Appendix, Surgery
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Appendix, Surgery

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Appendix, Surgery Presentation Transcript

  • 1. APPENDIX James Taclin C. Banez, MD, FPSGS,FPCS
  • 2. Anatomy / Function
    • Location, position
    • Function:
      • Immunologic organ
        • Secrets IgA, component of the GUT associated lymphoid tissue (GALT)
        • Not essential; it’s removal ----> (-) sepsis
  • 3. Appendiceal Conditions of Surgical Importance
    • Appendicitis:
      • Inflammation of the appendix
      • 1500 – perityphlitis – inflammation of the cecal region
      • Most common acute surgical disease of the abdomen
      • Peak ----> puberty / early adulthood
      • Male > female (1.3 : 1)
  • 4. Appendicitis
    • Pathogenesis:
      • Obstruction (dominant causal factor)
        • Fecalith – usual cause
        • Hypertrophy of the lymphoid tissue
        • Inspissated barium
        • Vegetable and fruit seeds
        • Intestinal worms (Ascaris)
        • Tumor
  • 5. Appendicitis
    • Pathogenesis:
      • Sequence of events in Luminal Obstruction
    • Proximal occlusion ---> Closed loop Obst. ---- ---> rapid distention due to:
          • Continuing secretion of the mucosa
          • Rapid multiplication of normal flora
        • ---> elevate pressure ---> capillary/venous occlusion ( CONGESTION 1 st stage):
        • S/Sx: (+) visceral afferent pain fibers (vague, dull, diffuse pain in mid-abdomen or lower epigastrium. Increase peristalsis (crampy pain); N/V and anorexia
  • 6. Appendicitis
    • Pathogenesis
      • Inflammatory process involves the serosa of appendix and in turns parietal peritoneum in the region.
      • Infiltration of PMN ( SUPPURATIVE 2 nd stage)
        • Damage of the lining epithelium ---> entrance of bacteria to the wall.
      • Impairment of blood supply (inc. pressure than arterial pressure)---> ellipsoidal infarct at antimesenteric border near the tip. ( GANGRENOUS 3 rd stage) ---> ( PERFORATION 4 th stage)
      • This process is not inevitable. Some subside spontaneously
  • 7. Appendicitis
    • Pathogens:
      • Anaerobes, aerobes
      • Bacteroides fragilis, Escherichia coli, Peptostreptococcus, Pseudomonas, Bacteroides splanchnicus, Lactobacillus
  • 8. Appendicitis
    • Clinical Manifestation:
      • Abdominal pain:
        • Classic pain sequence ……….
        • Right lower quadrant pain
        • Others:
          • Left lower quadrant pain (long appendix)
          • Flank or back pain (retro-cecal)
          • Supra-pubic (pelvic)
          • Testicular pain (retro-ileal ----> irritates the spermatic artery and ureter
      • Anorexia: nearly always present
      • Vomiting 75%
      • Obstipation / diarrhea
      • Usual sequence (95%) : ANOREXIA ---> ABD. PAIN ---> VOMITING
  • 9. Appendicitis
    • Signs: PE depends on the location of the appendix and presence of rupture
      • Direct and rebound tenderness at Mc Burney’s point. ROVSING sign ---> indicate muscles peritoneal irritation.
      • Involuntary muscle guarding (true reflex rigidity).
      • Psoas / Obturator signs ---> retrocecal appendix
      • Para-rectal tenderness
    • Stages I & II – uncomplicated
    • Stages III & IV – complicated
  • 10. Appendicitis
    • Laboratory Findings:
      • WBC: leucocytosis
      • simple = 10,000 to 18,000/mm3
      • perforated = >18,000/mm3
      • Urinalysis :
          • Hematuria and pyuria due to irritation of the ureter and urinary bladder
          • w/o bacteriuria
      • FPA: rarely helpful; (+) fecalith – rare,
      • highly suggestive of the dx.
  • 11. Appendicitis
    • Graded Compression sonogram:
      • 78–96% sensitivity; 85–98% specificity
      • (+) non-compressible appendix, 6mm or > at AP view
      • (-) easily compressible 5mm; not visualized a & (-) pericecal fluid or mass
      • False (-):
        • Appendicitis confined at the tip
        • Retrocecal position
        • Perforated appendix
      • False (+):
        • Periappendicitis from surrounding inflammation
        • Dilated fallopian tube
        • Inspissated stool can mimic an appendicitis
        • Obese pt., appendix not compressed
  • 12. Appendicitis
    • CT scan:
      • Shd. not delay or substitute for prompt operative intervention when clinically indicated
      • Used primarily for percutaneous drainage
  • 13. Appendicitis
    • Laparoscopy
      • Diagnostic /therapeutic
      • Useful for female to diferrentiate gynecological pathology
  • 14.
    • Appendiceal Rupture:
      • Increase morbidity / mortality
      • No accurate way to determine the occurrence of rupture
      • Suspected:
        • Fever > 39 C
        • WBC of > 18,000/mm3
        • Localized rebound, involuntary muscle guarding
        • Signs of genralized peritonitis
        • Ill defined mass (PHLEGMON – motted loops of bowel adherent to the inflamed appendix)
  • 15.
    • Differential Diagnosis:
    • Most common erroneous pre-op diagnosis:
        • Acute mesenteric lymphaditis
        • No organic pathologic condition
        • Acute pelvic pathologic condition
        • Twisted ovarian cyst / ruptured graafian follicle
        • Acute gastroenteritis
    • Acute mesenteric adenitis:
      • w/ present or recent URTI
      • Diffuse pain, tenderness not sharp, (-) rigidity
      • Self limited -----> observe
  • 16. Differential Diagnosis:
    • Acute gastroenteritis:
      • Childhood, viral gastroenteritis
      • Chills, fever, profuse watery diarrhea, N/V
      • Hyper-peristaltic abdominal cramps w/o localizing sign
    • Disease of the male:
      • Torsion of the testes and acute epididymitis
      • Diagnosed by palpating the enlarged tender seminal vesicle
    • Meckel’s diverticulitis:
      • Same clinical picture w/ AP
      • Associated w/ same complication of AP, hence needs prompt surgical intervention.
  • 17. Differential Diagnosis:
    • Intussusceptions:
      • Shd. Be differentiated pre-operatively due to different management.
      • Char:
        • Common under 2 y/o
        • Occur in well nourished infant who suddenly doubled up due to colicky pain. Hrs. later pass out bloody mucoid stool
        • Sausage shape mass in the RLQ
    • Regional enteritis (Crohn’s dse):
      • s/sx is almost the same w/ AP this is dx. in celiotomy
  • 18. Differential Diagnosis:
    • UTI / Ureteral stone:
      • Referred pain to the labia, scroyum or penis
      • Chills, fever (+) R costo-vertebral angle tenderness, hematuria, leucocytosis
      • Dx: -----> pyelography
    • Gynecological disorders:
      • Rate of erroneous diagnosis of AP is highest in young adult female
      • Order of frequency:
          • PID -----> ruptured grafian follicle ----> twistd ovarian cyst or tumor -----> endometriosis -----> ruptured ectopic pregnancy
  • 19. TREATMENT
    • Adequate hydration, correct electrolyte imbalance
    • Manage other medical problems
    • Pre-operative antibiotics:
      • Simple AP - hrs antibiotic
      • Ruptured AP - antibiotic until fever
      • Peritonitis - 10 days antibiotics
    • Surgery:
      • Open appendectomy:
        • McBurney (oblique); Rocky Davis (transverse);
        • right paramedian; midline incision
  • 20.
    • Open Appendectomy:
  • 21. TREATMENT
      • Laparoscopy:
  • 22. TREATMENT
      • Phlegmon and small abscesses can be treated conservatively w/ IV antibiotic
      • Well localized abscess ---> percutaneous drainage
      • Complex abscess ---> surgical drainage
      • Interval appendectomy – 6 wks. Following an acute event treated either non-operatively or w/ simple drainage of an abscess.
        • 0-37% recurrent appendicitis
  • 23. PROGNOSIS
    • Mortality:
      • 9.9% -------> 0.2%
      • Factors:
        • Ruptured prior to surgery
          • Simple - 0.06%
          • Ruptured - 3%
        • Age of pt.:
          • Ruptured - 15%
      • Death due to:
        • Uncontrolled sepsis (peritonitis, intra-abdominal abscess, gm (-) septicemia.
        • Cardiac / pulmonary insufficiency (elderly)
        • Pulmonary embolism
        • aspiration
  • 24. PROGNOSIS
    • Morbidity:
      • Simple - 3% Ruptured - 47%
      • Early:
        • Septic :
          • Wound infection / abscess
          • Intra-abdominal abscess (appendiceal fossa, pouch of Douglas, sub-hepatic space, multiple intestinal loops.
        • Fecal fistula:
        • Wound dehiscence
        • Intestinal obstruction: due to locculated abscess & exuberant adhesive formation
  • 25. PROGNOSIS
    • Morbidity:
      • Late:
        • Adhesived bands
        • Inguinal hernia (3x greater in pt. who had appendectomy)
        • Incisional hernia (paramedian / midline incision)
  • 26. Appendicitis in the Young
      • Difficult to establish diagnosis:
        • Inability of a child to give accurate history
        • Diagnostic delays by both parents & physicians
      • Rapid progression to rupture:
        • Underdeveloped greater omentum ----> higher morbidity
        • < 8y/o had a twofold increase rate of perforation as compared to older children
  • 27. Appendicitis during Pregnancy
      • AP is the most frequent extra-uterine dse. requiring surgical Tx during pregnancy
      • Most frequent during the 1 st & 2 nd trimesters
      • S/Sx:
        • Abdominal pain, tenderness
        • Rebound tenderness and guarding less due to laxity of abdominal wall
      • Increase WBC; abdominal ultrasound
      • Dx is difficult due to displacement of the appendix
  • 28. Appendicitis during Pregnancy
      • Dx is difficult due to displacement of the appendix
  • 29. Appendicitis during Pregnancy
      • Risk of surgery:
        • Premature labor - 10-15% both for negative laparotomy and appendectomy for uncomplicated AP
        • Appendiceal perforation is significant factor associated w/ fetal and maternal death.
          • Fetal mortality - 3-5% w/ early appendicitis
          • 20% perforation
      • Suspicion of appendicitis during pregnancy shd prompt rapid diagnosis and surgical intervention
  • 30. Tumors of the Appendix
    • Appendiceal malignancy is rare
    • Discovered during laparotomy or in association w/ acute inflammation of the appendix
    • CARCINOID:
      • Firm, yellow, bulbar mass in the appendix
      • Located: appendix ---> small bowel ----> rectum
      • Carcinoid syndrome is rare in appendiceal carcinoid unless widespread metastases are present
      • Malignant potential related to it’s SIZE ---> > 2cm
      • Treatment: < 2cm appendectomy
      • > 2cm right hemicolectomy
  • 31. Tumors of the Appendix
    • ADENOCARCINOMA:
      • Rare
      • Histologic type:
        • Mucinous adenocarcinoma
        • Colonic adenocarcinoma
        • Adenocarcinoid
      • Manifestation:
        • Acute appendicitis
        • RLQ mass
      • Treatment: right hemicolectomy
      • Prognosis:
        • 55% ----> 5yr. survival
  • 32. Tumors of the Appendix
    • MUCOCELE:
      • Progressive enlargement of the appendix from the intraluminal accumulation of a mucoid substance
      • Histologic type:
        • Retention cyst
        • Mucosal hyperplasia
        • Cystadenomas
        • Cystadenocarcinoma
      • Rarely occurs w/ gelatinous ascites (Pseudomyxoma Peritonei) usually associated w/ malignant ovarian or appendiceal mucinous CA. if present survival is decreased
  • 33. Tumors of the Appendix
    • MUCOCELE:
      • Treatment:
        • Benign - appendectomy
        • Malignant - right hemicolectomy for cystadenoCA of the appendix; THABSO and appendectomy for ovarian cystadenoCA
          • Adjuvant Tx:
            • Radiation, intraperitoneal and systemic chemotherapy recommended but it’s role is unclear
            • 57% local recurrence at appendiceal primary site
            • Death ensues due to progresive obstruction and renal failure
  • 34. THANK YOU