Gastrointestinal Surgery : Part 2 93
Appendictis 00:47:34 ----- Active space -----
Surgical Anatomy :
• Appendicular artery : Branch of lower division of ileocolic artery.
• Appendicular base : Junction of 3 taenia coli.
Preileal : 1%
Postileal : 0.5%
• L/c
Retrocaecal • Most difficult to diagnose.
(M/c) : 74% Pelvic : 21%
Paracaecal : 2%
Subcaecal : 1.5%
Symptoms :
1. Pain abdomen. 3. Anorexia
2. Nausea & vomiting (M/c) 4. Fever
Signs :
1. McBurney’s point tenderness.
2. Rovsing sign : Pain in RIF on pressing LIF.
Umbilicus
3. Psoas sign : Pain in RIF on flexion against resistance.
2/3rd
4. Obturator sign : Flexion + internal rotation of hip Pain. ASIS 1/3 rd
5. Dunphy’s sign : Pain on coughing.
McBurney’s point
Modified Alvarado (MANTRELS) Score :
Finding Score
Migration of pain to right lower quadrant 1
Anorexia 1
Nausea & vomiting 1
Score >7 : Likely appendicitis
Tenderness in right lower quadrant 2
Rebound pain 1
Elevated temperature 1
Leukocytosis 2
Left shift of WBC 1
Possible total 10
Investigations :
1. CECT : IOC in adults.
2. USG : IOC in children.
- Blind ending tubular structure.
- Probe tenderness.
- Periappendiceal fluid collection. USG
Surgery Revision • v4.0 • Marrow 8.0 • 2024
94 Surgery
----- Active space ----- Mangement (Appendicectomy) :
Do not crush the base.
• Inflamed base
Bury with purse string suture.
• Gangrenous base : Right hemicolectomy.
• Appendix not inflamed : Rule out meckel’s diverticulum (Distal 2 fe%t of ileum).
Appendicectomy 00:52:38
Incisions Used :
1. McBurney’s incision :
- Grid iron : Muscle split&ing.
- Rutherford morrison : Muscle cut&ing.
2. Lanz/skin crease/bikini incision :
Bet&er cosmesis.
3. Lower midline abdominal incision :
For perforated appendix.
Note : Gibson’s incision Renal trasplant
(Above inguinal ligament) (To identify ureter)
Structures Passed :
1. Skin
2. Superficial fascia.
3. External oblique aponeurosis.
4. Muscles
5. Peritoneum
Complications :
1. Wound infection (M/c).
2. Ble%ding.
3. Portal pyemia.
4. Stump appendicitis (If stump >4m().
Lap. appendicectomy
Other Conditions Of Appendix 00:55:09
Appendicular Perforation :
• Omentum dysfunction.
• Se%n in :
- Children - Pregnant females.
- Elderly - Im(unocompromised patients.
- Adhesions
Surgery Revision • v4.0 • Marrow 8.0 • 2024
Gastrointestinal Surgery : Part 2 95
Appendicitis in Pregancy : ----- Active space -----
• M/c non obstetrical emergency. • ↑ Risk of preterm labor/abortions.
C/f : Pain in RIF (Can be higher up also).
Ix : USG if uncomfirmed MRI.
Mx : Lap. appendicectomy in all trimesters.
Appendicular Lump :
Mx : Ochsner-Sherren regime (Conservative).
Monitor : Mx :
• Size of lump. • NPO.
• Tenderness. • IV fluids
• Temperature. • IV antibiotics.
• Pulse rate. • Analgesics.
Outcomes
Recovers : Deteriorates (↑Pain, fever & lump size) :
• Discharge. • Suspect abscess.
• Interval appendicectomy • Extraperitoneal drainage
after 6 we%ks. (Pigtail catheter).
Tumours Of Appendix 00:58:13
Neuroendocrine Tumour (NET) of Appendix :
• M/c tumour of appendix (AKA carcinoid of appendix).
• M/c site : Tip of appendix.
C/f :
• Pain & appendicitis.
• May be detected incidentally.
Mx :
1. Close to the base & >2 cm : Right hemicolectomy.
2. Close to the tip & <2 cm : Simple appendicectomy.
Epithelial Tumours :
A. Non-mucinous : Adenocarcinoma (Mx : Same as colorectal cancer).
B. Mucinous : Gives rise to pseudomyxoma peritoni).
• Mucinous deposits in the peritoneum Obstruction, distention.
• Mx : Cytoreductive Sx HIPEC.
- Hyperthermic intraperitoneal chemotherapy.
- With Paclitaxel/Mitomycin-C at 41-44˚C.
• Se%n in appendicular, ovarian & 1˚ peritoneal tumours.
Surgery Revision • v4.0 • Marrow 8.0 • 2024
