What does an appendicectomy entail?

Irum Amin is a consultant surgeon and clinical lead for the Cambridge Surgical Training Centre. I wanted to know how a person tends to present with the condition, how they’re investigated, how the surgery is carried out, and whether, actually, antibiotics might be a better alternative…

Irum - They would start off talking about feeling unwell, maybe having a temperature, having some pain, which initially starts off around the belly button, can't quite localise exactly where the pain is. And then over a number of hours it then changes and it moves to the right hand side. If, for example, they are being driven to the hospital, they may complain when they go over any speed bumps or, if they move, the pain is made worse. So when they come into the hospital, they will have observations taken and we will take a history. Something that can present very similarly to appendicitis, particularly in children, is if they have a viral illness. So if you get a virus, like you get lymph nodes that come up in your neck, well you have very similar lymph nodes that are near your appendix in your abdomen. So if they swell up, then you can present with very similar symptoms. So part of it is taking a history and then it is actually examining the patient, seeing where they are tender when you examine their abdomen. Bedside investigations such as a urine dip test. Have they got a water infection that might be mimicking appendicitis? And then also a number of blood tests which look for marks of infection. Most people tend to have some form of imaging, particularly in girls or young women because the symptoms can be mimicked by problems with their ovaries. For example, if there has been a cyst in the ovary that has ruptured and there's a little bit of blood in the abdomen, or if the ovary has become twisted and that can mimic exactly appendicitis.

Chris - And then when you do go off to theatre, what's actually involved?

Irum - The majority of these surgeries are done laparoscopically. This normally entails three small cuts to be made. So one cut is made at the belly button, one cut just above the pubic bone, and then there's one cart made on the left hand side so that you have the camera plus two instrument ports. Initially the patient is put head down, tilted, so their feet are up, their head is down so that the small bowel or the, or the bowel in the abdomen moves towards the head end. It moves out of the way. You then locate the appendix, which is attached to the caecum, which is the beginning of the large bowel or the colon, which is on the right hand side. And the position of the appendix can vary. It can be behind the caecum, it can be to the side of it, it could be going down into the pelvis. So you first identify where it is and then you free it up from all its attachments. And then there is something called an endoloop. So if you can imagine a suture that's in a loop, usually two loops are put at the end of the appendix, the appendix is taken out in a bag, and then the holes are sutured up.

Chris - You make it sound really easy. I mean that's because you are a transplant surgeon who's done a lot of surgery, but how long does that take you, if you were doing one now if you did that on me?

Irum - So essentially it depends on your experience. If somebody is learning compared to somebody who has done hundreds and hundreds, it can be anywhere between half an hour up to maybe an hour, maybe even longer. And sometimes it's not possible to do it keyhole. And you then have to convert to an open operation. And that can happen in a small number of cases if the appendix is particularly inflamed or if part of the colon is also involved.

Chris - And when you take them out, I know you said you put them in a bag to get them out safely, but what do they look like? Do they look grotty and ropey?

Irum - So sometimes yes, when you go in they can be quite red and inflamed. Or sometimes they can be a funny colour because it's quite an advanced appendicitis. And you put them in the bag so that when you take them out through the wound, it doesn't cross infect the skin as well. But sometimes it can do.

Chris - What would've happened to people then back in the day before, people like you came along and could fix it surgically? Would they have died?

Irum - Certainly before antibiotics, potentially yes. So for example, during Covid, laparoscopic surgery, certainly in our hospital and other hospitals, were stopped. So when somebody came in with what we call an uncomplicated appendicitis, they were sent home with antibiotics. And those people that we felt actually had a more advanced appendicitis had open surgery, which hadn't been done for many, many years as routine. Now there are lots of studies that have happened in the US, in Europe and also in the UK. And it shows that people who are treated just with antibiotics, about a third of them come back needing surgery to have the appendix taken out at a later date. But certainly pre antibiotics, some of these patients, if they'd had a mild appendicitis, may have recovered, but many of them may have died as a result.

Chris - So is the mood shifting then towards a more kind of watch and wait approach, not going straight in with the surgery and perhaps monitoring people and giving them antibiotics. Or is it still very much a let's just cut it out and be done?

Irum - So I think certainly in the UK, if somebody comes in with appendicitis, you take out the appendix. Now there are studies that are done in Europe and the US in selected groups of patients with careful follow up where they are given antibiotics and they're followed up quite closely where you potentially can have some people who are treated just with antibiotics, but still at least a third of them will need an appendicectomy within the first year.

Chris - So you're not totally doing yourself out of a job?

Irum - No, not completely <laugh>. Not just yet.