Appendectomy

Appendectomy is a simple operation in uncomplicated cases. The appendix is ligated, and the stump is often inverted. The McBurney incision, described in 1894, has been the conventional traditional approach; however others, including the transverse incision, the paramedian incision, and the "bikini" incision may also be employed. Laparoscopic appendectomy is now being routinely performed and has been shown to decrease the length of hospital stay [53].

The postappendectomy barium enema appearance will depend on whether the appendiceal stump has been inverted, and if so, to what degree. If inversion of the stump has not been performed, the length of the appendiceal stump left behind will be variable (ideally it should not be visible, but if visible, very short) (Figs. 6.34 and 6.35). The inverted appendiceal stump may produce a polypoid mass in the apex of the cecum that may be several millimeters to 3 cm in size (Fig. 6.36). The stump may be especially prominent shortly after surgery owing to edema and/or inflammation. The surface may be smooth, lobulated,

FiGuRE 6.35. Long appendiceal stump. Supine Figure 6.34. Short appendiceal stump after ap- film from a small-bowel series with filling of the pendectomy. Decubitus view from a double con- right colon after appendectomy shows a very trast barium enema after appendectomy. long appendiceal stump, which is generally undesirable.

FiGuRE 6.35. Long appendiceal stump. Supine Figure 6.34. Short appendiceal stump after ap- film from a small-bowel series with filling of the pendectomy. Decubitus view from a double con- right colon after appendectomy shows a very trast barium enema after appendectomy. long appendiceal stump, which is generally undesirable.

Figure 6.36. Inverted appendiceal stump. Film from a single-contrast barium enema demonstrating a small, smooth, polypoid defect in the cecum from inversion of the appendiceal stump at the time of appendectomy.

or irregular. The irregularities may be the result of the purse-string sutures, often used for this procedure [54]. In some cases endoscopy may be required to differentiate an inverted appendiceal stump from an adenomatous polyp.

The most common postoperative complications after appendectomy are wound infections and abscesses. These complications are observed twice as commonly in cases of perforated appendicitis than in nonper-forated cases [55]. The rate of pelvic abscess after perforated appendicitis is 1.4 to 18% [56]. Fecal fistula is a rare complication, usually related to an inflamed or gangrenous appendiceal stump.

Intussusception is an unusual complication of appendectomy, resulting from the appendiceal stump serving as a lead point [57,58]. The reported time interval between appendectomy and intussusception has varied between 3 days to 4.5 years [57,59]. The diagnosis of intussusception can be made by CT or ultrasound imaging, or by barium enema.

Rarely, recurrent appendicitis will develop in a long appendiceal stump [60-62]. Cases have been reported to occur from 4 weeks to 10 years after appendectomy. It is important to amputate the appendix as closely as possible to the cecum to avoid this complication. Incomplete removal of the appendix is usually the result of failure to locate the appendiceal-cecal junction. The potential for appendicitis to recur is increased with laparoscopic appendectomy, since it may be more difficult to visualize the base of the appendix with this technique. If the base of the appendix is not visualized laparoscopically, it may be necessary to convert to the standard open method.

The incidence of right inguinal hernia is increased after traditional appendectomy. In one study, the incidence of right inguinal hernia was approximately three times greater than in the general population [63]. The theory is that damage to the hypogastric nerve from the incision leads to weakening of the transversus abdominus muscle and the transversalis fascia. This presumably leads to damage of the "shutter mechanism," which closes the internal ring when intra-abdominal pressure rises. For this reason, the appendectomy incision should be placed above the anterior superior iliac spine to avoid the hypogastric nerve [63].

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