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Pathophysiology of acute appendicitis?
- luminal obstruction - elevated pressure in the distal portion because of ongoing mucus secretion and production of gas by bacteria within the lumen - progressive distention of the appendix, the
- venous drainage becomes impaired, resulting in mucosal ischemia. With continued obstruction, full-thickness ischemia ensues, which ultimately leads to perforation.
- Causes of obstruction – fecolith, lymphoid hyperplasia, neoplasm, parasites like ascaris
Atypical presentation of acute appendicitis?
- Retroperitoneal appendix – flank or back pain
- Pelvic appendix – suprapubic pain
- Small bowel obstruction – due to appendicular perforation
Important signs in acute appendicitis?
- Rovsing sign - the presence of right lower quadrant pain on palpation of the left lower quadrant
- Obturator sign - right lower quadrant pain on internal rotation of the hip
- Psoas sign - pain with extension of the ipsilateral hip
CECT findings in acute appendicitis?
- Thickened, inflamed appendix with surrounding “stranding” indicative of inflammation.
- Appendix > 7 mm in diameter with a thickened, inflamed wall and mural enhancement or “target sign”
- Periappendiceal fluid or air is also highly suggestive of appendicitis and suggests perforation
Incisions in appendectomy?|
- McArthur-McBurney - oblique muscle-splitting incision
- Rockey-Davis - a transverse incision
- Midline incision
Indications of interval appendectomy?
- Symptoms of recurrent appendicitis
- Presence of appendicolith
- Colonoscopy is recommended in all patients (>40 years) as a routine follow up after non operative management of complicated appendicitis
Normal appearing appendix intraoperatively, what next?
- Find out other causes
- Perforation of hollow viscus
- Meckles diverticulum
- Crohns disease
- Mesenteric lymphadenitis
- Tubo-ovarian or salpingeal diseases
- Gall bladder or duodenal perforation
Do we remove normal appendix?
Remove the normal appendix for following reasons.
1. appendectomy is advisable because it removes appendicitis from the differential diagnosis when the patient presents with recurrent right lower quadrant pain.
2. In addition, abnormalities of the appendix not apparent on gross inspection at the time of operation are sometimes identified on pathologic examination
What is incidental appendectomy?
- term applied when a grossly normal appendix is removed at the time of an unrelated procedure, such as a hysterectomy, cholecystectomy, or sigmoid colectomy.
- Do not remove appendix unless any abnormality is detected.
Appendicitis in elderly, Management?
- If peritonitis – emergency laparotomy
- If no peritonitis – CECT to confirm the diagnosis and to evaluate other pathology
- Lap appendectomy – procedure of choice
Management of carcinomid appendix?
- <1cm – are usually benign – appendectomy is sufficient
- >2cm with extension to base/mesoappendix – right hemicolectomy with regional lymphadenectomy
- Evidence of mucin spillage or mucinous ascites – appendectomy with peritoneal lavage with cytoreductive surgery/hyperthermic intraperitoneal chemotherapy (CRC-HIPEC)
What is HIPEC?
Hyperthermic intraperitoneal chemotherapy (HIPEC) is a highly concentrated, heated chemotherapy treatment that is delivered directly to the abdomen during surgery.