Different incisions: McBurney's point: Lanz, grid-iron. Occasionally, it is safer to use a lower mid-line incision when another more difficult pathology is suspected, e.g. a perforated caecal carcinoma in an older patient can mimic appendicitis)
Following incision through the skin and Scarpa's fascia, the next layers are the three layers of the anterior abdominal wall: the external oblique, internal oblique and transversus abdominis. Access through these layers is best achieved by splitting and separating them rather than cutting across them. The peritoneum can be recognised by its slightly shiny appearence. This should be lifted away from the underlying bowel and incised carefully to avoid perforation.
Using a fingertip to explore the undersurface of the peritoneum gives information on any adhesions that may cause a problem before the incision in widened. The caecum can then be identified and delivered through the incision if this is possible. The appendix should then be able to be identified. In more difficult cases a certain amount of exploration or mobilisation may be neccessary to locate the appendix.
The mesoappendix can then be ligated as can the appendix itself. A transfixion suture is likely to be needed for security. Some surgeons like to insert a purse-string type suture around the base of the appendix so that the stump can be buried in the wall of the caecum but there is no evidence that this reduces complication rates.
If the appendix is apparently normal (the so-called "lily-white" appendix) it is normally removed anyway to prevent diagnostic confusion in future. Other pathology should then be looked for at this point. The right ovary and salpinx should be palpable through the incision as should the left. Most of the right hemicolon and the terminal ileum should be accessible and this may show a Meckel's diverticulum. Mesenteric adenitis may also be palpable. Evidence of fibrinous exudate should alert the surgeon to definite pathology within the abdomen and if the source cannot be identified then a formal midline laparotomy may be considered.
It is a matter of surgeons preference whether to close the peritoneal layer. The muscle layers should come together of their own accord if they have only been split but may benefit from 2-3 gentle interupted sutures. Scarpa's fascia can be closed with absorbable sutures and the surgeons prefered skin closure can be used. It is not normal to place a drain unless there is a definitive abscess cavity that is not closing down.
Simple non-adherent dressings are all that is required.
As for any appendicectomy, gradual reintroduction of oral fluids and food as tolerated and home when well.