INTRODUCTION

Acute appendicitis a rapidly progressing inflammation of a small part of the large

intestine called the appendix. Acute appendicitis is a medical emergency that generally
requires prompt removal of the appendix to prevent life-threatening complications, such
as ruptured appendix and peritonitis.
Acute appendicitis can occur when a piece of food, stool or object becomes trapped in
the appendix. Acute appendicitis can also happen after a gastrointestinal infection. A
tumor may also cause acute appendicitis in rare cases. Sometimes the cause of acute
appendicitis isn't known.
Acute appendicitis is a very common condition and a frequent cause of emergency
surgery. Acute appendicitis can occur in any age group or population. However, it most
often occurs in teens and young adults. It is rare in children under two years of age.
Acute appendicitis is sudden inflammation of the appendix, usually caused by
obstruction of the lumen resulting in invasion of the appendix wall by the gut flora. If the
appendix ruptures, infected and fecal matter enter the peritoneum, producing lifethreatening peritonitis. Alternatively, particularly where perforation or gangrene occurs
after 24 hours, the peritonitis may be localised, or the inflamed appendix may be
surrounded by omentum to form an appendix mass or appendix abscess.
An acute appendicitis is often the first thought to the layperson when a sharp onset of
pain in the right lower abdominal quadrant occurs.
Acute appendicitis is the most common cause of an acute abdomen in young adults.
About 8% of people in Western countries have appendicitis at some time during their
1

life, with a peak incidence between 10 and 30 years of age. Acute appendicitis is the
most common general surgical emergency, Appendectomy is the most common
urgently performed surgical procedure as early surgical intervention improves
outcomes.

The lifetime rate of appendectomy is 12% for men and 25% for women.
Lifetime risk of undergoing appendectomy is between 7% and 12%.
The maximal incidence occurs in the second and third decades of life.

The vermiform appendix is a part of Gut or intestine which is considered by most to be a

vestigial organ(an organ of no use now), its importance in surgery is only to its
propensity for inflammation (that causes pain, swelling and other complication of the
organ) which results in the clinical syndrome or group of problems known as acute
appendicitis.
The diagnosis of acute appendicitis is predominantly a clinical one; many patients
present with a typical history and examination findings. The cause of acute appendicitis
is unknown but is probably multifactorial; luminal obstruction and dietary and familial
factors have all been suggested.1 Appendectomy is the treatment of choice and is
increasingly done as a laparoscopic procedure. This article reviews the presentation,
investigation, treatment, and complications of acute appendicitis and appendectomy.
Acute appendicitis could be the most typical cause of abdominal pain among children
and teenagers worldwide. They is usually either acute or chronic. Acute appendicitis
develops fast and might be removed using surgery. It can turn out to be severe, on the
other hand, if not discovered and treated in time.
Acute appendicitis is caused by bacterial infections inside vermiform appendix, a tubular
extension from the big intestine which functions as part from the digestive process.
When the appendix is blocked by feces or it really is squeezed by lymph nodes, it swells
and usually doesnt receive sufficient blood.
When this occurs, bacteria invade and grow inside the appendix, eventually causing its
death. Acute appendicitis is serious and can lead to complications like perforation,
gangrene and sepsis. A surgical emergency would be the only approach to remove it
but what normally occurs is that most patients already have complications prior to they
enter the operating room.
Acute appendicitis is an inflammation of the appendix. The appendix is a vermiform
structure that derives from the first portion of the large intestine. Its lengthy ranges by
around 10 cm and it is located in the lower part of the abdomen. The appendix has a
canal in its interior that communicates with the large intestine in which there are
semifluid feces. Appendicitis is caused usually by a small block of hardened feces that
obstructs the appendix.

Acute appendicitis, in its typical presentation, begins with pain around the navel,
accompanied by nausea and occasionally vomiting. Some hours later, the pain occurs
in the lower part of the abdomen, accompanied by moderate fever and appetite loss.
Appendicitis may be restricted to the inflamed organ or cause its rupture. When this
happens, the body defenses usually block the infection around the appendix, originating
an abscess. When the body defenses fail to block the infection, the content of the same
spreads across the abdomen, leading to a severe state of acute peritonitis. In this
circumstance, therell be intense diffuse pain, high fever and a severe toxic state,
requiring immediate surgical intervention.
Acute appendicitis is a disease that prevails in the age group between 15 and 50 years,
but it may occur in children and the elderly, too.
The described symptoms occur in a typical situation, the most habitual one, but
frequently the disease manifestations are quite diverse, and the diagnosis may become
hard to make. Its always necessary to make a differential diagnosis for urinary calculus,
other bowel disorders, cysts and pelvic infection in women, amongst other problems.
Acute appendicitis is the second most common cause of surgical abdominal disease in
late adulthood. It is a serious condition: major errors in management are made
frequently and the condition is associated with significant morbidity and mortality

In some cases the inflammation can be sourced locally or often unknown, although in
some cases was found obstructed by a foreign body, among them are: fruit seeds,
parasites.
SEX: Males are more common than female.
SOCIAL STATUS: Upper and middle class
DIET: One relatively rich in meat,& devoid of simple diet rich in cellulose Familial
susceptibility. OBSTRUCTION OF LUMEN OF APPENDIX: Fecalith ,a stricture,a
foreign body, a round worm or thread worms.
DISTAL OBSTRUCTION OF COLON: Carcinoma of right colon. Abuse of purgatives.
BACTERIA: a mixture of E. coli, Enterococci, non -hemolytic streptococci, anaerobic
streptococci, Cl welchi,& bacteroids.
Incidence: 60-80/100,000
Peak : @ 10-30yrs
The incidence is highest among males aged 10 to 14. And among females aged 15 to
19. More males than females develop appendicitis between puberty and aged 25.

It is very common, with a lifetime risk of 78% that favors males slightly.
Appendectomy is the most commonly performed emergency operation in the world.
The reported incidence has dropped by more than 50% in the past three decades for
unknown reasons. Over 250,000 patients per year are admitted for the management of
appendicitis, with the highest incidence in the second and third decades of life. The rate
of appendiceal perforation may be up to 80%. Mortality has dropped to less than 1%
with more timely and accurate diagnosis in high risk groups and advancements in
imaging techniques.
Extrapolation of Incidence Rate for Acute Appendicitis to Countries and Regions:
The following table attempts to extrapolate the above incidence rate for Acute
Appendicitis to the populations of various countries and regions. As discussed above,
these incidence extrapolations for Acute Appendicitis are only estimates and may have
limited relevance to the actual incidence of Acute Appendicitis in any region:
Country/Region

Extrapolated Incidence

Population Estimated Used

Acute Appendicitis in North America (Extrapolated Statistics)

USA

734,138

293,655,4051

Canada

81,269

32,507,8742

Acute Appendicitis in Europe (Extrapolated Statistics)

Austria

20,436

8,174,7622

Belgium

25,870

10,348,2762

Britain (United Kingdom)

150,676

60,270,708 for UK2

Czech Republic

3,115

1,0246,1782

Denmark

13,533

5,413,3922

Finland

13,036

5,214,5122

France

151,060

60,424,2132

Greece

26,618

10,647,5292

Germany

206,061

82,424,6092

Iceland

734

293,9662

Hungary

25,080

10,032,3752

Liechtenstein

83

33,4362

Ireland

9,923

3,969,5582

Italy

145,143

58,057,4772

Luxembourg

1,156

462,6902
4

Monaco

80

32,2702

Netherlands (Holland)

40,795

16,318,1992

Poland

96,565

38,626,3492

Portugal

26,310

10,524,1452

Spain

100,701

40,280,7802

Sweden

22,466

8,986,4002

Switzerland

18,627

7,450,8672

United Kingdom

150,676

60,270,7082

Wales

7,295

2,918,0002

Acute Appendicitis in the Balkans (Extrapolated Statistics)

Albania

8,862

3,544,8082

Bosnia and Herzegovina

1,019

407,6082

Croatia

11,242

4,496,8692

Macedonia

5,100

2,040,0852

Serbia and Montenegro

27,064

10,825,9002

Acute Appendicitis in Asia (Extrapolated Statistics)

Bangladesh

353,351

141,340,4762

Bhutan

5,463

2,185,5692

China

3,247,119

1,298,847,6242

East Timor

2,548

1,019,2522

Hong Kong s.a.r.

17,137

6,855,1252

India

2,662,676

1,065,070,6072

Indonesia

596,132

238,452,9522

Japan

318,332

127,333,0022

Laos

15,170

6,068,1172

Macau s.a.r.

1,113

445,2862

Malaysia

58,806

23,522,4822

Mongolia

6,878

2,751,3142

Philippines

215,604

86,241,6972

Papua New Guinea

13,550

5,420,2802

Vietnam

206,657

82,662,8002

Singapore

10,884

4,353,8932

Pakistan

397,990

159,196,3362

North Korea

56,743

22,697,5532

South Korea

120,584

48,233,7602
5

Sri Lanka

49,762

19,905,1652

Taiwan

56,874

22,749,8382

Thailand

162,163

64,865,5232

Acute Appendicitis in Eastern Europe (Extrapolated Statistics)

Azerbaijan

19,670

7,868,3852

Belarus

25,776

10,310,5202

Bulgaria

18,794

7,517,9732

Estonia

3,354

1,341,6642

Georgia

11,734

4,693,8922

Kazakhstan

37,859

15,143,7042

Latvia

5,765

2,306,3062

Lithuania

9,019

3,607,8992

Romania

55,888

22,355,5512

Russia

359,935

143,974,0592

Slovakia

13,558

5,423,5672

Slovenia

5,028

2,011,473 2

Tajikistan

17,528

7,011,556 2

Ukraine

119,330

47,732,0792

Uzbekistan

66,026

26,410,4162

Acute Appendicitis in Australasia and Southern Pacific (Extrapolated Statistics)

Australia

49,782

19,913,1442

New Zealand

9,984

3,993,8172

Acute Appendicitis in the Middle East (Extrapolated Statistics)

Afghanistan

71,284

28,513,6772

Egypt

190,293

76,117,4212

Gaza strip

3,312

1,324,9912

Iran

168,758

67,503,2052

Iraq

63,436

25,374,6912

Israel

15,497

6,199,0082

Jordan

14,028

5,611,2022

Kuwait

5,643

2,257,5492

Lebanon

9,443

3,777,2182

Libya

14,078

5,631,5852

Saudi Arabia

64,489

25,795,9382

Syria

45,042

18,016,8742
6

Turkey

172,234

68,893,9182

United Arab Emirates

6,309

2,523,9152

West Bank

5,778

2,311,2042

Yemen

50,062

20,024,8672

Acute Appendicitis in South America (Extrapolated Statistics)

Belize

682

272,9452

Brazil

460,252

184,101,1092

Chile

39,559

15,823,9572

Colombia

105,776

42,310,7752

Guatemala

35,701

14,280,5962

Mexico

262,398

104,959,5942

Nicaragua

13,399

5,359,7592

Paraguay

15,478

6,191,3682

Peru

68,860

27,544,3052

Puerto Rico

9,744

3,897,9602

Venezuela

62,543

25,017,3872

Acute Appendicitis in Africa (Extrapolated Statistics)

Angola

27,446

10,978,5522

Botswana

4,098

1,639,2312

Central African Republic

9,356

3,742,4822

Chad

23,846

9,538,5442

Congo Brazzaville

7,495

2,998,0402

Congo kinshasa

145,792

58,317,0302

Ethiopia

178,341

71,336,5712

Ghana

51,892

20,757,0322

Kenya

82,455

32,982,1092

Liberia

8,476

3,390,6352

Niger

28,401

11,360,5382

Nigeria

44,375

12,5750,3562

Rwanda

20,596

8,238,6732

Senegal

27,130

10,852,1472

Sierra leone

14,709

5,883,8892

Somalia

20,761

8,304,6012

Sudan

97,870

39,148,1622

South Africa

111,121

44,448,4702
7

Swaziland

2,923

1,169,2412

Tanzania

90,176

36,070,7992

Uganda

65,975

26,390,2582

Zambia

27,564

11,025,6902

Zimbabwe

9,179

1,2671,8602

Lifetime risk for Acute Appendicitis: 8.6% risk for males, 6.7% for females (Rothrock
et al, 2000). About 1 in 500 people has appendicitis each year.
The main symptom of acute appendicitis is abdominal pain or abdominal sensitivity.
However, abdominal pain occurs with many conditions and only an estimated 5% of
cases of abdominal pain are actually appendicitis. Although uncommon, appendicitis is
very serious, and difficulty in diagnosing appendicitis in the emergency department
makes appendicitis the 3rd leading cause of malpractice lawsuits. Misdiagnosis of
appendicitis is particularly common in children and infants with abdominal pain with
estimates of initial misdiagnosis rates from 28% to 57% for under age 2-12 and almost
100% misdiagnosis for appendicitis in infants.

Types of acute appendicitis :

Rare types of appendicitis include the following:

Spontaneously resolving appendicitis: If the obstruction of the appendiceal lumen

is relieved, acute appendicitis may resolve spontaneously.4,5 This occurs if the
cause of the symptoms is lymphoid hyperplasia or when a fecalith is expelled
from the lumen.
Recurrent appendicitis: The incidence of recurrent appendicitis is 10%. The
diagnosis is accepted as such if the patient underwent similar occurrences of
RLQ pain at different times that, after appendectomy, were histopathologically
proven to be the result of an inflamed appendix.
Chronic appendicitis: Chronic appendicitis occurs with an incidence of 1% and is
defined by the following: (1) the patient has a history of RLQ pain of at least 3
weeks duration without an alternative diagnosis; (2) after appendectomy, the
patient experiences complete relief of symptoms; (3) histopathologically, the
symptoms were proven to be the result of chronic active inflammation of the
appendiceal wall or fibrosis of the appendix.

The stages of appendicitis

Early stage of appendicitis: Obstruction of the appendiceal lumen leads to

mucosal edema, mucosal ulceration, bacterial diapedesis, appendiceal distention
due to accumulated fluid, and increasing intraluminal pressure. The visceral
afferent nerve fibers are stimulated, and the patient perceives mild visceral
periumbilical or epigastric pain, which usually lasts 4-6 hours.
Suppurative appendicitis: Increasing intraluminal pressures eventually exceed
capillary perfusion pressure, which is associated with obstructed lymphatic and
venous drainage and allows bacterial and inflammatory fluid invasion of the tense
appendiceal wall. Transmural spread of bacteria causes acute suppurative
appendicitis. When the inflamed serosa of the appendix comes in contact with
the parietal peritoneum, patients typically experience the classic shift of pain from
the periumbilicus to the right lower abdominal quadrant (RLQ), which is
continuous and more severe than the early visceral pain.
Gangrenous appendicitis: Intramural venous and arterial thromboses ensue,
resulting in gangrenous appendicitis.
Perforated appendicitis: Persisting tissue ischemia results in appendiceal
infarction and perforation. Perforation can cause localized or generalized
peritonitis.
Phlegmonous appendicitis or abscess: An inflamed or perforated appendix can
be walled off by the adjacent greater omentum or small-bowel loops, resulting in
phlegmonous appendicitis or focal abscess.

ANATOMY AND PHYSIOLOGY OF APPENDIX

The appendix (or vermiform appendix; also cecal (or caecal) appendix; also vermix) is a
blind ended tube connected to the cecum (or caecum), from which it develops
embryologicallly. The cecum is a pouch-like structure of the colon. The appendix is near
the junction of the small intestine and the large intestine.The term "vermiform" comes
from Latin and means "worm-like in appearance".
The appendix averages 10 cm in length, but can range from 2 to 20 cm. The diameter of
the appendix is usually between 7 and 8 mm. The longest appendix ever removed
measured 26 cm in Zagreb, Croatia. The appendix is located in the lower right quadrant
of the abdomen, or more specifically, the right iliac fossa. Its position within the
abdomen corresponds to a point on the surface known as McBurney's point. While the
base of the appendix is at a fairly constant location, 2 cm below the ileocaecal valve,
the location of the tip of the appendix can vary from being retrocaecal (74%) to being in
the pelvis to being extra peritoneal. In rare individuals with situs inversus, the appendix
may be located in the lower left side.
The appendix is a narrow, muscular tube. One end is attached to the first part of the
large intestine, while the other end is closed. The position of the appendix in the body
can vary from person to person.

An average adult appendix is about 4 inches (10cm) long. However, it can vary in length

10

from as less as an inch to 8 inches. Its diameter is usually about about 6 to 7 mm.
The function of the appendix is unknown.
Foods that have not been digested tends to move into the appendix and are forced out
again by the contractions of appendix. In herbivorous animals like cow and goat, the
appendix can function. In man, this has become what is called as a vestigial organ (an
organ that is no more required)..
The appendix is a blind-ending tube that comes off of the first part of the colon, the
cecum. In fact, the appendix resembles a worm arising from the colon, hence its full
name vermiform appendix which in Latin means worm.
The appendix has no known function. It is believed that it may have a role in the
immune system.
Since the appendix is a dead-end tube, stool can get trapped in it.Trapped stool is
called a fecalith. As a result of the fecalith, the appendix can become inflamed and
appendicitis develops. If the inflammation persists, the appendix is at risk for rupture.

11

PATHOPHYSIOLOGY OF ACUTE APPENDICITIS

NON- MODIFIABLE FACTOR

ACUTE APPENDICITIS

MODIFIABLE FACTOR

DIET
AGE

GENDER

OBSTRUCTION OF LUMEN

OBSTRUCTION OF THE OUTFLOW OF THE SECRETION

INCREASE MUCOSAL SECRETIONS

INCREASE INTRALUMINAL PRESSURE

DISTENTION OF THE APPENDIX

INFLAMMATION OF THE APPENDIX

LOCALIZED PERITONITIS

PERIAPPENDICEAL ABSCESS

12

Abdominal
pain
Tenderness in
RLQ
Fever,
vomiting
Loss of
appetite

Summary of Pathophysiology
Appendicitis is the most common cause emergency, abdominal surgery. It develops
when the lumen of the appendix becomes obstructed, usually by fecalith, foreign body
or tumors. The obstructed lumen does not allow drainage of the appendix and the
mucosal secretions
continues, intraluminal pressure increases. The resultant increase pressure decreases
mucosal blood flow and the appendix becomes hypoxic. The obstructed appendix
become distended because of continued secretion of mucus by the lining cell.

Typically, acute appendicitis progresses from obstruction of the lumen and distention of
the appendix from obstruction of the lumen and distention of the appendix to spread of
the inflammation beyond the appendix. The inflammatory process increases intraluminal
pressure, initiating a progressively severe generalized or upper abdominal pain which
within a few hours becomes localized in the RLQ of the abdomen. The pain is usually
accompanied by a low grade fever, nausea and often vomiting. Local tenderness is
noted when pressure is applied and loss of appetite is common. Initially there is a
localized peritonitis confined to the area of the appendix. If unrecognized and untreated,
this may lead to rupture and abscess.

13

DEFINITION OF TERMS:
Appendix- a narrow, blind tube protruding from the cecum, having no known useful
function, in humans being 3 to 4 in. (8 to 10 cm) long and situated in the lower righthand part of the abdomen.
Appendicitis- inflammation of the vermiform appendix called also epityphlitis
Peritonitis- Infection or inflammation of the peritoneal cavity, usually caused by a
ruptured organ, such as the appendix, in the gastrointestinal tract.
Tumor- a mass of tissue formed by a new growth of cells, normally independent of the
surrounding structures
Lumen- The inner open space or cavity of a tubular organ, as of a blood vessel.
Gut flora- consists of microorganisms that live in the digestive tracts of animals, and is
the largest reservoir of human flora. "Gut" (the adjective) is synonymous with intestinal
and "flora" with microbiota and microflora.
Peritoneum- large membrane in the abdominal cavity that connects and supports
internal organs. It is composed of many folds that pass between or around the various
organs. Two folds are of primary importance: the omentum, which hangs in front of the
stomach and intestine; and the mesentery, which attaches the small intestine and much
of the large intestine to the posterior abdominal cavity.
Perforation- a rupture in a body part caused especially by accident or disease
Gangrene- local death of soft tissues due to loss of blood supply.
Omentum- a fold of the peritoneum connecting the stomach and the abdominal viscera
forming a protective and supportive covering.
Appendectomy- surgical removal of the vermiform appendix.
Vermiform appendix- Also called appendix.
Gut- the belly; stomach; abdomen.
Vestigial- Occurring or persisting as a rudimentary or degenerate structure.
Laparoscopy- : visual examination of the inside of the abdomen by means of a
laparoscope called also peritoneoscopy
Sepsis- local or generalized invasion of the body by pathogenic microorganisms or their
toxins
14

Semifluid- having the qualities of both a fluid and a solid : VISCOUS

Feces- bodily waste discharged through the anus : EXCREMENT
Navel- a depression in the middle of the abdomen that marks the point of former
attachment of the umbilical cord to the embryo called also umbilicus
Cyst- a closed sac having a distinct membrane and developing abnormally in a body
cavity or structure
Calculus- a stone, or concretion, formed in the gallbladder, kidneys, or other parts of the
body.
Parasites- an organism that lives on or in an organism of another species, known as the
host, from the body of which it obtains nutriment.
Cellulose- A complex carbohydrate that is composed of glucose units, forms the main
constituent of the cell wall in most plants, and is important in the manufacture of
numerous products, such as pharmaceuticals.
Fecalith- a concretion of dry compact feces formed in the intestine or vermiform
appendix
Carcinoma- a malignant and invasive epithelial tumor that spreads by metastasis and
often recurs after excision; cancer.
Purgatives- a purgative medicine or agent; cathartic.
Cecum- The large blind pouch forming the beginning of the large intestine. Also called
blind gut .
Iliac- of or relating to either of the lowest lateral abdominal regions
McBurneys point- a point on the abdominal wall that lies between the navel and the
right anterior superior iliac spine and that is the point where most pain is elicited by
pressure in acute appendicitis
ileocaecal valve- the valve formed by two folds of mucous membrane at the opening of
the ileum into the large intestine called also Bauhin's valve ileocolic valve valvula coli
Fossa- a pit, cavity, or depression
situs inversus- a congenital defect in which an organ is on the side opposite from its
normal position.
Hyperplasia- enlargement of a part due to an abnormal numerical increase of its cells.
15

Lymphoid- of, relating to, or being tissue (as the lymph nodes or thymus) containing
lymphocytes
Fibrosis- the development in an organ of excess fibrous connective tissue.
Epigastric- lying upon or over the stomach
Diapedesis- the passage of blood cells, esp. leukocytes, through the unruptured walls of
the capillaries into the tissues.
Periumbilical- situated or occurring adjacent to the navel was initially localized to the
periumbilical region
pneumoperitoneum- an abnormal state characterized by the presence of gas (as air) in
the peritoneal cavity
laparotomy- surgical incision through the abdominal wall, esp to investigate the cause of
an abdominal disorder
General anesthesia- anesthesia affecting the entire body and accompanied by loss of
consciousness
Endotracheal intubation- The passage of a tube through the nose or mouth into the
trachea for maintenance of the airway, as during the administration of anesthesia.
anterior superior iliac spine- a projection at the anterior end of the iliac crest called also
anterior superior spine

16

SURGICAL PROCEDURE
APPENDECTOMY
An appendectomy (sometimes called appendisectomy or appendicectomy) is the
surgical removal of the vermiform appendix. This procedure is normally performed as an
emergency procedure, when the patient is suffering from acute appendicitis. In the
absence of surgical facilities, intravenous antibiotics are used to delay or avoid the
onset of sepsis; it is now recognized that many cases will resolve when treated nonoperatively. In some cases the appendicitis resolves completely; more often, an
inflammatory mass forms around the appendix. This is a relative contraindication to
surgery.
Appendectomy may be performed laparoscopically (this is called minimally invasive
surgery) or as an open operation. Laparoscopy is often used if the diagnosis is in doubt,
or if it is desirable to hide the scars in the umbilicus or in the pubic hair line. Recovery
may be a little quicker with laparoscopic surgery; the procedure is more expensive and
resource-intensive than open surgery and generally takes a little longer, with the (low in
most patients) additional risks associated with pneumoperitoneum (inflating the
abdomen with gas). Advanced pelvic sepsis occasionally requires a lower midline
laparotomy.
There have been some cases of auto-appendectomies, i.e. operating on yourself. One
was performed by Dr. Kane in 1921, but the operation was completed by his assistants.
Another case is Leonid Rogozov who had to perform the operation on himself as he
was the only surgeon on a remote Arctic base.[1]
In general terms, the procedure for an open appendectomy is as follows.
1. Antibiotics are given immediately if there are signs of sepsis, otherwise a single
dose of prophylactic intravenous antibiotics is given immediately prior to surgery.
2. General anaesthesia is induced, with endotracheal intubation and full muscle
relaxation, and the patient is positioned supine.
3. The abdomen is prepared and draped and is examined under anesthesia.
4. If a mass is present, the incision is made over the mass; otherwise, the incision is
made over McBurney's point, one third of the way from the anterior superior iliac
spine (ASIS) and the umbilicus; this represents the position of the base of the
appendix (the position of the tip is variable).
5. The various layers of the abdominal wall are then opened.
6. The effort is always to preserve the integrity of abdominal wall. Therefore, the
External Oblique Aponeurosis is slitted along its fiber, and the internal oblique
muscle is split along its length, not cut. As the two run at right angles to each
other, this prevents later Incisional hernia.
7. On entering the peritoneum, the appendix is identified, mobilized and then ligated
and divided at its base.

17

8. Some surgeons choose to bury the stump of the appendix by inverting it so it

points into the caecum.
9. Each layer of the abdominal wall is then closed in turn.
10. The skin may be closed with staples or stitches.
11. The wound is dressed.
12. The patient will be brought to the recovery room.
Recovery time from the operation varies from person to person. Some will take up to
three weeks before being completely active; for others it can be a matter of days. In
the case of a laparoscopic operation, the patient will have three stapled scars of
about an inch in length, between the navel and pubic hair line. When a laparotomy
has been performed the patient will have a 2-3 inch scar, which will initially be
heavily bruised.[

18

ROLE OF THE SCRUB NURSE

1. Works directly with surgeon within the sterile field, passing instruments, sponges
and other items needed during the procedure
2. Members of the surgical team who prepares and preserves a sterile field in which
the operation can take place
3. Responsible for the sponge counts, the blades and needles and instruments
check throughout the operation
4. Has a job requiring anticipation, quick reaction and conscientious observation as
well as knowledge of anatomy and of operative procedures
Before an operation

Ensures that the circulating nurse has checked the equipment

Ensures that the theater has been cleaned before the trolley is set
Prepares the instruments and equipment needed in the operation
Uses sterile technique for scrubbing, gowning and gloving
Receives sterile equipment via circulating nurse using sterile technique
Performs initial sponges, instruments and needle count, checks with circulating
nurse

When surgeon arrives after scrubbing

Perform assisted gowning and gloving to the surgeon and assistant surgeon as
soon as they enter the operation suite
Assemble the drapes according to use. Start with towel, towel clips, draw sheet
and then lap sheet. Then, assist in draping the patient aseptically according to
routine procedure
Place blade on the knife handle using needle holder, assemble suction tip and
suction tube
Bring mayo stand and back table near the draped patient after draping is
completed
Secure suction tube and cautery cord with towel clips or allis
Prepares sutures and needles according to use

During an operation

Maintain sterility throughout the procedure

Awareness of the patients safety
Adhere to the policy regarding sponge/ instruments count/ surgical needles
Arrange the instrument on the mayo table and on the back table

Before the Incision Begins

Provide 2 sponges on the operative site prior to incision

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Passes the 1st knife for the skin to the surgeon with blade facing downward and
a hemostat to the assistant surgeon
Hand the retractor to the assistant surgeon
Watch the field/ procedure and anticipate the surgeons needs
Pass the instrument in a decisive and positive manner
Watch out for hand signals to ask for instruments and keep instrument as clean
as possible by wiping instrument with moist sponge
Always remove charred tissue from the cautery tip
Notify circulating nurse if you need additional instruments as clear as possible
Keep 2 sponges on the field
Save and care for tissue specimen according to the hospital policy
Remove excess instrument from the sterile field
Adhere and maintain sterile technique and watch for any breaks

End of Operation

Undertake count of sponges and instruments with circulating nurse

Informs the surgeon of count result
Clears away instrument and equipment
After operation: helps to apply dressing
Removes and siposes of drapes
De-gown
Prepares the patient for recovery room
Completes documentation
Hand patient over to recover room

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ROLE OF THE CIRCULATING NURSE

1. Responsible for managing the nursing care of the patient within the OR and
coordinating the needs of the surgical team with other care provider necessary
for completion of surgery
2. Observes the surgery and surgical team from broad perspective and assists the
team to create and maintain a safe and comfortable environment for the patient
3. Asses the patients condition before, during and after the operation to ensure an
optimal outcome for the patient
4. Must be able to anticipate the scrub nurses needs and be able to open sterile
packs, operate machinery and keep accurate records
Before an operation

Checks all equipment for proper functioning such as cautery machine, suction
machine, OR light and OR table
Make sure theater is clean
Arrange furniture according to use
Place a clean sheet, arm board (arm strap) and a pillow on the OR table
Provide a clean kick bucket and pail
Collect necessary stock and equipment
Turn on aircon unit
Help scrub nurse with setting up the theater
Assist with counts and records

During the Induction of Anesthesia

Turn on OR light
Assist the anesthesiologist in positioning the patient
Assist the patient in assuming the position for anesthesia
Anticipate the anesthesiologists needs
If spinal anesthesia is contemplated:

Place the patient in quasi fetal position and provide pillow

Perform lumbar preparation aseptically
Anticipate anesthesiologists needs
After the patient is anesthetized

Reposition the patient per anesthesiologists instruction

Attached anesthesia screen and place the patients arm on the arm boards
Apply restraints on the patient
Expose the area for skin preparation
Catheterize the patient as indicated by the anesthesiologist
Perform skin preparation

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During Operation

Remain in theater throughout operation

Focus the OR light every now and then
Connect diatherapy, suction, etc.
Position kick buckets on the operating side
Replenishes and records sponge/ sutures
Ensure the theater door remain closed and patient s dignity is upheld
Watch out for any break in aseptic technique

End of Operation

Assist with final sponge and instruments count

Signs the theater register
Ensures specimen are properly labeled and signed

After an Operation

Hands dressing to the scrub nurse

Helps remove and dispose of drapes
Helps to prepare the patient for the recovery room
Assist the scrub nurse, taking the instrumentations to the service (washroom)
Ensures that the theater is ready for the next case

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BIBLIOGRAPHY

http://www.patient.co.uk/doctor/Acute-Appendicitis.htm
http://www.wrongdiagnosis.com/a/acute_appendicitis/intro.htm
http://appendicitisreview.com/how-to-detect-acute-appendicitis/
http://www.bmj.com/cgi/content/extract/333/7567/530
http://www.abcsalutaris.com/english/content/view/3
http://www.thedoctorsdoctor.com/diseases/appendix_appendicitis.htm
http://knol.google.com/k/acute-appendicitis#
http://www.cureresearch.com/a/acute_appendicitis/stats-country.htm
http://www.slideshare.net/crisbertc/acute-appendicitis-presentation
http://www.articlesbase.com/medicine-articles/acute-appendicitis-1044300.html
http://hubpages.com/hub/HERES-ANOTHER-HEAD-SCRATCHERAPPENDIX-DOESNOT-HAVE-ANY-FUNCTION-IN-THE-HUMAN-BODYACUTE-APPENDICITIS
http://nursingcrib.com/case-study/appendicitis-case-study/

http://www.medindia.net/surgicalprocedures/Appendectomy-anatomy.htm
http://www.surgeryinfo.org/appendectomy.html
http://en.wikipedia.org/wiki/Appendectomy
http://nursingcrib.com/nursing-notes-reviewer/role-of-scrub-nurse/
http://nursingcrib.com/nursing-notes-reviewer/duties-of-scrub-nurse-2/
http://nursingcrib.com/nursing-notes-reviewer/role-of-circulating-nurse/
http://nursingcrib.com/nursing-notes-reviewer/duties-of-scrub-nurse/
http://emedicine.medscape.com/article/363818-overview
www.dictionary.com
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INSTRUMENTATION

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