Appendectomy
What the Examiner Expects
Removal of the vermiform appendix, most commonly performed emergently for acute appendicitis. Laparoscopic appendectomy is the standard approach: the mesoappendix is divided (with its appendiceal artery), and the base of the appendix is ligated or stapled. The examiner expects you to diagnose appendicitis clinically (RLQ pain, periumbilical-to-RLQ migration, anorexia, fever) and with CT (appendiceal diameter > 6 mm, periappendiceal fat stranding, appendicolith). For uncomplicated appendicitis, proceed to appendectomy within 24 hours. For perforated appendicitis with a well-formed abscess, initial management with IV antibiotics and percutaneous drainage followed by interval appendectomy in 6–8 weeks is acceptable.
Key Examiner Focus Points
- Laparoscopic approach is standard; open via McBurney's (RLQ oblique) incision also acceptable
- Mesoappendix divided with its blood supply (appendiceal artery); base stapled or ligated
- Perforated with abscess: consider interval appendectomy after percutaneous drainage + antibiotics
- If appendix is normal at surgery, explore for other pathology (Meckel's, Crohn's, ovarian)
- Send all specimens for pathology — incidental carcinoid or adenocarcinoma may be found
Common Curveballs
Pathology returns showing a 2.5 cm carcinoid tumor at the tip
Carcinoid tumors < 2 cm at the tip: appendectomy is curative. For tumors ≥ 2 cm, tumors at the base, or tumors with mesoappendix invasion or positive margins: right hemicolectomy is indicated for adequate lymph node evaluation.
You find a normal appendix during surgery for suspected appendicitis
Remove the appendix anyway (eliminates it from future differential). Then systematically explore: run the small bowel looking for Meckel's diverticulum or Crohn's disease, examine the right colon and mesentery (mesenteric lymphadenitis), check the ovaries and fallopian tubes in women, evaluate for omental pathology.
CT shows a phlegmonous mass with contained perforation
If the patient is not septic or peritonitic, manage nonoperatively with IV antibiotics +/- percutaneous drainage of any drainable collection. Early surgery in a phlegmonous mass risks ileocecal resection or right hemicolectomy. Plan interval appendectomy in 6–8 weeks and consider colonoscopy to rule out underlying cecal pathology (especially in patients > 40).
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