1. Dr Anil Kumar Assistant Professor Department of Surgical Disciplines. All India Institute of Medical Sciences, Patna Email: dranil4@gmail.com 2. Objective History Anatomy & Anomaly Acute Appendicitis(Causes, Pathology, C/F, Inv & M/n) D/D of Acute Appendicitis Appendicular Lump & malignancy ( Carcinoid tumor) Appendectomy & Complications 3. History In 1492,Leonardo da Vinci first depicted the appendix in anatomic drawings In 1521, Jacopo Beregari da Capri, a professor of anatomy in Bologna, identified the appendix as an anatomic structure. In 1710, Phillipe Verheyen coined the term appendix vermiformis. The first recorded successful appendectomy was in 1735 by Claudius Amyand Kurt Semm, ( German gynecologist) did first laparoscopic appendectomy on May 30, 1980. 4. Anatomy 5. Position of the Appendix 6. Position of Appendix Position Incidence Retrocecal 74% Commonest postion Pelvic 21% 2nd Commonest position Pre-ileal 1% Post- ileal 0.5% Paracaecal 2% Promontoric( Subileal /subcaecal) 1.5% 7. In Situs Inversus Viscerum: Appendix in LIF 8. Size of the Appendix Range : 2- 20 cm Average: 11 cm Diameter: 7-8 mm 9. The longest appendix measured 26cm, Safranco August (Croatia) Zagreb, Croatia, on 26 August 2006. 10. Anatomy: Origin Postero-medial wall of the caecum ( 2 cm below the ileocaecal orifice) Appendicular orifice: Guarded by an indistinct semilunar fold of mucous membrane k/as Valve of Gerlach. Mesoappendix: peritoneum lower surface of the mesentery of the terminal ileum. 11. Appendicular Artery- Lower Division of Ileo-colic artery 12. Appendicular artery in mesoappendix 13. Thrombosis of Appendicular artery(as it is an end artery) - Gangrenous appendicitis 14. Venous Drainage & Nerve Supply Appendicular Vein Ileocolic vein Portal Vein Superior Mesenteric vein Sympathetic Nerves- Derived 4m T9-T10 ( Celiac Plexus) Para Sympathetic Nerves- Vagus 15. Lymphatic & KULTSCHITZSKY Cells 8-15 lymphatic vessels - mesoappendix Ileocolic Node ( Sup & Inf group) Ileocolic Nodes SMN Celiac nodes In the base of the crypts lie argentaffin cells (Kultschitzsky cells) which may give rise to carcinoid tumours . The submucosa contains numerous lymphatic aggregations or follicles. 16. Wallbridge Anomaly: A,B1,B2,C 17. Wallbridge Anomaly 1. Type A anomaly. Single cecum and a partial duplication of the appendix with a single base. 2. Type B1 anomaly. Two completely separate appendices arise from a single cecum. 3. Type B2 anomaly. The second appendix is usually found arising from the taenia coli of the wall of the cecum. 4. Type C anomaly. Double cecum, each with its own appendix, 18. Predisposing Factors:Appendicitis Age: 20-30 years( peack incidence in early 20s) Socio-economic condition: High profile( Low fibre) Lymphoid hyperplasia of the appendix Fibrosis of the appendix cos of previous damage 19. Causes of appendicitis: Obstructive causes- faecolith or stricture Bacterial proliferation : mixed growth commonest is streptococci & E.Coli. Intestinal parasites Oxyuris Vermicularis(pin worm) Tumour( Ca of the Caecum) in elderly & middle age. Fibrotic stricture of the appendix 20. Composition of Faecolith: Bacteria Calcium phosphate Epithelial Debris Inspissated fecal material Foreign bodies ( Rarely) 21. Pathology: Obstructive & Non obstructive Obstructive- Primarily - Acute appendicitis - Gangrenous appendicitis - Phlegmonous mass/paracaecal abscess - Mucocele of the appendix - Rupture of appendix 22. Obstruction: Mucus + Inflammatory exudation Increases intraluminal P Obstructing lymphatic drainage Edema+ M.Ulceration+ Bacterial Translocation to the submuosa. Venous obstruction( cos of further distension) Ischemia Bacterial Invasion Acute Append. 23. Inflamed Appendix 24. Perforation- If Fever > 102*F & WBC> 18,000 If Ischemia continue Necrosis of the appendicular wall Gangrenous appendicitis Perforation with free bacterial contamination of the peritoneal cavity 25. Gangrenous appendix. 26. Phlegmonous Mass/Paracaecal abscess Greater omentum & loops of small bowel become adherent to the inflamed appendix Walling off the spread of peritoneal contamination Phlegmonous Mass / Paracaecal abscess 27. Phlegmonous appendicitis 28. Appendicular inflammation- resolves- distended mucus filled organ- Mucocele of appendix 29. Peritonitis ??? If perforation?? Extreme of Age Immunosuppression Diabetes Mellitus Faecolith obstruction Pelvic appendix Previous Abdominal surgery 30. C/F- Symptoms PAIN: Initially Periumbilical region ( midgut visceral discomfort) in response to A.I & obstruction. :Pain shift to right iliac fossa : Parietal peritoneum irritated and inflamed. ANOREXIA NAUSEA/VOMITTING 31. Clinical Sign Pyrexia: Low grade after 6 hours Tenderness (localized) in the RIF Muscle guarding Rebound Tenderness/ BLUMBERGS Sign Foul breath. Tachycardia: Perforation, Gangrene & Peritonitis 32. Sign to elicit in Appendicitis 33. Rovsings Sign 34. Psoas Sign 35. Obturator Sign: 36. Obturator Sign 37. Dunphys Sign: Any movement ( Coughing) causes Pain. 38. Hyperesthesia in Sherrens 39. Localized tenderness at Mc Burneys Point 40. Mc Burneys Point -Tenderness 41. Investigation: TLC- Raised: 10000 to 18000 ( Neutrophils >75%). If TLC >18000 perforation. Abdominal X-Ray: TRO I.O, U.Colic etc. USG: Especially if clinical Dx is equivocal. CT: Especially in Adult patient with equivocal history , physical examination & lab findings. Pregnancy test: In reproductive age group 42. ALVARADO SCORING SYSTEM SYMPTOMS SCORE Migratory RIF Pain 1 Anorexia 1 Nausea/Vomiting 1 SIGN Tenderness in RIF 2 Rebound tenderness in RIF 1 Elevated Temperature 1 Laboratory Findings Leucocytosis 2 Shift to the left of neutrophils 1 Total 10 43. Interpretation of ALVARADO Score. Aggregates score 7-10 Strongly predictive of Appendicitis Aggregates score 5-6 Equivocal CT & USG helpful in making Dx. Aggregates score 1-4 Appendicitis can be ruled out 44. Treatment of Acute Appendicitis Absolute bed rest & NPO IV Fluids Supplements. Analgesics( Pethidine) Antibiotics( Ofloxacine + Orinidazole) Appendectomy ( within 24 hours ASAP) 45. Indications of Appendectomy Acute Appendicitis Recurrent Appendicitis Mucocele of Appendix Carcinoma confined to the mucosa. 46. Incision in Appendectomy. Gridiron and lanz incisions : Muscle-splitting incisions .They differ in the orientation of the skin incision alone. BIKNI INCISION: Modified Lanze incision slightly lower Rutherford Morison : The gridiron incision can be more readily extended laterally into an oblique, curvilinear muscle-cutting incision: 47. Grid-iron/ Lanze & Modified Lanze: GridIron LanzeIncision ModifiedLanze 48. Muscles splitting & Cut the Peritoneum 49. Follow the taneia coli to reach upto the appendix 50. Appendicular artery in the Mesoappendix 51. Identified the base of the appendix to Ligate 52. Ligate the base of the appendix. 53. After crushing the base, cut the appendix 54. Z-Suture to invaginate the stump 55. Invaginating the stump 56. Buried Appendicular stump 57. Remember the steps in Appendectomy Pre-Op( NPO, Shaving, consent, PAC, Draping) Incision- Grid-iron , Rutherford Incision, Bikney Incision) Follow the taenia coli to find the appendix Ligate the Appendicular artery in mesoappendix Crush the base of the appendix 58. Appendectomy Ligate the base of the appendix( absorbable suture) Appendix is divided distal to the ligature. Clean the stump with betadine Take purse string around the caecal wall to buried the stump. Close the wound in layers. 59. Methods in special situation When the cecal wall is edematous & Inflamed: Purse string is not recommended When the base of the appendix is inflamed: Base is not crushed . Appendix is ligated close to the caecum, after which it is amputed and the stump is being invaginated If the base of the appendix is gangrenous: It is neither ligated nor crushed. 2 stiches are placed through the caecal wall. Take the appendix out. Close the wound . 60. Complication of Appendectomy Wound Infection Intra-abdominal abscess Ileus Respiratory complication like pneumonia DVT & Embolism Portal Pyemia Adhesive Intestinal Obstruction Fecal Fistula Ritchers Hernia 61. Appendicular Lump 62. Appendicular Lump- on 3rd day. Appendix Edematous Caecum Terminal Ileum Omentum ( Greater Omentum) Loop of Intestine Ascending Colon Adjacent Peritoneum 63. Presentation of Appendicular Lump Usually on 3rd day of attack of appendicitis. Lump in RIF Rigidity over the lump Tenderness Fever/ Increase pulse. 64. Appendicular Lump- Dont Operate Severe adhesion/ Difficult to separate the part. Bloody and dangerous to operate Chance of Fecal fistula Max chance of iatrogenic injury 65. OCHSNER- SHERREN REGIMEN. Ist mark the size of the swelling for further assessment NPO & IV Fluid supplements Antibiotics, Analgesics Temp, Pulse( 4 hourly) & Fluid record charting . Allow oral liquid on subsequent days. 66. OCHSNER- SHERREN REGIMEN If more vomiting- antiemetic &/+ PPI If size of the lump decreases continue the same. After 6-8 weeks = Interval Appendectomy Prognosis: 90% success rate for this regimen. Failure to this regimen: suspect Crohns & Ca???? 67. When to stop conservative t/t in Lump CRITERIA FOR STOPPAGE OF CONSERVATIVE TREATMENT IN APPEDICULAR LUMP RISING PULSE RATE RISING TEMPERATURE INCREASING or SPREADING ABDOMINAL PAIN INCREASING SIZE OF MASS VOMITING or COPIOUS GASTRIC ASPIRATE 68. D/D of Appendicular Lump Hypertrophic Ileo- caecal Tuberculosis Carcinoma of the Caecum Crohns Disease Actinomycosis Twisted ovarian cyst in female Right sided iliac lymphadenitis Parametritis 69. Appendicular Malignancy Mucinous Adenocarcinoma - MC neoplasm of appendix 38% Adenocarcinoma 26% Carcinoid Tumour 17% Goblet Cell Carcinoma 15% Signet ring cell carcinoma 4% 70. Carcinoid tumor of Appendix Neuroendocrine tumor Origin- Argentaffin cells ( KULCHITSKY Cells of crypts of Lieberkuhn) Contains sustentacular cells that express S-100 MC Site: distal third i.e tip of the appendix 71. T/T 4 Carcinoid tumor of Appendix TOC- Appendectomy Right hemicolectomy is indicated when- - Tumor is > 2 cm in size. - Involves the base of the appendix. - Involves the caecal wall or mesoappendix. - Lymph nodes are involved. 72. D/D of Acute Appendicitis: In Adult In Female Terminal Ileitis Ruptured Ectopic Pregnancy Ureteric colic Torsion/Rupture of an Ovarian cyst Right sided pyelonephritis Salpingitis( Right sided) Perforated peptic ulcer Endometriosis Torsion of Testes Mittelschmerz ( Painful Ovulation) Acute Pancreatitis Rectus Sheath Hematoma 73. D/D of Acute Appendicitis: In Children In Elderly Gastroenteritis Sigmoid diverticulitis Meckeles Diverticultitis Intestinal obstruction Intussusception Carcinoma of the caecum Lobar Pneumonia Henoch- shchonlein Purpura Mesenteric adenitits 74. Home Message Appendicitis is common surgical emergency in 20-30 years age group Commonest cause is Faecolith Pain in RIF, N/V, Anorexia with findings of Tenderness in RIF, increase temp & Leucocytosis usually confirm the Dx Appendectomy should be performed ASAP 75. Home Message Ochsner- sherren regimen is the gold standard t/t for Appendicular lump Interval Appendectomy after 4-6 weeks is the preferred Surgical steps in Appendicular Lump Commonest site 4 Carcinoid tumor is the tip of the Appendix Appendectomy is the TOC for Carcinoid tumor of appendix