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The first 25 slides, exactly as they appear. The full deck has 180 content slides.
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