January 23, 2020
More than 4,000 years ago, the ancient Egyptians noticed the appendix during their funeral preparations. They called it “the worm of the bowel” and had no knowledge of its function. Today, although we understand the purpose of the appendix, we also know that its presence is not mandatory for a healthy life. In fact, over 5% of the population develops appendicitis at some point, resulting in the surgical removal of the organ. If you or a loved one is facing an appendectomy, this guide will give you all the information you’ll need on the surgery.
What Is the appendix?
The appendix is a narrow pouch, a few inches in length, located in the lower right quadrant of the abdominal cavity where the small and large intestines meet. It produces a protein to destroy bacteria and fight infection in the body. However, it is not an essential organ, as others will take over the production of this protein if removed.
What Is Appendicitis?
Appendicitis occurs when the appendix becomes obstructed or infected. Appendicitis is considered a medical emergency as the appendix can burst or rupture releasing infectious bacteria into the abdomen. Removing the appendicitis before rupturing will prevent further issues and complications, such as peritonitis, which left untreated, results in multiple organ failure and death.
Appendicitis Signs and Symptoms
Appendicitis usually begins with abdominal pain and tenderness radiating from the lower right section of the abdomen. Additional symptoms include:
- Appetite loss
- Frequent and/ or painful urination
- A burst appendix symptoms will also include a high fever and severe pain in the abdominal area.
What Is an Appendectomy?
An appendectomy procedure will remove the infected appendix and relieve pain. Appendectomy is one of the most common emergency surgical procedures done by surgeons today.
To determine appendicitis, a doctor may do the following:
- Physical exam
- Blood and urine tests
- Detailed imagery of the appendix including X-ray, ultrasound or CT scan
Appendicitis is considered an emergency condition. Once diagnosed, antibiotics will be started right away, and surgery will be scheduled as soon as possible to avoid rupture and further complications.
There is more than one way to perform an appendectomy. One form is a laparoscopic appendectomy.
Taking its name from the laparoscope, a slender tool with a light and camera, this procedure changes the technique a surgeon uses to gain access to the internal site of surgery. Unlike an open appendectomy, laparoscopic procedures require 1 to 3 small incisions in the abdominal cavity. With the help of the laparoscope and specially designed surgical instruments, an appendectomy can be less invasive without the large incision point of access or the hands of the surgeon directly inside the patient.
Common advantages of a laparoscopic appendectomy include:
- Less postoperative pain
- Shortened hospital stay
- Quicker return to bowel function
- Quicker return to normal activity
- Better cosmetic results
Laparoscopic Appendectomy Procedure
When undergoing a laparoscopic appendectomy, the surgeon will follow a standard procedure, typically completed in under 30 minutes.
- Anesthesia will be administered, placing the patient into an unconcious, pain-free state.
- Surgeons make 1 to 3 small, keyhole incisions in the abdomen.
- A port is inserted for carbon dioxide which will inflate the stomach, increasing visibility.
- A lighted camera, called a laparoscope will be inserted through another incision point. This will give the surgeon a magnified, 2D view of the internal organs on a monitor.
- Other small instruments are inserted to detach the appendix from surrounding tissue and attend to other internal needs of the operation.
- Through one of the small incisions, the surgeon will remove the appendix.
- Sterile fluid is then used to remove any infectious material that may remain and decrease the risk of any further infection.
- In the case of rupture, a drainage tube may be inserted to drain any fluid build up.
- All tools will be removed, and remaining carbon dioxide will escape through the incisions.
- Incisions are closed with sutures, staples or covered with a glue-like substance and sterile bandages.
Robot-Assisted Laparoscopic Appendectomy
Similar to a laparoscopic procedure, a robot-assisted appendectomy is performed through small keyhole incisions in the abdomen and specially designed mini-surgical tools. However, robotic laparoscopic surgery uses robotic arms to more specifically maneuver and a 3-dimensional camera for clearer imaging of the internal cavity.
With fewer complications and an easier recovery period, both laparoscopic and robotic surgeries have advantages. Robotic surgery also reduces blood loss and pain, and results in smaller scars, a shorter hospital stay and a faster recovery.
The main differences between robot-assisted and laparoscopic appendectomy are rooted in the technological advances robotics such as the da Vinci robotic surgery system provide.
- More dexterity. In a confined amount of space, there is a restriction in the freedom of movement and the range of motion of instruments. With the use of robotics, such as the da Vinci robot, surgical instruments are guided by the surgeon with robotic arms. The microprocessor between the surgeon’s hand and the tip of the instrument allows microscale tasks impossible without computer enhancement.
- Improved range of motion. Laparoscopic surgical instruments are similar to long, thin, metal pencils with specialized tips. Although effective in surgery, the metal shafts do not flex or bend. In robotic surgery, the miniaturized tools are mounted on 3 seperate robotic arms. Each arm is “wristed”—moving more like a hand. The robotic arms allow for seven degrees of movement freedom, simulating the human hand’s movements in real-time.
- Greater precision. In robotic surgery, larger hand movements are scaled into smaller movements which increase precision. With less manipulation of the surrounding tissue because of this precision, there is less bleeding and less postoperative pain than with laparoscopic. These robotic arms also have the added ability to filter out any errant hand tremors helping in highly precise surgical dissection during surgery.
- Better visualization. A magnified, high-definition 3D camera is mounted on one of the robotic arms. This type of imagery gives the surgeon better visibility and greater attention to internal structures.
- Reduced fatigue. The surgeon operates the robotic arms, views the imagery and navigates through the body cavity at a console. Because they are seated at the console, there is less worry of fatigue or fatigue-related risk factors during the operation.
Robot-assisted laparoscopic appendectomy procedure
Typically completed in under 30 minutes, robotic surgery is similar to a laparoscopic procedure in its minimally invasive techniques including small incisions, video imagery and small operative instruments.
The laparoscope will be attached to one of the robotic arms. The other arms will hold tools that are able to grasp, cut, dissect, and stitch including forceps, scissors, dissectors and scalpels.
The doctor will control the robotic arms and instruments from a console, where they will be viewing the procedure from high-definition, 3D imagery. The movements will be guided by the surgeon from the console with precision and dexterity while another surgeon will be near the patient to assist from that perspective.
- Anesthesia will be administered, placing the patient into an unconcious, pain-free state.
- Small keyhole incisions will be made in the abdomen.
- Carbon dioxide is piped in to inflate the stomach and increase visibility.
- Robotic arms, directed by the doctor at a control station, will be inserted into the incisions.
- The appendix is detached from the surrounding tissue.
- Through one of the incisions, the appendix is removed.
- A sterile, warm water solution mixed with antibiotics will be used to rinse the inside of the abdomen to further eliminate chances of infection.
- With a ruptured appendix, drainage tubes may be inserted for any fluid buildup.
- The incisions are then closed with sutures, staples or covered with a glue-like substance and sterile bandages.
Possible Complications for Both Laparoscopic and Robot-Assisted Appendectomy
Though complications are possible in any kind of surgery, they are rare. Complications may include:
- A leak at the removal edge of the colon
- Injury to adjacent organs
- Blood clots
- Anesthesia-related complications
In addition to standard surgery complication risks, if the surgeon cannot properly see the appendix, or if there are other health-related issues that make it impossible to complete the surgery laparoscopically, an open appendectomy, requiring a larger incision, may be performed.
Serious Complications Needing Immediate Attention
It is important to recognize the early signs of possible serious complications. Medical attention should be sought if there is:
- Severe abdominal pain that won’t go away
- Swelling, redness, bleeding or bad-smelling drainage from wound site
- Bloody stool
- Inability to have bowel movement for 3 days post surgery
Factors That May Increase Complication Risk for Appendectomy
Like any surgery, complications can occur and some factors may contribute to their development.
- Pre-existing heart of lung conditions
- Excessive alcohol use
- Previous abdominal or pelvic surgery
- Certain medications
- Age (65 years of age and older)
Right after the procedure, patients are placed in a recovery room where they will be observed and blood pressure, pulse and breathing are monitored. Pain medication, antibiotics and medication to prevent blood clots will be administered.
Recovery time can vary, especially if the appendix ruptured before surgery. Most patients will return home after 1 day, though any complications could extend the length of the stay.
While anesthesia will prevent pain during surgery, pain and discomfort after the procedure can be managed with standard medications.
If the appendix did rupture, and drainage tubes were used, they will be removed after a few days.
Full recovery can take 4 to 6 weeks. Activity restrictions will typically be suggested for roughly 14 days post surgery.
- Driving, drinking alcohol and operating machinery should be avoided for the first few days as the anesthetic may have a lingering effect.
- Patients may return to work as soon as they feel able, however, it is recommended that they not lift more than 10 pounds or participate in any strenuous activity for 3 to 5 days.
- Children can usually return to school within 1 week, or 2 weeks for a ruptured appendix.
- Children will be excused from Physical Education class and recess for 2 to 4 weeks post surgery.
State-of-the-Art Surgery With Dr. Pakula
Most of today’s hospitals have at least one robotic surgical machine. Dr. Pakula uses the state-of-the-art da Vinci robotic surgery system benefitting both complex and routine surgeries at Los Robles Medical Center. Contact her today for your operative needs.
Dr. Pakula, one of the most sought after practitioners of traditional and minimally invasive surgery, is one of the nation’s leading authorities in robotic surgery. She has published numerous journal articles and trains surgeons all over the country in various types of robotic surgery.