ACUTE APPENDICITIS
This is the most common abdominal surgical emergency. It occurs in 7 - 12% of the population in Europe and USA. The peak age for appendicitis is around 30 years. It is slightly more common in men but the operation is commoner in women (see later).
PRESENTATION
This can be very variable and thus makes diagnosing appendicitis difficult. This is more so in young women where pains due to problems with the ovaries and tubes can confuse the matter. Because of these additional problems in women, more of them undergo operations for presumed appendicitis.
The classical presentation of appendicitis is with vague central abdominal pain which over a period of 12 - 24 hours moves to the right lower quadrant of the abdomen. Nausea and vomiting are common but diarrhoea is less so. There may be a low grade fever and the patient is anorexic (does not feel hungry). Once the pain settles in the right lower quadrant of the abdomen it is made worse by movement, coughing / sneezing, deep breathing or by someone prodding the patient there (usually the GP or the surgeons in hospital). The pain is less if the patient keeps still and does not breathe too deeply.
This classical presentation occurs in 20 - 25% of cases making the diagnosis in the rest difficult. The symptoms in the rest can be confusing depending on the position of the appendix in the abdomen. If it is behind the caecum (part of the large bowel) the pain may be more in the loin with little tenderness on examining the abdomen. If the appendix is in the pelvis, it may sit next to the rectum (lowest part of the large bowel just above the back passage) causing diarrhoea or it may cause symptoms suggestive of a water infection if it lies next to the bladder. As mentioned above, other problems in the pelvis in women can be confused for appendicitis.
Sometimes the inflamed appendix may become surrounded by fatty tissue in the abdomen (called the omentum). The pain may subside somewhat and a lump may be felt on examination - this is called and 'appendix mass'. An 'appendix abscess' may form if the walled off appendix perforates.
WHAT WILL HAPPEN IN HOSPITAL?
Once you have been seen and examined by a surgeon, blood tests will be taken (a raised white cell count in the blood indicates the presence of an infection and helps support the diagnosis). A urine sample may be sent for analysis. If necessary you may have an x-ray of your chest or abdomen. If the diagnosis is still not certain, an ultrasound scan of the abdomen and pelvis may be needed.
If the diagnosis is certain, an operation will be arranged. If the diagnosis is uncertain, you may be admitted for observation. The pain will either settle or may stay the same or get worse. In the last 2 cases, assuming no other cause is found, an operation may be needed.
THE OPERATION
The conventional operation involves a 2 - 4 inch long cut in the right lower quadrant of the abdomen. This is done under a general anaesthetic. The appendix is removed - in about 20 - 30% of cases it will be normal. The abdominal cavity is then looked at to determine another cause of the symptoms. It is difficult to do this through such a small incision. For this reason and to make it easier to inspect the pelvis in women I prefer to carry out this operation using laparoscopic ('keyhole') surgery:
A 2 centimetre incision is made just below the belly-button. Through this a metal or plastic tube (port) can be inserted and the abdomen distended with carbon dioxide gas. A special camera can be passed through the port to inspect the abdominal and pelvic organs. Two other incisions are then made. These are very small (approx. 0.5 cm) and allow the passage of smaller ports for operating instruments to be introduced into the abdominal cavity.
In the video below you will see the appendix is grabbed and lifted up. Some adherent omentum (a fatty tissue found in all abdomens) is pulled of the appendix. At the base of the appendix, on the bottom right of the image, is the caecum (the beginning of the large bowel). The small intestine can be seen at the bottom left of the picture. A window is created near the base of the appendix and the base cut using a special stapling gun. The fatty tissue that holds the appendix in place and carries its blood supply is then cut using the same gun. The appendix is removed in a special bag. The area can then be washed with sterile salt solution before the end of the operation. At the end of the procedure, I leave about half a litre of this salt solution mixed with a local anaesthetic in the abdomen to help reduce post-operative pain.
This video may take some time to load - please be patient. Move the mouse over it to start the video.
The advantages of this way of removing the appendix are:
 | Better look around the rest of the abdomen and pelvis |
| More rapid recovery and return to normal activities |
| Better cosmetic outcome |