my presentation in intra dept.seminar

2. Dr Srinivasa reddy Bandi,
Pg scholar, Dept.of Shalya,
Dr.BRKR Govt Ayur college,
Hyderabad.

3. Appendicitis
 Inflammation of the
appendix is known as
appendicitis.

4. Appendix
 The vermiform or worm like
appendix, arising from the
posteromedial wall of the
caecum,about 2cm below the
ileocaecal orifice.
 Dimensions:
 The length varies from 2 to 20 cm
or 2-9 in. with an avarage of 9cm.
 It is longer in children than adults.
The diameter is about 5mm.
 The lumen is quite narrow and
may be obliterated after mid adult
life.

5. Positions
•The appendix lies in the right
iliac fossa.
• Although the base of the
appendix is fixed, the tip can
point in any direction.
• parabolic 11 o’ clock
• retrocaecal or colon
•the splenic 2 o’ clock
•horizontally to the left 3 o’clock
•pelvis(pelvic) 4 o’clock
•mid inguinal 6 o’clock

6. Peritonial relations
 The appendix is
suspended by a small,
triangular fold of
peritoneum, called the
mesoappendix, or
appendicular mesentery.
 The fold passes upwards
behind the ileum, and is
attached to the left layer
of the mesentery.

7. Appendicular orifice
 It is situated on the
posteromedial aspect of the
caecum 2cm below the
ileocaecal orifice.
 The appendicular orifice is
occationally guarded by an
indistinct semi lunar fold of
mucous membrane know as
‘valve of Gerlach’.
 The orifice is marked on the
surface by a point situated
2cm below the junction of the
trans tubercular and right
lateral planes.

8. Arterial blood supply

9. Venous blood supply

10. Lymphatic drainage

11. Nerve supply
 Sympathetic nerves are derived from segments T9
to T10 through the celiac plexus.
 Parasympathetic nerves are derived from the
Vegas.

12. Applied anatomy
 Inflammation of the appendix is
known as appendicitis.
 Pain caused by appendicitis is first felt
in the region of the umblicus. This is
referred pain.
 Note the fact that both the appendix
and the umblicus are innervated by
segment T10 of the spinal cord.
 With increasing inflammation pain is
felt in the right iliac fossa. This is
caused by involvement of the parietal
peritoneum of the region.

13. Symptoms
•Pain
•Vomiting
•Fever
•the sequence of these
symptoms is known as
Murphy’ syndrome
• Constipation is usually
associated.

14. Appendicitis
Physical signs
 Hyperesthesia in the right
iliac fossa
 Tenderness at Mc berney’s
point
 Muscle guard and rebound
tenderness over the
appendix
 Rovsing’s sign
 Cope’s psoas test
 Cope’s obturator test

15. Appendicitis
ETIOPATHOGENESIS
 The most common etiological factor is obstruction of
the lumen that leads to increased intra luminal
pressure.
 This presses upon the blood vessels to produce
ischemic injury which in turn favors the bacterial
proliferation and hence acute appendicitis.

16. Commonest causes
 Obstructive causes:
1. Faecolith
2. Caliculi
3. Foreign body
4. Tumor
5. Worms
6. Diffuse lymphoid hyperplasia
 Non obstructive causes:
1. Haematogenous spread of generalized infection
2. Vascular occlusion
3. In appropriate diet lacking roughage

17. PATHOLOGICAL CHANGES
MACRO SCOPICALLY:
In Early Acute appendicitis
In Acute suppurative appendicitis
In Acute gangrenous appendicitis

18. Appendicitis
 MICROSCOPICALLY:
Diagnostic histological criteria :
the neutrophilic infiltration of the muscularis.
 In early stage: Acute inflammatory changes
congestion
edema of the appendicitis wall.
 In lateral stages : The mucosa is sloughed off
The wall becomes necrotic
The blood vessels may get thrombosed
Neutrophilic abscesses in the wall.
 In either cases: An impacted foreign body, faecolith
or concretion may be seen in the lumen.

19. Appendicitis
COMPLICATIONS:
 1.Peritonitis
 2.Appendix abscess
 3.Adhesions
 4.Mucocele.

20. appendicectomy
Indications :
 Acute or chronic appendicitis
 Appendicular dyspepsia
 Carcinoid tumor.

21.  In acute appendicitis:
Appendicectomy
1 with in 48 hours of the onset
2 If seen after 48 hours
general peritonitis
(increasing pulse rate
increasing vomiting
increasing pain
spreading of tenderness
from the right to the iliac fossa)
Quiescent stage-say after 3 months.

22. However
• In spreading peritonitis
• In the case of children
• and the aged
• Taking of Strong purgative
Immediate operation

23. Choice of incision
1- Kocher incision
2- Midline incision
3- Mc Burney incision
4- Battle incision
5- Lanz incision
6- Para median incision
7- Transverse incision
8- Rutherford Morrison
incision
9- Pfannenstiel incision

24. Choice of incision
 For quiescent cases Mc Burney’s
gridiron incision is the best.
 For acute cases Mc Burney’s or
Rutherford Morison’s muscle
cutting incision
 When the appendix lies more
towards the middle line or in the
pelvic cavity,
 or when a general exploration is
necessary, a para median
incision should be chosen.

25. Appendicectomy acc.to Mac Burney
 Any incision in the right iliac or hypo gastric region
presents a suitable approach. The operation must be
adopted to the varying location of the appendix.
 In acute appendicitis, the para rectal incision has
proved useful; it permits an early incisional extension
at any time and better exposure of the abdominal
cavity.

26. Orthograde resection
in the case of mobile cecum
1.The small bowel is
pushed aside medially
with an abdominal
swab,and the cecum is
exposed using a
retractor.

27. Orthograde resection
2.The caecum is now
grasped with the left hand.
•By applying tension in a
slight upward curve, the
caecum is brought above the
abdominal wall.
•The appendix is identified
at the end of the tenia libera.
•It is grasped with a clamp at
its mesenteriolum.

28. Orthograde resection
3.If possible, the
appendicular artery
is doubly legated at
the base of the
appendix, and the
appendix
skeletonized down
to its base.

29. Orthograde resection
4.After the appendix
has been fully
skeletonized its base
is crushed with a
straight clamp
or an artery forceps.
•Below this, a purse
string suture is applied
to the caecum.

30. Orthograde resection
5.The base of the
appendix is ligated with
silk or catgut.
•It is then grasped with a
right angled clamp above
the crushed site.
•The appendix is resected
with a scalpel between
the ligature and the
clamp.

31. Orthograde resection
6.The previously iodized
appendix stump is
invaginated with the help
of a dissecting forceps
and the purse string
suture tied.
•A second similar suture
is applied as a precaution
•The second suture may
be a Z-stitch.

32. Orthograde resection
7.After burying the
stump,the serosal defect
of the mesenteriolum is
sewn with interrupted
sutures.
•If the appendix is
markedly inflammed,
these sutures should
not be made.

33. Retrograde resection in the
presence of an immobile caecum
 Since the appendectomy has to be
performed with in the abdominal cavity
owing to dense adhesions or the retrocaecal
position of the appendix, the incision must
be sufficiently large.

34. Retrograde resection
in the case of immobile caecum
1.In order to mobilize the
firmly adherent caecum,the
lateral peritonial reflection
is incised.
•The caecum is free from the
lateral abdominal wall by
blunt dissection until the
base of the appendix comes
into view as a prolongation
of the tenia libera.
•The appendix is then
isolated at its base, crushed,
and ligated.

35. Retrograde resection
2.By pulling the
appendix downward and
the caecum upward, the
course of the appendix
can be followed.
•Any adhesions and the
mesenteriolum itself
have to be ligated and
divided step by step.

36. Retrograde resection
3.After applying a
crushing clamp, the
appendix is transected,
and the stump buried
using two purse string
sutures.
•A Z-like suture may also
be applied

37. Retrograde resection
4.For better exposure,
the caecum is mobilized
further upward at its
lateral side until the
entire behind the
medially displaced
caecum is transected
from the lateral
abdominal wall.
•Sharp dissection can
not be avoided in most
cases.

38. Retrograde resection
5.The whole of the appendix,
including its tip,should be
removed.
• If a suppurative peritonitis
or an encapsulated abscess is
present, the operative field
must be drained.
• In these situations, blunt
dissection is preferred to
avoid injury.
•Usually the caecum can be
brought back into its
anatomic position with a few
interrupted sutures.

39. Thank u
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