General Overview and Surgical Approaches
The surgery is performed with the patient in the supine position. Both local anesthesia and full endotracheal anesthesia can be used for pain control. The choice of surgical approach is a crucial step that entirely depends on the clinical situation:
- Oblique muscle-splitting incision (McBurney / Rocky-Davis incision). This is the classical and most common approach used in routine elective and emergency cases. The incision is made in the right iliac region with a standard length of 8 to 10 cm. An important anatomical landmark is McBurney's point—the midpoint of the incision should lie strictly at the border of the middle and outer thirds of an imaginary line connecting the anterior superior iliac spine (spina iliaca anterior superior) to the umbilicus.
- Right paramedian incision (Lennander incision). Performed on the right side. Surgeons resort to this option in unclear cases when the diagnosis requires clarification during abdominal exploration.
- Midline incision (laparotomy). Used in severe situations, particularly in advanced peritonitis, when the widest possible exposure is required.
Technique of Layer-by-Layer Tissue Dissection
When using the classical McBurney / Rocky-Davis approach, the surgeon sequentially passes through all layers of the anterior abdominal wall:
- Skin and subcutaneous adipose tissue. Dissecting these layers transects branches of the superficial epigastric artery (a. epigastrica superficialis), which must be carefully ligated to achieve hemostasis.
- External oblique aponeurosis. It is first carefully incised with a scalpel, and then, using Cooper scissors, separated from the underlying muscle tissue.
- Internal oblique and transversus abdominis muscles. A feature of the muscle-splitting approach is that these muscles are not transected; their fibers are bluntly separated along their natural direction using closed scissors or a Kocher probe.
- Transversalis fascia. This thin layer is simply split and retracted.
- Peritoneum. Opening the peritoneum requires extreme caution. It is grasped with anatomical forceps and elevated into a cone shape. The surgeon must carefully verify that the underlying bowel wall is not caught along with the peritoneum. Only then is a small incision about 0.5 cm made. The edges of the incision are immediately secured with Mikulicz clamps, after which the peritoneal incision is safely extended to the full length of the muscle wound.
Exteriorization of the Bowel and Removal of the Appendix
After entering the abdominal cavity, the search phase begins. The surgeon must locate the cecal dome, which is situated in the right paracolic gutter.
To accurately identify the cecum and avoid confusing it with other bowel loops, three characteristic visual landmarks are used:
- A specific grayish-ashen color of the wall.
- The presence of a longitudinal muscular band (taenia coli).
- The complete absence of fat appendices (appendices epiploicae) on its surface.
After confirming that the cecum has been found, it is gently grasped and exteriorized into the wound. The appendectomy itself is performed using the classical ligation-invagination technique. In the first stage, the surgeon ligates the nourishing vessels and transects the mesoappendix. After excising the appendix itself, its remaining stump is invaginated into the lumen of the cecum. To securely fix the invaginated stump, a purse-string suture is placed on the serosa of the cecum.
Briefly: answers to topical questions
What are the atypical anatomical positions of the vermiform appendix in the abdominal cavity?
The sources indicate the following positions of the vermiform appendix:
- Pelvic (descending) — directed downwards into the pelvic cavity.
- Medial — located parallel to the ileum.
- Lateral — located in the right paracolic gutter.
- Anterior — lies on the anterior surface of the cecum.
- Ascending (subhepatic) — directed upward with its tip, often reaching the subhepatic region.
- Retrocecal — located behind the cecum; it may be intimately fused with its posterior wall or lie retroperitoneally.
What methods exist for managing the stump of the vermiform appendix?
The cited materials describe the ligation-invagination method for managing the appendiceal stump: after vessel ligation and division of the mesoappendix, the stump is invaginated using a purse-string suture.
What special surgical instruments are used to grasp and hold the cecum?
For gentle grasping and holding of tissues, including the bowel, anatomical forceps are used—an instrument with transverse serrations and no teeth. Elastic gastrointestinal clamps do not damage the bowel wall and are used prior to opening the lumen of the stomach or bowel.
How is the vermiform appendix located when it has a retrocecal position?
In a retrocecal position, the vermiform appendix lies behind the cecum. The base of the appendix is sought at the convergence of all three taeniae coli, which merge into the continuous muscular layer of the appendix. The appendix may be intimately fused with the posterior wall of the cecum or lie retroperitoneally.
To reliably identify the cecum in the surgical wound, remember the "rule of three": grayish-ashen color, presence of longitudinal bands (taenia coli), and absence of appendices epiploicae.
Class and exam questions
What incision is considered standard in an appendectomy?
In typical cases, an oblique muscle-splitting McBurney / Rocky-Davis incision in the right iliac region is used.
What should a surgeon do if the clinical picture is unclear?
If there is doubt about the diagnosis and a revision is needed, a right paramedian Lennander incision is advisable.
How to properly and safely open the peritoneum?
The peritoneum is elevated into a cone with anatomical forceps, checked to ensure no underlying bowel is caught, incised by 0.5 cm, secured with Mikulicz clamps, and extended along the length of the wound.
Where exactly is McBurney's point located?
It is located at the border of the outer and middle thirds of an imaginary line drawn from the anterior superior iliac spine (spina iliaca anterior superior) to the umbilicus.
What else to study on this topic
- Technique for placing a purse-string suture during invagination of the appendiceal stump.
- Features of ligating the vessels of the mesoappendix.
- Creation of a cecostomy and fixation of the tube to the cecal serosa.
- Creation of a double-barrel artificial anus on the sigmoid colon.
- Formation of a diverting "spur" during colon surgery.
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