Surgery - Appendicectomy
An acute case of appendicitis. interval treatment after using IV antibiotics to treat an appendix mass. Anatomy 2.5 cm below the connection with the terminal ileum, the appendix originates at the convergence of the taeniae coli on the posteromedial side of the caecum. The appendix can lay in the following positions: retrocaecal (70%), pelvic (20%), subcaecal (2%) and pre- or post-ileal (5%). Its length ranges from 1.2 to 22.0 cm. The appendicular artery, a branch of the ileocolic artery, passes via its mesentery, the mesoappendix. To empty into ileocaecal nodes, lymphatics from the appendix pass through the mesoappendix. Investigations FBC, U&Es, LFT, amylase, CRP, and urinalysis (to look into stomach pain) are performed prior to surgery. It is recommended that women who are fertile have a pregnancy test done. If sepsis symptoms are present, antibiotics are initiated; if not, a single preventive dosage is administered at the time of operation. Post-op: If the appendix is inflamed, antibiotics may need to be continued. prophlyaxis for DVT. Procedure can be carried out openly or by laparoscopy. Make sure you always look at the patient on the table to check for any lumps. Access: The subcutaneous fat is separated and the external oblique aponeurosis is exposed by a Lanz (horizontal skin crease) incision, which is centered on McBurney's point, which is two thirds the distance from the umbilicus to the anterior superior iliac spine. With scissors, a tiny incision is created in the direction of the fibers. Similar to transversus, internal oblique muscle is divided bluntly along the direction of its fibers, and the opening is gradually widened with retractors. The peritoneum is carefully lifted up with a clip after it is revealed. After that, the first clip is moved and a second clip is positioned. Make sure there is no bowel trapped between the clips by palpating the area before making a tiny cut and then extending. Identification: Pus or free fluid are looked for in the peritoneal cavity. The appendix's base is located by identifying the caecum and following the taeniae, after which it is gently bluntly dissected to release it from inflammatory adhesions. Using Babcock's forceps, the appendix is removed. Even if the appendix is determined to be normal (or "lily-white"), it should still be removed; still, the small bowel needs to be thoroughly examined to rule out mesenteric adenitis, terminal ileitis, or Meckel's diverticulum. The right ovary and fallopian tube should be examined in females. Resection: To maintain hemostasis, the mesoappendix is separated and clipped after being tied off. The appendix's base is crushed with a crushing clamp, and it is then transfixed or tied off before removal. The appendix is transported to be examined histologically. Typically, a purse string suture is used to bury the appendix stump. If there is pus or inflammatory fluid in the cavity, it should be cleaned. Closure: Subsequently, the incision is layered shut. The peritoneum is sutured continuously, followed by interrupted sutures to the muscle layers and finally continuous sutures to the external oblique—the latter of which is crucial in preventing more hernias. For the skin, a subcuticular absorbable suture is typically utilized. Infiltration of local anesthetic lessens post-operative pain. Laparoscopic appendicectomy: This alternate method can be both therapeutic and diagnostic, making it particularly helpful for women whose diagnosis may be unclear. The mesoappendix is separated from the appendix and loop sutured or endostapled across the appendix base before being excised and removed through a port after the capnoperitoneum and port insertion. Complications Very rare, but when present indicates the severity of peritonitis or inflammation; examples include ileus, hemorrhage, wound infection, and, less frequently, pelvic or local abscesses. Prognosis usually good with mortality less than 1%, however in older adults or in cases of perforation, this may be greater.
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