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Appendectomy
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291
(Figs.3 and 4). The tip of the appendix is grasped and retracted medially and anteriorly providing complete exposure.
11.3 Ligation ofMesoappendix
Our preferred approach is to transect the mesoappendix with a bipolar vessel sealing
system, such as LigaSure device (Figs.5 and 6). This method avoids the need to
create a mesoappendiceal window, decreasing the chance of appendiceal artery
injury. Alternatively, a window can be created in the base of the mesoappendix adjacent to the appendix. This maneuver can be performed with a Maryland or blunt
Fig. 3 Retroperitoneal
attachments of the cecum
and terminal ileum. Access
to the base of the appendix
and mesoappendix may be
difcult when there are
robust retroperitoneal
attachments between the
cecum and the abdominal
wall. Red arrow marks a
retroperitoneal attachment
Fig. 4 Dissection of
retroperitoneal
attachments. Mobilization
of the cecum and terminal
ileum away from
retroperitoneal attachments
is performed allowing
improved access to the
base of the appendix and
mesoappendix; this step is
critical in being able to
identify the
appendiceal base
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Fig. 5 Ligation of
mesoappendix. The
mesoappendix is transected
with a bipolar vessel
sealing system while the
appendix is retracted
Fig. 6 Visualization of the
appendiceal base. The
mesoappendix is
completely transected
allowing complete
visualization of the
appendiceal base
M. M. HollandWahlgren and M. Z. G. Hashmi
grasper. Once the window is complete, the mesoappendix and associated appendiceal artery can be divided using a bipolar vessel sealing system, ultrasonic sheers or
a linear stapler with a vascular load. Due to the stapler size, it must be placed into
the abdomen via the periumbilical 12mm port, necessitating the 10mm laparoscopic camera to be exchanged for a 5mm camera and moved to the left lower
quadrant 5mm port.
11.4 Transection ofAppendix
The appendix is then divided with an endo-GIA stapler paying careful attention to
ensure that stapler is located at the appendiceal base, and taking care to not include
the ileocecal valve or cecum (Fig.7). A standard 30 or 45mm stapler is typically
appropriate with a blue load. An alternative method for dividing the appendix is
using a pre-tied endoscopic ligature. Once resected, the appendix is placed into an
endoscopic retrieval bag and brought out through the 12 mm umbilical port or
port site.
Appendectomy
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Fig. 7 Transection of the
appendix. The appendix is
divided with an endo-GIA
stapler
Fig. 8 Inspection of staple
line and other transected
areas. The staple line and
other transected areas are
closely inspected for staple
failures or inadequate
hemostasis
293
11.5 Inspection andClosure
The staple line is closely inspected for staple malformation or ongoing bleeding
(Fig. 8). The right lower quadrant, pelvis, and right subdiaphragmatic space are
inspected for any contamination and irrigated until the efuent appears clear.
Omentum is placed in the right lower quadrant covering the operative site. The
5mm trocars are then removed under direct visualization followed by the 12mm
trocar. The abdomen is desufated and the fascial defect at the umbilical trocar site
is closed with an absorbable gure-of-eight suture. The skin is closed with subcuticular sutures and either steri-strips, topical skin adhesive, or gauze with tegaderm
(Fig.9).
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Fig. 9 Skin closure. The
skin is closed with
subcuticular sutures
followed by topical skin
adhesive
M. M. HollandWahlgren and M. Z. G. Hashmi
12 Open Appendectomy: Procedure Description
12.1 Abdominal Access
A 2–6cm incision is made at McBurney’s point in either a transverse (Rocky-Davis)
or parallel (McBurney) fashion. Rarely, a lower midline incision may be used to
facilitate exposure in the obese population, or extension of umbilical port in a laparoscopic converted to open operation. The incision is carried down to the external
oblique which is incised parallel to its bers. The internal oblique is then bluntly
separated exposing the transversus abdominus and underlying transversalis fascia,
which is then divided. The peritoneum is exposed, lifted and incised, opening a
window into the peritoneal cavity.
12.2 Identication ofAppendix
Once the peritoneal cavity has been accessed, the appendix and cecum are identied
and delivered anteriorly toward the working space through mobilization via blunt or
sharp dissection of the retroperitoneal attachments. In cases when the appendix is
difcult to locate, the surgeon utilizes the taenia coli of the cecum to trace them
inferiorly and thus identify the base of the appendix.
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12.3 Ligation ofMesoappendix
The mesoappendix and adjoining appendiceal artery are ligated via non-absorbable
suture and subsequent division, utilization of LigaSure device, or transected with a
GIA or TA stapler.
12.4 Ligation ofAppendix
Similar to the laparoscopic technique, a GIA or TA stapler is utilized to transect the
appendix. An alternative method is suture ligation, in which the appendiceal base is
rst suture ligated. Subsequently, a purse-string suture is then placed in the cecum
surrounding the base of the appendix. The appendix is divided just beyond the
suture ligature. Electrocautery may be used to cauterize the appendix with the intention of preventing a mucoceole. The appendiceal stump is inverted into the cecum
and the purse-string suture secured to invert the appendiceal base.
12.5 Inspection andClosure
Once the appendix and mesoappendix are removed from the operative eld, hemostasis is ensured and the right lower quadrant inspected. If spillage is present, the
area is aspirated and irrigated with several liters of normal saline until the efuent is
clear. The peritoneum and transversalis fascia are closed with a running suture followed by closure of the internal oblique with another running suture. The external
oblique fascia is closed with a running suture. The subcutaneous tissue is closed
with interrupted sutures. The skin is closed with subcuticular sutures and then with
either steri-strips or topical skin adhesive. The skin is typically left open or interrupted if the appendix is perforated to allow drainage.
12.6 Special Postoperative Considerations
In uncomplicated cases, further use of antibiotics after resection is not indicated. In
complicated cases or cases where the appendix is perforated, antibiotics may be
given for 4–7days [15]. Recent data, such as the STOP-IT trial, suggests that a xed
duration of 4days of antibiotic treatment after obtaining source control results in
similar outcomes when compared to longer antibiotic courses, and subsequently
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M. M. HollandWahlgren and M. Z. G. Hashmi
leads to fewer days of antibiotic exposure for patients in the era of antibiotic stewardship [16]. Patients’ clinical parameters should normalize within 24 to 48h following operative intervention, if they do not, suspicion for a surgical complication
such as abscess, staple line leak, staple line bleed, hematoma, or missed enterotomy
is indicated and should prompt further investigation.
References
1. Mentula P, Sammalkorpi H, Leppäniemi A.Laparoscopic surgery or conservative treatment for
appendiceal abscess in adults? A randomized controlled trial. Ann Surg. 2015;262(2):237–42.
2. Dueholm S, Bagi P, Bud M.Laboratory aid in the diagnosis of acute appendicitis. A blinded,
prospective trial concerning diagnostic value of leukocyte count, neutrophil differential count,
and C-reactive protein. Dis Colon Rectum. 1989;32(10):855–9.
3. Bliss LA, Yang CJ, Kent TS, Ng SC, Critchlow JF, Tseng JF.Appendicitis in the modern era:
universal problem and variable treatment. Surg Endosc. 2015;29(7):1897–902.
4. Tseng J, Cohen T, Melo N, Alban RF.Imaging utilization affects negative appendectomy rates
in appendicitis: an ACS-NSQIP study. Am J Surg. 2019;217(6):1094–8.
5. Doria AS. Optimizing the role of imaging in appendicitis. Pediatr Radiol. 2009;39(Suppl
2):S144–8.
6. Loftus TJ, Rosenthal MD, Croft CA, Stephen Smith R, Efron PA, Moore FA, etal. Effect of
time to operation on value of care in acute care surgery. World J Surg. 2018;42(8):2356–63.
7. Wagner M, Tubre DJ, Asensio JA.Evolution and current trends in the management of acute
appendicitis. Surg Clin North Am. 2018;98(5):1005–23.
8. Korndorffer JR, Fellinger E, Reed W.SAGES guideline for laparoscopic appendectomy. Surg
Endosc. 2010;24(4):757–61.
9. Ingraham AM, Cohen ME, Bilimoria KY, Pritts TA, Ko CY, Esposito TJ.Comparison of outcomes after laparoscopic versus open appendectomy for acute appendicitis at 222 ACS NSQIP
hospitals. Surgery. 2010;148:625–37.
10. Masoomi H, Mills S, Dolich MO, Ketana N, Carmichael JC, Nguyen NT, etal. Comparison
of outcomes of laparoscopic versus open appendectomy in children: data from the Nationwide
Inpatient Sample (NIS), 2006–2008. World J Surg. 2012;36:573–8.
11. Fischer J, Bland K, Callery M, editors. Mastery of surgery. 5th ed. Philadelphia: Lippincott
Williams & Wilkins; 2006.
12. Kim J-K, Ryoo S, Oh H-K, Kim JS, Shin R, Choe EK, etal. Management of appendicitis presenting with abscess or mass. J Korean Soc Coloproctol. 2010;26(6):413–9.
13. Bickell N, Aufses A, Rojas M, Bodian C.How time affects the risk of rupture in appendicitis.
J Am Coll Surg. 2006;202(3):401–6.
14. Levine J.Guidelines for deep venous thrombosis prophylaxis during laparoscopic surgery.
Surg Endosc. 2007;21(6):1007–9.
15. Taylor E, Berjis A, Bosch T, Hoehne F, Ozaeta M.The efcacy of postoperative oral antibiotics
in appendicitis: a randomized prospective double-blinded study. Am Surg. 2004;70(10):858–62.
16. Sawyer RG, Claridge JA, Nathens AB, etal. Trial of short-course antimicrobial therapy for
intraabdominal infection. N Engl J Med. 2015;372(21):1996–2005.
Meckel’s Diverticulum
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JanetRaeJulson andChinwenduOnwubiko
1 Background
First described by Johann Friedrich Meckel in 1809 [1], a Meckel diverticulum is a
congenital true diverticulum that persists as a result of incomplete atrophy of the
vitelline (omphalomesenteric) duct [2]. Characteristics of this anomaly are typically
described by the “Rule of 2’s”: occurring in 2% of the population, 2 inches long,
within 2feet of the ileocecal valve, containing 2 types of tissue, 2 times as likely to
present in males, and presenting before 2 years old [2]. In reality, a systematic
review conducted by Hansen etal. found the prevalence of Meckel diverticulum to
be 0.3–2.9% and up to 4 times more common in males, while diverticulum length
ranged from 0.4–11cm [3].
2 Presentation
The three most common presentations of symptomatic Meckel diverticulum are
lower gastrointestinal (GI) bleeding, intestinal obstruction, or diverticulitis [2, 3].
GI bleeding occurs in patients whose Meckel diverticulum contains heterotopic gastric mucosa, which, similar to a gastric ulcer, can cause patients to pass painless
J. R. Julson
Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
e-mail: jjulson@uabmc.edu
C. Onwubiko (*)
Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham,
Birmingham, AL, USA
e-mail: cconwubiko@uabmc.edu
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_24
297© The Author(s), under exclusive license to Springer Nature
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J. R. Julson and C. Onwubiko
blood per rectum as the excess acid production from the heterotopic gastric tissue
causes ulceration of the mucosa [3]. Obstructive symptoms can arise due to two
separate processes. In some patients, the diverticulum intussuscepts within the small
bowel resulting in obstruction. For others, obstructive symptoms may occur secondary to volvulus: a brous stalk may persist from failed involution of the omphalomesenteric duct, thus leaving a point of attachment to the umbilicus or the base of
the mesentery around which the small bowel can twist, resulting in volvulus and
subsequent obstruction [2]. Finally, in patients who develop diverticulitis, this can
occur as a disease process similar to appendicitis due to an obstructed diverticular
lumen or as a result of inammation of the heterotopic tissue within the diverticulum. Just like appendicitis, the diverticulum may perforate, causing patients to present in different ways, ranging from focal peritonitis to septic shock depending on
the extent of inammation and perforation [2]. Overall, children are more likely to
present with obstruction (60.1%) or GI hemorrhage (35.6%), while symptomatic
adults have a more even distribution of symptoms; 35.6% with obstruction, 27.3%
with GI bleed, and 29.4% with inammation [3].
Rarely, a Meckel diverticulum may be discovered as part of a Littre hernia;
which is a hernia sac containing a Meckel diverticulum. A systematic review by
Schizas et al. found the incidence of Littre hernia to be too low to accurately
describe, but it has been discovered as part of inguinal, umbilical, femoral, or obturator hernias and thus may present with symptoms of pain or obstruction similar to
any of these types of hernias [4].
3 Pre-operative Evaluation
As part of the workup, basic labs including a complete blood cell count can be
obtained to evaluate for leukocytosis as a marker of inammation or for downtrending hemoglobin suggesting GI bleeding. The imaging study of choice is a
99m
Tc-pertechnetate scan, as this molecule accumulates in gastric mucosa, facilitating the identication of ectopic gastric mucosa contained in a Meckel diverticulum
(Fig.1) [5, 6]. Sensitivity of this scan is reported at 85–90% in the pediatric population and about 60% in the adult population [5]. Additionally, it must be remembered
that this study is only useful in the case of patients with ectopic gastric mucosa
within the diverticulum [7]. Plain radiographs are of limited utility, but may demonstrate enteroliths or evidence of bowel obstruction [7]. Ultrasound or computed
tomography (CT) imaging may show a uid- or gas-lled blind-ending structure
connected to the small bowel (Fig. 2); additionally, CT may better demonstrate
associated pathology, such as enteroliths within the diverticulum, intussusception,
or bowel obstruction [7].
Meckel’s Diverticulum
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Fig. 1 The most sensitive
scan to detect a Meckel
diverticulum is a
technetium (Tc)-99m
pertechnetate nuclear
medicine, often referred to
as “Meckel scan.” In this
study, the tracer molecule
is taken up by gastric
mucosa and is visualized in
the upper abdomen as well
as the bladder. If a Meckel
diverticulum containing
gastric mucosa is present, a
separate focus of uptake
can be visualized in the
right hemi-abdomen at the
site of the Meckel. (Image
credit: Kara Gill, MD)
Fig. 2 Ultrasound imaging
will demonstrate a tube
shaped structure, apart
from the cecum
(distinguishing it from the
appendix). In this case,
inammation has caused
the wall of the
diverticulum to appear
thickened. (Image credit:
Kara Gill, MD)
299
4 Pre-operative Management
As with any surgical patient, ensure adequate intravenous access and resuscitation
prior to proceeding to the operating room. Patients with obstructive symptoms or
diverticulitis may require uid administration in the setting of dehydration from poor
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J. R. Julson and C. Onwubiko
oral intake or sepsis from intra-abdominal perforation and require possible decompression with a nasogastric tube; for those with GI bleeding, pre-operative red blood
cell transfusion may be necessary. Prophylaxis with a rst generation cephalosporin
such as cefazolin is recommended unless in the setting of obstruction or perforation
in which an antibiotic that covers enteric anaerobes should be considered [8].
5 Procedure
Operative treatment of Meckel diverticulum can be performed via laparotomy or
laparoscopy. Laparoscopy is often used, especially in pediatric patients, to conrm
presence of a Meckel diverticulum in cases where pre-operative workup has been
non-diagnostic [9]. If the diagnosis is known preoperatively, laparoscopy is still
preferred with no increase in post-operative complications [10]. In these cases, conversion to laparotomy may still occur for exteriorization of the bowel for small
bowel resection (SBR) or may be necessary due to severity of disease.
Laparoscopy can be performed either with a standard three port set-up similar to
an appendectomy (umbilical, left lower quadrant, and suprapubic ports) or with a
single incision at the umbilicus with a multi-trocar port system. As the Meckel
diverticulum may still have attachment to the umbilicus, the Hassan technique is
preferred for obtaining umbilical access. If the diverticulum is not readily apparent
upon entry, identify the cecum and terminal ileum, then run the small bowel proximally until the diverticulum is identied (Fig.3).
Once the diverticulum is identied, a diverticulectomy can be performed via
tangential ring of a TA or GIA (open) or endo GIA (laparoscopic) stapler (Fig.4),
ensuring that an adequate lumen remains or by performing a SBR with a stapled or
Fig. 3 Intra-operative
photograph demonstrates
an exteriorized section of
ileum with a Meckel
diverticulum. Arrow
indicates a mesenteric
vessel supplying the
diverticulum. (Modied
from JF Burke and CM
Leys)
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