**6. Appendectomy**

#### **6.1 Incisions for appendectomy**


**Figure 11.** *Incision for appendectomy.*

#### **6.2 Procedure of open appendectomy**

Abdomen is opened and caecum was identified. Appendix located at illeo caecal junction and mesoappendix dissected and clamped and tied.

Appendix was cut at the base after securing with purse string or Z stitch. Invagination of appendicular stump can be done. When the appendix is retrocaecal and adherent, it is advantageous to do retrograde appendicectomy.

See for Meckel's diverticulum. Put a drain if pus is there or in case of extensive dissection.

The definitive treatment of acute appendicitis is appendectomy and the sooner it is done, the better. There are four exceptions to this excellent rule:


## **6.3 Management of appendicular mass**

Ideal is to manage by the Ochsner-Scherren regimen (conservatively). In that regimen patient is treated by starting IV antibiotics and symptomatic treatment.

Patient is allowed orally only when it's tolerated otherwise to start IV fluids at initial part. Stop treating conservatively if:


### **6.4 Laparoscopic appendectomy**

As per some studies laparoscopic surgery is comparable or sometimes superior to open surgery in appendectomy. So while going for surgical management of appendicitis laparoscopy is preferred irrespective of clinical condition and diagnostic value [4].

Appendicular stump closure by single endoligature (endoloop) is procedure of choice as tactical modification nowadays. Other alternatives like endostapler, metal clips, bipolar endocoagulation, and polymer clips [5].

All alternative methods have never been assessed in prospective randomized studies but with proper knowledge about them one can do safe and cost-effective procedure [6].

In inflamed appendicular stump one can use enostapler which causes closing and transecting the appendix in one step but it's expensive [7].

Endoclip and endoloop are other methods which are equally cost effective but endoclip is easier to mastered than endoloop. Both offers closing and cutting the appendix before dissecting the mesoappendix. Appendicular base up to 16 mm can be clipped is a limitation of endoclip which is not offered by endoloop [7].

In bipolar coagulation technique there is no need of clip applicators, needle holders or knot pushers required and it is very simple and economical method. But it should be carried out by experienced surgeon [8].

#### **6.5 Advantages (laparoscopic appendectomy)**

