APPENDECTOMY

What is the appendix?
In humans, the vermiform appendix is a small, finger-sized structure, found at the end of our small caecum and located near the beginning of the large intestine.

The appendix is a small, finger-shaped pouch of intestinal tissue arising from the cecum near its junction with the small intestine.

What is appendicitis?
Inflammation of the vermiform appendix

What is an appendectomy?
An appendectomy is the surgical removal of the appendix. Appendectomy usually is done for appendicitis.

Causes
It's not always clear why appendicitis occurs. Sometimes it's the result of an obstruction when food waste or a hard piece of stool (fecal stone) becomes trapped in an orifice of the cavity that runs the length of your appendix.
Appendicitis may also follow an infection, such as a gastrointestinal viral infection, or it may result from other types of inflammation. In both cases, bacteria may subsequently invade rapidly, causing the appendix to become inflamed and filled with pus. If not treated promptly, your appendix eventually may rupture.

Signs and symptoms
Appendicitis can cause a variety of symptoms that may change over time. The most common early symptom is an aching pain around your navel that often shifts later to your lower-right abdomen. As the inflammation in your appendix spreads to nearby tissues, especially the inner lining (peritoneum) of your abdomen, the pain may become sharper and more severe.
Eventually, the pain tends to settle in your lower-right abdomen - just above your appendix at what's known as McBurney's point. This point is about halfway between your navel and the top of your right pelvic bone. But the location of your pain may vary, depending on your age and the position of your appendix. Young children, especially, may have appendicitis pain in different places.

If you apply gentle pressure to the area that hurts, it will feel tender. As you release the pressure, appendicitis pain often will feel worse (rebound tenderness). It will also tend to get worse if you cough, walk or make other jarring movements. This is particularly true if the inflamed appendix is touching the peritoneum. The pain may lessen somewhat if you lie on your side and pull your legs up beneath you.

In addition to pain, you may have one or more of the following signs and symptoms:
> Nausea and sometimes vomiting
> Loss of appetite
> A low-grade fever that starts after other signs and symptoms appear
> Constipation
> An inability to pass gas
> Diarrhea
> Abdominal swelling

How is appendicitis diagnosed?

In addition to a complete medical history and physical examination, diagnostic procedures for appendicitis may include the following:
> blood tests (to check for signs of infection such as elevated white blood cell count)
> urine tests (to rule out a urinary tract infection)
> imaging procedures (to determine if the appendix is inflamed), including the following:

• Computed tomography scan (Also called a CT or CAT scan.) - a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.
• Ultrasound - a diagnostic technique which uses high-frequency sound waves to create an image of the internal organs.
• X-Ray - a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.

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Treatment

Treatment for Appendicitis:
Specific treatment for appendicitis will be determined by your physician based on:
> your age, overall health, and medical history
> extent of the condition
> your tolerance of specific medicines, procedures, or therapies
> expectations for the course of the condition
> your opinion or preference

Medicines
If the diagnosis is uncertain, people may be watched and sometimes treated with antibiotics. This approach is taken when the doctor suspects that the patient's symptoms may have a nonsurgical or medically treatable cause. If the cause of the pain is infectious, symptoms resolve with intravenous antibiotics and intravenous fluids. In general, however, appendicitis cannot be treated with antibiotics alone and will require surgery.

How is appendicitis managed surgically?
During an appendectomy, an incision two to three inches in length is made through the skin and the layers of the abdominal wall in the area of the appendix. The surgeon enters the abdomen and looks for the appendix, which usually is located in the right lower part of the abdomen. After examining the area around the appendix to be certain that no additional problem is present, the appendix is removed. This is done by freeing the appendix from its attachment to the abdomen and to the colon. If present, abscesses can be drained with drains (rubber tubes) that go from the abscess and out through the skin to allow the pus from the abscess to drain out. The abdominal incision then is closed.

Newer techniques for removing the appendix involve the use of the laparoscope. The laparoscope is a thin telescope attached to a video camera that allows the surgeon inspect the inside of the abdomen through a small puncture wound (instead of a much larger incision). If appendicitis is found, the appendix can be removed with special instruments that can be passed into the abdomen, just like the laparoscope, through small puncture wounds. The benefits of the laparoscopic technique include less post-surgery pain (since much of the post-surgery pain comes from incisions) and a speedier recovery. An additional advantage of laparoscopy is that it allows the surgeon to look inside the abdomen in cases in which the diagnosis of appendicitis is in doubt and to make a clear diagnosis of the problem. For example, laparoscopy is especially helpful in menstruating women in whom bursting ovarian cysts may mimic appendicitis.

What are the risks of an appendicectomy?
As with any operation, the risks associated with an appendicectomy include:
> bleeding
> infection
> reaction to medications

What are the complications of an appendicectomy?
The most common complication of an appendicectomy is infection of the wound. Such infections vary from a superficial infection which only requires daily dressing of the wound; to a deeper infection which may require surgery.

Another complication is abscess, a collection of pus in the area of the appendix. This will require drainage of the abscess.

A third complication is blockage of the intestines. This results in the intestines becoming filled with liquid and gas. When this happens, it may be necessary to drain the contents of the intestine through a tube passed through the nose and oesophagus, and into the stomach. In most instances, this condition resolves spontaneously. Occasionally, another operation may be needed to free the obstruction.

What happens if an inflamed appendix is not removed?
Acute appendicitis may result in a rupture of the appendix (perforation) and the infection can spread to the entire abdominal space (peritonitis). Untreated acute appendicitis can result in death.

When can I drive a car?
You may resume driving when you are able to step on the foot pedal without causing excessive pain or when you do not require pain relief medication that makes you drowsy.

When can I resume work?
Most patients take up to 14 days off work to recuperate after an appendicectomy. Patients, whose jobs involve strenuous work or frequent lifting, may be off work for a longer period. Consult your surgeon for specific instructions.

When do I need to see a doctor?
Consult your doctor if any of the following occurs:
> body temperature higher than 38ºC
> drainage or fluid from incision
> increased wound tenderness or soreness
> significant redness or swelling at the incision site, or
> persistent nausea, vomiting, diarrhoea