APPENDIX
EPIDEMIOLOGY ● Most common surgical
emergency.
● Lifetime Risk - 7-8 %
● Peak : 10 - 30 years
● Delay increases morbidity
ANATOMY
Most common position
is retrocecal.
APPENDICITIS ● Luminal Obstruction : Fecolith
or Lymphoid Hyperplasia
ETIOPATHOGENESIS
● Parasites, Tumors, Foreign
bodies
● Obstruction leads to increased
pressure which in turn leads to
further ischemia resulting in
infection
CLINICAL ● ABDOMINAL PAIN
FEATURES Vague, colicky central
abdominal pain
Localising to RIF and
becomes constant
● Accompanied by LOW GRADE
FEVER
● NAUSEA
● VOMITING
● ANOREXIA
The position of appendix varies
and can result in different
symptoms
Eg. Pelvic appendix can cause
urinary symptoms and diarrhea
ON EXAMINATION General Signs of Sepsis
Low grade pyrexia initially which
may spike upto 38-39 degree
Celcius in the presence of
perforation or abscess formation
There may be tachycardia, flushing
and evidence of dehydration
PAIN IRRADIATION If pelvic localisation - Perineal pain
ON BASIS OF
POSITION OF If retroperitoneal localisation - Pain
in the right lumbar region
APPENDIX
If retrocecal localisation - Pain in
Right Hypochondrium
If median localisation - Pain in
mesogastrium
ABDOMINAL Tenderness over McBurney’s
EXAMINATION point
There may also be signs of
peritoneal inflammation
including: guarding, tenderness
on percussion and pain on
coughing or other movements
● ROVSING SIGN : Pain is felt in
Signs of generalised RIF when pressure applied to
peritonitis may LIF
develop as the illness ● PSOAS SIGN : The patient
keep his/her hip in flexion to
progresses with
relieve his/her pain.
abdominal rigidity. ● OBTURATOR TEST
● BLUMBERG SIGN
● HEEL DROP TEST
● PR examination may reveal
tenderness anterolaterally on
the right
DIAGNOSIS 1. Clinical Diagnosis
2. CBC : Leucocytosis
3. Urinalysis : to rule out UTI
4. UPT : to rule out pregnancy
5. ULTRASONOGRAPHY
6. CT SCAN
7. DIAGNOSTIC LAPAROSCOPY
allows immediate treatment
if appendicitis is confirmed
ALVARADO
SCORING
INTERPRETATION
INDICATIONS OF ● ACUTE APPENDICITIS
● RECURRENT APPENDICITIS
APPENDICECTOMY ● MUCOCELE OF APPENDIX
● CARCINOMA
SURGICAL Usually performed in children
APPROACHES : A LANZ INCISION is used for the
best cosmetic result
1. LANZ CREASE If the appendix is found to be
INCISION perforated or gangrenous, then
peritoneal lavage is performed to
remove pus or contamination
Most patients can be discharged
on POD 2 or 3
2. GRID IRON Incision placed perpendicular to
right spino umbilical line at
INCISION mcburney’s point
3. RUTHERFORD Muscle cutting incision : Muscles
are cut upwards and laterally.
MORRISON
INCISION
4. LAPAROSCOPIC Improves diagnostic accuracy and
minimises negative
APPENDICECTOMY appendicectomy.
● Under general anaesthesia, skin is incised. Two layers of
superficial fascia are cut. External oblique aponeurosis
Procedure 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 ileocaecal junction.
● Omentum when adherent is separated.
● Appendix is held with Babcock’s forceps.
● Meso appendix with appendicular artery is ligated.
● Using thread or silk, a purse—string suture is placed
around the base of the appendix.
● 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 appendicectomy can be
done.
COMPLICATIONS ●
●
Paralytic ileus
Reactionary haemorrhage due to
slipping of ligature of the
appendicular artery
● Residual abscess (pelvic, paracolic,
local, sub diaphragmatic)
● Pylephlebitis (portal pyaemia)
● Adhesions, kinking and intestinal
obstruction
● Right inguinal hernia (direct)—due to
injury to ilioinguinal nerve
● Wound sepsis 10%
● Faecal fistula
● Respiratory problems and DVT
● Localisation of infection after 3-5 days after
acute appendicitis.
APPENDICULAR ● Inflamed appendix, greater omentum,
ceacum, parietal peritoneum and dilated
MASS ●
ileum form a mass in RIF.
Mass is tender , smooth, well localised, not
mobile = , resonant on percussion.
● TLC increased
● USG confirms the mass
● Treatment is conservative
● OCHSNER SHERREN regimen- Monitor
temp, BP, pulse. Give antibiotics, IV fluid,
analgesics
90 percent patients respond to conservative
therapy
Patient discharged and asked to come for
interval appendectomy after six weeks
APPENDICULAR Commonly occurs in retroceacal region but
often can occur in subceacal, pre ileal, lumbar
ABSCESS or post ileal region.
High fever, tender, smooth, soft swelling in RIF
with clear upper margin but indistinct lower
margin
Treatment:
● Antibiotics
● CT guided aspiration or catheter drainage
● Interval appendicectomy after 3 months
A type of retention cyst
MUCOCELE OF Infection can lead to EMPYEMA of appendix
APPENDIX
Rupture of mucocele can lead to PSEUDOMYXOMA
PERITONEI
Jelly like mucoid yellowish-brown substance accumulates
in
peritoneal cavity
❏ Due to ruptured adenocarcinoma
appendix/mucocele or mucinous carcinoma of
ovary
❏ Common in females
❏ Painless progressive distension of abdomen with
intestinal obstruction occurs eventually
❏ Shifting dullness is absent
❏ Surgical debulking, oophorectomy, appendicectomy,
omentectomy are often done
❏ Chemotherapy is useful—cisplatin
❏ Carries poor prognosis
NEOPLASM OF 1.CYSTIC NEOPLASM
APPENDIX 2.CARCINOID TUMOR (MCC)
3.PRIMARY ADENOCARCINOMA OF
APPENDIX
Can be mucinious or colonic.
Mucinious type can rupture into the
peritoneal cavity and can cause
pseudomyxoma perotonei
DHANWAD
