Surgery Rotation CLERKSHIP

crucial role in capacitance by undergoing receptive relaxation

ILOILO DOCTORS’ COLLEGE OF MEDICINE site of the autonomic pacemaker responsible for initiating
Molo, Iloilo City S.Y. 2020-2021 gastric motor activity inferior extent of the fundus is
considered to be the horizontal plane of the GE junction
BATCH 2021
DISCIMUS SAPIENCIA UT VIRTUS Body/ Corpus: from the cardiac orifice to the incisura
angularis (angular notch) this contains most of the
SURGERY CLERKSHIP oxyntic or parietal cells that are also present in cardia
and fundus which secrete HCl and intrinsic factors.
LECTURER: DR. BITO-ONON
MAIN TOPIC: STOMACH Antrum: from the incisura angularis to the pylorus
forms the distal 25-30% of stomach

ANATOMY:
ARTERIAL AND VENOUS SUPPLY
ARTERIAL SUPPLY
Lesser Curvature:
-Right gastic artery
-Left Gastric artery
Greater Curvature:
-Right Gastroepiplioc Artery
-Left Gastroepiploic Artery
Fundus:
-Short Gastric Artery
VENOUS DRAINAGE
-Tributaries of Portal Vein
-Tributaries of Splenic Vein
-Tributaries of Superior Mesenteric Vein

NOTES: The arteries are derived from the branches of the

celiac artery.
MAIN PARTS:
The left gastric artery arises from the celiac artery. It supplies
• CARDIA
the lower third of the esophagus and the upper right part of
• FUNDUS
the stomach.
• BODY (CORPUS)
The right gastric artery arises from the hepatic artery. It
• ANTRUM
supplies the lower right part of the stomach.
• PYLORUS
The left gastroepiploic artery arises from the splenic
NOTES: The stomach is the most proximal abdominal organ of
artery at the hilum of the spleen and passes forward in the
the digestive tract and function in storing and facilitates the
gastrosplenic omentum (ligament) to supply the stomach
digestion and absorption of ingested food and helps regulate
along the upper part of the greater curvature.
appetite. Important secretory functions include the
production of acid, pepsin, intrinsic factor, mucus, and a
The right gastroepiploic artery arises from the
variety of GI hormones. Important motor functions include
gastroduodenal branch of the hepatic artery, supplies the
food storage (receptive relaxation and accommodation),
stomach along the lower part of the greater curvature.
grinding and mixing, controlled emptying of ingested food,
and periodic interprandial “housekeeping.”
The short gastric arteries arise from the splenic artery
at the hilum of the spleen and pass forward in the
Cardia: connects to the esophagus first region of the
gastrosplenic omentum (ligament)
stomach into which material (food) passes important for HCl
secretion
The veins drain into the portal circulation. The left and right
gastric veins drain directly into the portal
Fundus: superior most part and distensible bounded
vein.
superiorly by the diaphragm and laterally by the spleen. has

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The short gastric veins and the left gastroepiploic veins join Food ingestion is the physiologic stimulus for acid
the splenic vein. secretion. There are 3 phases in which gastric
secretion occurs namelu, the cephalic phase, gastric
The right gastroepiploic vein joins the superior mesenteric phase and intestinal phase. Cephalic phase which
vein. begins in the thought, sight, smell and or taste of
food. These stimulate the brain in the cortical and
LYMPHATIC DRAINAGE: hypothalamic sites and the signals are transmitted to
the stomach by the vagal nerves. Acetylcholine is
• All of the following eventually drain to the celiac released which in turn stimulates the ECL cells and
nodes: parietal cells. Cephalic phase accounts for the 30% of
• Left and right gastric nodes total acid secretion in response to a meal.
• Left and right gastroepiploic nodes
• Short gastric nodes

INNERVATION:
• Sympathetic: Celiac plexus from T5-TlO
• Parasympathetic:
– Right vagus (Posterior surface)
– Left vagus (Anterior surface)

• Functions of the vagus nerve:

– Gastric motility
– Relaxation of the pyloric sphincter
– Stimulation of parietal cells for acid
production
NOTES: The nerve supply includes sympathetic fibers derived
from the celiac plexus and parasympathetic fibers from the
right and left vagus nerves
The sympathetic innervation of the stomach carries a
proportion of pain-transmitting nerve fibers, whereas
the parasympathetic vagal fibers are secretomotor to the
gastric glands and motor to the muscular wall of the
stomach.

HISTOLOGY:
Four layers of the gastric wall:
• Mucosa
• Submucosa
• Muscularis propia
• Serosa

NOTES:
Meissner’s autonomic plexus: regulates the
configuration of the luminal surface, controls
glandular secretions, alters electrolyte and water
transport, and regulates local blood flow.
Auerbach myenteric plexus: provides motor
innervation to both layers of the muscular layer of
the gut having both para and sympa input

PHYSIOLOGY:
NOTES:

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The intestinal phase is poorly understood. This phase starts
when gastric emptying of ingested food begins and continues
as long as nutrients remain in the proximal small intestine.
10% of meal induced acid secretion.
MECHANISM OF GASTRIC SECRETION:
Parietal cells secrete HCl into the lumen of the stomach and,
concurrently, absorb HCO3 into the bloodstream as follows:
a. In the parietal cells, CO2 and H2O are converted
to H+ and HCO3 –catalyzed by carbonic anhydrase.
b. H+ is secreted into the lumen of the stomach by
the H+K+ pump (H+,K+-ATPase). Cl– is
secreted along with H+; thus, the secretion product
of the parietal cells is HCl.
■ A “proton pump inhibitor” inhibits the H+,K+-
ATPase and blocks H+ secretion.
c. HCO3 – produced in the cells is absorbed into the
bloodstream in exchange for Cl (Cl––HCO3 –
exchange). As HCO3– is added to the
venous blood, the pH of the blood increases
(“alkaline tide”).
addition to that stomach distention stimulates acid secretion
via vasovagal reflex arch which is abolished by truncal or
Highly Selective Vagotomy. Finally, ongoing cephalic vagal
input stimulates gastrin release, which in turn stimulates
histamine release from ECL cells and acid secretion.
STIMULATION OF GASTRIC H+ SECRETION
• Vagal stimulation
• direct pathway and an indirect
pathway
• Gastrin
• released in response to eating a
meal
• Histamine
• stimulates H+ secretion by
activating
• H2 receptors on the parietal cell membrane
• Potentiating effects of ACh, histamine,
and gastrin on H+ secretion

INHIBITION OF GASTRIC H+ SECRETION:

• Negative feedback mechanisms.

a. Low pH (< 3.0) in the stomach
b. Somatostatin
c. Prostaglandins

NOTES: When food reaches the stomach the gastric phase of
secretion begins. This phase lasts until the stomach is empty
and accounts for about 60% of the total acid secretion in
response to a meal. This phase has several components,
Amino acids and small peptides from ingested food stimulate
Antral G-cells to secrete gastrin which is then carried in the
blood stream to ECL cells and parietal cells and stimulates
acid secretion in an endocrine fashion (discuss next slide). In
NOTES: Negative feedback mechanisms inhibit the secretion
of H+ by the parietal cells.
A. LOW PH (< 3.0) IN THE STOMACH
■ After a meal is ingested, H+ secretion is
stimulated. After the meal is digested and the
stomach emptied, further H+ secretion decreases
the pH of the stomach contents. When the pH of the

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 Surgery Rotation CLERKSHIP

stomach contents is <3.0, gastrin secretion is GASTRIC HORMONES

inhibited and, by negative feedback, inhibits further
H+ secretion.

B. SOMATOSTATIN
■ inhibits gastric H+ secretion by a direct pathway
and an indirect pathway.
In the direct pathway, somatostatin binds to
receptors on the parietal cell that are coupled to
adenylyl cyclase, inhibiting adenylyl cyclase and
decreasing cAMP levels. In this pathway,
somatostatin antagonizes the stimulatory action of
histamine on H+ secretion.

■ In the indirect pathway somatostatin inhibits

release of histamine and gastrin, thus decreasing H+
secretion indirectly.

C. PROSTAGLANDINS
GASTRIC MOTILITY AND EMPTYING
• inhibit gastric H+ secretion by activating a Gi , • Stomach Relaxes to accommodate meal at the
inhibiting adenylyl cyclase and decreasing cAMP beginning of a meal
levels. • Food breakdown by regulated motor activity and
controls output to duodenum
GASTRIC MUCOSAL BARRIER • Coordinated muscle relaxation and contraction of
• Provides resistance to autodigestion by HCl the various gastric segments
and active pepsin
• Maintains intact gastric mucosal layer SOLID VS LIQUID EMPTYING
• When these defences breakdown—ULCERATION LIQUID EMPTYING
• follows first-order kinetics, with a half
emptying time around 12 minutes.
• Caloric density, osmolarity and nutrient
composition of the liquid changes
• 1M osmolarity= 200kcal/hour
• Duodenal osmoreceptors and hormones–
modulators
• Delayed in supine position

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BARIUM UPPER GI STUDY:

SOLID EMPTYING • Plain Abdominal X-rays
• Half emptying time: <2 hours • Gastric Perforation
• Initial lag phase (Pneumoperitoneum)
• Meal particle size, caloric content and • Delayed gastric emptying (Large air
composition fluid level)
• Stored in fundus and delivered to distal
stomach at constant rates Double Contrast upper GI-series
• Better than EGD at elucidating
DIAGNOSIS OF GASTRIC DISEASES Gastric diverticula, fistula,
• Signs and symptoms: tortuosity, stricture location and
• Pain size of hiatal hernia.
• Nausea
• Weight loss *Gatric ulcers require biopsy.
• Vomiting
• Early satiety COMPUTED TOMOGRAPHY SCANNING
• Bloating AND MAGNETIC RESONANCE IMAGING
• Anorexia
• Anemia • should be part of routine staging work-up for
patients with malignant gastric tumor
*Dyspepsia – pain, bloating, nausea, and early MRI:
satiety – common causes are GERD, • quantitative test for gastric
helicobacter gastritis, and other disorders • in patients with gastroparesis
of the stomach. emptying.
• analysis of myoelectric
derangements.
Arteriography:
• Occasional poor risk patient with
gastric hemorrhage or in patients with
occult gastic bleeding.

ENDOSCOPIC ULTRASOUND:
DIAGNOSTIC TESTS: • Accurate for local staging of gastric adenocarcinoma
Esophagogastroduodenoscopy and therapy plan
• Indication: Patients with 1 or more of the alarm • Used to assess tumor response to chemotherapy
symptoms • Can provide reassurance but no guarantee that small
• Advantage: lesions are benign.
• Safe and accurate • Assess submucosal varices
• Smaller flexible scopes with
excellent optics SCINTIGRAPHY
• Procedure: • Standard evaluation of gastric emptying which
Following an 8 hour fast, the flexible scope involves the ingestion of a test meal with one or two
is advanced under direct vision in the isotopes and scanning the patient under a gamma
esophagus, stomach and duodenum , the camera.
fundus and GE junction are inspected by • Allows the semiquantitative assessment of how
retroflexing the scope. much isotopes refluxes to the stomach.

• Complications: TEST FOR HELICOBACTER PYLORI

• Perforation (rare), aspiration and • Positive serologic test
respiratory depression from • Histologic examination of gastric mucosal biopsy
excessive sedation. (Gold Standard).

• Commercially available rapid urease tests for the

presence of urease in mucosal biopsy specimens
(strong presumptive evidence of infection).

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• Urease is an omnipresent enzyme in H pylori strains OTHER CAUSES:

that colonize the gastric mucosa. ZES (Gastrinoma), antral G-cell
• Urea Breath Test: standard test for eradication of H. hyperfunction and/or hyperplasia,
pylori after treatment systemic mastocytosis, trauma, burns
and major physiologic stress,
ANTRODUODENAL MOTILITY TESTING AND drugs,smoking and psychologic stress
ELECTROGASTROGRAPHY
• Performed in specialized centers and may be useful
in the evaluation of the occasional patient with
dyspeptic symptoms.
• EGG consists of the transcutaneous recording of
gastric myoelectric activity.

• Antroduodenal motility testing is done with a tube

placed transnasally or transorally into the distal
duodenum.

DISEASES OF THE STOMACH

Helicobacter pylori Infection

• H. pylori- uniquely equipped for survival in hostile
environment of the stomach.
CLASSIFICATION BASED ON ANATOMIC LOCATION &
• Urease– converts urea to ammonia and bicarbonate,
PATHOPHYSIOLOGY (PUD)
buffers acid secreted by stomach
• Types I and IV: associated with normal or low acid
output
• Causes disturbance in gastric acid secretion leading
• Types II and Ill: associated with gastric acid
to gastric injury.
hypersecretion (similar to duodenal ulcers)

NOTES: Modified johnson classification.

Human beings are the only reservoir for H pylori. • The most common, Johnson type I gastric ulcer, is
H. pylori– specialized flagella and a rich supply of typically located near the angularis incisura on the
urease lesser curvature, close to the border between antral
• Infection can occur by oral ingestion of the and corpus mucosa. Patients with type I gastric ulcer
bacterium usually have normal or decreased acid secretion.
• Pathogenesis: survival in the acidic gastric lumen, Type II gastric ulcer is associated with active or
flagellated movement from the lumen across the quiescent duodenal ulcer disease, and type III gastric
mucus layer to the surface epithelial cell, adhesion ulcer is prepyloric ulcer disease. Both type II and
to the surface epithelial cell, and toxin production. type III
• Major cause of peptic ulceration. • Gastric ulcers are associated with normal or
• Noninvasive methods for diagnosis: include the urea increased gastric acid secretion and surgically are
breath test, serology, and detection of stool antigen. treated similar to duodenal ulcer. Type IV gastric
• Antimicrobial drugs must be combined with gastric
acid secretion inhibitors or bismuth salts.
PEPTIC ULCER DISEASE
• Focal defects in the gastric or duodenal mucosa
which extends into the submucosa or deeper
• caused by an imbalance between the action of acid
and mucosal defense
• PATHOPHYSIOLOGY AND ETIOLOGY:
• Caused by H. pylori infection
and/or NSAID use
• Final common pathway: Acid-
peptic injury of the gastroduodenal
mucosal barrier.

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ulcers occur near the GE junction, and acid secretion
is normal or below normal. Type V gastric ulcers are
medication induced and may occur anywhere in the
stomach.
NOTES:
Medications
• Proton pump inhibitors are the mainstay of medical
therapy for PUD, but highdose H2RAs and sucralfate
can also be effective. Patients hospitalized for ulcer
complications should receive high-dose intravenous
PPI and, when discharged, should be considered for
lifelong PPIs unless the definitive cause is eliminated
or a definitive operation performed
• Antibiotics: Amoxicillin, Tetracycline, Clarithromycin.
Diagnostics
• Upper GI endoscopy
• Sclerosing agents
• Upper GI series or barium swallow
Indication for Surgery:
1. Intractability
2. Bleeding
3. Perforation→ peritonitis→ air under the
diaphragm
TERMS USED IN SURGICAL MANAGEMENT
Following antrectomy, GI continuity may be reestablished
with a Billroth I gastroduodenostomy or a Billroth II loop
gastrojejunostomy
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Surgery Rotation CLERKSHIP
SURGICAL OPTIONS.
NOTES: Choice of operation depend on the physiologic status
of the patient (most important). The location of the ulcer
(gastric vs. duodenal), and the type of ulcer complication
Majority of peptic ulcers were treated by a variant of one of
the three basic operations: parietal cell vagotomy, also called
highly selective vagotomy (HSV) or proximal gastric
vagotomy, vagotomy and drainage (V+D), and vagotomy and
distal gastrectomy. Recurrence rates are lowest but morbidity
highest with the distal gastrectomy, while in highly selective
vagotomy high recurrence rate. HSV has not performed
particularly well for type II (gastric and duodenal) and type III
(prepyloric) gastric ulcer, perhaps because of
hypergastrinemia caused by gastric outlet obstruction and
persistent antral stasis.
V + D is widely accepted as a successful definitive operation
for complicated PUD. Although vagotomy and antrectomy (V
+ A) is associated with a very low ulcer recurrence rate and is
applicable to many patients with complicated PUD, V + A has
a higher operative mortality risk (compared with HSV or V +
D), and is irreversible. V + A should be avoided in
hemodynamically unstable patients, and in patients with
extensive inflammation and/or scarring of the proximal
duodenum, because secure anastomosis (Billroth I) or
duodenal closure (Billroth II) may be difficult.
NOTES:
Pyloroplasty: dilation of the pylorus (done to compensate for
decreased gastric emptying after vagotomy)
Heineke-Mikulicz pyloroplasty consists of a longitudinal
incision through the pylorus from the distal antrum to the
proximal duodenum. This incision is closed transversely to
increase the diameter of the pyloric channel.
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NOTES:
• Bleeding is the most common cause of ulcer related
death.
• It is likely that patients currently coming to
operation for bleeding PUD are at higher risk for a
poor outcome than ever before.
• The surgical options for treating bleeding PUD
include:
▪ Suture ligation of the bleeder
▪ Suture ligation and definitive non-resective
ulcer operation
▪ Gastric resection

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A. Airway Management with Cervical Spine

ILOILO DOCTORS’ COLLEGE OF MEDICINE Protection
Molo, Iloilo City S.Y. 2020-2021 ➢ Level of Consciousness
➢ Establish Definitive Airway
BATCH 2021
DISCIMUS SAPIENCIA UT VIRTUS ➢ Assess Need for:
◆ Intubation
SURGERY CLERKSHIP ◆ Cricothyroidotomy
◆ Emergent Tracheostomy
LECTURER: DR. LAGOS
MAIN TOPIC: TRAUMA ➢ Ensuring a patent airway is the priority in
the primary survey.
TRAUMA ➢ Ssimultaneously, all patients with blunt
✓ Cellular disruption caused by environmental trauma require cervical spine
energy that is beyond the body’s resilience, immobilization until injury is excluded.
which is compounded by cell death due to ➢ All patients with blunt injury should be
ischemia/ reperfusion. assumed to have unstable cervical spine
✓ Most common cause of death in ages 1-44 injuries until proven otherwise.
years
✓ 3rd most common cause of death regardless ➢ Options for Endotracheal Intubation
of age 1. Orotracheal Intubation
2. Nasotracheal Intubation
INITIAL EVALUATION AND RESUSCITATION 3. Operative Routes
Phases: (Cricothyroidotomy,
1. Primary Survey Tracheostomy)
2. Secondary Survey ➢ Indication for emergency endotracheal
3. Definitive Care intubation:
4. Tertiary Care ✓ acute airway obstruction
✓ hypoventilation
Primary Survey ✓ severe hypoxemia despite
Goal: To identify and treat conditions that constitute an supplemental oxygen
immediate threat to life ✓ altered mental status (eg GCS
“ABCDE”: <8)
Airway ✓ Cardiac arrest
Breathing ✓ Severe hemorrhagic shock
Circulation
Disability
Exposure

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B. Breathing and Ventilation 2. Open Pneumothorax

➢ Adequate oxygenation and ventilation
must be ensured. ➢ “sucking chest wound”
➢ Assess for: ➢ Permits free communication between the
1. Tension pneumothorax pleural space and the atmosphere.
2. Open pneumothorax ➢ Complete occlusion of the chest wall defect
3. Flail chest with underlying without a tube thoracostomy may convert
pulmonary contusion an open pneumothorax to a tension
4. Massive hemothorax, and pneumothorax.
5. Major air leak due to a ➢ Open Pneumothorax Management
tracheobronchial injury. Temporary management: cover the
wound with an occlusive dressing
1. Tension Pneumothorax that is taped on three sides
➢ Respiratory distress and hypotension with any of
the following: Definitive treatment: closure of the
1. Tracheal deviation away from the affected side chest wall defect and tube
2. Lack/decreased breath sounds on the affected thoracostomy remote from the
side wound
3. Subcutaneous emphysema on the affected
side

➢ Patients may have distended neck veins due to

impedance of venous return, but the neck veins
may be flat due to concurrent systemic
hypovolemia.

A. Full-thickness loss of the chest wall results in an

open pneumothorax. B. The defect is temporarily
managed with an occlusive dressing that is taped on
three sides, which allows accumulated air to escape
from the pleural space and thus prevents a tension
pneumothorax. Repair of the chest wall defect and
tube thoracostomy remote from the wound is definitive
treatment.

3. Flail Chest
➢ Occurs when three or more contiguous ribs are
fractured in at least two locations.
➢ Paradoxical movement of this free-floating
segment of chest wall is usually evident in
patients with spontaneous ventilation, due to the
negative intrapleural pressure of inspiration.
➢ Pulmonary contusions often progress during the
first 12 hours.
➢ Resultant hypoventilation and hypoxemia may
require intubation and mechanical ventilation.

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A. Admission chest film may not show the full extent of
the patient’s pulmonary parenchymal injury. This
patient’s left pulmonary contusion blossomed 12 hours
later, and its associated opacity is noted on repeat chest
radiograph. The patient’s initial chest radiograph often
underestimates the extent of the pulmonary
parenchymal damage close monitoring and frequent
clinical re-evaluation are warranted.
4. Major Air Leak
➢ Occurs from tracheobronchial injuries
➢ Type I:
◆ occurring within 2 cm of the carina.
◆ these may not be associated with a
pneumothorax due to the envelopment
in the mediastinal pleura.
➢ Type II:
◆ more distal injuries within the
tracheobronchial tree and hence
manifest with a pneumothorax.
➢ Bronchoscopy confirms the extent of the
injury and its location, and directs
management.
C. Circulation with Hemorrhage Control
➢ In general, any episode of hypotension
(defined as a SBP <90 mmHg) is
assumed to be caused by hemorrhage
until proven otherwise.
➢ Blood pressure and pulse should be
measured at least every 5 minutes in
patients with significant blood loss until
normal vital sign values are restored.
➢ Intravenous (IV) access for fluid
resuscitation and medication
administration is obtained with two
peripheral catheters
➢ Intraosseous infusions are indicated for
patients in whom one or two attempts at
IV access have failed.
➢ In general, initial access in trauma
patients is best secured in the groin so
that placement of the catheter will not
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Surgery Rotation CLERKSHIP
interfere with the performance of other
diagnostic and therapeutic thoracic
procedures.
➢ A rule of thumb to consider for
secondary access is placement of
femoral access for thoracic trauma and
jugular or subclavian access for
abdominal trauma.
➢ On this section of the primary survey,
four life-threatening injuries must be
identified promptly:
1. massive hemothorax
2. cardiac tamponade
3. massive hemoperitoneum and
4. mechanically unstable pelvic
fractures with bleeding
1. Massive Hemothorax
➢ >1500 mL of blood
➢ >25% of the patient’s blood volume
in the pleural space (pediatrics)
➢ Tube thoracostomy is the only
reliable means to quantify the
amount of hemothorax
A massive hemothorax is an indication for operative
intervention. Tube thoracostomy is critical to facilitate
lung reexpansion, which may improve
oxygenation and cardiac performance as well as
tamponade venous bleeding.
Picture: More than 1500 mL of blood in the pleural
space is considered a massive hemothorax. Chest film
findings reflect the positioning
of the patient. A. In the supine position, blood tracks
along the entire posterior section of the chest and is
most notable pushing the lung away
from the chest wall. B. In the upright position, blood is
visible dependently in the right pleural space.
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2. Cardiac Tamponade because the one-handed massage technique

➢ Occurs after penetrating thoracic wounds poses the risk of myocardial perforation with the
➢ <100mL of pericardial blood may cause thumb.
pericardial tamponade

➢ Beck’s Triad:
dilated neck veins
muffled heart sounds
decline in arterial pressure

➢ Pericardiocentesis is successful in decompressing

tamponade in approximately 80% of cases;
the majority of failures are due to the
presence of clotted blood within the
pericardium.

➢ Patients with a persistent SBP <60 mmHg warrant

resuscitative thoracotomy (RT) with opening
of the pericardium for rapid decompression
and control of bleeding.

D. Disability and Exposure

➢ The Glasgow Coma Scale (GCS) score
should be determined for all injured
patients.
➢ The GCS is a quantifiable determination
of neurologic function that is useful for
triage, treatment, and prognosis.
➢ An abnormal mental status should
prompt an immediate reevaluation of the
patient’s ABCs and consideration of
central nervous system injury.
1. Pericardiocentesis is indicated for patients with
evidence of pericardial tamponade. A. Access to GCS 15 - normal
the pericardium is obtained through a subxiphoid GCS 3 - lowest
approach, with the needle angled 45° up from the Mild injury - GCS 13-15
chest wall and toward the left shoulder. B. Moderate injury - GCS 9 to 12
Seldinger technique is used to place a pigtail Severe injury - GCS ≤8
catheter. Blood can be repeatedly aspirated with a
syringe, or the tubing may be attached to a gravity
drain. Evacuation of unclotted pericardial blood
prevents subendocardial ischemia and stabilizes
the patient for transport to the operating room for
sternotomy.

2. A. Resuscitative thoracotomy (RT) is performed

through the fifth intercostal space using the
anterolateral approach. B and C. The pericardium
is opened anterior to the phrenic nerve, and the
heart is rotated out for evaluation. D. Open
cardiac massage should be performed with a
hinged, clapping motion of the hands, with
sequential closing from palms to fingers. The two-
handed technique is strongly recommended

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Shock Classification and Initial Fluid Resuscitation
➢ Classic signs and symptoms:
tachycardia
hypotension
tachypnea
altered mental status
diaphoresis
pallor
➢ Tachycardia (HR >110 bpm) is often the
earliest sign of ongoing blood loss, but the
critical issue is change in HR over time.
➢ Bradycardia can occur with rapid severe
blood loss; this is an ominous sign, often
heralding impending cardiovascular
collapse.
➢ In general, the quantity of acute blood loss
correlates with physiologic abnormalities.
➢ The goal of fluid resuscitation is to re-
establish tissue perfusion.
➢ Fluid resuscitation usually begins with isotonic
crystalloid, typically Ringer’s lactate
➢ Urine output is a reliable indicator of organ
perfusion but requires time to quantitate.
➢ Adequate urine output:
✓ 0.5 mL/kg/hr- adult
✓ 1 mL/kg/hr- child
✓ 2 mL/kg/hr- infant <1 year of age
Hypovolemic Patients
1. RESPONDERS
✓ Stable
✓ Have a good response to initial fluid
therapy
✓ Normal vital signs, mental status and
urine output
✓ No hemorrhage
✓ Diagnostic evaluation for occult injuries
can proceed in an orderly fashion
2. TRANSIENT RESPONDERS
✓ Respond initially to volume loading
with improvement in vital signs but
subsequently deteriorate
hemodynamically
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3. NONRESPONDERS
✓ persistent hypotension despite
aggressive resuscitation
Persistent Hypotension
➢ Underlying causes:
✓ hemorrhagic
✓ cardiogenic
✓ neurogenic
➢ Persistent hypotension- high mortality
➢ Rapid search for the source of hemorrhage -
visual inspection, eFAST, and chest and pelvic
radiographs.
➢ In patients with persistent hypotension and no
clear operative indications, evaluate the scalp,
chest, abdomen, pelvis, and extremities.
➢ Fracture-related blood loss, when additive,
may be a potential source of the patient’s
hemodynamic instability.
rib fracture-100-200mL of blood loss
tibial fractures- 300-500 mL of blood loss
femur fractures- 800-1000 mL of blood
loss
pelvic fractures- >2000 mL of blood loss
SSECONDARY SURVEY
✓ Thorough History
✓ AMPLE history (Allergies, Medications, Past
illnesses or Pregnancy, Last meal, and Events
related to the injury).
✓ Complete Physical Examination (special
attention to the patient’s back, axillae, and
perineum)
✓ Digital Rectal Examination
✓ Vaginal examination
DIAGNOSTIC EVALUATION
➢ Selective radiography and lab tests
➢ For patients with severe blunt trauma: lateral
cervical spine, chest and pelvic radiographs
(Big three)
➢ For patients with truncal gunshot wounds: AP
and lateral radiographs of the chest and
abdomen
➢ In critically injured patients: blood samples
for a routine trauma panel (type and cross-
match, CBC, blood chemistries, coagulation
studies, lactate level, and ABG)
➢ For less severely injured patients: CBC and
urinalysis
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Mechanisms and Patterns of Injury
1. Blunt trauma
➢ In blunt trauma, organs that cannot yield to
impact by elastic deformation are most likely
to be injured, namely, the solid organs (liver,
spleen, and kidneys).
➢ It is associated with multiple widely
distributed injuries.
2. Penetrating trauma
➢ Organs with the largest surface area are most
prone to injury (small bowel, liver, and colon).
Additionally, because bullets and knives
usually follow straight lines, adjacent
structures are commonly injured.
➢ Can be stab, gunshot or shotgun wound.
Regional Assessment and Special Diagnostic Tests
➢ Based on mechanism, location of injuries
identified on physical examination, screening
radiographs, and the patient’s overall condition,
additional diagnostic studies often are indicated.
1. HEAD assessment
➢ includes examination for injuries to the
scalp, eyes, ears, nose, mouth, facial
bones, and intracranial structures
➢ Head palpation: identify scalp lacerations
(depth and associated depressed/open
skull fractures)
➢ Eye examination: pupillary size and
reactivity, visual acuity and presence of
hemorrhage within the globe
◆ Ocular entrapment:
impingement of the ocular
muscles, patient cannot move
eyes through an entire range of
motion
➢ Tympanic membrane examination:
identify hemotympanum, otorrhea, or
rupture
◆ Basilar skull fracture: otorrhea,
rhinorrhea, raccoon eyes, and
Battle’s sign (ecchymosis
behind the ear)
➢ All patients with a significant closed head
injury (GCS score <14) should undergo
CT scanning of the head.
➢ Intracranial lesions following trauma
include hematomas, contusions,
hemorrhage into ventricular and
subarachnoid spaces, and diffuse axonal
injury (DAI).
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Epidural hematomas
A. have a distinctive convex shape on computed
tomographic scan, whereas subdural
hematomas
B. are concave along the surface of the brain.
2. NECK assessment
➢ All blunt trauma patients should be
assumed to have cervical spine injuries,
until proven otherwise
➢ PE: maintain cervical spine precautions
and in-line stabilization.
➢ Patients with high spinal cord disruption:
risk for shock
➢ Indications for immediate operative
intervention for penetrating cervical
injury: hemodynamic instability,
significant external hemorrhage,
evidence of aerodigestive injury.
➢ For the purpose of evaluating
penetrating injuries, the neck is divided
into three zones.
Zone I is to the level of the clavicular
heads and is also known as the thoracic
outlet.
Zone II is located between the
clavicles and the angle of the mandible.
Zone III is above the angle of the
mandible
➢ For the purpose of evaluating
penetrating injuries, the neck is divided
into three zones. Zone I is to the level of
the clavicular heads and is also known as
the thoracic outlet. Zone II is located
between the clavicles and the angle of
the mandible. Zone III is above the angle
of the mandible
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➢ TREATMENT: Head Injuries
Intracranial Injuries
✓ CT scanning in patients with a
significant closed head injury (GCS
score <14).
✓ Indications for operative intervention
to remove space occupying
hematomas: clot volume, amount of
midline shift, location of the clot,
GCS score, and ICP.
✓ CT scanning, performed on all
patients with a significant closed
head injury (GCS score <14),
identifies and quantitates
intracranial lesions as well as
intracranial hypertension. Patients
with intracranial hemorrhage,
including epidural hematoma,
subdural hematoma, subarachnoid
hemorrhage
✓ Intracerebral hematoma or
contusion, and diffuse axonal injury,
are admitted to the SICU.
✓ A burr hole is made for
decompression of an epidural
hematoma as a life-saving
maneuver. One or more branches of
the external carotid artery usually
must be ligated to gain access to the
skull. No attempt should be made to
control intracranial hemorrhage
through the burr hole. Rather, the
patient’s head should be wrapped
with a bulky absorbent dressing and
the patient transferred to a
neurosurgeon for definitive care.
Maxillofacial Injuries
✓ common with multisystem trauma
✓ coordinated management: trauma &
specialists (otolaryngology, plastic
surgery, ophthalmology, and oral
and maxillofacial surgery)
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1. Le Fort type I
a) horizontal maxillary fracture,
separating the teeth from the upper
face
b) fracture line passes through the
alveolar ridge, lateral nose and
inferior wall of the maxillary sinus
2. Le Fort type II
a) pyramidal fracture, with the teeth at
the pyramid base, and nasofrontal
suture at its apex
b) fracture arch passes through the
posterior alveolar ridge, lateral walls
of maxillary sinuses, inferior orbital
rim and nasal bones
c) uppermost fracture line can pass
through the nasofrontal junction or
the frontal process of the maxilla 3
3. Le Fort type III
a) craniofacial disjunction
b) transverse fracture line passes
through nasofrontal suture, maxillo-
frontal suture, orbital wall,
and zygomatic
arch / zygomaticofrontal suture
c) because of the involvement of the
zygomatic arch, there is a risk of
the temporalis muscle impingement
✓ maxillofacial complex 3 regions: the
upper face (frontal sinus and brain), the
midface (orbits, nose, and zygomatico-
maxillary complex), and the lower face
(mandible)
✓ most common scenario (life-threatening):
bleeding from facial fractures
✓ After initial stabilization systematic head
& neck PE
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➢ TREATMENT: Neck Injuries ➢ INJURY TO THE GREAT VESSELS

Cervical Injuries
A. Spine: level of injury, the stability of the
spine, the presence of subluxation, the
extent of angulation, the level of
neurologic deficit, and the overall
condition of the patient
B. Vascular: repair techniques apply to
carotid injuries; end-to-end primary
repair, graft interposition, and
transposition procedures
C. Aerodigestive: Fractures of the larynx
and trachea may manifest as cervical
emphysema. Fractures documented by LEFT SIDED HEMATOMAS-Descending blunt aortic
CT scan are usually repaired. injuries

3. CHEST assessment RIGHT SIDED HEMATOMAS-

➢ Most common injuries from both blunt
and penetrating thoracic trauma are A. Widening of the mediastinum on initial
hemothorax and pneumothorax. anteroposterior chest radiograph, caused by a
➢ Blunt trauma to the chest: hematoma around an injured vessel that is
1. The chest wall contained by the mediastinal pleura.
2. Thoracic spine and thoracic B. Location of the hematoma within the mediastinal
aorta silhouette suggests the type of great vessel
3. Heart, and Great vessels injury
4. Lungs C. Left-sided hematomas are associated with
5. Esophagus (Rarely) descending blunt aortic injuries
➢ EVALUATION: PE, *CHEST D. Right-sided hematomas are seen with innominate
RADIOGRAPHY, CT SCANNING injuries

Persistent pneumothorax - Fiber optic bronchoscopy to

exclude tracheobronchial injury or foreign bodies

Persistent hemothorax/Caked Hemothorax -

Immediate thoracotomy

Apical capping

FINDINGS ON CHEST RADIOGRAPH SUGGESTIVE OF

DESCENDING
THORACIC AORTIC TEAR:
1. WIDENED MEDIASTINUM
2. ABNORMAL AORTIC CONTOUR
3. TRACHEAL SHIFT
4. NASOGASTRIC TUBE SHIFT
5. LEFT APICAL CAP
6. LEFT OR RIGHT PARASPINAL STRIPE
Persistent pneumothorax- large air leaks after tube THICKENING
thoracostomy 7. DEPRESSION OF THE LEFT MAIN
BRONCHUS
Caked hemothorax- is not drained by two chest tubes. 8. OBLITERATION OF AORTIC PULMONARY
WINDOW
9. LEFT PULMONARY HILAR HEMATOMA

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➢ Penetrating thoracic trauma -Over 90% of thoracic
great vessel injuries are due to penetrating
trauma
1. Physical examination
2. Plain posteroanterior and lateral chest
radiographs with metallic markings of wounds
3. Pericardial ultrasound
➢ More than 85% of patients can be definitively
treated with a chest tube.
➢ Indications for thoracotomy
➢ THORACIC INCISIONS
ANTEROLATERAL THORACOTOMY
1. Supine
2. Most versatile incision for
emergent thoracic exploration
3. 5th interspace inframammary
line
➢ Clamshell thoracotomy
1. For access to both pleural
cavities,
2. Original incision can be
extended across the sternum
with a Lebsche knife
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In the picture, “clamshell” thoracotomy provides
exposure to bilateral thoracic cavities
➢ Median sternotomy with cervical
extension
1. Proximal subclavian,
innominate, or proximal carotid
artery injuries.
2. Care must be taken- avoid
injury to the phrenic and vagus
nerves
Care must be taken- avoid injury to
the phrenic and vagus nerves that pass
over the subclavian artery and to the
recurrent laryngeal nerve passing
posteriorly
➢ Posterolateral thoracotomies
A. Right posterolateral
thoracotomy- injuries to the
trachea or main stem bronchi
near the carina or the upper
esophagus
B. Left posterolateral
thoracotomy-descending
thoracic aorta or lower
esophagus
➢ GREAT VESSELS -
✓ Bypass exclusion technique-
Innominate artery injuries
.
In the first stage of the bypass exclusion technique, a
12-mm polytetrafluoroethylene graft is anastomosed
end to side from the proximal undamaged aorta,
tunneled under the vein, and anastomosed end to end
to the innominate artery. C. The origin of the
innominate is then oversewn at its base to exclude the
pseudoaneurysm.
✓ Descending BAI may require urgent intervention.
✓ To prevent aortic rupture:
✓ pharmacologic therapy with a selective
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✓ B1-antagonist, esmolol, should be instituted in the ➢ CHEST- Other injuries

trauma bay, Trachea, Bronchi and Lung
✓ with a target SBP of <100 mmHg and heart rate of Parenchyma
<100/min.41,98 1. < 1% of all injured patients
✓ Endovascular stenting is now the mainstay of sustain intrathoracic
treatment tracheobronchial injuries,
2. Small number require operative
intervention. T
Open Repair of Descending 3. Empyema- most common
aorta complication. Management is
based on CT diagnostic criteria.
When repairing a tear of the Esophagus
descending thoracic aorta, 1. Injuries often occur with
perfusion of the spinal cord tracheobronchial injuries
while the aorta is clamped is achieved by using partial 2. With sufficient mobilization, a
left heart bypass. The venous cannula is inserted into primary single-layer end-to-end
the left superior pulmonary vein because it is less anastomosis may be performed
prone to tearing than the left atrium. after appropriate debridement
Chest Wall and Diaphragm:
✓ Lateral aortorrhaphy- Simple lacerations of the Virtually all chest wall injuries are
ascending or transverse aortic arch treated non-operatively with:
✓ Full cardiopulmonary bypass- Posterior aortic 1. Pain control
injuries, complex ascending or transverse 2. Pulmonary toilet or ventilatory
injuries, interposition grafting of the arch management
✓ PTFE graft interposition- Subclavian artery 3. Drainage of the pleural space as
injuries indicated.
Blunt diaphragmatic injuries usually
➢ CHEST- HEART result in a linear tear and most are large
Definitive repair of cardiac injuries is Penetrating diaphragmatic injuries are
performed with either running 3-0 variable in size and location depending on
polypropylene suture or interrupted, the agent of injury.
pledgeted 2-0 polypropylene suture * Regardless of the etiology, acute
diaphragmatic injuries are usually repaired
through an abdominal approach to manage
potential associated visceral injury.

4. Abdomen assessment
➢ Evaluation of the head includes
examination for injuries to the scalp,
eyes, ears, nose, mouth, facial bones,
and intracranial structures

Liver and Extrahepatic Biliary Tract:

A variety of techniques may be necessary
to repair cardiac wounds. Generally, pledget
support is used for the relatively thinwalled
right ventricle
✓ The liver’s large size makes it the organ
most susceptible to blunt trauma, and it
is frequently involved in upper torso
penetrating wounds.
✓ Initial control of hemorrhage is best
accomplished using perihepatic packing
and manual compression.
✓ With extensive injuries and major
hemorrhage, a Pringle maneuver should
be done immediately.
✓ If bleeding continues despite repeated
attempts at packing, then direct repair,

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with or without hepatic vascular isolation,
should be attempted.
✓ Pringle Maneuver - technique to
minimize blood loss during hepatic
surgery by clamping the vascular pedicle
✓ Three Techniques used in hepatic
vascular isolation:
a) direct repair with suprahepatic and
infrahepatic clamping of the vena
cava and stapled assisted
parenchymal resection
b) temporary shunting of the
retrohepatic vena cava
c) venovenous bypass
Spleen:
✓ Splenic injuries are managed operatively
by splenectomy, partial splenectomy, or
splenic repair (splenorrhaphy), based on
the extent of the injury and the
physiologic condition of the patient.
✓ Subphrenic abscess
1. Common complication after
splenectomy
2. Percutaneous drainage
✓ Postsplenectomy sepsis
◼ caused by Streptococcus
pneumoniae, Haemophilus
influenzae, and Neisseria
meningitidis,
◼ Resistant to antimicrobial treatment.
◼ Prophylaxis: vaccine administered
optimally at >14 days postinjury.
Stomach and Small Intestine:
✓ Gastric wounds can be oversewn with a
running single-layer suture line or closed
with a stapler.
✓ Small intestine injuries can be repaired
using a transverse running 3-0 PDS
suture if the injury is less than one-third
the circumference of the bowel.
Duodenum and Pancreas:
✓ The spectrum of injuries to the
duodenum includes hematomas,
perforation and combined pancreatico
duodenal injuries.
✓ The majority of duodenal hematomas are
managed non-operatively with
nasogastric suction and parenteral
nutrition.
✓ Patients with suspected associated
perforation should undergo operative
exploration.
✓ Extensive injuries of the first portion of
the duodenum (proximal to the duct of
Santorini) can be repaired by
debridement and end-to-end
anastomosis.
✓ The second portion is tethered to the
head of the pancreas by its blood supply
and the ducts of Wirsung and Santorini,
should be “patched” with a Roux-en-Y
duodenojejunostomy.
✓ Injuries in the distal third and fourth
portions of the duodenum (behind the
mesenteric vessels) should be resected,
and a duodenojejunostomy should be
performed on the D3 side of the superior
mesenteric vessels
✓ Optimal management of pancreatic
trauma is determined by
1. Where the parenchymal damage is
located and
2. Whether the intrapancreatic
common bile duct and main
pancreatic duct remain intact.
✓ Pancreatic contusions- non-operatively or
with closed suction drainage.
✓ Proximal pancreatic injuries- closed
suction drainage
✓ Distal ductal disruption- distal
pancreatectomy, preferably with splenic
preservation.
✓ Pancreatic head injuries- Distal
pancreatectomy or Central
pacreatectomy
✓ Complications:
Delayed hemorrhage-
angioembolization
Pancreatic and duodenal fistulas-
adequate drainage
Pancreatic pseudocysts- ERCP
Intra-abdominal abscesses-
percutaneous drainage
Colon and Rectum
There are 3 methods used for treating
colonic injuries:
1. Primary repair
2. End colostomy
3. Primary repair with diverting loop
ileostomy
✓ All suturing and anastomoses are
performed using a running single-layer
technique.
✓ Current options for treating rectal injuries
are loop ileostomy and sigmoid loop
colostomy.

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✓ If the rectal injury is extensive, another
option is to divide the rectum at the level
of the injury, oversew or staple the distal
rectal pouch if possible, and create an
end colostomy (Hartmann’s procedure).
Abdominal and Pelvic Vasculature
✓ Penetrating trauma indiscriminately
affects all blood vessels, blunt trauma
most commonly involves renal
vasculature and occasionally the
abdominal aorta.
Genitourinary Tract
✓ Parenchymal renal injuries are treated
with hemostatic and reconstructive
techniques.
✓ Bladder injuries are subdivided into:
1. Intraperitoneal extravasation-
operatively closed with a running,
single-layer, 3-0 absorbable
monofilament suture
2. Extraperitoneal extravasation-
treated non-operatively with bladder
decompression for 2 weeks.
✓ Urethral injuries are managed by
bridging the defect with a Foley catheter,
with or without direct suture repair.
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5. Extremity Vascular Injuries, Fractures, and
Compartment Syndromes
➢ Patients with injured extremities,
immediate stabilization of fractures or
unstable joints is done in the ED using
Hare traction, knee immobilizers, or
plaster splints.
➢ Patients with open fractures, the wound
should be covered with povidone-iodine
(Betadine)-soaked gauze and antibiotics
administered.
➢ Options for fracture fixation include
external fixation or open reduction and
internal fixation with plates or
intramedullary nails.
➢ Vascular injuries, either isolated or in
combination with fractures, require
emergent repair
➢ Common combined injuries:
1. clavicle/first rib fractures and
subclavian artery injuries
2. dislocated shoulder/proximal
humeral fractures and axillary artery
injuries
3. supracondylar fractures/elbow
dislocations and brachial artery
injuries
4. femur fracture and superficial
femoral artery injuries
5. knee dislocation and popliteal
vessel injuries
Compartment Syndromes
➢ acute increase in pressure inside a closed
space, which impairs blood flow to the
structures within.
➢ Causes:
◼ arterial hemorrhage
◼ venous ligation or thrombosis
◼ crush injuries
◼ reperfusion injury
➢ In conscious patients, pain is the
prominent symptom, and active or
passive motion of muscles in the involved
compartment increases the pain.
Paresthesias may also be described. In
the lower extremity, numbness between
the first and second toes is the hallmark
of early compartment syndrome.
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Abdominal Compartment Syndrome

➢ Classified as pathologic intra-abdominal Generally, no specific bladder pressure prompts
hypertension due to intra-abdominal therapeutic intervention, except when the pressure is
injury (primary) or splanchnic reperfusion >35 mmHg. Emergent decompression is carried out
after massive resuscitation (secondary). when intra-abdominal hypertension reaches a level at
➢ The most common technique for the which end-organ dysfunction occurs.
diagnosis is to measure the patient’s
bladder pressure. Abdominal compartment syndrome is defined by the
➢ Fifty milliliters of saline is instilled into the end organ sequelae of intra-abdominal hypertension.
bladder via the aspiration port of the CO = cardiac output;
Foley catheter with the drainage tube CVP = central venous pressure; ICP = intracranial
clamped, and a three-way stopcock and pressure; PA = pulmonary artery; SV = stroke volume;
water manometer is placed at the level of SVR = systemic vascular resistance; UOP = urine
the pubic symphysis output; VEDV = ventricular end diastolic volume.
➢ Secondary abdominal compartment
syndrome may result from any condition
requiring extensive crystalloid
resuscitation, including extremity trauma,
chest trauma, or even postinjury sepsis.
➢ The sources of increased intra-abdominal
pressure include bowel edema, ascites,
bleeding, and packs. A diagnosis of intra-
abdominal hypertension cannot reliably
be made by physical examination;
therefore, it is obtained by measuring the
intraperitoneal pressure. The most
common technique is to measure the
patient’s bladder pressure

First picture - Bladder pressure is measured on the

manometer in centimeters of water and correlated with
the physiologic sequelae. Conditions in which the
bladder pressure is unreliable include bladder rupture,
external compression from pelvic packing, neurogenic
bladder, and adhesive disease.

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ILOILO DOCTORS’ COLLEGE OF MEDICINE ANATOMY

Molo, Iloilo City S.Y. 2020-2021 • A true diverticulum of the cecum as it contains all
the histological layers of the colon
• Average appendix measures 6-9 cm
BATCH 2021
DISCIMUS SAPIENCIA UT VIRTUS • Base – follows the longitudinally oriented taeniae
coli to their confluence on the cecum; constant in
SURGERY CLERKSHIP location
• Tip – is not constant of its location
LECTURER: DR. FERNANDEZ ET AL • Outer diameter: 3-8 mm
MAIN TOPIC: APPENDIX • Luminal Diameter: 1-3 mm

FUNCTION
HISTORY • Previously believed to be a vestigial organ
❑ Claudius Amyand (early 18th century) - first surgeon • Currently linked to the development and
to describe a successful appendectomy preservation of gut-associated lymphoid tissue
❑ Chester McBurney (1889) - advocated for early (GALT)
appendectomy • Maintenance of intestinal flora
❑ 1940’s - introduction and widespread use of • An immunologic organ that actively participates in
antibiotics the secretion of immunoglobulins, particularly
❑ Kurst Semm (1982) - a gynecologist, reported on immunoglobulin A
first laparoscopic appendectomy • A reservoir to recolonize the colon with healthy
bacteria
EMBRYOLOGY
POSITION
• In the 6th week of human embryonic
development, the appendix and cecum appear
as outpouchings from the caudal limb of the
midgut.
• Appendicial outpouching, initially noted in the
8th week, begins to elongate at about the 5th
month to achieve a vermiform appearance.
• As the gut rotates medially, the cecum becomes
fixed in the right lower quadrant, thus
determining the final position of the appendix

HISTOLOGY
MCBURNEY’S POINT
• 3 LAYERS: • It is found 1/3 of the distance between the right
o OUTER SEROSA – extension of the peritoneum anterior superior iliac spine and the umbilicus
o MUSCULARIS LAYER – not well defined and • Often the point of maximal tenderness in a patient
may be absent in certain locations with anatomically normal appendix
o SUBMUCOSA AND MUCOSA
– lymphoid aggregates occur in the BLOOD SUPPLY
submucosal layer and may extend into the
• Arterial supply: APPENDICULAR BRANCH OF THE
muscularis mucosa
ILEOCOLIC ARTERY
– the mucosa is like that of the large
• Originates posterior to the terminal ileum, entering
intestine, except for the density of the lymphoid
the mesoappendix close to the base of the appendix
follicles
AUTONOMIC INNERVATION
• CRYPTS (Crypts of Lieberkuhn)
• Derived from sympathetic elements contributed by
o APPENDIX: irregularly sized and shaped
the superior mesenteric plexus (T10-L1)
o COLON: more uniform in appearance
• Afferents from the parasympathetic elements via the
o Neuroendocrine complexes (ganglion cells,
vagus nerves.
Schwann cells, neural fibers, and neurosecretory
cells) are positioned just below the crypts.

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ACUTE APPENDICITIS diapedesis, appendiceal distention due to

• Inflammation of the appendix caused by obstruction
of the appendiceal lumen
• More common in males (8.6%), while in females
(6.7%)
• Highest incidence in the 2nd and 3rd decades of life
ETIOLOGY
• Luminal obstruction due to lymphoid hyperplasia
(pediatrics) or due to fecaliths, fibrosis, foreign
bodies (parasite and food), or neoplasia (adults)
MICROBIOLOGY
• 60% of aspirates of inflamed appendices have
anaerobes (25% in normal appendices)
• Tissue specimens from the inflamed appendix wall
virtually all grow Escherichia coli and
Bacteroides species
• Fusobacterium nucleatum/necrophorum (not
present in normal cecal flora) has been
identified in 62% of inflamed appendices.
• Peptostreptococcus, Pseudomonas, Bacteroides
splanchnicus, Bacteroides intermedius,
Lactobacillus
• Fastidious gram-negative anaerobic bacili
• Bacteroides – more common in patients with
gangrene or perforated appendicitis
accumulated fluid, and increasing
intraluminal pressure.
- Visceral afferent nerve fibers are
stimulated, and the patient perceives mild
visceral periumbilical or epigastric pain,
which usually lasts 4-6 hours.
• SUPPURATIVE
- Obstruction of lymphatic and venous
drainage leading to bacterial multiplication
- Inflammation progresses to the parietal
peritoneum, classic shift of pain from the
periumbilicus to the right lower abdominal
quadrant (RLQ) will occur.
• GANGRENOUS
- Intramural venous and arterial thromboses
• RUPTURED/PERFORATED
- Persistent tissue ischemia results in
appendiceal infarction and perforation.
- Perforation can cause localized or
generalized peritonitis.

PATHOPHYSIOLOGY

SYMPTOMS
• Vague, dull, diffuse mid-abdominal pain
• Crampy abdominal pain
• Anorexia
• Nausea
• Vomiting
• Localization to the right lower quadrant
• Generalized abdominal pain

SIGNS
• Early in presentation: Vital signs are minimally
altered
• Changes of greater magnitude in vital signs:
complication
• Patients move slowly
PERIUMBILICAL PAIN: Due to visceral nerve fibers and • Prefer to lie supine due to the peritoneal irritation
stimulation & dermatome affected
LOCALIZATION TO THE RLQ: Serosa of the appendix is already PHYSICAL EXAM
involved
• INSPECTION:
o Patients move slowly, and prefer to lie supine
STAGES
• PALPATION:
• CONGESTIVE
o Warm to touch (low-grade fever, ~38.0oC)
- Obstruction of the appendiceal lumen leads
o Tenderness with maximum at or near
to mucosal edema, ulceration, bacterial
McBurney’s point

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o Deep palpation: muscular resistance (guarding)
in the right iliac fossa
• SIGNS TO BE ELICITED
o Rovsing’s sign – pain in the right lower quadrant
after release of gentle pressure on the left lower
quadrant (normal position)
o Dunphy’s sign – pain with coughing (retrocecal
appendix)
o Obturator sign – pain with internal rotation of
the hip (pelvic appendix)
o Iliopsoas sign – pain with flexion of the hip
(pelvic appendix)
• PAIN WITH RECTAL/CERVICAL EXAM – pelvic
appendicitis
CLINICAL SCORING SYSTEMS
• The method relies on a combination of factors
derived from physical signs, symptoms, and
laboratory tests and produces a numerical score
used to rule in or rule out acute appendicitis.
ALVARADO SCORE
• Most widespread scoring system.
• Useful for ruling out appendicitis and selecting
patients for further workup
APPENDICITIS INFLAMMATORY RESPONSE
• Resembles the Alvarado score but uses more graded
variables and includes C reactive protein.
• Studies have shown that it performs better than the
Alvarado score in accurately predicting appendicitis
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DIAGNOSTIC AND ANCILLARY PROCEDURE
• COMPLETE BLOOD COUNT
o Mild leukocytosis (10,000 cells/mm3) - is
often present in patients with acute,
uncomplicated appendicitis and is usually
accompanied by a polymorphonuclear
prominence.
o Higher leukocytosis (>18,000 cells/mm3)-
counts above this level raise the possibility
of a perforated appendix with or without an
abscess
• C REACTIVE PROTEIN
o strong indicator of appendicitisespecially
for complicated appendicitis
• URINALYSIS
o Useful to rule out the urinary tract as the
source of infection
o Several white or red blood cells can be
present from irritation of the ureter or
bladder
o Bacteriuria is generally not seen
NORMAL APPENDIX VS INFLAMED APPENDIX
• Normal appendix
o Ultrasonography and computed
tomography (CT) scan - seen as a blind-
ending nonperistaltic tubular structure
arising from the base of the cecum. The
location of the base of the appendix is
relatively constant, located roughly
between the ileocecal valve and the apex of
the caecum.
• Inflamed appendix
o Outer-to-outer diameter - is the most
important imaging criterium.
o Threshold value of 6-7 mm is generally
used.
o An inflamed appendix has a diameter larger
than 6 mm and is usually surrounded by
inflamed fat. The presence of a fecolith or
hypervascularity on power Doppler strongly
supports inflammation.
o graded compression ultrasonography
o Inexpensive, can be performed rapidly,
does not require a contrast medium, and
can be used in pregnant patients
Findings supportive of the diagnosis of appendicitis include:
• Aperistaltic, noncompressible, dilated appendix
• >6 mm outer diameter
• Appendicolith
• Distinct appendiceal wall layers
• Echogenic prominent pericecal fat
• Periappendiceal hyperechoic structure (PHS)
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• an ultrasound finding described as an amorphous
hyperechoic structure (usually greater than 10mm)
• Periappendiceal fluid collection
• Target appearance (axial section)
o Alternating echogenicity of the appendix
that represents the presence of
periappendiceal fluid and intact echogenic
submucosal layer
CONTRAST-ENHANCED CT SCAN
• Highly sensitive (94-98%) and specific (up to 97%)
• Allows for alternative causes of abdominal pain also
to be diagnosed
• Findings supportive of the diagnosis of appendicitis
include:
• Double wall thickness
• dilated appendix with distended lumen
• >6 mm
• Thickened and enhancing wall
• >2 mm
• Periappendiceal fat stranding
• periappendiceal inflammation, including stranding of
the adjacent fat and thickening of the lateroconal
fascia or mesoappendix.
• Appendicolith
• Appendiceal wall thickening
• Arrowhead sign
o Seen as secondary sign.
o Refers to the Focal cecal thickening
centered on the appendiceal orifice
o Applicable only when enteric contrast
distends the cecum.
o Contrast material in the cecal lumen
assumes arrowhead configuration
MANAGEMENT
• Uncomplicated appendicitis
o Refers to non-perforated and non-
gangrenous appendicitis.
o IV Antibiotics (at least 30-60 minutes prior
to skin incision)
o Cefoxitin,ampicillin/sulbactam, and
cefazolin plus metronidazole.
o Post-op antibiotics - not necessary
o Operative: surgical treatment has been the
standard of treatment
o Non operative: is possible for patients in an
environment where surgical treatment is
not available. Study shows that treatment
with antibiotics alone was noted to be
effective. Also, many patients with signs
and symptoms consistent with appendicitis
who did not pursue operative treatment
would occasionally have spontaneous
resolution of their illness.
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TIMING
➢ Urgent (12-24 hrs) appendectomy
➢ Emergent (<12 hours) appendectomy
o Study shows that there is no significant
difference in terms of complicated
appendicitis, surgical site infection and
abscess formation.
• COMPLICATED APPENDICITIS
o Refers to perforated appendicitis commonly
associated with an abscess
o IV Antibiotics (at least 30-60 minutes prior
to skin incision)
o Monotherapywith piperacillin/ tazobactam
or combination of cephalosporin with
metronidazole.
o The duration of postoperative antibiotics is
generally less than 4 days once complete
source control has been achieved
o Conservative management - is considered
for confined abscess and in patients with
limited peritonitis.
o Broad spectrum antibiotics
o Bowel rest (NPO)
o Fluids (crystalloid)
o Possible percutaneous drainage - drain if
abscess is >3cm in diameter
OPERATIVE MANAGEMENT
• Failed conservative management
• Patients with free intra-peritoneal perforation
• Interval Appendectomy
• Successful conservative management
• 6-12 weeks later when inflammation diminished
• Prevents the recurrence
• May identify the presence of malignancy
OPERATIVE INTERVENTION
OPEN APPENDECTOMY
• INDICATIONS
o Acute appendicitis
o Interval appendectomy following
conservative treatment of appendiceal
abscess
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o Mucocele of appendix
o Adenocarcinoma and carcinoid of appendix
• INDICATIONS
• PITFALLS o Acute appendicitis
o Inadvertent laceration of inflamed cecum o Right lower quadrant pain of unknown
dissection etiology
o Inadequate control of blood vessels in o Interval appendectomy
edematous mesoappendix
o Performed with a patient under general • PITFALLS
anesthesia. o Injury to bladder from trocars
o The patient is placed in supine position. o Injury to cecum from traction or dissection
o The bed is positioned in Trendelenburg’s o Incomplete appendectomy, resulting in a
with the left side down. retained stump
o Early nonperforated appendicitis, o Performed with a patient under general
➢ McBurney’s incision - oblique anesthesia.
fashion o The patient is placed in supine position.
➢ Rocky- Davis incision - transverse o The bed is positioned in Trendelenburg’s
incision with the left side down
o Perforated appendicitis o Location of port sites for laparoscopic
➢ Lower midline laparotomy incision appendectomy.
o Division of the mesoappendix from ➢ 5-mm ports are placed at the
appendiceal artery suprapubic and left lower quadrant
➢ Fowler extension - In the event of areas
retraction of the appendiceal ➢ 10-12-mm port is placed at the
artery or unexpected bleeding, right upper quadrant
extension or the incision can be
extended medially.

• Division of the mesoappendix using the harmonic

• Figure B - Ligation of the base and division of the scalpel.
appendix. • Figure B - Placement of an absorbable endoloop
• Figure C - Placement of purse-string suture or Z encircling the base of the appendix
stitch • Figure C - Division of the appendix between
• Figure D - Inversion of the appendiceal stump endoloops. The base of the appendix is divided
• Skin closure is performed in a layered fashion either with an endoscopic stapler or after placing an
o secondary intention or delayed primary endoloop.
closure is done if there is abscess or • Figure D - Placement of the appendix into a
contamination specimen bag before removal of the appendix with
the umbilical port.
LAPAROSCOPIC APPENDECTOMY
ADVANTAGES
• OPEN APPENDECTOMY
o Shorter operating time
o Lower operating room costs
o Fewer intraabdominal abscess
o Lower hospital costs
• LAPAROSCOPIC APPENDECTOMY
o Diagnosis of other conditions

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o Decreased pain and lower narcotic
requirement
o Reduced length of stay
o Fewer wound infections
o Quicker return to usual activities
INCIDENTAL APPENDECTOMY
• Neither clinically nor economically appropriate
• Special patient groups in whom this can be done:
- Children about to undergo chemotherapy
- Disabled who cannot describe symptoms or react
normally to abdominal pain
- Patients with Chron’s disease
- Individuals who are about to travel to remote
places where there is no access to medical or
surgical care
Additional notes:
• In patients ten to 30 years of age--the age group
associated with a higher incidence of acute
appendicitis--who are otherwise healthy, incidental
appendectomy is effective in preventing morbidity
and death associated with acute appendicitis
• In patients 30 to 50 years of age, incidental
appendectomy should be left to the discretion of the
surgeon
• In mentally handicapped patients less than 50 years
of age and who are physically healthy, incidental
appendectomy should be performed
POST-OP CARE AND COMPLICATIONS
A. Surgical Site Infection:
• Most common site of surgical site infection
following Lap Appendectomy :Extraction Port
Site
• In patients with incisional surgical site infection:
treatment should be opening of the incision and
obtaining a culture.
B. Intra-abdominal abscesses
• Small abscesses can be simply treated with
antibiotics
• Larger abscesses require drainage.
Additional notes:
• Patients with postoperative intra-abdominal
abscesses can present in a variety of ways. Although
fever, leukocytosis, and abdominal pain are common
presentations, patients with ileus, bowel
obstruction, diarrhea, and tenesmus may also harbor
intra-abdominal abscesses
• Most commonly, percutaneous drainage with CT or
ultrasound guidance is effective. For abscesses not
amenable to percutaneous drainage, laparoscopic
abscess drainage is a viable option.
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C. Stump Appendicitis
• Stump appendicitis is defined by the recurrent
inflammation of the residual appendix after
the appendix has been only partially removed during
an appendectomy for appendicitis
• Patients typically present with recurrent symptoms
of appendicitis approximately 9 years after their
initial surgery.
• Prevention is done by using the “appendiceal critical
view of safety”
• The remaining stump should be no longer than 0.5
cm
Additional notes:
• The key to avoiding Stump appendicitis is
“Prevention.So the appendix placed at 10 o’clock,
taenia coli/libera at 3 o’clock, and terminal ileum at
6 o’clock and identification of where the taeniae coli
merge and disappear is paramount to identifying
and ligating the base of the appendix during the
initial operation.
• The remaining stump should be no longer than 0.5
cm, as stump appendicitis has only been noted in
stumps ≥0.5 cm in the literature.
SPECIAL CIRCUMSTANCES
A. APPENDICITIS IN CHILDREN
• Infants and young children - most likely to
present perforated disease
• PE findings with highest sensitivity rate in
children with appendicitis:
- Maximal tenderness in the right lower
quadrant
- The inability to walk or walking with a limp
- Pain with percussion, coughing, and
hopping
• Management: Laparoscopic Appendectomy
Additional notes:
• The inability of young children to give an
accurate history, diagnostic delays by both
parents and physicians, and the frequency of
gastrointestinal distress in children are all
contributing factors to the misdiagnosis and
delay in diagnosis.
• The more rapid progression to rupture and the
inability of the underdeveloped greater
omentum to contain a rupture lead to
significant morbidity rates in children.
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B. APPENDICITIS IN THE ELDERLY
• The perforation rate appears to increase with
age greater than 80 years.
• Higher risk for complications because of their
premorbid conditions
• Laparoscopic appendectomy is safe and might
allow patients to reduce pain and their hospital
stay
Additional notes:
• The perforation rate appears to increase with
age greater than 80 years.
• Higher risk for complications because of their
premorbid conditions
• Laparoscopic appendectomy is safe and might
allow patients to reduce pain and their hospital
stay
C. APPENDICITIS IN PREGNANT WOMEN
• Can occur at any time during pregnancy but is
rare in the third trimester.
• The most consistent sign encountered in acute
appendicitis during pregnancy is pain in the right
side of the abdomen.
• When the diagnosis is in doubt, abdominal
ultrasound may be beneficial.
• Management: Laparoscopic appendectomy
Additional notes:
• Appendectomy for presumed appendicitis is the
most common surgical emergency during
pregnancy.
• Another option is magnetic resonance imaging,
which has no known deleterious effects on the
fetus. The American College of Radiology
recommends the use of nonionizing radiation
techniques for front-line imaging in
• Laparoscopic appendectomies can be safely
performed in pregnant patients but with
increase pregnancy-related complications.
NEOPLASMS OF THE APPENDIX
A. Carcinoid
• Characteristics:firm, yellow, bulbar mass
• Appendix: Most common site of GI carcinoid
• Location of the majority of carcinoids:in the tip
of the appendix
• The mean tumor size for carcinoids is 2.5 cm.
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Additional notes:
• The majority of carcinoids are located in the tip of
the appendix. Malignant potential is related to size,
with tumors <1 cm rarely resulting in extension
outside of the appendix or adjacent to the mass
• Symptoms attributable directly to the carcinoid are
rare, although the tumor can occasionally obstruct
the appendiceal lumen much like a fecalith and
result in acute appendicitis
B. ADENOCARCINOMA
• Three major histologic subtypes:
-mucinous adenocarcinoma
-colonic adenocarcinoma
-adenocarcinoid
• Most common mode of presentation: that of acute
appendicitis
• Recommended treatment: right hemicolectomy
Additional notes:
• Primary adenocarcinoma of the appendix is a rare
neoplasm with three major histologic subtypes:
mucinous adenocarcinoma, colonic adenocarcinoma,
and adenocarcinoid
• The most common mode of presentation for
appendiceal carcinoma is that of acute appendicitis.
Patients also may present with ascites or a palpable
mass, or the neoplasm may be discovered during an
operative procedure for an unrelated cause
• Overall 5-year survival is 55% and varies with stage
and grade.
C. MUCOCELE
• May be caused by one of four processes: Surgery
-Retention cysts
-Mucosal hyperplasia
-Cystadenomas
-Cystadenocarcinomas.
• Surgery:
-Resection of the appendix, wide resection of the
mesoappendix
- Right hemicolectomy is reserved for patients with a
positive margin at the base of the appendix or
positive periappendiceal lymph nodes.
Additional notes:
• A mucocele of the appendix is an obstructive
dilatation by intraluminal accumulation of mucoid
material. The clinical presentation of a mucocele is
nonspecific, is often an incidental finding at
operation for acute appendicitis.
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• An intact mucocele presents no future risk for the

patient; however, the opposite is true if the
mucocele has ruptured and epithelial cells have
escaped into the peritoneal cavity. As a result, when
a mucocele is visualized at the time of laparoscopic
examination, conversion to open laparotomy is
recommended.

• Resection of the appendix, wide resection of the

mesoappendix to include all the appendiceal lymph
nodes, collection and cytologic examination of all
intraperitoneal mucus, and careful inspection of the
base of the appendix.

CONGRATULATIONS ON FINISHING SURGERY CLERKSHIP!

HELLO PCM!

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