American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Appendectomy: Surgical Removal of the Appendix

Removal of the Appendix

The Condition, Signs and Symptoms, and Diagnostic Tests

The Condition

The Appendix

The appendix is a small pouch that hangs from the large intestine where the small and large intestine join. If the appendix becomes blocked and swollen, bacteria can grow in the pouch. The blocked opening can be from an illness, thick mucus, hard stool, or a tumor.

Appendicitis

Appendicitis is an infection of the appendix. The infection and swelling can decrease the blood supply to the wall of the appendix. This leads to tissue death, and the appendix can rupture or burst, causing bacteria and stool to release into the abdomen. This is called a ruptured appendix. A ruptured appendix can lead to peritonitis, which is an infection of your entire abdomen. Appendicitis most often affects people between the ages of 10 and 30 years old. It is a common reason for an operation in children, and it is the most common surgical emergency in pregnancy.3

Appendectomy is the surgical removal of the appendix.

Keeping You Informed

Appendicitis Pain

Pain can be different for each person because the appendix can touch different organs. This can be confusing and make it difficult to diagnose appendicitis.

Most often pain starts around the navel and then moves to the right lower abdomen. The pain is often worse with walking or talking. During pregnancy, the appendix sits higher in the abdomen, so the pain may seem to come from the upper abdomen. In the elderly, symptoms are often not as noticeable because there is less swelling.4

Appendicitis

Other medical disorders have symptoms similar to appendicitis, such as inflammatory bowel disease, pelvic inflammatory disease, gastroenteritis, urinary tract infection, right lower lobe pneumonia, Meckel’s diverticulum, intussusception, and constipation.

Symptoms

  • Stomach pain that usually starts around the navel and then moves to the lower right side of the abdomen
  • Loss of appetite
  • Low fever, usually below 100.3°F
  • Nausea and sometimes vomiting
  • Diarrhea or constipation

Common Diagnostic Tests

History and Physical

The focus will be on your abdominal pain. There is no single test to confirm appendicitis.3

Tests (see glossary)

Abdominal ultrasound or abdominal CT scan—Checks for an enlarged appendix

Complete blood count (CBC)—A blood test to check for infection

Rectal exam—Checks for tenderness on the right side and for any rectal problems that could be causing the abdominal pain

Pelvic exam—May be done in young women to check for pain from gynecological problems like pelvic inflammation or infection

Urinalysis—Checks for an infection in your urine, which can cause abdominal pain

Electrocardiogram (ECG)—Sometimes done in the older adult to make sure heart problems are not the cause of pain

Surgical and Nonsurgical Treatment

Surgical Treatment

Acute appendicitis is an urgent problem requiring surgical consultation.

Laparoscopic versus Open Appendectomy

Laparoscopic Appendectomy

This technique is the most common for simple appendicitis. The surgeon will make 1 to 3 small incisions in the abdomen. A port (nozzle) is inserted into one of the slits, and carbon dioxide gas inflates the abdomen. This process allows the surgeon to see the appendix more easily. A laparoscope is inserted through another port. It looks like a telescope with a light and camera on the end so the surgeon can see inside the abdomen. Surgical instruments are placed in the other small openings and used to remove the appendix. The area is washed with sterile fluid to decrease the risk of further infection. The carbon dioxide comes out through the slits, and then the slits are closed with sutures or staples or covered with glue-like bandage or Steri-Strips. Your surgeon may start with a laparoscopic technique and need to change to an open technique. This change is done for your safety.4

Endoloop

Open Appendectomy

The surgeon makes an incision about 2 to 4 inches long in the lower right side of the abdomen. The appendix is removed from the intestine. The area is washed with sterile fluid to 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 wound is closed with absorbable sutures and covered with glue-like bandage or Steri-Strips.

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 uncomplicated appendicitis, antibiotics may be effective, but there is a higher chance of reoccurrence.1-2,5

Keeping You Informed

Laparoscopic versus Open

For both adults and children, laparoscopic appendectomy has the advantage of lower infection rates, shorter hospital and recovery times, and lower pain scores.5

Ruptured Appendix

Unfortunately, many people do not know they have appendicitis until the appendix bursts. If this happens, it causes more serious problems. The incidence of ruptured appendix is 270 of 1,000 patients. This is higher in the very young and very old and also higher during pregnancy because the symptoms (nausea, vomiting, right-sided pain) may be similar to other pregnancy conditions.1,6

Antibiotic Therapy

In a comparison trial of 530 patients with confirmed appendicitis, 273 had their appendix removed. 257 patients were only treated with antibiotics. In the antibiotic group, 70 patients (27%) had a second episode within a year and needed an appendectomy.7

Risks of This Procedure

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

Risks of This Procedure from Outcomes Reported in the Last 10 Years of Literature

Percentage

Keeping You Informed

Intestinal obstruction: Short-term blockage of stool or fluids

3%

Swelling of the tissue around the intestine can stop stool and fluid 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 days to remove fluid from your stomach.

Pregnancy risks

Premature labor:
8 to 10%
Fetal loss: 2%

The risk of fetal loss increases to 10% when the appendix ruptures and there is peritonitis (infection of the abdominal cavity).6

Pediatric risks

Less than 1% for all complications

Children with perforated appendix have increased wound infection rates and abdominal infections. There are no deaths reported with simple appendectomy.

Risks of This Procedure Based on the ACS Risk Calculator in May 2017*

Percentage

Keeping You Informed

Wound Infection: Infection at the area of the incision

Laparoscopic: 1.4%
Open: 4.0%

Antibiotics are typically given before the operation. Smoking can increase the risk of infection.

Return to the operating room 

Laparoscopic: less than 1%; open: 1.6%

Significant pain and bleeding may cause a return to surgery.

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 of the bladder or kidneys

Less than 1%

A urinary catheter (small thin tube) that drains urine from the 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 that can travel to the lung

Less than 1%

Longer surgery and bed rest increase the risk. Getting up, walking 5 to 6 times per day, and wearing support stockings reduce the risk.

Heart complication: Includes heart attack or sudden stopping of the heart 

Less than 1%

Problems with your heart or lungs can be sometimes be 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 infections, breathing difficulties, blood clots, renal (kidney) complications, cardiac complications, and return to the operating room

Laparoscopic: 3.7%
Open: 7.9%

Complications are higher in smokers, obese patients, and those with other diseases such as diabetes, heart failure, renal failure and lung disease. Wound healing may also be decreased in smokers.

Predicted length of stay

 

Laparoscopic ½ day; open 1.5 days.

*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.

Expectations: Preparing for Your Operation

Preparing for Your Operation

Home Medication

Appendectomy is usually an emergency procedure. You can help prepare for your operation by telling your surgeon about other medical problems and medications that you are taking.

Be sure to tell your surgeon if you are taking blood thinners (Plavix, Coumadin, aspirin).

Anesthesia

You will meet with your anesthesia provider before the operation. Let him or her know if you have allergies, neurologic disease (epilepsy or stroke), heart disease, stomach problems, lung disease (asthma, emphysema), endocrine disease (diabetes, thyroid conditions), loose teeth, or if you smoke, drink alcohol, use drugs, or take any herbs or vitamins. Let your surgical team know if you smoke and plan to quit. Quitting decreases your complication rate. Resources to help you quit can be found at facs.org/quitsmoking.

Length of Stay

You can often go home in 1 or 2 days. Your hospital stay may be longer for a ruptured appendix, if you have severe vomiting, or are unable to pass urine.

Don’t Eat or Drink

You will not be allowed to eat or drink while you are being evaluated for appendectomy. Not eating or drinking reduces your risk of complications from anesthesia.

What to Bring

  • Insurance card and identification
  • Advance directive (see glossary)
  • List of medicines
  • Loose-fitting, comfortable clothes
  • Slip-on shoes that don’t require you to bend over
  • Leave jewelry and valuables at home

What You Can Expect

Safety Checks

An identification (ID) bracelet and allergy bracelet with your name and hospital/clinic number will be placed on your wrist. These should be checked by all health team members before they perform any procedures or give you medication. Your surgeon will mark and initial the operation site.

Fluids and Anesthesia

An intravenous line (IV) will be started to give you fluids and medication. For general anesthesia, you will be asleep and pain free during the operation. A tube may be placed down your throat to help you breathe during the operation.

After Your Operation

You will be moved to a recovery room where your heart rate, breathing rate, oxygen saturation, blood pressure, and urine output will be closely watched. Be sure that all visitors wash their hands.

Preventing Pneumonia and Blood Clots

Movement and deep breathing after your operation can help prevent postoperative complications such as blood clots, fluid in your lungs, and pneumonia. Every hour, take 5 to 10 deep breaths and hold each breath for 3 to 5 seconds.

When you have an operation, you are at risk of getting blood clots because of not moving during anesthesia. The longer and more complicated your surgery, the greater the risk. This risk is decreased by getting up and walking 5 to 6 times per day, wearing special support stockings or compression boots on your legs, and for high-risk patients, taking a medication that thins your blood. 

Questions to Ask About My Operation

What are the side effects and risks of anesthesia?

What technique will be used to remove my appendix? Laparoscopic or open?

What are the risks of this procedure for me?

Will you be performing the entire operation yourself?

What level of pain should I expect, and how will it be managed?

How long will it be before I can return to my normal activities (work, driving, lifting)?

Your Recovery and Discharge

Your Recovery and Discharge

Thinking Clearly

The anesthesia may cause you to feel different for 1 or 2 days. Do not drive, drink alcohol, or make any big decisions for at least 2 days.

Nutrition

  • When you wake up, you will be able to drink small amounts of liquid. If you do not feel sick, you can begin eating regular foods.
  • Continue to drink lots of fluids, usually about 8 to 10 glasses per day.
  • Eat a high-fiber diet so you don’t strain during bowel movements.

High-fiber foodsKeeping You Informed

High-Fiber Foods
Foods high in fiber include beans, bran cereals and whole-grain breads, peas, dried fruit (figs, apricots, and dates), raspberries, blackberries, strawberries, sweet corn, broccoli, baked potatoes with skin, plums, pears, apples, greens, and nuts.

Activity

  • Don't lift 10 lbsSlowly increase your activity. Be sure to get up and walk every hour or so to prevent blood clots.
  • Do not lift or participate in strenuous activity for 3 to 5 days for laparoscopic and 10 to 14 days for open procedure.
  • You may go home in 1 day. If your appendix ruptured or you have other health issues or complications, you may stay longer.
  • It is normal to feel tired. You may need more sleep than usual.

Work and Return to School

  • You can go back to work when you feel well enough. Discuss the timing with your surgeon.
  • Children can usually go to school 1 week or less after an operation for an unruptured appendix and up to 2 weeks after a ruptured appendix.
  • Most children will not return to gym class, sports, and climbing games for 2 to 4 weeks after the operation.

Wound Care

  • Wound careAlways wash your hands before and after touching near your incision site.
  • Do not soak in a bathtub until your stitches or Steri-Strips® are removed. You may take a shower after the second postoperative day unless you are told not to.
  • Follow your surgeon’s instructions on when to change your bandages.
  • A small amount of drainage from the incision is normal. If the drainage is thick and yellow or the site is red, you may have an infection, so call your surgeon.
  • If you have a drain in one of your incisions, it will be taken out when the drainage stops.
  • Steri-Strips will fall off in 7 to 10 days or they will be removed during your first office visit.
  • If you have a glue-like covering over the incision, allow the glue to flake off on its own.
  • Avoid wearing tight or rough clothing. It may rub your incisions and make it harder for them to heal.
  • Protect the new skin, especially from the sun. The sun can burn and cause darker scarring.
  • Your scar will heal in about 4 to 6 weeks and will become softer and continue to fade over the next year.
  • Sensation around your incision will return in a few weeks or months.

Bowel Movements

  • After intestinal surgery, you may have loose watery stools for several days. If watery diarrhea lasts longer than 3 days, contact your surgeon.
  • Pain medication (narcotics) can cause constipation. Increase the fiber in your diet with high-fiber foods if you are constipated. Your surgeon may also give you a prescription for a stool softener.

Pain

The amount of pain is different for each person. Some people need only 1 to 3 doses of pain control medication, while others need more.

Home Medications

The medicine you need after your operation is usually related to pain control.

When to Contact Your Surgeon

If you have:

  • Pain that will not go away
  • Pain that gets worse
  • A fever of more than 101°F (38.3ºC)
  • Repeated vomiting
  • Swelling, redness, bleeding, or bad-smelling drainage from your wound site
  • Strong abdominal pain
  • No bowel movement or unable to pass gas for 3 days
  • Watery diarrhea lasting longer than 3 days

Pain Control

The goal of pain control is to minimize pain, keep you moving and help you heal. Your surgical team will work with you on your pain plan. Most often a combination of therapies and medications are used to control your pain. You may also be given medication (local anesthetic) at the surgical site. This may help control your pain for several days.

Use the guide below for ways to manage your post-operative pain. Learn more by going to facs.org/safepaincontrol.

How Intense Is My Pain

Common Therapies to Feel Better

I hardly notice my pain, and it does not interfere with my activities.

I notice my pain and it distracts me, but I can still do activities (sitting up, walking, standing).

Non-Medication Therapies

  • Ice (in a bag, applied over clothing at the surgical site), elevation, rest, meditation, massage, distraction (music, TV, play) walking and mild exercise
  • Splinting the abdomen with pillows

+

Non-Opioid Medications

  • Acetaminophen (Tylenol®)
  • Non-steroidal anti-inflammatory drugs (NSAIDS) Aspirin, Ibuprofen (Motrin®, Advil®) Naproxen (Aleve®)
  • Take these as needed, when you feel pain. Both acetaminophen and NSAIDs help to decrease pain and swelling (inflammation).

My pain is hard to ignore and is more noticeable even when I rest.

My pain interferes with my
usual activities.

Non-Medication Therapies

+

Non-Opioid medications 

Take on a regular schedule (around-the-clock) instead of as needed. (For example, Tylenol® every 6 hours at 9:00 am, 3:00 pm, 9:00 pm, 3:00 am and Motrin® every 6 hours at 12:00 am, 6:00 am, 12:00 pm, 6:00 pm)

I am focused on my pain, and I am not doing my daily activities.

I am groaning in pain, and I cannot sleep. I am unable to do anything.

My pain is as bad as it could be, and nothing else matters.

Non-Medication Therapies

+

Around-the-Clock Non-Opioid Medications

+

Short-acting opioids

Opioids should be used with other medications to manage severe pain. Opioids block pain and give a feeling of euphoria (feel high).
Addiction, a serious side effect of opioids, is rare with short-term (a few days) use.

Examples of short-acting opioids include: Tramadol (Ultram®), Hydrocodone (Norco®, Vicodin®), Hydromorphone (Dilaudid®), Oxycodone (Oxycontin®)


Keeping You Informed

Extreme pain puts extra stress on your body at a time when your body needs to focus on healing. Do not wait until your pain has reached a level “10” or is unbearable before telling your doctor or nurse. It is much easier to control pain before it becomes severe.

Laparoscopic Pain

Following a laparoscopic procedure, pain is sometimes felt in the shoulder. This is due to the gas inserted into your abdomen during the procedure. Moving and walking helps to decrease the gas and the right shoulder pain.

Glossary of Terms and More Information

For more information, please go to the American College of Surgeons Patient Education website at surgicalpatienteducation.org.

For a complete review of appendectomy, consult Selected Readings in General Surgery, “Pediatric Surgery” 2014 Vol. 40 No. 4 and “Colon, Rectum & Anus, Part I” 2015 Vol. 41 No. 4 at facs.org/srgs.

Glossary

Abdominal ultrasound: Sound waves are used to determine the location of deep structures in the body. A hand roller is placed on top of clear gel and rolled across the abdomen.

Abscess: Localized collection of pus.

Advance directives: Documents signed by a competent person giving direction to health care providers about treatment choices. They give you the chance to tell your feelings about health care decisions.

Adhesion: A fibrous band or scar tissue that causes internal organs to adhere or stick together.

Complete blood count (CBC): A blood test that measures red blood cells (RBCs) and white blood cells (WBCs). WBCs increase with inflammation. The normal range for WBCs is 8,000 to 12,000.

Computed tomography (CT) scan: A specialized X ray and computer that show a detailed, 3-D picture of your abdomen. A CT scan normally takes about 1½ to 2 hours.

Electrocardiogram (ECG): Measures the rate and regularity of heartbeats, the size of the heart chambers, and any damage to the heart.

Nasogastric tube: A soft plastic tube inserted in the nose and down to the stomach.

Urinalysis: A visual and chemical examination of urine, most often used to screen for urinary tract infections and kidney disease.

References

The information provided is chosen from clinical research. The research below does not represent all of the information available about your operation.

  1. Wilms IM, de Hoog DE, de Visser DC, et al. Appendectomy versus antibiotic treatment for acute appendicitis. Cochrane Database Syst Rev. 2011;11:CD008359.
  2. Kao LS, Boone D, Mason RJ; Evidence-based reviews in surgery. Antibiotics vs appendectomy for uncomplicated acute appendicitis. J Am Coll Surg. 2013;216(3):501-505.
  3. Cheng HT, Wang YC, Lo HC, et al. Laparoscopic appendectomy versus open appendectomy in pregnancy: a population-based   analysis of maternal outcomes. Surgical Endoscopy. Aug 30, 2014; epub ahead of print.
  4. Stewart D. The management of acute appendicitis. In JL Cameron & AM Cameron (Eds), Current Surgical Therapy (11th Ed). 2014:252-254. Philadelphia: Elsevier Saunders.
  5. Di Saverio S, Sibilio A, et al. The NOTA Study (Non operative treatment for acute appendicitis): prospective study on the efficacy and safety of antibiotics (amoxicillin and clavulanic acid)   for treating patients with right lower quadrant abdominal pain and long-term follow-up of conservatively treated suspected   appendicitis. Ann Surg. 2014;260:109-117.
  6. Peled Y, Hiersch L, Khalpari O, et al. Appendectomy during pregnancy—is pregnancy outcome dependent on operator technique? J Matern Fetal Neonatal Med. 2014;27:365-367.
  7. Salminen P, Paajanen H, Rautio T, et al. Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute    Appendicitis: The APPAC Randomized Clinical Trial. JAMA. 2015 Jun 16;313(23):2340-2348. doi:10.1001/jama.2015.6154.
  8. Li X, Zhang J, et al. Laparoscopic versus conventional appendectomy—a meta-analysis of randomized controlled trials. BMC Gastroenterol. 2010;10:129. Available online www.ncbi.nlm.nih.gov/pmc/articles/PMC2988072.

Disclaimer

This information is published to educate you about your specific surgical procedures. It is not intended to take the place of a discussion with a qualified surgeon who is familiar with your situation. It is important to remember that each individual is different, and the reasons and outcomes of any operation depend upon the patient’s individual condition.

The American College of Surgeons (ACS) 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 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.


Reviewed 2008, 2014, 2015, and 2017 by:
Thomas Whalen, MD, MMM, FACS
Marshall Schwartz, MD, FACS
Kathleen Heneghan, RN, MSN, CPN

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