Ultrasound

Here in the ultrasound we can see the comparison of a normal appendix and a one with
appendicitis. The one on the left is in a coronal view and the one on the right is in longitudinal
plants.in appendicitis there is distension and thickenin of the appendix wall and blood flow is
increased as seen tin the images. This is nows as a ring of e appearance

Among patients with abdominal pain, ultrasonography has

a sensitivity of approximately 85% and a specificity of more than
90% for the diagnosis of acute appendicitis. Sonographic
findings
consistent with acute appendicitis include an appendix of
7 mm or more in anteroposterior diameter, a thick-walled, noncompressible
luminal structure seen in cross section, known as
as a target lesion, or the presence of an appendicolith
Ultrasonography has the advantages of being a noninvasive
modality requiring no patient preparation that also avoids
exposure to ionizing radiation. Thus, it is commonly used in
children and in pregnant patients with

Ct scan
Computed tomography (CT) is commonly used in the evaluation
of adult patients with suspected acute appendicitis.
Classic findings include a distended appendix
more than 7 mm in diameter and circumferential wall thickening
and enhancement, which may give the appearance of a halo
or target
CT scan is unnecessary,
wastes valuable time, may be misinterpreted, and exposes
the patient to risks for allergic contrast reaction, nephropathy,
aspiration pneumonitis, and ionizing radiation. The latter carries
increased risk in children in whom the rate of radiation-induced
cancer has been estimated at 0.18% following an abdominal CT
scan.11 CT has proved most valuable for older patients in whom
the differential diagnosis is lengthy, clinical findings may be
confusing, and appendectomy carries increased risk
For the ct scan,
CT scan of the abdomen or pelvis in a patient
with acute appendicitis may reveal an appendicolith (arrow). Seen on the topleft picture where
the arrow is pointed
B, CT typically shows a distended appendix (arrow) with diffuse wall
thickening and periappendiceal fluid (arrowhead).
C, The appendix
may be described as having mural stratification, referring to the
layers of enhancement and edema within the wall (arrow); this
may also be referred to as a target sign. C, Cecum; TI, terminal
For the OR technique, patient’s pre-operativ diagnosis is acute appendicitis thus he was
subjectedto emergency appendectomy vthorugh a rockey davis incision

Here is an algorithm or the evaluation and management of patients with possible acute
appendicitis based on the assessment and clinical probability of diagnosis
Since the patient is in high probability he needs an operation

Most patients with acute appendicitis are managed by surgical removal of the appendix.
resuscitation is usually sufficient to ensure the general anesthesia will be delivered safely
Preoperative antibiotics should cover aerobic and anaerobic colonic flora.
For patients with nonperforated appendicitis, a single preoperative dose of antibiotics reduces
postoperative
wound infections and intra-abdominal abscess formation.
For patients with perforated or gangrenous appendicitis, we continue postoperative IV antibiotics
until the patient is afebrile.

Several studies have compared

laparoscopic and open appendectomy, and the differences in outcome are not that significant.
People nowadays opt for laparoscopic appendectomy thus the use of this procedure continues to
increase. This may be due to shorter hospital stays

The percentage of appendectomies

performed laparoscopically continues to increase.23 Obese
patients have less pain and shorter hospital stays after laparoscopic
versus open appendectomy.24 Patients with perforated
appendicitis have lower rates of wound infections following
laparoscopic removal of the appendix.25 Patients treated laparoscopically
have improved quality of life scores 2 weeks after
surgery26 and lower readmission rates.

As compared with openappendectomy, the laparoscopic approach involves higher operating

room costs, but these have been counterbalanced iby shorter length of stay.

For open appendectomy, which was done in the patient, it can be done through a rockey davis
incision which is a transverse incision in the lower right or macarthur mcurney incision which is
an oblique incision. Local anesthetic will be administered before the incision to reduce postop
pain
Mesoappendix is divided between clamps and ties
The base of the appendix is held at its junction with the cecum
Next, we see that an absorbable heavy tie is placd around the base of the appendix and the
specimen is clamped and divided. Appendix is excised
Next an absorbable purse string suture or z stitch is placed into the cecal wall and the
appendiceal stump is inverted into a fold in the wall if the cecym

So here is a video of an open appendectomy, first they need to identify mcburneys point
Then an incidision iif made throught subcutaneous fascia fascia ext oblique muscle.
Then proceed until we see the aponeuorosi
Then incision is made ext oblique is ipened in the line of incision and the muscle layers split to
expose the peritoneum
Until we see peritoneum
Then the ascending colon is identified. Then follow the taenia coli to automatically find the
appendix with the index finger, identify the appendix and it is seen a inflamed and by gently
pulling to deliver the appendix.
Position the clamp at the distal part of mesoappendix and start dentifying app artery.
Ligate it at the base of appendix.
Then once the artery is ligated, the base of the appendix can be crushed. Clamp it then place a
ligature around it. Then cut the appendix below the clamp.
Reposition cecum back into abdominal cavity
Close peritoneum
Inject local anesthesisa

Laparoscopic appendectomy has the advantage of diagnostic laparoscopy combined with the
potential for shorter recovery and incisions that are less conspicuous
If a CT scan was obtained preoperatively, it needs to be reviewed by the
surgeon to know the position of the appendix relative to the cecum.
After injection of local anesthetic, we place a 10-mm port into the umbilicus, followed by
a 5-mm port in the suprapubic midline region and a 5-mm port midway between the first two
ports and to the left of the rectus abdominis muscle (Fig. 51-5). The 5-mm, 30-degree
laparoscope is moved to the central port, with the surgeon and assistant both on the patient’s left.
With the patient in the Trendelenburg position and rotated left side down, we gently
sweep the terminal ileum medially and follow the taeniae of the cecum caudad to locate the
appendix, which is then elevated.
The mesoappendix is divided using a 5-mm harmonic scalpel or
Liga-Sure, or between clips, depending on the thickness of this
tissue (see Fig. 51-5A). We typically encircle the appendix with one or two heavy absorbable
Endoloops cinched down at the base of the appendix, then place a third Endoloop on the
specimen
side (≈1 cm distally), and divide the appendix (see Fig. 51-5B and C).
In patients in whom the base is indurated and friable, a 30-mm endoscopic stapler is used to
divide the appendix.
For most patients, , the considerable added cost of the stapler is not needed. Any spillage of fluid
is aspirated and, any identified appendicoliths are removed to prevent postoperative abscess
formation. The
appendix is placed into a specimen bag and removed with the port through the umbilical wound
(see Fig. 51-5D). Fascia at the 10-mm trocar site is closed, and all wounds are closed
primarily.

__
So here we can see a video of laparoscopic appendectomy
Op room setup surgeon and assistant on the left
Make a 10 mmincision on the umbilicus
Then inflate abdomen maintain pressure within normal limits
Next 10 mm trochar can be placed I the umbilical incision
Using lap camera inspect abdomen to cofirm no stuctures damages upon entry
5 mm trochar place in suprapubic and left lower quadrant
Prefrrred position tredelenberg with right side up
For better visualization of appendix
Insert lap camera
Assess append
Identify appendix cecum
Examine signs perforation
Electrocautery and blunt dissection- mobiliza appendix from mesoappendix and other
surrounding peritoneal attachments
Once appendix is mobilized it can be transected at the base
Stapler can detach appendix rom cecumonce appendix is completely separated, I can be placed in
specimen bag and removed from abdomen
Irrigate with saline
Remove trochards
Close incision

Post operative diagnosis of the patient is acute suppurative appendicitis

Intraoperative findings
Upon opening, noted minimal suppurations at the right lower quadrant. The Appendix was
retrocecally located measuring 8 x 1 cm in gangrenous state with no point of rupture. Base was
noted to be viable

Course in the Wards

---