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Berengario DaCarpi, a physician-anatomist,

made the first description of the appendix in


1521
Leonardo DaVinci demonstrated the appendix in
drawings made in 1492 but not published until
the 18th century.
Lorenz Heister gave the first unequivocal account
of appendicitis in 1711
The appendix is clearly illustrated in De Humani
Corporis Febrica Liber V by Andreas Vesalius
published in 1543
The Appendix
Introduction
The Appendix
Introduction
Heister, a student of Boerhaave, described a
perforation of the appendix with a small abscess
adjacent to a gangrenous appendix
Heister speculated that the appendix might be
the site of acute inflammation. He described the
autopsy on the body of a criminal
Francois Melier, a Parisian physician, described
6 cases of appendicitis at autopsy and first
suggested the possibility of removing the
appendix in 1827

The Appendix
Introduction
Claudius Amyand, Sergeant Surgeon to George
II, performed the first known appendectomy in
1735. He operated on an 11-year-old boy with a
right scrotal hernia and a fistula. He identified the
appendix, perforated by a pin, within the scrotum.
He ligated the appendix and removed it.
The Appendix
Introduction
Fitz 1886
Proposed that the appendix is the cause of
most inflammatory disease of the right lower
quadrant. He went on to describe the clinical
features of appendicitis and, importantly, proposed
early surgical removal of the appendix
The Appendix
Introduction
In 1889, McBurney of New York published the
first of several important papers regarding the
appendix. He suggested early operative
intervention and developed the muscle-splitting
incision that bears his name and is commonly
used today

The Appendix
Surgical Anatomy
Surface anatomy
Development: diverticulum of ceacum appearing
in the 8
th
week of life
Positions: constant base, tip varies (retroceacal,
pelvic, subcaecal, preileal, pericolic)
Blood supply
Location during surgery
Surrounding anatomical structures
Part of the gut lymphoid tissue.
The Appendix
Surgical Anatomy
The Appendix
Surgical Anatomy
The Appendix
Surgical Anatomy
The Appendix
Surgical Anatomy
The Appendix
Acute Appendicitis
Epidemiology
Most common surgical emergency.
Slightly more common in men.
Incidence are falling from 100 to 50 in 100 000 (1975-1991).
1 in 6 of the population will have an appendectomy.
More common in European societies (Diet).
Relation to class status.
Age > 2 yrs, (associated with lymphoid development).
Up to 16% of appendicectomies are normal 75% are in women
Age 1-5 has 70% perforation rate
Age < 1yr has almost 100% perforation rate
REASONS
Communication
Shorter, incompletely formed omentum
The Appendix
Acute Appendicitis
Epidemiology
The Appendix
Acute Appendicitis
Pathology I
Luminal obstruction.
Lymphoid hyperplasia 60%
Faecolith 35%.
Fruit seeds. }<4%
Worms. < 1%
Extra-luminal obstruction eg Ca Cecum

Raised intra-luminal pressure
Mucus accumulation
Multiplication of bacteria.
( E.Coli, Bacteroids, peptostreptococcus, Psuedomonas)
Venous and lymphoid congestion and Impaired arterial
flow, thrombosis and gangrene.
Perforation may occur through devitalized tissue.

The Appendix
Acute Appendicitis
Pathology II
Histological terms used:

Acute
Suppurative
Necrotic
Gangrenous
Perforated
Appendicular mass

The risk of perforation is not inevitable.
The Appendix - Acute Appendicitis
Clinical Features I
Only 55% have classical features.
Atypical 45%
History 24-36 hours
Abdominal pain:
(diffuse and periumbilical, localizing to the RIF)
Anorexia (almost always).
Vomiting (75%).
Low grade fever.
If >38 suspect perforation
Tenderness, guarding and rebound: Be gentle
Rovsings, psoas, obturator signs: unreliable and late
The Appendix - Acute Appendicitis
Clinical Features II
Tender Appendicular mass
Atypical:
Groin, high RUQ, deep pelvic
Diarrhea (not always gastroenteritis)
Urinary frequency
The Extremes of Age:
Children < 5 rapid progression
Pain in the elderly is less intense
The Appendix - Acute Appendicitis
Signs & Symptoms

MANTRELS Score
Established in 1986
Migration of pain
Anorexia
Nausea / vomiting
Tenderness RLQ
Rebound
Elevated temp.
Leukocytosis
Shift to left
RLQ tenderness and leukocytosis = 2
points each ; all others 1 point
Score of 5 to 6 = possible appendicitis
Score of 7 to 8 = probable
appendicitis
Score of 9 to 10 = very probable
appendicitis
MANTRELS Score
The Appendix - Acute Appendicitis
Investigations
White cell count: high sensitivity 96%, low specificity
Urine analysis
Plain Xray, nonspecific
Ultrasound highly sensitive (80-90%), excludes
other pathologies.
Computer Tomography: More superior to USS in diagnostic
accuracy.
Barium enema: Good accuracy, but technically
difficult and false positives are common.
Laparoscopy
Active observation
Computer aided diagnosis.
Peritoneal lavage


The Appendix - Acute Appendicitis
Imaging
Deutsch and Leopold visualised appendix in 1981
Graded pressure technique (compresses the
bowel overlying the appendix)
Immobile, non-compressible, blind-ending
structure consisting of an anechoic lumen
surrounded by an echogenic mucosa and
hypoechoic thickened wall adjacent to the
caecum.
ULTRASOUND
The Appendix - Acute Appendicitis
Imaging
ULTRASOUND
The diagnostic accuracy of graded compression
ultrasound has been reported to range from 71%
to 97%, with sensitivities and specificities in the
76% to 96% and 47% to 94% ranges,
respectively
Operator dependent
Normal appendix must be visualised to rule out
appendicitis (60-82%)
Retrocaecal appendix difficult to visualise
The Appendix - Acute Appendicitis
Imaging
Appendicitis features:
Appendiceal diameter > 6-7mm (sensitivity
100%, specificity 64%)
Target sign
Loculated pericaecal fluid (rupture)
Appendicolith
Absence of gas in appendix lumen
ULTRASOUND
The Appendix - Acute Appendicitis
Imaging
ULTRASOUND
The Appendix - Acute Appendicitis
Imaging
Disadvantages
Low specificity
Discomfort for patient with probe pressure

Advantages
Inexpensive
Non-invasive
No radiation
Can find other abdominal pathology
ULTRASOUND
The Appendix - Acute Appendicitis
Imaging
CT SCAN
Accuracy of 93-98%
Sensitivity 87-100%
Specificity 95-99%
Enlarged appendix
Appendiceal wall thickening
Peri-appendiceal fat stranding
Appendiceal wall enhancement
The Appendix - Acute Appendicitis
Investigations
CT advantages
Higher diagnostic accuracy
Operator independence

CT Disadvantages
Contrast problems
Radiation
Cost
CT SCAN
The Appendix - Acute Appendicitis
Investigations
CT SCAN
The Appendix - Acute Appendicitis
The Very Young
Diagnosis may be more difficult to
establish, WBC is likely to be normal
(12% are normal).

Children are more likely to progress to
perforated appendix
(? Under-developed Greater Omentum).

The Appendix - Acute Appendicitis
The Very Old
Greater morbidity and mortality
Less typical presentation
Cancer may be a possibility as an
underlying cause.
Perforation of 50% and mortality of
20% has been reported

The Appendix - Acute Appendicitis
The Pregnant
Implications: Clinical Findings, Lab Ix, Surgery
1: 2000 pregnancies.
More common in the first two trimesters
The appendix is pushed superiorly and laterally
WBC > 15
Premature Labor 10-15% with surgery
Perforated appendix leads to fetal death in 20%
Rapid diagnosis and treatment is advised.
The Appendix - Acute Appendicitis
In AIDS Patients
Be aware of CMV or Kaposi sarcoma as
the underlying cause

WBC may not rise

The Appendix - Acute Appendicitis
The Management
Preop:
IVI,
analgesia,
IV antibiotics
Conventional appendicectomy
Types of incisions
Laparoscopic appendicectomy:
(questions regarding pain, hospital stay, operation
time, to daily activity, wound infection)
The Appendix - Acute Appendicitis
Post-Operative
1. Check the vitals
2. Check the abdominal signs and bowel
movement
3. Check the wound
4. Advise on mobilization
5. In OPD:
1. Check wound
2. Check the Histology
The Appendix - Acute Appendicitis
Prognosis
Mortality: from 0.2% to 1%
Complications increase with perforation
Morbidity:
Wound abscess,
Wound infection (less with MacBurneys incision),
Wound dehiscence
Intra-abdominal abscess,
Faecal fistula,
Intestinal obstruction,
Adhesive band,
inguinal hernia.
Fertility
The Appendix - Acute Appendicitis
Problems
Mass palpable pre-operatively

Appendix is normal at operation

Tumor is found in appendix

Prophylactic appendicectomy

The Appendix Chronic Appendicular Conditions
Chronic Appendicitis
A loose term referring to a multitude of
conditions associated with RIF pain and
in which pathology of the appendix has
been found.

The Appendix Chronic Appendicular Conditions
Appendicular Mass
Results from either:
1. Localized by edematous, adherent omentum
and loops of small bowel
2. Appendicular abscess
Incidence is 10%
Higher in children
Management controversy:
Interval vs Immediate appendicectomy
The Appendix Chronic Appendicular Conditions
Tumors of The Appendix
Carcinoid:
Arise from Kluchitsky cells
Mean age 20-40
Yellow bulbar mass
In F>M
In third decade of life
Usually lies near the tip
In the absence of LN spread with <2 cm in
diameter appendicectomy is sufficient.
Otherwise a R hemicolectomy is necessary.
Adenocarcinoma and Lymphoma.
ABA-The Appendix- 4
th
year
Lectures
Differential diagnosis:

Intraperitoneal Extraperitoneal
Gastroenteritis
Mesenteric adenitis


Lobar Pneumonia
Ileocaecal Pathology:
Regional ilitis
Crohns
Meckels diverticulitis
Intussusceptions
Carcinoma
FB perforation
Constipation
Appendices epiplocae torsion


Osteomyelitis
Female pelvis:
Ovarian: ruptured follicle
Torsion of cyst
Haemorrhagic cyst
Acute salpingitis (PID)
Ruptured ectopic pregnancy
Uterine fibroid
Endometriosis



Haematoma of the rectus sheath
Genitourinary disorders:
Pyelonephritis
Ureteric calculi
Cystitis

Neuralgic pains
Others
Perforated DU
Pancreatitis
Acute cholecystitis
Diverticulitis


Ruptured aortic/iliac aneurysm