Appendix Chapter, Sabiston Textbook of Surgery

Telephone Email: +86-136 045 402 35 shuo.huang@hotmail.com

Appendix

Huang,Shuo

Specialist Surgeon

Section of General Surgery

Department of Surgery

Jiamusi university hospital

• Appendicitis

• History

• Although appendicitis has been a common problem for centuries, it was not until the early 19th century that the appendix was recognized as an organ capable of causing disease.

• In 1827, Melier described several autopsy cases of appendicitis and clearly stated the opinion that the appendix was the likely cause, including the presumed pathophysiology that is accepted today.

• By 1880, both Matterstock in Germany and with in Norway published papers that clearly suggest the appendix as a significant cause of iliac fossa inflammation.

• In 1886, Reginald Fitz of Boston made a landmark contribution by discussing the appendix as the primary cause of right lower quadrant inflammation.

• He coined the term appendicitis and, importantly, recommended early surgical treatment of the disease.

• In 1889, Chester McBurney described the migratory pain as well as the finger point localization of pain between 1.5 and 2 inches from the anterior iliac spine on an oblique line to the umbilicus.

• He incorrectly stated that this was an almost constant finding in patients with appendicitis.

• McBurney in New York and McArthur in Chicago described a right lower quadrant muscle splitting incision for surgical treatment in 1894.

• It is interesting to note that McBurney kept his patients on bed rest for at least 4 weeks after surgery.

• In 1905, Murphy clearly described the appropriate sequence of symptoms of pain followed by nauseas and vomiting with fever and exaggerated local tenderness in the position occupied by the appendix.

• Currently, the mortality rate is 0.25% if all ages are considered

• Pathophysiology

• It is widely accepted that the inciting event in most instances of appendicitis is obstruction of the appendiceal lumen.

• Given the correlation with the incidence of appendicitis by age and the size and distribution of the lymphoid tissue, it is likely that lymphoid obstruction or partial obstruction of the lumen is a common cause.

• Necrosis of the appendiceal wall subsequently occurs along with translocation of bacteria through the ischemic wall.

• This is gangrenous appendicitis.• Without intervention, the gangrenous appendix will

perforate, with spillage of the appendiceal contents into the peritoneal cavity.

• If this sequence of events occurs slowly, the appendix is contained by the inflammatory response and the omentum, leading to localized peritonitis and eventually an appendiceal abscess.

• If the body does not wall off the process, the patient may develop diffuse peritonitis.

• Clinical• history • physical findings, laboratory and radiographic

examinations.• Vomiting • anorexia and nausea.• The pain • in the epigastrium and gradually moves towards

the umbilicus, finally localizing in the right lower quadrant.

• diminished bowel sounds• direct tenderness • muscle spasm • rebound tenderness.• The temperature • The appendix is often situated at or around

McBurney’s point.

Rovsing’s sign

The psoas sign .• The obturator sign

• Rectal examination

• Radiographic

• flat and upright abdominal radiograph

• useful in patients with atypical symptoms and physical signs.

• Ultrasound

• the initial diagnostic imaging

• Noninvasive • rapidly available • avoids radiation exposure.• Sensitivity more than 85%

• Computed tomography

• atypical for appendicitis

• appears as a thin tubular structure in the right lower quadrant

• Abnormal (distended or thickened)

• Sensitive

• 48-72 hours

• Nuclear medicine• Noninvasive• not promptly available.• Accuracy (unknown)

• Laboratory

• complete blood count • left shift• C-reactive protein• Urinalysis

• Diagnoses• a thorough history • physical examination • laboratory tests.

• Diagnostic laparoscopy • Female,15 and 45

• whether to remove a normal appearing appendix at laparoscopy.

• Differential diagnoses

• Preschool children• Intussusception• Meckel’s diverticulitis• Acute gastroenteritis

• School-age children• Gastroenteritis • Functional pain

• Adolescent boys and young adult men

• Crohn’s disease • ulcerative colitis• epidihymitis.

• Adolescent girls and young adult women

• gynaecologic conditions.

• Pelvic inflammatory disease

• Ovarian cysts (ruptured cyst, ovarian torsion)

• Urinary tract infections

• Elderly age group• gastrointestinal tract

• reproductive system.• Diverticulitis• perforated ulcers• cholecystitis.

• Types of treatment

• fluid resuscitation before surgery.

• nonperforated disease

• perforated appendicitis.

• acute, nonperforated appendicitis

• antibiotic therapy alone for appendicitis.

• rare situations such as with sailors on long submarine tours

• Incision

• transverse right lower quadrant skin incision • oblique version • paramedian incision

• Handle removal of the appendix.

• suture ligate

• purse string

• Z-stitch

• Laparoscopy• • superior to an open approach?

• adult, • operative costs are higher • longer procedure • more equipment • Pain less • return to work sooner.

• To children?

• Perforated appendicitis

• require several hours or more of fluid resuscitation before operative intervention.

• Management of appendiceal mass

• Percutaneous drainage

• Appendicitis during pregnancy

• the location of point tenderness varies during gestation.

• The white blood cell count

• Common symptoms

• Ultrasound

• Crohn’s disease

• Meckel’s diverticulum

• Postoperative complications• Infection• Bowel obstruction• Infertility• Miscellaneous

• Urinary tract infections, pneumonia, and other complications of hospitalization

During an appendectomy for acute appendicitis, a 4 cm mass is found in the midportion of the appendix. Frozen section reveals this lesion to be a carcinoid tumor. Which of the following statements is true?

A Ni further surgery is indicated

B A right hemicolectomy should be performed

C There is about a 50% chance that this patient will develop the carcinoid syndrome

D Carcinoid tumors arise from islet cells

E Carcinoid syndrome can occur only in the presence of liver metastases

Appendix Chapter, Sabiston Textbook of Surgery

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