Appendicectomy
Download as PPTX, PDF99 likes39,332 views
This document provides information about the anatomy, clinical presentation, diagnosis, and treatment of appendicitis. It describes the appendix's location, blood supply, and relations to other structures in the abdomen. Common symptoms of appendicitis include pain, vomiting, fever, and tenderness in the right lower quadrant. Diagnosis is based on physical exam findings at McBurney's point. Treatment is an appendectomy, which can be performed via open or laparoscopic surgery using various incision types depending on the appendix's position and degree of inflammation. Complications may include peritonitis if not treated promptly.
Appendicectomy
- 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.
- 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 THANK U