Acute Appendicitis- Appendicectomy- Open & Laparoscopic.pdf

This is a small handbook on individual surgical disease and its management . I have discussed about Acute Appendicitis and then step by step I explain both open and laparoscopic appendicectomy in this book.
The operative surgery part is very useful for surgical trainees.

2. AcuteAppendicitis/Appendicectomy-Open And
Laparoscopic-StepByStep
Prof.Dr.Selvaraj
Surgical Educator

3. TABLEOFCONTENTS
1.Tableofcontents
2.Preface
3.AcuteAppendicitis
4.OpenAppendicectomy
5.Laparoscopicappendicectomy
6.References

4. PREFACE
InthisseriesofE-books,Iwillbediscussingthecommonsurgicalproblemsand
theiroperativemanagement.
InthisE-bookIdiscussaboutacuteappendicitisanditsmanagementbothopenand
laparoscopicappendicectomy-acomprehensivereviewofAppendicularpathologies.
Idiscussaboutacuteappendicitisfirstandthenwilldiscussabouthowtodobothopen
andlaparoscopicappendicectomystepbystep.
Iwillbeusinglotofpicturestodemonstratethevariousstepsofthesurgeryandyouwill
haveafeelasifwatchinganoperativesurgeryatlas.Youcanalsoviewmyembedded
YouTubevideoshereinthisbookitselfwithoutleavingforYouTube.
Irequestallsurgicaltraineesandmedicalstudentstomentallyrehearsethevarioussteps
oftheseoperativeproceduresthedaybeforeyouaregoingtodothesurgerysothatyou
candevelopthemuch-neededconfidencetodothesurgerysuccessfully.
Prof.Dr.Selvaraj-(Surgical Educator)
WWW.surgicaleducator.com

5. Acuteappendicitis-LearningOutcomes
✓CausesofRLQPain
✓Etiology
✓Pathology
✓Clinicalfeatures-Symptoms&Signs
✓Investigations
✓Scoring system
✓Treatment
✓Complications
✓Mind map
✓Algorithm for RLQ Pain
✓Treatment Algorithm for Acute
Appendicitis

6. CausesofAcuterightlowerquadrantpain
Inadultfemales Inadultmales InPediatricage
Acuteappendicitis Acuteappendicitis Acuteappendicitis
Twistedovariancyst Righturetericcalculus Meckel’sdiverticulitis
Ectopicpregnancy Crohn’sinterminalileumIntussusception
Endometriosis Cecaldiverticulitis Mesentericlymphadenitis
Pelvicinflammatory
disease
Valentinoappendicitis
AcuteCholecystitis
AcutePancreatitis
Tubo-ovarianpathologyInferiorwallMI

7. AcuteAppendicitis-Etiology
1.Obstructive:
✓Fecolith
✓Worms-EnterobiousVermicularis
✓LymphoidHyperplasiain
Children
2.Non-Obstructive:
✓Catarrhal-infection

8. AcuteAppendicitis-Pathology

9. Acute Appendicitis-Symptoms
Murphy’s Triad
✓PaininRLQ
✓Vomiting/Nausea
✓Fever-lowgraded

10. Acute Appendicitis-Signs
✓RIFTendernessinMcBurny’spoint
✓RIFReboundTenderness,Releasetenderness
orBlumberg’sSign
✓Guarding/Rigidity/Cope’sPsoasTest
✓Cope’sObturatorTest,
✓Rovsing’sSign,
✓HyperasthesiainSherren’sTriangle

11. Acute appendicitis–Investigations
Labinvestigations:
1.TotalWBCandDifferentialcounts
2.C-ReactiveProtein-CRP
2.Urine-FEMEifpositiveforC&S
3.B-HCGtoR/Opregnancy
Imagingstudies:
1.CXR-ErectorAXRincludingbothsidediaphragmtoR/O
Pneumoperitoneum
2.USG-ToR/Oanyotherpathologyinwomenofchildbearingagegroup
3.USG-ToconfirmAppendicitis
4.CECTabdomen

12. Acute Appendicitis-USG Abdomen

13. Acute Appendicitis-CECT

14. AcuteAppendicitis-Alvarado’sScoring
✓Nemonic-MANTRELS
✓Score<4-discharge
patient
✓Score>8-Surgery
✓Score4to7-Admit
andobserve

15. AcuteAppendicitis-Treatment
✓IfsimpleAppendicitis→Open/Lap
Appendicectomy
✓IfPerforatedAppendicitis→
ExploratoryLaparotomy,
Appendicectomy&Peritoneal
toileting
✓IfAppendicularAbscess<5cms→USG
guidedNeedleaspirationor
tubedrain.If>5cms→Opendrain
✓IfAppendicularLump:
-Ochsner-SherrenRegimenofConservative
treatment
-NPO&IVF
-IVbroadspectrumAntibiotics
-Analgesics&Anti-inflammatorydrugs
-VitalSignsQ2H

16. AcuteAppendicitis-Treatment

17. Acuteappendicitis-Complications

18. Acuteappendicitis-MindMap

19. AcuteRLQPain-TreatmentAlgorithm

20. AcuteAppendicitis-TreatmentAlgorithm

21. AcuteAppendicitis-MyEmbeddedYouTubeVideo
You can watch my YouTube video on Acute Appendicitis here.
https://www.youtube.com/watch?v=rut4xUmuVnM&t=2s

22. OPENAPPENDICECTOMY
STEPBYSTEP

23. OPEN APPENDICECTOMY -STEP BY STEP
INDICATIONS:
Ac. Appendicitis
Subacute Appendicitis
ANESTHESIA:
GA/ SA or Epidural
POSITION:
Supine with slight left tilt
Informed consent-risks of surgery:
✓Post-op adhesions < 4%
✓Intra abdominal abscess <5%
✓Fecal fistula < 2%
✓Wound infection high in perforation
✓Overall mortality from 0.2% for
uncomplicated appendicitis to > 10% in
perforated appendicitis

24. OPEN APPENDICECTOMY -STEP BY STEP
INCISION: ACCESS
-McBurney’s
-Lanzor modified McBurney’s
-Rocky-Davis
-Fowler-Weir medial extension
-Rutherford Morrison lateral
extension
Division of External Oblique
Aponeurosis
-Incise the aponeurosis of the
external oblique along the line of its
fibers

25. OPEN APPENDICECTOMY -STEP BY STEP
SPLITTING THE MUSCLES
-Internal oblique & Transversus
oblique muscles are bluntly spread
apart with scissors
-These muscles are held apart by 2
Richardson’s retractors
INCISION OF PERITONEUM
-Peritoneum is divided between
2 hemostats obliquely

26. OPEN APPENDICECTOMY -STEP BY STEP
Mobilisationof Cecal pole and
delivering it into the wound
-Identify Cecum by tenia coli and
mobiliseit with Babcock’s forceps and
gauze piece
-3 tenia coli converge at base of
appendix
Anatomy of Appendix
-Mesoappendix extends behind
the ileum
-Skeletonisationof mesoappendix
should proceed to posterior surface
of ileum

27. OPEN APPENDICECTOMY -STEP BY STEP
Skeletonisationof Mesoappendix
-Clamp and divide mesoappendix
serially
Crushing the base of Appendix
-Crush the base of appendix with
straight artery forceps for few minutes
-Then remove and reapply few cms
above

28. OPEN APPENDICECTOMY -STEP BY STEP
Ligation and removal
-Appendix is ligated in the crush
mark
-Transact 0.5cm distally with knife
Alternate method of removal
-Mesoappendix and base of
appendix both divided with a linear
stapler

29. OPEN APPENDICECTOMY -STEP BY STEP
Appendiceal stump management
-Appendix stump is inverted with purse
string suture or Z stitch
-I just cauterize the appendicular mucosa

30. OPEN APPENDICECTOMY -STEP BY STEP
Retrocecal appendix
-Make a window in mesoappendix
near the base, crush the base and
apply ligature
-Divide the appendix at the base first
Retrograde Appendicectomy
-Then serially clamp the
mesoappendix and divide until you
reach the tip of appendix

31. OPEN APPENDICECTOMY -STEP BY STEP
Closure of peritoneum
-Wash with povidone iodine
-Close peritoneum with vicryl
Closure of muscles and skin
-Close muscles also with
interrupted vicryl
-Close External oblique aponeurosis

32. OPEN APPENDICECTOMY -STEP BY STEP
My Embedded YouTube Video
You can watch my YouTube video on Open Appendicectomy here.
https://youtu.be/CuGCjaUUCes

33. LAPAR0SCOPIC
APPENDICECTOMY
STEPBYSTEP

34. LAPAROSCOPIC APPENDICECTOMY -STEP BY STEP
INDICATIONS:
-Ac. Appendicitis
-Subacute Appendicitis
-Diagnostic Laparoscopy in
doubtful cases
ANESTHESIA:
-GA (ET)
POSITION:
-Supine with slight left tilt
Informed consent-risks of surgery:
-Post-op adhesions < 1%
-Intra abdominal abscess <8%
-Fecalfistula < 2%
-Injury to hollow viscus & vascular
injury
-Hypercarbia
-Air embolism
-Conversion to open method if
dense adhesions

35. LAPAROSCOPIC APPENDICECTOMY -STEP BY STEP
Position of patient & surgeon
-Patient supine with Rt hand
extended on a board
-Surgeon & assistant on Lt side
Port Placement
-Primary 10mm camera port through umbilicus
-Two 5mms secondary ports through RIF and
hypogastrium

36. LAPAROSCOPIC APPENDICECTOMY -STEP BY STEP
Creating Pneumoperitoneum:
Closed or Veress needle method
Open or Hasson’s cannula method

37. LAPAROSCOPIC APPENDICECTOMY -STEP BY STEP
Identification of Appendix
-Appendix is identified by confluence
of 3 teniaecoli in cecum
Skeletonisationof Appendix
-Appendix is serially clamped off it’s
blood supply in mesoappendix

38. LAPAROSCOPIC APPENDICECTOMY -STEP BY STEP
Ligation of appendix base
-3 endoloopswith vicrylor chromic
catgut are applied in the base of
appendix one above the other
Transaction of Appendix
-Transact the appendix in between
the 2
nd
& 3
rd
endo-loops.

39. LAPAROSCOPIC APPENDICECTOMY -STEP BY STEP
Alternate Method Stapler Method
-Create a window at base of appendix in
mesoappendix
-Divide both appendix and mesoappendix
with stapler

40. LAPAROSCOPIC APPENDICECTOMY -STEP BY STEP
Retrocecal Appendicitis
-Retrograde appendicectomy done
using stapler or multiple clips.
Retrograde Appendicectomy
-Here dissection method is shown
where cecum should be mobilised
by incising White line of Toldt.

41. LAPARASCOPIC APPENDICECTOMY -STEP BY STEP
Watch my embedded YouTube video here
You can watch my YouTube video on Laparoscopic Appendicectomy here.
https://www.youtube.com/watch?v=_WfviiQwPqk&t=18s

42. AcuteAppendicitis/Appendicectomy-Open And
Laparoscopic-StepByStep
References
1.Atlas of GI Surgery –2
nd
Edition By
Cameron & Sandone
2.Atlas of General Surgery-4
th
Edition By David Carter & Russell
3.Atlas of General Surgery-1
st
Edition By Volker Schumpelick
4.Atlas of General Surgical
Techniques-1
st
Edition By
Towensend& Evers
5.Chassin’soperative strategy in
General Surgery-4
th
Edition By
Carol E. H. Scott & Conner
6. Mastery of Surgery –7
th
Edition
By Josef E.Fischer
7. Maingot’sAbdominal Operations-
13
th
Edition By Zinner
8. Zollinger’s Atlas of Surgical
Operations-11
th
Edition By Zollinger
& Ellison
9. Oxford Operative Surgery-3
rd
Edition By Anil Agarwal & McLatchie
10. Bailey & Love’s short practice of
surgery-28
th
Edition, By Ronnan
Connell & Robert Mccaskie

43. USEFUL LINKS
Website:
WWW.surgicaleducator.com
YouTube Channel:
WWW.youtube.com/c/surgicaleduc
ator
Surgical Educator Podcast:
WWW.podcasters.spotify.com/pod/
show/surgical-educator-podcast
FB Fan Page:
WWW.facebook.com/surgicaltutor