Editing Appendectomy (section)

==Procedure==
[[File:Young nurses assist at an appendectomy 8b07788v.jpg|thumb]]
[[File:Appendectomy incision locations.jpg|thumb|Four incisions for an appendectomy, corresponding to the order listed.]]
[[File:Laparoscopic Port Site.jpg|thumb|Hasson Entry: The two red lines mark the sites of the 5mm laparoscopic ports. The blue line above the umbilicus marks the site of the camera port]]
[[File:US Navy 060227-N-9742R-004 The Ship's Surgeon Lt. Cmdr. Michael Barker, center, and Senior Medical Officer Commander David Gibson, left, perform an urgent laparoscopic appendectomy.jpg|thumb|Surgeons perform a laparoscopic appendectomy.]]
In general terms, the procedure for an open appendectomy is:
# Antibiotics are given immediately if signs of actual [[sepsis]] are seen (in appendicitis, sepsis and bacteremia usually only occurs at some point after rupture, once peritonitis has begun), or if there is reasonable suspicion that the appendix has ruptured (e.g., on imaging) or if the onset of peritonitis – which will lead to full sepsis if not quickly treated – is suspected; otherwise, a single dose of prophylactic intravenous antibiotics is given immediately before surgery.<ref name=":2">{{Cite book|title=Zollinger's Atlas of Surgical Operations|last=Zollinger|first=Robert|publisher=McGraw-Hill Education|year=2016|isbn=978-0-07-179756-6|pages=162}}</ref>
# [[General anaesthesia]] is induced, with [[endotracheal tube|endotracheal intubation]] and full [[Muscle relaxant|muscle relaxation]], and the patient is positioned [[supine position|supine]].<ref name=":2" />
# The [[abdomen]] is prepared and draped and is examined under anesthesia.<ref name=":2" />
# If a mass is present, the incision is made over the mass. Otherwise, the incision is made over [[McBurney's point]] (one-third of the way from the [[anterior superior iliac spine]] <!-- (ASIS) --> to the [[Navel|umbilicus]]), which represents the most common position of the base of the appendix.<ref name=":2" />
# The various layers of the [[abdominal wall]] are opened. To preserve the integrity of abdominal wall, the [[external oblique]] [[aponeurosis]] is split along the line of its fibers, as is the [[internal oblique]] muscle. As the two run at right angles to each other, this reduces the risk of later [[incisional hernia]].<ref name=":2" />
# On entering the [[peritoneum]], the appendix is identified, mobilized, and then [[ligature (medicine)|ligated]] and divided at its base.<ref name=":2" />
# Some surgeons choose to bury the stump of the appendix by inverting it so it points into the [[caecum]].<ref name=":2" />
# Each layer of the abdominal wall is then closed in turn.<ref name=":2" />
# The skin may be closed with staples or stitches.<ref name=":2" />
# The wound is dressed.
# The patient is brought to the recovery room.

===Incisions===
The standardization of an incision is not best practice when performing an appendectomy given that the appendix is a mobile organ.<ref name=":2" /> A physical exam should be performed prior to the operation and the incision should be chosen based on the point of maximal tenderness to palpation.<ref name=":2" />

These incisions are placed for appendectomy:
# McBurney's incision, also known as grid iron incision
# Lanz incision
# Rutherford Morison incision
# Paramedian incision

[[File:Appendectomy plus 10 days.png|thumb|Wound healing - ten days after a laparoscopic appendectomy]]
Over the past decade, the outcomes of laparoscopic appendectomies have compared favorably to those for open appendectomies<ref>{{Cite journal |last=Jaschinski |first=Thomas |last2=Mosch |first2=Christoph G |last3=Eikermann |first3=Michaela |last4=Neugebauer |first4=Edmund AM |last5=Sauerland |first5=Stefan |date=2018-11-28 |editor-last=Cochrane Colorectal Cancer Group |title=Laparoscopic versus open surgery for suspected appendicitis |url=https://doi.wiley.com/10.1002/14651858.CD001546.pub4 |journal=Cochrane Database of Systematic Reviews |language=en |volume=2018 |issue=11 |doi=10.1002/14651858.CD001546.pub4 |pmc=6517145 |pmid=30484855}}</ref> because of decreased pain, fewer postoperative complications, shorter hospitalization, earlier mobilization, earlier return to work, and better [[cosmesis]]; however, despite these advantages, efforts are still being made to decrease abdominal incision and visible scars after laparoscopy.<ref>{{Cite book|title=Zollinger's Atlas of Surgical Operations|last=Zollinger|first=Robert|publisher=McGraw-Hill Education|year=2016|isbn=978-0-07-179756-6|pages=49}}</ref> Recent research has led to the development of [[natural orifice transluminal endoscopic surgery]] (NOTES); however, numerous difficulties need to be overcome before a wider clinical application of NOTES is adopted, including complications such as the opening of hollow viscera, failed sutures, a lack of fully developed instrumentation, and the necessity of reliable cost-benefit analyses.<ref name="journalofmas.com">{{cite journal | last1 = Ashwin | first1 = Rammohan | last2 = Paramaguru | first2 = Jothishankar | last3 = Manimaran | first3 = A. B. | last4 = Naidu | first4 = R. M. | year = 2012 | title = Two-port vs. three-port laparoscopic appendicectomy: A bridge to least invasive surgery | journal = Journal of Minimal Access Surgery | volume = 8 | issue = 4 | pages = 140–144 | doi = 10.4103/0972-9941.103121 | pmid = 23248441 | pmc = 3523451 | url = http://www.journalofmas.com/text.asp?2012%2F8%2F4%2F140%2F103121 | access-date = 2012-11-10 | archive-date = 2018-06-01 | archive-url = https://web.archive.org/web/20180601221648/http://www.journalofmas.com/text.asp?2012%2F8%2F4%2F140%2F103121 | url-status = live | doi-access = free }}</ref>

Many surgeons have attempted to reduce incisional morbidity and improve cosmetic outcomes in laparoscopic appendectomy by using fewer and smaller ports. Kollmar'' et al.'' described moving laparoscopic incisions to hide them in the natural camouflages like the suprapubic hairline to improve cosmesis. Additionally, reports in the literature indicate that minilaparoscopic appendectomy using 2– or 3-mm or even smaller instruments along with one 12-mm port minimizes pain and improves cosmesis. More recently, studies by Ates ''et al.'' and Roberts ''et al.'' have described variants of an {{Linktext|intracorporeal}} sling-based single-port laparoscopic appendectomy with good clinical results.<ref name="journalofmas.com"/>

Also, a trend is increasing towards single-incision laparoscopic surgery (SILS), using a special multiport umbilical trocar.<ref>{{Cite journal|last1=Far|first1=Sasan Saeed|last2=Miraj|first2=Sepide|date=October 2016|title=Single-incision laparoscopy surgery: a systematic review|journal=Electronic Physician|volume=8|issue=10|pages=3088–3095|doi=10.19082/3088|issn=2008-5842|pmc=5133033|pmid=27957308}}</ref> With SILS, a more conventional view of the field of surgery is seen compared to NOTES. The equipment used for SILS is familiar to surgeons already doing laparoscopic surgery. Most importantly, it is easy to convert SILS to conventional laparoscopy by adding a few trocars; this conversion to conventional laparoscopy is called 'port rescue'. SILS has been shown to be feasible, reasonably safe, and cosmetically advantageous, compared to standard laparoscopy; however, this newer technique involves specialized instruments and is more difficult to learn because of a loss of triangulation, clashing of instruments, crossing of instruments (cross triangulation), and a lack of maneuverability.<ref name="journalofmas.com"/>  The additional problem of decreased exposure and the added financial burden of procuring special articulating or curved coaxial instruments exist. SILS is still evolving, being used successfully in many centres, but with some way to go before it becomes mainstream. This limits its widespread use, especially in rural or peripheral centres with limited resources.<ref name="journalofmas.com"/>