1. Mark incision site
The position of the incision is based upon the location of the McBurney point.  Skin incision is based on McBurney point, which lies one third of distance along imaginary line between right anterior superior iliac spine (ASIS) and umbilicus. Incision is made through this point perpendicular to this line (McBurney-McArthur) or horizontally (Lanz). Incision extends 3-5 cm along skin creases.
2. A scalpel with No. 10 blade is used to incise the epidermis and the dermis.
3. A Bovie electrocautery is used to incise through both the superficial Camper (the fatty outer layer) and the deep Scarpa fascia (more membranous inner layer) See Figure 2
4. Use retractors to hold aside camper and scarpa fascia
5. External oblique aponeurosis is exposed and incised in a superolateral to inferomedial direction along the direction of its fibers to expose the internal oblique muscle.
6. External oblique aponeurosis is held aside with retractors
7. The internal oblique muscle is bluntly divided to the direction of its fibers with alternating Kelly clamps and Roux retractors (perpendicular to upper layer)
8. The transverse abdominal muscle (trasnversus abdominis) is divided in the direction of its fibers
9. The peritoneum is identified.
10. Transversalis fascia is divided and the peritoneum is grasped with forceps (hemostats) by the surgeon first followed by the assistant
(or Transversalis fascia and peritoneum are grasped with 2 straight clamps, with palpation between surgeon's fingers, and with care taken to avoid entrapment of any underlying structures)
11. Operator drops the original bite and picks up close to the assistant and compresses the peritoneum to free the underlying intestine
12. Peritoneum is clamped to moist sponges surrounding the wound.
13. Perform the incision on peritoneum in a craniocaudal direction with Metzenbaum scissors (or a 15 blade knife) thereby gaining access to the peritoneal cavity.
14. Retractors inserted into the peritoneum and other instruments taken off
15. Once the cavity is opened, any fluid encountered should be sent for Gram stain and culture.
16. Identify the cecum by seeing its taeniae coli – will be used as a guide to help identify the appendix.
17. Cecum is held in a moist gauze and delivered into the wound
18. Babcock forceps can be used to grasp the taeniae coli and follow them to the convergence of the three taenia, identifying the base of the appendix.
19.  Free the appendix-mesoappendix complex from its adjacent, often inflamed, tissue, and externalize it.
  • Alternatively, a finger can be swept around the cecum, beginning superolaterally and continuing inferomedially to locate the appendix.
20. The mesoappendix is dissected.
21. The appendiceal artery is then are divided between clamps and ligated with silk sutures (3-0 Vicryl 2 times) and separated from the appendix. (See the image below.)

Removing the appendix: 3 different ways:
1.     Simple ligation
2.     Purse-stringing
3.     Inversion appendectomy.
The actual method of resection has not been shown to make a significant difference with respect to wound infection, length of hospital stay, postoperative fever, and intra-abdominal abscess formation. 

Simple Litigation Method:
22.  The appendiceal/cecal base is clearly exposed
23. Appendix is crushed using right angled artery forceps/ hemostats near the base
24. The forceps is moved 1 cm towards the of the appendix
25. Appendix is ligated with 2-0 plain polyglactin (heavy absorbable suture) which is held in a clamp proximal to the first crush; this ligation is performed twice.
26: Place a clamp just proximal to the distal ligature on the appendix, avoiding any inadvertent contamination, and divide sharply. Stump must not be more than 3 mm.
27: Cauterize the exposed mucosa.

The retrograde technique is used under the following circumstances:
·       The appendix is very inflamed, and manipulation may cause perforation
·       The appendix is in a retroperitoneal position
·       The appendix is surrounded by inflammatory tissue, omentum, or both, which makes identification difficult
In the retrograde technique, the base of the appendix is found first, exposed, ligated, and transected. Attention is then turned to the mesoappendix, which is ligated last.

28. Check hemostatis
29. The wound is copiously irrigated with normal saline

30. If appendix is not obviously involved in inflammation, thorough exploration for other causes to be looked for (fallopian tubes if female, small intestine check)

31. If the inflammation extends to the base and the cecum or ileum, a ileocecectomy may be contemplated with primary anastamosis

32. Grasp the peritoneum with two straight clamps

33. Close peritoneum and transversalis fascia with a continuous absorbable suture (3-0 polyglactin stitch).

34. Internal oblique muscle closed with interrupted/ continuous absorbable suture  (using 3-0 polyglactin at each level).

35. Close the external oblique muscle with a continuous 2-0 polyglactin stitch.

36. Scarpa fascia is closed with interrupted sutures (with 3-0 polyglactin)

37. Use 4-0 poliglecaprone subcuticular interrupted sutures for skin closure.

38. Apply sterile dressings.

If wound contamination is a concern in complicated appendicitis, the wound may be closed at the musculofascial level, left open and packed for 3-5 days, and closed secondarily.
Another option is to leave a Penrose drain in the wound and remove it 2-3 days later. If a phlegmon or abscess is encountered, the abdomen should be thoroughly irrigated with normal saline. Closed suction drainage may be used in these circumstances or if the adequacy of appendiceal stump closure is of concern. According to a 2015 Cochrane review, it is unclear whether routine abdominal drainage is effective in preventing intraperitoneal abscesses after open appendectomy for complicated appendicitis.



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