Friday, April 25, 2014

Appendicectomy


Indications: Acute appendicitis, recurrent appendicitis

Procedure:

Incision

  • McBurney's grid incision is the most popular incision. it is right angles to the spino-umbilical line placed at Mcburney's point.It is about 6-8cm in length.
  • Lanz incision are cosmetically better than McBurney's.
  • Right paramedian incision is made when diagnosis is in doubt as a part of exploratomy laparotomy.


Layers opened:
  • skin
  • two layers of subcutaneous tissue: Camper's, Scampa's..
  • external oblique aponeurosis running downwards and medially.it is incised in the direction of the fibres
  • Internal and transverse abdominal muscles are split
  • Peritoneum.
Surgical procedure
  • Appendix is gently held at mesoappendix by using Babcock's forceps and blood vessels in the mesoappendix are divided.These include appendicular artery, branch of ileocolic artery.Once the appendix is freed upto the base (caecum), a purse string suture is applied all round appendix, taking bites from caecum , using 2-0 atraumatic silk.
  • Appendix is crushed at the base and is held 1cm above the crush. A tight silk ligature is applied at the crushed site and appendix is cut in between.Stump is cleaned with spirit.invaginated and purse string is tightened.This is called burial of the stump.Perfect haemostasis is obtained.
Closure
  • Peritoneum -continous 2-0 catgut/vicryl
  • Split muscles -sutured together by a few interrupted suteres using chromic catgut/vicryl
  • External oblique is sutured with silk
  • Subcutaneous fat is sutured with vicryl 
  • Skin with interrupted silk .Instead of catgut, 2-0 silk , 2-0 vicryl is being used more often nowadays.
  • Corrugated red rubber drain is not kept routinely unless there is gangrenous appendicitis or a lot of pus in the peritoneal cavity.

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