Appendix removal surgery: how long it takes, what recovery involves and returning to work

In everyday language, the appendix (medically, the vermiform appendix) is a narrow pouch attached to the first part of the large bowel, usually in the lower right part of the abdomen. When the appendix becomes inflamed, this is called appendicitis. An inflamed appendix can burst and cause inflammation of the lining of the abdomen (peritonitis), so appendicitis is usually treated with an operation to remove the appendix.

The decision to operate is made by the surgeon after an examination, blood tests and, if needed, an ultrasound or CT scan. For some adults with uncomplicated appendicitis, the doctor may suggest treatment with antibiotics instead of surgery. This treatment is not suitable for everyone, and the inflammation can come back later.

Appendicitis needs urgent assessment. The pain usually starts around the belly button and, over a few hours, moves to the lower right part of the abdomen and gets steadily worse. It is often accompanied by loss of appetite, nausea, vomiting or a high temperature. In children, older people and pregnant women, the symptoms may be different. If you have severe abdominal pain or pain that is getting worse, call an ambulance on 194 or go to the nearest emergency department.

The operation itself usually takes about an hour. It can take longer if the appendix has burst or there is a collection of pus (an abscess), because the surgeon then needs to clean and wash out the abdominal cavity. It also takes longer when there are adhesions (bands of scar tissue) from previous operations that need to be separated. The operation is usually done under general anaesthetic, so the patient is asleep throughout the procedure. The type of anaesthetic is recommended by the anaesthetist after an assessment.

The total time spent in hospital on the day of the operation is longer than the procedure itself. Before the operation, the patient is assessed by the anaesthetist, and after the procedure the patient stays under observation until they have recovered from the anaesthetic. Family members should therefore allow several hours.

The appendix is removed in one of two ways:

• Keyhole (laparoscopic) surgery is usually done through three small cuts, one of them at the belly button. The surgeon inserts a thin camera and instruments, and the abdomen is gently inflated with gas to create space to work.
• Conventional (open) surgery is done through a single cut a few centimetres long in the lower right part of the abdomen.

A review of research published in 2018 by the international research network Cochrane found that in adults, keyhole surgery on average led to slightly less pain on the first day, a shorter hospital stay, a quicker return to normal activities and fewer wound infections. A collection of pus in the abdomen (abscess) was more common after keyhole surgery. The quality of the evidence is moderate to low.

Keyhole surgery is not suitable for every patient. Sometimes the surgeon switches to open surgery during the procedure if they judge this to be safer, for example because of adhesions or a burst appendix. The Maja Hospital price list itemises appendicectomy, laparoscopic appendicectomy and complex laparoscopic appendicectomy separately. The surgeon recommends the appropriate method after a consultation and a review of your test results.

Patients are usually encouraged to get up and walk a few hours after the operation, because moving helps recovery. Eating and drinking can start when the doctor allows it and the patient feels ready. Pain around the wounds is expected and usually starts to ease after two to three days. After keyhole surgery, there may also be pain in the shoulder. This is caused by the gas used to inflate the abdomen during the operation and usually goes away on its own.

The length of the hospital stay depends on the method and how recovery goes. After uncomplicated keyhole surgery, patients often go home the next day. After open surgery, or if the appendix has burst, the stay is longer. The surgeon decides when the patient can go home, and on discharge the patient receives a discharge summary and instructions on wound care, diet, activity and the follow-up appointment.

A special diet is usually not needed after appendix surgery. Eating returns to normal gradually, and the bowels need a few days to get back into their usual rhythm. General recommendations are:

• Fluids first (water, tea, soup), then lighter meals, if the body tolerates them well.
• Smaller meals several times a day, rather than two or three large ones.
• Plenty of fluids throughout the day.
• Fewer fatty, fried and spicy foods in the first few days, if they cause bloating or nausea.
• Fruit, vegetables and wholegrain cereals once your appetite returns, because they help with constipation.

Constipation is common after surgery, because of moving around less and taking painkillers, while some people have looser stools for a few days. Fluids, fibre-rich foods and a daily walk help with constipation. If the appendix burst or recovery was more complicated, the dietary advice may be different, so follow what is written in your discharge summary.

Instructions vary from patient to patient, but the following usually applies:

• Showering is usually allowed in the first few days after the operation, unless the surgeon says otherwise. After a shower, gently pat the wound dry with a clean towel.
• Baths and swimming should wait until the wound has fully healed, usually about two weeks.
• Redness and tenderness around the wound are expected during the first one to two weeks and gradually ease. Numbness of the skin around the wound may last longer, and is sometimes permanent.
• Stitches or clips are removed at the follow-up appointment, unless dissolvable stitches or skin glue were used.
• A daily walk is recommended, and activity should be increased gradually.
• Heavy lifting, contact sports and strenuous exercise are usually avoided for about a month. The exact timing is set by the surgeon.
• Driving is possible once you can do an emergency stop without pain and are not taking medicines that cause drowsiness, usually after one to two weeks.

When you can return to work depends on the method of surgery, how recovery goes and the type of work you do. After uncomplicated keyhole surgery, patients usually return to office work and other lighter work after one to two weeks. Work that involves lifting and physical effort needs more time. After open surgery, time off work often lasts three to four weeks, and if the appendix has burst, recovery may take even longer.

Sick leave is decided by your registered GP at your local health centre. Take the hospital discharge summary to your GP, as the surgeon includes recommendations for recovery in it. If recovery is slower than expected, the timing of your return to work is reviewed with the surgeon at the follow-up appointment.

As with any operation, complications can occur, for example a wound infection, a collection of pus in the abdomen (abscess), bleeding or slowed bowel function. The risk is higher if the appendix has burst. After discharge, contact your surgeon or GP without delay if you notice any of the following:

• A high temperature, shivering or feeling very weak.
• A wound that is becoming redder, more swollen and more painful, or is leaking pus or blood.
• Abdominal pain that is getting worse instead of better.
• Nausea and vomiting that do not stop, being unable to keep fluids down, or a swollen abdomen without passing stools or wind.
• Pain or swelling in the calf.

If you have severe abdominal pain, difficulty breathing, chest pain or confusion, call an ambulance on 194. This article is general information and does not replace an examination and instructions from your surgeon.