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Appendectomy

Appendicitis is one of the most common causes of abdominal pain with a lifetime risk of 8.6% in men and 6.7% in females. Appendectomy is the surgical removal of the appendix. The operation is done to remove an infected appendix. An infected appendix, called appendicitis, can burst and release bacteria and stool into the abdomen.

Appendectomy

Common Symptoms

  • Abdominal pain that starts around the navel and may move to lower right abdomen
  • Not wanting to eat
  • Low fever
  • Nausea and sometimes vomiting
  • Diarrhea or constipation

Treatment Options

appendix-graphic.png

Surgical Procedure

  • Laparoscopic appendectomy—The appendix is removed with instruments placed into small abdominal incisions.
  • Open appendectomy—The appendix is removed through an incision
    in the lower right abdomen.

Nonsurgical Procedure

Surgery is the standard treatment for an acute (sudden) infection of the appendix. Antibiotic treatment might be used as an alternative for specific patients and children.2

endoloop-graphic.png

Benefits and Risks of Your Operation

Benefits—An appendectomy will remove the infected organ and relieve pain. Once the appendix is removed, appendicitis will not happen again. The risk of not having surgery is the appendix can burst, resulting in an abdominal infection called peritonitis.

Possible complications include abscess, infection of the wound or abdomen, intestinal blockage, hernia at the incision, pneumonia, risk of premature delivery (if you are pregnant), and death.

Expectations

Before your operation—Evaluation usually includes blood work, urinalysis, and an abdominal CT scan, or abdominal ultrasound. Your surgeon and anesthesia provider will review your health history, medications, and options for pain control.3

The day of your operation—You will not be allowed to eat or drink while you are being evaluated for an emergency appendectomy.

Your recovery—If you have no complications, you usually can go home 1 day after a laparoscopic or open procedure.

Call your surgeon if you are in severe pain, have stomach cramping, a high fever, odor or increased drainage from your incision, or no bowel movements for 3 days.

appendectomy-graphic-2.png

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

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.

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.5

The Procedure

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 occurs more often in males and people who are over 40 years, diabetic, obese or have a ruptured appendix.7

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.8

 

Common Tests

History and Physical

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

Tests (see glossary)

Abdominal ultrasound or abdominal CT scan—Abdominal CT scan is used in adults to diagnose appendicitis. Abdominal ultrasound may be used more frequently in children and pregnant women to decrease Xray exposure.

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

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

laproscopic-vs-open.png

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. A ruptured appendix may occur in up to 32% of patients who have acute appendicitis.1 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

Antibiotic treatment can be used to treat appendicitis if there is no rupture. This may result in fewer complications, less sick leave and less pain medication than surgery. Of those treated with antibiotics, 40% had a second event within a year and needed an appendectomy.8

Risks Based on the ACS Risk Calculator
Your surgeon will do everything possible to minimize risks, but an appendectomy, like all operations, has risks.

Risks of This Procedure Based on the ACS Risk Calculator in Feb 2022*

Percentage

Keeping You Informed

Wound Infection: Infection at the area of the incision

Open: 5.3%

Laparoscopic: 1.5%

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

Return to the operating room

Open: 2.3%

Laparoscopic: 0.8%

Significant pain and bleeding may cause a return to surgery.

Pneumonia: Infection in the lungs

Open: 0.8%

Laparoscopic: 0.2%

Stopping smoking, walking, and deep breathing after your operation can help prevent lung infections.

Urinary tract infection: Infection of the bladder or kidneys

Open: 0.4%

Laparoscopic: 0.3%

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

Open: 0.5%

Laparoscopic: 0.2%

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

Open: 0.3%

Laparoscopic: 0.1%

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

0%

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

Open: 10.3%

Laparoscopic: 3.7%

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

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).10

*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.

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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.

DISCLAIMER

The American College of Surgeons (ACS) is a scientific and educational association of surgeons that was founded in 1913 to improve the quality of care for the surgical patient by setting high standards for surgical education and practice. The ACS endeavors to provide procedure education for prospective patients and those who educate them. It is not intended to take the place of a discussion with a qualified surgeon who is familiar with your situation.  The ACS makes every effort to provide information that is accurate and timely, but makes no guarantee in this regard.

Reviewed 2014 and 2015;
Revised 2019 and 2022 by:
Nancy Strand, RN, MPH
Kathleen Heneghan, RN, PhD, PNP-C
Robert Roland Cima, MD, FACS

References

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

  1. Acute Appendicitis: Efficient Diagnosis and Management. Am Fam Physician. 2018;98(1):25-33. Copyright © 2018 American Academy of Family Physicians.] Accessed Feb 17, 2022 https://www.aafp.org/afp/2018/0701/afp20180701p25.pdf
  2. CODA Collaborative. Antibiotics versus Appendectomy for Acute Appendicitis—Longer Term Outcomes. Research letter. N Engl J Med. Posted online October 25, 2021. https://www.nejm.org
  3. Doniger SJ, Kornblith A. Point-of-care ultrasound integrated into a staged diagnostic algorithm for pediatric appendicitis. Pediatr Emerg Care. 2018;34(2):109–115.]
  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. Zingone F, Sultan AA, Humes DJ, West J. Risk of acute appendicitis in and around pregnancy: a population-based cohort study from England. Ann Surg. 2015;261(2):332–337.]
  6. Depinet H, von Allmen D, Towbin A, Hornung R, Ho M, Alessandrini E. Risk stratification to decrease unnecessary diagnostic imaging for acute appendicitis. Pediatrics. 2016;138(3): e20154031.]
  7. Conversion-to-open in laparoscopic appendectomy: A cohort analysis of risk factors and outcomes. Finnerty B M, Wu X, Giambrone GP, et al. International Journal of Surgery, Volume 40, 2017. https://doi.org/10.1016/j.ijsu.2017.03.016
  8. Talan DA, Saltzman DJ, Mower WR, et al. Antibiotics-First Versus Surgery for Appendicitis: A US Pilot Randomized Controlled Trial Allowing Outpatient Antibiotic Management. Ann Emerg Med. 2017;70(1):1-11.e9. doi:10.1016/j. annemergmed.2016.08.446
  9. Leung TT, Dixon E, Gill M, Mador BD, et al. Bowel obstruction following appendectomy: what is the true incidence? Ann Surg. 2009 Jul;250(1):51-3. doi: 10.1097/SLA.0b013e3181ad64a7. PMID: 19561482.
  10. Aptilon Duque G, Mohney S. Appendicitis in Pregnancy. [Updated 2021 Aug 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551642/