Learning objectives

❑To understand:
ØThe aetiology and surgical anatomy of acute appendicitis
ØThe clinical signs and differential diagnoses of appendicitis
ØThe investigation of suspected appendicitis
ØEvolving concepts in the management of acute appendicitis
ØBasic surgical techniques, both open and laparoscopic
ØThe management of postoperative problems
 Introduction and Anatomy

Appendix:- It is a blind muscular tube with 4 layers (mucosal, submucosal, muscular

and serosal layers) , and its average length is between 7.5 and 10 cm.

• The function of appendix is not entirely clear but it may have important roles
in both immune function and maintaining gut microbiota

• At birth, the appendix is short and broad at its junction with

the caecum, but typical become tubular structure by age of 2 years.
 Introduction and Anatomy

• In approximately one-quarter of cases, rotation of the appendix does not occur into retrocaecal
intraperitoneal position by growth of the caecum , resulting in a pelvic, subcaecal or paracaecal
position.
• Rarely, the caecum does not migrate during development to its normal position So the appendix can
be found near the gall bladder.
• Or it found in in the left iliac fossa in intestinal malformation.
 Introduction and Anatomy

The position of the base of the appendix is constant, being found at the confluence of the
three taeniae coli of the caecum which fuse to form the outer longitudinal muscle coat of
the appendix.
At operation a gentle traction on the taeniae coli, will lead the operator to the
base of the appendix.
 Introduction and Anatomy

• Blood supply: The appendicular artery, a branch of the lower division of the ileocolic artery.

• lymphatics: Four, six or more lymphatic channels traverse the mesoappendix to empty into the
ileocaecal lymph nodes.

• Nerve supply: derived from sympathetic elements contributed

by the superior mesenteric plexus (T10-L1).
 Acute appendicitis

Acute appendicitis is the most common cause of an ‘acute abdomen’ in young adults.

Appendicectomy is the most frequently performed urgent abdominal operation.

Acute appendicitis is relatively rare in infants and becomes increasingly common in childhood and early
adult life, reaching a peak incidence in the teens and early 20s.

• After middle age, the risk of developing appendicitis is quite small.

• The incidence of appendicitis is equal among males and
females before puberty.
• In teenagers and young adults, the male–female ratio increases
to 3:2 at age 25; thereafter, the greater incidence in males
declines.
 Acute appendicitis

Aetiology:
There is no unifying hypothesis regarding the aetiology of acute appendicitis.
1- Decreased dietary fibre and increased consumption of refined carbohydrates may be
important.
2- Bacterial proliferation within the appendix No single organism responsible, a mixed growth of aerobic
& anaerobic organisms is usual.
3- Obstruction of the lumen play important
factor in developing acute appendicitis
Acute appendicitis
 Acute appendicitis

Pathology:
Once obstruction occurs;
• Continued mucus secretion and inflammatory exudation.
• Increase intraluminal pressure.
• Obstructing lymphatic drainage and further distention of the appendix may cause venous obstruction
& ischemia of the appendicular wall.

Finally, ischaemic necrosis of the appendix wall produces gangrenous appendicitis, with free bacterial
contamination of the peritoneal cavity.
 Acute appendicitis

Pathology:
• Alternatively, the greater omentum and loops of small bowel become
adherent to the inflamed appendix, walling off the spread of peritoneal
contamination and resulting in a phlegmonous mass or paracaecal abscess.

• Rarely, appendiceal inflammation resolves, leaving a distended

mucus-filled organ termed a mucocele of the appendix.
 Acute appendicitis

The great threat of acute appendicitis is Peritonitis and occur as result of perforation of a gangrenous
appendix or the delayed perforation of an appendix abscess.

Risk factors for perforation of the appendix:

1. Extreme of age.
2. Immunosuppression.
3. D.M.
4. Fecalith obstruction of the lumen.
5. Pelvic appendix
6. Previous abdominal surgery

• In these situations, a rapidly deteriorating clinical course

is accompanied by signs of diffuse peritonitis
and systemic sepsis syndrome
 CLINICAL DIAGNOSIS
History:
1- Pain:-
The classical features begin with poorly localised colicky rapid abdominal
pain, aggravated by movement or cough.
• At first Pain is most marked in periumbilical area because Visceral
pain fibers from the appendix travel along the sympathetic to the
periumbilical region. nervous system and enter the spinal cord at the
level of T10 corresponds.
With progressive inflammation of the appendix, the parietal peritoneum
in the right iliac fossa becomes irritated produce localised ,sharp somatic
pain.

• The classic visceral–somatic sequence of pain is present in only about

half of the patients
 CLINICAL DIAGNOSIS
History:
2- Anorexia:- is a useful and constant clinical feature
3- Nausea nearly always present with Vomiting which occurs once or twice
only & if persistant , it indicates complications.
4- Constipation is common but diarrhea may be present .
5- slight pyrexia with a corresponding increase in the pulse rate.
 CLINICAL DIAGNOSIS
History:
Atypical presentation:-
• pain that is predominantly somatic or visceral and poorly localised specially in the elderly, in whom
localization to the right iliac fossa is unusual.
• Pelvic inflamed appendix may never produce somatic pain instead cause suprapubic discomfort
and tenesmus. tenderness may be elicited only on per-rectal examination.

Timing of symptoms progression:-

Typically, two clinical syndromes of acute appendicitis can be seen:
1- acute catarrhal (non-obstructive) appendicitis.
2- acute obstructive appendicitis.

The later is characterised by a much more acute course (sudden generalised abdominal pain - vomiting
- normal temperature or mild fever) may mimic acute intestinal obstruction. And need urgent surgical
intervention (perforation risk high)
 CLINICAL SIGNS
On general examination the patient look unwell with low-grade pyrexia and might have tachycardia

On abdominal examination:-
1- limitation of respiratory movement in the lower abdomen with localized tenderness
2- Muscle guarding (over the point of maximum tenderness, McBurney’s point)
3- Rebound tenderness
• Asking the patient to cough or gentle percussion over the site of maximum tenderness
 CLINICAL SIGNS
4-Signs to be elicited in acute appendicitis:
A- pointing signs:
• The patient is then asked to point to where the pain began and where it
moved.
B- Rovsing’s sign:
• pressure on the left iliac fossa causes pain in the right iliac fossa due to
displacement of gases from the pelvic colon to the appendix.
C- psoas sign:
• inflamed appendix lies on the psoas muscle, and the patient,
often a young adult, will lie with the right hip flexed for pain relief.
D- Obturator sign:
• pain in the hypogastrium due to Spasm of the obturator internus by
inflamed appendix when the hip is flexed and internally rotated.
CLINICAL SIGNS
CLINICAL SIGNS
summary
Special features
according to
the position
of appendix
Special features
Retrocecal:
o Rigidity is often absent in abdomen but present in quadratus
lumborum.
o silent appendix (deep pressure fail to elicit tenderness) due to
distended cecum anteriorly.
o Deep tenderness in the loin.
o Psoas spasm (sign):
appendix→ in contact with the muscle→ flexion of hip joint
→ Hyperextension of hip joint→ abdominal pain
Special features
pelvic:
o Tenderness is just above and to right side of the symphysis pubis
and on Rectal Exam.
o Spasm of the Psoas and Obturator Internus muscles. (both signs
are positive)
o Increased frequency, urgency & diarrhea (due to irritation of
Urinary bladder and rectum)
o Absence of abdominal pain and rigidity.
Special features
Post-ileal:
o Inflamed appendix just behind terminal ileum
o Greatest difficulty in diagnosis (Pain does not shift)
o Diarrhea is marked feature
o Tenderness in right side of umbilicus (ill defined).
Special Signs
According to Age
Group
Special signs
Infants:
o rare in infants.
o Not able to speak.
o Appendix has a wide base (shorter tube).
o High risk for rupture and diffuse peritonitis (underdeveloped
omentum).

Children:
o Prominent features are vomiting & anorexia.
Elderly:
o Decrease Sensitivity to pain.
o No shifting of pain.
o Increase risk to develop gangrene and perforation.
o High mortality rate (especially in HTN or diabetes).
Special signs
Pregnant:
-Commonly mistaken for other conditions (pain of pregnancy) due
to similar symptoms.
-Most common Extrauterine pain is appendicitis
-Risk factor for fetal loss.
-Pain may be in upper quadrant due to push of cecum and appendix
by gravid uterus

Obese: too much subcutaneous fat, no signs, Do laparoscopy for

diagnosis
Differential Diagnosis
 Diagnosis
The diagnosis of acute appendicitis is essentially clinical however, a decision to operate based on
clinical suspicion alone can lead to the removal of a normal appendix in 15- 30% of cases.

A number of clinical and laboratory-based scoring systems have been devised to assist diagnosis The
most widely used is the Alvarado score.
Diagnosis
Calculate Alvarado score

Score 5-6 (equivocal), abdominal

score of 7 or more is strongly ultrasound or contrast enhanced CT
predictive of acute appendicitis. examination reduce the rate of
negative appendicectomy.
 Investigation
Abdominal ultrasonography is more useful in children and thin adults, particularly if gynaecological
pathology is suspected, with a diagnostic accuracy 90%.

Low dose protocols which reduce the radiation dose to the patient may applied when considering a
diagnosis of acute appendicitis, particularly in the younger adult.

Contrast enhanced standard dose CT is especially useful in patients in whom there is diagnostic
uncertainty, particularly older patients, where acute diverticulitis, intestinal obstruction and neoplasm
are likely differential diagnoses.
Investigation
Abdominal ultrasound

Ultrasound image of the right iliac

fossa demonstrating a mildly
enlarged appendix, measuring 8
mm in diameter,
Arrow indicates a small pocket of
free fluid more inferiorly in the RIF
Investigation
Appendicitis with target sign

Ultrasound of the appendix (axial view)

The diameter of the appendix is
increased to 12.1 mm.
The wall has hyperechoic and
hypoechoic layers due to inflammation
and resulting edema;, this sign is
termed target sign.
Investigation
Perforated appendicitis due to fecalith

CT abdomen (IV contrast; axial section)

There is distension of the appendix with
periappendiceal edema and
mesenteric fat stranding. A well-defined,
round, hyperdense lesion (black arrow),
characteristic of an appendiceal fecalith, is
seen at the proximal end of the
appendiceal lumen. A small pocket of
extraluminal air (red overlay) is also visible
near the distal appendix.
Investigation
Preoperative investigations in appendicitis:

• full blood count

Routine • urinalysis

• Pregnency test
• Urea and electrolytes
• C-reactive protein
Selective • Supine abdominal radiograph
• Ultrasound of abdomen, pelvis
• Contrast enhanced abdomen and pelvic ct scan
(consider low dose protocol in young adults).
Management
Non-operative management:
uncomplicated appendicitis
Appendicular mass

Operative management
Management
Conservative management:
Uncomplicated Appendicitis : Less severe, no mass, no perforation, no peritonitis.
Managed conservatively:
• Pain management (painkillers).
• IV fluids
• NPO (nothing by mouth).
• IV antibiotics:
-Metronidazole (for anaerobes).
- 3rd generation Cephalosporins (e.g., Ceftriaxone for G-ve bacteria, E coli).
Management
Management of an appendix mass:
The standard treatment is the conservative Ochsner–Sherren regime:
1. Monitor Vital Signs: Regular checks for PR, BP, Temperature, repeated abdominal exam.
2. Make a circle by a pen on abdomen to detect size of the mass.
3. Resuscitate: IV fluids (hydration), antibiotics (metronidazole for anaerobes, ceftriaxone for G-ve),
painkiller.
4. CT or Ultrasound to exclude other diagnoses, If abscess is present, Perform drainage.

• Clinical improvement is usually evident within 24-48 hours.

• Failure of the mass to resolve should raise suspicion of a carcinoma or Crohn's disease.

• Using this regimen, approximately 90% of cases resolve without incident.

Management
Criteria for stopping conservative treatment an appendix mass:
• A rising pulse rate

• Increasing or spreading abdominal pain

• Increasing size of the mass

Management
Operative management:
The traditional treatment for acute appendicitis is appendicectomy.
The operation is preceded by a short period of intensive preoperative
preparation which is:
1- Nill by mouth.
2- Intravenous fluids, sufficient to establish adequate urine output
(catheterization is needed only in the very ill),and appropriate
antibiotics should be given.

Risk factors for venous thromboembolism should be considered

and appropriate prophylaxis (mechanical and/or pharmacological)
initiated.
Management
Operative management:
• There is evidence that, in the absence of purulent peritonitis, a
single perioperative dose of antibiotics reduces the incidence
of postoperative wound infection.

• When peritonitis is suspected, therapeutic intravenous

antibiotics to cover Gram-negative bacilli as well as anaerobic
cocci should be given.
• Hyperpyrexia in children should be treated with salicylates in
addition to antibiotics and intravenous fluids.
• Appendicectomy should be performed under general anesthesia
with the patient supine on the operating table and may be
undertaken using either an open or laparoscopic approach.
Management
Operative management:
Incisions of appendectomy;
Open Appendectomy
1- At McBurney point: between umbilicus and ASIS 2\3 away from
umbilicus
- Grid Iron incision: (Not cosmetic), Muscle splitting incision, Not cutting
(Muscle sparing)
- Rutherford incision: cutting muscle , give better access if appendix in para
or retrocecal position
2- Lanz incision: Imaginary line at Mid clavicular line, 2 cm below umbilicus,
At midway below ASIS & symphysis Pubis (The most cosmetically
appealing). better exposure and easier extension and small size.
3- Lower midline abdominal incision: when diagnosis in doubt and bowel
obstruction.
Management
Operative management:
Laparoscopy:
• When the appropriate equipment and expertise are available and
cost allows; the laparoscopic approach is advantageous.

• The initial laparoscopy allows the diagnosis to be established and

may reduce the negative appendicectomy rate.

• Furthermore, the patient may benefit from the quicker recovery

afforded by a minimally invasive approach, the rate of wound infection
is lower (when compared with open surgery).
Management
Operative management:
1- A normal appendix is found:
careful exclusion of other possible diagnoses (terminal ileitis, Meckel's diverticulitis, tubal or ovarian
causes).
It is usual to remove the appendix to avoid future diagnostic difficulties, even though the appendix
is normal, particularly if a skin crease or gridiron incision has been made.
2- The appendix cannot be found:
The caecum should be mobilized, and the taeniae coli should be traced to their confluence on the
caecum before the diagnosis of 'absent appendix' is made.
3- An appendicular tumour is found:
Small tumours (under 2.0 cm in diameter) can be removed by appendicectomy; larger tumors
should be treated by a right hemicolectomy.
4- An appendix abscess is found and the appendix cannot be removed easily;
This should be treated by local peritoneal toilet, drainage of any abscess and intravenous
antibiotics. It may be impossible to find the appendix and, occasionally, a faecal fistula may form.