thumb Four incisions for an appendectomy, corresponding to the order listed. Hasson Entry: The two red lines mark the sites of the 5mm laparoscopic ports. The blue line above the umbilicus marks the site of the camera port Surgeons perform a laparoscopic appendectomy. In general terms, the procedure for an open appendectomy is: # Antibiotics are given immediately if signs of actual sepsis are seen (in appendicitis, sepsis and bacteremia usually only occurs at some point after rupture, once peritonitis has begun), or if there is reasonable suspicion that the appendix has ruptured (e.g., on imaging) or if the onset of peritonitis - which will lead to full sepsis if not quickly treated- is suspected; otherwise, a single dose of prophylactic intravenous antibiotics is given immediately before surgery. # General anaesthesia is induced, with endotracheal intubation and full muscle relaxation, and the patient is positioned supine. # The abdomen is prepared and draped and is examined under anesthesia. # If a mass is present, the incision is made over the mass. Otherwise, the incision is made over McBurney's point (one-third of the way from the anterior superior iliac spine to the umbilicus), which represents the most common position of the base of the appendix. # The various layers of the abdominal wall are opened. In order to preserve the integrity of abdominal wall, the external oblique aponeurosis is split along the line of its fibers, as is the internal oblique muscle. As the two run at right angles to each other, this reduces the risk of later incisional hernia. # On entering the peritoneum, the appendix is identified, mobilized, and then ligated and divided at its base. # Some surgeons choose to bury the stump of the appendix by inverting it so it points into the caecum. # Each layer of the abdominal wall is then closed in turn. # The skin may be closed with staples or stitches. # The wound is dressed. # The patient is brought to the recovery room. Incisions The standardization of an incision is not best practice when performing an appendectomy given that the appendix is a mobile organ. A physical exam should be performed prior to the operation and the incision should be chosen based on the point of maximal tenderness to palpation. These incisions are placed for appendectomy: # McBurney's incision, also known as grid iron incision # Lanz incision # Rutherford Morison incision # Paramedian incision Wound healing - ten days after a laparoscopic appendectomy Over the past decade, the outcomes of laparoscopic appendectomies have compared favorably to those for open appendectomies because of decreased pain, fewer postoperative complications, shorter hospitalization, earlier mobilization, earlier return to work, and better cosmesis; however, despite these advantages, efforts are still being made to decrease abdominal incision and visible scars after laparoscopy. Recent research has led to the development of natural orifice transluminal endoscopic surgery (NOTES); however, numerous difficulties need to be overcome before a wider clinical application of NOTES is adopted, including complications such as the opening of hollow viscera, failed sutures, a lack of fully developed instrumentation, and the necessity of reliable cost-benefit analyses. Many surgeons have attempted to reduce incisional morbidity and improve cosmetic outcomes in laparoscopic appendectomy by using fewer and smaller ports. Kollmar et al. described moving laparoscopic incisions to hide them in the natural camouflages like the suprapubic hairline to improve cosmesis. Additionally, reports in the literature indicate that minilaparoscopic appendectomy using 2– or 3-mm or even smaller instruments along with one 12-mm port minimizes pain and improves cosmesis. More recently, studies by Ates et al. and Roberts et al. have described variants of an sling-based single-port laparoscopic appendectomy with good clinical results. Also, a trend is increasing towards single-incision laparoscopic surgery (SILS), using a special multiport umbilical trocar. With SILS, a more conventional view of the field of surgery is seen compared to NOTES. The equipment used for SILS is familiar to surgeons already doing laparoscopic surgery. Most importantly, it is easy to convert SILS to conventional laparoscopy by adding a few trocars; this conversion to conventional laparoscopy is called 'port rescue'. SILS has been shown to be feasible, reasonably safe, and cosmetically advantageous, compared to standard laparoscopy; however, this newer technique involves specialized instruments and is more difficult to learn because of a loss of triangulation, clashing of instruments, crossing of instruments (cross triangulation), and a lack of maneuverability. The additional problem of decreased exposure and the added financial burden of procuring special articulating or curved coaxial instruments exist. SILS is still evolving, being used successfully in many centres, but with some way to go before it becomes mainstream. This limits its widespread use, especially in rural or peripheral centres with limited resources.
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