PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)

October 5, 2020

I. Ward

Other 10 group were presented

Doc’s comments on the presented cases:
Concise
Stages of appendicitis
Appendix is part of the lymphatics
Obstruction of the appendix there will increase the
intraluminal pressure-> impingement of LE with a BS from
the basement membrane.
Contents of appendix: Fecal material and bacteria
Fecalith adults, lymphoid hyperplasia pedia

1st stage: Congestive general diffuse visceral pain which is

non localized. It also stimulates vomiting via vagus nerve
impingement.

2nd stage: Suppurative. Neutrophils go into another layer.

Inflammation goes outside it will.
All hollow organs outer layer is adventitia but in GIT it is
serosa. Therefore this is neutrophilic.

3rd stage: Gangrenous. Prolonged ischemia

4th stage: Perforated

SIRS: >90HR, >20RR(tachypnea), >38(Fever) or <

36(Hypothermia), >12 Leukocytosis or <4 Leukopenia. You
need at least 2 to conclude you have SIRS. BP not included.
Without identifiable causes of infection.

Sepsis: SIRS plus identifiable cause of infection

BS of appendix is ASIA. Aorta, Superior Mesenteric artery,

Aorta…..
It is more prone to ischemia…

Diagnostic:
Cxr
CBC
BT
Electrolytes

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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)

Whole abdomen ultrasound II. Cine Clinics

Topic: Laparoscopic Appendectomy
Imaging: Lecturer: Dr. Richard Velarde-FELLOW, FOCALS
Most important...: PE ad History Review the important surgical anatomy in laparoscopic
Most accurate CT with contrast chole
Share the basic
CRP is recently added to Alvarados scoring Lifted from PALES
Anatomy
CT scan and Uts if equivocal
Pregnant and children we use UTZ if inconclusive do CT
scan.
Gold standard is laparoscopy: EArly recovery and less
scaring
Antibiotics given as prophylactic , empiric are broad
spectrum. Therapeutic t=it is susceptible
To prevent SSI (Surgical Site Infection) 1hr prior OR DOC
Cefoxitin 2g IV 1 hr prior OR for prophylaxis. In WHO it is
given 30 mins prior to OR, if general surgeon …. 1 hr prior
to OR
If no Cefoxitin give …..

Therapeutic AB
Gangrenous and Ruptured Mx as Complicated AP DOC
Ertapinemen for adults, Ticarcillin/Clavulanic Acid for Pedia
it is an extended spectrum penicillin
Alternative: give CoAmoxiclav or 2nd gen cephal plus
metronidazole.

Rocky Davis. We draw an imaginary line from ASIS going to

the umbilicus and then 1/3 from ASIS is the Mcburney’s
point. This is where you put a transverse incision called the
Rocky Davis incision 1-2inches from.
In this case since we are dealing with ruptured
appendicitis. Usually we start with Low Midline incision for
better exposure. When you have a patient with ruptured
appendicitis most likely there will be generalized
peritonitis already
Emergency Appendectomy NPO 8 hrs agad this is not an
elective so NPO agad. ● The gallbladder is a hollow organ, sits in the
NGT is not needed in this case’ gallbladder fossa in the segments 4b and 5
IFC because dehydrated px. ● In adults the gallbladder measures approximately
LTM incision 10 cm in length and 4 cm in diameter when fully
distended
Psoas:.... ● Function is to store and concentrate bile
Obturator : px supine ad flex hip and knee with internal
rotation passive if pain elicited positive.

Planes: Retrocecal, pelvis, postileal , pre ileal

If negative AP after opening;

Still take out the appendix. Explain that appendix is at a
normal looking but still needs to take out it might be the
cause of pain.

Antibiotics given IV …
IV antibiotic is stopped when

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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)

Ducts – cystic, common bile and common hepatic duct

Cystic duct is connected to the GB.
Vasculature – cystic artery

2 approaches in cholecystectomy
· Open
· Laparoscopy – gold standard Advises training
Indication for cholecystectomy institution to do 4 ports, but any number of ports will do
Trauma
Malignancy

Asymptomatic indication would be:

Needed for work
…
Suspected GB malignancy

Choledocholithiasis – is the presence of stone in the bile

duct, most common is type secondary stones.
· The secondary are the most common stones if it
came from the GB
· The primary stones are from the common bile or
common hepatic duct
· If the patient is asymptomatic, the gallbladder is not Team position:
remove The camera operator will be at the left side, the 1st assist
will be at the side of the patient
Cholelithiasis
· Except
o In patients who are diabetic, and they have an
asymptomatic gallbladder disease
o Asymptomatic patients like seafarers, because the
company will require to do the surgery since it will be
difficult to air travel the patient when he is on board

Cholangitis – as impacted stone causing stasis of the bile

in the ampula and it would promote growth of
microorganisms, schedule patients for cholecystectomy
and removal of the stone by ERCP or choledocotomy and
remove GB to prevent recureences

Trauma - Rare. Removed if vasculature affected

Malignancy

Cholecystitis – most common indication

· The presence of stone

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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)

cleavage of lines of skin, heal better than incisions

that cross those lines

Trocar placement
· Working port – Rt MCL
· RT AAL port – Assist port Upon entry
· Epigastric port: working port · Limited diagnostic lap
· Umbilical Port: Optical Port o Trocar related injuries
o Status of the gallbladder
o Other intra abdominal pathology
· Position the patient on reverse Trendelenburg
with right side up
· Insert other trocars under direct visualization

Difference of 4 port and 3 port

4 ports
Optical in the umbilicus
3 port
The difference is the 3rd port is placed 1cm under, but they
are still the same

The initial access

· Surgical incisions made along or parallel to the
lines of langer, in the umbilicus, which define natural

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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)

· Traction of the hartmann's pouch is done infero

laterally
o Opens the hepato cystic triangle
· Contains the cystic artery “triangle of calot”
Dissection of the peritoneal covering at the infundibulo –
cystic junction using either the ESU or by peeling
1. Separate the liver from the cystic plate
2. -

To prevent biliary duct injury during lap

1. Rouviere's sulcus or right hepatic sulcus.

Dissection above Sulcus
2. 1st portion of the duodenum
CBD is located superiorly
3. Pulsating proper hepatic artery
a. The CBD is located parallel and lateral to the
artery
4. Common bile duct
a. Must be identified if possible
5. Infundibulo-cystic junction
a. Where you see the cystic duct, above the
rouviere's sulcus
b. Where dissection is done

Traction and initial dissection

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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)

Some use retrieval bags such as condoms to prevent SSI

Titanium clips are usually used. Hemoclip is also used

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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)

III. Lecture
CASE STUDY: “ABDOMINAL PAIN IN ACUTE APPENDICITIS”
WITH DOCTOR MEDINA
BLUE MEANS OCTOBER NOTES
A 30y/o female was admitted due to hypogastric pain >24
hours, LMP: last month with regular menstrual cycle. PE:
stable vital sign, T-38.4 C: abdomen: globular (+) Direct and
rebound tenderness right iliac fossa and hypogastric area
(+) involuntary muscle guarding.

Labs: WBC: 10 000/uL (N-80%, E-1%, B-1%, L-20%, M-5%)

Urinalysis: yellow, ph-5 pus cells 20-25, leukocyte (+), sp.gr Visceral:
- 1.015 ● The receptor of visceral is visceral peritoneum
and that is why when we conduct our surgery
QUESTIONS: (i.e. hernia surgery via local technique/approach,
1. Is this an acute abdomen? whenever I open the sac, I put anesthesia
a. Yes (ans) because that’s part of the visceral peritoneum,
b. No that’s very painful!
2. Does the patient need immediate surgery? ● It has a poor specificity because it has primitive
a. Yes qualities. (Clinical correlation: “If you ask the
b. No (ans) patient ‘Saan ba masakit?’, ‘Where is the most
3. What will be the appropriate management for painful site?’Due to poor localization, they will
this case? use a much bigger way to cover the area such as
a. Broad spectrum antibiotic the hand.)
b. Ultrasound (ans) ● Almost all organs are being covered by visceral
c. CECT Scan peritoneum.
d. Immediate Surgery ● It is vague and dull! Patient usually uses his hand
and touches a huge area.
Let’s suppose that this patient underwent surgery, ● Early stage of acute abdomen

SIDE QUESTION: What is acute abdomen?

4. Intraoperative findings of the appendix. What
will be the manner of administration of
antibiotics in this patient?
a. Prophylactic (ans)
b. Therapeutic (BUT IN THE CASE OF THE
VIDEO THIS IS THE ANSWER)
- Sudden, abrupt pain, first time experience,
unbearable
- Important: You need to do immediate
evaluation! (mandated/warranted)
- After assessing, doing blood work, you will
decide if it’s surgical or non-surgical
- All surgical abdomen presents as ACUTE
abdomen but NOT ALL acute abdomen are
surgical in nature!
Somatic:
● If you ask the patient where the pain is mostly
located, the patient can easily point to the
specific area that is in pain. Finger and hand
tests could help us.
● Directly above the organ being addressed (target
organ)
● Acute appendicitis is the best example of
inflammatory pain.
● When you palpate, you create pressure in the
abdomen and this will stimulate pain receptors
in the parietal peritoneum.

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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)
These are the sites which represent the specific organs.
Midgut derivatives such as our appendix are found in the
periumbilical area. That’s why the patient says “there is
pain in my umbilicus”.
Hindgut, the remaining transverse colon up to the distal
colon and rectal can be found infraumbilical.
Organs found in pelvic cavities (presentation is usually at
the back) are difficult to diagnose by history and PE).
In our case “Acute Appendicitis”, midgut would be a
favorite spot initially, this can more or less confirm that
you are in the right track of your evaluation.
Retroperitoneal can occupy the renal colic and hindgut.
Manifestation of pancreas is usually at the back.
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Lungs and myocardium (extraperitoneal organs).
Those highlighted organs, CONSIDER THEM FIRST.
In order of occurrence!
Somatic pain is more specific.
In our case, RUQ pain, our #1 consideration is the
APPENDIX, #2 Gynecologic problems (affects ovary and
fallopian tubes together with some retroperitoneal organs
like the ureter).
Patients >50 age, consider malignancy (LLQ)
Usually, when we have strangulated hernia, we have a
perforated bowel like in typhoid infection. The tenderness
is at the center. When it’s at the center, the primary
consideration would be a small bowel!
Pain at the back, aorta is highlighted because it is the
most common presentation of dissecting aortic aneurysm.
Shoulder, when you have a ruptured ectopic pregnancy,
the tip of the shoulder is most commonly in pain as your
patient is lying down the blood can touch the diaphragm
which is innervated by your C4 and C5 which is the same
innervation as your shoulders -> There would be
diaphragmatic irritation which would manifest as shoulder
pain.
RUQ pain: Abscess and infusion
Doc’s diaries: Shoulder pain, BP is going down -> Ruptured
ectopic pregnancy
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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)
In clinical practice, there are 3 clinical patterns namely:
Colicky, Inflammatory and Ischemic or vascular type.
Colicky: PROGRESSION (CRESCENDO AND DECRESCENDO)
hollow viscus, intermittent & there is a period of normal
phase followed by abnormal, antispasmodic will give relief
since it is secondary to contraction of muscle. Obstructive
in nature, patients like to move!
Inflammatory: PROGRESSIVE! main focus: involvement of
peritoneum (initially visceral peritoneum and parietal
peritoneum) and condition known as secondary
peritonitis. Inflammatory type is usually somatic in nature.
Somatic type of pain are specific & due to contamination
chemical or bacterial, intestinal(perforated abscess),
preferred not being touched, less no movement ( any
movement can stimulate the parietal peritoneum and
cause severe pain to the patient). Patient is motionless!
Ischemic or vascular type: MOST URGENT CONDITION!
Pain is out of proportion! NEEDS IMMEDIATE AND
URGENT ATTENTION. (deprivation of blood supply)Typical
myocardial infarction heart attack and ischemia, heart
attack posture seen in the movies, grimace and pain out of
proportion from being felt, vascular type of pain found in
patient exhibited with obstruction such as Superior
Mesenteric thrombosis, difficult to diagnose, diagnosis rely
only in diagnostic imaging, associated with systemic signs,
associated with delayed diagnosis, strangulated her
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A patient with a chief complaint of pain the first thing to
ask always includes age. Majority of Acute appendicitis
occurs at less than 30 y/o or middle age group (70 %) will
manifest. Also consider the sex it is more common in
females in some studies it is 22% in female.
Sometimes, you may open the female patients and there is
no appendicitis. They do less imaging in males compared
to females even if the patient has RUQ.
You need to be very cautious in females!
Advance age 60> or 70>: variability in the presentation of
these patients.
We don’t consider acute appendicitis without perforation
in this patient.
Below 50 nonsurgical followed by appendicitis
50 and above there is markedly increasing incidence of
abdominal pain secondary to malignancy (tumor) because
of delay diagnosis, do not rely solely with on your Hx & PE
relay also to CT Scan ( emits radiation)
Pregnancy the gravid uterus different location of appendix
depending on the AOG. It distorts clinical presentation.
Ultrasound is more commonly used to see this. Delay
would perforation and pregnancy state would lead to fetal
loss almost 40%
Most common acute abdomen condition affecting
pregnancy: Acute Appendicitis (treat patient as if patient
isn’t pregnant; take out source of infection ASAP).
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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)

Adults food matter, parasite, adhesion

Children lymphoid hyperplasia
Obstruction increase the intraluminal pressure

CHECK LECTURIO FOR VICIOUS CYCLE OF SIRS

Further increase will initially increase the lymphatic

drainage lead to mucosal compromise; bacteria try to
invade leading to bacterial translocation
The inflammatory cell goes up reflected by CBC or WBC
count

In further progression of the disease itself then it will lead

to infarction, finally perforation with Initially localized
peritonitis and generalized peritonitis. This picture tells
you that the pathophysiology of the continuing process
causes a simple obstruction without any intervention and
eventually the natural cause would be perforation. Some
would have localized forms of peritonitis and some
patients will have generalized peritonitis. Remember that
the danger in generalized peritonitis, that in a matter of
minutes, the infection will now be absorbed in the
systemic circulation and you will enter the cycle of (zehrs,
mots and mohs)?

ASSIGNMENT FOR THURSDAY:

BREAST CARCINOMA

Visceral pain! He will use the hand to localize pain.

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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)
As the inflammatory process continues, it will go into
serosa then trigger somatic fibers. As you palpate the area
or move, it will touch the peritoneal area and the patient
can localize the pain in RLQ.
The most important symptom of a patient with acute
appendicitis is pain. Let’s correlate the previous formation
events to the manifestation of abdominal pain in our
patient. Because of obstruction, it will lead to distention.
distention will trigger visceral fibers and these will give you
again the visceral type of pain in the early stage of acute
appendicitis. So this will be poorly localized and usually
vague because its midgut derivative organ is felt in a
periumbilical area.
And as the inflammation causes, we already know the
lateral cause of patients with acute appendicitis then there
would be involvement of the serosa. And now, this will
trigger the (weighing you)? when the serosa that is
remarkably touches the parietal peritoneum then the type
of pain now would be somatic in origin, and this is being
represented by your patient as the right lower quadrant.
Again, when you still remember the table right lower
quadrant with the first condition that should enter your
mind must be acute appendicitis.
Ask the patient:
Is the pain more intense now or a while ago? If Yes, you are
already on the right track! High possibility of Acute
Abdomen which is SURGICAL in nature!
So the change of the stimulation from the periumbilical or
the change of site, denotes the classic migration of pain
and this is in progression. So this inflammatory type of
pain usually progresses and of course you need to
intervene now and this is somehow giving a very high
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likelihood of diagnosing acute appendicitis. So that, the
combination of the series of events with the migration of
pain from periumbilical to the denotes only one thing that
you are dealing with that your patient is actually becoming
forced. So you now need to do something.
Always ask:
IS THIS THE FIRST TIME? The likelihood of diagnosing AP if
it is.
If the patient says, it is not! This will make a diagnosis have
a big difference.
What do we do during the preoperative? Of course we
need to assess. But this time, before we are being thought
on how to do a good data gathering of a complete story
and PE. We have to know What is useful information will
lead us to correct diagnosis. So don't ask many questions
because your patient is actually in the midst of pain, he
does not want to be irritated with so many unnecessary
questions, so we must be focused. We were moderately
useful and we got to gather them. but one thing I would
like to give emphasis on would be the Measurement of
accuracy in clinical practice.
You will be encountering the word sensitivity, specificity,
positive likelihood ratio, positive predictive value, negative
predicted value. These are the measure of accuracy. so you
need to know when to use them.
In textbooks there is a table that tells the possible
likelihood ratio of all of the historical features and physical
findings and even some laboratory tests, they are all found
in one table. There is a column under positive likelihood
ratio that tells you the probability that once they are
present the patient is likely suffering from acute
appendicitis. but there needs to be a value. a value has to
be more than 1. In clinical practice, the value has to be
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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)
more than 10 in considering individual patients, if you
notice there, not a single parameter has been valued guess
the highest is 7, that is around wbc >15,000.
RETROILEAL/POST ILEAL - RAREST LOCATION OF TIP OF
APPENDIX; can be presenting as GUT. If you examine urine
is normal, consider the location of the appendix in
retroileal and do imaging.
I mention the variability of symptoms; the atypical
presentation would be best because of different
anatomical variation.
The most common location is Retrocecal, followed by the
Pelvic (that’s the reason why when you are dealing with
female patients, you have to highly consider Pelvic
derivative organs, so that has to be part of your evaluation
of Preoperative).
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DISTENTION is important to ask because it could be
secondary to ileus (because of the presence of
inflammation).
In that table again, there are so many features like direct,
indirect tenderness, the value is more than 1. They can be,
but they should not be totally relied on individually. That’s
the message of that table. The combination of History and
PE is good, but should not rely totally especially when you
are dealing with a female patient.
For the PE on male, maybe, Rigidity is one of those findings
that has a high likelihood ratio (LR) or positive likelihood
ratio; therefore this can more or less guide us in deciding
whether to open the patient or to do further evaluation
using imaging modality.
Rectal examination should not be performed. Unlike
before, it has been taught that you have to perform this
routinely, but not anymore.
So, the key word is Focused.
Measurement of Accuracy in clinical practice:
-Sensitivity is the True Positive
-Specificity is the True Negative
Sensitivity that is below 60% and a wide range, this tells
you that you should not consider that particular
examination.
Very low sensitivity 8%, very wide broad range, therefore it
should not be done. NON-RELIABLE. DON’T PERFORM
THESE ABDOMINAL MANEUVERS (accdg kay doc).
That’s the reality. You are now in the evidence based clinic
practice so you have to highly consider evidence when you
are dealing with decision making.
Abdominal signs are already out of the picture. It is very
important that you do not perform them because they can
harm your patients also. They can elicit more pain.
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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)
It is part of preop evaluation. Doc doesn’t like it though.
Another Algorithm is the ALVARADO Scoring system
The magic number is 7.
Anything more than 7 increases the likelihood of you might
be dealing with Acute Appendicitis.
Let us know the Sensitivity and Specificity of Alvarado
scoring compared to other diagnostic modalities that we
can use.
A study from King Hussein Hospital, Middle East
It is a prospective study, a good methodology of 320
patients. It was distributed to 196 males, 124 females, and
the average age is 26 years old. They underwent operation,
and the Gold Standard is Histopath.
In that study, the negative appendectomy rate is 14%
(which is considered as acceptable negative appendectomy
rate because the sample is 15%), same as the standard
globally.
These are the results: (in order) Sensitivity, Specificity,
Positive Likelihood Ratio, Negative Likelihood Ratio. It
shows there, for the CT scan, the sensitivity indicates that
there is a chance of Appendicitis (based on the CT scan
result 94.2%); therefore, you need to operate on that
patient. Because 94% of the time, they are correct.
For those patients who underwent Alvarado scoring, it’s
85.4%. So big a difference, almost 10%. For the specificity,
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90%. If the CT scan is negative, then don’t operate on that
patient. For the Alvarado, if it’s still negative through a
negative rate of 65%, it really does not have a good
specificity. So your patient might still be having an Acute
Appendicitis even though the score is below 7. That’s the
meaning of it.
Likelihood ratio
Positive likelihood ratio -> ratio to rule in (you have) AP
Negative likelihood ratio -> ratio to rule out AP
If it’s more than 1, that's good but the range is one to
infinity. So, the higher you go, the better.
Between 2 and 9, 9 is much better.
In the table that i have mentioned a while ago, the highest
score would be 7 only; but here, CT scan likelihood ratio is
9. It’s really good.
Of course, the lower you go for the negative ratio, the
much better. 0.065 for CT scan, 0.224 for Alvarado score.
The summary.
P Value (P means Probability, P is a test of significance)
For you to say if all these numbers are significant, the P
Value should be less than 5%. 5 divided by 100 is 0.05.
Since the P value is less than 5%, then there results are
NOT significant, and the overall accuracy is 92.6% CT Scan
and 77.5% Alvarado score
Kay doc, dapat 60% sensitivity or else di niya irerequest.
Another thing we do during pre op is CBC that's the
favorite of all our residents, CBC and of course urinalysis,
but if you will look at this slide instead of urinalysis CRP
would even give you a much better assessment pre op, bec
the sensitivity can be as high as 85% although for
specificity not a good measure because of the wide range,
the wider the range you have to reconsider that, or there
should be reservation before you say that your patient is
not having any form of inflammation inside the abdomen,
so the WBC goes higher the sensitivity decreases, in clinical
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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)

practice 60% cut off but here it's only 62%, so I think the 3. Plain abdominal film: Abdominal obstruction
specificity is much more important than sensitivity when
you consider the usefulness of your WBC but in your table DOC:
if you have more than 15,000, I think 7 is the value for Female, abdominal pain, no scars, plain abdominal film
WBC. shows free air -> open

Urinalysis should only be requested if you are entertaining

renal problems.

Pregnancy test is mandatory for all females in their

reproductive age, it is mandatory, do not rely on verbal
response. You have to be objective!

ULTRASOUND SHOULD BE USED IN OUR PATIENT FOR

INITIAL BECAUSE SHE’S A FEMALE (no radiation).

Ultrasound is the favorite of the OB dept and also our dept

specially when we are entertaining pregnancy, so if the
patient is pregnant this is the imaging of choice, look at the
measures of accuracy 90% small range right? and then
specificity 83-95%, so what are the things that you have to
If there is doubt in initial evaluation. Resolved to imaging look for when diagnosing a patient using UZ as your
Radiography to see distention of abd primary imaging modality, the appendix should be
When uncomplicated perforation present as intestinal non-compressible and the lumen has to be more than
obstruction especial with no abd scan, with hx of abd pain. 6-7mm, the presence of appendicolith not fecalith. This is
a calcified, look white on UZ and of course when the
What is the role of imaging pre op? reader tells you there is a presence of "peri something?"
Imaging has to be selective, if there is doubt in your initial we all know that the primary limitation of your UZ is it is
evaluation using your hx and pe and even your initial blood reader dependent and coupled with retrocaecal appendix
work up then you resort to imaging, radiography has no this will more or less bring down the sensitivity of your UZ
role in diagnosing acute appendicitis, you see the range,
this is only done if the pain is more of obstructive in nature Appendicolith - hard, calcified excretion
meaning the involved organ is hollow organ like your small Fecalith - hardened stool
bowel, if you are entertaining intestinal obstruction by all
means do radiography , but let me share with you the
experience in our clinical practice, when you are dealing
with the complicated type of appendicitis like perforation
this will lead to, this will clinically present as intestinal
obstruction especially when you look at the abdomen and
no previous operative scar, so a virgin abdomen with
intestinal obstruction with the pain, with still pain before,
should make you suspect that you are dealing with
complicated type of acute appendicitis so that's the only
value of radiograph to document, if the abdomen is
distended by all means request for plain abdominal
radiograph.

3 things doc consider which leads to >50% acute

appendicitis:
1. AGE
2. HX OF OPERATION (Virgin Abdomen); distended
abdomen with no scar

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FAT STRANDING CAN BE SEEN ON CT-SCAN ONLY.

This picture shows an appendicolith, presented with the

solid big arrow, the presence of the appendicolith, you can
see the posterior shadowing 2 appendicolith with the
corresponding shadowing, it is a dilated bowel or some air,
so this confirms the diagnosis via UZ of acute appendicitis

You can see the appendicolith!

Another way is non-compressible appendix as you can see

the lumen, that is the lumen of the appendix, the criteria is
more than 6mm or more than 7 mm, here it measures 1cm
or 10mm, and another observation is the thicken
appendiceal wall with 3mm in thickness, so this can
confirm the diagnosis of acute appendicitis

Dilated Cecum

Comes with radiation!

Positive predictive value tells you the chance you are
dealing with an AP post op.
Positive predictive value like in mammography higher
specificity of microcalcification but only 10% positive
predictive value.
PPV is important in diagnosing px.
Fat stranding refer to inflammatory processes

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More advanced AP Fat stranding there is marked
inflammation with abscess. You have to send px to the
operating room.
More advanced AP Fat stranding there is marked
inflammation with abscess. You have to send px to the
operating room.
We also have MRI in our institution – look at the sensitivity
of the MRI compared to CT Scan, they are almost the
same. What is good about MRI is that it has no Radiation
so you can do this on a pregnant patient if the ultrasound
is inconclusive – it’s not operator dependent and you can
see the positive predictive value of 92% and negative
predictive value of 99.7%.
The only limiting factor of MRI is its cause. And it is not
also for claustrophobic people because a slight movement
will distort the image.
This is an example of a coronal view of MRI – you can see
here a fluid filled appendix. Anatomical location is very
clear if you do the MRI.
Axial view – Arrow pointing to the fluid filled appendix
which confirms the diagnosis.
The 21st century entails use of imaging selectively. You
don’t use this routinely.
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The last is the use of Laparoscopy. This is very
advantageous – you do this especially in situations in
which the picture is so obscure. Resolution – to see is to
believe – there is direct visualization through laparoscopy.
High risk aerosolized generating procedure! Can contribute
for transmission of COVID-19 airborne.
When you perform open for AP, you always have to
remove the appendix but in MIS, there is a choice NOT to
remove the appendix esp. If it turns out to be ovarian cyst
(normal looking appendix), deal with pathology.
If you do open, Rocky-Davis incision, take out the
appendix.
ACTUAL PATIENT:
This is a case of a 30 year old female who presented with
abdominal pain initially. Patient was having pleuritic pain,
presenting with RUQ. She was treated differently
conservative and then the Px developed dyspnea and then
there was pain with RUQ. Hepatobiliary but also lung is
included.
Chest X Ray was done with a result of massive effusion -
>50% of lung is obliterated with fluid. They were referred
to surgery.
There was also generalized tenderness (rigidity) on the
abdomen. The team decided to do a Diagnostic
laparoscopy (VIDEO).
Part of the pre operative assessment would be forming a
lot of differential diagnosis. The most important here is
gynecologic. 32% of the location of the tip of the appendix
is found in the pelvic area and this can confuse the surgeon
or the initial evaluator.
Standard of care is Appendectomy. We all know that
laparoscopic now is seen to be more advantageous than
open because as you witnessed a while ago, you make a
small incision – if you do that using the open technique the
incision would be from xiphoid down to the pubis.
One of the basic principles in surgery is – Exposure.
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You can see a 1cm incision in the umbilicus, leading to the

exploration of the entire abdomen. That’s the Diagnostic
Laparoscopy

Appendectomy addresses the principle of bacterial

peritonitis – source control. Take off the source of
infection, that’s the principle.
The other principle is treatment – Antibiotics

MAINTENANCE: 2L PER DAY

So, we label now our diagnosis based on the Actual case!
Intraoperative findings, whether uncomplicated such as Suppurative with fibrins
(this particular appendix).

Pinkish Appendix – congestive

Fibrins and Reddish – suppurative
Complicated – which you have witnessed a while ago.

Intraoperatively, you need to label whether your patient is

having an uncomplicated or complicated case. And of
course, the giving of antibiotics is based on the .. college of
surgeons evidenced based clinical practice. Guidelines for
uncomplicated, you just give it as prophylaxis. Principles of
prophylactic administration – you have to review them
because they are very important.

And then of course, for the complicated, you have a

different shift from a more broader antibiotic and a more
potent one and (Tapenem?) is the first line for your
information and of course the duration is up to 1 week –
that’s the maximum.

Ertapenem is the first one max of one week max.

FF up:
1 week after
1 month after
To check for recurrence of SSI

Assess/monitor:

1. Monitor urine output -monitor every hour

There would be huge or tremendous loss of
fluids in the 3rd space. Tea colored means
concentrated
2. The site of the wound
3. Intra abdominally bowel moves 3-4days
4. Px released from the operating room with Ngt -
check if properly placed and know the content
that comes out.

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 PUSTAHAN GROUPMATES (SURGERY ROTATION 2: OCT 2020)

5. Monitor if there would be abdominal distension -

with ngt there should be no distention

AP is life threatening because it can lead to sepsis

Appendectomy is the most commonly performed
operation secondary to trauma

Most common non-traumatic condition: Appendicitis

(second is gallbladder)

Algorithm by PSGS

- Telemedicine approach
- The patient and the doctor are separated by a
glass to avoid airborne transmission
- Both Wearing of mask
- Until now we only cater what is urgent and life
threatening

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No aerosolized generating procedure - we use level 3 PPE

In AP we do gen anes in open or lap. Lap is now a
secondary priority. Wear the highest level of PPE level 4.
MONA

Less Hx we rely more on imaging.

Examination is subjective! You don’t want to do operation
via hx and pe only.

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Success rate is 50% if with appendicolith

Grade 2, Obese patient, intubated, bombared antibiotics

There is resumption of GI tract. First Successful
conservative management of AP.

4-6 contrast enhanced CT. Non operative bombarded with Percutaneous drainage if toxic to remove microorganism
antibiotic present (If patient is toxic, ultrasound guided).
7-10 do Open CT scan percutaneous drainage to remove microorganism
in the abdomen
Complicated Appendicitis the risk for morbidity and
mortality increase

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Additional set- up: ULPA (ultra-low particulate air) filter,
HEPA (high frequency particulate air), Vacuum
QUESTIONS:
1. Mas maganda if one group of drug; if there’s
availability, then you can! Clinical improvement is
the main dictator on when to stop your
antibiotics. Govt institution - do less ideal but
still safe and acceptable. If the patient is hungry,
then there is GI resumption.
2.
MGA INISKIP NI DOC:
1.Arcofeola (meandering artery) will have ischemic AP Not
all but possible in can more or less delay.
The value of focus history resolve to other imaging
modalities
High index of suspicion is needed.
Treat patients more rather than laboratories
Should we treat it cumulative?
The message of the table is you can’t solely rely on one
diagnostic
2. Table in Schwartz how would we treat as cumulative or
dependent
Summary of the table cannot solely rely,does not totally
relay and resort to other approach for diagnosis
Individually di pwede. If cumulative, better.
Imaging will help
3. Patients will undergo emergency appendectomy with a
pending COVID19 result, where should we put them
post-operatively in the COVID ward or regular ward?
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3 division of ward
1. COVID ward : (+) COVID PCR 2.PUI-ANSWER
4. Use of drain in Appendectomy should be discourage.?
The principle of drainage is to drain locally(only the area
involved)
If you have mass from pelvic to subhepatic space. Drainage
will not serve the purpose; the drainage will be foreign
body harboring more infection.
I will not use intra abdominal drainage.
Friable base I could probably place drain near the ileocecal
area creating controlled fistula.
Abdominal area has so many compartments used in
pancreatic infection(use drains) but not usually is AP
Drain use for local infection
General infections drain will not serve its purpose
Lecture
Case discussion
A 24 year old female was admitted due to hypogastric pain
> 24 hours. LMP: last month with regular menstrual cycle.
PE: stale vital signs, Temp: 38.4֩ C; abdomen: globular, (+)
direct and rebound tenderness right iliac fossa and
hypogastric area, (+) involuntary muscle guarding.
Laboratories: WBC- 10,000/ uL (N-80%, E- 1%, B-1%,
L-20%, M-5%),
urinalysis: yellow, ph-5, pus cells- 20-25, leukocyte (+), sp.
Gr.- 1.015
If VS becomes unstable and with abd consider aneurysm
Globular not meaningful but distended is meaningful
Drainage if toxic to remove microorganism present
Answer:
CECT is more specific provided stable and not pregnant Px
Management for Female Non-pregnant patient
1. CECT scan
2. Broad spectrum antibiotics
Manner of antibiotic administration depends on the result
of CT scan
2. What will be the matter of administration of antibiotics
in this patient?
a.) Prophylactic
b.) Therapeutic
Answer:
Prophylactic
● Broad-spectrum antibiotics can be part of the
management.
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● I would suggest first CECT before giving this if the
patient is not pregnant.
● If in case, you are going to give antibiotics,
always start with Prophylaxis.
● The answer to this will depend on CT scan if with
abscess give immediately antibiotic as
Therapeutic rather than Prophylactic and carry
this on.
● If there is really abscess or perforation detected
by CT scan then you have to continue this
further.
● It is very important to consider these things in
making a decision from general data upto
utilization.
Key Points
● Obstruction= progression of pain.
o Initiating event would be obstruction.
o Since the obstruction is kinda permanent
would result in the progression of pain
such as migration of pain very important.
● Historical features: RLQ pain, migration of pain,
pain precedes vomiting, no history of prior
similar pain.
● Physical features: RLQ tenderness, rigidity, pain
at McBurney’s Point
o If male not request CT scan I would do
diagnostic lap or proceed with lap
appendectomy
● Psoas, Obturator, Rovsing sign???
not only take out the Appendix.
● Age and sex
● Female
● Hypogastric pain possible location in pelvic area.
● Pain with tenderness
● VS is stable if unstable aneurysm and ruptured
ectopic pregnancy
● Fever score of 1 meaning there is inflammatory
reaction ongoing
● SIRS was defined as fulfilling at least two of the
following four criteria:
o fever >38.0°C or hypothermia <36.0°C
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o Abdominal signs are of no use
● Alvarado score: >7 increases likelihood
o Due to the pandemic, there is a new
approach: Alvarado Score with CT scan.
● Clinical assessment
● HIGH RISK GROUP: Ultrasound, CT scan, MRI,
Diagnostic laparoscopy
o During pre-operative assessment Identify
high risk groups such as females, advanced
age, pregnant. In this group you can’t
totally rely only on focus history and PE.
You have to make things clearer by the
selective use of ultrasound, CT scan,
sometimes MRI and when indicated
invasive procedures. Now in the days of
pandemic they prefer Open but because of
good et up like negative pressure room,
smoke evacuator during lap then it is
already feasible to perform laparoscopic
examination. You got to protect yourself
and other health care worker by using
appropriate PPE level 4.
● Surgery mainstay: Open vs laparoscopy
● Antibiotics prophylactic vs therapeutic
● Conservative treatment selected cases.
o If grade 2 then you can try
o If a patient is covid positive and is exposed to
surgery the mortality rate goes up. Save life
o tachycardia >90 beats/minute
o tachypnea >20 breaths/minute
o leukocytosis >12*10^9/l or leukopenia
<4*10^9/l.
Kartagener Syndrome if the appendix is on the left side
rather than right.
Left side atypical resort to imaging. The CT scan will help
you in these findings.
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Dictum Transcribed by the future PGIs of January 2021

When in doubt Open but now when in doubt assess SRT INT JRT LAV JST MDT JT MLT MAT
further using imaging. ·
The atypical presentation would prompt you more on
imaging modalities or diagnostic laparoscopic.
Pleural effusion on right but with tenderness on the left

Transcribed by the future PGIs of January 2021

SRT INT JRT JT

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