APPENDICITIS APPENDIX The appendix is a closed-ended, narrow, worm-like tube up to several inches in length that attaches to the cecum

(the first part of the colon). The appendix is located in the lower abdomen. (The anatomical name for the appendix, vermiform appendix, means worm-like appendage.) The wall of the appendix contains lymphatic tissue that is part of the immune system that makes antibodies. The appendix has no function in modern humans; however, it is believed to have been part of the digestive system in our primitive ancestors.

The cecum is the pouch where the large intestine begins. It is where the ileum opens from one side and continues with the colon.

APPENDICITIS Appendicitis means inflammation of the appendix. It is thought that appendicitis begins when the opening from the appendix into the cecum becomes blocked. The blockage may be due to a build-up of thick mucus within the appendix, or to stool that enters the appendix from the cecum. The mucus or stool hardens, becomes rock-like, and blocks the opening of the appendix into the cecum. If the blockage continues, bacteria that are normally present within the appendix invade (infect) the wall of the appendix. This causes inflammation in the wall of the appendix, and, as a result, the wall of the appendix begins to die, which finally results in the appendix bursting.

Appendicitis is a common condition that affects 6% of the population. It most commonly occurs among those 10-30 years of age, though it can occur at any age. Increased vigilance in recognizing and treating potential cases of appendicitis is required for the very young and old who have a higher rate of complications. What are the most frequent complications of appendicitis? The most frequent complication of appendicitis is perforation. Perforation of the appendix can lead to a periappendiceal abscess (a collection of infected pus) or diffuse peritonitis (infection of the entire lining of the abdomen and the pelvis). The major reason for appendiceal perforation is delay in diagnosis and treatment. In general, the longer the delay between diagnosis and surgery, the more likely is perforation. The risk of perforation

36 hours after the onset of symptoms is at least 15%. Therefore, once appendicitis is diagnosed, surgery should be done without unnecessary delay. The most common complications of appendicitis are perforation, abscess, and peritonitis. What is another complication of appendicitis? Blockage occurs when the inflammation surrounding the appendix causes the intestinal muscle to stop working, and this prevents the intestinal contents from passing. If the intestine above the blockage begins to fill with liquid and gas, the abdomen distends and nausea and vomiting may occur. It then may be necessary to drain the contents of the intestine through a tube passed through the nose and esophagus and into the stomach and intestine. A less common complication of appendicitis is blockage of the intestine. What are the symptoms of appendicitis? The main symptom of appendicitis is abdominal pain. The abdominal pain is at first not confined to one spot. The pain is so difficult to pinpoint that when asked to point to the area of the pain, most people indicate the location of the pain with a circular motion of their hand around the central part of their abdomen. A second, common, early symptom of appendicitis is loss of appetite which may progress to nausea and even vomiting. Nausea and vomiting also may occur later due to intestinal obstruction. The diagnosis of appendicitis begins with a thorough history and physical examination. How is appendicitis diagnosed? The diagnosis of appendicitis begins with a thorough history and physical examination. However, a White blood cell count, Urinalysis, Abdominal X-ray, Barium enema, Ultrasonography, CT scan, Andlaparoscopy also may be helpful in diagnosis. Patients often have an elevated temperature, and there usually will be moderate to severe tenderness in the right lower abdomen when the doctor pushes there. If inflammation has spread to the peritoneum, there is frequently rebound tenderness. Rebound tenderness is pain that is worse when the doctor quickly releases his hand after gently pressing on the abdomen over the area of tenderness.

How is appendicitis treated? Treatment usually consists of appendectomy (surgical removal of the appendix). Once a diagnosis of appendicitis is made, an appendectomy usually is performed (surgical removal of the appendix). Antibiotics almost always are begun prior to surgery and as soon as appendicitis is suspected. On the next several slides we'll take a look at an actual stepby-step laparoscopic appendectomy procedure being performed.

STEPS ON HOW APPENDECTOMY IS DONE Step 1: This is a normal appendix in a female patient found to have an infection of the reproductive organs. Since the appendix serves no useful function, it will be removed to save her from getting appendicitis in the future.

Step 2: The next step is to free up the appendix down to where it is attached to the large bowel. This requires dividing the mesentery which contains the blood vessels that supply the appendix. Bipolar forceps apply an electric current which seals the blood vessels and prevents bleeding. The mesentery (the tissue that suspends the appendix and carries blood vessels to the appendix) is divided from the appendix.

Step 3: Next, scissors are used to divide the mesentery. Alternating application of the bipolar electrocautery forceps and scissors allow complete mobilization of the appendix down to its base. Scissors are used to free the appendix from its mesenteric attachment to the abdomen and colon.

Step 5: As shown in this picture, the suture is now cut with the scissors. An

Step 6: Using the same scissors, the appendix is cut free and ready to be removed.

Step 4: Now the base of the appendix is tied off using a pre-tied suture which is now being positioned. The suture has now been tightened and appears secure. The knot is a fisherman's knot, which can be tightened but will not loosen on its own. Step 7: The operation is complete, and the area is inspected one final time to make sure there is no bleeding.

An example of an infected appendix that has been removed (left) and the resulting incisional scar from an appendectomy (right).

removing the appendix, although a slight increase in some diseases has been noted, for example, Crohn's disease (a chronic inflammatory disease of the intestines).

Are there complications and/or long-term consequences of appendectomy? The most common complication of appendectomy is infection of the wound, that is, of the surgical incision. Such infections vary in severity from mild, with only redness and perhaps some tenderness over the incision, to moderate, requiring only antibiotics. It is not clear if the appendix has an important role in the body in older children and adults. There are no major long-term health problems resulting from
6