Acute appendicitis is an acute septic inflammatory disease with an incidence of about 1:1000 and can occur in people of any age, so the general public seems to know a lot about this disease and I often hear family members or the patients themselves say easily that it is a minor surgery and since it is a minor surgery, of course, nothing can or should go wrong. In fact, however, the diagnosis and treatment of acute appendicitis is not as simple and easy as one might think.
The claim that appendicitis is a minor surgery may be based on three “theoretical foundations”.
The shape of the appendix is small: The appendix is earthworm-shaped and attached to the wall of the cecum, and in most people it is only a few centimeters long and probably no more than 1 cm in diameter.
The incision for acute appendicitis surgery is small: the length of the incision is only a few centimeters, which is naturally the best example of a small surgery. And at some point, the size of the incision became the patient’s indicator of the quality of the procedure. The young surgeon’s first contact with the surgery must be appendicitis, and the legendary story of “so-and-so Li’s knife” removing the appendix in just a few minutes is often circulated among the public, so that appendectomy becomes a surgery that is not a surgery in the minds of both patients and doctors, and the technical content is ignored and becomes a victim of time.
The incidence of the disease is high and most of the population has heard or experienced it: acute appendicitis can occur at any age, especially more in young people, the stomach pain is also in the lower right abdomen, the rest of the body is fine, and the surgery naturally becomes smaller again after the surgery when friends and relatives visit to exchange their former experiences and comfort the patient by the way.
But in fact, is acute appendicitis really that simple? The answer is no. The author has analyzed it from a professional point of view, hoping to provide the public with an in-depth understanding of what acute appendicitis is really like.
The anatomical complexity of the appendix: the appendix generally opens at the meeting point of the three colonic bands and communicates with the cecum. The relationship between the base of the appendix and the cecum is constant, so the position of the appendix also varies with the position of the cecum. In addition to the common position, it can also be as high as the subhepatic, as low as the pelvis, or even cross the midline to the left. The appendix may be positioned anywhere within a 360 degree range centered on its base.
There are at least six types of appendiceal tip pointing.
(1) anterior ileal position ;
(2) pelvic position;
(3) Posterior cecum;
(4) Inferior cecum;
(5) lateral cecum;
(6) posterior ileum.
The easiest position to be removed is the anterior ileum, which is often referred to by doctors as “the appendix pops out on its own when you cut open the stomach”. The posterior cecum appendix is not so easy to find, especially the intramural appendix, which is more difficult to remove, and the ileocecal part needs to be free and placed on the outside of the incision for careful exploration.
Instability of patient symptoms: The initial stage of the onset of acute appendicitis is mainly characterized by epigastric discomfort, malignancy, vomiting and other symptoms, when it is often diagnosed as a condition such as acute gastritis. In this regard, it is often difficult for the general public to understand why acute gastroenteritis is diagnosed when it is clearly appendicitis. These two organs are too far apart! In fact, there is a specific anatomical basis for this condition. The nerves of the appendix enter the spinal cord at the 10th and 11th thoracic segments, while the 10th spinal nerve is located in the upper abdomen and around the umbilicus, so when a patient develops appendicitis, it often causes discomfort and pain in other areas, which is medically known as referred pain.
The change in symptoms of acute appendicitis is closely related to the stage of disease development and is not invariably manifested as stomach pain. In the early stage of the disease, patients often have only epigastric discomfort, nausea and vomiting, and their pathological type is acute simple appendicitis. After 4-8 hours, the pain is gradually fixed in the right lower abdomen, and if the inflammation is further aggravated or if there are fecal stones causing obstruction of the appendiceal cavity, the disease will gradually progress to acute suppurative appendicitis, with marked swelling of the appendix and accumulation of pus in the cavity and even in all layers of the appendiceal wall. Thin pus appears in the peritoneal cavity around the appendix, forming a limited peritonitis. At this time, the pain is often progressively worse, the bacterial spread leads to inflammatory reaction with fever, and localized muscle tension begins to appear, with more pronounced pressure and rebound pain in the right lower abdomen. In acute appendicitis, the appendix may be perforated, but there is sometimes no necessary connection between perforation and the time of onset. When some patients come to the hospital for emergency treatment, the appendix is often already perforated, and under the action of the body’s own protective mechanism, the surrounding intestinal canal and large omentum and other tissues will try to wrap around the perforated appendix to form a periappendiceal abscess. The abscess can be gradually absorbed. If the abscess wall is not firmly formed, or if a small amount of intestinal contents has flowed into the abdominal cavity before the abscess is formed, the patient may have more severe abdominal pain and may also have symptoms such as intestinal obstruction.
Surgical uncertainty: The notion that surgery for appendicitis is a minor operation can be deeply rooted, so it is often difficult for the public to understand when complications arise. However, the fact is that surgery for acute appendicitis is not just an appendectomy. It is true that appendectomy is not considered a major surgery, but even if it is considered a minor surgery, it should be called a minor open surgery. The possibility of complications in any surgery is directly related to the surgery itself. In other words, the choice of surgery means the choice of possible complications of the surgery.
What exactly are the annoying complications for a minor surgery like appendix?
(1) Intestinal adhesions and intestinal obstruction: appendectomy requires access to the abdominal cavity, on the one hand, inflammatory stimulation of the appendix may cause intestinal adhesions, on the other hand, both surgical instruments and the surgeon’s hands entering the abdominal cavity for surgery may also lead to local exudation, so some patients may develop intestinal adhesions and intestinal obstruction after surgery, although the chance of complications is less than ten percent, but the symptoms of intestinal obstruction will probably Although the complication rate is less than 10%, the symptoms of intestinal obstruction may recur, and although it can be improved by conservative treatment methods, it will affect the quality of life of patients to a certain extent.
(2) Stump fistula: It is the poor healing of the appendix root after appendectomy due to tissue edema, long-term use of hormonal drugs and other reasons. In this case, the colon contents may flow into the peritoneal cavity causing severe peritoneal irritation, which often requires secondary surgery, and even with active surgery, it is difficult to re-suture the appendiceal root and only peritoneal irrigation and drainage can be performed, with the direct consequence that the hospital stay is greatly prolonged and the medical costs may be significantly increased.
(3) Incisional hernia: This condition occurs more frequently in diseases such as periappendiceal abscess, which is caused by contamination of the incision with intestinal contents or abdominal exudate, and the rate of incisional healing is also affected to some extent. As the incision is contaminated with bacteria, the incision is much less firm and the chance of forming an incisional hernia jumps to more than 50%, so the population should have a very deep understanding of the surgical approach and the various complications.
How acute appendicitis should be managed in special persons: Acute appendicitis can occur at any age, and pregnant women can also develop the disease. In the first trimester of pregnancy, the clinical presentation is similar to that of general acute appendicitis. In the middle of pregnancy, the uterus increases faster, the appendix and appendix are pushed by the enlarged uterus to the right upper abdomen, and the location of pressure pain is also shifted upward, and the pressure pain point has shifted upward to two transverse fingers on the iliac crest in the eighth month of pregnancy; because the enlarged uterus elevates the abdominal wall, the inflammatory appendix does not stimulate the wall peritoneum, so the pressure pain, muscle tension and rebound pain are not obvious, and the clinical manifestations are not consistent with the pathological changes; because the large omentum and small intestine are also pushed by the uterus In late pregnancy, when perforation occurs, it is difficult for the greater omentum to wrap the appendix, which may result in diffuse peritonitis.
Surgical treatment is advocated for early gestational appendicitis, when only conservative treatment with penicillin is possible due to the critical time period of embryonic development, and its effect is king wagner, but surgery should be considered as soon as severe mid-gestational appendicitis is diagnosed. Surgery for appendicitis of pregnancy will not interfere with pregnancy more than the inflammatory peritoneal exudate interferes with pregnancy, and the consequences of any appendicitis of pregnancy, once perforated and causing diffuse peritonitis, will only be more severe than those of non-expectant appendicitis.
Therefore, appendicitis should also be beware and should not be taken lightly.