Appendix 2

د.ليث نايف

الجراحة العامه /المرحلة الرابعه
كلية طب الكندي/جامعة بغداد
INVESTIGATION OF AA.
The diagnosis (DX) of AA is essentially clinical. However clinically based DX can lead to removal of the normal appendix in 15-30% of cases. Alvarado score is widely used to assist diagnosis:

Symptoms; -Migratory RIF pain 1
- Anorexia 1
-Nausea& vomiting 1
Signs; -Tenderness (RIF) 2
-Rebound tenderness 1
-Elevated temp. 1
Laboratory; -Leucocytosis 2 -Shift to left (segmented neutrophil) 1

A score of 7 or more is strongly predictive of AA. If equivocal score (5-6), U/S or CT scan examination of the abdomen are helpful in diagnosis of AA.

Preoperative investigations in AA include:

-The routine investigation: complete blood count, urinanalysis.
-Selective investigation: Pregnancy test, BU& electrolytes, abdominal XR, U/S of abdomen & pelvis, CT scan of abdomen.
Finding in ultra sound of the abdomen in AA showing distended oedematous appendix, a faecolith is seen.
Contrast-enhanced CT scan of the abdomen showing a faecolith at the base of the distended appendix with intramural gas with stranding of periappendiceal fat indicative of AA.


TREATMENT;
Treatment of AA is Appendicectomy. Urgent operation is essential to prevent the morbidity & mortality of peritonitis. Preoperative preparations include IVF, antibiotics, however single peroperative dose of antibiotics reduce the incidence of postoperative wound infection. When peritonitis is suspected, antibiotic against gram -ve & anaerobic organism should be given IV.

APPENDICECTOMY

-Should be done under general anesthesia with the Pt. supine, either laparoscopically or by conventional appendicectomy.
-Palpate RIF for a mass & if found, a conservative approach should be adopted
-Appropriate antiseptic solution for the entire abdomen
-Gridiron incision is made at right angle to a line joining the anterior superior iliac spine to the umbilicus, its center at McBurney point, ext. oblique is incised in the line of its fibres. The fibres of int. oblique & transverses are split & peritoneum is opened
If better access is required, it's possible to convert the Gridiron to the Rutherford Morison incision by cutting the int. oblique& transverses muscle in the line of the incision
-In recent years, a transverse skin crease incision (Lanz) has become more popular, better exposure & extension when needed is easier, it's made 2cm below the umbilicus centered on the midclavicular-midinguinal line. The ext., int. & transverses are split in the direction of the fibres, Peritonium is opened

-When DX is in doubt especially when IO is suspected, a lower midline abdominal incision or Rt lower paramedian incision, the later difficult to extend, difficult to close & provide poorer access to the pelvis& peritoneal cavity.
-When the abdomen has been opened, if pus or exudates present, it must be removed with a sucker, Identify the caecum, the appendix will be found at the base of the caecum, remove the inflammatory adhesions.
The base of mesoappendix is clamped, divided & ligated. The appendix is now clear, crushed near its junction with the caecum, ligate the crushed portion, the appendix is amputated, purse string suture is inserted into the caecum, the stump of the appendix is invaginated, thus burying the appendix stump. Many surgeons believe that invagination of the stump is unnecessary.
-Patients undergo laparoscopic appendicectomy are likely to have less postoperative pain, discharged from hospital sooner than open appendicectomy, post operative infection lower after the laparoscopic appendicectomy but the incidence of postoperative sepsis may be higher in Pts with gangrenous or perforated appendicitis.

METHODS TO BE ADAPTED IN SPECIAL CERCUMSTANCES

-When the caecal wall is oedematous, the purse string suture is in danger of cutting out. If odema is of limited extend, the purse string suture can be inserted into healthy caecal wall, if odema is extensive, it's better not to attempt invagination.
-when the base of the appendix is inflamed, it should not be crushed but ligated close to the caecal wall just tightly enough to occlude the lumen, after which the appendix is amputated and the stump invaginated. Should the base of the appendix be gangrenous, neither crushing nor ligation must be attempted. Two stitches are placed through the caecal wall closed to the base which is amputated flush with the caecal wall, after which these stitches are tied. Further clossur is effected by means of a second layer of interrupted sero-muscular sutures.
-Retrograte appendecectomy when the appendix is retrocaecal and adherent.
-Drainage of the peritoneal cavity. This is usually unnecessary providing adequate peritoneal toilet has been done. If there is considerable purulent fluid in the retrocaecal space or the pelvis, a soft silastic drain may be inserted through a separate stab incision.

PROBLEMS ENCONTERED DURING APPENDICECTOMY
-If normal appendix is found, this needs careful exclusion of other causes, ex terminal ileitis, Mickels diverticulitis, tubo-ovarian diseases in women. It's usual to remove appendix to avoid future diagnostic difficulties even although the appendix is macroscopically normal, particularly if a skin crease or gridiron incision has been made.
-If appendix can't be found, caecum should be mobilized & taenia coli should be traced to their confluence before the DX of "absent appendix" is made.
-If appendix tumour is found, small tumour less than 2 cm can be removed by appendicectomy. Larger tumour should be treated by Rt hemicolectomy.
-If appendix abcess is found& appendix can't be removed easily, local peritoneal toilet, drainage of abscess & IV antibiotic. Rarely caecectomy or Rt hemicolectomy is required.


APPENDICITIS COMPLICATING CROHNS DISEASE
If concomitant crohns is found during appendicectomy, providing caecal wall is healthy, appendicectomy can be done without increasing risk of enterocutaneous fistula.
Rarely appendix is involved with the crohn's disease; in this case a conservative approach& a trial of IV steroid & systemic antibiotic to resolve the acute inflammatory process.

APPENDIX ABSCESS

Failure of resolution of the appendix mass or continued spiking pyrexia usually indicates that there is pus within the phlegmonous appendix mass. U/S, CT scan may identify an area suitable for insertion of percutaneous drain, if unsuccessful laparotomy through a midline incision is indicated.

PELVIC ABSCESS

It's an occasional complication of AA& can occur irrespective of the position of the appendix. The most common presentation is spiking pyrexia several days following appendicitis, pelvic discomfort associated with loose stool& tenesmus. PR reveals boggy mass in the pelvis anterior to the rectum. Pelvic U/S or CT scan will confirm. Treatment is by trans-rectal drainage under GA.

MANAGEMENT OF AN APPENDIX MASS;

If an appendix mass is present& the condition of the Pt is satisfactory, the standard treatment is the conservative Ochsner-sherren regimen. It's based on that the inflammatory process is already localized& surgery is difficult& may be dangerous. It may be impossible to find the appendix & occasionally a faecal fistula may form.

Conservative management includes:

Admission of the patient to the hospital
Nothing by mouth
I.V. fluid therapy, daily requirement according to the weight of patient
Antibiotics therapy against aerobic and anaerobic organisms
Regular measurements of temperature and pulse rate every 4 h.
Its helpful to mark the mass on the abdominal wall using skin pencil
A contrast-enhanced CT examination of the abdomen should be performed


Criteria for improvement:
Improvement of general condition of the patient
Improvement of appetite
Decrease in the abdominal pain
Decrease in temp. and pulse rate
The mass decreased in its size and tenderness.
Its advisable to remove the appendix after an interval of 6-8 weeks

Criteria for stopping conservative treatment of appendix mass:

Increasing or spreading abdominal pain
Rising temp. and pulse rate
Increase in the size of the mass and become more tender
Evidence of peritonitis
It needs early laparotomy.

POST-OPERATIVE COMPLICATIONS OF APPENDECECTOMY

1-WOUND INFECTION
It occurs in 5-10 % of all Pts, presented with pain, erythema of the wound on the 4th or 5th post operative day. Treatment is by wound drainage & antibiotic. Organism responsible usually mixture of G-ve& anaerobic bacteria (Bacteroid& anaerobic strep.).

2-INTRA-ABDOMINAL ABSCESS

Rare with use of peroperative antibiotic. Postoperative spiking fever, malaise, anorexia 5-7 postoperative days suggest an intraperitoneal collection (interloops, paracolic, pelvic or subphrenic).
U/S& CT scan assist the DX & allow percutaneous drainage.


3-ILEUS
A period of adynamic ileus is to be expected after appendicectomy.
Ileus persisting more than 4 0r5 days especially in the presence of fever is indicative of intraabdominal sepsis.

4-RESPIRATORY COMPLICATIONS

Are rare, adequate postoperative analgesia& physiotherapy reduce the incidence.

5-VENOUS THROMBOSIS& EMBOLISM

Rare except in the elderly& in women on contraceptive pills. Appropriate prophylactic measures should be taken in such cases.

6-PORTAL PYEMIA

Rare but very serious complication of gangrenous appendicitis. High fever, rigor jaundice are present. It's caused by septicemia in the portal venous system led to intrahepatic abscess (multiple). Treatment by systemic antibiotic& percutaneous drainage of hepatic abscesses.

7-FAECAL FISTULA

Leakage from the appendicular stump occurs rarely, but may follow if the encircling stitch has been put in too deeply or if the caecal wall was involved by oedema or inflammation. Occasionally, a fistula may result following appendicectomy in Crohn's disease.

8-ADHESIVE INTESTINAL OBSTRUCTION

Most common late complication of appendicectomy, usually single band adhesion is found. Occasionally it causes postoperative RIF pain. Laparoscopy is useful to confirm the DX & to divide the band.

9-RIGHT INGUINAL HAERNIA

Especially in gridiron incision due to injury to ileohypogastric nerve.


RECURRENT ACUTE APPENDICITIS
Appendicitis is notoriously recurrent, the attack vary in intensity, may occur every few mths& majority of cases ultimately pass in sever AA. If careful history is taken from Pts with AA, many remember milder but similar attacks of pain, in these cases, the appendix shows fibrosis, indicative of previous inflammation.

LESS COMMON PATHOLOGICAL CONDITIONS

MUCOCELE OF THE APPENDIX
May occur when the proximal end of the lumen slowly occluded, usually by fibrous stricture& the retained secretions remains sterile, the appendix greatly enlarged. The symptoms are those of mild subacute appendicitis unless infection supervenes (empyema).

DIVERTICULA OF THE APPENDIX

Rare, may be true congenital (all coats) or acquired (no muscularis layer). It may occur in conjunction with mucocele when the intramural pressure rises sufficiently to cause herniation of the mucous membrane through the muscle coat. Diverticula is liable to perforate when inflamed, so if it's found during the course of an operation for another condition should be removed.

INTUSSUSCEPTION OF THE APPENDIX

It's rare the DX only at operation. Untreated, it may pass on to an appendiulocolic intussusception. Treatment is appendicectomy.

NEOPLASM OF THE APPENDIX

CARCINOID TUMOUR (ARGENTAFFINOMA)
Arise in argentaffin tissue& are most commonly in the appendix. It's found once in 300-400 appendices subjected to histopathological examination. It can occur in any part of the appendix commonly in distal 1/3. The appendix feels moderately hard& on sectioning it looks as a yellow tumour between the intact mucosa& the peritonum.
Unlike carcinoid tumour of other part of GIT, carcinoid tumour of the appendix rarely gives rise to metastases
Appendicectomy is sufficient treatment unless:
-The caecal wall is involved.
-Tumor is 2 cm or more in size.
-LN involvement, when Rt hemicolectomy is indicated.


PRIMARY ADENOCARCINOMA
Is extremely rare, it's of columnar type& should be treated by Rt hemicolectomy. It may rupture into peritoneal cavity seeding it with mucus-secreting malignant cells. Presentation is often delayed until the Pt has gross abdominal distension as a result of pseudomyxoma peritoneii

Treatment by radical resection of all involved parietal peritoneal surfaces & aggressive chemotherapy.









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