The Difficulties Faced When Performing a Total Appendectomy

The Difficulties Faced When Performing a Total Appendectomy

Introduction

This article discusses the risk factors associated with performing an appendectomy, including not fully visualising the organ and the risk of leaving part of the appendix in situ.

A Case Example

Patient was referred for an appendectomy, during which, part of the appendix was removed, leaving the remaining ‘stump’ in situ. The stump that was left was over the advised 0.5cm amount and resulted in the patient developing stump appendicitis, following which another surgery was mandated. This second surgery included a right hemicolectomy due to the intense inflammation found, which necessitated the removal of a small part of the patient’s distal small bowel and the entire right colon.

Independent Recommendations to Improve Healthcare Standards and Patient Safety

Appendectomies can sometimes be a difficult emergency procedure. In some instances, these surgeries can be fraught with complications, making a relatively straight-forward procedure, more technically challenging.

Difficulties and Complications

Often, some of the main reasons for the complexity of the operation are:

  • The appendix may not be fully visualised
  • Rupture during the procedure
  • Caecal adhesions are present

Most appendectomies are performed laparoscopically in this day and age, however when the above complications occur, conversion to open surgery should be considered.

The advised amount of appendix stump to leave in situ is 0.5cm – if this cannot be achieved laparoscopically due to poor visualisation, then the decision to proceed to open surgery should be contemplated. Additionally, rupture of the appendix during surgery is a recognised complication but can make the surgery difficult – especially when the appendix cannot be visualised and/or caecal adhesions are present.

In these circumstances, the move to open surgery should be fully considered, to limit the risk of a stump being left behind. If a stump over the recommended size is left in situ, the patient has a higher risk of developing stump appendicitis, which requires resection surgery and extended healing time.

Preventing Stump Appendicitis

Limiting the risk of partial appendix removal should be borne in mind during all appendectomies, and pre-assessments should be fully undertaken to make sure that where possible, the whole appendix can be removed.

These can include:

  • measuring the appendix before and after the removal
  • noting the length of the appendix and comparing this to the organ’s size, post-removal
  • measuring any stump left in situ (clinicians should bear in mind the length of the stump and determine if this is short enough to limit the risk of stump-appendicitis from occurring)
  • taking care to remove as much of the appendix as possible
  • making the best efforts to fully visualise the appendix, even if this requires the need for conversion surgery.

The importance of visualisation, recognising and comparing measurements cannot be overlooked when performing these common procedures as it could mean the difference between an uncomplicated surgery with good prospects, or an unfortunate need to resection surgery, introducing an increased risk for infection, complications and aesthetic consequences.

Next Steps

If a total appendectomy is not achieved and a stump is left in situ, care should be taken to ensure that it is within the recommended size limits – 0.5cm or below, to reduce the risk of stump appendicitis, which can be extremely painful for the patient.

A patient presenting with stump appendicitis means the patient must undergo another operation, to remove the remaining portion of the appendix, often resulting in further scarring and prolonged healing time. More serious complications can include requiring a hemicolectomy and increases the patient’s overall risk of developing an incisional hernia.

After the initial operation, the patient should be monitored for wound infection, especially in patients where the total appendectomy could not be achieved. Follow-up care should be in place, and the patient should be made aware to raise any further pains or worries to their GP so that they can be monitored.

Conclusion

Where there is any doubt about the identification or visualisation of the appendix, conversion from laparoscopic surgery to open surgery should be considered to prevent part of the appendix being left in situ, raising the risk of developing stump appendicitis.

Prior to appendectomies, the size of the appendix is noted and compared with the removed organ, during and post-surgery. This can limit the need for resection surgery and overall, improve the patient’s recovery time.

By raising awareness of the above issues, THEMIS aims to assist in developing guidance as to recognising when an appendix has not been completely removed, therefore improving healthcare standards and reducing litigation risk.

References

  • Co-authored by the THEMIS Clinical Defence Publishing Team and Ms Kayley Newman, TMLEP Analyst.. (2021). The Difficulties Faced When Performing a Total Appendectomy. The THEMIS Clinical Defence Case Studies. 1 (4), 1.

Important Note

This article is intended to raise awareness to clinical risk issues in an effort to reduce incidence recurrence and improve patient safety. This is not intended to be relied upon as advice. Facts have been altered to ensure this case is non-identifiable, albeit clinical learning points remain applicable. To request an independent clinical review, please contact [email protected] or call +44 (0) 203 355 9796.