Appendix
Surgery
Presentation
Appendix Outline:
Introduction (Basic medicine)
Anatomy + Physiology
Appendicitis
Etiology
Pathophysiology
History
Clinical Examination + Findings
Diagnosis + Imaging and Laboratory Investigations
Surgical Management
Case presentation and Differential Diagnosis
Q/A
Anatomy of Appendix
What About the Site?
Base of the appendix is located at the
McBurney point (2/3 the distance from the
umbilicus & 1/3 the distance from the right
ASIS)
[Link]/retrocolic (most common)
[Link]/descending
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[Link]
[Link]/postileal
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Neurovascular & Lymphatics
Blood Supply Venous Drainage Lymphatics
Abdominal Aorta SMA Appendicular V. Ileocecal V. Ileocecal LN Superior Mesenteric L
Ileocecal A. Appendicular A. SMV Portal V. Preaortic LN
Innervation:
Sympathetic: Lesser Splanchnic N. (Pre-ganglion) Superior Mesenteric Plexus
Parasympathetic: Vagus Nerve
Appendicitis
Epidemiology
Incidence: 10–19 years of age
♂ ♀
Sex: >
Etiology
Obstruction of the appendiceal lumen
Fecalith in adults, lymphoid hyperplasia in children
Lymphoid tissue hyperplasia (60% of cases): most common cause in children and
young adults
Appendiceal fecalith (concretion of feces that develops in the appendix that can
obstruct the appendiceal lumen) and fecal stasis (35% of cases): most common cause in
adults
Neoplasm (uncommon): more likely in patients > 50 years of age
Parasitic infestation
Pathophysiology
Obstructed proximal appendiceal lumen (closed-loop obstruction),
resulting in:
Stasis of mucosal secretions → bacterial multiplication and local
inflammation → transmural spread of infection → clinical features of
appendicitis
Increased intraluminal pressure → obstruction of veins → edema of the
appendiceal walls → obstruction of capillaries → ischemia →
gangrenous appendicitis with/without perforation
Inflammation can spread to serosa, leading to peritonitis
How To Diagnose
Appendicular
Disoreders??
Patient History
History:
Age: 10 – 19 years Periumbilical colic
Gender: Male > Female (higher incidence in males) Pain shifting to the Right iliac fossa
Past Medical History (PMHx): Free Anorexia
Past Surgical History (PSHx): Free Nausea
Symptom Timeline
1. Acute Onset
Vague abdominal pain
2. Within Hours
Pain localizes to the right lower quadrant (RLQ)
3. Within 48 Hours
This is the usual time of presentation for appendicitis
4. After 5 Days
High-grade fever
Tender mass in the RLQ
Physical Examination
1- McBurney point (RLQ) tenderness
2- Blumberg Sign (Rebound tenderness)
3- RLQ Rigidity or Guarding
4- Lanz point tenderness
5- Rovsing sign positive
6- Sherren Triangle Hyperesthesia
7- Right rectal wall tenderness on PR exam if the appendix is in the pelvis
8- Psoas sign positive
9- Obturator Sign positive
Rovsing Sign
Deep palpation of the LLQ elicit pain at
RLQ, because we increase intraluminal
pressure in the desc. Colon, which is
transmitted to the cecum & appendix,
irritating the parietal peritoneum
Psoas Sign
On hip flexion against resistance, or on
passive hip extension.
The pain produced as a result of irritated
psoas muscle, or trapping of inflamed
appendix between psoas and parietal
peritoneum
Obturator Sign
On hip and knee flexion & hip internal
rotation.
The pain produced as a result of irritated
Obturator internus muscle, or trapping of
inflamed appendix between muscle and
parietal peritoneum
Management
[Link] Management
[Link]
[Link]
Supportive care:
Keep patient NPO (Nil Per Os – nothing by mouth).
IV fluids for hydration and electrolyte balance.
Analgesia (e.g., IV paracetamol, NSAIDs, or opioids if severe pain).
Antiemetics (e.g., ondansetron or metoclopramide).
Assess Likelihood of Appendicitis:
Consider patient demographics (age, sex).
Evaluate clinical features (e.g., right lower quadrant pain,
rebound tenderness, fever).
Perform initial laboratory studies (CBC, CRP, urinalysis).
Use appendicitis risk scores (e.g., Alvarado score).
Alvarado Score
Scoring tool: Alvarado score (MANTRELS)
Laboratory Studies
Labs
CBC Mild leukocytosis, Lt shift
CRP Elevated
BMP Electrolyte abnormalities if severe
vomiting or diarrhea
Usually normal, but pyuria &
Urinalysis hematuria may be seen (ureter infl)
B-hCG To Rule out ectopic pregnancy
Imaging
First Line Imaging:
Ultrasound
CT-Abdomen
First-Line Imaging
Non-pregnant adults:
CT abdomen (most accurate initial modality)
Ultrasound abdomen (alternative option)
Pregnant adults & children:
Ultrasound abdomen (preferred due to safety)
Ultrasound Findings Suggestive of
Appendicitis
Primary findings:
Distended appendix (diameter > 6 mm)
Non-compressible, aperistaltic, distended
appendix
Target sign: Concentric rings of hypo- and
hyperechogenicity in the axial/transverse section
CT Findings (with IV contrast)
Most accurate initial imaging modality
Supportive findings:
Distended appendix (diameter > 6
mm)
Edematous appendix with
periappendiceal fat stranding
CT showing a dilated, thick-walled, fluid-
filled appendix containing appendicoliths, Coronal CT- Normal Appendix
indicating Acute Appendicitis
Surgical
Management
[Link] Appendectomy
[Link] Appendictomy
Incision Choices:
Gridiron (McBurney's) incision: Right-angled to ASIS-umbilical line at McBurney’s point.
Lanz incision: Transverse skin crease incision for better exposure.
Lower midline incision: Preferred for uncertain diagnosis or obstruction.
Rutherford Morison incision: For fixed retrocecal appendix.
Open Appendectomy
Laparoscopic Appendectomy
Non-operative Treatment
Empiric parenteral antibiotic therapy for 2–3 days
Supportive care
Periappendiceal abscess > 4 cm: image-guided
percutaneous drainage
Complications
1. Perforated Appendix
2. Appendiceal Abscess
3. Phlegmon (mass)
4. Pylephlebitis
5. Gangrenous
Thank You