Appendectomy Basics

Part of Surgery

Removing the inflamed appendix to prevent rupture and fatal peritonitis.

Why This Matters

Appendicitis is one of the most common surgical emergencies in the world. The appendix — a small blind-ended tube attached to the large intestine — can become infected and inflamed, progressing through stages from simple inflammation to perforation (rupture) and peritonitis (spreading abdominal infection). Without treatment, a ruptured appendix kills most patients within days.

In pre-surgical eras, appendicitis was uniformly fatal once the appendix perforated. The first successful appendectomy was performed in 1880. Today it is one of the most commonly performed surgeries worldwide. In post-collapse conditions, an untreated appendicitis will kill people who could otherwise survive decades.

The good news: appendectomy is among the more manageable emergency abdominal surgeries. The appendix is consistently located, its removal is straightforward, and when operated upon before perforation, recovery is rapid. The key is diagnosis before rupture and adequate surgical capability.

Recognizing Appendicitis

Classical Presentation

The typical progression over 12-36 hours:

1. Early: vague central or generalized abdominal pain, loss of appetite, nausea
2. Developing: pain migrates to right lower quadrant (right side of lower abdomen), becomes more constant and severe
3. Established: point tenderness at McBurney’s point (one-third of the way from the right hip bone to the navel), fever (38-38.5°C), patient prefers to lie still

Diagnostic Signs Without Imaging

McBurney’s point tenderness: press firmly at McBurney’s point (between right anterior superior iliac spine and umbilicus, one-third from the hip bone). Significant tenderness strongly suggests appendicitis.

Rebound tenderness: press slowly on the right lower quadrant, then release suddenly. Sharp pain on release indicates peritoneal irritation — appendicitis or other intra-abdominal pathology.

Rovsing’s sign: press on the LEFT lower quadrant. Pain felt in the RIGHT lower quadrant suggests right-sided peritoneal irritation.

Psoas sign: ask patient to raise right leg against resistance, or passively extend right hip with patient on left side. Pain in right lower quadrant suggests appendix is near the psoas muscle (retrocecal appendix).

Guarding: involuntary tightening of the abdominal muscles when the right lower quadrant is touched. Sign of peritoneal irritation.

Distinguishing Early from Perforated

Simple appendicitis (not yet ruptured):

• Localized pain at McBurney’s point
• Low-grade fever (37.5-38.5°C)
• Patient looks unwell but is alert
• Abdomen soft except at McBurney’s point

Perforated appendicitis:

• Pain initially severe, then may briefly improve as pressure releases — but then becomes generalized
• Higher fever (39°C+)
• Rigid abdomen (board-like throughout)
• Patient looks seriously ill, may be trembling or barely responsive
• Hours since perforation matter: early perforation is better than late

Act Quickly

A perforated appendix is still survivable with surgery. A perforated appendix treated with observation and hope is nearly always fatal. When doubt exists, operate.

Conservative Management Option

Randomized trials show that uncomplicated appendicitis (not yet perforated) can be successfully treated with antibiotics alone in approximately 70% of cases, with recurrence in 25% of those within 5 years.

When to try conservative management:

• Clear diagnosis of simple appendicitis, no perforation signs
• Antibiotics available (broad-spectrum: amoxicillin-clavulanate, or metronidazole + trimethoprim)
• Surgical capability limited or anesthesia unavailable
• Close monitoring possible

Conservative management protocol:

1. Nothing by mouth (NPO)
2. Antibiotics IV or oral if IV unavailable
3. Monitor every 4 hours: temperature, pulse, abdominal exam
4. If improving at 12-24 hours: continue antibiotics for 7-10 days
5. If deteriorating: operate immediately

If antibiotics are not available, conservative management is not an option. Operate.

The Appendectomy Procedure

Incision

McBurney’s point incision (Gridiron incision):

1. Mark a line between the umbilicus and the right anterior superior iliac spine (right hip point)
2. The incision is centered one-third of the way along this line from the hip, perpendicular to the line
3. Length: 5-8 cm
4. Cut through: skin, fat, external oblique muscle (following fiber direction), internal oblique (split along fibers, do not cut), transversus abdominis (split), peritoneum

Alternative: lower right midline incision. More versatile if the diagnosis is uncertain — better access to look at other structures.

Finding the Appendix

1. Once inside the peritoneum, identify the cecum (the large blind pouch where the large intestine begins in the right lower quadrant)
2. Follow the taeniae coli (three longitudinal muscle bands) — they converge on the base of the appendix
3. The appendix hangs from the cecum; it may be tucked behind the cecum (retrocecal) — in this case, retract the cecum upward to see behind

Removing the Appendix

1. Deliver the appendix out of the wound
2. Ligate (tie) the mesoappendix (the fatty tissue carrying the appendix’s blood supply) in sections with absorbable suture — this controls bleeding
3. Crush the appendix at its base with a clamp, then move the clamp 0.5 cm distally
4. Tie an absorbable suture tightly around the crushed base (this closes the cecum at the base of the appendix)
5. Cut the appendix off above the tie — remove it
6. Invaginate the stump: place a purse-string suture around the cecum surrounding the stump, then push the stump into the cecum while pulling the purse-string tight. This buries the stump, reducing infection risk. (Optional but recommended.)
7. If the appendix was not perforated: wash the area with saline, close in layers
8. If the appendix was perforated: wash copiously (1-2 liters of saline or boiled water) until return is clear, consider leaving a drain, close fascial layers, leave skin open

Closure

• Peritoneum: continuous absorbable suture if intact
• Muscle layers: loose interrupted absorbable sutures — do not over-tighten
• Fascia: interrupted absorbable sutures
• Skin: interrupted non-absorbable sutures if no contamination; leave open if perforation was present

Post-Operative Care

Simple appendectomy (no perforation):

• Sips of water within 6 hours if no nausea
• Regular diet by 24-48 hours
• Up and walking by 24 hours (reduces blood clot risk)
• Wound care daily
• Back to light activity at 2 weeks

Perforated appendectomy:

• NPO until bowel sounds return (may take 48-72 hours)
• Monitor for ongoing infection: fever, wound drainage, abdominal pain
• Wound left open heals slowly by secondary intention — pack daily with clean moist cloth
• Full recovery 4-6 weeks

Expected outcomes in resource-limited setting:

• Simple appendectomy, no antibiotics: 85-90% survival
• Perforated appendectomy, no antibiotics: 40-70% survival (depends on how long since perforation)
• Perforated appendectomy with antibiotics: 70-85% survival

These numbers are sobering but far better than the near-zero survival of untreated perforated appendicitis. The surgery is worth attempting.