Appendectomy Surgical Removal of the Appendix

Patient Education Partners in Your Surgical Care American College of Surgeons Division of Education Appendectomy Surgical Removal of the Appendix

Removal of the Appendix Patient Education This educational information is to help you be better informed about your operation and empower you with the skills and knowledge needed to actively participate in your care. Keeping You Informed Information that will help you Small intestine further understand your operation Appendix and your role in healing. Large intestine Education is provided on: Appendectomy Overview...... 1 Treatment Options Expectations Condition, Symptoms, Tests...... 2 Surgery Before your operation— Treatment Options...... 3 Evaluation usually includes Laparoscopic appendectomy—The blood work, urinalysis, and Risks and Possible Complications...... 4 appendix is removed with instruments an abdominal CT scan, or Preparation and Expectations...... 5 placed into small abdominal incisions. abdominal ultrasound. Your Your Recovery and Discharge...... 6 Open appendectomy—The appendix surgeon and anesthesia Pain Control...... 7 is removed through an incision provider will review your health history, medications, Glossary/References...... 8 in the lower right abdomen. and options for pain control. Nonsurgical The day of your operation— Surgery is the only option for an acute You will not be allowed (sudden) infection of the appendix. to eat or drink while you The Condition are being evaluated for an Appendectomy is the surgical removal Benefits and Risks emergency appendectomy. of the appendix. The operation is An appendectomy will remove the Your recovery—If you done to remove an infected appendix. have no complications you An infected appendix, called infected organ and relieve pain. Once the appendix is removed, appendicitis usually can go home in 1 or appendicitis, can burst and release 2 days after a laparoscopic bacteria and stool into the abdomen. will not happen again. The risk of not having surgery is the appendix or open procedure. What are the common symptoms? can burst resulting in an abdominal Call your surgeon if you are infection called peritonitis. in severe pain, have stomach  Abdominal pain that starts Possible complications include cramping, a high fever, odor around the navel or increased drainage from  abscess, infection of the wound Not wanting to eat or abdomen, intestinal blockage, your incision, or no bowel  Low fever hernia at the incision, pneumonia, movements for 3 days.  Nausea and sometimes vomiting risk of premature delivery (if  Diarrhea or constipation you are pregnant), and death.

This first page is an overview. For more detailed information, review the entire document.

American College of Surgeons • 633 N. Saint Cl air St. • Chicago, IL 60611 • www.facs.org Appendectomy The Condition, Signs and Symptoms, and Diagnostic Tests The Keeping You Condition Informed The Appendix Appendix Small intestine Appendicitis Pain The appendix is a Pain can be different for each small pouch that person because the appendix hangs from the can touch different organs. This large intestine can be confusing and make it where the small difficult to diagnose appendicitis. and large intestine join. If the Most often pain starts around appendix becomes the navel and then moves to Large blocked and the right lower abdomen. The intestine swollen, bacteria pain is often worse with walking Appendix can grow in the or talking. During pregnancy, pouch. The cause of the appendix sits higher in the infection can be from an abdomen so the pain may seem illness, thick mucus or hard stool to come from the upper abdomen. trapped in the opening of the appendix, Common In the elderly, symptoms are or parasites. often not as noticeable because Diagnostic Tests there is less swelling.1,2 Appendicitis History and Physical Appendicitis is an infection of the The focus will be on your abdominal pain.

Upper appendix. The infection and swelling can Right Left decrease the blood supply to the wall of Tests (see glossary) the appendix. This leads to tissue death, Abdominal ultrasound—checks and the appendix can rupture or burst for an enlarged appendix causing bacteria and stool to release into Computed tomography (CT) scan—checks Right Left the abdomen. This is called a ruptured for an enlarged appendix and infection appendix. A ruptured appendix can Complete blood count (CBC)—a Lower lead to peritonitis, which is an infection of your entire abdomen. Appendicitis blood test to check for infection Other medical disorders have affects 1 in 1,000 people, most often Rectal exam—checks for tenderness on symptoms similar to appendicitis, between the ages of 10 and 30 years old. the right side and for any rectal problems such as inflammatory bowel It is a common reason for an operation that could be causing the abdominal pain in children, and it is the most common disease, pelvic inflammatory Pelvic exam—may be done in surgical emergency in pregnancy. disease, gastroenteritis, urinary young women to check for pain tract infection, right lower Appendectomy is the surgical from gynecological problems like lobe pneumonia, Meckel’s removal of the appendix. pelvic inflammation or infection diverticulum, intussusception, Urinalysis—checks for an and constipation. Symptoms infection in your urine, which can cause abdominal pain  Stomach pain that usually starts Electrocardiogram (ECG)—sometimes around the navel and then often moves done in the older adult to make sure to the lower right side of the abdomen. heart problems are not the cause of pain  Loss of appetite  Low fever, usually below 100.3°F  Nausea and sometimes vomiting  Diarrhea or constipation

American College of Surgeons • 633 N. Saint Cl air St. • Chicago, IL 60611 • www.facs.org American College of Surgeons • 633 N. Saint Cl air St. • Chicago, IL 60611 • www.facs.org Appendectomy Surgical and Nonsurgical Treatment Surgical Treatment An operation is the only option for Keeping You acute infection of the appendix. Informed Laparoscopic Appendectomy Laparoscopic versus Open Appendectomy Laparoscopic versus Open Appendectomy Conversion Rates This technique is the most common LaparoscopicLaparoscopic Appendectomy Appendectomy Open Open Appendectomy Conversion rates from a for simple appendicitis. The surgeon laparoscopic to an open will make 1 to 3 small incisions in the procedure average 110 per 1,000 abdomen. A port (nozzle) is inserted patients.2 Conversion to an open into one of the slits, and carbon technique is most commonly dioxide gas inflates the abdomen. This due to adhesions (bands of process allows the surgeon to see the scar-like tissue sticking on appendix more easily. A laparoscope organs), followed by perforation is inserted through another port. It (bursting) and peritonitis.3,4 looks like a telescope with a light and camera on the end so the surgeon Pediatric Considerations can see inside the abdomen. Surgical There is no reported difference instruments are placed in the other in the length of hospital stay small openings and used to remove for laparoscopic versus open the appendix. The area is washed with procedures for nonruptured (2.3 sterile fluid to decrease the risk of versus 2.0 days) and ruptured further infection. The carbon dioxide Endoloop used to Anterior cecal artery (5.5 versus 6.2 days) appendices.5 comes out through the slits, and then the manipulate and position appendix Ileum sites are closed with sutures or staples Ruptured Appendix

or covered with glue-like bandage and Ascending colon Unfortunately, many people do steri-strips. Your surgeon may start Appendicular artery not know they have appendicitis with a laparoscopic technique and until the appendix bursts. If need to change to an open technique. Appendix this happens, it causes more This change is done for your safety. serious problems. The incidence Open Appendectomy of ruptured appendix is 270 Endoloop used to per 1,000 patients. This is The surgeon makes an incision about 2 manipulate and position appendix higher in the very young and to 4 inches long in the lower right side Appendix stapled very old and also higher during of the abdomen and cuts through fat pregnancy because the symptoms and muscle layers to the appendix. The (nausea, vomiting, right-sided appendix is removed from the intestine. pain) may be similar to other The area is washed with sterile fluid to pregnancy conditions.1,7 decrease the risk of further infection. A small drainage tube may be placed going from the inside to the outside of the abdomen. The drain is usually removed in the hospital. The site is Appendix stapled closed with sutures or staples or covered with glue-like bandage and steri-strips. Removal of appendix Nonsurgical Treatment If you only have some of the signs of appendicitis, your surgeon may monitor you to see if the symptoms get any worse. If you have an abscess (a collection of pus), your surgeon may treat you with antibiotics first and may have you come back for elective surgery in 4 to 6 weeks.

Removal of appendix

Your surgeon will do everything possible to minimize risks, but appendectomy, like all operations, has risks.

The Risk What Happens Keeping You Informed Infection For simple acute appendicitis, wound infection Antibiotics are typically given right before is reported as 0 to 34 per 1,000 patients for the operation. Your health care team should laparoscopic and 1 to 70 per 1,000 for open wash their hands before examining you. procedures. The risk increases for a perforated appendix and abdominal infection.2,3,8-11

Abscess An abscess is reported as 0 to 24 per Call your surgeon if your wound is red or draining 1,000 patients for laparoscopic and 0 to pus. Antibiotics are used to treat an abscess. 10 per 1,000 for open procedures.2,3,8

Intestinal Swelling of the tissue around the intestine can Your abdomen will be checked for bowel sounds, and you will obstruction stop stool and fluid from passing through your be asked if you are passing gas. If you have a temporary block, intestine. Short-term intestinal obstruction a nasogastric tube may be placed through your nose into your is reported as 38 per 1,000 patients.8 stomach for 1 to 2 days to remove fluid from your stomach.

Pneumonia Pneumonia is reported as 25 per 1,000 patients.3,8 Deep-breathing exercises and movement can help expand your lungs and decrease this risk.12

Heart problems Heart problems are rare. Heart attacks Call your surgeon if you have chest pain. Your are reported as 4 per 1,000 patients anesthesia provider is always prepared in advanced and stroke as 2 per 1,000.8 cardiac life support. Special leg compression stockings and blood thinning medication may be given.

Kidney Urinary tract infections are reported Let your nurse know when you urinate. Call your problems as 11 per 1,000 patients and decreased surgeon if you have signs of a urinary infection renal flow as 4 per 1,000.8 (pain with urination, fever, cloudy urine). Blood work may be done to check for renal flow.

Deep vein No movement during the operation can lead Your surgeon or nurse will place support or thrombosis to blood clots forming in the legs. In rare compression (squeezing) stockings on your legs and (blood clots) cases the clot can travel to the lungs. may give you blood thinning medication. Your job is to get up and moving after the operation.

Bleeding Bleeding is extremely rare.2,3 A blood transfusion is usually not required.

Pregnancy risks Premature labor is reported as 83 per 1,000 The risk of fetal loss increases to 109 per 1,000 patients patients and fetal loss as 26 per 1,000.7 with peritonitis (infection of the abdominal cavity).7

Pediatric risks Complications are rare and range from 0 to 5 Children with gangrenous or perforated appendices have per 1,000 patients for simple appendectomy. increased wound infection rates (26 per 1,000) and There are no deaths reported in current abdominal infections (44 per 1,000). There is an increased studies for simple appendectomy.5,9-11 rate of abscess (90 per 1,000) with laparoscopic surgery.5

Elderly risks The complication rate is higher in the elderly, Complications, lengths of stay, and deaths are with 143 to 208 per 1,000 patients. Death is lower with laparoscopic versus open procedure reported as 3 to 20 per 1,000 elderly patients.6 in the elderly, while the cost is higher.6

Death Death is extremely rare in healthy The risk of death increases with having another severe people for appendectomy without disease, total dependence on others to function, a peritonitis, with mortality reported contaminated wound, and chronic pulmonary disease.8 as 0 to 18 per 1,000 patients.2,8

Preparing What You Can Expect Questions to Ask for Your Operation A bracelet with your name and  Ask about the risks, identification number will be placed on problems, and side effects Appendectomy is usually an your wrist. Your wristband should be of general anesthesia. emergency procedure. You can help checked by all health care team members prepare for your operation by telling before providing any procedures or your surgeon about other medical giving you medication. If you have problems that you have and all of the any allergies, an allergy bracelet medications that you are taking. should also be placed on your wrist. Be sure to tell your surgeon if An intravenous line (IV) will be started you are taking blood thinners to give you fluids and medication. The (Plavix, coumadin, aspirin). medication will make you feel sleepy. Keeping You Home Preparation A tube will be placed down your throat to help you breathe during the operation. Informed You can often go home in 1 or 2 Anesthesia days. Your hospital stay may be Your surgeon will perform your operation longer for a ruptured appendix. and then close your incisions. A drain The most frequent option for may be placed from the inside of your general anesthesia is called Anesthesia incision out your abdomen. balanced anesthesia, where a You will meet with your anesthesia After your operation, you will be moved combination of different drugs provider before the operation. Let him or to a recovery room. is used. Common drugs are: her know if you have allergies, neurologic  Preventing Pneumonia Inhaled gases— disease (epilepsy or stroke), heart nitrous oxide disease, stomach problems, lung disease Movement and deep breathing after  Barbiturates—thiopental (asthma, emphysema), endocrine disease your operation can help prevent fluid  Benzodiazepines— (diabetes, thyroid conditions), loose in your lungs and pneumonia.10 teeth, or if you smoke, drink alcohol, use midazolam  drugs, or take any herbs or vitamins. Preventing Blood Clots Opioids—fentanyl, morphine Don’t Eat or Drink When you have an operation, you are at  risk of getting blood clots because of not Other agent—propofol You will not be allowed to eat or drink moving during anesthesia. The longer Deep Breathing while you are being evaluated for and more complicated your operation, the your emergency appendectomy. Not greater the risk. Your doctor will know Take 5 to 10 deep breaths eating or drinking reduces your risk of your risk for blood clots, and steps will be every hour while you are complications from anesthesia. taken to prevent them. This may include awake. Breathe deeply and What to Bring blood thinning medication and support hold for 3 to 5 seconds. or compression (squeezing) stockings. Young children can do deep  Insurance card and identification breathing by blowing bubbles.  Advance directive (see terms) Preventing Infection  List of medicines  The risk of infection can be  Personal items such as lowered if antibiotics are given eyeglasses and dentures right before the operation and hair is removed at the surgical site  Loose-fitting comfortable clothes with clippers versus shaving.  Leave jewelry and valuables at home  All health care providers should wash their hands before examining you.

after the second postoperative Your Recovery day unless you are told not to. and Discharge  Follow your surgeon’s instructions on when to change your bandages. Thinking Clearly  A small amount of drainage from The anesthesia may cause you to feel the incision is normal. If the different for 1 or 2 days. Do not drive, drainage is thick and yellow or drink alcohol, or make any big decisions the site is red, you may have an for at least 2 days. infection, so call your surgeon. Avoid driving x  If you have a drain in one of Nutrition your incisions, it will be taken  When you wake up, you will be out when the drainage stops. able to drink small amounts of  Surgical staples will be removed liquid. If you are not nauseous, you during your first office visit. can begin eating regular foods.  Steri-strips will fall off in 7 to  Continue to drink lots of fluids, 10 days or they will be removed usually about 8 to 10 glasses per day. during your first office visit.  Activity Avoid wearing tight or rough clothing. It may rub your incisions and  You will be helped getting make it harder for them to heal. out of bed and walking.  Protect the new skin, especially  Slowly increase your activity. from the sun. The sun can burn  Do not lift or participate in strenuous and cause darker scarring. Steri-strips will fall off or activity for 3 to 5 days for laparoscopic  they will be removed during Your scar will heal in about 4 to and 10 to 14 days for open procedure. your first office visit 6 weeks and will become softer  Avoid driving until your pain is and continue to fade over the next under control without narcotics. year. Keep the wound site out  You can have sex when you feel of the sun or use sunscreen. ready, usually after your sutures  Sensation around your incision will or staples are removed. return in a few weeks or months.  It is normal to feel tired. You may need more sleep than usual. Bowel Movements  After intestinal surgery, you may Work and Return to School have loose watery stools for several  You can go back to work when you feel days. If watery diarrhea lasts longer well enough. Discuss the timing with than 3 days, contact your surgeon. your surgeon.  Pain medication (narcotics) can  Children can usually go to school 1 cause constipation. Increase the week or less after an operation for fiber in your diet with high-fiber an unruptured appendix and up to 2 foods if you are constipated. Your Wash your hands before and weeks after a ruptured appendix. surgeon may also give you a after touching near your  Most children will not return to gym prescription for a stool softener. incision site  class, sports, and climbing games for Foods high in fiber include beans, 2 to 4 weeks after the operation. bran cereals and whole grain breads, Wound Care peas, dried fruit (figs, apricots, and dates), raspberries, blackberries,  Always wash your hands before and strawberries, sweet corn, broccoli, after touching near your incision site. baked potatoes with skin, plums,  Do not soak in a bathtub until your pears, apples, greens, and nuts. stitches, steri-strips, or staples are removed. You may take a shower

Pain Pain Control Keeping You The amount of pain is different for each Everyone reacts to pain in a different Informed person. Some people need only 1 to 3 way. A scale from 0 to 10 is often Extreme pain puts extra stress doses of pain control medication, while used to measure pain. At a “0,” you on your body at a time when others use narcotics for a full week. do not feel any pain. A “10” is the your body needs to focus on Home Medications worst pain you have ever felt. healing. Do not wait until your pain has reached a level “10” The medicine you need after Common Medicines to Control Pain or is unbearable before telling your operation is usually Narcotics or opioids are used for severe your doctor or nurse. It is much related to pain control. pain. Some side effects of narcotics easier to control pain before it are sleepiness; lowered blood pressure, becomes severe. When to Contact heart rate, and breathing rate; skin rash and itching; constipation; Laparoscopic Pain Your Surgeon nausea; and difficulty urinating. Some examples of narcotics include morphine, Following a laparoscopic If you have: oxycodone, and hydromorphone. procedure, pain is sometimes felt  Pain that will not go away Medications are available to control in the shoulder. This is due to the gas inserted into your abdomen  Pain that gets worse many of the side effects of narcotics.  during the procedure. Moving and A fever of more than 101°F (38.3ºC) Non-narcotic Pain Medication walking helps to decrease the gas  Vomiting and the right shoulder pain.2,3  Most nonopioid pain medications Swelling, redness, bleeding, are nonsteroidal anti-inflammatory or bad-smelling drainage drugs (NSAIDs). They are used to from your wound site treat mild pain or combined with a  Strong abdominal pain narcotic to treat severe pain. They  No bowel movement or unable also can reduce inflammation. Some to pass gas for 3 days side effects of NSAIDs are stomach  Watery diarrhea lasting upset, bleeding in the stomach or longer than 3 days intestines, and fluid retention. These side effects usually are not seen with short-term use. Examples of NSAIDs Other Instructions: include ibuprofen and naproxen. Splinting your stomach Non-medicine Pain Control Distraction helps you focus on other activities instead of your pain. Music, games, and other engaging activities are especially helpful with children in mild pain. Follow-up Appointments Splinting your stomach by placing a Who Date Phone pillow over your abdomen with firm pressure before coughing or movement can help reduce the pain.

Guided imagery helps you direct and control your emotions. Close your eyes Guided imagery and gently inhale and exhale. Picture yourself in the center of somewhere beautiful. Feel the beauty surrounding you and your emotions coming back to your control. You should feel calmer.

Glossary of Terms For More Information Abdominal ultrasound Sound waves are used For more information, please go to the American to determine the location of deep structures College of Surgeons Patient Education Web site in the body. A hand roller is placed on top of at www.facs.org/patienteducation/. clear gel and rolled across the abdomen. References Abscess Localized collection of pus. The information provided is chosen from clinical Advance directives Documents signed by research. The research below does not represent all of a competent person giving direction to the information available about your operation. health care providers about treatment 1. Anderson B, Nielsen TF. Appendicitis in pregnancy: choices. They give you the chance to tell diagnosis, management and complications. ACTA Obstetricia your feelings about health care decisions. Gynecologica Scandinavica. 1999;78(9):758-762. Adhesion A fibrous band or scar 2. Ho H. Appendectomy. In: ACS Surgery: Principles and tissue that causes internal organs Practice 2004. New York, NY: WebMD, 2004. to adhere or stick together. 3. Sauerland S, Lefering R, Neugebauer EAM. Laparoscopic versus open surgery for suspected appendicitis (Review). The Complete blood count (CBC) A blood test Cochrane Database of Systemic Reviews 2004, Issue 4 Art No: that measures red blood cells (RBCs) CD001546. pgb2.DOI: 10.1002/14651858.CD001546.pub2. and white blood cells (WBCs). WBCs 4. Liu SI, Siewart B, Raptopoulos V, Hodin RA. Factors increase with inflammation. The normal associated with conversion to laparotomy in patients range for WBCs is 8,000 to 12,000. undergoing laparoscopic appendectomy. Journal of the American College of Surgeons. 2002;194(3):298-305. Computed tomography (CT) scan A specialized 5. Paik PS, Towson JA, Anthone GF, et al. Intra-abdominal X ray and computer that show a detailed, 3- abscesses following laparoscopic and open appendectomies. dimensional picture of your abdomen. A CT Journal of Gastrointestinal Surgery. 1997;1(2):188-193. scan normally takes about 1½ to 2 hours. 6. Harrell AG, Lincourt AE, Novitsky YW, et al. Electrocardiogram (ECG) Measures the rate Advantages of laparoscopic appendectomy in the and regularity of heartbeats, the size of the elderly. American Surgeon. 2006;72(6):474-480. heart chambers, and any damage to the heart. 7. Cohen-Kerem R, Railton C, Oren D, Lishner M, Koren G. Pregnancy outcome following non-obstetric surgical intervention. Nasogastric tube A soft plastic tube inserted American Journal of Surgery. 2005;190(3):467-473. in the nose and down to the stomach. 8. Margenthaler JA, Longo WE, Virgo KS, Johnson FE, Oprian Radiographic barium contrast enema CA, Henderson WG, Daley J, Khuri SF. Risk factors for adverse outcomes after the surgical treatment of appendicitis A special X ray of the large intestines. in adults. Annals of Surgery. 2003;238(1):59-66. Pictures are taken of the abdomen after 9. Emil S, Laberge JM, Mikhail P, Baican L, Flageole H, Nguyen L, barium dye is inserted into the rectum. Shaw K. Appendicitis in children: a ten-year update of therapeutic Urinalysis A visual and chemical examination recommendations. Journal of Pediatric Surgery. 2003;38(2):236-242. of the urine most often used to screen for 10. Newman K, Ponsky T, Kittle K, et al. Appendicitis 2000: variability urinary tract infections and kidney disease. in practice, outcomes and resources utilization at thirty pediatric hospitals. Journal of Pediatric Surgery. 2003;38(3):372-379. 11. Chen C, Botelho C, Cooper A, et al. Current practice patterns in the treatment of perforated appendicitis in children. Journal This information is published to educate you about your of the American College of Surgeons. 2003;196(2):212-221. specific surgical procedures. It is not intended to take the place of a discussion with a qualified surgeon who is familiar 12. Overend TJ, Anderson CM, Lucy SD, et al. The effect of incentive with your situation. It is important to remember that each spirometry on post-operative complications. Chest. 2001;120:971-978. individual is different, and the reasons and outcomes of any operation depend upon the patient’s individual condition. Reviewed by: Thomas Whalen, MD, MMM, FACS The American College of Surgeons is a scientific and educational organization that is dedicated to the ethical and competent practice of surgery; it was founded to raise the standards of surgical Marshall Schwartz, MD, FACS practice and to improve the quality of care for the surgical patient. The ACS has endeavored to present information for prospective surgical patients based on current scientific information; there is no warranty on the timeliness, accuracy, or usefulness of this content. We are grateful to Ethicon Endo-Surgery for their suppport in printing this document.

American College of Surgeons • 633 N. Saint Cl air St. • Chicago, IL 60611 • www.facs.org Doctor’s Name:

Phone Number:

Instructions: