A) Emergency -
Acute appendicitis, with rebound tenderness, before lump forms
Generalized peritonitis because of appendicitis.
Appendicular abscess - per say is a does not require appendicectomy with drainage. However, if the appendix is found floating in the abscess cavity, one may remove it.
Acute right iliac fossa pain & vomiting
Localized tenderness at McBurney's point
Positive rebound tenderness in right iliac fossa
Adequate pre-op. preparations done
X-ray chest and abdomen
Ultrasonography with full bladder to rule out pelvic pathology
Written informed consent
B) Elective -
Conserved attack of acute appendicitis. Surgery after 6 weeks to 3 months
Tumors e.g. Carcinoid, mucocele
C) Incidental -
During other surgeries if the appendix is found to have characters of recurrent appendicitis i.e. short, kinked, serosal shine absent, with adhesions, then it may be removed, if there is no focus of sepsis elsewhere in the abdomen
Appendicular mass - More chances of trauma to surrounding bowel and omentum during dissection
I would like to describe procedure of emergency appendicectomy for an acute onset right iliac frssa pain with rebound tenderness at McBurney's point.
Anesthesia - SA / GA
Parts are prepared, painted and draped
Patient in supine position
McBurney's grid-iron incision- perpendicular to the spinoumbilical line centered at McBurney's point.
Muscle splitting incision, can be extended if required Excellent postoperative healing and strength
Used in emergency appendicectomy
Lanz's Incision (Bikini Incision)
Skin incision along the skin creases at McBurney's point, rest as above Cosmetically better
Used in elective appendicectomy
Sir Rutherford Morrison's muscle cutting Incision
Same as McBurney's grid-iron incision but muscle is cut.
Advantage - wide exposure.
Disadvantage - healing by fibrosis.
Used in emergency appendicectomy when the procedure is difficult like refrocecal & long pelvic appendix.
Medial extension of McBumey's grid-iron incision to cut the lateral aspect of the rectus sheath used for long pelvic appendix.
Incision taken lateral to rectus muscle and rectus is refracted laterally
Disadvantage - Incisional Hernia as neurovascular bundle is cut.
Right infra umbilical paramedian incision or Infra umbilical midline incision
Allows wide exposure of infracolic and pelvic regions
Perforated appendix with generalized peritonitis
Female with differential diagnosis of ruptured ectopic pregnancy.
McBurney's gridiron incision is taken with the help of a skin knife.
The Incision is then deepened through the subcutaneous tissue
Edges of the incision are then refracted with 2 C-shaped retractors until the fibers of the external oblique aponeurosis are identified as shiny structure running medially and downwards.
With the help of a deep knife, a nick is made on fibers of the external oblique aponeurosis which is then caught with the help of toothed forceps & extended with the help of sharp fine scissors.
The fibers of internal oblique & transversus abdominis are then split along their course with curved, medium sized hemostat guided with the index finger.
The opening is then stretched with 2 C-shaped retractors.
Peritoneum is identified as glistening, thin, translucent membrane & is held with the help of 2 hemostats taking care not to damage the intra-abdominal organs. It is incised along the direction of the skin incision.
The incision is refracted with 2 C-shaped retractors.
Identify cecum, as dilated blind end of colon in right iliac fossa with three columns of tenia converging at the base of the appendix
Cecum held with Babcock's forceps & delivered out.
Tenia are traced downwards to the base of the appendix.
The appendix is identified & the meso-appendix is held with a Babcock's forceps (actually the appendix is encircled the meso appendix is held)
A second Babcock is attached to the tip of the appendix.
Signs of acute appendix
Fibrinous flakes on serosa
Palpate for fecoliths
Any fibrous adhesions, if present, are separated carefully with blunt dissection.
Mesoappendicular vessels are then serially clamped, cut & ligated from the tip to the base with 60 linen making avascular window in the mesoappendix.
The cecum is stabilized with the help of a Babcock forceps holding the taenia coll. The appendix is held vertically with a Babcock forceps.
A purse string suture is taken around 1.25 cm from the base of the appendix on the cecal wall with 60 linen (intestinalised / parrafinised) on a round body needle. These sutures should preferably go through the 3 tenia coli. Their ends are kept long & held with small hemostat.
The base of the appendix is crushed with a fully serrated straight medium sized hemostat. The hemostat is then advanced distally & reapplied.
Advantages of crushing
Necrosis leads to fibrosis
Blood vessels crushed leads to less bleeding.
Good held for the tie otherwise serosa is slippery
A 40 linen ligature is tied over the groove to occlude the lumen & blood vessels which are coming from the cecum. Ends kept long.
The appendix is then transected in between the ligature & the hemostat with a stab knife.
The stab knife & the artery with the appendix is removed in a septic tray.
Tip of the appendicular stump is cauterized with carbolic acid taken on a cotton carrier - bactericidal stump becomes white because of protein coagulum.
Excess carbolic acid is removed by touching the tip with a swab dipped in spirit. The spirit also dissolves the fatty substances.
Excess spirit removed by saline on a cotton carrier to prevent peritoneal contamination after inverting. All swabs are discarded.
Ends cut short.
The stump is held with plain forceps by assistant & buried into the cecal wall. At the same time the purse string suture is tightened keeping one end stationary & pulling the other end.
Any fatty tissue / appendices epiploacae around are pulled towards the stitch & over it the stitch is tied & cut short.
If appendix not inflammed - female internal genitalia
Ileal mesentery and mesenteric lymph nodes
Hemostasis is confirmed
Peritoneum 2/0 chronic catgut continuous interlocking
Internal oblique, External oblique, Transversus abdominis - 2/0 chromic catgut simple interrupted
Subcutaneous - 2/0 Plain catgut simple interrupted
Skin — 3-0 ethilon
Damage to superficial and muscular blood vessel causing hemorrhage
Damage to ilio - inguinal nerve, external oblique/ internal oblique aponeurosis
Damage to intra-abdominal organs while opening peritoneum
Tear of the appendix (especially inflammed)
Spilling of contents into peritoneal cavity
Appendicular stump blowout leading to fecal fistula
Pyelephlebitis (Portal vein pyemia and thrombosis) — may lead to portal hypertension
Intestinal obstruction because of adhesion band
Persistent fecal fistula because of distal obstruction •?•
Direct inguinal hernia
Post operative management
NBM for 24 hours
Full course of antibiotics in case of emergency surgery
Suture removed on day 7
Rest as in any major abdominal surgery
If pathological report comes as Carcinoid (spread via mucosa) - right hemicolectomy
Severe cecal wall edema -
Avoid purse-string sutures (cut - through)
Right hemicolectomy if cecum not viable In/lammed base of appendix -
No crushing as infection spreads
By blood vessels
Just ligate flush with cecum
Gangrenous base -
Do not crush
Ligate flush with cecum cut
Retrocecal appendix -
Appendicular artery is a branch of the lower division of the ileo - colic artery. It runs behind the terminal part of ileum and enters the mesoappendix. At a short distance from it's base gives a recurrent branch which anastomoses with a branch of the posterior cecal artery.
In case of damaged appendicular artery, mobilize the cecum, go posterior to it and then treat the condition.