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Vermiformis Appendix

It is the part of large intestine, averages about 7.5 – 10 Cm in length and its irregular lumen is about 0.5 Cm in diameter. It is a narrow muscular tube containing a large amount of lymphoid tissue. Usually the base is attached to the posteromedial surface of cecum about 2.5 Cm below the ileocecal junction. The remainder of the appendix is free. It has a complete peritoneal covering, which is attached to the lower layer of mesentery of small intestine to form a short mesentery of its own called mesoappendix, which contains the appendicular vessels and nerves. It lies in the right iliac fossa.

Blood supply comes from the appendicular artery, a branch of lower branch of ileocolic artery. Accessory artery may also be present. Appendicular vein joins the posterocecal vein. Four, six or more lymphatic traverse the mesoappendix to empty into ileocecal lymph nodes.

Acute Appendicitis


Etiology
Gender: Males are much more affected than females
Social Status: Upper and middle classes
Diet:Rich in proteins

Obstruction of the lumen of the appendix and/or distal obstruction of colon in mainly caused by E.Coli, Streptococcus, Anaerobic Streptococci etc.

First appendectomy was performed in 16th century (1534) as classic appendectomy by Amiad from the hernial sac, which was punctured and perforated. The region is rich in lymphatic follicles. At the age of 20 – 30 years follicles are in found in extreme quantity, by the age of 30 years they start to decrease and after 60 years they usually degenerate.

Pathology:
Appendicitis can result either from obstruction or without any abstruction and their sequence of infalmmation is as follows:
  • Obstructive type:
    • Felgminose
    • Gangrenous
    • Perforated
  • Non-Obstructive:
    Simple or cattarrhal inflammatory processes confined to the wall of appendix
Complications:
  1. Appendicular mass or appendicular infiltrate
  2. Acute peritonitis: Local or General
    Local is the abscess accumulation in the Doughlas pouch, which is located in men and between bladder and rectum in females. There may also be intraintestinal or subdiaphragmatic abscess.
    General may be diffused and/or total. Diffused form occupies 1-5 segments while total occupies more than 5 segments when there is inflammatory process.
  3. Pyelophlebitis
Clinical Signs:
  • Main symptoms are the pain and anorexia. Pain arises from the umblicus and the shifts to inferior abdominal cavity or so called the ileoecal region (Kocher's sign)
  • Pyrexia (10)
  • Nausea and vomiting
    • Blumberg’s sign (reflux rebound) is positive in obstructive process i.e. when the inflammatory process occurs in the peritoneum
  • Parasthesia and pain occurs if we touch ileocecal region
  • Bracktonic Nickelson’s sign:when patient lies on left side and palpation increases the pain
  • Murphy triad:(pain, vomitting and temperature) in seen
Fate of appendicitis:(Acute)
  • Surgical removal
  • Appendicular lump
  • Appendicular abscess
  • Spreading peritonitis
  • Gangrene, perforation and faecal peritonitis
  • Mucocoele of appendix
  • Fibrosis
  • Resolution
Differencial Diagnosis:
  • Acute gastric enteritis (increased leucocytes, vomiting, nausea and diarrhoea)
  • Ectopic pregnancy (rupture of tube)
  • Acute peptic ulcers
  • Acute cholangitis
  • Intestinal obstruction
  • Enterocolitis
Appendectomy:
Incisions:
Grid Iron Incision: Incision is made at right angle to a line joining anterior superior iliac spine and symphysis pubis (Mc.Burney’s point).
Rutherford’s and Morrison’s incision: with the incision of oblique muscles
Median or Paramedian incision.

Mc.Burney's Incision:(10 - 12 Cm)
First we remove the skin and then superficial layer of fats (adipose tissue). Then we remove superficial fascia and then we cut the external oblique muscles and its facia. Finally we dissect the internal oblique muscles along with its fascia (here the fibres are located perpendicular to each other). Now we bluntly separate these fibres and then peritoneum is taken up and finally we make the incision. Then try to find cecum to locate the appendix. Next appendicular artery is legated and appendix is separated from cecum. Finally we make per string sutures (Z-like) and close the site.

It needs local or general anaesthesia. If the complication of appendicitis such as inflammatory mass or appendicular infiltrate occurs and/or if surgeon can palpitate inflammatory mass or swelling under skin like tumour (inflammatory tumour in Mc.Burney’s point), he can diagnose inflammatory mass then this complication is contraindicated to surgery.

Inflammatory mass is formed by the fibrin like deposition, which has adhesive character and adheres to omentum, loops etc.

Intragrade and Retrograde techniques for appendectomy:
Intragrade is classical technique when after the legation of appendicular artery, surgeon begins to divide the appendix from its top towards its base. If the loop of appendix is not found due to some inflammatory process, he begins to divide the appendix from its base or from proximal to top until it is found (retrograde).

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This article has been written by Dr. M. Javed Abbas.
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21:04 21/12/2002