appendix may serve as a reservoir of “good” intestinal bacteria and may aid in recolonization and maintenance of the normal colonic flora
patients who have had previous appendectomy have been demonstrated to have a more difficult clinical course and overall poorer outcomes in recurrent cases of Clostridium difficile infection
Appendix Size and how to identify
- appendix is of variable size (5–35 cm in length) but averages 8 to 9 cm in length in adults.
- Its base can be reliably identified by defining the area of convergence of the taeniae at the tip of the cecum
MC location for Appendix Tip
- most common being retrocecal (but intraperitoneal) in approximately 60% of individuals
- pelvic in 30%,
- retroperitoneal in 7% to 10%.
Amyand Appendix
Appendix found within an inguinal hernia sac
The most common sequela in Appendicitis
- formation of an abscess in the periappendiceal region or pelvis
- On occasion, however, free perforation occurs that results in diffuse peritonitis
Bacteria commonly isolated in perforated appendicitis
Gram-Negative Bacteria
Escherichia coli MC 64%
Gram-Positive Bacteria
Enterococcus species 3.9%
Causes of Appendicitis
most commonly include
- fecal stasis and fecaliths
- Lymphoid hyperplasia
- neoplasms
- fruit and vegetable material
- ingested barium
- parasites such as ascaris or pinworm infestation
Appendix Pain
- Distention of the appendix is responsible for the initial vague abdominal pain (visceral) often experienced by the affected patient.
- The pain typically does not localize to the right lower quadrant until the tip becomes inflamed and irritates the adjacent parietal peritoneum (somatic) or perforation occurs, resulting in localized peritonitis
Rovsing sign, obturator sign, psoas sign
- Rovsing sign (the presence of right lower quadrant pain on palpation of the left lower quadrant)
- the obturator sign (right lower quadrant pain on internal rotation of the hip)
- the psoas sign (pain with extension of the ipsilateral hip)
Alvarado score sensitivity
sensitivity of an Alvarado score of <4 was most useful in excluding a diagnosis of appendicitis (96% sensitive)
but that a higher score lacked specificity in diagnosing appendicitis as the cause of the patient’s abdominal pain
The Alvarado score
Interpretation:
<4 Appendicitis unlikely
5–6 Compatible with appendicitis
7–8 Probable appendicitis
9–10 Very probable appendicitis
CT findings in appendicitis
thickened, inflamed appendix with surrounding “stranding” indicative of inflammation
The appendix is typically more than 7 mm in diameter with a thickened, inflamed wall and mural enhancement or “target sign”
Periappendiceal fluid or air is also highly suggestive of appendicitis and suggests perforation
When to used US for Appendix
evaluation of the pediatric or pregnant patient
MRI ?
- reserved for use in the pregnant patient
- performed without contrast agents.
Criteria for MRI diagnosis include appendiceal enlargement (>7 mm), thickening (>2 mm), and the presence of inflammation.
open appendectomy
- supine position
- incision :
- oblique muscle-splitting incision (McArthur-McBurney)
- transverse incision (Rockey-Davis)
- conservative midline incision.
- The cecum is grasped by the taeniae and delivered into the wound
- visualization of the base of the appendix
- delivery of the appendiceal tip.
- The mesoappendix is divided
- appendix is crushed just above the base
- ligated with an absorbable ligature, and divided.
- The stump is then either cauterized or, if desired, inverted by a purse-string or “Z” suture technique. Finally, the abdomen is irrigated and the wound closed in layers.
When to use stapler in appendicitis
the appendix and mesoappendix may be divided with an endoscopic stapling device. We prefer this technique in cases in which the entire appendix is friable because it allows the staple line to be placed slightly more proximally, on the edge of the healthy cecum, thereby theoretically reducing the risk of leakage from breakdown of a tenuous appendiceal stump.
does perforated appendicitis requires C/S ?
Cultures are not mandatory unless the patient has had exposure to a health care environment or has had recent exposure to antibiotic therapy
Do you do Suction and irrigation , and Drain ?
Although large volume irrigation has been traditionally advocated, recent data suggest that simple suction aspiration of gross purulence may be just as effective in cases of appendiceal rupture.
Drains are not routinely placed unless a discrete abscess cavity is present.
How to close Skin in open technique
If an open technique was used, the skin and subcutaneous tissues are left open for 3 or 4 days to prevent development of wound infection, at which time delayed primary closure may be performed at the bedside with sutures, surgical skin clips, or Steri-Strips, depending on the surgeon’s preference.
Post op in perf app , When to stop abx and start feed
broad-spectrum antibiotics for 4 to 7 days
If culture specimens were obtained, antibiotic therapy should be modified in accordance with the results.
Nasogastric suction is not employed routinely but may be necessary if postoperative ileus develops.
Oral alimentation is begun after return of bowel sounds and passage of flatus and is advanced as tolerated.
Once the patient is tolerating a diet, is afebrile, and has a normal white blood cell count, the patient may be discharged home.
If the patient develops fever, leukocytosis, pain, and delayed return of bowel function post op
the possibility of a postoperative abscess must be entertained.
In complicated appendicitis, laparoscopic appendectomy had a higher what ?
was associated with fewer wound complications but a slightly higher incidence of intraabdominal abscess.
delayed appendicitis with phlegmon ? how to Tx
If a periappendiceal phlegmon is present or if the amount of fluid present is not sufficient to drain, the patient may be treated with antibiotics alone, typically for 4 to 7 days
Interval Appendectomy
the actual risk of recurrent appendicitis appears to be small, 8% at 8 years in one study of 6439 pediatric patients.
In addition, interval appendectomy can be challenging and consequently yield a higher risk of postoperative complications when performed
interval appendectomy should be reserved only for patients who present with symptoms of recurrent appendicitis.
the presence of an appendicolith on CT has also been shown to be predictive of a higher risk of recurrent appendicitis and has been used as a justification to proceed with interval appendectomy
