Professional Documents
Culture Documents
Badrek-Amoudi FRCS
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Introduction
1889 Mac Burney described location,
the clinical features of appendicitis and
the importance of operative intervention
and muscle-splitting incision.
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Surgical Anatomy
Surface anatomy
Development: diverticulum of ceacum appearing
in the 8th week of life
Positions: constant base, tip varies (retroceacal,
pelvic, subcaecal, preileal, pericolic)
Blood supply
Location during surgery
Surrounding anatomical structures
Part of the gut lymphoid tissue.
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Acute Appendicitis
Epidemiology
Most common surgical emergency.
Slightly more common in men.
Incidence are falling from 100 to 50 in 100 000 (1975-1991).
1 in 6 of the population will have an appendectomy.
In Saudi Arabia incidence are comparable to western figures
? More common in European societies (Diet).
? Relation to class status.
Age > 2 yrs, (associated with lymphoid development).
Up to 16% of appendicectomies are normal 75% are in women
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Acute Appendicitis
Pathology I
Luminal obstruction.
Lymphoid hyperplasia 60%
Faecolith 35%.
Inspissated barium.
Fruit seeds. }<4%
Worms. < 1%
Extra-luminal obstruction eg Ca Cecum
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Acute Appendicitis
Pathology II
Impaired arterial flow, thrombosis and gangrene.
Perforation may occur through devitalized tissue.
Catarrhal appendicitis
Suppurative ;;;
Necrotic ;;;
Gangrenous ;;;
Perforated ;;;
Appendicular mass
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Investigations
White cell count: high sensitivity 96%, low specificity
Urine analysis
Plain Xray, nonspecific
Ultrasound highly sensitive (80-90%), excludes
other pathologies.
Computer Tomography: More superior to USS in diagnostic
accuracy.
Barium enema: Good accuracy, but technically
difficult and false positives are common.
Laparoscopy
Active observation
Computer aided diagnosis.
Peritoneal lavage
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The Very Young
Diagnosis may be more difficult to
establish, WBC is likely to be normal
(12% are normal).
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The Very Old
Greater morbidity and mortality
Less typical presentation
Cancer may be a possibility as an
underlying cause.
Perforation of 50% and mortality of
20% has been reported
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The Pregnant
Implications: Clinical Findings, Lab Ix, Surgery
1: 2000 pregnancies.
More common in the first two trimesters
The appendix is pushed superiorly and laterally
WBC > 15
Premature Labor 10-15% with surgery
Perforated appendix leads to fetal death in 20%
Rapid diagnosis and treatment is advised.
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In AIDS Patients
Be aware of CMV or Kaposi sarcoma as
the underlying cause
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The Management
Preop:
IVI,
analgesia,
IV antibiotics
Conventional appendicectomy
Types of incisions
Laparoscopic appendicectomy:
(questions regarding pain, hospital stay, operation
time, to daily activity, wound infection)
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Post-Operative
1. Check the vitals
2. Check the abdominal signs and bowel
movement
3. Check the wound
4. Advise on mobilization
5. In OPD:
1. Check wound
2. Check the Histology
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Prognosis
Mortality: from 0.2% to 1%
Complications increase with perforation
Morbidity:
Wound abscess,
Wound infection (less with MacBurneys incision),
Wound dehiscence
Intra-abdominal abscess,
Faecal fistula,
Intestinal obstruction,
Adhesive band,
inguinal hernia.
Fertility
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Problems
Mass palpable pre-operatively
Prophylactic appendicectomy
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Chronic Appendicitis
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Appendicular Mass
Results from either:
1. Localized by edematous, adherent omentum
and loops of small bowel
2. Appendicular abscess
Incidence is 10%
Higher in children
Management controversy:
Interval vs Immediate appendicectomy
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Tumors of The Appendix
Carcinoid:
Arise from Kluchitsky cells
Mean age 20-40
Yellow bulbar mass
In F>M
In third decade of life
Usually lies near the tip
In the absence of LN spread with <2 cm in
diameter appendicectomy is sufficient. Otherwise
a R hemicolectomy is necessary.
Adenocarcinoma and Lymphoma.
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