For undergraduate student

1. VERMIFORM APPENDIX
LT COL SM SHAHADAT HOSSAIN
MCPS,FCPS( Surgery),FCPS(Thoracic Surgery)
Adv Trg on Thoracoscopy,CNUH,South Korea

2. INTRODUCTION
 Most common cause of an ‘acute abdomen’ in
young adults.
 Most frequently performed operation.
 First major procedure performed by a surgeon
in training.

3. ANATOMY
 Average length is between 7.5 and 10 cm,
 It is supplied by appendicular artery.

4. Positions of the appendix

5. ACUTE APPENDICITIS
Aetiology:
 Common in young males and white races.
 Less fibre diet.
 Family history:30%
 Obstruction: faecoliths, stricture, foreign body,
round worm or threadworm.

6. ACUTE APPENDICITIS
 Rare in infants and common in childhood and
early adult life.
 Peak: teens and early 20s.
 Male–female:3:2.

7. Types
1. Acute non-obstructive appendicitis (catarrhal):
 Red
 Oedematous
 Haemorrhagic.
Fate:
 ™Resolution
 ™Fibrosis
 ™Suppuration
 ™Recurrent appendicitis.
™

8. Types
2. Acute obstructive appendicitis:
• Blackish
• Gangrenous
• Oedematous.
perforation is found at the tip or base.
3.Recurrent appendicitis:
• Fibrosed
• Thickened.

9. PATHOGENESIS
Luminal obstruction by faecolith
→mucus and inflammatory fluid collects inside the
lumen
→increases intraluminal pressure
→leads to blockage of lymphatic and venous
drainage
→causes mucosal ulceration and ischaemia
→bacterial spread through submucosa and
muscularis propria
→acute obstructive appendicitis.

10. Risk factors for perforation
1. Extremes of age
2. Immunosuppression
3. Diabetes mellitus
4. Faecolith obstruction
5. Pelvic appendix
6. Previous abdominal surgery.

11. Clinical Features
Symptoms:
 Pain
Peri-umbilical colic
Pain shifting to the right iliac fossa
 Anorexia
 Nausea
 Vomiting

12. Clinical signs:
 Pyrexia
 Localised tenderness
 Muscle guarding
 Rebound tenderness

13. Signs to elicit in appendicitis:
 Pointing sign
 Rovsing’s sign
 Psoas sign
 Obturator sign

14. McBurney’s point/ Sherren’s triangle

15. Special features
Retrocaecal
 Rigidity is often absent.
 Deep tenderness:present.
 Hip joint in flexed position.
 Hyperextension causing pain; psoas test
positive.

16. Pelvic
 Early diarrhoea.
 Frequency of micturition.
 Absence of rigidity and tenderness.
 Rectal examination reveals tenderness.
 Obturator sign; positive.

17. Special features
Infants
 Rare in infants.
 Perforation and postoperative morbidity-high.
Children
 Rare, usually have complete aversion to food.

18. Special features
Elderly
 Gangrene and perforation occur frequently.
 Localisation is poor.
 Peritonitis occurs early.

19. Special Features
Pregnancy
 Most common extra-uterine acute abdomen.
 Incidence1:1500–2000.
 Diagnosis is delay.
 Pain in the right lower quadrant of the abdomen.
 Fetal loss occurs in 3–5%.

20. Differential diagnosis
Children
 Gastroenteritis
 Meckel’s diverticulitis
 Mesenteric lymphadenitis
 Intussusception
 Henoch–Schönlein purpura
 Lobar pneumonia

21. D/D
Adult
 Regional enteritis
 Ureteric colic
 Perforated peptic ulcer
 Torsion of testis
 Pancreatitis
 Mesenteric infarction

22. D/D
Adult female
 Mittelschmerz Diverticulitis
 Pelvic inflammatory disease
 Ectopic pregnancy
 Torsion/rupture of ovarian cyst
 Endometriosis

23. D/D
Elderly
 Diverticulitis
 Intestinal obstruction
 Colonic carcinoma
 Mesenteric infarction
 Leaking aortic aneurysm

24. Investigations
Routine
 Full blood count
 Urinalysis
Selective
 Pregnancy test
 Urea and electrolytes
 Supine abdominal radiograph
 Ultrasound of the abdomen/pelvis (accurracy90%)
 Contrast-enhanced abdomen and pelvic computed
tomography scan (95%).

25. Sonographic criteria:
 Non-compressible appendix of size > 6 mm AP
diameter,
 Thickened appendix wall > 2 mm—target sign.
 Appendicolith.
 Interruption of submucosal continuity.
 Periappendicular fluid.

26. Indications of Appendectomy
 Acute Appendicitis
 Recurrent Appendicitis
 Mucocele of Appendix
 Carcinoma

27. Alvarado (MANTRELS) score
Score of 7 or more is strongly predictive of acute appendicitis
An equivocal score (5–6)

28. TREATMENT
Appendicectomy

29. APPROACHES
1. Gridiron incision.
2. Rutherford Morison’s incision.
3. Lanz crease incision.
4. Right lower paramedian incision/lower midline
incision.
5. Laparoscopic.

30. Appendicectomy

31. Postoperative complications
Wound infection
 Incidence:5–10% of patients on the fourth or
fifth postoperative day.
 Organisms; Bacteroides species and anaerobic
streptococci.
Treatment:
 Wound drainage
 Antibiotics

32. Postoperative complications
Intra-abdominal abscess
 Approximately 8% of patients, developing 5–7
days after operation.
Treatment:
 Percutaneous drainage
 Laparotomy.

33. Postoperative complications
Paralytic Ileus
Respiratory
Venous thrombosis and embolism( Rare)

34. Postoperative complications
Portal pyaemia (pylephlebitis)
Rare, serious complication of gangrenous
appendicitis.
C/F
 High fever with rigors.
 Jaundice.
Treatment:
 Antibiotics.
 Percutaneous drainage.

35. POSTOPERATIVE COMPLICATIONS
Faecal fistula
 Leakage from the appendicular stump.
Adhesive intestinal obstruction
 Late complication.
 Single band adhesion is often found.

36. APPENDICULAR MASS
(Periappendicular Phlegmon)
 Occurred 3 to 5 days after an attack of acute
appendicitis.
Composed of:
 Inflamed appendix
 Greater omentum
 Oedematous caecum
 Ileum

37. APPENDICULAR MASS
 Tender
 Smooth
 Firm
 Well localised

38. Management of an appendix mass
Conservative ochsner–sherren regime:
 NPO.
 IV Fluid.
 Broad Spectrum antibiotics.
 Daily measurement of the mass.
 Temperature and pulse rate should be recorded
4-hourly.

39. Criteria for stopping conservative
treatment
1. A rising pulse rate.
2. Increasing or spreading abdominal pain.
3. Increasing size of the mass.

40. Contraindications of Ochsner-Sherren regimen
1. When diagnosis is in doubt.
2. Acute appendicitis in children and elderly.
3. Burst, gangrenous appendicitis.
4. Diffuse peritonitis.

41. APPENDICULAR ABSCESS
Due to suppuration in an acute appendicitis.
occurs in
 Retrocaecal
 Subcaecal
 Preileal
 Postileal regions

42. Clinical Features
 High fever, features of toxicity.
 Tender
 Smooth
 Soft swelling in right iliac fossa.

43. TREATMENT
i. Incision is made in the lower lateral aspect of
the swelling.
ii. Skin, external oblique muscle is cut.
iii. Abscess cavity is opened
iv. Pus is drained extraperitoneally.
v. Wound is closed.

44. RECURRENT ACUTEAPPENDICITIS
 Characterised by recurrent episodes of lower
abdominal pain.
 Incomplete obstruction.
 Intensity vary, occur every few months.
 Appendix is thickened and fibrosed.

45. CARCINOID TUMOUR
(ARGENTAFFINOMA)
 Carcinoid tumours arise in argentaffin tissue
(Kulchitsky cells of the crypts of Lieberkühn).
 Incidence: One in every 300–400.
 Site: Any part but frequently found in the distal
third of appendix.
 Presentation: Acute appendicitis.

46. TREATMENT
Appendicectomy
Right hemicolectomy:
1. Tumour is 2 cm or more.
2. lymph nodes are involved.