Umbilical appendicectomy
Appendix can be removed from umbilicus when cosmetic is more important. This is new approach, safe, practicable with different vision and new concept. First prerequisite is surgeon must be experience and routinely doing appendicectomies. Second there should be no doubt regarding the diagnosis and all relevant investigations are done. Third start doing it in simple and straight forwarded cases preferably less than 15 years age group than in complicated cases even in perforated appendix.
Instruments requirements
Narrow neck retractor or retractors, light retractor, ribbon abdominal sponges and general trolley instruments.
Investigations
Routine body tests with ultrasonography.
Anesthesia
Umbilical appendicectomy can be done under general anesthesia or spinal anesthesia.
Procedure
Under anesthesia after draping the patient give semicircle infra umbilical or c shape incision. Deepen the incision up to linea alba. Detach the umbilicus from linea alba for free movements of this incision. Open the linea alba in midline as your requirements 2 to 5 cm in routine. Lift the abdominal wall on right side, pack the small intestine on left side with ribbon abdominal sponge of appropriate size. Identified the caecum by tenia coli and access the mobility of caecum, if freely mobile then bring it in wound if not then operate appendix in abdomen. Follow the tenia coli to base of appendix, hold the appendix and free it from rest of structures. Inject SKL at base of appendix. If appendix and mesoappendix are not very thick and inflammable and one cane en masse ligate them then it is ok if not then separately ligate it. Do routine appendicectomy, confirm hemostasis. Closed the wound in layers and reattach the umbilicus. The best stitch for appendicectomy is chromic one, and wound closure is vicryl 2/0 in multilayers and for skin as well.
Difficulties
If caecum is not identified; further search extreme right and posterior side for caecum or ascending colon by their tenia coli those will lead to appendix. Further pack the gut and retract toward left side.
Appendix is badly adherent; slowly and gently dissection will help, finger dissection is very important. At extreme end mobilize the ileocaecal junction and ascending colon
Perforated appendix; the procedure is same as you do in standard incisions.
Hemostasis; not big issue everything is under direct vision and easily manageable.
Difficult to do appendicectomy just enlarge the linea alba incision, extreme cases either use the mid line incision or another incision on right side of abdomen at more appropriate site.
Apply SKL in wound to almost no post-operative pain.
Regarding appendicular abscess and appendicular mass we can’t say anything at moment.
Incisional hernia after this approach
If you know the reason of incisional hernias than you can reduce them.
The commonest cause of incisional hernia is prolene stitch itself which is use to prevent it. It cause cheese wire effect which cause solely tissue cutting leading to micro hemorrhage where greater omentum stuck and with passage enter into multiple hole made by prolene stitch and one or more of them enlarge enough leading to incisional hernia.
If you don’t close the peritoneum properly; even smallest trocar site enter can lead to incisional hernia.
If wound is not close properly and especially greater omentum is trap in it than it definitely lead to incisional hernia.
Conclusion
For cosmetic purposes this is best approach, time tested, safe, practicable and at extreme end advantages over laparoscopic approach, as it is under direct vision with tactile sensations and normal sizes. There is lot of time saving and guaranteed operation. Appendix is completely removed with no doubt. Patient can go home from operation theater.