Anatomy

a blind muscular tube with mucosal, submucosal,

muscular and serosal layers.

At birth, appendix is short and broad and its function with

the cecum, but differential growth of the cecum- typical
tubular structure by about the age of 2 years.
•During childhood, continued growth of the
caecum commonly rotates the appendix into
a retrocecal but intraperitoneal position.

•Position of the base of the appendix is

constant, being found at the confluence of
the three taeniae coli of the cecum,
which fuse to form the outer longitudinal
muscle coat of the appendix
Various positions of appendix:

• Mesentery of the appendix or mesoappendix arises

from the lower surface of the mesentery or the terminal
ileum and is itself subject to great variation.
Variations in Appendices
Origin (Treves)
Type I Fetal type, funnel shaped origin

Appendix originates from the

Type II
cecal funds

Appendix originates
Type III posteromedially out of the
cecum

Appendix originates directly

Type IV
beside the ideal orifice
Blood Supply

• Appendicular Artery which arises from the

posterior cecal branch of the ileocolic artery

Lymph Drainage

• Nodes along the ileocolic artery, into the

superior mesenteric nodes
 Innervation

• Sympathetic originates from the celiac and superior

mesenteric ganglia

• Parasympathetic originates from the vagus nerve.

• Sensory innervation for pain is carried by T8 spinal

nerve down to T10-L1 spinal nerve.
Definition:
An inflammation of the vermiform appendix.

Aetiology:
• No unifying hypothesis

• Decreased dietary fibre and increased consumption of refined

carbohydrates.

• Obstruction of the appendix lumen.

-Fecolith (composed of inspissated fecal material, calcium phosphates, bacteria,

epithelial debris, rarely a foreign body)

-Tumour (carcinoma of caecum)

-Intestinal parasites (Oxyuris/Enterobius vermicularis-pinworm)

PATHOPHYSIOLOGY:
 ACUTE APPENDICITIS:
I. PATHOPHYSIOLOGY
• Definition: inflammation of the appendix caused by obstruction of the appendiceal lumen (this produces
a closed loop, resulting in necrosis and/or perforation).

• Most common acute surgical abdomen (risk is higher in males)

• Most frequent in the 2nd and 3rd decade of life (rare in the very young)

• Etiology and pathogenesis:

Fecalith: most common cause

Obstruction of the lumen: increase intraluminal pressure (Laplace law)

Hypertrophy of the lymphoid tissue

Inspissated barium

Vegetable and fruit seeds

Intestinal worms (ascariasis)

Sequence of Events following Occlusion of
the Appendiceal Lumen

• Closed loop obstruction (lumen occlusion by fecalith,

which is the most common cause)

• Continuing normal secretion of appendiceal mucosa

• Rapid distention of the appendix with stimulation of

visceral nerve pain fibers

• Rapid bacterial multiplication

• Lymphatics,venules, and capillaries are occluded

• Vascular engorgment & congestion results (causes reflux nausea
and vomiting)

• Inflammatory process involves the serosa of the appendix

(causes stimulation of somatic nerve and right and right lower
quadrant pain)

• Absorption of necrotic tissue & bacterial toxins (causes signs of

inflammation: fever,tachycardia, and leukocytosis)

• Progressive distention may cause infarction and perforation (In

complicated and/or cases)
Risk Factors for Perforation of the Appendix

Extremes of age Immunosuppression

Faecolith obstruction Pelvic appendix

 Clinical Manifestations
Symptoms Signs Signs to elicit

• Pointing sign (patient is asked to point

• Peri-umbilical • Pyrexia (37.2- where the pain began and where it
moved)
colic 37.7’C) • Rovsing’s sign (deep palpation of the
• Pain shifts to • Localised iliac fossa may cause pain in the right
right iliac tenderness in the iliac fossa)
fossa right iliac fossa • Psoas sigh (patient will lie with the right
hip flexed for pain relief)
• Anorexia • Muscle guarding • Obturator sign (the hip is flexed and
• Nausea • Rebound internally rotated. If an inflamed
tenderness appendix is in contact with the obturator
internus, this manoeuvre will cause pain
in the hypogastrium)
 Special features based on
Appendix locations

Retroceccal (silent appendicitis)

• Rigidity is often absent but deep pressure fail to elicit

tenderness

• Deep tenderness often present in the loin

Pelvic

• Early diarrhoea results from an inflamed appendix being

in contact with the rectum

• Complete absence of abdominal rigidity and lacking

tenderness over McBurney’s point

• Deep tenderness-symphysis pubs, on the right side

• Spasm of psoas/ obturator interns muscle

• Contact with bladder- frequency of micturition (mostly in

children)
Postileal

• the inflamed appendix less behind the terminal ileum

• Greatest difficulty

• pain may not shift

• diarrhoea is a feature

• marked retching ( spasm which causes vomiting) may

occur

• Tenderness if any

• ill-defined
 The Alvarado Score

• Symptoms
• Migratory Right iliac fossa pain 1
• Anorexia 1
• Nausea and vomiting 1

• Signs
• Tenderness on the Right Iliac Fossa 2
• Rebound tenderness 1
• Elevated temperature 1
• Laboratory
• Leukocytosis 2
• Shift to the left (segmented neutrophil) 1
• TOTAL 10
• <5 is strongly against a diagnosis of appendicitis

• 7 or more is strongly predictive of acute appendicitis

• In patients with an equivocal score of 5 or 6,

abdominal ultrasound or contrast- enhanced CT scan
is used to further reduce the rate of negative
appendicectomy.
 Treatment
• Intravenous fluids

• to establish adequate urine output

• Appropriate antibiotics

• reduces the incidence of post operative wound infection

• when peritonitis is suspected, therapeutic intravenous

antibiotics to cover Gram-negative bacilli as well as anaerobic
cocci should be given

• Appendectomy
 Appendectomy

• Conventional

• Laparoscopic
 Conventional Appendectomy
• Cecum is identified

• Base of mesoappendix is clamped in artery forceps, divided and ligated

• The freed appendix is crushed near its junction with the cecum in artery
forceps, which is removed and reapplied just distal to the crushed
portion

• As absorbable purse string or Z suture may then be inserted into the

cecum about 1.25 cm from the base

• The stump of the appendix is invaginated while the purse- string Z

suture is tied thus burying the appendix stump.
 Laparoscopic Appendectomy

• The placement of operating ports may vary according to

the operator preference and previous abdominal scars

• The operator stands to the patient’s left and faces a video

monitor placed at the patient’s right foot

• A moderate Trendelenburg tilt of the operating table

• By elevating the appendix is identify and controlled using

a laparoscopic tissue-holding forceps
• By elevating the appendix, the mesoappendix is
displayed

• A dissecting forceps is used to create a window in the

mesoappendix to allow the appendicular vessels to be
coagulated or ligated using a clip applicator.

• The appendix, free of its mesentery, can be ligated at

its base with an absorbable loop ligature, divided and
removed through one of the operating sutures.
• It is not usual to invert the stump of the appendix.

• A single absorbable suture is used to close the lines

alba at the umbilicus, and the small skin incisions
may be closed with subcuticular sutures.

• Patients who undergo laparoscopic appendectomy are

likely to have less postoperative pain and to be
discharged from hospital and return to activities of
daily living sooner than those who have undergone
open appendectomy.
 Post operative complications

• Wound infection

• Intra abdominal access

• Adhesive intestinal obstruction