Appendicitis

Anatomy

Appendix located in the region of the right

iliaca. Basic appendix is located at 1/3 on
the line connecting the anterior superior
spina iliaca the umbilicus (McBurney's point)
and the base of the appendix vermiformis
inward more than a point on the boundary
between the third and two-thirds of the
medial lateral oblique lines between spina
iliaca anterior superior and umbilical
annulus (McBurney's point). The position of
the free end of the appendix are very
different. Vermiformis appendix layout
varies, but usually appendix vermiformis
located retrosekal but often also found in
other positions.

Source: Bailey & Loves Short Practice of Surgery 25th

Various positions of the appendix:

1.
2.
3.
4.
5.
6.

Appendix
Appendix
Appendix
Appendix
Appendix
Appendix

Retrocaecalis
Retroilealis
Pelvicum
Epiploika
Subsekal
Pre-ileal

Source: Bailey & Loves Short Practice of Surgery 25th

Definition:
An inflammation of the vermiform appendix

Aetiology:

No unifying hypothesis
Decreased dietary fibre and increased consumption of

refined carbohydrates
Obstruction of the appendix lumen
Fecolith (composed of inspissated faecal material,
calcium phosphates, bacteria, epithelial debris, rarely
a foreign body)
Tumour (carcinoma of caecum)
Intestinal parasites (Oxyuris/Enterobius vermicularis
pinworm)
Source: Bailey & Loves Short Practice of Surgery 25th

PATHOPHYSIOLOGY

Risk Factors for Perforation of The Appendix

Source: Bailey & Loves Short Practice of Surgery 25th

Clinical Manifestations

Source: Bailey & Loves Short Practice of Surgery 25th

Special Features Based On

Appendix Locations

Source: Bailey & Loves Short Practice of Surgery 25th

Differential Diagnosis

Source: Bailey & Loves Short Practice of Surgery 25th

Investigation

Source: Bailey & Loves Short Practice of Surgery 25th

Diagnostic Scoring

Diagnosis is essentially clinical;

HOWEVER a decision to operate based on clinical
suspicion only can lead to the removal of a
normal appendix.
A number of clinical and laboratory-based scoring
systems have been devised to assist diagnosis.
The most widely used isAlvarado score.

Source: Bailey & Loves Short Practice of Surgery 25th

The Alvarado (MANTRELS)

Score
Score
Symptoms
Migratory RIF pain
Anorexia
Nausea and vomiting

1
1
1

Signs
Tenderness (RIF)
Rebound tenderness
Elevated temperature

2
1
1

Laboratory
Leucocytosis
Shift to the left (segmented neutrophils)

2
1

TOTAL

10

0 4 : Extemely unlike
5 6 : Compatible with , but not diagnostic of
appendicitis
7 - 8 : Have a like hood of appendicitis
9 10 : Almost certain to have appendicitis , should go to
Source: Bailey & Loves Short Practice of Surgery 25
the operating

th

CT Scan images of Appendicitis:

1. enlarged appendix

2. appendiceal wall
thickening

Source:Choi D, Park H, Lee YR, Kook SH, Kim SK, Kwag HJ, Chung EC. The most useful findings for diagnosing acute
appendicitis on contrast-enhanced helical CT. Acta Radiologica 44 (2003) 574-582.

CT Scan images of Appendicitis

3. appendicolith

4.periappendiceal fat
stranding

Source:Choi D, Park H, Lee YR, Kook SH, Kim SK, Kwag HJ, Chung EC. The most useful findings for diagnosing acute
appendicitis on contrast-enhanced helical CT. Acta Radiologica 44 (2003) 574-582.

Treatment
Intravenous fluids

to establish adequate urine output

Reduces the incidence of postoperative wound infection

Appropriate antibiotics
When peritonitis is suspected, therapeutic intravenous antibiotics to
cover Gram-negative bacilli as well as anaerobic cocci should be given

Salicylates
Appendicectomy

Source: Bailey & Loves Short Practice of Surgery 25th

Appendicectomy

Conventional Appendicectomy
Laparoscopic Appendicectomy

Source: Bailey & Loves Short Practice of Surgery 25th

Conventional Appendicectomy

1/3

2/3

Gridiron incision : right

angles to a line joining
the ASIS to the
umbilicus. Centred on
McBurneys point

2 cm

Lanz incision : 2 cm
below the umbilicus
centred on the midclavicular-midinguinal
line

Conventional Appendicectomy
Caecum is identified
Base of mesoappendix is clamped in artery forceps, divided, and ligated
The freed appendix is crushed near its junction with the caecum in artery

forceps, which is removed and reapplied just distal to the crushed portion
An absorbable ligature is tied around the crushed portion close to the
caecum
The appendix is amputated between the artery forceps and the ligature
An absorbable purse-string or Z suture may then be inserted into the
caecum about 1.25 cm from the base
The stump of the appendix is invaginated while the purse-string or Z suture
is tied, thus burying the appendix stump

Source: Bailey & Loves Short Practice of Surgery 25th

Source: Bailey & Loves Short Practice of Surgery 25th

Laparoscopic appendicectomy
The placement of operating ports may vary according to operator preference

and previous abdominal scars.

The operator stands to the patients left and faces a video monitor placed at
the patients right foot.
A moderate Trendelenburg tilt of the operating table
The appendix is identify & controlled using a laparoscopic tissue-holding
forceps.
By elevating the appendix, the mesoappendix is displayed
A dissecting forceps is used to create a window in the mesoappendix to allow
the appendicular vessels to be coagulated or ligated using a clip applicator.
The appendix, free of its mesentery, can be ligated at its base with an
absorbable loop ligature,divided, & removed through one of the operating
ports.
It is not usual to invert the stump of the appendix
A single absorbable suture is used to close the linea alba at the umbilicus, and
the small skin incisions may be closed with subcuticular sutures.
Patients who undergo laparoscopic appendicectomy are likely to have less
postoperative pain & to be discharged from hospital and return to activities of
daily living sooner than those who have undergone open appendicectomy.
Source: Bailey & Loves Short Practice of Surgery 25th

Source: Bailey & Loves Short Practice of Surgery 25th

Problems Encountered During

Appendicectomy
Problems

Management

A normal appendix is found

Demands careful exclusion of other

possible diagnosis
Remove the appendix to avoid future
diagnostic difficulties

The appendix cannot be

found

Caecum should be mobilised, and the

taeniae coli should be traced to their
confluence on the caecum before the
diagnosis of absent appendix is made

An appendicular tumour is
found

Small tumours (< 2.0 cm in diameter)

can be removed by appendicectomy
Larger tumours should be treated by a
right hemicolectomy

An appendix abscess is found Should be treated by local peritoneal

and the appendix cannot be
toilet, drainage of an abscess and
removed easily
intravenous antibiotics
Source: Bailey & Loves Short Practice of Surgery 25th

Appendix mass
If an appendix mass is present & the condition of the patient is

satisfactory, the standard treatment is the conservative

Careful recording of the patients condition and the extent of
the mass should be made and the abdomen regularly reexamined.

mark the limits of the mass using a skin pencil.

Temperature and pulse rate should be recorded 4- hourly and

a fluid balance record maintained

A contrast-enhanced CT examination of the abdomen should
be performed and antibiotic therapy instigated.
An abscess, if present, should be drained radiologically.
Clinical deterioration or evidence of peritonitis is an indication
for early laparotomy.
Clinical improvement is usually evident within 2448 hours
Source: Bailey & Loves Short Practice of Surgery 25th

Criteria for stopping conservative

treatment of an appendix mass
A rising pulse rate
Increasing or spreading abdominal pain
Increasing size of the mass

Source: Bailey & Loves Short Practice of Surgery 25th

Postoperative Complications
Wound infection
Intra-abdominal abscess
Adhesive intestinal obstruction
Rare

Ileus
Respiratory pneumonitis or collapse
Venous thrombosis and embolism
Portal pyaemia (pylephlebitis)
Faecal fistula

Source: Bailey & Loves Short Practice of Surgery 25th

Other causes of acute

appendicitis

Recurrent Acute Appendicitis

Neoplasms of the Appendix

Recurrent Acute Appendicitis

Widely known but unfavourable
Not uncommon for patients to attribute such

attacks to biliousness or dyspepsia

Attacks vary in intensity and may occur every few
months
Through history, patient might have had milder but
similar attacks of pain showing fibrotic appendix
indicative of previous inflammation
Chronic appendicitis, per se, does not exist;
however, there is evidence of altered neuroimmune
function in the myenteric nerves of patients with so
called recurrent appendicitis (Bchler)
Source: Bailey & Loves Short Practice of Surgery 25th

Excised appendix showing the point

of luminal
obstruction with distal fibrosis

Source: Bailey & Loves Short Practice of Surgery 25th

Neoplasms Of The Appendix

Source: Bailey & Loves Short Practice of Surgery 25th

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