Appendicitis Inflammation of the appendix is known as appendicitis.
Appendix The vermiform or worm like appendix, arising from the posteromedial wall of the caecum,about 2cm below the ileocaecal orifice. Dimensions: The length varies from 2 to 20 cm or 2-9 in. with an avarage of 9cm. It is longer in children than adults. The diameter is about 5mm. The lumen is quite narrow and may be obliterated after mid adult life.
Positions•The appendix lies in the rightiliac fossa.• Although the base of theappendix is fixed, the tip canpoint in any direction.• parabolic 11 o’ clock• retrocaecal or colon•the splenic 2 o’ clock•horizontally to the left 3 o’clock•pelvis(pelvic) 4 o’clock•mid inguinal 6 o’clock
Peritonial relations The appendix is suspended by a small, triangular fold of peritoneum, called the mesoappendix, or appendicular mesentery. The fold passes upwards behind the ileum, and is attached to the left layer of the mesentery.
Appendicular orifice It is situated on the posteromedial aspect of the caecum 2cm below the ileocaecal orifice. The appendicular orifice is occationally guarded by an indistinct semi lunar fold of mucous membrane know as ‘valve of Gerlach’. The orifice is marked on the surface by a point situated 2cm below the junction of the trans tubercular and right lateral planes.
Nerve supply Sympathetic nerves are derived from segments T9 to T10 through the celiac plexus. Parasympathetic nerves are derived from the Vegas.
Applied anatomy Inflammation of the appendix is known as appendicitis. Pain caused by appendicitis is first felt in the region of the umblicus. This is referred pain. Note the fact that both the appendix and the umblicus are innervated by segment T10 of the spinal cord. With increasing inflammation pain is felt in the right iliac fossa. This is caused by involvement of the parietal peritoneum of the region.
Symptoms•Pain•Vomiting•Fever•the sequence of these symptoms is known as Murphy’ syndrome• Constipation is usually associated.
AppendicitisPhysical signs Hyperesthesia in the right iliac fossa Tenderness at Mc berney’s point Muscle guard and rebound tenderness over the appendix Rovsing’s sign Cope’s psoas test Cope’s obturator test
AppendicitisETIOPATHOGENESIS The most common etiological factor is obstruction of the lumen that leads to increased intra luminal pressure. This presses upon the blood vessels to produce ischemic injury which in turn favors the bacterial proliferation and hence acute appendicitis.
Commonest causes Obstructive causes: 1. Faecolith 2. Caliculi 3. Foreign body 4. Tumor 5. Worms 6. Diffuse lymphoid hyperplasia Non obstructive causes: 1. Haematogenous spread of generalized infection 2. Vascular occlusion 3. In appropriate diet lacking roughage
PATHOLOGICAL CHANGESMACRO SCOPICALLY: In Early Acute appendicitis In Acute suppurative appendicitis In Acute gangrenous appendicitis
Appendicitis MICROSCOPICALLY:Diagnostic histological criteria : the neutrophilic infiltration of the muscularis. In early stage: Acute inflammatory changes congestion edema of the appendicitis wall. In lateral stages : The mucosa is sloughed off The wall becomes necrotic The blood vessels may get thrombosed Neutrophilic abscesses in the wall. In either cases: An impacted foreign body, faecolith or concretion may be seen in the lumen.
In acute appendicitis: Appendicectomy 1 with in 48 hours of the onset 2 If seen after 48 hours general peritonitis (increasing pulse rate increasing vomiting increasing pain spreading of tenderness from the right to the iliac fossa) Quiescent stage-say after 3 months.
However • In spreading peritonitis • In the case of children • and the aged • Taking of Strong purgative Immediate operation
Choice of incision 1- Kocher incision 2- Midline incision 3- Mc Burney incision 4- Battle incision 5- Lanz incision 6- Para median incision 7- Transverse incision 8- Rutherford Morrison incision 9- Pfannenstiel incision
Choice of incision For quiescent cases Mc Burney’s gridiron incision is the best. For acute cases Mc Burney’s or Rutherford Morison’s muscle cutting incision When the appendix lies more towards the middle line or in the pelvic cavity, or when a general exploration is necessary, a para median incision should be chosen.
Appendicectomy acc.to Mac Burney Any incision in the right iliac or hypo gastric region presents a suitable approach. The operation must be adopted to the varying location of the appendix. In acute appendicitis, the para rectal incision has proved useful; it permits an early incisional extension at any time and better exposure of the abdominal cavity.
Orthograde resection in the case of mobile cecum 1.The small bowel is pushed aside medially with an abdominal swab,and the cecum is exposed using a retractor.
Orthograde resection2.The caecum is nowgrasped with the left hand.•By applying tension in aslight upward curve, thecaecum is brought above theabdominal wall.•The appendix is identifiedat the end of the tenia libera.•It is grasped with a clamp atits mesenteriolum.
Orthograde resection3.If possible, theappendicular artery is doubly legated at the base of theappendix, and theappendixskeletonized down to its base.
Orthograde resection4.After the appendix has been fullyskeletonized its base is crushed with astraight clampor an artery forceps.•Below this, a purse string suture is applied to the caecum.
Orthograde resection5.The base of theappendix is ligated withsilk or catgut.•It is then grasped with aright angled clamp abovethe crushed site.•The appendix is resectedwith a scalpel betweenthe ligature and theclamp.
Orthograde resection6.The previously iodizedappendix stump isinvaginated with the helpof a dissecting forcepsand the purse stringsuture tied.•A second similar sutureis applied as a precaution•The second suture maybe a Z-stitch.
Orthograde resection7.After burying thestump,the serosal defectof the mesenteriolum issewn with interruptedsutures.•If the appendix ismarkedly inflammed,these sutures shouldnot be made.
Retrograde resection in thepresence of an immobile caecum Since the appendectomy has to be performed with in the abdominal cavity owing to dense adhesions or the retrocaecal position of the appendix, the incision must be sufficiently large.
Retrograde resection in the case of immobile caecum 1.In order to mobilize the firmly adherent caecum,the lateral peritonial reflection is incised. •The caecum is free from the lateral abdominal wall by blunt dissection until the base of the appendix comes into view as a prolongation of the tenia libera. •The appendix is then isolated at its base, crushed, and ligated.
Retrograde resection2.By pulling theappendix downward andthe caecum upward, thecourse of the appendixcan be followed.•Any adhesions and themesenteriolum itselfhave to be ligated anddivided step by step.
Retrograde resection3.After applying acrushing clamp, theappendix is transected,and the stump buriedusing two purse stringsutures.•A Z-like suture may alsobe applied
Retrograde resection4.For better exposure,the caecum is mobilizedfurther upward at itslateral side until theentire behind themedially displacedcaecum is transectedfrom the lateralabdominal wall.•Sharp dissection cannot be avoided in mostcases.
Retrograde resection5.The whole of the appendix,including its tip,should beremoved.• If a suppurative peritonitisor an encapsulated abscess ispresent, the operative fieldmust be drained.• In these situations, bluntdissection is preferred toavoid injury.•Usually the caecum can bebrought back into itsanatomic position with a fewinterrupted sutures.