certain hospitals. Although this method has got several advantages including faster recovery time, shorter hospital stay, lower risk of post operative infection, and smaller scars, it is not always possible to use this method in complicated cases. General anaesthesia is used in this method.

A very small incision is made just below the navel, and the abdomen is filled with carbon dioxide to allow space to manipulate the instruments inside. The laparoscope (a thin telescope with a camera attached to one end) is inserted in the abdomen at the navel. The abdominal organs can now be examined with the laparoscope via a video monitor (Laparoscopy). The laparoscope allows the surgeon to see the appendix and with two further small incisions, laparoscopic instruments are inserted, which are used to clamp off and cut the appendix. The appendix is then removed through the little hole. The carbon dioxide is allowed to escape and the small incisions are then closed.

The laparoscope is essential as a diagnostic tool. The surgeon is able to see whether the appendix is inflamed or there are other causes for the patient's symptoms. A thorough investigation of the other organs can be performed to eliminate or identify any other source of the symptoms.

If there is no other complication after the operation within two or three days, the patient can be discharged as long as his temperature is normal and his bowel starts to function again. The stitches can be removed between eight to ten days and a return to normal life is usual within two to four weeks.