Procedure
• In uncomplicated appendicitis, access to the McBurney point may be provided by selecting either an oblique (McBurney) incision or a transverse (Rockey-Davis or Elliot) incision. Alternatively, based on preoperative imaging, an incision can be made using the point of maximal tenderness or appendiceal location.
• A McBurney incision is made one-third of the way from the anterior-superior iliac spine (ASIS) to the umbilicus following Langer lines. Separate the external oblique, internal oblique, and transversus abdominis muscles along their fibers.
• The Rockey-Davis or Elliot incision is a transverse incision close to the McBurney point, extending medially to the rectus abdominis muscle and laterally an equal distance. Blunt dissection and electrocautery are used to dissect the external aponeurosis. Expose the external aponeurosis in a superolateral to inferomedial fashion along its fibers to expose the underlying internal oblique muscle. Use blunt dissection to divide the internal oblique perpendicular to the direction of the fibers to expose the transverse abdominal muscle, which is divided in a similar fashion to expose the peritoneum.
• Grasp the peritoneum with forceps, and if free of adhesion, incise it with a scalpel.
• Attention is then turned to locating the appendix. If the cecum can be visualized, it can be mobilized and used to identify the appendix. The appendix can be externalized using atraumatic graspers to advance with the taeniae coli. Alternatively, the cecum can be used as a guide to locate the appendix.
• Once the appendix is identified, dissect the mesoappendix, divide the appendiceal vessels between clamps, and ligate them with silk sutures.
• Crush the tissue at the appendiceal base with a right-angle clamp. Move the clamp distally and ligate the appendiceal base distal to the clamp with an absorbable suture.
• Excise the appendix proximal to the right-angle clamp with a blade. The appendiceal stump mucosa can be obliterated using electrocautery. Place a silk purse-string suture around the appendiceal base and invert the stump
• Confirm hemostasis. Close the peritoneal and fascial layers using absorbable sutures.
• Close the skin according to the surgeon's preference.
• Even in class III (contaminated) wounds due to perforated or gangrenous appendicitis, primary skin closure, and broad-spectrum antibiotic coverage are recommended.
