Surgeries and Procedures: Appendectomy
Appendectomy is the surgical removal of the appendix when an infection has made it inflamed and swollen. This infection, called appendicitis, is considered an emergency because it can be life-threatening if it's not treated — the appendix occasionally bursts less than a day after symptoms start. So it's very important to have it removed as soon as possible.
Fortunately, appendectomy is a common procedure and complications are rare. And if appendicitis is promptly diagnosed and an appendectomy is performed, most kids recover quickly and with little difficulty.
Still, it helps to know some of the basics so you can feel confident about what is happening and support your child. The more prepared, calm, and reassuring you are about the anesthesia and surgery, the easier the experience will probably be for both of you.
Located in the abdomen, the appendix is a small organ that resembles a worm. One end of the appendix is closed and the other opens into the large intestine, the organ that absorbs water from waste (or stool) and moves it out of the body through the anus. Experts don't completely understand what the appendix does, but most agree that it's not important to a person's health.
Doctors aren’t always exactly sure what causes appendicitis. Because the appendix is so close to the large intestine, it can become clogged with stool and bacteria. Other times, mucus produced by the appendix can thicken and cause a blockage. In both cases, once the opening to the appendix is congested, it can become inflamed and swollen. Bacteria inside the appendix can multiply and cause appendicitis.
Signs and Symptoms
Appendicitis can cause sudden pain in the middle of the abdomen, usually concentrated around the bellybutton. The pain often moves to the lower right part of the abdomen. At first, the pain might come and go, but then it becomes persistent and sharp.
Appendicitis also can cause:
- loss of appetite
- sometimes painful or frequent urination
If the appendix bursts, a child can develop a fever as high as 104º Fahrenheit (40º Celsius), and pain will move throughout the abdominal area.
Preparing for Surgery
Once it's determined that your child needs an appendectomy, he or she will be admitted to the hospital. You'll have to fill out some paperwork and provide basic information, including:
- your child's health history
- name and phone number of your child's pediatrician
- your insurance provider
- any illnesses and medical conditions your child has
- any allergies your child has
- any medication, vitamin supplements, or herbal remedies your child is taking
You'll wait for surgery either in the emergency room or another room in the hospital, and your child will be given an ID bracelet and asked to change into a hospital gown and remove any jewelry. A nurse will check some of your child's vital signs and put in place these monitors:
- a blood pressure monitor, which periodically checks blood pressure throughout the procedure. It is measured by a cuff that fits around the arm.
- a pulse oximeter, which measures the level of oxygen in the blood. A pulse oximeter resembles a Band-Aid and is placed on a patient's fingertip.
- a heart monitor, which checks the rhythm and rate of the heart beat. A heart monitor is connected to a series of small metal tabs (called electrodes) and records the activity of the heart. The electrodes have adhesive backs that stick to the patient's skin and are placed on the chest.
Depending on how long it's been since your child ate or drank, you and your child might have to wait for a little while for the surgery to begin.
Starting an IV Line
Before the surgery a nurse will begin an intravenous line (IV). After a needle punctures the child's arm or hand, a tiny tube is attached to IV tubing, which connects to a bag containing the mixture of medicines and fluids needed to keep the infection in check. The medicines and fluids flow out of the bag, into the tubing, through the tiny tube in the skin, and into the bloodstream.
Since it involves a needle at first, starting an IV can cause a little bit of pain (kind of like a small pinch). To ease discomfort, a nurse might put some numbing cream on your child's hand a little while before inserting the needle.
Meeting the Surgeon
The surgeon will describe the procedure and answer any questions you and your child might have. This is a good time to ask the surgeon to explain anything about the procedure you don't understand.
Once you feel comfortable with the information, and your questions have been fully answered, you'll be asked to sign an informed consent form stating that you understand the procedure and its risks, and give your permission for the surgery.
Soon after, an anesthesiologist or a certified registered nurse anesthetist (CRNA) will come in to talk to you and your child. Anesthesiologists and CRNAs specialize in giving and managing anesthesia (medicines that prevent pain and sensation during the surgery). The anesthesiologist or CRNA will explain the details about the type of anesthesia to be used.
General anesthesia, which is used for appendectomies, keeps the patient in a deep sleep-like state throughout the procedure, so that he or she is completely unaware of what's happening and doesn't feel any pain.
In addition to checking your child's breathing and heart rate, the anesthesiologist or CRNA will ask about your child's medical history. You might have answered some of the questions already when you filled out paperwork, but it's important to let the anesthesiologist or CRNA know the following:
- your child's current and past health history
- your family's health history
- any medications, supplements, or herbal remedies your child is taking
- any previous reactions your child or any family member has had to anesthesia
- any allergies (especially to foods, medications, or latex) your child has had
- whether your child smokes, drinks alcohol, or takes recreational drugs or birth control pills
You'll also be asked how long it's been since your child has eaten or had anything to drink. It may seem like an odd question, but this is important because the stomach must be empty at the time of surgery so that food or liquid will not be aspirated (inhaled) into the lungs.
Anesthetic medications can suspend the body's normal reflexes, which could cause food to become inhaled into the lungs. It can take up to 6 hours for a person to completely digest food, so if your child has eaten recently, he or she may have to wait a little while for surgery.
To ensure your child's safety during the surgery, it's extremely important to answer all of these questions as honestly and thoroughly as possible, so that the anesthesiologist or CRNA can give the right amount of anesthetic medications and tailor them to your child's needs. After you've provided all of this information and the anesthesiologist or CRNA has answered any questions, you'll be asked to sign an informed consent form that authorizes the use of anesthesia.
Shortly before going into the operating room, your child will be given a sedative (a type of medicine that helps patients relax before a procedure). The sedative is usually given through the IV that is already in place.
Once your child is relaxed, the anesthesiologist or CRNA will start to administer the anesthesia. Usually the medications are given through the IV or with gas given through a mask that covers the mouth and nose. Often, the gas has a flavor like banana or bubblegum to make inhaling it more pleasant.
Within a few minutes, your child will drift into a sleepy state. When your child is taken into surgery, you'll be directed to a waiting area and a hospital staff member will update you during the procedure and notify you when it is over.
During the Surgery
When your child is taken into surgery, a few devices will be used to prevent any complications, including:
- a nasogastric tube, a slender soft tube that's inserted through the nose or mouth and down into the stomach to suck out stomach fluids to make sure they don't interfere with the surgical procedure
- an endotracheal tube, a plastic tube inserted into the throat and the windpipe to help a patient breathe during surgery. This tube is connected to a ventilator that pushes air in and out of the lungs.
- a catheter, a long, thin tube that drains urine from the bladder and empties it. The catheter is carefully inserted into the patient's urethra (which passes urine from the bladder to the outside of the body), and then into the bladder. A catheter isn't used in all cases.
Once these monitors are in place, the surgery can begin. The two common types of appendectomy are:
- Open Appendectomy
An open appendectomy is the "traditional" way of removing an infected appendix. Basically, a surgeon makes an incision in the abdomen and locates the infected appendix. The appendix is cut away from the large intestine and removed from the body. The incision is then closed with stitches.
- Laparoscopic Appendectomy
You've probably heard the word "laparoscopy," which is a type of surgery that uses a tiny video camera called a laparoscope to help surgeons see inside the body. The thin tube of the laparoscope is inserted into the body through a small incision and guided to the appendix to act as the surgeon's "eyes." Other small incisions are made so medical instruments can be guided to the area, and the entire operation is done while looking at a TV monitor.
Your child's surgical team will determine and discuss with you which method is appropriate.
During Open Procedure
For an open appendectomy, the surgeon first cleanses the skin of the abdomen with an antiseptic solution. Then he or she makes an incision, about 2 inches long, through the skin of the abdomen, past the abdominal muscles, and into the abdominal wall (layers of tissue that protect the abdomen). The abdominal muscles are then separated and the appendix is located.
By using sutures (stitches) or a special stapling tool, the surgeon closes the open area of the appendix connected to the large intestine to prevent it from tearing and spreading bacteria through the abdomen while it's being removed. (The stapling tool uses stainless steel staples that are slightly smaller than those used in a standard office stapler.)
The surgeon then cuts the appendix away from the large intestine and pulls it out of the body through the incision.
Once the appendix is removed, the surgeon closes the abdominal wall and abdominal muscles with dissolvable stitches. Then, the opening on the skin is closed with stitches and is covered with a bandage.
During Laparoscopic Procedure
As with an open appendectomy, the surgeon first cleanses the skin with an antiseptic solution. However, instead of making one large incision, the surgeon makes a small incision (about ½ to 1 inch long) in the crease of the bellybutton. This incision allows the laparoscope to be guided to the appendix.
Two more small incisions are made to allow the surgeon to guide other special instruments to the appendix area. These instruments are used to close off the appendix and remove it.
The small incisions are closed with dissolvable stitches and covered with small bandages.
Laparoscopic to Open Procedure
In some rare cases, a surgeon might start with the laparoscopic procedure but change to an open procedure during surgery. This can happen for a variety of reasons: The surgeon might have trouble finding the appendix with the laparoscope or the patient might have had previous surgeries that have left scar tissue in the abdominal area, making it difficult to remove the appendix through laparoscopy.
If the surgeon decides to switch from the laparoscopic procedure to the open procedure, he or she will either close up the small incisions and immediately begin the open appendectomy or end the surgery and reschedule the appendectomy for another time.
After the Surgery
After the surgery, your child will be taken to a recovery room, which is sometimes called the "post-op" (post-operative) room or PACU (post-anesthesia care unit). Here, your child will continue to be closely monitored by the medical team.
The surgeon will come out to talk to you about what happened during the surgery and let you know how your child is doing, and in most cases you'll be able to join your child in the recovery room.
It usually takes about an hour for a child to completely wake up from the anesthesia. People react to anesthesia in a variety of ways, and while most feel fine afterwards, it's possible your child may feel groggy, confused, chilly, nauseated, scared, alarmed, or even sad when waking up.
Also, your child might feel a little bit of pain near the incisions, but a doctor can prescribe medication to help lessen it. Be sure to let doctors or nurses know if your child is uncomfortable or in pain.
Typically, a child stays in the hospital for 2 to 3 days after an appendectomy, a little longer if the appendix burst before it was removed. Many hospitals allow at least one parent to stay with the child throughout the day and overnight.
Once the doctors decide your child is ready to leave the hospital, you'll get instructions on home care and when to come back for a follow-up visit with the doctor. This usually happens within a few weeks.
In cases where the appendix has burst, doctors typically keep a child on antibiotics for a week or more. Sometimes antibiotics are given through a portable IV that remains in place when the child leaves the hospital. A nurse comes to the home in the following days to monitor the IV and remove it.
Other things to think about as your child recovers at home:
- Eating and drinking: There probably won't be any food or drink restrictions after the surgery, but it's likely that your child won't have much of an appetite at first.
- Caring for the incision: Be sure to keep the area clean and watch for signs of infection. Call your doctor if you notice any redness or swelling around the incision, or your child develops pain or a fever greater than 101° Fahrenheit (38.3° Celsius).
- Returning to school: The doctor will let you know when your child can return to school and get back to normal activities. In most cases, kids can be back within a week of surgery, longer if the appendix burst.
- Resuming physical activity: The doctor may recommend that your child stay out of gym class, sports, and other physical activities for a few weeks.
With a little rest and care, most kids recover from appendicitis and an appendectomy with little difficulty.
Risks of Surgery
All surgery has some risks. The surgical team will discuss them with you before the surgery and do everything possible to minimize them. If you have any questions or concerns, make sure they're addressed before the surgery.
Anesthesia is very safe. But in some cases it can cause complications in children (such as irregular heart rhythms, breathing problems, allergic reactions to medications, and, in very rare cases, death). These complications are not common, and usually involve patients who have other medical problems.
In any surgery, there's a possibility of bleeding. Severe bleeding is rare during an appendectomy, and almost all bleeding is controlled without the need for a blood transfusion.
It is possible that a patient can have an allergic reaction to the anesthesia or other medication given during the surgery.
Symptoms of an allergic reaction can range from something minor, like a skin rash, to something more serious, like dizziness, trouble breathing, or swollen lips or tongue. Allergic reactions typically develop within a few minutes after the anesthesia is given. The doctors can provide immediate medical attention if that happens.
Surgery is performed in a sterile environment, but any time the skin is cut and the internal body is exposed, there's a risk of infection. Symptoms of an infection can develop in the first few days after surgery and might include pain or a fever of about 101° Fahrenheit (38.3° Celsius).
In cases where the appendix has ruptured, an abscess can form. This is a pocket of pus that collects in the abdomen. An abscess is usually detected and treated (often by draining the infected fluid) before a child is discharged from the hospital, but in some cases additional surgery may be needed.
Problems going to the bathroom
It is common for kids to have some trouble going to the bathroom after the surgery. That's because the doctors operate near the digestive system when removing the appendix. Also, some of the pain medication given for the surgery can lead to constipation. All of this can make it difficult for a child to urinate, pass gas, and have bowel movements.
These problems usually develop in the first hours after the surgery and go away on their own within a day or two. Your child will be monitored closely for any signs of problems in the hospital.
Rarely, the incision becomes infected and will be treated with antibiotics. Signs of infection include redness, pus, pain, and swelling around the incision, or a fever greater than 101° Fahrenheit (38.3° Celsius). If you notice any of these signs, call the doctor.
In nearly all cases of appendicitis, an appendectomy is the only option. If the appendix isn't removed and it bursts, other organs can become infected. And if infections aren't treated, they can continue to spread. So it's important to diagnose and treat appendicitis as soon as possible.
In some cases, doctors will perform what is known as an "interval appendectomy." This means the operation is delayed because the appendix has ruptured. In the weeks leading up to the surgery, the infection can be treated with antibiotics.
When your child is having any kind of procedure or surgery, it's understandable to be a little uneasy. But it helps to know that in most cases, appendectomies are common procedures and complications are rare. Most kids who undergo an appendectomy recover from the surgery without any difficulty or health problems. If you have any questions about appendectomies, talk with your doctor.