Acute appendicectomy

Dr Mohd Hafidz Rizal Click to edit Master subtitle style

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outline

Intoduction Anatomy of appendix Acute appendicitis

Epidemiology Aetiology Pathophysiology Clinical features Differential diagnoses

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introduction

Inflammation of the appendix Most common of acute abdomen and most common surgical emergency lifetime rate of appendectomy is 12% for men and 25% for women, with approximately 7% of all people undergoing appendectomy for acute appendicitis
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Anatomy
-Vermiform appendix, a blind intestinal diverticulum -6 10 cm in length -Situated at 2cm posteromedial to ileocecal junction, at the point of convergence of the three taenia coli 4/6/12 -McBurneys point

Position variation
E, F: Retrocecal, 74% H: Pre ileal, 1% I: Post ileal, 0.5%

D: Paracecal, 2% C: Subcecal, 1.5% 4/6/12 B: Pelvic, 21%

-Position of the base is constant, found at the conflunce of the 3 taenia coli -Gentle traction of the anterior taenia coli will lead to the base durg op.

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Mesoappendix, appendicular art.

Mesoappendix allow appendix to be mobile, contains appendicular artery at its free edge. Appendicular art. -br of ileocolic art -end artery, thus appndix is more liable to ischaemia

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Microscopic anatomy

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epidemiology

Rare in <2 years old More common in childhood and early adult Peak: teens and early adult Small risk after midlife incidence of appendicitis is lower in cultures with a higher intake of dietary fiber Slight preponderance for male, 3:2

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Faecolith/lymphoid proliferation/stricture/tumor/worm

obstruct ion

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inflamma tion Incr. Mucus/exudat Incr. Intraluminal e pressure Lymphatic obst. Venous obst. Incr. edema Impede arterial supply ischaemi a
perforatio

Bacteria proliferation

Mucosal ulceration result in migration of bacteria to deeper st.

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Approach to acute appendicitis

Typical presentation Chief complaint -RIF pain -burning -duration -acute (less 72 hours) -aggravated by taking food
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-start as non specific colicky

Approach to acute appendicitis

Typical presentation Chief complaint -RIF pain -a/w low grade fever nausea and vomiting

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Approach to acute appendicitis

Atypical presentation -high retrocecal appendix -RHC pain
cholecystitis/hepatitis/PUD/acute pancreatitis

-acute

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Approach to acute appendicitis

Atypical presentation
-pelvic appendix -frequency -UTI -Tenesmus/early diarrhea -pelvic pain -PID/ectopic pregnancy/ovarian cyst/torsion
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-involuntary right hip flexion

Approach to acute appendicitis

Atypical presentation
-children -non specific acute abdomen -vomiting/diarrhea -intussuception/AGE/mesenteric adenitis

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Approach to acute appendicitis

Atypical presentation
-pregnancy Fetal mortality increases from 3 to 5% in early appendicitis to 20% with perforation.

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Approach to physical examination

General -unwell -mild pyrexia Abdomen -localised peritonitis -RIF-tenderness -guarding
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-rebound tenderness

Approach to physical examination

Abdomen generalised peritonitis -generalised tenderness -boardlike rigidity -hyperactive or absent bowel sound appendicular mass -cecal ca/cecal TB 4/6/12

Investigation

Dx through clinical FBC -leucocytosis

Selective IX TRO other causes -UPT -ectopic pregnancy -UFEME

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-UTI, acute pyelonephrosis,

Treatment
General -Keep NBM, IVD -monitor vital sign -analgesia -prophylactic antibiotic (metronidazole and cefoperazone)

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Appendicectomy: skin incision

perpendicular to line fr ASIS to umbilicus, centred on Mc Burneys point 4/6/12

Grindiron incision:

Lanz Incision: 2cm

below umbilicus, centred on mid clavicularmidinguinal line

Appendicectomy: exposure

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Appendicectomy: exposure

Deepen the incision to the level of the external oblique aponeurosis and cut through this in line with its fibres

Retractors hold the skin, subcutaneous tissue, and external oblique fascia while a large hemostat is used to split the external oblique muscle to expose the transversalis fascia.

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Appendicectomy: exposure
-peritoneum

is picked up between forceps, and opened with a small incision -peritoneum is widened and two hand-held retractors are placed to expose the cecal area -In perforated appendicitis, peritoneal fluid is immediately inspected for amount and

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Appendicectomy: removing the appendix

The appendix delivered up into the wound digitally and inspected with close attention to the base 4/6/12

The appendiceal vascular arcade is taken between clamps and subsequently ligated with catgut 3.0

Appendicectomy: removing the appendix

Base of appendix is crushed using spencer well forcep 4/6/12

clamp is moved 1 cm toward the tip of the appendix. Just at the proximal edge of the crushed portion, the appendix is ligated using catgut 3.0

Appendicectomy: removing the appendix

purse-string suture is laid in the wall of the cecum at the base of 4/6/12 the appendix

appendix is divided between the ligature and clamp

Appendicectomy:closure

Peritoneum closed with continuos suture with catgut 3.0 4/6/12

Internal oblique muscle closed with interupted suture with catgut 3.0

Appendicectomy:closure
External oblique aponeurosis closed with continuos suture Skin closure with subcuticular suture with monosyn 3.0 or interupted suture with dafilon 3.0

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complication
Post operative period -wound infection -most common -D3 onward -sx: op site inflammed, pus discharge, -mx:wound drainage, antibiotics
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complication
Post operative period -intraabdominal abscess -D5 onward -sx: spiking fvr, ill-looking, loose stool, ileus -mx: abdominal U/S

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complication
Post operative period -ileus -period of adynamic ileus is to be expected -may last a few days in gangrenous appendicitis -if last >4-5 days with fever, suggest cont intraabd. Sepsis
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-sx: intestinal obstruction

complication
Post operative period appendiceal stump leakage -rare, encircling stump too deep or cecal wall involved in inflammation -mx: concervative management with low residue enteral nutrition will result in closure
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complication
Late complication -adhesive intestinal obstruction -incisional hernia

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Reference

Zollinger Atlas of Surgical Operations 8th_edition 2006 McGH Schwartz's Principles Of Surgery - 8th Edition Brunicardi et al 2007 McG-H

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