Appendix

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

8. Wallbridge Classification:

9. 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.

10. 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.

11. 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.*

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

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

14. Types: Simple (Catarrhal) appendicitis Phlegmonous appendicitis Gangrenous appendicitis Perforative appendicitis

15. 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.

16. 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.

17. 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.

18. 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.

19. 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

20. 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.

21. 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.

22. 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.

23. In pregnancy: Incidence in pregnancy is 1 in 2000 pregnancies. It is more common in 1 st and 2 nd 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.

24. 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 3 rd trimester. Surgery is the treatment.

25. 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.

26. Ochsner and Sherren regime: A spiration with Ryle’s tube to give rest to the gut. B owel care- purgatives should not be used (may cause perforation) C harts- temperature, pulse, respiration, diameter of mass. Changing in temperature and increase in size of mass indicates an appendicular abscess. D rugs- Antibiotics are used. E xploratory 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. F luids

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

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

29. 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.

30. 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.

31. 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.

32. 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.

33. 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

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

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

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

37. 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.

38. 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.

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

40. Laparoscopic Appendicectomy Indications: All kinds of appendicitis including appendicular abscess. Specially suitable for obese patients and females of reproductive age group.

41. 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.

42. 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.

43. 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

44. 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 2 nd assistant on right side Video monitor on right side Urinary bladder should be evacuated before trocar insertion

45. 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.

46. 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.

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

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

49. 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.

50. Points to remember:

51. 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

52. THANK YOU!