Faecolith

This is a a mix of faecal matter, calcium phosphate, bacteria and epithelial debris, the incidental finding of which is a relative indication of prophylactic appendicectomy.

#Appendix
#Surgery

Aetiologic implications of acute appendicitis:

¶ No single unifying hypothesis can explain the cause.
¶ No single organism was found to be responsible.
¶ Bacterial proliferation usually is a mixture of aerobic and anaerobic bacteria.
¶ Low fibre diet is found to be important, just like with diverticulitis the incidence of appendicitis is higher in those with low fibre and high refined carbohydrate diet.
¶ Proliferation of submucous lymphoid tissue was found to be important as it narrows the lumen.
¶ Obstruction of the lumen is found in majority of cases and held as an important factor.
¶ Luminal obstruction may be due to a faecolith (see image below), Stricture of appendix (usually as a consequence of previous appendicitis resolved without surgery), Parasite (especially pinworm), or tumors (like caecum adenocarcinoma or carcinoid).

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#Surgery

Important note

The incidence of acute appendicitis is EQUAL among males and females BEFORE puberty, in teens and young adults the male to female ratio is 3:2 at age 25 years, this increased incidence of appendicitis among males declines thereafter

#Appendix
#Surgery

Note

The appendicular artery usually is an end artery, meaning that thrombosis of this artery will cause necrosis of the appendix i.e Gangrenous appendicitis, sometimes this does not occur as few indivisuals have an accessory appendicular artery which provide an alternative blood supply.

The lymphatic drainage of appendix goes to the ileocaecal lymph nodes.

#Appendix

#Surgery

Important surgical anatomy of the appendix :

1) The base of the appendix is always present at the confluence of the three taeniae coli, this helps the surgeon to locate the appendix whenever elusive.

2) The mesoappendix arise from the lower surface of the mesentry or sometimes the terminal ileum, it can be so transperant that it shows the vessels within,
especially in children, but in adults it can be laden with fat and obsecures these vessels.

3) The appendicular artery is a branch of the lower division of the ileocolic artery, it pass behind the terminal ileum to enter the mesoappendix at short distance away from the base.

Appendix
#Surgery

Note

The appendix is an intraperitoneal structure, but occasionally the tip of the appendix becomes extraperitoneal lying behind the caecum or ascending colon.

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#Surgery

Note
The appendix in infants has a wider mouth and also shorter when compared to older age groups, this makes it less liable to occlusion and Inflammation.

#Surgery

The vermiform appendix is a muscular tube and has all the layers common to the rest of the intestine namely mucosa, submucosa, muscularis propria and serosa, note the narrow lumen, combined with the blind end, indeed is liable to occlusion and becoming inflamed

#Surgery

What are the other benign tumors of the parotid gland?

•Warthin’s tumors (papillary cyst adenoma, lymphomatosum)
•Oxyphylic adenoma (Oncocytoma).



-What is the origin of Warthin’s tumor?
-The tumor probably arises from parotid tissue included in the lymph nodes which are usually present within the parotid sheath.
-Micro scopically it is lined by columnar epithelial cells supported by lymphoid stroma.

•What are the features of  Warthin’s tumor?
Clinical features of Warthin’s tumor:
•2nd most common benign tumor
•It is soft and sometimes fluctuant(cystic)
•Seen usually in males
•Seen after 40 years •May be bilateral (10%bilateral).
•This tumor has nomalignant potential.

#Salivary
#Surgery

Paraesophageal hernia (Rolling hiatus hernia)

◼️This includes protrusion of the greater curve of the stomach through the esophageal hiatus, sometimes the entire stomach is present in the chest, also small intestine and colon can be occasionally found in the hernial sac.

◼️Pure rolling hernia i.e the cardia of the stomach is located at its normal anatomical position, is very rare, the vast majority cases has a sliding component in which the gastroesophageal junction pass through the esophageal hiatus.

◼️It is potentially dangerous because it can twist (volvulus) and undergo perforation and even gangrene.

◼️Look at the above figure, this is a barium meal showing part of the stomach in the chest cavity with compression of the lower esophagus.

#Surgery

Sliding inguinal hernia

◼️It result from slippage of the posterior parietal peritoneum on the retroperitoneal structures bringing them to lie in the posterior wall of the hernial sac (figure c shows the caecum slipped down to form the posterior wall of the hernial sac).
◼️It is most common on the left side and almost always in those over 40 years.
◼️It is almost exclusive in men.
◼️This sliding may occur on the right side "Caecum" or on the left side "sigmoid colon" or the bladder on either sides (figure a show part of the bladder sliding in a left inguinal hernia).
◼️Occasionally large intestine is strangulated in an inguinal hernia but usually the non strangulated large bowel is present behind the sac containing strangulated small bowel.

#Surgery

What is incarcerated hernia?

Here the contents are fixed in the sac because of their size or adhesions. The hernia is irreducible, but the bowel is not strangulated.

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What is strangulated hernia

-Strangulation is a condition where constriction of the venous return of the bowel occurs initially, which leads to congestion, arterial occlusion and gangrene of the bowel.
-When a loop of gut is strangulated there will also be intestinal obstruction.

#Hernia
#Surgery

•What is the current gold standard surgery for hernia repair [hernioplasty]?

-The gold standard current hernia surgery is the Lichtenstein Tension-free Hernioplasty.
-Here approximately 16 × 8 cm size mesh (polypropylene) is placed anterior to the posterior wall after herniotomy and overlapping it generously in all directions including medially over the pubic tubercle.

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What are the preoperative preparations required in incisional hernia?

•Weight reduction by dieting and exercise.
•Patient is asked to stop smoking
•Treat the respiratory problems or BBH.

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#Surgery

•What is ventral hernia?

-The term ventral hernia should be restricted to incisional hernia arising in abdominal midline operative wounds.

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-What is the most important clinical sign for incisional hernia?

•The swelling will be come more prominent in head raising test. •Reducibility and cough impulse.

#Hernia
#Surgery

•If the lump does not reduce and does not have a cough impulse, what are the differential diagnoses in incisional hernia?

-Then it may not be a hernia.

-The following differential diagnoses are to be considered:
-Differential diagnoses if it is not reducible
•Deposit of tumor—Desmoid tumor •Hematoma
•Foreign-body granuloma
•Old abscess
•Lipoma.

#Hernia
#Surgery

Remember:

-Aspirin need not be stopped before surgery.

-Thyroid medications should be continued.

-Anti-hypertensives should be continued (even losartan).

-OCPs should be continued till day of surgery.

-Anti-depressants, anti-epileptics, anti-psychotics should be continued except TCA, which should be stopped 3 weeks before surgery due to risk of intra operative arrhythmia.

-Ticlopidine: 14 days before surgery.

-Clopidogrel: 7 days before surgery.

-Warfarin: 3 days before surgery.

-LMWH: 12 hours before surgery.

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