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General Surgery
Appendix, Meckel’s, and Other Small Bowel Diverticula
Built from Maingot's Abdominal Operations
What’s inside
16 sections · 180 slides
Overview
- Scope of this topic
- Terms used throughout
Anatomy and history
Where the appendix sits, how it is fed, and how surgeons learned to remove it
- Earliest descriptions of the appendix
- Milestones in the surgery of appendicitis
- Amyand's hernia and McBurney's point
- Development and dimensions of the appendix
- Landmarks for the base and the tip
- Positions taken by the appendiceal tip
- Arterial supply and lymphatic drainage
How acute appendicitis develops
Who gets it, what blocks it, and what the evidence for obstruction really shows
- Age and sex distribution
- Perforation risk at the extremes of age
- Diet, geography and the faecalith
- Closed-loop obstruction sequence
- Why the appendix obstructs so readily
- Evidence against obstruction as the only cause
Clinical presentation
The classic story, the many exceptions, and what changes once the appendix perforates
- Classic sequence of symptoms
- Reading the classic history
- Departures from the classic picture
- Time course of progression to perforation
- Does in-hospital delay cause perforation?
- Clinical picture of perforated appendicitis
- Uncommon presentations of perforation
Diagnosis
History, examination, blood tests, scores and the modern role of ultrasound and CT
- History taking in suspected appendicitis
- Abdominal examination findings
- Tenderness in unexpected sites
- Named signs of appendicitis
- Laboratory studies
- Interpreting the urinalysis
- Additional tests in selected patients
- The Alvarado diagnostic score
- Plain radiographs and the appendicolith
- Ultrasound findings in acute appendicitis
- Strengths and limits of ultrasound
- CT findings in acute appendicitis
- Acute appendicitis on axial CT
- Perforated appendix with retrocaecal abscess on CT
- Prospective comparisons of CT and ultrasound
- Accuracy of CT and ultrasound for acute appendicitis
- Effect of CT on hospital resource use
- Pathway for suspected acute appendicitis
- Choosing between the two scans
Differential diagnosis
Almost anything in the abdomen can imitate appendicitis, and some things outside it
- Common mimics in young patients
- Mimics in middle-aged and older adults
- Features suggesting colonic malignancy
- Right lower quadrant pain in women of childbearing age
- Differential diagnosis: gastrointestinal and infectious causes
- Differential diagnosis: genitourinary, non-abdominal and obstetric causes
Special patient groups
Children, the elderly, pregnancy and immunocompromise each shift the picture
- Appendicitis in children
- Imaging children with equivocal findings
- Body mass index and ultrasound accuracy
- Radiation risk and imaging strategy in children
- Appendicitis in the elderly
- Why appendicitis is hard to detect in pregnancy
- Diagnoses specific to pregnancy
- Site of pain and predictive features in pregnancy
- Imaging the pregnant patient
- Operating on the pregnant patient
- Laparoscopy during pregnancy
- Comparing the two approaches in pregnancy
- Appendicitis in the immunocompromised patient
- Appendicitis in HIV and AIDS
Treatment decisions
Antibiotics versus operation, preparation for theatre, and open versus laparoscopic
- Early experience with antibiotics alone
- Eriksson's randomised trial of antibiotics
- A larger antibiotics versus appendectomy trial
- Reading that trial critically
- Preoperative preparation for appendectomy
- Antibiotic prophylaxis and appendiceal flora
- Laparoscopic versus open appendectomy
- Interpreting the comparative evidence
- Reported advantages of each appendectomy approach
- When laparoscopy is the better choice
Open appendectomy
Incision, delivery of the appendix, division of the mesoappendix, the stump, and closure
- Planning the incision
- Opening the abdominal wall
- Opening the abdominal wall in open appendectomy
- Delivering the appendix into the wound
- Extending exposure and handling the appendix
- Dividing the mesoappendix
- Dividing the mesoappendix and clamping the base
- Dividing the appendix at its base
- Whether to invert the appendiceal stump
- Technique of purse-string inversion
- Ligating the base and beginning stump inversion
- Completed purse-string closure over the buried stump
- Retrograde dissection of the appendix
- When inflammation reaches the caecum
- Closure after open appendectomy
- Closing the muscle and fascial layers
Laparoscopic appendectomy
Ports, positioning, dissection of the mesoappendix and retrieval of the specimen
- Port placement, triangulation and theatre set-up
- Patient position and port sites for laparoscopic appendectomy
- Establishing access to the abdomen
- Instrument set-up inside the abdomen
- Exposing a retrocaecal appendix laparoscopically
- Creating a window in the mesoappendix
- Dividing the appendix laparoscopically
- Stapling the mesoappendix and retrieving the specimen
- Retrieval and closure
- Postoperative care after appendectomy
Perforation, abscess and the normal appendix
Phlegmon, abscess, free perforation, interval appendectomy and what to do with a healthy appendix
- Three patterns of appendiceal perforation
- Managing free perforation
- Closing a contaminated appendectomy wound
- Suspected abscess or phlegmon without peritonitis
- Non-operative management of an appendiceal mass
- Drainage of an appendiceal abscess
- The interval appendectomy debate
- Where interval appendectomy stands
- The normal appendix found at operation
- Reasons to remove a grossly normal appendix
- Searching for another cause at operation
- Chronic appendicitis
- The asymptomatic appendicolith
Neoplasms of the appendix
Mucinous lesions and pseudomyxoma, adenocarcinoma, and the carcinoid tumour
- Appendiceal neoplasms: how they present
- Types of appendiceal tumour
- The mucocele and what hides behind it
- Presentation of a mucinous cystadenoma
- Resected mucinous cystadenoma of the appendix
- Mucinous cystadenoma on axial CT
- Management of mucinous appendiceal masses
- Mucinous cystadenocarcinoma
- Treatment of mucinous cystadenocarcinoma
- Adenocarcinoma of the appendix
- Dukes stage and five-year survival
- Carcinoid tumours of the appendix
- Size and behaviour in appendiceal carcinoid
- Operation chosen by carcinoid size
- Other indications for right hemicolectomy
Duodenal and jejunoileal diverticula
Acquired pouches of the small bowel: how often they matter, and what to do when they do
- Classifying small bowel diverticula
- True and false diverticula compared
- Duodenal diverticula: frequency and site
- Symptoms and complications of duodenal diverticula
- Perforation of a duodenal diverticulum
- Diagnosing a complicated duodenal diverticulum
- Endoscopy in duodenal diverticular disease
- Choosing management for a duodenal diverticulum
- Operating on a perforated duodenal diverticulum
- When the diverticulum cannot safely be excised
- When the problem is duct obstruction, not perforation
- Jejunoileal diverticula: frequency and cause
- Distribution of jejunoileal diverticula
- Diagnosing jejunoileal diverticula
- Chronic symptoms from jejunoileal diverticula
- Blind loop syndrome and its medical treatment
- Acute complications of jejunoileal diverticula
- Diverticulitis, perforation and when to operate
- Obstruction from a jejunoileal diverticulum
- Enterolith obstruction and multiple diverticula
- Bleeding from a jejunoileal diverticulum
Meckel's diverticulum
The commonest congenital anomaly of the gut, its complications, and the incidental-finding dilemma
- What a Meckel's diverticulum is
- Tissue types found inside a Meckel's diverticulum
- How often a Meckel's diverticulum causes symptoms
- Complications of a Meckel's diverticulum
- Presentations of a symptomatic Meckel's diverticulum
- Mechanisms behind obstruction and bleeding
- Preoperative diagnosis of a Meckel's diverticulum
- Resecting a symptomatic Meckel's diverticulum
- Suture closure, and when diverticulectomy is not enough
- Criteria proposed for removing an incidental Meckel's
- Evidence against routine incidental resection
Key points
What to carry away from the appendix and the diverticula of the small bowel
- Key points: appendicitis and its diagnosis
- Key points: operative management
- Key points: tumours and diverticula
References
The reference list of this topic, as published
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- Maingot's Abdominal Operations, 12th Edition