Appendix
Dept. General Surgery
1st Affiliated Hospital of AHMU
Guodong Cao
Contents
• Anatomy and Embryology
• Appendicitis
• Treatment of Appendicitis
• Appendicitis in Special Populations
• Neoplasms of the Appendix
Learning Objectives
To understand
• The aetiology and surgical anatomy of acute appendicitis
• The clinical signs and differential diagnoses of
appendicitis
Loading…
• The investigation of suspected appendicitis
• Evolving concepts in management of acute appendicitis
• Basic surgical techniques, both open and laparoscopic
• The management of postoperative problems
• Less common conditions encountered
ANATOMY AND PHYSIOLOGY
Enlarged image
caecum
ileum
ileocecum
appendix
阑尾动脉
Appendicular artery
mesenterium
The various positions of the appendix
Loading…
ANATOMY AND PHYSIOLOGY
Right lowerr Pelvicr
Under the right rib
Location of
appendix
Left-sided caecum and appendix due to
intestinal mal-rotation
ANATOMY AND PHYSIOLOGY
• A large concentration of lymphoid
follicles
• Probably has some physiological
functions related to immune
ACUTE APPENDICITIS
Overview
• The most common acute surgical emergency
of the abdomen (acute abdominal disease).
• Occurs most often between the ages of 10
and 30.
• The current annual incidence is 10 cases per
100,000 population.
• The overall mortality rate of 0.2-0.8% is
attributable to complications of the disease
rather than to surgical intervention.
Essentials of Diagnosis
• Abdominal pain
eating weight
disorder : abnormally body weightdistorted perception of
·
fear of
gainingmeight
• Anorexia, nausea and vomiting
• Localized right lower quadrant abdominal
tenderness Loading…
• Low-grade fever
where white blood cell
count
• Leukocytosis conditionthe normal range
is
-
.
above
cont love
white blood celt
Leukocytopenial
Leukopenia
.
Cause and Pathology
• Obstruction of the proximal lumen has long
been considered to be the major cause of
acute appendicitis.
• For example --- fibrous bands, lymphoid
hyperplasia, fecaliths, calculi, or parasites
Bacteria Commonly Isolated
in Perforated Appendicitis
Disease process & Severity Pathology Serosal layer
became deeper in color with
hyperaemia and hydroncus
heavy hyperaemia and
hydroncus, Purulent liquid
exudation on the surface
Simple Suppurative
The symptoms of peritonitis
are relatively mild
high pressure, necrosis of
appendix tissue, pus entering the Greater omentum wrap the
abdominal cavity purulent liquid
Perforated and gangrenous Appendiceal mass
·
Risk factors for perforation of the
appendix
• Extremes of age
• Immunosuppression
• Diabetes mellitus
• Faecolith obstruction
• Pelvic appendix
• Previous abdominal surgery
Clinical Findings
Symptoms
Begins with midabdominal discomfort
followed by nausea, vomiting, anorexia and
Indigestion. Within several hours the pain shifts
to the right lower quadrant and becomes
localized
Clinical Findings
B. Signs
Localized tenderness
(McBurney’s point)
[Location: 1/3 from anterior
superior iliac spine to
umbilicus]
Slight muscular guarding
Rebound or percussion
tenderness
Temperature is only slightly
elevated
Obturator
Sign
Raise right leg
Psoas
Sign
Extend right leg backwards
Rovsing press the abdomen, make
the gas in colon to the
Sign ileocecum
Clinical Findings
C. Laboratory Findings & Imaging Studies
Blood routine testing
Leukocyte count is over 10×109/L
White count shows more than 75%
Plain films are nonspecific
CT and Ultrasound are not reliable in some
cases
Imaging of
Ultrasound & CT of
Appendicitis
CT scan of the abdomen demonstrating
classic findings of acute appendicitis
• A, Sagittal view with arrow demonstrating a thickened, inflamed, and fluid-
filled appendix (target sign)
• B, Coronal view of same patient. The arrow points to the thickened,
elongated appendix with periappendiceal fat stranding and fluid around the
appendiceal tip
• Sagittal (A) and coronal (B) CT images demonstrate an appendiceal
abscess in a patient who presented with a 2-week history of
abdominal pain and was found to have a palpable mass on
examination.
The arrows point to a periappendiceal abscess cavity. She was
successfully managed with percutaneous drainage and antibiotic
therapy.
• CT scan of the abdomen
in a patient with a
benign
10-cm mucocele. The
axial image shows a
distended fluid-filled
mass medial to the
appendix (arrow),
without associated
inflammation.
• C=Cecum;
• TI=terminal ileum
Remembering
(1) Localized tenderness over McBurney’s
point is the cornerstone of diagnosis
(2) Never place appendicitis lower than
second in the differential diagnosis of
acute abdominal pain
Special Cases
Pregnant women :
• Do not experience
the classic symptoms
• The appendix tip is
rotated medially by
the gravid uterus
Appendicitis During Pregnancy
• The most common non-obstetric surgical disease
of the abdomen during pregnancy.
• The most common presentation is right lower
quadrant pain and tenderness, but the enlarged
uterus will probably push the appendix into the
right upper quadrant (give rise to pain in this
location)
• The main problem is to recognize the possibility
of appendicitis and perform appendectomy
(laparoscopic appendectomy is better) promptly.
Special Cases
Infants :
• Without a clear history
• Symptoms vary widely
• Leading to the
perforation easily
Special Cases
The elderly :
• A slight fever and
abdominal pain
Loading…
• Worse body condition
• More time to recover
Diagnosis and Differential Diagnosis
Diagnosis
1) Pain shifts to the right lower quadrant and becomes
localized
2) Localized tenderness (McBurney’s point)
3) Leukocyte count is over 10×109/L and white count
shows more than 75%
Differential Diagnosis
4) Difficult in the very young and in the elderly
5) Highest incidence of false-positive diagnosis (20%)
is in women between ages 20 and 40 (pelvic
inflammatory disease and other gynecologic
conditions)
Differential diagnosis of acute appendicitis
Children Adult Adult female Elderly
Gastroenteritis Regional enteritis Mittelschmerz Diverticulitis
Mesenteric adenitis Ureteric colic Pelvic inflammatory Intestinal
disease obstruction
Meckel’s Perforated peptic Pyelonephritis Colonic carcinoma
diverticulitis ulcer
Intussusception Torsion of testis Ectopic pregnancy Torsion appendix
epiploicae
Henoch-Schonlein Pancreatitis Torsion/rupture of Mesenteric
Purpura ovarian cyst infarction
Lobar pneumonia Rectus sheath Endometriosis Leaking aortic
haematoma aneurysm
Complications
A. Perforation
Accompanied by more severe pain and higher
fever
B. Peritonitis
Implies gross perforation, increasing tenderness
and rigidity, abdominal distention, adynamic ileus,
high fever and severe toxicity mark progression
Complications
C. Appendiceal Abscess (Appendiceal
mass)
Cause: Periappendiceal infection becomes walled off
by omentum and adjacent viscera
Diagnosis: Appendicitis plus right lower quadrant
mass, ultrasound or CT
Treatment: Percutaneous ultrasound-guided
aspiration; Antibiotics and expectant management
followed by elective appendectomy 6 weeks later;
Immediate appendectomy
Complications
D. Pylephlebitis
Suppurative thrombophlebitis of the portal venous
system
The most dangerous complication
Presentation: Chills, high fever, low-grade jaundice,
hepatic abscesses
CT is the best means of detecting thrombosis and gas
in the portal vein
Treatment: Prompt surgery and vigorous antibiotics
Treatment
• Main treatment is surgery (appendectomy)
• Performed by open or laparoscopy
operation
• Prophylactic antibiotics: Preoperatively and
single-drug regimen
• Abdominal drains only to treat established
abscesses
• Antibiotics alone in few conditions
Criteria for stopping conservative
treatment of an appendix mass
• A rising pulse rate
• Increasing or spreading abdominal pain
• Increasing size of the mass
Preoperative investigations in appendicitis
• Routine
• Full blood count
• Urinalysis
• Selective
• Pregnancy test
• Urea and electrolytes
• Supine abdominal radiograph
• Ultrasound of the abdomen/pelvis
• Contrast-enhanced abdomen and pelvic CT scan
Open Appendectomy
• A, Left, Location of possible
incisions for an open
appendectomy
• A, Right, Division of the
mesoappendix
• B, Ligation of the base and division
of the appendix
• C, Placement of purse-string suture
or Z stitch
• D, Inversion of the appendiceal
stump
• A, Upper left, Location of port sites
for laparoscopic appendectomy.
Right, Division of the mesoappendix
using the harmonic scalpel
• B, placement of an absorbable
Endoloop encircling the base of
the appendix
• C, Division of the appendix
between Endoloops
• D, placement of the appendix into
a specimen bag before removal of
the appendix with the umbilical port
Laparoscopic appendectomy
• A, Visualization and upward retraction of appendix.
• B, Division of mesoappendix using harmonic scalpel.
• C, Application of endoloops to appendix. Two loops are used to secure the base; a
third loop is applied distally to avoid spillage of the luminal contents. The specimen is
then divided between the endoloops.
• D, View of completed appendectomy after removal of the specimen.
(Note: Depending on the surgeon’s preference, an endoscopic stapling device may
be used to divide the mesoappendix and appendix instead of the harmonic scalpel
and endoloops.)
Do you know NOTES?
NOTES (natural orifice transluminal endoscopic
surgery)
Complications of Appendectomy
. Incision infection:
Highest incidence (2.8~20%)
Diagnosis: Complaint & Sign & Lab Investigation
Prevention: Sterile --- Infective --- Sterile
Treatment: Change dressings & Antibiotics
. Bleeding:
Most dangerous
Cause: Iatrogenic more than pathologic
Presentation: Hemorrhagic shock & Peritoneocentesis
Treatment: Conservation or Laparotomy
Complications of Appendectomy
C. Peritoneal abscess
Cause: Serious infection, unthorough ablution
Prevention: Drainage
D. Adhesive ileus
Early or late onset
Prevention: Thorough ablution & Early mobilization
E. Stump infection of appendix
Cause: Stump > 1cm
F. Fecal fistula
Cause: Too short or serious infectious stump
Prognosis
• Death rate in simply acute appendicitis is
approximately 0.1%
• Death rate in perforative appendicitis is
about 5%
• Postoperative infections still occur in 30%
of cases of gangrenous or perforated
appendix
CHRONIC APPENDICITIS
• Pain lasts for 3 weeks
• Acute illness compatible with acute
appendicitis nonoperatively
• Barium X-ray are sometimes helpful
Barium X-ray
0 4 24 h
h h
TUMORS OF THE APPENDIX
• Benign tumors --- appendectomy
• Appendix is the commonest location of
carcinoid tumors of the gastrointestinal
tract. Treatment --- appendectomy or right
hemicolectomy (more aggressive lesions)
• Adenocarcinoma --- right hemicolectomy
• Mucocele --- appendectomy
Summary (Acute Appendicitis)
• The most common acute surgical emergency of the
abdomen.
• Pathology (4 types): simple, suppurative, gangrenous &
perforative, appendicealmass
• Diagnosis: Pain shifts to the right lower quadrant and
becomes localized; Localized tenderness (McBurney’s
point); Leukocyte count is over 10×109/L and white count
shows more than 75%
• Complications: Perforation; Peritonitis; Appendiceal
Abscess; Pylephlebitis
• Complications of appendectomy: Incision infection;
Bleeding; Peritoneal abscess; Adhesive ileus; Stump
infection of appendix; Fecal fistula
• Main treatment is surgery (appendectomy)