CHAPTER 76 — THE VERMIFORM APPENDIX

OT Visual Study Guide | Bailey & Love

📍 ANATOMY AT A GLANCE
WHAT IS IT? BLOOD SUPPLY ⚠️

• Blind-ended tube off the caecum • Appendicular artery

• Length: 7.5 – 10 cm • Branch of ileocolic artery

• 4 layers (same as bowel wall) • It is an END-ARTERY

• Present in humans, apes & wombat ↓

• Has IMMUNE function (lymphoid • NO backup blood supply

tissue)
• Thrombosis = GANGRENE

• This is why it perforates!

POSITIONS OF THE APPENDIX (Most → Least Common)

RETROCAE ➜ PELVIC ➜ SUBCAECA ➜ PREILEAL ➜ POSTILEAL

CAL 21% L 1% 0.5%
74% (in pelvis) 1.5% → Rare →
(behind → Low → Unusual Diarrhoea
caecum) pelvic pain
→ → Mimics
Loin/back gynae
pain
→ Psoas
sign +ve

💡 74% + 21% = 95% of cases are RETROCAECAL or PELVIC. Just know these two and you're set!

🔬 PATHOLOGY — HOW APPENDICITIS DEVELOPS

🔒 LUMEN OBSTRUCTED
Faecalith | Swollen lymph nodes | Tumour | Parasites
▼
🦠 BACTERIA MULTIPLY
Mucus builds up → Pressure rises → Mucosal ulceration
▼
🔴 ACUTE APPENDICITIS
Bacteria invade wall → Inflamed, swollen appendix
 ▼
☠️ GANGRENOUS APPENDICITIS
Venous obstruction → Ischaemia → Full wall necrosis
▼
💥 WALL PERFORATES
Bacteria spill into peritoneal cavity

↙ TWO OUTCOMES ↘

🟠 CONTAINED (Appendix Mass) 🔴 FREE PERFORATION

• Omentum + bowel wall off infection • No containment possible

• Palpable lump in RIF • Bacteria spread everywhere

• = APPENDIX MASS • = GENERALISED PERITONITIS

• → Treat conservatively first • → SEPSIS SYNDROME

• → Ochsner-Sherren regime • → Emergency surgery

🩺 CLINICAL DIAGNOSIS

SYMPTOM SEQUENCE — In This Exact Order!

1
1️⃣ ➜ 2️⃣ ➜ 3️⃣ ➜ 4️⃣ ➜ 5️⃣
CENTRAL ANOREXIA NAUSEA / PAIN FEVER
PAIN Loss of VOMITING SHIFTS 37.2–
Colicky appetite 1–2 to RIGHT 37.8°C
Periumbili (ALWAYS episodes ILIAC Pulse ↑
cal present!) AFTER FOSSA 80–90/min
(vague, pain (somatic,
visceral) sharp)

💡 PAIN BEFORE VOMITING = Appendicitis | VOMITING BEFORE PAIN = Gastroenteritis — This is a classic exam differentiator!

EXAMINATION SIGNS — Visual Map

McBURNEY'S POINT ROVSING'S SIGN REBOUND

📍 RIF tenderness ↔️Press LEFT TENDERNESS
2/3 from umbilicus iliac fossa 🤚 Press slow,
to ASIS → pain in RIGHT release suddenly
= THE classic sign = peritoneal spread → pain worse

PSOAS SIGN OBTURATOR SIGN POINTING SIGN

🦵 Extend right 🔄 Flex + internally 👆 Patient points:
hip backwards rotate right hip where it started
→ pain → pain then where it moved
= retrocaecal = pelvic appendix = classic shift
💡 Retrocaecal appendix = Psoas sign+ve, rigidity ABSENT (caecum hides it) | Pelvic appendix = Obturator sign+ve, rectal exam positive

🔍 INVESTIGATIONS FLOWCHART

SUSPECT APPENDICITIS
▼
🩸 BLOODS + 🚽 URINE + 🤰 PREG TEST + 📡 ULTRASOUND
FBC Urinalysis All women First-line
(WBC ↑) (rule out of childbearing Appendix
CRP ↑ UTI/kidney) age — always! >6mm
= appendicitis
CT SCAN
90–95%
accurate
Gold standard
in adults

▼
ALVARADO SCORE — Score ≥7 = Operate!
 SYMPTOMS SIGNS LAB TOTAL

Migratory
RIF pain
Anorexia Nausea /
Vomiting
RIF
Tenderness
Rebound
Tenderness
Fever Leuko-
cytosis
Shift to
left
10
1 1 1 2 1 1 2 1

Score ≥ 7 Score 5–6 Score < 5

→ OPERATE → GET IMAGING (CT/US) → OBSERVE / DISCHARGE
 🔪 SURGICAL PROCEDURE — APPENDICECTOMY
🏥 OT RELEVANCE: You need to understand EXACTLY what was done in surgery — this tells you what structures were cut,
what to protect during rehab, and what complications to watch for.

FIRST DECISION: Which Approach?

OPEN APPENDICECTOMY LAPAROSCOPIC APPENDICECTOMY

• Gridiron OR Lanz incision in RIF • 3 tiny port holes

• Muscles split (not cut) layer by layer • Camera at umbilicus + 2 working ports

• Full visibility of abdomen • Can see whole abdomen =

DIAGNOSTIC
• Cheaper, always available
• Lower wound infection rate
• More post-op pain
• Less post-op pain
• Longer recovery (4–6 weeks)
• Faster recovery (2–3 weeks)

🏥 OT RELEVANCE: Laparoscopic patients mobilise FASTER. Plan earlier OT intervention. Open patients have MORE pain —
prioritise breathing exercises + pain management before ADLs.

📋 OPEN APPENDICECTOMY — Step by Step Visual

STEP 1 — INCISION
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Gridiron (McArthur): Diagonal cut at RIF, centred on McBurney's point
OR
Lanz: Horizontal skin crease cut, 2 cm below umbilicus (better scar)
▼
STEP 2 — ENTER THE ABDOMEN
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
External oblique aponeurosis → cut along fibres
Internal oblique → split along fibres
Transversus abdominis → split along fibres
Peritoneum → picked up + opened with scissors
(Muscles are SPLIT not cut = less damage, heals faster)
▼
STEP 3 — FIND THE APPENDIX
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Bring caecum into wound → identify TAENIAE COLI (3 muscle bands on caecum)
Follow the taeniae → they ALL converge at the appendix base
Break any adhesions gently with finger
If retrocaecal: mobilise caecum first to expose appendix
▼
STEP 4 — CONTROL BLOOD SUPPLY
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Mesoappendix contains the appendicular artery
Clamp mesoappendix → Divide → Ligate with absorbable suture
⚠️If not properly tied → HAEMORRHAGE
▼
STEP 5 — REMOVE THE APPENDIX
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Crush appendix at its BASE with clamp (creates a groove)
Apply clamp just distal to groove
Tie absorbable 2/0 ligature in the groove (at base)
Cut appendix between ligature and clamp
Appendix removed!
▼
STEP 6 — BURY THE STUMP
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Why? → To prevent stump leakage into abdomen
Purse-string suture OR Z-suture placed in caecal wall around stump
Stump is INVAGINATED (pushed inside caecum)
Suture tied → stump disappears inside caecum
Sealed securely
▼
STEP 7 — CLOSE IN LAYERS
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Peritoneum closed → Muscles fall back together
Fascia sutured → Subcutaneous tissue → Skin
If CONTAMINATED (pus/peritonitis): skin left OPEN → closed later
Wound dressing applied

🔭 LAPAROSCOPIC APPENDICECTOMY — Steps

PORTS ➜ CO₂ GAS ➜ FIND ➜ DIVIDE ➜ LIGATE ➜ REMOVE

IN INSUFFL APPEND MESOAP BASE IN BAG
━━━━━━ ATED IX PENDIX ━━━━━━ ━━━━━━
━━━━ ━━━━━━ ━━━━━━ ━━━━━━ ━━━━ ━━━━
Camera: ━━━━ ━━━━ ━━━━ Loop Specime
UMBILIC Abdome Follow Diather ligature n bag
US n caecal my / OR Pulled
Port 2: inflated taeniae Clips / Linear through
Suprapu Patient with Harmoni stapler umbilica
bic tilted laparosc c scalpel (NOT l port
Port 3: (Trendel opic buried Wound
Left enburg forceps like in washed
lower + open)
quadran right
t (LLQ) side up)
 ⚠️POST-OPERATIVE COMPLICATIONS — YOUR #1 OT FOCUS
🏥 OT RELEVANCE: As an OT you will work with patients AFTER surgery. You must know: what can go wrong, when it
happens, the signs, and how it affects your rehab plan.

COMPLICATIONS TIMELINE — What Happens When?

TIMING COMPLICATION SIGNS & SYMPTOMS WHY IT HAPPENS OT ACTION

DAY 1–3 ILEUS No bowel sounds Normal after surgery Expect NBM/fluids
(Immediate) (Bowel stops No flatus (bowel 'stunned') Plan gentle sitting up
working) Abdominal distension → >4–5 days = ongoing Breathing exercises
Nausea sepsis No heavy ADLs yet
DAY 3–5 ⭐ WOUND INFECTION Wound: Red, hot, Contamination during Pain limits movement
(Early) (MOST COMMON swollen, painful surgery especially Adapt transfers
5–10% of patients) Discharge from wound if perforated Positioning away
Fever on day 4–5 Gram-neg + anaerobes from wound side
DAY 5–7 INTRA-ABDOMINAL Spiking fever Pus from perforated Patient unwell →
(Early) ABSCESS Returning abdo pain appendix not fully pause rehab sessions
(8% of patients) Malaise + anorexia cleared Watch for: fever
Tender RIF again Pelvic/paracolic site returning, RIF pain
DAY 5+ CONTINUING Vomiting returns Ongoing sepsis Mobilise EARLY
ILEUS Distension worsens or early adhesions (best prevention)
(Obstruction) No bowel movement from surgery Report to team if
not improving
RARE PORTAL PYAEMIA HIGH fever + JAUNDICE Bacteria travel from SERIOUS — patient
(Any time) (Pylephlebitis) + RIGORS appendix → portal needs ICU
= liver abscesses vein → liver OT role paused
WEEKS LATER ADHESIVE INTESTINAL Colicky abdo pain Scar tissue (adhesions) Educate patient
(Late) OBSTRUCTION Vomiting from surgery narrow before discharge!
(Most common LATE) Distension the bowel 'If these return
Constipation → go to hospital'

⭐ DVT / PULMONARY EMBOLISM — CRITICAL FOR OT

⚠️WHY IT HAPPENS ✅ PREVENTION (OT ROLE!)

• Immobility after surgery → blood • LMWH (blood thinner) injection

pools in legs → clot (DVT) preoperatively

• Clot travels → blocks lung artery → PE • TED compression stockings

(life-threatening)
• EARLY MOBILISATION after surgery
• Signs: Calf pain/swelling (DVT), Chest
pain + SOB + ↑HR (PE) • Deep breathing exercises

• Leg exercises in bed

🏥 OT REHABILITATION CHECKLIST — POST-APPENDICECTOMY

TIMEPOINT OPEN SURGERY LAPAROSCOPIC KEY OT GOALS

DAY 1 Pain: moderate Pain: mild-moderate • Breathing exercises
NBM or sips Lighter fluids earlier • Sitting up in bed
Bed rest Sit up same day • Assess pain level
• Leg exercises
DAY 2–3 Standing + short Standing + walking • Assisted transfers
walks with support Basic self-care • Wash face/brush teeth
Light self-care independently • Short corridor walks
• Monitor for signs of
complications
DAY 3–5 Stairs assessment Usually discharged • ADL independence
(Discharge if needed day 2–3 • Stair practice
Prep) Wound still tender Much less pain • Home environment
advice
• Discharge education
DISCHARGE No lifting >5 kg No lifting >5 kg • Lifting restrictions
Advice for 6 WEEKS for 2–3 WEEKS • Wound care advice
No driving 4–6 wks Driving after 1–2 wks • Return-to-work plan
• When to seek help

Signs to Tell Patient to WATCH FOR After Discharge (Educate before they leave!)

• Wound: Increasing redness, swelling, or pus leaking = wound infection

• Abdomen: Spiking fever returning + abdominal pain = abscess (go to hospital)

• Bowel: Not opening bowels, vomiting, colicky cramps = bowel obstruction

• Chest: Sudden chest pain + shortness of breath = possible PE (call 999/112)

• General: Feeling worse after initially feeling better = something is wrong

 ⚡ RAPID REVISION — Everything at a Glance

EXAM Q&A — Top Questions

QUESTION ANSWER
Most common appendix position? Retrocaecal — 74%
Most common cause of appendicitis? Faecalith (blocked lumen)
Classic pain pattern? Central → RIF (visceral → somatic shift)
Pain BEFORE or AFTER vomiting? PAIN before vomiting (opposite in gastroenteritis)
Alvarado ≥7 means? High probability — proceed to surgery
What is McBurney's point? 2/3 from umbilicus to ASIS — maximum tenderness
Open incision options? Gridiron (McArthur) OR Lanz (skin crease)
Why bury the stump? Prevent stump leak / faecal fistula into abdomen
Most common post-op complication? Wound infection — 5–10% of cases, day 4–5
Most common LATE complication? Adhesive intestinal obstruction
What is pylephlebitis? Bacteria → portal vein → liver abscesses (fever + jaundice +
rigors)
What is the Ochsner-Sherren regime? Conservative management of appendix mass — antibiotics +
monitoring
OT priority Day 1 post-op? Breathing exercises + sitting up + leg exercises (DVT
prevention)
Lifting restriction: Open / Lap? Open = 6 weeks | Laparoscopic = 2–3 weeks

DIFFERENTIAL DIAGNOSIS — Quick Visual

CHILDREN / ALL ADULT MALE ADULT FEMALE

• Gastroenteritis • Ureteric colic • Ectopic pregnancy ⭐

• Mesenteric adenitis • Testicular torsion ⭐ • PID

• Meckel's divert. • Perforated PU • Mittelschmerz

• Intussusception • Pancreatitis • Torsion ovarian cyst

• Lobar pneumonia • Regional enteritis • Pyelonephritis

• Henoch-Schonlein • Rectus sheath • Endometriosis

purpura haematoma

💡 ⭐ Always examine scrotum in young males (testicular torsion!) | ⭐ Always do pregnancy test in women!

NEOPLASMS (Tumours) OF THE APPENDIX — Summary

TUMOUR TYPE FREQUENCY KEY FEATURE TREATMENT

NET (Carcinoid) Most common Usually at tip <1cm = Appendicectomy alone
(30% of neoplasms) Found incidentally >2cm = Right hemicolectomy
Goblet Cell Rare (<5%) Both neuro + glandular Right hemicolectomy
Carcinoma (GCC) More aggressive than NET (treat like adenocarcinoma)
LAMN/HAMN Uncommon Pushing invasion (LAMN) LAMN: Appendicectomy
(Mucinous neoplasm) or infiltrative (HAMN) HAMN: Right hemicolectomy
 Risk of PMP if perforates!
Pseudomyxoma 3.2/million/yr Abdomen fills with mucin CRS + HIPEC
Peritonei (PMP) 'Jelly belly' (Sugarbaker procedure)
Fatal without treatment 87% 5-yr survival

ONE LINE SUMMARY

Obstruction → Bacteria → Acute inflammation → Gangrene → Perforation → Mass OR Peritonitis

Diagnose: Clinical (McBurney's, Alvarado) + CT/US | Treat: Appendicectomy (open/lap)
Post-op watch for: Wound infection (day 4–5) | Abscess (day 5–7) | Late: Adhesive obstruction
OT focus: DVT prevention + early mobilisation + discharge education + lifting restrictions