Appendectomy Surgical Removal of the Appendix
A M E R I C AN C O L L E G E O F S U R G E O N S • D IVIS I O N O F E D U C A T I O N 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. Small intestine Appendix Keeping You Large intestine Informed Information that will help you The Condition Bene ts and Risks further understand your operation Appendectomy is the surgical removal An appendectomy will remove the infected and your role in healing. of the appendix. The operation is done organ and relieve pain. Once the appendix is removed, appendicitis will not happen again. Education is provided on: to remove an infected appendix. An infected appendix, called appendicitis, The risk of not having surgery is the appendix Appendectomy Overview ...... 1 can burst and release bacteria can burst, resulting in an abdominal infection called peritonitis. Condition, Symptoms, Tests ...... 2 and stool into the abdomen. Treatment Options ...... 3 Possible complications include abscess, What are the common symptoms? infection of the wound or abdomen, Risks and Possible Complications ...... 4 Abdominal pain that starts intestinal blockage, hernia at the incision, Preparation and Expectations ...... 5 around the navel pneumonia, risk of premature delivery (if you are pregnant), and death. Your Recovery and Discharge ...... 6 Not wanting to eat Pain Control ...... 7 Low fever Nausea and sometimes vomiting Glossary/References ...... 8 Expectations Diarrhea or constipation Before your operation—Evaluation usually includes blood work, urinalysis, and an abdominal CT scan, or abdominal Treatment Options ultrasound. Your surgeon and anesthesia Surgery provider will review your health history, medications, and options for pain control. Laparoscopic appendectomy—The appendix is removed with instruments The day of your operation—You will not be placed into small abdominal incisions. allowed to eat or drink while you are being evaluated for an emergency appendectomy. Open appendectomy—The appendix is removed through an incision Your recovery—If you have no complications, in the lower right abdomen. you usually can go home in 1 or 2 days after a laparoscopic or open procedure. Nonsurgical Call your surgeon if you are in severe pain, Surgery is the standard treatment have stomach cramping, a high fever, odor for an acute (sudden) infection of or increased drainage from your incision, or the appendix. Antibiotic treatment no bowel movements for 3 days. might be used as an alternative for 1,2
This rst page is an overview. For more detailed information, review the entire document.
AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation The Condition, Signs and Appendectomy Symptoms, and Diagnostic Tests
Keeping You The Condition The Appendix Informed The appendix is a small Appendix Small intestine Appendicitis Pain pouch that hangs from the large intestine where the small and person because the appendix large intestine join. If the appendix becomes can be confusing and make it blocked and swollen, bacteria can grow in Most often pain starts around the the pouch. The blocked Large navel and then moves to the right opening can be from intestine lower abdomen. The pain is often an illness, thick mucus, Appendix worse with walking or talking. hard stool, or a tumor. During pregnancy, the appendix sits higher in the abdomen, so Appendicitis the pain may seem to come Appendicitis is an infection of the appendix. Common Diagnostic from the upper abdomen. In The infection and swelling can decrease the the elderly, symptoms are often blood supply to the wall of the appendix. This Tests not as noticeable because leads to tissue death, and the appendix can History and Physical there is less swelling.4 rupture or burst, causing bacteria and stool to release into the abdomen. This is called The focus will be on your abdominal
Upper a ruptured appendix. A ruptured appendix pain. There is no single test to Right Left can lead to peritonitis, which is an infection 3 of your entire abdomen. Appendicitis most Tests (see glossary) and 30 years old. It is a common reason for Abdominal ultrasound—Checks Right Left an operation in children, and it is the most for an enlarged appendix 3 common surgical emergency in pregnancy. Complete blood count (CBC)—A Lower Appendectomy is the surgical blood test to check for infection removal of the appendix. Rectal exam—Checks for tenderness on Other medical disorders the right side and for any rectal problems have symptoms similar that could be causing the abdominal pain to appendicitis, such as Symptoms Pelvic exam—May be done in young Stomach pain that usually starts women to check for pain from gynecological around the navel and then moves to gastroenteritis, urinary the lower right side of the abdomen. tract infection, right lower Loss of appetite Urinalysis—Checks for an infection in your lobe pneumonia, Meckel’s urine, which can cause abdominal pain diverticulum, intussusception, Low fever, usually below 100.3°F Electrocardiogram (ECG)—Sometimes and constipation. Nausea and sometimes vomiting done in the older adult to make sure heart Diarrhea or constipation problems are not the cause of pain
2 AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation Surgical and Appendectomy Nonsurgical Treatment
Laparoscopic versus Open Appendectomy Surgical Treatment Laparoscopic versus Open Appendectomy LapaLaparoscoproscopic Appendeic Appectomyn decto m y Open Open Appen Appendecdtomectoy my Keeping You Acute appendicitis is an urgent problem requiring surgical consultation. Informed Laparoscopic Appendectomy Laparoscopic versus Open This technique is the most common for For both adults and children, simple appendicitis. The surgeon will make laparoscopic appendectomy 1 to 3 small incisions in the abdomen. has an advantage of lower A port (nozzle) is inserted into one of infection rate, shorter hospital and recovery time, and lower the abdomen. This process allows the pain scores. There was a slightly surgeon to see the appendix more easily. increased risk of infection of A laparoscope is inserted through another the urinary tract and within port. It looks like a telescope with a light the abdomen (abdominal and camera on the end so the surgeon can abscess) and bleeding see inside the abdomen. Surgical instruments within the abdomen.5 are placed in the other small openings and used to remove the appendix. The area is Anterior cecal artery Ruptured Appendix Ileum Unfortunately, many people of further infection. The carbon dioxide comes do not know they have Ascending colon out through the slits, and then the sites are Appendicular artery appendicitis until the appendix Endoloop used to closed with sutures or staples or covered manipulate and bursts. If this happens, it causes with glue-like bandage and Steri-Strips. position appendix more serious problems. The Appendix Your surgeon may start with a laparoscopic incidence of ruptured appendix technique and need to change to an open is 270 per 1,000 patients. This technique. This change is done for your safety.4 is higher in the very young and very old and also higher Open Appendectomy Endoloop used to during pregnancy because the manipulate and The surgeon makes an incision about 2 to position appendix symptoms (nausea, vomiting, 4 inches long in the lower right side of the right-sided pain) may be similar abdomen. The appendix is removed from the to other pregnancy conditions.1,7 to decrease the risk of further infection. A small Appendix stapled drainage tube may be placed going from the inside to the outside of the abdomen. The drain is usually removed in the hospital. The wound is closed with absorbable sutures and covered with glue-like bandage or Steri-Strips.
Appendix stapled Nonsurgical Treatment If you only have some of the signs of appendicitis, your surgeon may treat you with antibiotics and watch for improvement. In an Removal of appendix uncomplicated appendectomy, antibiotics of reoccurrence.1-2,5
Removal of appendix
3 Appendectomy Risks of This Procedure
Your surgeon will do everything possible to minimize risks, but appendectomy, like all operations, has risks.
Risks of This Procedure from Outcomes Percentage Keeping You Informed Reported in the Last 10 years of Literature
Intestinal obstruction: Short-term 3% from passing. You will be asked if you are passing gas, and bowel sounds will be checked. If you have a temporary block, a tube may be placed through your nose into your stomach for 1 or 2
Pregnancy risks Premature labor The risk of fetal loss increases to 10% when the appendix ruptures 8 to 10% and there is peritonitis (infection of the abdominal cavity).6 Fetal loss 2%
Pediatric risks Less than 1% for Children with perforated appendix have increased wound all complications infection rates and abdominal infections. There are no deaths reported with simple appendectomy.
Risks of This Procedure Based Percentage Keeping You Informed on the ACS Risk Calculator*
Wound Infection: Infection at the Laparoscopic 1.9% Antibiotics are typically given before the operation. Smoking can area of the incision or near the organ Open 4.3% increase the risk of infection. where the surgery was performed
Return to the operating room 1.8%
Pneumonia: Infection in the lungs Less than 1% Stopping smoking, walking and deep breathing after your operation can help prevent lung infections.
Urinary tract infection: Infection Less than 1% A urinary catheter (small thin tube) that drains urine from the of the bladder or kidneys bladder is sometimes inserted. Signs of a urinary tract infection include pain with urination, fever, and cloudy urine.
Blood clot: A clot in the legs Less than 1% Longer surgery and bed rest increase the risk. Getting up, that can travel to the lung walking 5 to 6 times per day, and wearing support stockings reduce the risk.
Heart complication: Includes heart Less than 1% Problems with your heart or lungs can be sometimes be attack or sudden stopping of the heart worsened by general anesthesia. Your anesthesia provider will take your history and suggest the best option for you.
Death Less than 1% Death is extremely rare in healthy people.
Any complication, including: Surgical Laparoscopic 3.4% Complications are higher in smokers, obese patients, and Open 6.4% those with other diseases such as diabetes, heart failure, clots, renal (kidney) complications, cardiac renal failure and lung disease. Wound healing may also be complications, and return to the operating room decreased in smokers.
Predicted length of stay Laparoscopic ½ day; open 1 day.
*The ACS Surgical Risk Calculator estimates the risk of an unfavorable outcome. Data is from a large number of patients who had a surgical procedure similar to this one. If you are healthy with no health problems, your risks may be below average. If you smoke, are obese, or have other health conditions, then your risk may be higher. This information is not intended to replace the advice of a doctor or health care provider. To check your risks, go to the ACS Risk Calculator at http://riskcalculator.facs.org/online.
4 AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation Expectations: Preparing Appendectomy for Your Operation
Preparing What You Can Expect Questions to Ask Safety Checks for Your Operation About My Operation: Home Medication allergy bracelet with your name and W Appendectomy is usually an emergency hospital/clinic number will be placed and risks of anesthesia? procedure. You can help prepare for on your wrist. These should be checked What technique will be used your operation by telling your surgeon by all health team members before to remove my appendix? about other medical problems and they perform any procedures or give Laparoscopic or open? medications that you are taking. you medication. Your surgeon will Be sure to tell your surgeon if you are taking mark and initial the operation site. What are the risks of this procedure for me? blood thinners (Plavix, Coumadin, aspirin). Fluids and Anesthesia Anesthesia Will you be performing the An intravenous line (IV) will be started entire operation yourself? You will meet with your anesthesia provider before the operation. Let him or her know general anesthesia, you will be asleep What level of pain should if you have allergies, neurologic disease and pain free during the operation. A I expect, and how will (epilepsy or stroke), heart disease, stomach tube may be placed down your throat to it be managed? problems, lung disease (asthma, emphysema), help you breathe during the operation. How long will it be before I can endocrine disease (diabetes, thyroid After Your Operation return to my normal activities conditions), loose teeth, or if you smoke, (work, driving, lifting)? drink alcohol, use drugs, or take any herbs or You will be moved to a recovery room where vitamins. Let your surgical team know if you your heart rate, breathing rate, oxygen smoke and plan to quit. Quitting decreases saturation, blood pressure, and urine output your complication rate. Resources to help will be closely watched. Be sure that all you quit can be found at www.facs.org/ visitors wash their hands. patienteducation/quitsmoking.html. Preventing Pneumonia Length of Stay and Blood Clots You can often go home in 1 or 2 days. Your Movement and deep breathing after your hospital stay may be longer for a ruptured operation can help prevent postoperative appendix. your lungs, and pneumonia. Every hour, take Don’t Eat or Drink 5 to 10 deep breaths and hold each breath for You will not be allowed to eat or drink while 3 to 5 seconds. you are being evaluated for appendectomy. When you have an operation, you are at risk Not eating or drinking reduces your risk of getting blood clots because of not moving of complications from anesthesia. during anesthesia. The longer and more What to Bring complicated your surgery, the greater the risk. This risk is decreased by getting up and I walking 5 to 6 times per day, wearing special Advance directive (see glossary) support stockings or compression boots on your legs, and for high-risk patients, taking a List of medicines medication that thins your blood. L Leave jewelry and valuables at home
5 Your Recovery and Discharge Appendectomy
Your Recovery Keeping You and Discharge Informed Thinking Clearly High-Fiber Foods for 1 or 2 days. Do not drive, drink alcohol, or Handwashing Steri-Strips bran cereals and whole-grain make any big decisions for at least 2 days. Follow your surgeon’s instructions on when to change your bandages. Nutrition apricots, and dates), raspberries, A small amount of drainage from the blackberries, strawberries, When you wake up, you will be able to drink incision is normal. If the drainage is thick sweet corn, broccoli, baked small amounts of liquid. If you do not feel and yellow or the site is red, you may have potatoes with skin, plums, pears, sick, you can begin eating regular foods. an infection, so call your surgeon. apples, greens, and nuts. If you have a drain in one of your incisions, it 8 to 10 glasses per day. will be taken out when the drainage stops.
during bowel movements. Activity If you have a glue-like covering over the Slowly increase your activity. Be sure to get up and walk every hour or so to prevent own. blood clots. Avoid wearing tight or rough clothing. It Do not lift or participate in strenuous activity may rub your incisions and make it harder for 3 to 5 days for laparoscopic and 10 to 14 for them to heal. days for open procedure. Protect the new skin, especially from the sun. You may go home in 1 to 2 days for a The sun can burn and cause darker scarring. laparoscopic repair. If your appendix Your scar will heal in about 4 to 6 weeks ruptured or you have other health issues or and will become softer and continue to complications, you may stay longer. fade over the next year. It is normal to feel tired. You may need more Sensation around your incision will return sleep than usual. in a few weeks or months. Work and Return to School Bowel Movements You can go back to work when you feel After intestinal surgery, you may have loose well enough. Discuss the timing with watery stools for several days. If watery your surgeon. diarrhea lasts longer than 3 days, contact Children can usually go to school 1 week your surgeon. or less after an operation for an unruptured Pain medication (narcotics) can cause appendix and up to 2 weeks after a ruptured appendix. Most children will not return to gym class, constipated. Your surgeon may also give sports, and climbing games for 2 to 4 weeks you a prescription for a stool softener. Do not lift anything after the operation. over 10 pounds. Pain A gallon of milk Wound Care weighs 9 pounds. Always wash your hands before and after person. Some people need only 1 to 3 doses touching near your incision site. of pain control medication, while others need Do not soak in a bathtub until your stitches more. or Steri-Strips are removed. You may take a shower after the second postoperative day Home Medications unless you are told not to. The medicine you need after your operation is usually related to pain control.
6 AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation Appendectomy
Non-Medicine Pain Control When to Contact Keeping You Distraction helps you focus on other Your Surgeon activities instead of your pain. Music, Informed If you have: games, and other engaging activities are Extreme pain puts extra stress especially helpful with children in mild pain. on your body at a time when Pain that will not go away Splinting your stomach by placing your body needs to focus on Pain that gets worse a pillow over your abdomen with healing. Do not wait until your pain has reached a level “10” A fever of more than 101°F (38.3ºC) movement can help reduce the pain. or is unbearable before telling Repeated vomiting your doctor or nurse. It is much Guided imagery helps you direct and easier to control pain before it Swelling, redness, bleeding, or bad- control your emotions. Close your eyes becomes severe. smelling drainage from your wound site and gently inhale and exhale. Picture Laparoscopic Pain Strong abdominal pain yourself in the center of somewhere beautiful. Feel the beauty surrounding Following a laparoscopic No bowel movement or unable you and your emotions coming back to procedure, pain is sometimes to pass gas for 3 days your control. You should feel calmer. felt in the shoulder. This is Watery diarrhea lasting longer than 3 days due to the gas inserted into your abdomen during the OTHER INSTRUCTIONS: procedure. Moving and walking Pain Control helps to decrease the gas and the right shoulder pain. scale from 0 to 10 is often used to measure pain. At a “0,” you do not feel any pain. A “10” is the worst pain you have ever felt. FOLLOW-UP APPOINTMENTS Common Medicines to Control Pain WHO: Narcotics or opioids are used for severe sleepiness; lowered blood pressure, heart DATE: rate, and breathing rate; skin rash and urinating. Some examples of narcotics include Splinting your stomach morphine, oxycodone (Percocet/Percodan), PHONE: and hydromorphone (Dilaudid). Medications are available to control many of the side
Non-Narcotic Pain Medication Most non-opioid pain medications are
(NSAIDs). They are used to treat mild pain and
NSAIDs are stomach upset, bleeding in the
Guided imagery use. Examples of NSAIDs include ibuprofen, Mortrin, Aleve, and Toradol (given as a shot).
7 Glossary of Terms and Appendectomy More Information
For more information, please go to the American College of Surgeons Patient Education Web site at www.facs.org/patienteducation. For a complete review of appendectomy, consult Selected Readings in General Surgery, “Pediatric Appendectomy” 2014 Vol. 40 No. 4 and “Adult Appendectomy” 2011 Vol. 38 No. 5 at www.facs.org/SRGS. GLOSSARY REFERENCES Abdominal ultrasound: Sound waves are used The information provided is chosen from clinical research. The research to determine the location of deep structures below does not represent all of the information available about your in the body. A hand roller is placed on top of operation. clear gel and rolled across the abdomen. 1. Wilms IM, de Hoog DE, de Visser DC, et al. Appendectomy versus Abscess: Localized collection of pus. antibiotic treatment for acute appendicitis. Cochrane Database Syst Rev. 2011;11:CD008359. Advance directives: Documents signed by a competent person giving direction to health care providers 2. Kao LS, Boone D, Mason RJ; Evidence-based reviews in surgery. about treatment choices. They give you the chance Antibiotics vs appendectomy for uncomplicated acute appendicitis. J to tell your feelings about health care decisions. Am Coll Surg. 2013;216(3):501-505. 3. Cheng HT, Wang YC, Lo HC, et al. Laparoscopic appendectomy versus Adhesion: open appendectomy in pregnancy: a population-based analysis of internal organs to adhere or stick together. maternal outcomes. Surgical Endoscopy. Aug 30, 2014; epub ahead of Complete blood count (CBC): A blood test that print. measures red blood cells (RBCs) and white blood 4. Stewart D. The management of acute appendicitis. In JL Cameron & AM Cameron (Eds), Current Surgical Therapy (11th Ed.). 2014:252-254. The normal range for WBCs is 8,000 to 12,000. Philadelphia: Elsevier Saunders. Computed tomography (CT) scan: A specialized X ray 5. Di Saverio S, Sibilio A, et al. The NOTA Study (Non operative treatment and computer that show a detailed, 3-D picture of your f abdomen. A CT scan normally takes about 1½ to 2 hours. of antibiotics (amoxicillin and clavulanic acid) for treating patients with Electrocardiogram (ECG): Measures the rate right lower quadrant abdominal pain and long-term follow-up of and regularity of heartbeats, the size of the heart conservatively treated suspected appendicitis. Annals of Surgery. 2014; chambers, and any damage to the heart. 260:109-117. 6. Li X, Zhang J, et al. Laparoscopic versus conventional appendectomy Nasogastric tube: A soft plastic tube inserted —a meta-analysis of randomized controlled trials. BMC Gastroenterology. in the nose and down to the stomach. 2010;10:129. Available online www.ncbi.nlm.nih.gov/pmc/articles/ Urinalysis: A visual and chemical examination PMC2988072. of the urine, most often used to screen for 7. Peled Y, Hiersch L, Khalpari O, et al. Appendectomy during pregnancy— urinary tract infections and kidney disease. is pregnancy outcome dependent on operator technique? Journal of Maternal-Fetal & Neonatal Medicine. 2014;27:365-367.
DISCLAIMER
procedures. It is not intended to take the place of a discussion with a
of any operation depend upon the patient’s individual condition.
organization that is dedicated to the ethical and competent practice of surgery; it was founded to raise the standards of surgical practice Reviewed 2008 and 2014 by: and to improve the quality of care for the surgical patient. The ACS has Thomas Whalen, MD, MMM, FACS endeavored to present information for prospective surgical patients based Marshall Schwartz, MD, FACS Kathleen Heneghan, RN, MSN, CPN accuracy, or usefulness of this content.
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