Open Appendectomy : Operative Procedure Video

[starttext]Definition: Open surgery is the traditional type of surgery where a long incision is made for the surgeon to insert the instruments, visualizing the surgery through the incision. With an open approach, the incision for a typical appendectomy is approximately 4 inches long.

  1. When patient prefers open procedure (cheaper) 
  2. When surgeon prefers open procedure (lack of surgical expertise and necessary equipments for laproscopic procedure) 
  3. Laproscopic procedure is contraindicated (severe pulmonary disorders, bleeding diathesis, portal hypertension, intolerance of (ie, hypotension due to) Trendelenburg positioning, poor visualization, and severe adhesive disease from previous abdominal surgeries)
Operative procedure:

1. Preoperative preparations: General anesthesia, Supine position, Prophylactic antibiotics, Draping and exposure

2. Skin incision:
  • Classical 'gridiron' incision: Incision through McBurney's point perpendicular to the imaginary line joining umbilicus and anterior superior iliac spine
  • Cosmetic Laz incision: Horizontally over McBurney's point
3. Abdominal wall incision:
  • Subcutaneous fat
  • Superficial fascia
  • Fat
  • External oblique aponeurosis
  • Internal oblique
  • Transversus abdominis
  • Vascular layer
  • Parietal peritoneum
  • Visceral peritoneum
4. Finding and delivering appendix:
a. Identify the cecum to identify appendix
b. If cecum is not identifiable, track the appendix following convergence of taenia
c. Forefinger palpates for appendix
  • If mobile: pushed out from within
  • If adherent: dissected out
  • If truly retrocecal: division of lateral peritoneum followed by dissection of appendix
5. Dividing the blood supply:
  • Appendix is held with babcock forceps
  • The vessels are clipped and ligated after pushing holes in meso-appendix on either side 
6. Removing the appendix:
  • Tie appendix base
  • Invert the stump with a purse-string suture
  • Crush appendix with hemostat at the site of tie
7. Peritoneal toileting

8. Closure: using absorbable sutures
  • Peritoneum: Continuous
  • Internal oblique muscle: Loose interrupted
  • External oblique aponeurosis: Continuous
  • Skin: Subcuticular if not inflamed and left open for delayed primary suturing if infected


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