What is the Appendix?
The appendix is a three-to six-inch long tube like structure located at the junction of the small and large intestines. The wall of the appendix contains lymphatic tissue which in childhood serves an immune function, however in adults the appendix serves little –if any, function.
It is when the appendix becomes infected or inflamed that it must be removed. The surgical removal of the appendix is called an appendectomy.
What is Appendicitis?
Appendicitis is an inflammation of the appendix. It usually occurs when there is a blockage in the opening of the appendix, usually by feces. This leads to an overgrowth of the bacteria within the appendix. Appendicitis usually develops rapidly with little warning over a period of six to 12 hours. The usual symptom is abdominal pain, which begins as vague discomfort around the belly button. Most patients often mistake this initial pain as indigestion. Over the next several hours, the pain becomes much more severe and is localized to the lower right side of the abdomen. The abdomen may become rigid and very sensitive to pressure. Pain is typically accompanied by nausea, vomiting and a slight fever. Often patients with appendicitis have no appetite, and the presence of hunger makes the diagnosis of appendicitis less likely.
An appendectomy is almost always performed as an urgent surgery. Therefore, a diagnosis of appendicitis is usually made quickly and is based primarily on an analysis of your symptoms and the findings on physical examination. Laboratory work done may show an elevation in the White Blood Cell (WBC) count which is a marker for inflammation and infection, although this may not always be the case. If there is a question regarding the nature of your symptoms or if the diagnosis of appendicitis is in doubt, a CAT Scan of the Abdomen and Pelvis can be helpful in diagnosing an inflamed appendix, or revealing any conditions which may mimic appendicitis.
It can be difficult to diagnose appendicitis. The position of the appendix in the abdomen may vary. Most of the time the appendix is in the right lower abdomen, but in some individuals the appendix may extend down into the pelvis or be located behind the colon (called a retro-colic appendix). In either case, inflammation of the appendix may act more like the inflammation of other organs, some of which are not treated surgically. Therefore, it is common to observe patients with suspected appendicitis for a period of time to see if the problem will resolve on its own or develop characteristics that more strongly suggest appendicitis or, perhaps, another condition.
Surgery to Remove the Appendix
A surgeon can perform an appendectomy in one of two ways: through what is called an open operation or through the laparoscopic technique.
In this operation, the surgeon makes a small incision through the skin and underlying fat of the right lower side of the abdomen over the area of the appendix. The muscles of the wall are then separated, revealing the peritoneum, which is the lining of the abdominal cavity. The peritoneum is cut to reveal the cecum, the section of the large intestine to which the appendix is attached. The appendix is then identified and carefully freed from the surrounding structures. Blood vessels around the site are tied off. At this point, the appendix is tied off and transected. The appendix is then sent to the pathology laboratory for examination. The peritoneum, the muscle wall, and the skin incision are then closed. Closure of the skin is done either with sutures or tiny staples.
In most laparoscopic appendectomies, surgeons operate through 3 small incisions (each ¼ to ½ inch) while watching an enlarged image of the patient’s internal organs on a television monitor. Surgical instruments called cannulas are inserted into other small openings and used to remove the appendix. Laparoscopic appendectomy is a safe alternative to the open technique. Advantages of Laparoscopic Appendectomy include less postoperative pain, shorter hospital stays, quicker return to normal activities, and better cosmetic results. Although laparoscopic appendectomy has many benefits, it may not be appropriate for some patients. Early, non-ruptured appendicitis usually can be removed laparoscopically. Laparoscopic appendectomy is more difficult to perform if there is advanced infection or the appendix has ruptured. A traditional, open procedure using a larger incision may be required to safely remove the infected appendix in these patients. Regardless of the type of procedure you undergo, minimal postoperative discomfort is likely to occur after an appendectomy.
WHAT HAPPENS IF THE OPERATION CANNOT BE PERFORMED OR COMPLETED BY THE LAPAROSCOPIC METHOD?
In a small number of patients the laparoscopic method is not feasible because of the inability to visualize or handle the organs effectively. When the surgeon feels that it is safest to convert the laparoscopic procedure to an open one, this is not a complication, but rather sound surgical judgment. Factors that may increase the possibility of converting to the “open” procedure may include:
- Extensive infection and/or abscess
- A ruptured appendix
- A history of prior abdominal surgery causing dense scar tissue
- Inability to visualize organs
- Bleeding problems during the operation
The decision to perform the open procedure is a judgment decision made by your surgeon either before or during the actual operation. The decision to convert to an open procedure is strictly based on patient safety.