Appendicitis

Diagnosis. - The most fixed part of the appendix is its root. This corresponds to a point on the linea semilunaris opposite to the anterior superior spine of the ilium. The painful tip of the appendix may be anywhere in a circle around this point 10 cm. (4 in.) in radius. It may be lying posterior and simulate caiculus or other kidney trouble; it may be up toward the liver or gall-bladder; it may be toward the left, even beyond the midline; it may be in Douglas's cul-de-sac and be confounded with disease of the uterus, tubes, and bladder. It overlies the ureter and may be mistaken for calculus therein. An enlarged gall-bladder can have its painful apex at McBurney's point. Typhoid ulcers occur close to and, as we have observed, may involve the appendix. All these relations must be remembered. McBurney placed the most tender point 4 to 5 cm. (1 1/2 to 2 in.) from the anterior superior spine in a direction toward the umbilicus. Personally we would place it near the root of the appendix at least 2.5 cm. (1 in.) lower down and a little farther in.

Operation

An incision for appendicitis often used is a longitudinal one over the . edge of the rectus muscle, either going directly through it or drawing it to one side (Fig. 425). In McBurney's operation the external oblique is split in the direction of its fibres and the internal oblique and transversalis are parted upward and inward in the direction of their fibres, thus making a square hole through which the appendix is removed. The writer {Annals of Surgery, Jan. 1906, p. 106) uses a transverse incision with its centre over the linea semilunaris opposite to or 2.5 cm. (1 in.) above the anterior superior spine. The sheath of the rectus is divided transversely and the muscle displaced toward the median line. The outer portion of the incision runs slightly oblique to the fibres of the external oblique and almost exactly in the direction of the fibres of the internal oblique and transversalis (Fig. 426).

As soon as the peritoneum is opened the omentum may present itself. This is to be displaced to the left. Some coils of small intestine if present are to be pushed also to the left. The intestine then presenting will be the colon or caecum, because it is fastened to the posterior wall and cannot be moved away. The longitudinal bands will also identify it. Another way is to pass the finger down the inside of the abdominal wall and the floor of the iliac fossa and bring up the caecum. Always work from the outer toward the inner side, because (see Fig. 422) the ascending colon and caecum almost always lie against the abdominal wall on the surface of the iliacus muscle above the outer half of Poupart's ligament.

Fig. 425.   Incisions used for operations on the appendix. The longitudinal operation passes through and separates the fibres of the rectus muscle. The oblique operation (that of McBurney) separates the external oblique, internal oblique, and transversalis muscles in the direction of their fibres.

Fig. 425. - Incisions used for operations on the appendix. The longitudinal operation passes through and separates the fibres of the rectus muscle. The oblique operation (that of McBurney) separates the external oblique, internal oblique, and transversalis muscles in the direction of their fibres.

Fig. 436.   Author's incision for appendicitis. The caecum has been lifted out of the wound, bringing with it the appendix.

Fig. 436. - Author's incision for appendicitis. The caecum has been lifted out of the wound, bringing with it the appendix.

The caecum is to be drawn up and turned toward the head. The longitudinal bands, all of which lead to the appendix, are to be followed down over the caecum until the appendix is reached. If the bands are not visible, identify the ileocaecal junction and about 2 cm. (3/4 in.) or less below and behind it will be the root of the appendix; its tip may be anywhere. It can be enucleated from its root out to its tip. A ligature is to be placed around the meso-appendix because the appendicular artery, especially its recurrent branch, may bleed quite freely. The root of the appendix may sometimes be at, instead of below, the ileocaecal junction. The small intestine and caecum almost always overlie the appendix.