a brief discussion over appendix and it's treatment procedure.

1. Appendix
Dr. Konark Thakkar
Guide: Dr. Dhawal Sharma
Department of General Surgery

2. Objectives
• Introduction
• Surgical anatomy
• Positions
• Acute appendicitis
• Scoring systems
• Treatment (Open/Laparoscopic)
• Complications and troubles during the surgery
• Points to remember

3. Introduction
• Appendix is narrow, finger like pouch that projects out
from the colon.
• Regiland Fitz coined term appendicitis in 1886 formerly
called typhlitis.
• Charles McBurney described McBurney’s point devised
the grid iron incision in 1889.

4. Surgical Anatomy:
• Appendix is located at the terminal end of the caecum where the three
taeniae join, about 2cm below the ileocecal orifice.
• Usually, around 5-10 cm in size but can be variable.
• Diameter of appendix is 3-8 mm, diameter of lumen is 1-3 mm.
• Mucosa of appendix is lined by columnar cells with crypts.
• Submucosa contains numerous lymphatic aggregations.
• Opening of the appendix into caecum is guarded by ‘Valve of Geralch.’

5. • Mesoappendix is extension of the mesentery contains
appendicular artery, a branch of ileocolic artery.
• Often an accessory appendicular artery may be present.
• Thrombosis of these vessels leads to gangrenous
appendicitis.

6. Blood Supply
• Appendicular Artery branch of inferior division of ileocolic
artery.
• Recurrent branch supplies base of appendix and
anastomose with posterior caecal artery.
Nerve Supply
• Parasympathetic: Vagus.
• Sympathetic: T10 segments of spinal cord.
Lymphatic Drainage
• Lymphatics drain into superior mesenteric lymph
nodes via ileocolic nodes.

7. Different Anatomical Positions:
• Most common position is Retrocaecal (65%).
• Next common is Pelvic(31%).
Other sites are:
• Preileal (Anterior)- Rare (1%)
• Postileal (Posterior)- Rarest
• Paracaecal
• Subcaecal
• Subhepatic

9. Wallbridge Classification:

11. Acute appendicitis
 Aetiology:
 It is common in young males.
 It is most common in white races.
 Fibre rich diet prevents appendicitis, less fibre diet
increases chance of appendicitis.
 It is rare before the age of two, common in children and
other age groups.

12. • Obstruction of the lumen of appendix causing obstructive
appendicitis.
Blockage occurs due to- faecoliths, stricture, foreign body,
round worms etc.
Adhesions and kinking- carcinoma caecum near the base,
ileocecal Crohn’s disease.
• Distal colonic obstruction.
• Abuse of purgatives.
• Faecolith is the most common cause.

13. • Organisms:
• E.coli (85%)
• Enterococci (30%)
• Streptococci
• Anaerobic streptococci
• Cl. Welchii
*Pseudoappendicitis is appendicitis due to acute ileitis following
Yersinia infection. Its often due to Crohn’s disease.*

14. Pathogenesis
Lymphatic hyperplasia
Luminal obstruction
Increased intra-luminal pressure
Oedema, mucosal ulceration
Bacterial translocation to submucosa

15. Resolution Venous obstruction
ischemia of appendix wall
Invasion of muscularis propria, submucosa
Acute appendicitis Lump/Mucocele
Gangrenous appendicitis
Peritonitis

16. Types:
1. Simple (Catarrhal) appendicitis
2. Phlegmonous appendicitis
3. Gangrenous appendicitis
4. Perforative appendicitis

17. Simple (Catarrhal) appendicitis:
• Appendix looks normal or slightly hyperemic and swollen.
• The serous membrane presents no exudates.
• The mucous membrane may covered with be focal
hemorrhages and ulceration.

18. Phlegmonous appendicitis:
• Appendix is swollen, tense, thickened, compacted,
sometimes covered with fiber like depositions.
• Sometimes the appendix is inflated, fluctuations are
observed , inside there may be some pus and in
abdominal cavity serous, seropurulent exudate is found.

19. Gangrenous appendicitis:
• It is characterized by destructive changes of the entire
wall of the appendix.
• Appendix is thickened, earthy-grey, with purulent and
fibre like- depositions. Its’s wall is flabby and can be
easily perforated.
• Parietal peritoneum is often altered: edematous,
infiltrated, covered by fibrin.

20. Perforative appendicitis:
• The wall of the appendix is perforated in place of
necrosis. Abdominal cavity contains purulent exudate
with faecal odour.
• Perforation hole is often located near the top on the side
opposite to mesentery where blood supply is less.
• Perforation in of the appendix in young children causes
widespread peritonitis.
• Parietal peritoneum is oedematous, hyperaemic,
thickened and can be easily torn.

21. Signs and symptoms
• PAIN: It is the earliest symptom. Visceral pain starts around the
umbilicus and due to distension of appendix, few hours later, somatic
pain occurs in right iliac fossa due to irritation of parietal peritoneum
due to inflamed appendix. Called as migratory pain. Pain eventually
becomes severe diffuse which signifies spread of infection into the
general peritoneal cavity.
• VOMITING: Due to reflex pylorospasm.
*MURPHY’S TRIAD: Pain- First
Vomiting- next
Temperature- last

22. • CONSTIPATION: It is a usual feature but Diarrhoea can
occur if appendix is in pelvic position.
• URINARY FREQUENCY: inflamed appendix may come
in contact with bladder and can cause bladder irritation.
• REBOUND TENDERNESS (BLUMBERG SIGN)
• ROVSING’S SIGN: On pressing left iliac fossa ,pain
occurs in right iliac fossa which is due to shift of bowel
loops which irritates the parietal peritoneum.
• Hyperextension (in case of retrocecal appendix – Cope’s
psoas test) or internal rotation of right hip causes pain in
right iliac fossa due to irritation of psoas muscle and
obturator internus muscle respectively.

23. • Baldwing’s test is positive in retrocecal appendix –when
legs are lifted off the bed with knee extended ,the patient
complains of pain while pressing over the flanks.
• Dumphy’s Cough tenderness sign
• Per rectal examination shows tenderness in the right side
of the rectum.
• Hyperesthesia in ‘Sherren’s Triangle.’ the triangle is
formed by anterosuperior iliac spine, umbilicus, pubic
symphysis.

24. • Acute appendicitis in infancy:
Even though it is rare, when it occurs, it has got 80% chances of
perforation with high mortality.(50%)
• Acute appendicitis in children:
Here localization is not present, and so peritonitis occurs early.
It requires early surgery. Dehydration and septicaemia are common,
• In elderly:
Gangrene and perforation are common. Because of lax abdominal
wall, localization is poor and so peritonitis occurs sets in early.

25. • In pregnancy:
Incidence in pregnancy is 1 in 2000 pregnancies. It is more common in
1st and 2nd trimesters.
Appendix shift to upper abdomen. So pain is higher and more lateral.
Rebound tenderness may not be evident.
Total counts will be high with neutrophilia.
Risk of premature labour is 15%.
Foetal death in early appendicitis is 5% but it becomes 29% once
appendix perforates in pregnancy.

26. After 6 months, mortality increases by 10 times then
usual and also leads to premature labour.
Appendicitis is the most common non-gynaecological
surgical emergency during pregnancy
Incidence of perforation is highest in 3rd trimester.
Surgery is the treatment.

27. Complications of
Acute appendicitis
• Appendicular mass- presence of mass is a
contraindication for appendicectomy because it is very
difficult to remove appendix from such mass, an attempt
may result in a faecal fistula.
It is treated by Ochsner and Sherren regime.

28. Ochsner and Sherren regime:
o Aspiration with Ryle’s tube to give rest to the gut.
o Bowel care- purgatives should not be used (may cause
perforation)
oCharts- temperature, pulse, respiration, diameter of
mass. Changing in temperature and increase in size of
mass indicates an appendicular abscess.
o Drugs- Antibiotics are used.
o Exploratory laparotomy should not be done. However,
when the condition of patient is not improving, there is a
suspicion of an abscess and when doubtful of the
diagnosis, exploration is indicated.
o Fluids

29. • Perforated appendicitis-
o Incidence is 8-10%
oMore common in children and elderly patients.
o Factors which precipitate perforation are diabetes, AIDS,
faecolith.
o Pain usually localise to the right lower quadrant.
o Emergency laparotomy, appendicectomy, drainage of pus,
peritoneal lavage, antibiotics can be given.
o Mortality in this cases can be high.

30. Differential diagnosis
• Perforated duodenal ulcer
• Acute pancreatitis
• Acute typhlitis
• Acute bacterial enterocolitis
• Pelvic inflammatory diseases
• Ectopic pregnancy
• Meckel’s diverticulum
• Intussusception
• Carcinoma caecum

31. Investigations
• Total leukocyte count is increased.
• Ultrasound is done to rule out other conditions like
ureteric stone, pancreatitis, ovarian cyst, ectopic
pregnancy and also to confirm appendicular mass or
abscess.
• Laparoscopy is the most useful method.

32. Sonographic criterias for appendicitis
• This has specificity of 85%
• Noncompressible appendix of size >6 mm AP diameter,
hyperechoic thickened appendix wall >2 mm- TARGET
SIGN.
• Appendicolith
• Interruption of submucosal continuity.
• Periappendicular fluid.

33. Contrast CT Scan:
• It is very useful when the diagnosis is difficult especially in old
people.
• It has 95% sensitivity and specificity with 95% of accuracy.
• Dirty fat thickened mesoappendix, appendicular faecolith and
thickened caecum funnelling contrast into the orifice of appendix as
arrowhead sign.

34. C reactive protein, even though non specific increases in
acute phase.
MRI is very useful tool in pregnancy.
Plain X-ray is useful to rule out
intestinal obstruction, ureteric stone.

35. Different scoring systems used
Alvarado scoring for appendicitis (1986):
• Migrating Pain- 1
• Anorexia- 1
• Nausea and vomiting- 1
• Tenderness in right iliac fossa- 2
• Rebound tenderness- 1
• Elevated temperature- 1
• Leucocytosis with count more then 10,000- 2
• Shift to left with neutrophilia in peripheral smear- 1
TOTAL:10

36. • Score less then 5- Not sure.
• Score between 5-6: Compatible.
• Score between 6-9: Probable.
• Score more then 9: Confirmed.

37. Tzanakis scoring system 2005-
• lower abdominal tenderness-4
• Rebound tenderness-3
• Total count > 12,000/cm-2
• USG features-6

38. Treatment
Surgical appendectomy: (one of the most common surgical
operation)
• Approaches:
1. Gridiron incision: incision is placed perpendicular to
the right spinoumblical line at the McBurney’s point (at the
junction of lateral 1/3rd and medial 2/3rd of the
spinoumbilical line).
2. Rutherford Morison's muscle incision
3. Lanz crease incision centering at McBurney’s point-
Cosmetically better.
4. Right lower paramedian incision/lower midline incision
when in doubt or when there is diffuse peritonitis.
5. Laparoscopic approach becoming popular and better.

41. Procedure
• Under general anaesthesia, skin is incised. Two layers of
superficial fascia are cut.
• External oblique aponeurosis is opened in the line of
incision.
• Internal oblique and transverse muscles are split in the
line of fibres.
• Peritoneum is opened in the line of incision.
• Caecum is identified by taeniae, and ileocecal junction.
Omentum when adherent is separated. Appendix is held
with Babcock's forceps.
• Mesoappendix with appendicular artery is ligated.
• Using thread or silk, a purse- string suture is placed
around the base of the appendix.

42. • Base of the appendix is crushed with artery forceps and
transfixed using vicryl (absorbable).
• Appendix is cut distal to the suture ligature and removed.
Stump is cleaned with antiseptics.
• Purse string suture is tightened so as to bury the stump.
• In difficult cases- Retrograde appendectomy can be done.
In presence of pus or burst appendix, the peritoneal
cavity is drained.
• Postoperatively, IV fluids, antibiotics are given. Once
bowel sounds are heard, oral diet is started.

43. Complications of Open
Appendicectomy
• Paralytic ileus
• Residual abscess
• Haemorrhage
• Portal pyaemia
• Adhesions and intestinal obstruction
• Right inguinal hernia
• Wound sepsis10%
• Faecal fistula

44. Laparoscopic Appendicectomy
Indications:
o All kinds of appendicitis including appendicular abscess.
oSpecially suitable for obese patients and females of
reproductive age group.

45. Advantages:
• Less operative trauma.
• Early mobilization and return to work.
• Associated pathologies can be detected specially in
females of reproductive age group.
• Specially beneficial for obese patients which obviates the
necessity of large incisions.
• Cosmetically better acceptable.

46. Contraindications:
• Patients with coagulopathy and cardio-respiratory
instability.
• Presence of severe distension may result in enterotomy
during trocar incision.
• Extensive adhesions due to previous pelvic surgery.

47. Equipments:
• Standard laparoscopic video system.
• CO2 insufflator
• 10mm trocar-2
• 5mm trocar-1
• Atraumatic grasper, like Babcock’s forceps
• Maryland’s dissector
• Bipolar forceps/ Harmonic scalpel

48. Technique:
• Anaesthesia: General Anaesthesia
• Ports- 1. Infra-umbilical 10mm for telescope
2. Right iliac fossa 10mm/5mm port
3. Left iliac fossa 5mm port
• Position of OT table- Trendlenberg/Right up
• Position of surgeon and camera assistant- Left side and
2nd assistant on right side
• Video monitor on right side
• Urinary bladder should be evacuated before trocar
insertion

49. Steps:
• Sub-umbilical port 10mm, insertion of Veress needle and
creation of pneumoperitoneum.
• Intra-abdominal pressure 12mm/Hg.
• First diagnostic laparoscopy starting from Right iliac
fossa and inspect all four quadrants.
• Visualise uterus and adnexa.
• Identify caecum, trace taenia coli to the base of appendix.
• Hold appendix with atraumatic grasper and lift up.
• Bipolar cauterization of mesoappendix up to the base of
appendix.

50. • Ligation of the base with Roeders knot, 2 knots
proximally and other knot, 1cm distally.
• Incise appendicular wall partially in between proximal
and distal sutures, suck out the purulent contents of
faecoliths.
• Resect the appendix, bipolar cautery of the stamp.
• Irrigate if necessary and do toileting.
• Removal of resected appendix through 10mm port.
• Give drain if necessary through right iliac fossa port.
• Closure of ports.

51. Complications:
• Bleeding-managed by bipolar cautery.
• Spillage of appendiceal contents-managed by through
toileting and putting drain.

52. Newer techniques:
• Single port lap appendectomy
• NOTES (Natural Orifice Transluminal Endoscopic
Surgery)

53. Troubles in Appendicectomy
• During appendicectomy if appendix is found normal,
other causes for symptoms should always be looked for
Meckel’s diverticulum, Crohn’s disease, ovarian/pelvic
causes in females, malignancy, etc.
• Appendicular tumour may be found. If it is in the tip,
appendicectomy is sufficient. It could be carcinoid
tumour. If it is in the base right hemicolectomy is done.
• Absence of appendix- a rare occasion can occur. Caecum
and taeniae should be traced properly before finalising it.
• Appendicular abscess/pelvic abscess formation.
• Malignancy in the caecum is identified on table- Right
hemicolectomy should be done.

54. Points to remember:

55. References:
• Short practice of Surgery- Baily and Love
• SRB’s Manual of Surgery
• Manipal Manual of Surgery
• https://pubmed.ncbi.nlm.nih.gov/10800305/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3555584

56. THANK YOU!