Open Appendectomy

A transverse Rocky-Davis or the classical McBurney skin incision is made in the RLQ over the area of maximal tenderness. If purulent or cloudy peritoneal fluid is encountered, it should be sent for culture and sensitivity. The appendix is identified at the confluence of the taeniea coli, and the mesoappendix is clamped and divided. A silk purse string suture is placed at the base of the appendix, which is then clamped, ligated with catgut, and divided sharply. The appendiceal stump can be cauterized either chemically or electrically (dealer's choice), and "dunked" into the cecum. The fascia is closed, and the skin also except in cases of perforated appendicitis.

If the appendix is perforated, historical management has been either delayed primary closure or primary closure with drainage. This becomes more an issue in

the pediatric population where follow-up and cosmesis play a larger role. Serour et al suggests that primary closure with triple antibiotic therapy for 7-10 days results in a wound infection rate of 6% for children after perforated appendicitis.4 Fischer suggests that primary closure should include the placement of either a Penrose or closed suction drain.3

When a normal appendix is encountered, a limited exploration is warranted to rule out nearby pathology. In all cases except for IBD, the appendix should be removed to eliminate the possibility of confusion in future cases of RLQ pain. If an appendix is removed in the presence of active IBD, a fecal fistula may ensue.

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