CLINICAL APPROACH TO APPENDISECTOMY.pptx

appedicectomy

1. INTRODUCTION APPENDICECTOMY Surgical removal of appendix when infected . Overall mortality rate appendicitis ranges from 0.3% in non perforated appendix to 6.5% in cases of perforation . Peak incidence occur between the age of 10-30 yrs. Any delay in the diagnosis of acute appendicitis and a consequent delay in appendicectomy can lead to serious outcome like perforation and peritonitis. It is a common surgical emergency. 1

2. Claudius Amyand 1736 Removed inflammed appendix from hernia sac Reginald Heber Fitz 1886 Coined term Appendicitis Charles Mc Burney 1889 Described Mc Burney point Kurt Semm 1981 First Laparoscopic appendectomy Santiaggo Horgan Mark A. Talawamini 2009 NOTES (Natural Orifice Transluminal Endoscopic Surgery) HISTORY 2

3. VERMIFORM APPENDIX “ Vestigeal Organ” L atin word - worm shaped Worm - like diverticulum A rising from posteriomedial wall of the caecum 2cm below ileocaecal orifice Dimension Length-9 cm Diameter of appendix-3-8 mm Diameter of lumen -1-3 mm Luminal Capacity of normal appendix - 0.1 ml 3

4. POSITIONS The appendix lies in the right iliac fossa. B ase of appendix - fixed Tip can point in any direction. 4

5. 5 ARTERIAL SUPPLY Accesory appendicular artery also known as artery of Seshachalam Branch of posterior caecal artery. Named after prominent Indian surgeon Sheshachalam He described appendiceal vascularisation

6. VENOUS DRAINAGE 6

7. NERVOUS SUPPLY TO APPENDIX Sympathetic nerves - T9 to T10 through the celiac plexus. Parasympathetic nerve - Vagus nerve. Upper ileocaecal Lower ileocaecal LYMPHATIC DRAINAGE Lymph nodes 7

8. ACUTE APPENDICITIS Etiology Faecolith Stricture Neoplasm Diet Familial susceptibility 8

9. 9

10. CLINICAL FEATURES MURPHY’S TRIAD PAIN IN RIGHT QUADRANT VOMITING FEVER 10

11. THE ALVARDO MANDRALS SCORE SYMPTOMS SCORE M igratory RIF pain A norexia N ausea andVomiting 1 1 1 SIGNS SCORE T enderness (RIF) R ebound tenderness E levated temperature 2 1 1 LABORATORY SCORE L eucocytosis S hift to left (segmented neutrophils) 2 1 TOTAL =10,<5 against diagnosis of appendicitis, 7 or more strongly predictive of appendicitis 11

12. GUARDING DUNPHY’S SIGN ROVSING SIGN MC BURNEY’S SIGN HYPERAESTHESIA CLINICAL EXAMINATIONS POINTING SIGN 12 REBOUND TENDERNESS

13. PSOAS SIGN OBTURATOR SIGN PR EXAMINATION 13 CLINICAL EXAMINATIONS (CONTD…)

14. INVESTIGATIONS Blood routine C- reactive protein Urine routine Erect X- ray of abdomen USG of Abdomen and pelvis CT scan of abdomen Contrast CT Scan of abdomen MRI X- RAY USG 14

15. 15 Perforated peptic ulcer

16. DIFFERENTIAL DIAGNOSIS THORACIC CAUSES Basal pneumonia Pleurisy 16

17. TREATMENT 17 Conservative treatment Surgical management

18. SURGICAL MANAGEMENT Open Surgery Laparoscopic Surgery 18

19. PRE OPERATIVE INSTRUCTIONS 19

20. INCISIONS Rt.Paramedian incision Vertical incision - 2.5 cm below the umbilicus 1.2-2.5 cm - right of the midline Ends just above the pubis Lanz ’ sTransverse incision Incison - 2-3 cm below umbilicus Centered on midclavicular , mid inguinal line Cosmetically better Mc Burney’s grid –iron incision Oblique incision through the Mc Burney’s point Rutherford morison’s incision Similar to Mc Burney’s incison It is muscle cutting 20 Umbilicus Lower midline Gridiron incision Lanz incision ASIS

21. 21

22. POST OP CARE After completion of surgery, the patient is transferred to the post op ward and closely monitored Patient is allowed to take orally after 24 - 48 hours of surgery after observing the peristaltic movements. Catheterization done Check for any surgical site infection Antibiotics IV fluid electrolyte Monitor vitals 22

23. COMPLICATIONS AFTER APPENDECTOMY 23 Wound Infection Pelvic abscess Faecal Fistula Pylephlebitis Right inguinal hernia Intestinal obstruction Reactionary haemorrhage due to slippage of ligature of appendicular artery

24. COMPLICATION IF LEFT UNTREATED 24 Appendicular mass ( phlegmon ) Appendicular abscess Appendicular rupture

25. 25 Suppurative pylephlebitis

26. The direct reference for appendix or appendicitis is not available in our classics. Unduka pucha sotha is a coined name as told by Gananatha sen Unduka has been mentioned by Acharya Susrutha as one among the koshtangas . But Unduka pucha is not available. Depending on the stages of disease we can corelate it with different conditions. In the first stage when pain is ellicited it can be taken as shoola 26 AYURVEDIC CORRELATION

27. As the stage advances it can be taken as vidradhi in the stage of appendicular mass ( antar vidradhi ) and when when neglected and peritonitis occurs then chidrodara Apart from this Susrutha Acharya has uniquely mentioned the concept of Shat kriya kala संचयं च प्रकोपं च प्रसरं स्थानसंश्रयम् । व्यक्तिं भेदं च यो वेत्ति दोषाणां स भवेद्भिषक् ।। (SU.SU.21/36 ) 27

28. DISCUSSION A direct reference for Appendix or Appendicitis is unavailable in our classics. But there is a coined term as Unduka pucha sotha as told by Gananatha Sen According to different stages in appendicitis we can correlate it with different conditions . If it is appendicitis sanga is produced which leads to shotha Appendicular abscess  Abhyantara Vidradhi Appendicular rupture  Chidrodhara 28

29. But there is nothing to feel ashamed for the inefficiency to name the disease, as Acharya Vaghbata has told it has not been possible yet to name all the diseases. विकारनामाकुशलो न जिहीयात्कदाचन । न हि सर्वविकाराणां नामतोऽस्ति ध्रुवा स्थितिः ।। While dealing with the treatment of this disease it should be decided after understanding the doshas and the severity of the disease. एकं शास्त्रमधीयानो न विद्याच्छास्त्रनिश्चयम् । तस्माद्बहुश्रुतः शास्त्रं विजानीयाच्चिकित्सकः।। (SU.SU 4/7) Appendicitis is a Pitta Pradhana Tridosha Chedya Sadhya Roga . 29 (A.H 12/63)

30. When a patient approaches with a pain in the umbilicus or right iliac fossa along with vomiting immediate action has to be taken as the 48 hr is the maximum limit we can wait for. It has the chance to move on to appendicular abscess and rupture following further complications like peritonitis. The longer the delay the crucial will be the situation. Appendicectomy should be done at the first place without h esitency provided all clinical features and examinations supports appendicitis . 30

31. Appendicectomy is a simple procedure but a skilled hand is required for the same. If the mass is ruptured then an end to end anastomosis will be complicated and it require a expert surgeon. The total duration of the appendicectomy procedure will take maximum 10 minutes by the expert surgeon. 31

32. CONCLUSION Unduka puchasotha is a coined term and no detail discussion on that topic is available in our classics. Appendicitis is an emergency condition that almost always require prompt surgery to remove appendix. Left untreated inflamed appendix will eventually perforate spilling the infectious material in to abdominal cavity leading to peritonitis. Hence special care should be taken when a patient presents with Murphy’s triad 32