4-73
Instruments: Scalpel, 2 needle drivers, 2 tissue forceps, 2 retractors, 6 clamps and scissors.
Additional things to do prior to surgery: Obtain a well-ventilated space with good lighting and a narrow
tabletop that allows access to both sides of the patient. A headlight is extremely useful. Obtain good IV
access and instill additional IV antibiotics, if not already given. Ensure that the NG tube and Foley catheter
are in place prior to the first incision.
What To Do:
- This procedure should not be performed without the radio consultation of a physician experienced in
intra-abdominal surgery, - Stay calm.
- Place the patient in the supine position on the table.
- Have the anesthesia technician start the anesthetic.
- Prep the patient’s abdomen from pubic area to nipples and from side to side down to the level of the
posterior axillary line. - Place NG tube and Foley if not already in place.
- Place an incision between the umbilicus and the anterior superior iliac crest, transversely across the
abdomen (Figure 4-2). Make a larger, instead of smaller, incision to see better (at least 4-6 inches long).
The incision should cut through the skin, and then down through subcutaneous fat. Apply clamps to
bleeders as required. Ensure you are clamping a vascular structure before you do so. Using the silk
ligatures, tie off bleeders whose clamps obstruct the incision. Carefully deepen the incision down to
the fascia, which is the shiny white tissue (gristle). Make an incision through the anterior fascial (Figure
4-3). Stay lateral to the rectus muscle seen beneath the fascia. At this point take a hemostat and spread
in the tissue lateral to the rectus muscle along the line of your incision. Using the spreading motion,
progress deeper through the lateral abdominal wall, and into the peritoneal cavity. Once into the
peritoneal cavity, fluid should come out. Place both index fingers into the peritoneal cavity and spread
in the direction of your incision to widen the peritoneal opening (Figure 4-4). Place the retractors at the
medial and lateral portion of the incision, with the end of the retractor in the peritoneum. Have the
assistants pull in opposite directions along the direction of the incision to enlarge access to the peritoneal
cavity. Have your assistants keep the retractors in the wound. - The cecum is the part of the large bowel in the right lower quadrant, to which the appendix is attached.
Following teniae (which are the longitudinal bands that are seen on the colon) on the colon down to the
cecum, pull the cecum into the wound, and locate the appendix at the base of the cecum (Figure 4-5).
This maneuver is not as easy as it sounds and may take some time. - If the appendix is easily seen, and is acutely inflamed (red, swollen) it must be removed. Dissect the
mesoappendix (where the artery to the appendix lies) from the appendix, doubly ligate the mesoappendix,
and cut in between the two ligatures (Figure 4-6). These ligatures must be tied down well to close the
appendiceal artery running through the mesoappendix, and prevent significant bleeding. Now isolate the
appendix by doubly ligating its base, adding a third ligature more distal to the proximal two and dividing
between the ligatures (Figure 4-7). Remove and dispose of the appendix. Inspect the base of the
appendix left on the cecum to make sure both ligatures are tight, as a loose ligature will fall off and
cause a cecal fistula, resulting in worsening intra-abdominal sepsis and death. - If upon entering the peritoneal cavity, you discover an abscess and an abdominal cavity full of pus, it
is strongly recommended that this abscess cavity be drained out the right flank by placing a stab wound
incision (carefully avoid organs and important structures) lateral to the original incision, placing a drain
into the abscess cavity and exiting it through the flank stab wound. Remember the iliac artery
and the ureter also reside in the right lower quadrant; both are tubular structures and should be avoided.
Irrigate the abscess and abdomen copiously with 4 to 6 liters of sterile fluid. There is no need to remove
the perforated appendix. - If upon entering the peritoneal cavity you discover a localized abscess full of pus, drain it and irrigate
as above. - Hemostasis is critically important. Closing the abdomen with ongoing bleeding will result in sepsis,
hypotension and eventual death. Obtain hemostasis by tying the silk ligatures around any remaining
clamped vessels. Search for other bleeding sites including those near the flank stab wound. Place a
finger over the bleeding site, collect your thoughts and take a deep breath. This is a valuable maneuver