Appendectomy
An appendectomy (American English) or appendicectomy (British English) is a surgical operation in which the vermiform appendix (a portion of the intestine) is removed. Appendectomy is normally performed as an urgent or emergency procedure to treat complicated acute appendicitis.[1]
Appendectomy
Appendectomy may be performed laparoscopically (as minimally invasive surgery) or as an open operation.[2] Over the 2010s, surgical practice has increasingly moved towards routinely offering laparoscopic appendicectomy; for example in the United Kingdom over 95% of adult appendicectomies are planned as laparoscopic procedures.[3] Laparoscopy is often used if the diagnosis is in doubt, or in order to leave a less visible surgical scar. Recovery may be slightly faster after laparoscopic surgery, although the laparoscopic procedure itself is more expensive and resource-intensive than open surgery and generally takes longer. Advanced pelvic sepsis occasionally requires a lower midline laparotomy.
Complicated (perforated) appendicitis should undergo prompt surgical intervention.[1] There has been significant recent trial evidence that uncomplicated appendicitis can be treated with either antibiotics or appendicectomy.[4][5] After appendicectomy the main difference in treatment is the length of time the antibiotics are administered. For uncomplicated appendicitis, antibiotics should be continued up to 24 hours post-operatively. For complicated appendicitis, antibiotics should be continued for anywhere between 3 and 7 days.[1] An interval appendectomy is generally performed 6–8 weeks after conservative management with antibiotics for special cases, such as perforated appendicitis.[6] Delay of appendectomy 24 hours after admission for symptoms of appendicitis has not shown to increase risk of perforation or other complications.[7]
Pregnancy[edit]
Appendicitis is the most common emergent general surgery related problem to arise during pregnancy. There is a natural elevation in white blood cell count in addition to anatomical changes of the appendix that occur during pregnancy.[13] These findings, in addition to non-specific abdominal symptoms make appendicitis difficult to diagnose. Appendicitis develops most commonly in the second trimester.[2] If appendicitis develops in a pregnant woman, an appendectomy is usually performed and should not harm the fetus.[14] The risk of premature delivery is about 10%.[15] The risk of fetal death in the perioperative period after an appendectomy for early acute appendicitis is 3 to 5%. The risk of fetal death is 20% in perforated appendicitis.[16]
There has been debate regarding which surgical approach is preferred during pregnancy. Overall, there is no increased risk of fetal loss or preterm delivery with the laparoscopic approach (LA) as compared to the open approach (OA). However, the LA was associated with shorter length of stay in the hospital as well as reduced risk of wound infection.[2]
Patient positioning is of utmost importance to ensure safety of the fetus during the procedure. This is especially important during the third trimester due to the potential of compression of the inferior vena cava leading by the enlarged uterus. Placing the patient in a 30-degree left lateral decubitus position alleviates this pressure and prevents fetal distress.[13]
One area of concern related to the LA during pregnancy is pneumoperitoneum. This causes an increase in the intra-abdominal pressure, leading to decreased venous return and therefore, decreased cardiac output. The decreased cardiac output may lead to fetal acidosis and cause distress. However, an animal pregnancy model demonstrated that a 10-12mmHg insufflation pressure demonstrated no adverse effects on the fetus. SAGES (Society of American Gastrointestinal and Endoscopic Surgeons) currently recommends an insufflation pressure of 10-15mmHg during pregnancy.[2]
Complications[edit]
One of the most common post-operative complications associated with an appendectomy is the development of a surgical site infection (SSI).[19] Signs and symptoms indicative of a superficial SSI are redness, swelling, and tenderness surrounding the incision and are most likely to arise on post-operative day 4 or 5. These symptoms oftentimes precede fluid drainage from the incision. Tenderness extending beyond the redness that surrounds the incision, in addition to the development of cutaneous vesicles or bullae may be indicative of a deep SSI.[19]
Patients with complicated appendicitis (perforated appendicitis) are more likely to develop a SSI, abdominal abscess, or pelvic abscess during the post-operative period. Placement of an abdominal drain was originally thought to reduce the risk of these post-operative complications. However, abdominal drains have not been found to play a significant role in reducing SSIs and have led to increased length of stay in the hospital in addition to increased cost of the operation.[20]
Cost[edit]
United States[edit]
While appendectomy is a standard surgical procedure, its cost has been found to vary considerably in the United States. A 2012 study analyzed 2009 data from nearly 20,000 adult patients treated for appendicitis in California hospitals. Researchers examined "only uncomplicated episodes of acute appendicitis" that involved "visits for patients 18 to 59 years old with hospitalization that lasted fewer than four days with routine discharges to home." The lowest charge for removal of an appendix was $1,529 and the highest $182,955, almost 120 times greater. The median charge was $33,611.[30][31] While the study was limited to California, the researchers indicated that the results were applicable anywhere in the United States. Many, but not all, patients are covered by some sort of medical insurance.[32]
A study by the Agency for Healthcare Research and Quality found that in 2010, the average cost for a stay in the United States involving appendicitis was $7,800. For stays where the appendix had ruptured, the average cost was $12,800. The majority of patients seen in the hospital were covered by private insurance.[17]