Last edited Michael edwards 06 September 2009.

APPENDICECTOMY - OPEN

This operation script is under construction and should not be used until finished later this month.

A PANTOGEN OPERATION SCRIPT

MICHAEL EDWARDS

NO INFORMATION IN THIS SCRIPT SHOULD BE USED WITHOUT THE APPROVAL OF A FULLY TRAINED PRACTISING SURGEON

THIS SCRIPT COVERS:

ADULT PATIENT

CHILD PATIENT

EXPLORATION FOR SUSPECTED APPENDICITIS

EMERGENCY APPENDICECTOMY

DRAINAGE OF INCIDENTAL APPENDIX ABSCESS

INTERVAL APPENDICECTOMY

ELECTIVE APPENDICECTOMY

MANAGEMENT OF CONDITIONS MIMICKING APPENDICITIS

MECKEL'S DIVERTICULUM AND MECKEL'S DIVERTICULITIS

MUSCLE SPLITTING INCISION

PARAMEDIAN INCISION

MIDLINE INCISION

THESE STEPS DO NOT COVER

LAPAROSCOPIC APPENDICECTOMY

SEE APPENDICECTOMY - LAPAROSCOPIC

PATHOLOGY OF APPENDICITIS

First 24 hours

1a Inflammation of the lymphatic tissue in the mucosa of the appendix.

1b Obstruction of the lumen of the appendix by a faecolith.

2 Contraction/distention of the muscle of the appendix causing appendicular colic.

Colicky referred pain centred around the umbilicus.

3 Build up of infected fluid in the lumen of the appendix.

4 Inflammation of the full thickness of the appendix with irritation of the overlying

parietal peritoneum.

Secretion of an inflammatory exudate of peritoneal fluid.

Pain felt over the appendix. eg In the right iliac fossa over a para-ileal appendix.

5 Greater omentum adherent to the inflamed appendix.

6 Necrosis of part of the appendix wall.

Perforation of the appendix.

Generalised peritonitis.

2-3 weeks

Death from multiple systems failure.

NB Appendicitis may be precipitated by a subclinical obstruction of the large bowel

due to a carcinoma or diverticular disease.

LAY OUT OF OPERATION SECTIONS AND STEPS

The operation is divided into SECTIONS.

The SECTIONS are displayed in sequence in the following paragraphs.

Each SECTION is divided into an unlimited number of very small STEPS.

Each STEP contains an unlimited amount of supporting information (PANTINOS)

SECTION 1.00 PRELIMINARIES AND WHO SAFE SURGERY CHECKLISTS SIGN IN AND TIME OUT

STEP 1.01 CHECK YOU HAVE THE CORRECT PATIENT

STEP 1.02 CHECK YOU HAVE THE CORRECT SIDE.

STEP 1.03 CHECK THERE IS A DIATHERMY PAD

STEP 1.04 CHECK THERE IS AN ECG MONITOR

STEP 1.05 CHECK THE PATIENT IS SHAVED FROM COSTAL MARGIN TO PUBIS

STEP 1.06 CHECK ANTIBIOTICS HAVE BEEN GIVEN

STEP 1.07 CHECK THERE IS NO OTHER PROCEDURE TO DO

WHO SAFE SURGERY CHECKLISTS SIGN IN AND TIME OUT

SECTION 2.00 ANAESTHESIA

GENERAL ANAESTHESIA WITH MUSCLE RELAXATION

INFILTRATE THE WOUND WITH BUPIVACAINE AT THE END OF THE OPERATION

SECTION 3.00 POSITION

SUPINE

Bare skin from costal margin to mid thigh, free from all tubing, wires, electrodes, etc.

This amount of access is needed if you have to perform a laparotomy

SECTION 4.00 STANCE

Stand on the patient's right hand side with your one assistant on the opposite side.

SECTION 5.00 CATHETERISE THE BLADDER

Only do this if the bladder is palpable or if a laparotomy is likely.

SECTION 6.00 SKIN PREPARATION

Use, for example, 2 swabs on sticks with 0.5% Chlorhexidine in 70% Propanol and one

to dry off.

Clean the skin from the umbilicus to the mid- thigh, and from the iliac crest to 5 cm beyond the mid-line.

For a suspected need for a laparotomy:

Clean the skin from the costal margin to the mid thigh and from 1 iliac crest to the other.

SECTION 7.00 TOWELLING UP

STEP 7.01 Place an upper towel down to just above the umbilicus.

STEP 7.02 Place a lower towel up to the symphysis pubis.

STEP 7.03 Place a lateral towel to the right anterior superior iliac spine.

STEP 7.04 Place a medial towel 5 cm. beyond the midline.

Keep the umbilicus and the anterior superior iliac spine exposed as land marks.

STEP 7.05 FIX THE TOWELS

Fix the towels to the skin with adhesive drape edges or 4 towel clips.

STEP 7.06 CHECK THE DIATHERMY IS WORKING

SECTION 8.00 THE INCISION

A muscle-splitting gridiron incision will be suitable for 90% of patients and is described here. The script links to paramedian and midline incisions.

A gridiron refers to a metal frame with parallel bars used for cooking meat on an open fire.

The gridiron incision refers to an incision, generally parallel in direction to the fibres of the aponeuroses and of the oblique and transversus muscles of the anterior abdominal wall.

The gridiron incision runs in the line of the fibres of the aponeuroses and and splits the muscle fibres. It is thought to be less painful and to heal more quickly and strongly than a muscle (and aponeurosis) cutting operation (eg a midline or paramedian incision)

Consider using a low midline incision or paramedian incision for:

An elderly ( eg over 50 years) patient where the diagnosis could easily be a carcinoma of the caecum.

A patient with a previous midline or paramedian incision, where the diagnosis could be related to the incision. eg An adhesive obstruction.

STEP 8.01 CHOOSING THE SKIN INCISION

Normally centre the incision on McBurney's point.

This is one third of the way from the anterior superior iliac spine to the umbilicus.

McBurney's point is the usual site of maximum tenderness of an inflamed appendix lying next to the terminal ileum (para-ileal appendix).

Maximal tenderness lower than normal suggests a pelvic appendicitis.

Centre the incision 2cm. below McBurney's point.

Tenderness above McBurney's point suggests:

A retrocaecal appendix.

A degree of malrotation of the gut with a high caecum and appendix.

Centre the incision 2cm. below McBurney's point.

Choose a skin crease incision.

This is usually an oblique incision running down towards the pubis, though in some ::patients the skin crease is transverse.

The classical incision is somewhat more vertical and likely to produce a more noticeable scer.

Plan to make the incision 6cm. long for a non obese patient.

This will be big enough for:

Insertion of two fingers and a retractor for exploring the wound.

Dissection and removal of most appendixes.

It does not need to be big enough to insert your hand.

For an obese patient, plan an incision at least 10cm. long

STEP 8.02 STEADY THE SKIN

Press on the skin with one swab held by your assistant and another held in your left hand.

STEP 8.03 MAKE THE INCISION

Use a scalpel with a no. 22 Swann-Morton blade.

Incise the skin and fat at the chosen site.

Beware of cutting through the external oblique aponeurosis in a thin child.

STEP 8.04 DEEPEN THE INCISION

Concentrate on making the cut the same depth at the ends of the wounds as in the middle.

This will optimise the exposure of the abdominal contents.

Aim to cut through all the subcutaneous fat to display the oblique stripes of the external oblique aponeurosis.

In the fat, you will probably find the deep layer of superficial fascia (Scarpa's fascia) as a definite layer.

It may be mistaken for the external oblique aponeurosis.

The fat has blood vessels running through it.

They will be:

The superficial epigastric artery and vein centrally.

The superficial circumflex iliac artery and vein laterally.

Tributaries of the superficial external pudendal vein medially.

STEP 8.05 COAGULATE THE VESSELS

Use coagulation diathermy.

Ligate any vessels which continue to bleed with (eg 2/0 Vicryl Ethicon W9025).

SECTION 9.00 DISSECTING THE DEEPER ABDOMINAL WALL STRUCTURES

STEP 9.01 EXPOSE THE EXTERNAL OBLIQUE APONEUROSIS

Firmly sweep the fat off the external oblique aponeurosis along the whole extent of the wound.

Expose the stripes of the aponeurosis clearly before you continue.

STEP 9.02 PICK UP THE EXTERNAL OBLIQUE APONEUROSIS

Use 2 artery forceps 5mm. apart in the middle of the wound.

STEP 9.03 OPEN TH E EXTERNAL OBLIQUE APONEUROSIS

Use a scalpel with a 22 Swann-Morton blade.

Make a 10mm. cut in the aponeurosis between the 2 forceps in the line of the aponeurosis fibres.

Extend the incision in the line of the fibres to the limits of the wound.

Use a pushing action with half opened scissors.

Hold the cut edges of the aponeurosis open with the forceps.

STEP 9.04 DISPLAY THE SURFACE OF THE INTERNAL OBLIQUE MUSCLE

Use a gauze swab to free the muscle from the overlying adventitia.

Do not use the handle of the scalpel as a dissector, since you may injure your assistant.

Retract the external oblique aponeurosis laterally with a Langenbeck retractor.

This will ensure you are not straying medially onto the aponeurosis of the internal oblique or the rectus sheath.

If the internal oblique muscle fibres are still not visible:

Enlarge the skin incision laterally.

Retract the external oblique aponeurosis even further laterally.

If you cannot see the internal oblique muscle:

Call a more experienced surgeon.

STEP 9.05 SPLIT THE INTERNAL OBLIQUE MUSCLE

Use dissecting scissors to start splitting the muscle in the line of its fibres.

Complete the split of the internal oblique muscle for the full length of the wound.

Inserting your 2 index fingers into the split and pull the muscles strongly apart in the line of the muscle fibres.

STEP 9.06 DISPLAY THE TRANSVERSUS ABDOMINUS MUSCLE

This lies under the internal oblique muscle, but slightly more laterally.

It is a darker reddish brown than the internal oblique.

Retract the internal oblique laterally to see clearly the muscle fibres of the transversus muscle lateral to its aponeurosis.

STEP 9.07 SPLIT THE TRANSVERSUS ABDOMINUS MUSCLE

Use dissecting scissors to start splitting the muscle in the line of its fibres, as you did for the external oblique muscle.

As for the external oblique muscle, complete the split of the transversus muscle for the full length of the wound using your 2 index fingers.

If the abdominal wall muscles and peritoneum are oedematous:

This often indicates well established sepsis underneath due to eg:

Severe appendicitis with perforation and abscess formation.

Perforated right sided colonic carcinoma or caecal diverticulum.

Crohn's disease of the terminal ileum adherent to the anterior abdominal wall.

STEP 9.08 IDENTIFY THE PERITONEUM

Use a gauze swab to clear adventitia deep to the transversus muscle.

The peritoneum is normally a thin bluish sheet of tissue.

It becomes thicker and redder when inflamed with an inflammatory process deep to it.

The adventitia under the internal oblique may be mistaken for the peritoneum.

Break through the adventitia with blunt dissection using a pledget

If the peritoneum is not visible:

You may be too far lateral.

Dissect more medially.

Consider asking a more experienced surgeon to help.

SECTION 10.00 HOW THE DIAGNOSIS EMERGES

The pathological diagnosis becomes clearer progressively as the surgeon obtains evidence from the following sources:

1 The clinical history, examination and special tests.

2 Palpation of the abdomen after induction of anaesthesia.

3 The peritoneal fluid on opening the peritoneum.

4 Digital examination of the contents of the peritoneal cavity.

5 Visual examination of the contents of the peritoneal cavity.

6 Examination of structures brought out of the wound.

7 There will be cases where no pathology is found.

The cases in group 7 may be the most worrying, because of the danger of having missed something.

At the same time, the surgeon should remain alert to there being more than one disease process in the abdomen or pelvis at the same time.

The script below describes some of the commoner diagnoses, but is not comprehensive.

The script describes the features of appendicitis ranging from the mildest mucosal inflammation to the most severe intraabdominal and pelvis abscesses.

SECTION 11.00 OPENING THE PERITONEUM

STEP 11.01 PICK UP THE PERITONEUM

You are making preparations leading to a longitudinal incision in the peritoneum

Use 2 artery forceps.

Place the forceps 5mm. apart on the peritoneum on each side of the middle of the wound .

Take 5mm. bites.

This will tent up a ridge of peritoneum running across the wound, ready for the :longitudinal incision.

Squeeze the tented peritoneum between finger and thumb to make sure there is no intervening tissue such as bowel or omentum.

STEP 11.02 OPEN THE PERITONEUM

Have the sucker working before you start, ready to clear away any peritoneal fluid.

Have a bacteriology swab ready to take a specimen.

Use a scalpel with a no.10 Swann-Morton blade.

Hold the blade held flat to cut onto the tented peritoneum.

A blade held vertically to cut the peritoneum stands more chance of damaging underlying tissues.

Make a 5mm. opening.

Aspirate the peritoneal contents to avoid contamination of the wound.

STEP 11.03 ENLARGE THE PERITONEAL OPENING

Retract the opening in the internal oblique and transversus abdominis muscles.

Use 2 Langenbeck forceps.

For best exposure of the peritoneum, make sure the opening in the internal oblique is as long as the skin incision.

Extend the peritoneal incision

Use dissecting scissors.

Slit each end of the 5mm. opening in the peritoneum so that the opening is as long as the skin and muscle incisions

STEP 11.04 EXAMINE ANY PERITONEAL FLUID

Remember that although the word fluid is mostly used to mean a liquid, strictlly speaking it also includes gases. See the bottom of this list.

NO FREE PERITONEAL FLUID:

There may an early appendicitis or no intraperitoneal disease.

THIN YELLOW SEROUS FLUID:

Early appendicitis.

Mesenteric adenitis.

Early Meckel's diverticulitis.

Small bowel perforation.

Perforated galbladder.

Early inflammatory intraperitoneal processes.

Acute ileitis.

Salpingitis (Pelvic inflammatory disease).

THICKER YELLOWISH FLUID SMELLING OF FAECES (ie with anaerobic organisms):

More advanced appendicitis.

Diverticular abscess.

Meckel's diverticulitis.

Inflamed solitary diverticulum of the caecum.

Crohn's disease.

GREEN NON SMELLY FLUID (ie containing bile):

Perforated peptic ulcer.

Small bowel perforation.

NON SMELLY BLOODY FLUID:

Ruptured ovarian cyst.

Torsion of an ovarian cyst with infarction.

Ectopic pregnancy.

Aneurysm of the aorta.

BLOODY FLUID SMELLING OF ROTTEN FLESH:

Infarcted bowel eg due to:

Strangulation.

Mesenteric vessel obstruction

THIN PURPLE FLUID:

Pancreatitis

BROWN FLUID SMELLING OF FAECES:

Perforated diverticular disease.

Perforated colon carcinoma.

Perforated solitary diverticulum of the caecum.

INTRAPERITONEAL GAS

Gas escaping from the peritoneal cavity when it is opened will be:

Air from a perforated viscus ie bowel or stomach.

Gas from gas forming organisms in the peritoneal cavity.

KEEP THESE DIAGNOSES IN MIND AS YOU CONFIRM WHAT INTRAPERITONEAL DISEASE, IF ANY, IS PRESENT

SECTION 12.00 EXPLORING THE ABDOMINAL AND PELVIC CAVITIES

The exploration consists of the following procedures used in sequence:

Digital examination.

Visual examination with wound retraction.

Visual examination after packing off the tissues.

Visual examination of organs brought out of the wound.

Visual examination after enlarging the wound.

STEP 12.01 CONTROL ANY PROLAPSING PERITONEAL CONTENTS

If peritoneal contents such as omentum, small bowel or caecum push out of the wound:

There is probably a failure of relaxation of the muscles of the abdominal wall.

Press on the tissues with a gauze pack to prevent further prolapse.

Wait until the anaesthetist has regained control of muscle relaxation.

Replace the prolapsing structures.

STEP 12.02 ASPIRATE ANY INTRAPERITONEAL FLUID

STEP 12.03 DIGITAL EXAMINATION OF THE WOUND

An examination using the index finger of your dominant hand will often reveal the diagnosis within 30 seconds.

Follow the procedure below.

STEP 12.04 FEEL FOR A PARA-ILEAL APPENDICITIS

Try to palpate an inflamed appendix in the peritoneal cavity immediately under the wound opening.

This most commonly will be an para-ileal appendix, medial to the caecum and above the pelvic brim.

It will be a swelling between 1-3cm. in diameter, rather firmer than the omentum or bowel.

Make sure you are not feeling the right common iliac artery, which pulsates!

If the omentum is adherent to the appendix:

This may be sealing off a perforation of the inflamed appendix.

Wait until you have delivered the appendix into the wound, later on, before detaching the omentum.

This will prevent faecal contamination of the wound.

STEP 12.05 FEEL FOR A PELVIC APPENDICITIS

Slide your finger over the pelvic brim into the pelvis.

A swelling the same size as a para-ileal appendix may be palpable.

You should also be able to feel the right ovary, either a normal one or a cystic one.

An ectopic pregnancy in the right Fallopian tube would also be palpable.

An iliac artery aneurysm would also be palpable.

STEP 12.06 FEEL FOR A RETROCAECAL APPENDICITIS

Feel for a mass behind thecaecum.

(A retrocaecal appendix may not be palpable at this stage in the operaton.)

SECTION 13.00 VISUAL EXAMINATION OF THE PERITONEAL CAVITY.

STEP 13.01 RETRACT THE WOUND EDGES

Depending on the size of the wound and the amount of subcutaneous fat, use:

2 artery clips on the peritoneal edge.

Or 2 Langenbeck retractors.

Or 2 Morris retractors.

Or 2 narrow Kelly retractors

STEP 13.02 PACK OFF THE INTRAPERITONEAL ORGANS

To push the intraperitoneal tissues, such as omentum and small bowel out of the way, use:

A swab on a stick.

A gauze swab or pack.

Make sure you attach an artery forcep to any swab or pack placed in the peritoneal cavity to prevent losing or forgetting the item.

A retractor.

Any combination of the above.

STEP 13.03 EXAMINE THE FOLLOWING ORGANS

The sequence here examines the organs that are the most likely to be the cause of the patient's condition.

The commoner conditions mimicking appendicitis are listed with the relevant organ.

The appendix.

Appendicitis with all its variants is the most likely diagnosis.

A carcinoid tumour of the appendix is a rare and usually incidental finding.

The omentum.

The omentum may be sealing a perforated appendix.

Torsion of the omentum is a relatively rare condition.

The caecum.

A perforated solitary diverticulum.

Perforated caecum secondary to a closed loop obstruction of the more distal large bowel

The right ovary .

The right ovary should always be visualised via a gridiron incision, though the left ovary may only be palpable.

Ovarian cyst.

Distended or ruptured.

Follicular cyst from a Graafian follicle.

Luteal cyst from a corpus luteum.

Ovarian tumour.

Benign or malignant.

Infarcted following torsion.

Spontaneous haemorrhage into the tumour.

Right Fallopian tube.

Salpingitis (pelvic inflammatory disease)

Ectopic pregnancy.

The terminal ileum.

Acute ileitis.

Chronic ileitis (Crohn's disease).

Ileo-caecal tuberculosis.

Perforated typhoid.

Ascariasis (round worms).

Accessible parts of the rest of the small bowel.

Skip lesions from Crohn's disease.

Internal hernia.

Overlooked external hernia.

Perforation from eg fish bone.

The colon and rectum.

Diverticular disease.

Peridiverticular abscess or perforation.

Carcinoma.

Free or sealed perforation.

SECTION 14.00 MANAGING A PARA-ILEAL APPENDICITIS

This is the most likely condition to be present.

For the management of retrocaecal and pelvic appendicitis::

Go to SECTION 15.00 MANAGING A RETROCAECAL APPENDICITIS

Go to SECTION 16.00 MANAGING A PELVIC APPENDICITIS

For the management of other condtions:

Go to SECTION 17.00 MANAGING CONDITIONS MIMICKING APPENDICITIS

For management of incidental conditions:

Go to SECTION 18.00 MANAGING INCIDENTAL CONDITIONS

STEP 14.01 FIND THE CAECUM.

The caecum is usually in the right iliac fossa.

It may be as high up as the hepatic flexure or as low down as the bottom of the pelvis, but start by lookng in the right iliac fossa.

On any bowel visible in the wound, look for taeniae.

A taenia is one of 3 ribbon-like stripes which run along the outside of the caecum and colon

They are the external longitudinal muscle grouped into 3 stripes.

If the bowel you see does not have taeniae:

You are probably looking at the small bowel or even a loop of redundant rectum.

The small bowel (and the rectum) has a complete layer of external longitudinal muscle, not gathered into stripes.

The appendix similarly does not have taeniae.

Push this bowel out of sight in the wound.

You need to look more laterally for the caecum.

Slide your index finger between the lateral abdominal wall and the lateral side of the ascending colon and caecum.

To do this, point your finger towards you.

Sweep this bowel into view.

The medial side of the ascending colon and caecum is usually too smooth to give a grip to the finger.

Push any bowel without taeniae out of sight in the peritoneal cavity.

You will probably have found the caecum, but it may be the ascending colon.

STEP 14.02 CHECK THE BOWEL REALLY IS THE CAECUM

Follow the bowel downwards until you see the bulbous shape of the caecum.

If you find the bowel has taeniae, but not the bulbous end of the caecum:

You may be holding a loop of sigmoid colon or even transverse colon.

Replace the loop of bowel.

Look for the caecum in the right lateral side of the abdominal cavity.

The taeniae on the caecum coalesce (join together) as they pass down towards the appendix.

Shortly, you will be following these taeniae right down to lead you to the appendix.

STEP 14.03 DELIVER THE CAECUM INTO THE WOUND

Aim to have a 5cm. long section of the caeum out of the wound so that your assistant can grasp it.

Elevate the edges of the peritoneum.

Use the 2 artery clips on the peritoneal edge.

Use 2 Langenbeck retractors.

Pick out the bowel using index finger and thumb.

Roll the bowel out of the wound to comply with the shortness of the mesocolon.

Do not try to pull the colon out in a straight line.

If you cannot get a grip on the bowel with your digits:

Use a Babcock forcep which has relatively atraumatic ends.

Even this instrument can tear the bowel if used roughly or if the bowel is weakend by inflammatory oedema.

If the caecum is adherent to the lateral abdominal wall:

Divide these bands with dissecting scissors.

Beware of the right ureter underlying the peritoneum.

If the caecum is too short:

Plan to perform the appendicectomy inside the peritoneal cavity.

STEP 14.04 HOLD THE CAECUM.

Get your assistant to hold the caecum.

Use a gauze swab folded over the caecum to grip the portion of caecum.

The caecum, covered with inflammatory peritoneal fluid, is usually too slippery to be held securely in the fingers by your assistant.

STEP 14.05 ENLARGE THE INCISION AS NECESSARY.

An incision that is too small makes an operation unnecessarily difficult.

Difficulty in seeing.

Difficulty in access.

Danger of missing pathology.

Damaging the intraperitoneal contents and the wound itself.

An enlargement of 1-2cm often transforms an operation into an easy one.

It has an uncanny effect of improving your assistant's cooperation and also the quality of the anaesthetic!

Lengthen the wound medially or laterally or both according to the site of difficulty.

Lengthen the wound by doing the following:

However such a large incision is rarely needed.

Ask a more experienced surgeon.

Consider closing the muscle splitting incision and making a mid-line incision.

If the caecum is too short to come out of the wound:

You will have to perform the appendicectomy inside the peritoneal cavity.

STEP 14.06 FREE THE APPENDIX

Use finger dissection to free the appendix from surrounding tissues.

The omentum will peel off easily unless it is sealing a perforation of the appendix.

If you think the appendix may be sealing a perforation:

Plan to remove the adherent omentum with the appendix.

Clip, cut and ligate healthy omentum proximal to its attachment to the appendix.

Cut any fibrous congenital adhesions between the appendix and abdominal wall, particularly laterally.

Use dissecting scissors.

STEP 14.07 DELIVER THE APPENDIX INTO THE WOUND.

The appendix (plus any sealing omentum) should now be mobile enough to come out of the wound.

Use finger and thumb to ease the appendix out of the wound.

Beware: Inflammation makes the appendix easy to snap across during delivery.

Use a Babcock forcep if the appendix is too slippery for the digits.

Beware: Inflammation makes tearing the appendix with the Babcock forcep even easier than tearing the caecum.

If the appendix will not come out of the wound:

Free it off more thoroughly.

Nearly always the problem of inability to mobilise the appendix is inexperience.

Call a more experienced surgeon.

STEP 14.08 CHECK THAT THE APPENDIX IS INFLAMED

If the appendix is definitely inflamed:

Slight oedema of the appendix wall may be all that you see in a mild appendicitis.

Remember that the appendix can become inflamed by contact with another inflammatory process nearby.

If the appendix is perforated:

The operation is likely to be more difficult due to surrounding inflammation.

There may well be difficulties in closing the caecal opening and invaginating the appendix stump.

Look out for and remove any faecolith that may have escaped from the perforation.

Go to SECTION 17.00 REMOVING THE APPENDIX

If the appendix looks normal or if you are not sure if it is:

Go to SECTION 18.00 MANAGING CONDITIONS MIMICKING APPENDICITIS

SECTION 15.00 MANAGING A RETROCAECAL APPENDICITIS

STEP 15.01 FINDING A RETROCAECAL APPENDIX

A retrocaecal appendix will run upwards behind the caecum towards the transverse colon.

The retrocaecal appendix will usually be hidden behind the caecum.

Sometimes the appendix is lying free behind the caecum.

More commonly, the appendix is covered by the peritoneum of the caecum or

by the peritoneum of the lateral abdominal wall. (The "absent" appendix.)

Follow the taeniae of the caecum down the caecum.

The taeniae will coalesce on the base of the appendix.

Do not decide that the appendix has been removed at an earlier operation

until you have examined this area thoroughly under direct vision.

STEP 15.02 RETRACT THE TISSUES

Retract the omentum, caecum and small bowel medially.

Retract the lateral abdominal wall laterally.

Use Langenbeck or narrow Kelly retractors.

For an obese adult, you may need even longer retractors.

Be prepared to enlarge the wound laterally at an early stage.

Check the incisions in the subcutaneous fat, the muscle layers and

the peritoneum are as long as the skin incision.

Lengthen the skin and subcutaneous fat incisions.

Lengthen the muscle splitting incisions.

If necessary, cut the muscle in the line of the skin incision.

Laterallly, the extension can continue right round to the mid axillary line.

STEP 15.03 MOBILISE A RETROCAECAL APPENDIX

The adherence will range from:

Virtually nil.

A fibrinous exudate.

Dense inflammatory adhesions.

The visceral peritoneum on the caecum.

The parietal peritoneum of the postero-lateral abdominal wall.

Use finger dissection, dissection with a pledget on a stick, or dissecting scissors depending on the toughness of the tissues.

Dissect on the lateral side of the appendix to avoid the vessels in the mesoappendix lying medially.

Beware the right ureter lying posteriorly.

Mobilise the appendix right up to its tip.

This will be a difficult dissection in an obese adult.

Make sure you have enlarged the wound sufficiently.

You should end up with an appendix sufficiently mobile to come out of the wound.

If the appendix is too short or immobile to come out of the wound:

Perform the next step of ligating and dividing the mesenteric vessels inside the wound.

If you cannot mobilise the appendix to do this safely:

The problem is nearly always an inadequate incision.

Call a more experienced surgeon.

Go to SECTION 17.00 REMOVING THE APPENDIX

SECTION 16.00 MANAGING A PELVIC APPENDICITIS

STEP 16.01 FINDING A PELVIC APPENDIX

A pelvic appendix runs from the caecum, over the right sacro-iliac joint and into the pelvic cavity.

It may be hidden under the greater omentum and the small bowel.

It may be lying free in the pelvis or adherent to the structures there.

Ie. Posteriorly, the right ovary and Fallopian tube. (Rectum in the male).

Anteriorly, the uterus (bladder in the male).

Laterally, the right ureter and the right common iliac artery and vein, all behind the parietal peritoneum.

Medially, the sigmoid colon and rectum.

A retrocaecal appendix will run upwards behind the caecum towards the transverse colon.

If you cannot see a pelvic appendix:

Follow the taeniae of the caecum down to where they coalesce on the base of the appendix.

Do not decide that the appendix has been removed at an earlier operation until you have examined this area thoroughly under direct vision.

STEP 16.02 RETRACT THE TISSUES

Retract the omentum, and small bowel medially.

Retract the medial abdominal wall medially:

Use Langenbeck or narrow Kelly retractors.

For an obese adult, you may need even longer retractors.

Be prepared to enlarge the wound medially at an early stage.

Check the incisions in the subcutaneous fat, the muscle layers and the peritoneum are as long as the skin incision.

Lengthen the skin and subcutaneous fat incisions.

Lengthen the muscle splitting incisions.

If necessary, cut the muscle in the line of the skin incision.

Medially, the extension can continue into the rectus sheath.

STEP 16.03 MOBILISE A PELVIC APPENDIX

The adherence will range from:

Virtually nil.

A fibrinous exudate.

Dense inflammatory adhesions to pelvic organs.

Use finger dissection, dissection with a pledget on a stick, or dissecting scissors depending on the toughness of the tissues.

Dissect on the lateral side of the appendix to avoid the vessels in the mesoappendix lying medially.

Beware the right ureter lying posteriorly.

Mobilise the appendix right down to its tip.

This will be a difficult dissection in an obese adult.

Make sure you have enlarged the wound sufficiently.

You should end up with an appendix sufficiently mobile to come out of the wound.

If the appendix is too short or immobile to come out of the wound:

Perform the next step of ligating and dividing the mesenteric vessels inside the wound.

If you cannot mobilise the appendix to do this safely:

The problem is nearly always an inadequate incision.

Call a more experienced surgeon.

SECTION 17.00 REMOVING THE APPENDIX

STEP 17.01 ELEVATE THE APPENDIX

Place a Babcock forcep on the base of the appendix and another near its tip.

Avoid perforating an oedematous appendix with the Babcock forcep by using minimal compression and delicate handling.

Free off any peritoneal folds in front of or behind the appendix.

Eg The bloodless ileo-caecal fold of Treves anteriorly.

STEP 17.02 OPEN THE MESO-APPENIDX.

The aim is to pass a ligature around the mesoappendix and tie off the vessels that are running in it to the appendix.

Use an artery forcep.

Stretch/dissect a hole in the meso-appendix at the junction of the appendix with the caecum.

Make the hole 7mm in diameter.

STEP 17.03 PASS THE ARTERY FORCEP THROUGH THE DEFECT.

STEP 17.04 GRASP A GAUZE SWAB ON THE FAR SIDE OF THE DEFECT.

This will identify the defect later when you cut the meso-appendix.

STEP 17.05 DRAW A LIGATURE THROUGH THE DEFECT.

Use eg 2/0 Vicryl (Ethicon W9025).

STEP 17.06 TIE THE MESOAPPENDIX LIGATURE

It is usually possible to pass a secure tie around the meso-appendix and its vessels from the base of the appendix.

This is quicker than clipping and cutting the meso-appendix in several places.

A tie is as safe as a transfiction stitch, as long as the knots are tied correctly and tightly.

Pass the tie around the free edge of the meso-appendix.

Check that you are not nipping other tissues with this tie.

eg Terminal ileum on the far side of the meso-appendix.

Tighten the tie in the meso-appendix at least 1cm from the appendix.

Use a double first throw.

Make a triple knot.

Hold the ends of the ligature with an artery clip.

If the mesoappendix is too oedematous or too fatty for a safe ligature in one go:

Clip the mesoappendix with separate 1cm. bites using artery clips.

Ligate, tie and cut each bite of mesoappendix seperately.

If the mesoappendix ties slip or look insecure:

Use transfixion stitches instead of ligatures.

Eg 2/0 Vicryl (Ethicom 9136)

STEP 17.07 CUT THE MESOAPPENDIX.

Use scissors.

Cut the meso-appendix 1mm away from the appendix.

Start at the free border of the meso-appendix.

Continue until you have cut into the meso-appendix defect marked by the swab.

Tie individually clipped pieces of mesentery with eg 2/0 Vicryl (Ethicon W9025).

STEP 17.08 CUT THE MESOAPPENDIX STITCHES.

Use stitch scissors.

Leave the ends 10mm long.

Transfix any bleeders with interrupted stitches of 2/0 Vicryl (Ethicom 9136).

It is essential to be confident of haemostasis at this point.

STEP 17.09 ELEVATE THE APPENDIX AGAIN

Pull gently on the Babcock forceps.

Free off any strands of mesoappendix to obtain a clear view of the appendo-caecal junction.

You should be able to elevate the appendix vertically.

Check your assistants grip has not slipped on the caecum.

STEP 17.10 CRUSH THE APPENDIX STUMP.

Use an artery forceps.

The traditional reason for crushing the appendix is to destroy mucous-secreting cells at the line of resection.

Crushing the appendix is aimed to prevent the formation of a mucocele of the appendix stump. This may just be a theoretical reason

However, if the appendix base is crushed, the tie on the appendix stump is more secure than if the tie has to grip a non-crushed stump.

If there is a thickening in the base of the appendix:

Consider there may be a carcinoma in the base.

Call a more experienced surgeon for a right hemi-colectomy.

If the appendix is perforated at its base:

Cut the appendix off at its junction with the caecum.

Control the escape of any caecal contents using a swab on the caecum.

Close the opening in the caecum.

Use a figure of eight stitch of eg 2/0 Vicryl (Ethicon 9136) followed by a purse string suture. (See below.0

If crushing a very oedematous or necrotic appendix with this manouevre causes the appendix to break off:

Oversew the defect in the caecum with a figure of eight, 2/0 Vicryl (Ethicon 9136).

If there is faecal leakage from the caecum:

Control the leakage with a non crushing Doyens clamp on the caecum.

Remove the appendix.

Suck out the contents from the isolated caecum.

Close the defect in the caecum with interrupted sutures of eg 2/0 Vicryl (Ethicon 9136).

STEP 17.11 CLIP THE APPENDIX.

Use an artery clip.

Clip the appendix transversly at the distal limit of the crushed segment.

Give the artery forceps to your assistant to hold, as well as the Babcock forcep.

STEP 17.12 TIE OFF THE APPENDIX STUMP.

Use eg a 2/0 Vicryl tie (Ethicon 9025).

Place the tie on the crushed section of appendix, 7mm proximal to the artery clip.

Tie the Vicryl with a triple knot.

Clip the Vicryl ends adjacent to the knot with another artery forcep.

This artery forcep will be used shortly to invaginate the appendix stump.

Cut the Vicryl ends 3mm long.

Hand the second artery forcep to your assistant to hold with the other instruments.

STEP 17.13 INSERT A PURSE STRING STITCH AROUND THE APPENDIX STUMP.

Use eg 2/0 Vicryl (W9136).

Insert the purse string into the caecum with 4 bites.

Use the 4 points of the compass, ie north, south, east and west.

Place the stitches 2cm from the appendix stump.

Stitching closer to the stump makes invagination of the appendix stump difficult or impossible, with a risk of tearing the caecum.

Avoid placing a stitch into the vessels of the mesoappendix.

Put 1 throw on the purse string but do not tighten the purse string.

Clip the ends 10cm long and cut off the needle.

STEP 17.14 PREPARE YOUR ASSISTANT FOR INVAGINATING THE APPENDIX STUMP.

Your assistant will now be able to release the caecum.

Have your assistant hold the artery on the stump ligature in his right hand.

Your assistant holds the 2 Babcocks and the appendix artery forceps in his other hand ready to be passed into the waiting receiver.

STEP 17.15 CUT THE APPENDIX.

Check the artery forceps are horizontal and are holding the crushed part of the appendix vertically.

Use a scalpel with a 22 Swann-Morton blade.

Cut through the crushed part of the appendix, immediately proximal to the appendix artery forcep.

Place the appendix with its forceps and the 2 Babcock forceps in a receiver.

STEP 17.16 INVAGINATE THE APPENDIX STUMP.

Have your assistant push the appendix stump with the appendix stump forceps into the caecum.

Make sure the stump inverts properly.

If the stumps will not invaginate:

The purse string stitches are probably too close to the appendix stump.

Replace the first purse string with a new purse string further from the appendix stump.

Place the new purse string into healthy caecum that will be flexible enough to let the appendix invaginate.

If the new purse string does not allow invagination:

Use interrupted sutures.

STEP 17.17 TIE THE PURSE STRING SUTURE.

Tighten the purse string as the appendix stump inverts into the centre of the purse string.

Have the assistant release the purse string artery clip.

Assistant places the now contaminated forceps in a receiver.

Finish the tightening of the purse string to make sure that the appendix stump remains inverted.

Place 2 more throws on the purse string suture.

If the appendix stump pops out of the purse string suture:

Oversew the stump with the 20 Vicryl to make sure that it is inverted.

If the appendix stump will still not invert, flex at this but place a drain down to the appendix stump.

Consider there may be a carcinoma at the based of the appendix stump.

STEP 17.18 CHECK HAEMOSTASIS.

Check there is no bleeding from:

The appendix stump.

The meso-appendix.

Any other intra-abdominal tissue.

SECTION 18.00 MANAGING CONDITIONS MIMICKING APPENDICITIS

primary peritonitis

no disease found.

Many conditions can mimick acute appendicitis, particularly if their presentations are atypical.

The list below is not comprehensive, but covers the most frequent conditions you might meet when operating for a suspected appendicitis.

In most cases, the management should include removal of the "normal" appendix.

An appendix with early appendicitis may look normal externally.

To a clinician in the future, a gridiron incision would usually imply that an appendicectomy has been performed.

In most cases of conditions mimicking appendicitis, the advice of a more experienced surgeon from the relevant speciality should be sought.

THE APPENDIX.

The account given above for paraileal, retrocaecal and pelvic appendicitis should have described the mamagement of most of the variants of appendicitis except an appendix abscess.

Appendix abscess

If an established appendix abscess is found:

Suck out the pus.

Take a swab for culture and sensitivity.

Do not attempt an appendicectomy:

The surrounding tissues will be too adherent for safe dissection.

The appendix may have undergone complete necrosis already.

Go to SECTION 20.00 INSERTING A DRAIN

Carcinoid tumour of the appendix

This is a rare finding and is usually symptom free.

The carcinoid tumour will usually form a firm 1-2cm. swelling in the tip of the appendix.

The cause of the patient's condition is usually something else.

Continue the search for conditions mimicking appendicitis.

And perform an appendicectomy.

If the swelling is larger than 2cm., or if it is at the base of the appendix:

Perform a limited right hemicolectomy.

THE OMENTUM

Torsion of the omentum.

This is a relatively rare condition where partof the omentum twists around itself leading to infarction.

There are often adhesions from previous surgery or past pathology such as perforated peptic ulcer.

Remove the piece of omentum.

Perform an appendicectomy.

Malignant infiltration of the omentum.

Tumours, particularly of the ovary or intestinal tract, may present with omental secondaries before the primaries cause symptoms.

Try to identify the site of the primary by examining the abdominal and pelvic contents.

Enlargement of the wound or a midline incision may be needed.

Take a biopsy of the omentum for histology.

THE CAECUM.

Necrotic or perforated caecum secondary to a closed loop obstruction of the more distal large bowel.

Obstruction by a carcinoma of the colon or rectum, or by diverticular disease in the sigmoid colon, may present with ischaemic damage to the caecum.

Make a full laparoscopic examination.

Remove necrotic caecum.

Perform a defunctioning caecostomy.

An ileostomy will not decompress the large bowel.

Since, in a closed loop obstruction, the ileo-caecal valve is competent.

Consider an extended right hemicolectomy,

removing the bowel from below the level of obstruction to the last 10cm. of the terminal ileum.

Perforated carcinoma of the caecum.

Perform a right hemicolectomy.

A perforated solitary diverticulum of the caecum.

For this benign condition:

Excise the diverticulum with oversewing of the defect and placing of an omental patch.

Remove the appendix.

If there is concern that there is a carcinom a of the caecum:

Perform a limited right hemicolectomy.

,,,OVARY

if the fluid welling up is blood in a female, this may well be from a ruptured ovarian cyst or an ectopic pregnancy.

Call an experienced gynaecologist. Inspect her pelvis. Consider coagulation to the edge of the cyst.

The right ovary should always be visualised via a gridiron incision.

It is acceptable to decide the left ovary is normal just on palpation.

Small thin walled ovarian cyst.

A thin walled cyst less than 5cm. in diameter is most likely to be benign.

Follicular cysts from a Graafian follicle and luteal cysts from a corpus luteum come into this category.

Such cysts may present with rupture and bleeding or just distension.

Puncture distended cysts with diathermy.

Coagulate any bleeding sites in a ruptured cyst.

Remove the appendix.

Conserve the ovaries in patients of child bearing age.

Consider removal of an ovary only if malignancy is suspected.

Larger ovarian swellings

Ovarian tumour.

Benign or malignant.

Infarcted following torsion.

Spontaneous haemorrhage into the tumour.

FALLOPIAN TUBE

Salpingitis (pelvic inflammatory disease).

::Ectopic pregnancy.

UTERUS

, degeneration of a fibroid, torted fibroid, pregnancy, endrometriosis, pyometrium:

TERMINAL ILEUM

IF THE SMALL BOWEL IS DAMAGED. Oversew the damaged part with 2 layers of continuous 20 Vicryl (Etihcom W9136). Make sure the defect is closed with a transverse wound to avoid narrowing. If there is inflammation in the terminal ileum this may be an acute ileitus of Crohn’s disease or very rarely tuberculosis. If there is only redness with minor oedema of the terminal ileum, limited to its most distal 15cm, it is most likely to be an acute ileitis, provided there was no obstruction. Take a swab from the peritoneal fluid. Remove a lymph node and sent it for histology and culture. Close the wound. ::Acute ileitis.

In severe cases, there may be adhesion to other organs and fistula formation. Call a more experie

=Chronic ileitis (Crohn's disease).

Ileo-caecal tuberculosis.

Perforated typhoid ulcer

Ascariasis (round worms).

THE REST OF THE SMALL BOWEL

Skip lesions from Crohn's disease.

Internal hernia.

Overlooked external hernia.

Perforation from eg fish bone.

THE COLON AND RECTUM.

disease of the sigmoid colon, perforated diverticular disease, diverticular disease, perforated carcinoma, ::Diverticular disease.

Peridiverticular abscess or perforation.

Carcinoma.

Free or sealed perforation.

NO PATHOLOGY FOUND

Ideally confer with a more experienced surgeon.

Remove the appendix.

PERITONEUM

Primary peritonitis Peptic ulcer. perforated peptic ulcer, perforated malignancy, small bowel perforation.

Go to Step 15.**

SECTION 19.00 MANAGING INCIDENTAL CONDITIONS

In cases of definite appendicitis, other conditions may be detected in addition.

Most of these conditions do not need surgical treatment at the same time as the appendicectomy.

eg Gallstones, aortic aneurysm, ,

MECKEL'S DIVERTICULUM

ADHESIONS

SECTION 20.00 INSERTING A DRAIN

A drain is only needed if the cause of suppuration has not been removed or it is likely that there will be leakage from a viscus eg an insecurely closed appendix stump.

11.06 CHOOSE A TUBE DRAIN Use a plastic tube drain 1cm. external diameter. E.g Portex Check the drain is long enough to reach the paracolic gutter from the skin of the right ilac fossa. Have 4 side holes cut in the inner end of the drain. 70 SECTION 11.00 PRECLOSURE PROCEDURE STEP NUMBER 11.06 continued Cut the external end of the drain at 45 degrees for ease of insertion. 11.07 INCISE THE SKIN Use a no.22 Swann Morton scalpel for a 1cm. drain. Make the incision 1.5cm. long in the right iliac fossa. Avoid vessels in the subcutaneous tissues. 11.08 DEEPEN THE INCISION Use an artery forceps to push through the skin incision into the peritoneum. Make sure you do not damage any structures in the peritoneal cavity. 11.09 CATCH THE DRAIN IN THE ARTERY FORCEPS 11.10 PULL THE DRAIN INTO THE WOUND 11.11 CUT THE DRAIN TO FIT INTO THE PARACOLIC GUTTER Use stitch scissors. 11.12 TUCK THE DRAIN INTO THE PARACOLIC GUTTER Make sure the drain does not kink, or press on delicate structures. 11.13 CUT THE BEVEL OFF THE OUTER END OF THE DRAIN Use stitch scissors. Fasten the drain temporarily to the drapes with the artery forcep 11.14 STITCH THE DRAIN TO THE SKIN Use No.1 silk (Ethicon W799). Tie with 4 half hitches at skin level. Wrap the silk tightly around the drain 4 times at skin level to make a waist in the drain. Then tie 4 more half hitches to finish. Cut the silk ends 4 cms. long. STEP 20.03 STITCH THE DRAIN TO THE SKIN

Use a No 1 silk stitch (eg Ethicon W799).

Tie the skin stitch with 4 half hitches.

Wrap the stitch 4 times tightly around the drain at skin level so that the drain is

pinched very slightly.

Tie the stitch with 4 more half hitches.

Cut the ends 4cm. long.

SECTION 21.00 WOUND CLOSURE

CLIP THE PERITONEUM. Use a total of 4 artery clips. 2 will already be on the sides of the peritoneal opening. Place 2 more exactly on the apesis of the peritoneal incisions. Check you have not clipped any bowel or omentum or other organ.

DO A PERITONEAL WASH. Use 500mls of normal Saline containing 1g of Tetrocycline. Elevate the peritoneal edge with the forceps and Langanbeck retractor to tent up the anterior abdominal wall. Pour in the irrigating fluid. Aspirate the irrigating fluid. Check the irrigating fluid is not bloody. If it is bloody look for bleeders and obtain haemostasis.

STITCH THE PERITONEUM. Use a continous 20 Vicryl (Ethicon 9136). Insert the first stitch at the medial apex of the wound. Tie the stitch with a triple knot and cut the end 3mm long. Take 5mm bites of peritoneum 5mm apart to completely close the peritoneum. Remove the forceps as you near them, but tie the stitch with a triple knot. Cut the end 3mm.

CLOSE THE MUSCLE LAYERS. The aim is simply to approximate the muscle layers to prevent strangulating stitches which could damage the muscle. Use interupted 20 Vicryl (Ethicon 9136). Place the stitches 1cm apart throught the muscle 1cm back from the wound. Usually 2 stitches are sufficient . Tie the stitches lightly with triple knots. Cut the end 3mm. Repair any extension of the wound into aponeurosis with similar stitches.

CHECK FOR HAEMOSTASIS IN THE SUBCUTANEOUS TISSUE.

CLOSE THE SUBCUTANEOUS TISSUES. Use 20 Vicryl (Ethicon 9136). Use continuous stitches 1cm apart. Tie the first knot with a triple knot. Cut the end 3mm and tie the last stitch with a triple knot. Cut the end 3mm.

CHECK YOU HAVE GIVEN AN ANTIBIOTIC. Bolus for a perforated appendix, plan to continue the antibiotics for 3 days.

Close the skin as standard.

STEP 20.05 CHECK THE SWAB, NEEDLE, AND INSTRUMENT COUNTS

STEP 20.06 SKIN CLOSURE

Use eg continuous subcuticular 3/0 Vicryl (Ethicon W9890).

Check the Vicryl has a 5 throw knot on its end.

Take 6 continuous sub cuticular bites before tightening up the stitch.

STEP 20.07 SPRAY THE WOUND

Use an acrylic spray (Nobecutaine).

CHECK THERE IS NO OTHER PROCEDURE TO DO

APPLY WOUND DRESSINGS

Use a compliant dressing (eg Mepore).

Cover the wound(s) and the drain site(s) with

the same dressing(s).

STEP 16.05 CONNECT THE SUCTION SYSTEM

SECTION 22.00 FINAL TOUCHES AND WHO SAFE SURGERY CHECKLIST SIGN OUT

STEP 21.01 CLEAN THE SKIN SURROUNDING THE DRESSING

Use Chlorhexidine in Propanol.

STEP 21.02 CHECK THE WOUND DRAIN IS WORKING

STEP 21.03 WRITE LEGIBLE OPERATION DETAILS

STEP 21.04 FILL IN THE SURGICAL AUDIT FORM

STEP 21.05 DICTATE AN OPERATION LETTER TO THE GENERAL

PRACTITIONER AND THE REFERRING PHYSICIAN

END OF OPERATION

WHO SAFE SURGERY CHECKLIST SIGN OUT

SECTION 23.00 EQUIPMENT AND MATERIALS LIST

1 BASIC PACK

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FINAL TOUCHES

In severe cases there may be adhesion to other organs and fistula formation. Call a more experienced surgeon. Consider closing the wound and performing a laparotomy to assess the presence of skip lesions. Consider a right hemi-colectomy. The right for the transversus abdominus muscle. This lies deep to the internal oblique muscle and also 1-2cm laterally.

You need to avoid opening the internal oblique upper nerosis. You also want to avoid opening the transversus abdominus upper nerosis. The transversus abdominus muscle slightly darker and more purple than the brown internal oblique muscle. Enlarge the large transversus abdominus muscle incision with 2 fingers stretching as for the internal oblique. Form an 8cm opening in the transversus muscle.

FIND THE PERITONEUM. This may be separated from the deep surface of the transversus abdominus by a thick layer of extra peritoneal fat. Sweep this fat away with a gauze section. You may find the tissues are appearing odematis due to the underlying appendicitis. The peritoneum is a thin bluish white sheet if not inflammed. If inflammed it becomes much thicker and pinker.

Check the sucker is working. Pick up the centre of the peritoneum between 2 of the forceps. Pinch the tented peritoneum to make sure the clips have not picked up any bowel. Open the peritoneum. Use a 22 blade held flat to avoid cutting intra-peritoneal tissues. Make a 5mm opening in the peritoneum between the 2 artery forceps. Use the sucker to control any peritoneal fluid draining from the incision. Take a bacteriology swab. Widen the peritoneal incision. Use dissecting scissors. Widen the incision by cutting to 1cm in diameter, insert the sucker and move forward until no more until no more is welling up. Make the incision in the line of the opening of the transverses muscle. Widen if any intra abdominal contents should drop back. Extend the peritoneal incision to 6cm. Make sure that you do not open the large bowel, congenitally plastered to the peritoneum. If you have inadvertently onced surgeon. Consider closing the wound and performing a laparotomy to assess the presence of skip lesions. Consider a right hemi-colectomy. The right ¤ƒ.¥ÂA¦¡ § ¨û ©Ð bacteriologyperitoneumperitoneumforcepsoedematousoedematousperformedAPPENDIXdissectmesenteryhomeostasismanoeuvreIfinterruptedtransversallyHOMEOSTASISHOMEOSTASISappeasesTetracyclinecontinuosthroughileitisileitisMackerelsileitisMESENTERYIn severe casesight hemi-colectomy. CFS RIGHT HEMI.

The condition is indistinguishableScalplefax

Appendicectomy

This operation covers an elective appendicectomy and emergency appendicectomy.

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from the cascostal margin to the mid thigh, the lateral boarder of one side of the abdomen to the other, . Check there is a diathermy pad, stand on the patients right side with your assistant opposit.

Skin preperation.

Clean from costal margin to the groin and from the mid line to the right lateral boarder of the abdomen. AB scrub, towel up from the umbilicus down to the pubis from mid line lateral to the the right antirier supierior iliac crest. This will expose the umbilicus and the anterior spine for localising the incission. Check where you think the appendicitis lies. Fix towels check the diothermia is working, check there is a sucker working. Incise the skin, standard incision complete incision over McBurney’s point 8cm long. Make this longer in an obese patient. Choose a site 2cm higher if you suspecta a retro-caecal appendix, 2cm lower if you suspect a pelvic appendix. Use a 22 blade. Cut through the skin and fat. Make sure the cuts are of an even depth. Consentrate on making the cuts at the ends of the wounds as deep as in the centre of the wound. Avoid an incision which is deep in the middle and shallow at the ends of the wounds. Expect bleeding from the superficial epigastric vessels towards the centre of the wound and sperficial circumflex iliac vessels more laterally. Deepen the incision through the fat to display the oblique stripes of the external oblique upper nerosis. Coagulate blood vessels as you go. The deep layer of superficial fasia may look like to external oblique. Sweep the fat with a gauze swab to display 8cm of external oblique upper nerosis.

RETRACT SKIN AND FAT. Use 2 Langanbeck forceps held by your assistant. INCISE THE EXTERNAL OBLIQUE. Use a 22 blade. Make a 1cm incision into the external oblique upper nerosis in the line of the stripes. Make this incision in the lateral half of the wound to avoid opening the rectus sheath. Pick up the external oblique upper nerosis. Use 2 artery clips. Enlarge the external oblique incision. Use disecting scissors with the jaws just open. Snip the incision by pushing the scissors laterally and medially widening the incision to 8cm.

FIND THE INTERNAL OBLIQUE MUSCLE. Freely insert under the surface of the external oblique upper nerosis with a blunt disection. You will find the oblique muscle fibres of the internal oblique laterally under the external oblique upper nerosis. Hold the external oblique upper nerosis. Move laterally with a Langanbeck if needed if the fibres are not visible enlarge the external oblique incision laterally. If the fibres are still not visible enlarge the skin incision laterally and also the external oblique even further laterally. If you cannot see these fibres call a more experienced surgeon. Open the internal oblique muscle. Use scissor stretch disection. Open the muscle obliquely in the line of the fibres 5th muscle will be at least 1cm thick. Stretch the incision open with the scissors to about 5cm long. Make the incision bigger by stretching the internal oblique in the line of its fibres by inserting 2 index fingers and pulling them forcably apart. LookKING. Use progressively no wound packing. Next 1 swab on the stick. Next 2 swabs on sticks. Next abdominal pack.

Finding the appendix. Dissecting the appendix. Removing the appendix. Finding a normal appendix.

DELIVER THE APPENDIX. The appendix may pop out of its own accord. Use a finger to hook the appendix out. Use gentle traction with a Babcock forceps or 2 Babcock forceps. Avoid perforating the inflamed part of the appendix by gentle clipping. Free off inflammatory adhesions with a pledget. ¤ƒ.¥ÂA¦¡ § ¨û ©Ð At this point you will find appendicitis, something else or nothing. If you find appendicitis go to step , if you find something else go to , this will include what to do with a normal appendix. If you find nothing go to , this will include not being able to find the appendix.

Take a bacteriorology swab of the fluid.

IF YOU FIND APPENDICITIS. You need to be quite sure about this. The appendix should be swollen (the extent will vary from the tip only to the whole length of the appendix being reddened or even blackened or a greenish colour with necrosis, a yellow colour, a perforation from a 1mm leak to a fracture across the whole lumen.

Appendicitis starts with an inflammation in the lumen and spreads through the wall. Early appendicitis may produce only some pinkness of the serosal surface. A similar appearance is seen if the serosa is inflamed from an external cause in the periteneum such as peritonitis from elsewhere. You need to confirm the former by opening the appendix after its removal. Confirm the latter by careful examination of the rest of the peritonium during exploration.

For an older patient examine the ascending colon within reach to exclude a carcinoma. IF THERE IS GREEN FLUID CALL A MORE EXPERIENCED SURGEON. Defer to a laparotomy for a possible perforated peptic ulcer. If there is faecal fluid close the laparotomy. For perforated small bowel. If there is a small mass in the caecum consider a solitary diverticular of the caecum. Consider a local excision. Call a more experienced surgeon concerning a right hemi-colectomy. If there is a loop of strangulated bowel consider enlarging the incision or converting to a laparotomy. For ischemic bowel close and convert. For a bleeding follicular cyst oversew it. For an ovarian cyst perform a cystectomy, consider a hysterectomy with bilateral sub inguinal oophrectomy.

For salpingitis swab the salpix and close up. Following broad ligament herniation, widen incision or convert to a laparotomy. Count if there is red degeneration of a fibroid, close up. If the appendix is normal examine the most distal 2 feet (70cm) of the terminal ileum. If there is a diverticulum leave this. If it is not thickened, not inflamed, has a neck of more than 2cm in diameter it is not any larger than 2cm long and there is no bands extending to the umbilicus. If any of these features are present, excise the diverticulum. Examine the right ovary and tube. Examine the uterus, palpate the left tube and ovary. In a male perform an appendicectomy. In a female perform an appendicectomy. Consider the chance of inducing steroity.