Appendectomy

The appendix is a thin, hollow organ, which extends from the first part of the large intestine called the caecum. It is present near the junction of the large and small intestine. Normally, the appendix is situated on the right side of the belly but sometimes it's confusing to tell because of the distension of the gut adjacent to the appendix, breathing and posture. Its actual function is not known.

Appendectomy is a surgical procedure to remove the appendix. It is removed mainly because of extreme pain and discomfort caused by infection and swelling in the appendix, which is known as appendicitis. It is an emergency situation as the infection from the appendix can spread to the surrounding areas, which can be life-threatening.

Appendectomy is done when you have appendicitis, which is the inflammation or swelling of the appendix. Mostly, appendicitis occurs in young age. If you have appendicitis, you will have pain in the lower belly, which starts from the belly button and shifts down to the right side of the belly. The pain may keep getting worse with time. It can be acute where the swelling develops with pain in a very short time or rarely, chronic where it can be present for a long time. Acute appendicitis needs immediate surgery. The pain can increase while doing normal activities like walking around, sneezing and coughing. The pain is so severe that it can also disturb your sleep. Nausea, vomiting, diarrhoea, low fever, constipation, dehydration, swelling, decreased appetite are other problems which you can face if you have appendicitis.

The infected appendix can burst, which spreads the infection to other surrounding organs and the layer covering them, such as the peritoneum. The peritoneum covers the organs in the belly and when it gets infected and swollen, it is known as peritonitis. It can make you very ill and cause diarrhoea or loose stools, vomiting, nausea and pain. It is an emergency situation and if not taken care of at an early stage, it can lead to death.

There can also be pus formation in the appendix, which makes it swollen and painful, and is known as an appendiceal abscess.

Before appendectomy is performed, a few things should be taken care of. Since appendectomy is an emergency procedure, the time to do prior testing is much less. You should go to the doctor when you have symptoms of appendicitis and the doctor will diagnose it by:

• Asking you about your medical history and symptoms so that he/she can rule out other conditions.
• Physical examination in which the assessment of pain is done by pressing certain areas on your belly.
• Imaging tests, such as an MRI, X-ray, CT scan, and lab tests, such as urine test, pregnancy test and ultrasound of the belly.

There are a few other things that are done before surgery, such as:

• Initially, antibiotics can be started to reduce the infection but the success rate of antibiotic treatment is very less and it usually ends up into the removal of the appendix.
• The numbing agent, which will be used during the surgery so that you don't feel pain, will be tested on you before administering it into your body so that there is no adverse reaction to it.
• You should tell your doctor about any previous medical condition, such as diabetes, high blood pressure, heart, lung or kidney diseases, HIV and so on so that there are no complications during the surgery.
• Tell your doctor if you consume tobacco or alcohol. You should avoid all these before surgery as these create problems in conducting the surgery and slow down the healing process.
• It is important for you to take the medication that the doctor prescribes before the surgery.
• You will be given medication before surgery to calm you down.
• You will be asked to give consent before the surgery.
• Blood pressure, temperature and airway will be checked again before preparing you for the surgery.
• Before making the cut on your belly, you will be given the numbing agent so that you don't feel pain then the further procedure will be carried out.
• During surgery, you will be covered with a germ-free cloth and only the area where the surgery is to be performed will be exposed.

There are two ways by which appendectomy can be done: Open appendectomy and Laparoscopic appendectomy.

Open appendectomy  

It is the most commonly employed surgical procedure to remove the infected and swollen appendix from your body. It is performed within 12 hours of its diagnosis as an emergency procedure if you have acute appendicitis. The procedure is as follows:

• In this procedure, a numbing agent is used so that you don't feel pain during surgery. The numbing agent can be administered in two ways - through your back (spinal anaesthesia), which will only numb your waist and legs, and the other one is called general anaesthesia, in which the whole body is numb and you are in a deep sleep while the surgery is being performed.
• Once you are under the effect of anaesthesia, the surgeon makes a small cut of about 5 cm on the lower right side of your belly to expose the appendix and its surrounding tissues. Hence, it is called an open appendectomy.
• After making the cut, the layers of muscles of the belly and the membranous covering of the belly organs known as peritoneum are separated slowly and carefully without injuring other surrounding organs to expose the caecum.
• After that, the mesoappendix, which is the connection between the appendix and ileum where the last part of the small intestine ends and the first part of large intestine starts, is tied up and the appendix is removed.
• After removing the appendix, the tissues and skin are stitched back together and are covered with a dressing.
• If the appendix bursts before or during surgery, which is a very dangerous situation, then after making the cut and exposing the appendix, the surrounding organs are washed with saline (germ-free salt solution) and a small tube is inserted which drains all the liquid out of the body.

Laparoscopic appendectomy

A laparoscope is an instrument, which is made up of a thin tube with a small camera at the end so that it can be put inside the body to have a three-dimensional view of the organs on a screen. It gives a more accessible and clear view of the surgical area and can help the surgeon to perform the surgery without damaging any surrounding organs. The steps of laparoscopic appendectomy are discussed below:

• In laparoscopic appendectomy, instead of making a big cut, two or three small cuts are made.
• From one of the cuts, the laparoscope is inserted and the other cut is used to put carbon dioxide gas to inflate the belly, for a clear view of the organs.
• Lastly, from the third cut, surgical instruments are inserted to remove the appendix.
• After it is removed, the carbon dioxide gas comes out of the cuts. Through one of the cuts, saline is used to flush the surgical area and a draining tube is attached to ensure that any pus or blood is washed out from the body.
• The cuts are then stitched back. It is considered esthetic as the scar after healing is smaller than that in an open appendectomy.
• The cost of appendectomy ranges between 8,500 to 1,20,000 INR. It depends upon the severity of your condition, the locality (city, town or state), the expertise of your surgeon, and also on whether the health care facility is a government or a private one. The charges in a government set up would be relatively less. The cost also depends upon the type of procedure; the cost of laparoscopic appendectomy is higher than that of an open appendectomy.

You need care after surgery, both at the hospital as well as when you are at home so that healing is speedy.

Care at hospital

After surgery, you will be shifted from the operation theatre to the recovery room. The nurse will check your vitals, such as blood pressure, heart rate, breathing, and body temperature to see if they are in the normal range. When you will get stable, you will be shifted to the hospital room or ward.

Your recovery also depends upon the kind of surgery you have undergone for the removal of the appendix. In an open appendectomy, there is a need to stay in the hospital until the drainage tube to remove excess body fluid is removed. After a laparoscopic appendectomy, there is no need for hospitalisation and you may be discharged on the day of the surgery itself.

You will have to take painkillers as prescribed by your doctor after surgery.

Hospital stay also depends upon the numbing agent and the way it was given. If it was administered to numb the whole body (general anaesthesia), you might have to stay hospitalised for at least a night. However, in case the numbing agent was given in the spine, you are most likely free to go home after surgery.

Care at home

Care at home is equally important for recovery as it is in the hospital. To have a speedy recovery, there are a few things that you should take care of, such as:

• The amount of work you do should be increased slowly and gradually. You can ask your doctor when you can start going to work.
• You should do brisk walking. Don't put stress on your body. Avoid heavy workout like going to the gym, jogging, swimming and lifting weights.
• The prescribed ointment should be applied and the dressing should be changed twice a day or as suggested by your doctor.
• Take the medicine prescribed by your doctor regularly keeping in mind its correct dosage and the number of times it is to be taken in a day.
• Try to follow a schedule for taking medicines, that is, take the medicines every day at the same time as the previous day or at regular intervals, especially painkillers because it increases their effect.
• The swelling and pain in or around the area of surgery can be reduced by using ice packs for the first few days.
• You should try to keep the wound clean and dry. Don't expose it directly to water. Instead, you can have a sponge bath or follow what your doctor suggests.
• You should go for follow-ups as scheduled by your doctor so that he/she can assess the improvement in your condition and keep an eye on any complications if they occur.
• After a laparoscopic appendectomy, you may have a feeling that there is still some carbon dioxide in your belly. This feeling will remain for a while but it will gradually go away.

Appendectomy is not much of complicated surgery. The risks associated with it are much less as compared to other surgeries. Laparoscopic surgery allows you to go home even on the day of surgery. There are some complications, however, which may occur and you should be prepared for:

• You may have a fever during the recovery period due to an infection in the wound. In such a case, you should contact your doctor immediately. He/She will prescribe you antibiotics, which will help you in resolving the infection.
• During an open appendectomy, if there is an injury to the surrounding organs or blood vessels then there can be bleeding. Usually, the doctors do ask you to check with the blood bank in the hospital for the blood of the same blood group as yours so that if this kind of situation arises, it can be handled smoothly.  
• Complications can arise while your doctor gives you numbing agent if you have an addiction to tobacco, alcohol or any other drug.
• There can be swelling in the belly or redness around the area of surgery if the appendix bursts during surgery releasing all the pus in the belly space.
• You may have difficulty in passing stools due to blockage of the intestine.
• Appendicitis can recur if the appendiceal stump which is left after surgery is large and it again can get infected.

There can be blockage of an artery, vein or organ due to carbon dioxide gas used during laparoscopic appendectomy as the gas can get trapped which can lead to serious problems.

Follow up is necessary after you go home from the hospital where you were under observation. These follow up visits are scheduled by your doctor to see:

• If there are any complications after surgery.
• If the wound is healing properly.
• That all the stitches are removed.
• Your progress and give you proper knowledge about what to expect in the following days and when you can start your normal daily life activities.
• That your doubts regarding your recovery are clear.