- Spinal anesthesia is batter choice but general anesthesia may be required according to age, severity of disease, preference of patient, surgeon or anesthetist.
- Preoperative broad spectrum antibiotic with metronidazole is must and most important.
- Prepare the entire abdomen with pyodine antiseptic and drape the abdomen as operation is planed.
- Recommended incision is skin crease incision with slightly concavity above at McBurney’s point or else due to preoperative or under anesthesia evaluation.
- This incision can be extended medially in case of pelvic pathology or laterally in case of high retrocaecal appendix.
- Underneath fat is cut in direction of skin incision.
- External oblique is incised in its fibres direction above and laterally while at right angle to it internal oblique and transverses abdominis muscle are separated in their fibres direction as an en masse.
- Carefully open the peritoneum and see what is inside peritoneal cavity , air, fluid, blood, puss or any thing else.
- Identify the caecum by taeniae coli, gently follow the anterior taeniae coli to base of appendix and deliver it out.
- Compare the appendix to preoperative assessment, if same than all right if not than see for other pathology.
- There are verity of ways in which mesoappendix is tied depending upon its thickness, it may be an en masse with appendix or separately in one go or in multiple steps to secure the homeostasis.
- Appendix is tied at its junction to caecum without crushing, just to occlude its lumen than about five mm distal to it amputate it and clean the stump with antiseptic.
- There is no need to bury the stump and routinely drainage is not required.
- Some times appendix need retrograde removal (retrograde appendicectomy).
- Closing of peritoneal sheath is must to prevent future incesional hernia and adhesions.
- Do not pass the stitch through internal oblique and transverse abdominis muscles, if needed bring together the fibres by approximating their epimysium, same practice should be done to close the external oblique muscle, by doing this postoperatively pain will be much less and patient will walk very comfortably.
- During closing wash the wound so blood will be wash out and necrotic tissue taken away, this will cause less postoperative pain and less chances of infection.
- Close the skin with vicral repead and usually dressing is not required.
- Immediately post operative allow the fluid even in spinal per operative fluid can be given and patient can be discharged just after four hours in routine appendicectomy.
Appendicectomy (Personal experience)
- Appendicectomy can be done within 2 cm incision, even up to 1 cm with out putting the finger in are taking out the caecum (stab appendicectomy).
- Use the forceps to identify caecum by taeniae coli than follow the anterior taeniae coli to base of appendix, deliver it out, ligate it, amputate it and close the wound in routine.
- In case of difficulty or doubt you can extend the incision.
- In very high retrocaecal appendix if muscle cutting is needed as advocated , first try to make another hole in internal muscles quit above and deal with problem directly by doing this usually no need of muscle cutting is required and postoperative recovery is smooth and less chances of incesional hernia.
- If you practice it than there is no need of laparoscopic appendicectomy.
- Appendix can be removed even through umbilical scar with out laparoscope (scar less appendicectomy).
- We are practicing these techniques from last more than 10 years with out any resent.