Appendicitis

Appendicectomy

is the surgical removal of the vermiform appendix. This procedure is normally performed as an emergency procedure, when the patient is suffering from acute appendicitis. In the absence of surgical facilities, intravenous antibiotics are used to delay or prevent the onset of sepsis.

Indications: Acute appendicitis, recurrent appendicitis

Acute appendicitis
is the  inflammation of the appendix .

Symptoms:
Pain first, vomiting next and fever last has been described as the classic presentation of acute appendicitis. Since the innervation of the appendix enters the spinal cord at the same level as the umbilicus ), the pain begins stomach-high. Later, as the appendix becomes more swollen and irritates the adjoining abdominal wall, it tends to localize over several hours into the right lower quadrant, except in children under three years. This pain can be elicited through various signs and can be severe. Signs include localized findings in the right iliac fossa. The abdominal wall becomes very sensitive to gentle pressure (palpation). Also, there is severe pain on sudden release of deep pressure in the lower abdomen (rebound tenderness). In case of a retrocecal appendix (appendix localized behind the cecum), however, even deep pressure in the right lower quadrant may fail to elicit tenderness (silent appendix) because the cecum, distended with gas, protects the inflamed appendix from pressure. Similarly, if the appendix lies entirely within the pelvis, there is usually complete absence of abdominal rigidity. In such cases, a digital rectal examination elicits tenderness in the rectovesical pouch. Coughing causes point tenderness in this area (McBurney's point).


Procedure:
Incision:
Types:
1.Grid iron incision
2.Lanz incision
3.Rigth paramedian incision

McBurney point
an imaginary line joining anterior superior iliac spine and umbilical.The point is at 1/3 lateral and 2/3 medially

McBurney's grid incision is the most popular incision. it is right angles to the spino-umbilical line placed at Mcburney's point.It is about 6-8cm in length.
Lanz incision are cosmetically better than McBurney's.
Right paramedian incision is made when diagnosis is in doubt as a part of exploratomy laparotomy.



Layers opened:
1.skin
2.two layers of subcutaneous tissue: Camper's, Scampa's.
external oblique aponeurosis running downwards and medially.it is incised in the direction of the fibres
3.Internal and transverse abdominal muscles are split
4.Peritoneum.

Surgical procedure:
1.Antibiotics are given immediately if there are signs of sepsis; otherwise, a single dose of prophylactic intravenous antibiotics is given immediately before surgery.
2.General anaesthesia is induced, with endotracheal intubation and full muscle relaxation, and the patient is positioned supine.
3.The abdomen is prepared and draped and is examined under anesthesia.
4.If a mass is present, the incision is made over the mass; otherwise, the incision is made over McBurney's point.(this represents the position of the base of the appendix .The position of the tip is variable).
5.The various layers of the abdominal wall are opened.

6.Appendix is gently held at mesoappendix by using Babcock's forceps and blood vessels in the mesoappendix are divided.These include appendicular artery, branch of ileocolic artery.Once the appendix is freed upto the base (caecum), a purse string suture is applied all round appendix, taking bites from caecum , using 2-0 atraumatic silk.

Appendix is crushed at the base and is held 1cm above the crush. A tight silk ligature is applied at the crushed site and appendix is cut in between.Stump is cleaned with spirit.invaginated and purse string is tightened.This is called burial of the stump.Perfect haemostasis is obtained.

Closure

1.Peritoneum -continous 2-0 catgut/vicryl

2.Split muscles -sutured together by a few interrupted suteres using chromic catgut/vicryl

3.External oblique is sutured with silk

4.Subcutaneous fat is sutured with vicryl 

5.Skin with interrupted silk .Instead of catgut, 2-0 silk , 2-0 vicryl is being used more often nowadays.

6.The wound is dressed.

7.The patient is brought to the recovery room.
Corrugated red rubber drain is not kept routinely unless there is gangrenous appendicitis or a lot of pus in the peritoneal cavity. 

Recovery

Recovery time from the operation varies from person to person. Some will take up to three weeks before being completely active; for others it can be a matter of days. In the case of a laparoscopic operation, the patient will have three stapled scars of about an inch in length, between the navel and pubic hair line. When an open appendectomy has been performed the patient will have a 2–3 inch scar, which will initially be heavily bruise.

by Lakdhes