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03 / General Surgery · open

Open appendectomy

The classic muscle-splitting RLQ operation, and the traditional first case a student scrubs into.

Indication: Acute appendicitis, particularly where laparoscopy is unavailable or unsuitable.

Part of General Surgery →6 stages3 complications to knowopen
Open surgery in progress under theatre lights
Wikimedia Commons · Public domain

Read the imaging first

CT
Axial CT slice of the lower abdomen showing the appearance of appendicitis
CT abdomen · hyperdense inflamed appendix

On the tray for this operation

Test yourself on the tray

Stage

1 / 6

Incision

Transverse or oblique incision centred on McBurney's point.

🔧 ScalpelExplore anatomy: Open appendectomy approach (RLQ)

Watch for: Wrong-site incision, the reason site marking is checked in the time-out

Why are we operating?

Appendectomy removes an inflamed appendix before it perforates, converting a contained local disease into a cured one. The open muscle-splitting approach remains the teaching classic: a small incision centred on the point of maximal tenderness, through layers that are separated rather than cut, and an operation most surgeons learned their first anatomy inside.

Pulls toward surgery

Clinical appendicitis with a convincing storyImaging-confirmed appendicitisPerforation with localised peritonitisFailed or unsuitable non-operative management

Gives the team pause

An appendix mass or abscess (often drained and cooled first)The wrong diagnosis wearing the right storyCaecal pathology at the appendix base

Shared foundations

The acute abdomen method

Every general surgical emergency passes through the same funnel. Learn the funnel once and appendicitis, obstruction and perforation become variations, not separate subjects.

Understand it once, in the specialty hub

What the surgeon is thinking

  • Incision

    Why is the incision centred where it is?

    McBurney's point is a statistical statement about where appendix bases live, but the better answer is the patient's own examination: the incision goes over the maximal tenderness, because the operation's exposure budget is small and should be spent exactly over the disease.

  • Muscle-splitting approach

    Why split the muscles instead of cutting them?

    The three flat abdominal muscles run in different directions, and each can be opened along its own grain like parting curtains: nothing is transected, so the closure is strong and the pain is small. It is the operation's signature idea, exposure borrowed rather than taken.

  • Finding & delivering the appendix

    How do you find an appendix that does not want to be found?

    Follow the taenia: the three ribbons of the caecum converge on the appendix base like roads to a landmark, which is why delivering the caecum first turns a hunt into a walk. A retrocaecal appendix explains both the atypical story and the extra mobilisation.

  • Mesoappendix, base, removal

    What does the stump actually need?

    A secure tie on healthy base tissue: the feared complication is a stump blow-out into the caecum, so a gangrenous base changes the plan from tying the appendix to managing the caecal wall. The mesoappendix is taken separately because the appendicular artery deserves its own attention.

Decision points

  • The appendix looks entirely normal. What now?

    • Remove it anyway, and go hunting

      The standard: a normal-looking appendix can hide mucosal disease, and the scar will forever say it is gone. Then check terminal ileum (Meckel's, Crohn's) and the pelvis.

    • Close and reassess

      Rarely right once you are in: leaving the appendix invites the same diagnostic confusion next year with a scar as a red herring.

    A white appendix is a question, not an anticlimax: the operation's job becomes finding the disease that faked its story, and the checklist (ileum, mesentery, tubes and ovaries, bile staining from above) is run before anything closes.

  • The appendix has perforated and there is pus in the pelvis.

    • Appendectomy, washout, targeted antibiotics

      The standard: source control plus toilet. Drains are for established abscess cavities, not routine insurance.

    • Extend the operation

      For the rare caecal-base destruction: a limited resection rather than an heroic tie on dead tissue.

    Perforation changes the postoperative script more than the operation: longer antibiotics, a real ileus risk, and the day-5 pelvic collection as the complication to anticipate rather than be surprised by.

Leaving the OR

The handoff

Procedure
Open appendectomy via muscle-splitting incision
Findings
Suppurative appendicitis, no perforation; base healthy, tied and clean
Antibiotics
Per protocol; short course for non-perforated disease
Watch for
Fever past POD 2, wound erythema, or right-sided pain returning after settling

A fictional educational patient, handed over the way real ones are.

The postoperative course

  1. POD 0Eating and walking the same evening; pain controlled with simple analgesia and the split muscles complaining briefly.
  2. POD 1Home for most non-perforated cases, with wound advice and honest safety-netting.
  3. POD 3-5The surveillance window for perforated cases: swinging fever here means a collection, imaged and usually drained rather than re-operated.
  4. Week 2Wound review; back to school or desk work, with sport following the wound's comfort.

Watch it done

Find Open appendectomy videos on YouTube

What can go wrong

Surgical-site infectionIntra-abdominal abscessPostoperative ileus
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