Appendectomy

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Appendectomy
Intervention
Blinddarm-01.jpg
An appendectomy in progress
ICD-10-PCS 0DTJ?ZZ
ICD-9-CM 47.0
MeSH D001062
MedlinePlus 002921

An appendectomy (sometimes called appendisectomy or appendicectomy) (British English) is the surgical removal of the vermiform appendix. This procedure is normally performed as an emergency procedure, when the patient is suffering from acute appendicitis. In the absence of surgical facilities, intravenous antibiotics are used to delay or prevent the onset of sepsis; it is now recognized that many cases will resolve when treated perioperatively. In some cases the appendicitis resolves completely; more often, an inflammatory mass forms around the appendix, causing transruptural flotation. This is a relative contraindication to surgery.

Appendectomy may be performed laparoscopically (this is called minimally invasive surgery) or as an open operation. Laparoscopy is often used if the diagnosis is in doubt, or if it is desirable to hide the scars in the umbilicus or in the pubic hair line. Recovery may be a little quicker with laparoscopic surgery; the procedure is more expensive and resource-intensive than open surgery and generally takes a little longer, with the (low in most patients) additional risks associated with pneumoperitoneum (inflating the abdomen with gas). Advanced pelvic sepsis occasionally requires a lower midline laparotomy.

History[edit]

An appendectomy at the French Hospital in Tbilisi, Georgia, 1919.

The first recorded successful appendectomy was in 1735 when French surgeon Claudius Amyand described the presence of a perforated appendix within the hernial sac of an 11-year-old boy who had undergone successful herniotomy. The operation was performed on December 6, 1735, at St. George’s Hospital in London. The organ had apparently been perforated by a pin that the boy had swallowed. The patient, Hanvil Andersen, made a spectacular recovery and was discharged a month later.[1]

There have been some cases of auto-appendectomies. One was attempted by Evan O'Neill Kane in 1921, but the operation was completed by his assistants. Another was Leonid Rogozov, who had to perform the operation on himself as he was the only doctor on a remote Antarctic base.[2]

Procedure[edit]

In general terms, the procedure for an open appendectomy is as follows.

Surgeons perform a laparoscopic appendectomy.
  1. Antibiotics are given immediately if there are signs of sepsis; otherwise, a single dose of prophylactic intravenous antibiotics is given immediately before surgery.
  2. General anaesthesia is induced, with endotracheal intubation and full muscle relaxation, and the patient is positioned supine.
  3. The abdomen is prepared and draped and is examined under anesthesia.
  4. If a mass is present, the incision is made over the mass; otherwise, the incision is made over McBurney's point, one third of the way from the anterior superior iliac spine (ASIS) to the umbilicus; this represents the position of the base of the appendix (the position of the tip is variable).
  5. The various layers of the abdominal wall are opened.
  6. The effort is always to preserve the integrity of abdominal wall. Therefore, the external oblique aponeurosis is split along the line of its fibers, as is the internal oblique muscle. As the two run at right angles to each other, this reduces the risk of later incisional hernia.
  7. On entering the peritoneum, the appendix is identified, mobilized and then ligated and divided at its base.
  8. Some surgeons choose to bury the stump of the appendix by inverting it so it points into the caecum.
  9. Each layer of the abdominal wall is then closed in turn.
  10. The skin may be closed with staples or stitches.
  11. The wound is dressed.
  12. The patient is brought to the recovery room.

Over the past decade, the outcomes of laparoscopic appendectomies have compared favorably to those for open appendectomies because of decreased pain, fewer postoperative complications, shorter hospitalization, earlier mobilization, earlier return to work, and better cosmesis. However, despite these advantages, efforts are still being made to decrease abdominal incision and visible scars after laparoscopy. Recent research has led to the development of natural orifice transluminal endoscopic surgery (NOTES).[3] However, there are numerous difficulties that need to be overcome before a wider clinical application of NOTES is adopted, including complications such as the opening of hollow viscera, failed sutures, a lack of fully developed instrumentation; and the necessity of reliable cost-benefit analyses.[3]

Many surgeons have attempted to reduce incisional morbidity and improve cosmetic outcomes in laparoscopic appendicectomy by using fewer and smaller ports. Kollmar et al. described moving laparoscopic incisions to hide them in the natural camouflages like the suprapubic hairline in order to improve cosmesis. Additionally, reports in the literature indicate that mini-laparoscopic appendectomy using 2–3 mm or even smaller instruments along with one 12-mm port minimizes pain and improves cosmesis. More recently, studies by Ates et al. and Roberts et al. have described variants of an intracorporeal sling based single-port laparoscopic appendectomy with good clinical results.[3]

There is also an increasing trend towards single incision laparoscopic surgery (SILS), using a special multiport umbilical trocar. With SILS, there is a more conventional view of the field of surgery compared to NOTES. The equipment used for SILS is familiar to surgeons already doing laparoscopic surgery. Most importantly, it is easy to convert SILS to conventional laparoscopy by adding a few trocars, this conversion to conventional laparoscopy being called 'port rescue'. SILS has been shown to be feasible, reasonably safe and cosmetically advantageous, compared to standard laparoscopy.[3] However, this newer technique involves specialized instruments and is more difficult to learn because of a loss of triangulation, clashing of instruments, crossing of instruments (cross triangulation), and a lack of maneuverability. There is also the additional problem of decreased exposure and the added financial burden of procuring special articulating or curved coaxial instruments. SILS is still evolving, being used successfully in many centres, but with some way to go before it becomes mainstream. This limits its widespread use, especially in rural or peripheral centres with limited resources.[3]

Pregnancy[edit]

If appendicitis develops in a pregnant woman, an appendectomy is usually performed and should not harm the fetus.[4] 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.[5]

Patient Safety[edit]

Although the American healthcare system provides high quality care for most patients most of the time, there is significant room for the improvement of patient safety. Medical errors harm approximately one in seven Medicare patients during their hospital stay.[6] According to a recent review of studies published between 2008 and 2011, between 210,000 and 400,000 deaths each year in the United States are associated with preventable harm.[7] One in 20 hospitalized patients suffer from healthcare-acquired infections, such as catheter-related bloodstream infections, hospital-acquired pneumonia, or surgical site infections 3.[8]

Simple checklists are often used to reduce costly and dangerous mistakes in complex industries such as aviation and medicine. Checklists for doctors have been shown to reduce patient complications and even death.[9] Checklists have been particularly successful in improving outcomes after surgery. Peter Pronovost, an intensive care specialist at Johns Hopkins Hospital, patient safety expert, and leading advocate for checklists, has demonstrated that simple checklists are effective in reducing preventable harm. In a program developed at Johns Hopkins, Dr. Pronovost has shown that a simple checklist of safety procedures can significantly reduce catheter-associated bloodstream infections in the intensive care unit (ICU), saving lives and millions of dollars.[10] In Michigan, Dr. Pronovost’s introduction of an intensive care checklist protocol over an 18 month period saved 1,500 lives and $100 million.[11] Dr. Pronovost has described his findings on physician checklists in a book he co-authored: Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out.[12] Training surgeons in communication and using a procedure checklist before, during, and after surgery has also been shown to significantly decrease patient complications up to 30 days after surgery.[13] One study found that a surgical safety checklist used at 8 hospitals around the world reduced major complications after surgery by 36% and lowered the death rate by nearly half.[14]

Checklists including essential questions for the doctor are also an important way for patients to ensure that they receive high quality health care. Asking doctors key questions at each stage of care improves communication between patients and their health care team, leading to better, safer, and more efficient health care.[15] Many leading health care organizations including the Centers for Disease Control and Prevention (CDC), the Cleveland Clinic, and the U.S. Department for Veterans Affairs provide key questions for patients to ask their doctors. The Agency for Healthcare Research and Quality (AHRQ) provides tips and tools for patients to ask their doctors informed and important questions. Better communication between patients and doctors leads to better health care for patients, as well as greater satisfaction among physicians. In a recent randomized controlled trial of knee and hip replacement patients who were given a structured list of questions to ask their surgeon, significantly more patients in the intervention group (58%) reached an informed decision during the first visit on whether or not to have surgery compared to a control group (33%). Surgeons had higher ratings of the number and appropriateness of patient questions, better satisfaction with the efficiency of the visit, and were more satisfied overall with patients in the intervention group compared to the control group.[16] Patients can find tailored lists of questions for their surgeon and doctors on many websites. List of questions to ask your doctor can be found here. Lists of questions to ask your doctor can be found here.

Recovery[edit]

Scar and bruise 2 days after operation.
Scar 10 days after operation. Male, 23-y.o. patient. Hospital "Manuel Gea González", Mexico City, Tuesday, March 8, 2011.

A study from 2010 found that the average hospital stay for patients with appendicitis in the United States was 1.8 days. For patients with a perforated (ruptured) appendix, the average length of stay was 5.2 days.[17]

Recovery time from the operation varies from person to person. Some will take up to three weeks before being completely active; for others it can be a matter of days. In the case of a laparoscopic operation, the patient will have three stapled scars of about an inch in length, between the navel and pubic hair line. When an open appendectomy has been performed the patient will have a 2–3 inch scar, which will initially be heavily bruised.[18]

Epidemiology[edit]

Approximately 327,000 appendectomies were performed during U.S. hospital stays in 2011, a rate of 10.5 procedures per 10,000 population. Appendectomies accounted for 2.1% of all operating room procedures in 2011.[19]

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 from the University of California, San Francisco published in the Archives of Internal Medicine 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, more than 120 times greater. The median charge was $33,611.[20][21] 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.[22]

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]

References[edit]

  1. ^ *(1736) C. Amyand: Of an inguinal rupture, with a pin in the appendix caeci, incrusted with stone; and some observations on wounds in the guts. Philosophical Transactions of the Royal Society of London, 39: 329-336.
  2. ^ Rogozov V, Bermel N (2009). "Auto-appendectomy in the Antarctic: case report". BMJ 339: b4965. doi:10.1136/bmj.b4965. PMID 20008968. 
  3. ^ a b c d e Ashwin, Rammohan; Paramaguru, jothishankar; Manimaran, AB; Naidu, RM (2012). "Two-port vs. three-port laparoscopic appendicectomy: A bridge to least invasive surgery". Journal of Minimal Access Surgery. 
  4. ^ Factors That Develop During Pregnancy at Merck Manual of Diagnosis and Therapy Home Edition
  5. ^ Sabiston Textbook of Surgery 2007
  6. ^ "Adverse events in hospitals: National incidence among Medicare beneficiaries". Retrieved 2014-04-01. 
  7. ^ James JT (September 2013). "A new, evidence-based estimate of patient harms associated with hospital care". J Patient Saf. 9 (3): 122–8. doi:10.1097/PTS.0b013e3182948a69. PMID 23860193. 
  8. ^ "Key facts about patient safety". Retrieved 2014-04-01. 
  9. ^ "Checklists to improve patient safety". Retrieved 2014-04-22. 
  10. ^ Pronovost PJ (Apr 2011). "His program reduces bloodstream infections across the country. What’s next?". Manag Care 20 (4): 28–31. PMID 21553685. 
  11. ^ Pronovost, Peter (December 9, 2007). All Things Considered. (Interview). National Public Radio. 
  12. ^ Vohr, Eric; Pronovost, Peter (February 2010). Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out. New York, NY: Hudson Street Press. ISBN 978-1-101-18527-8. 
  13. ^ Bliss LA, Ross-Richardson CB, Sanzari LJ, Shapiro DS, Lukianoff AE, Berstein BA, Ellner SJ (December 2012). "Thirty-day outcomes support implementation of a surgical safety checklist". J Am Coll Surg. 215 (6): 766–76. doi:10.1016/j.jamcollsurg.2012.07.015. PMID 22951032. 
  14. ^ Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA; Safe Surgery Saves Lives Study Group (January 29, 2009). "A surgical safety checklist to reduce morbidity and mortality in a global population". N Engl J Med. 360 (5): 491–9. doi:10.1056/NEJMsa0810119. PMID 19144931. 
  15. ^ "Questions to ask your doctor: Questions are the answer". Retrieved 2014-04-01. 
  16. ^ Bozic KJ, Belkora J, Chan V, Youm J, Zhou T, Dupaix J, Bye AN, Braddock CH 3rd, Chenok KE, Huddleston JI 3rd (September 2013). "Shared decision making in patients with osteoarthritis of the hip and knee: results of a randomized controlled trial". J Bone Joint Surg Am. 95 (18): 1633–9. doi:10.2106/JBJS.M.00004. PMID 24048550. 
  17. ^ a b Barrett ML, Hines AL, Andrews RM. Trends in Rates of Perforated Appendix, 2001–2010. HCUP Statistical Brief #159. Agency for Healthcare Research and Quality, Rockville, MD. July 2013. [1]
  18. ^ http://www.scribd.com/doc/17692145/Surgery-2
  19. ^ Weiss AJ, Elixhauser A, Andrews RM. (February 2014). "Characteristics of Operating Room Procedures in U.S. Hospitals, 2011.". HCUP Statistical Brief #170. Rockville, MD: Agency for Healthcare Research and Quality. 
  20. ^ "Health Care as a 'Market Good'? Appendicitis as a Case Study".  JournalistsResource.org, retrieved April 25, 2012
  21. ^ Hsia, Renee Y.; Kothari, Abbas H.; Srebotnjak, Tanja; Maselli, Judy (2012). "Health Care as a 'Market Good'? Appendicitis as a Case Study". Archives of Internal Medicine. 
  22. ^ Tanner, Lindsey (April 24, 2012). "Study finds appendectomy could cost as much as house". Florida Today (Melbourne, Florida). pp. 6A. 

External links[edit]