. Last Updated: 07/27/2016

The Perfect Appendectomy: A Recipe That's as Easy as Pie

Why is going for an operation so terrifying? I think it's partly because we overestimate the complexity of routine surgery. Something like removing an appendix is actually much less difficult than boning and stuffing a duck. You can learn how to make stuffed duck, as I did, in Pru Leith's cook book. Here's how to do the appendix:


You approach your patient from the right side and put a hand on the pelvic bone above the top of the groin. You will feel a bony lump there. Judge the distance from this to the umbilicus, then go a third of the way along that line. Your finger is now on McBurney's point, the most likely position of the appendix. Your incision should be centered here and run parallel to the adjacent skin creases. The length of cut varies with the size of the patient. If you make it too small, you won't be able to find the appendix. If you make the incision too big, all sorts of things might pop out and you'll just have to put them back in again.


The depth of this first incision is something you quickly get a feel for. If you only cut part way through the skin, you'll have to do it again, and the cut won't be a clean one. So be bold here. Not too bold. Ooops. Bit too deep. Never mind, that yellow stuff's just fat. In an adult, you won't hit intestines until you go in at least an inch, and most major blood vessels lie much deeper on the back wall of the abdomen. Keep cutting through the fat, cauterizing any little bleeding points, until you get to a white fibrous sheet. This is part of the first layer of muscles of the abdomen. You can make a little hole in this tendon sheet, then separate the fibers along their length. There's another layer of muscle underneath that needs to be separated. People think of surgery as all cutting and chopping, but it is mainly done (as is the trick with the duck) by blunt dissection, which means finding the tissue planes and gently prying them apart. One of the best tools for this purpose is the blunt tip of your scissors. You press the scissors, closed, into this muscle sheet and gently open them. This should separate the fibers enough so you can stick two fingers in. Now widen the gap as far as you can, put in a couple of retractors and have someone adjust the light so you can see what you're doing.


What you'll see at the bottom of the hole is a shiny membrane called the peritoneum, which encloses the abdominal contents. Pick the membrane up between two pairs of forceps and make a little nick with the scalpel. This allows air into the abdominal cavity. Any bowel that has been sticking under the peritoneum will now fall away, so you can enlarge the incision in the peritoneum with your scissors without the fear of damaging anything underneath. Clamp a pair of forceps on either end of this incision so you can find this layer of tissue when you come to sew it up again.You should now be looking at the caecum, which is the right end of your patient's colon. Pull it up out of the wound. Not that -- that's a small intestine; put it back. We're after a big, wide pouch of gut that, if inflated, would be about the size of a cricket ball. It's difficult to miss. Around the back of it you should find the appendix.


Everyone expects surgery to be bloody, but it shouldn't be. A good surgeon would cause hardly any bleeding at all during an appendectomy. The trick is to identify the blood vessels as you go along and clamp them before you cut them. The blood supply to the appendix is contained in a transparent web of tissue called its mesentery. Before you remove the appendix, you clamp this web of tissue with two pairs of forceps, cut between the two, and tie the blood vessels on both sides. Now you can take these forceps off and check so that there's no leakage.


The next step is to put a stitch in the caecum, running all the way around the base of the appendix, like a purse string. Now move up to the next of the appendix, clamp it with the forceps, then release. This makes a little depression in the tissue, around which you now tie a ligature.


Now move your forceps a little further along the appendix. Clamp it here. Cut the appendix with your scalpel between the ligature and the forceps and put all this -- the appendix, the forceps and the scalpel -- into a bowl to be taken away. Now dab the stump of the appendix with iodine, push it down until it dimples the caecum, simultaneously pulling the purse-string tight, so that even the stump of the appendix is no longer visible on the surface of the bowel. It's not as though anyone would see it, of course, but surgeons are fussy people who like these little aesthetic touches.


Now poke the bowel back into the abdominal cavity and check all instruments and swabs, just in case you've dropped something in the patient -- watch, earrings, tie-pin. If you're not missing anything, you can start stitching up the various layers, first the delicate membrane of the peritoneum, then the tendinous part of the outer muscle layer. Finally you stitch up the skin, put on a dressing, then go and have a nice cup of tea. See -- easy peasy. And only one dish to wash afterward.