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Speak. Everyone will be able to hear. That's fine. Thank you. Ok. One there to anyone there. Yeah, 22 people have joined. You can start at seven. Right? Mm Yes. Should I start? Mhm Yeah. So hi everyone. I hope all are good. I'm a, I'm a surgical working in Queen's Hospital. We are starting a new series surgical emergencies, common bleeds and scenarios and welcome to our first session, acute appendicitis, which is one of the most common surgical emergencies that you would face when you are in your hospital orations. It will taught by my colleague, Mister Punch. He's a senior clinical fellow working in surgery in Queens Hospital and and if you guys have any doubts in between, just feel free to pop them in the chat box and we'll try our best to answer in between the sessions over to you, Mister B. Thank you made. Uh Hello everyone. I'm Mister B. One of this is a clinical fellow has she said and we'll talk about appendicitis, but appendicitis is very common as you all probably know already, but it has got few facets in the sense, different presentations and different pathologies as well. So I will try and touch each aspect but with the time limit, of course. So I'm going to start. OK. So let's start with the embryology itself first. OK. And why is it important? Because when we say embryology, we need to know what exactly the appendix is and what exactly it matters in the body. So I'm sure uh you all are uh familiar to vi duct, vitellin or vitellointestinal duct. OK. Uh We'll talk about it, but this is just a quick uh summary of embryo that it basically like uh develops in one line and then it rotates further, but we'll talk about it as we go along. OK. So just as a quick summary, it's the rotation of the mid gut mainly, first of all, out of the tummy 90 degree and inside the tummy 180 degrees. So that everything falls in a place where CEC lies in the right side. Of course, appendix ends up in the right side and other like descending and everything falls in the left side. Why it is important because that is the location of the appendix where it matters. So for the appendix itself, it is called cecal diverticulum, which is basically it is also called as vermiform appendix. And as you can see on the slide, six weeks, anti meric water, which also relates to something called medicum anti meric border. So these appendix and diverticulum, similar similarity is they have their own blood supply and Michael's diverticulum relates to we I duct which we saw in the last slide. And the si uh appendix does not relate to vi duct. Yeah, it is a small diuretic lump with its own blood supply arising from the cecum and it decides the positions as well if we go here. So most common is retrocecal 64% pelvic, 32% and then it can be pre posterial and subsequent as well. So just to touch base on letting worm a little word for one. And hence it is like worm like wor and appendix means hanging or extra part of cecal diverticulum. So of course, you all know appendicitis, inflammation of the appendix can be of many reasons can be just inflammation due to infection. Sometimes we call it pardon me for that spelling mistake or even foreign body or tumor. So, pathophysiology, appendix. When does it get inflamed or edim? I would love if uh you guys uh I if I could ask you questions. But anyway, appendix gets inflamed and as a result of as I just mentioned, but inflammatory process is what basically it's like inflammation of the mucosa starts with due to intraluminal pressure. And if it goes on, it ends up with different including like involvement of cirrhosa and getting into perforation or gangrene. However, when we say it initiates periumbilical pain, which is basically a visceral peritoneum. Inflammation means inflammation of its own cirrhosa of the appendix. And when it gets inflamed and if it reaches to parietal peritoneum, then it ends up having right elect fossa pain, which is usually a clinical clear history of appendicitis. Ok. According to the inflammation, sometimes you can see filled with mucus basically for the obstruction, ok, or pulse and can get necrosis and flag bone according to the inflammation of the appendix itself. So depending on history, for example, if someone is having one day history, it is unlikely to have perforation or even flag m. However, if there is a history on and off or continuous from few days, then it might end up having necrosis of leg month. Yeah. So inflammation great, of course. And if obstruction present, for example, if a fecolith is not going to go away and it progresses very quickly. So in the history or historical inflammation thing, there are two types. Mainly, one is called cat. Cat means just inflamed without obstruction, means without fecal or without foreign body or without tumor where it just gets inflamed and unlikely to end up having uh perforation. It can but unlikely and obstructed. Yes. More of the complications of appendix. For example, gangrene necrosis and perforation. They are usually obstructed, obstructed due to tumor we call it or for embo. Ok. So as we go along, we'll talk about it. But let's see, epidemiology. Ok. Incidence 7% more in um age, I mean 10 to 30 or after 14 males affected more than females and teenage more than adults. The reason behind that is as we grow older, there are papers to say that appendix also gets older means it cannot get inflamed. More prevalent in countries where they consume diet low in fiber and a refined carbohydrate, which is just two people overall. And it is not proven, but I would say more constipated or congenital abnormalities or uh incidental. Those are the three things. Now now talking about muscles and why I'm talking about this. Uh let's see. So this is a small bowel. OK. And of course, XSA and longitudinal muscle which covers all around and circular muscle on the side, submucosa and mucosa. And there are two plexuses, something is called Orex and something is called business. Business is I could ask a question. But anyway, uh ORBC is venal and submucosal is business and the importance is peristalsis. They help to peristalsis to work. OK. So what happens to colon? Now this is colon? OK. And of course, again, mucosa submucosa internal circular all around, but longitudinal is what it is called tinea coli. Yeah, we all know that the tinea coli also is in with the breaks, breaks in the sands. It has got attachment and uh there are only three longitudinal muscle muscles as in sense of bunch of muscles in colon. OK. And what is appendix? Then appendix is what this is appendix. OK. So, c glands mucosa submucosa, some lymphoid tissues which is more common in small bowel and literally uncommon or very less in la with fully or completely two layers of muscles around it, inner circular, outer, longitudinal, but fully circular, not like colon. So what does that mean? Is it a part of small valve or is it part of large valve? So to say this tsum itself, yeah, is intraperitoneal and the rest of the glass is extraperitoneal uh sorry retroperitoneal. So in the sense of this, it is basically adjunction of small bowel and large bowel from where large bowel itself starts because appendix does not have tinea. So if and why does it matter that for a surgeon if they can't find appendix, we follow Tinea Coli. So as simple as that appendix does not have tinea apple whereas lb has right. So whenever you struggle as a surgeon or if you're asked, please follow Tinea Clay to find the appendix. OK. I'm sorry, I'm using my notes as well so that I cannot miss what I need to talk if that is OK for you guys. Ok. Right now there is Ileos valve. Anyone knows what is it called, as I would say, uh because I can't ask you questions now, that is the limitation for me. But uh it is also called Bohs B AU H I Ns Hans. Well, OK. So why I'm asking? Because small bowel, large bowel appendix, that's what I was talking about and lymphoid tissue as you can see, germinal center, lymphoid tissue. Ok? Or lymphoid or lymphatic nodule that gets inflamed when I was talking about tri as well as obstructive. But obstructive can be severe cat as in like we have sore throat, lymph nodes on the throat or in the neck and it gets better with the treatment. So that's the difference. And let's see further. So let's say Sam receives ky, ky means digested or half digested material from the ileum. Yeah. And that's what I was talking about which I just said your hands swell colon, coo colic junction, which is junction between cecum and ascending colon. OK. And in herbivores now this is what I got it after the research. But cecum stores food material where bacteria are able to break down the cellulose in humans. Cecum is involved in absorption of salts and electrolytes and lubricates a solid waste which passes into large intestine because large intestine. So main work of absorption of electrolytes and nutrients finishes once it passes through the UC valve, that is the traditional thought. And we know that and in colon is mainly responsible for uh fluid absorption. Su again, I would repeat, follow tinea if you struggle to find an appendix because where tinea meet, that's where the appendix is now. Just a summary inflammation or obstruction. Yeah. Intra pressure goes up. Lymphoid swelling affects the venous drainage, venous thrombosis pectoral invasion, creating an abscess if untreated or long history or sometimes depending on the infection or anatomical difference. Gangrene can happen with perforation and peritonitis, peritonitis and perforation stands like single quadrant, localized abscess, single quadrant peritonitis or for CHD peritonitis, if it is spread all over the peritoneal cavity. Now, this was the quick highlight of everything. However, let's go ahead to talk about diagnosis. Now, uh as a senior clinical fellow and I come from India and I must say that I have researched the appendix in my uh postgraduate era as well And that was my major project. But clinical stands first because if you are sure clinically that this is appendix that says sensitivity and specificity very, very high. However, we also do investigations which we'll go through and different scoring systems, you might be aware of it. There are different scoring systems but most commonly outed is uh a and then modified Arado. Yeah. So let's go to next slide clinical. So yes, anyone typical history umbilical goes to right elect fossa. Yeah, and not on and off because it cannot be on and off. It must be like once you, for example and simple to understand is once your visceral peritoneum is inflamed and then it reaches to parietal peritoneum, it cannot be intermittent. So yes, history is important and if it is a typical one and small period of time or big, I mean few days of time, but sometimes uh we come across like, oh someone had a pain two days ago and then it started it again. Yes, it is possible in the sense that it wasn't inflamed on the first part. But now it is inflamed. But once it is inflamed, then it cannot be intermittent. Ok. And then it comes with this kind of anorexia, fever, nausea, vomiting, ok. Sometimes constipation and sometimes diarrhea depends on the position of the appendix. For example, to make it clear if appendix is pelvic in the body. Ok. Most likely that patient will develop diarrhea rather than constipation. But yes, constipation is uncommon than diarrhea. Whereas whereas if different positions other than pelvic without any abscess, then there will not might be any constipation or diarrhea. Ok. Rebound tenderness. Now let's say rebound tenderness. We we all talk about rebound tenderness but why I written it already because I knew that I wouldn't be able to talk to you guys. But when parietal peritoneum gets inflamed, that's when you get rebound tenderness. So when you palpate gently praise and leave it, that's when ba and jumps because parietal peritoneum is inflamed on that area. Ok. And that is a sign of appendicitis. Of course, as we know the same way we talk about Rosenstein. Now, what is rosing sign again? Same principle parietal peritoneum is inflamed because when you press on the other side, left, lower quadrant, yeah, organs or intestines fuss and touches those inflamed areas of appendix and parietal peritoneum, when they feel pain, that is called rosing sign. Ok. Now, we have heard and we have learned swine and obturator sign. Now, these are very uncommon and we normally, or usually I don't know about your trust, but uh usually like you go see the patient feel uh can be appendix, but we don't see this kind of signs, do we? But I will tell you more about this with picture WSU there are a few tests which you probably, you guys are aware of something called coughing test means you ask patient, Usually a kid of course, uh cough and it hurts again. Parietal peritoneal inflammation. These all tests are all based on parietal peritoneal inflammation. OK? Hot taste or jolting or jumping taste. Yeah, when we ask them to poke or make a small jump and if it hurts and this is again for kids because this number six is all about kid kids means of course, less than 16 years, I would not say 18 years because normally 16 to 18, it is usually very sensible and clear. But for small kids, hot taste, jolting, jumping hill tap or hills are I would say that but uh test at line means you lift the leg and straighten the ankle and then you tap on the hill. OK, right hill. And this pain same as Markel means similar to hot test or jumping test when you ask a kid to stand on their toes and then come back on their hills and if it is painful, that is usually positive for appendicitis. But to understand here is yes per parietal peritoneum as I said. But then also it relates to Sua sign. OK. And uh next slide, we'll talk about it. But also when it is quite obvious when you know, uh right, elect for some or peritonitis with the history of but right, uh umbilical to right cause of pain. But then pa patient is in a lot of pain with uh findings of peritonitis, what we call guarding, rigidity, tenderness and so on. OK. So this is where mcburney's point. Ok. Now everyone knows that, but then just to remind what is Mc Ney's point, it connects to umbilicus to interiliac. Yeah. And medial two third and later one third. That is where neck point, OK, where you eli basically rebound caring and other signs, a rosing of those left to right. No diagnostic value. According to the paper, remember this rosing has no diagnostic value if or provided it is supported by typ typical history. OK. So sign 13 to 42% sensitivity, 70 to 95% specificity, but then how to do it. And you can see in the picture it's basically stretching the so, so measure oh sore as muscle which comes from the back joints, the hip or or femur, yeah, in the groin. So if you stretch it by extending the right hip and if it is painful, it is called so positive. And usually it happens with retrocecal appendicitis, ok. Obturator 8% sensitivity. But if it is positive, 94% specific. And how we do it flex the hip and then rotate internally by rotating leg outside means rotating the hip internally. So flex and rotate internally. Ok. Again, specific, but not sensitive that much. And I would say I haven't done it for many years. But if you do it, yes, it is important if in case it is positive and it says appendix is touching or inflamed with localized abscess near to obturator. Now I'm not going to Duana told me of octial muscle here, but basically, it's inside the hip wall. So most likely it is a pelvic. Now, I was talking about scoring system. So I would say everyone c know this modified Aldo score. Initial score was a total of 10. OK? And then uh what is taken out was safe to like for the white cells safe to left. But anyway, other than that, everything scores one except tenderness and leukocytosis. OK. What is sensitivity and specificity? Now whenever it is positive, I mean, uh according to there are a lot of numbers and I would say, and I I've gathered and I'm just summing it up but uh I would say modified sco sensitive less than 50% and specific 60 to 62%. OK. What this is what it means. 5 to 6 possible appendicitis. 7 to 8, probable nine most probably but not zero. OK. Now, this is what I was talking about more accurate xrays than for a skulls. That means if it is nine. Yes, specificity goes up. However less than nine might be might not be, I don't know, symptoms may hold up as cause in non appendix uh cases as well. Ok. For example, diverticulitis or pid. Yeah. So clinical picture history. That is more important scoring. Yes, it might be helpful but not sure pregnant Children and low resource setting. Mm. Not sure as in you need a specific surely you you cannot rely on the school itself. But in the history, a school remains studied and validated in general population. As I said, there are other schools as well but different things for think about in kids. Now, let's talk about kids. We talked about examination but then let's go back to the clinical history like young boy, let's say 10 years. OK. With typical right electro uh pain differential diagnosis one day history or seven day history. What you need to know what you need to know is history, of course, as I said previously. But other than that, you need to talk to parents that anyone or including kid it himself or herself. Did he have sore throat or upper respiratory tract infection? Recently, viral bacterial can be OK because differential diagnosis lies with a male kid commonly is either appendix or mesenteric adenitis. You OK. There are other things as well. Of course, as I was saying about developmental causes from embryology as in like since birth but then appears for example, into ion and other things in girls specific in teenage girls. Ok. Yes, history is important but then it varies and chances of appendicitis falls down than having it in a boy or male kid. Ok. The reason behind that is in the next slide, urinary tract infection. Ok. Kim being boy or girl equal chances interception more in boys and usually in case of course, urine tract uh can be in kids specifically in what we call posterior urethral wall. Now, what is urethral valve? I mean I can teach you but this is not a uh plate to these there, but basically it can end up having urinary tract infection in male kid. But otherwise it is common in adults. Natal smell. Yes, of course. It is uh in female, especially in teenage and it is said that almost 80% of female felt pain due to me smudge in the lifetime in, in their young age. Of course. Yeah. Uh teenage again, retro menses other differential diagnosis. And because of the teenage, we need to know pregnancy taste of any teenage female or adult female as it can also b ectopic pregnancy, which is a surgical emergency and needs a treatment as soon as possible. Ok. So never ignore pregnancy test in a female inflammatory bowel disease. Yes. Again, uh boys more common than girls. But is there any family history of inflammatory disease? We need to know that if there is not, that doesn't mean that he does not have inflammatory bowel disease. However, it is uncommon in kids, but common in teenage and I've seen a 18 year old boy with Crohn's disease. Only one case, of course, but it is possible. So think about it, Michael's thyroiditis. Uh, we'll talk about it later on as we go along. But Michael's diverticulitis common in boys than girls. And that is from the v vitellointestinal duct. Ok. So if the eye duct is open towards the umbilicus, it is called umbilical sinus. It can be middle where it appears as a band or cyst. And if it is towards the intestine, it is called sterum which has its own blood supply tumor, possible it can be any tumor and we'll talk about it. But remember in adult, more than 35 year old, please check. Yes, it can be simple appendicitis even in 55 year old. But we need to confirm that it is just appendicitis and last but not the least diverticulitis when sigmoid colon is redundant. Ok. Redundant means um with the diverticulum or inflamed diverticulum and it reaches towards the right leg fossa when you won't be able to differentiate between diverticulitis and appendicitis. So that is why all adults needs to be investigated before, to be operated. Ok. Other causes right to, to of course, in females dysmenorrhea and where is where diabetic ketoacidosis, which can present as abdominal pain. Usually it is uh not specific and findings won't be there. And that's why clinical examination as well as history is very, very important. And post surgical a in abdomen, which can cause, for example, uh internal hernia or you know, pain can, can present with RA FSA pain. But of course, they will have history of abdominal surgery. Previously. Funny enough, I was referred a patient who had appendectomy 20 years ago, but right elect was a pain and people thought yeah, can be appendix. But then history that is why history is very important and examination is next. Ok. Investigations white blood cells. Of course, we know that it would be high with high C RP. Yeah, we need urine analysis in almost every patient who comes with lower abdominal pain as I was talking about and if he's in sepsis, then we all know about sepsis. Six. What do you do in sepsis? Six game three. Take three. Yeah, we all know or shall I go through it? I'm sorry, I cannot talk to you guys, but I'm sure you guys know sepsis. Ok. But in the sense give antibiotics if you think patient is in sepsis, otherwise please do not give antibiotic if patient is not in sepsis. Reason behind that is if it is appendicitis, excuse me, it can, it can mask the pain, it can mask the pain. So first make a decision, make a diagnosis and then start antibiotics except patient is in sepsis. Ok? So don't give antibiotics on first go. Yes, sepsis. We don't have a choice but otherwise to a clinical diagnosis investigations. And then yes, once you know that this is appendicitis, then yes. Go with antibiotics. Ok. Abdomen x-ray. Yeah. Not that sensitive. But sometimes you can see if you call it or it can be helpful to rule out perforation. Yeah. Ultrasound specifically for kids. Ok, because you don't want a CT scan on them. And ultrasound is the best option if there is unsure clinically, if you are sure clinically then talk to your seniors or to have a second opinion, but you don't need investigations like CT scan or anything. But yes, ultrasound, sensible, noninvasive quick to do sensitivity low. But specificity means for example, I would say uh ultrasound report, ultrasound uh appendix not seen. OK. Ultrasound report two means another scenario, tubular structure seen in right elect Phosa. Normally if it says that appendix is inflamed, then it is quite specific 98% space obesity, ok. But if there are any doubts and we end up doing specific for kids and pregnant ladies, MRI, it has got good sensitivity and specificity. Yeah. But then MRI takes time as we all know in NHS doing an MRI immediate mm work on it. But then yeah. So if there is a doubt, then MRI is next step. Ok? And when to do CT scan, as I was mentioning in my previous slides, more than 35 years tumor diverticulitis. So check it out sensitivity specificity we all know but it you cannot do CT scan or should not do CT scan in young patients due to radiation. One ct scan is equal to 400 x-rays in terms of radiation. Ok. So that is why it is not preferred for young patients. Just a quick research thing. What is sensitivity? And I would say chances of false neg I mean, I have written this slide but in simple words, how do I remember that if chances are false negative, low sensitivity means if it's a it's not there less sensitive. Where is specificity if it says it is there, that means it is there. OK. So false positive, less that good space, obesity. If it goes high, of course, space it goes down right now. This is a quick video to see uh CT scan of the appendix in an adult and I'm going to play, pardon me? If it is with the advertised, see check. I, that's what I hi there, I'm Doctor Andrew Dixon from Radio pia.org. And in this video, we're gonna look at some of the ct features of acute appendicitis. And we're gonna do it by looking at axial and coronal images from a case of a 60 year old male presenting with right sided abdominal pain. We're gonna begin by looking at the Coronal images and you can see here in the right iliac fossa that there is a blind ending tubular structure. And as we follow it back, we can see that it arises from the base of the cecum consistent with it being the appendix. When we switch to the axial plane, we can see that the appendix is abnormally distended, measuring greater than six millimeters in diameter. And the fat surrounding the appendix is abnormal. Instead of appearing nice and black, the fat is edematous and has turned gray an appearance known as fat stranding. We can compare that to a region of normal intra on the fat here which has a nice black appearance. We can also see that there is a linear structure coming off the appendix, which is an inflamed mesoappendix, which is often seen in the setting of appendicitis. This patient also has reactive enlargement of their mesenteric lymph nodes, which is another common finding in acute appendicitis. Importantly, our patient does not have evidence of an abscess or any cules of free gas to suggest perforation. He is a different patient showing an abscess adjacent to the tip of an inflamed appendix. This patient also has a calcified appendicolith at the base of the appendix causing the obstruction. This is a common finding in appendicitis but it is certainly not present in every case. This patient also has an unrelated but a very important pathology demonstrated on these images here in the left adrenal upper pole. There is a heterogenous mass which is quite large and is invading beyond gros fascia and probably getting into the left adrenal gland. This finding in this patient rupture in the right iliac fossil cum with thickening greater than six millimeters and surrounding inflammatory fat change. This is on the outside of that margin are several small dots of air. There's also extensive surrounding inflammation indicating perforation. So I hope you like this week there for a free trial account which will give you access to selected bathers of the course. So once we have diagnosed the appendix, I'm sorry, I think uh I need to be a little bit quicker. But anyway, let's go. Uh with the treatment. Of course, there are two options either to operate or not to operate. Ok. So when to operate and when not to and then if not, which is called conservative treatment, when to use it, if we, if we decide to operate, ok, then important part is surgical consent. So of course, um you would be probably, I mean, aware of this kind of scenario. But then if, for example, if I ask you to consent, how would you consent? And what would you consent for laparoscopic appendicectomy? But always mention that it can be open, for example, uh because of the system failure questionable. But yes, it has happened previously and few times. In fact where uh you have only one laparoscopic stalk and tray is not working. And if you think yes, operation is needed, mm you end up doing open surgery. But other than that if it is, for example, you diagnosed an appendi appendicitis and then when you do laparoscopy, you find something else and you end up opening it. So yes, always consent laparoscopy plus minus open surgery. Ok? And complications common as we all know, pain, scars, infection, injury to surrounding structures. Uh in laparoscopy, always mention good side hernia, usually umbilical at less than five. And if it is open incisional hernia and in females, when we say diagnostic laparoscopy, always mention that even if appendix is normal, we will take it out to avoid future concerns about appendicitis, which is called negative appendicectomy. Yeah. And we end up doing 35 to 40% or even in the male but less common. Ok? And rare complications. STIs means inflammation of the stump and you might end up depending on the what you find inside because as I was saying, every appendix is different. Ok. I've done appendix in 25 minutes and I've done in three hours as well. So differs. So if for example, you find gangrenous appendix, which is like including base and you can't remove the appendix uh safely, then you end up using a stapler or sometimes even taking a part of cecum with a stapler or sometimes even right Colectomy. And if it is a tumor, you end up freezing less than 0.1%. But then you might be saying right hemicolectomy and maybe creating the stoma as well. And if you do appendectomy Crohn's we fistula is a common complication, not as in common, common, but about 18 to 20%. Ok. And of course, the, the question from the patient would be ok. I'm happy to go with the surgery. But then what is postoperative recovery? And when would I go home? Ok. So usually every person without complication. Yeah. Goes home either on the same day or next day, depending what we find, but expected to return or back to normal within a week. OK. But then again, you need to be clear here depending on what we find because sometimes if there is four quadrant, um pus for example, due to perforated appendix and then we advise five days of antibiotics or so on, then yes, it needs to stay in or do ET OK. Means in community they can take antibiotics but then do not promise the discharge yet. OK? If anything goes to work or if you have any doubt, do not take risk for yourself and the patient. Because if you comment and if you document that is you who is documenting surgical matters and steps, I'm sure you guys would have seen the surgery so that I have a few videos. But anyway, um this is not the time to so those videos but how to operate. OK. That is not a question. This is what you need to search and met you if you were uh like video person and want to see different videos of surgery. Even in the surgery. If you're helping, please do not take risk because that can alter your own as well as patient's outcome. Ok. Now, we talked about surgery now in surgery, of course, uh, I'll come to next slide, but, uh, I've just mentioned here, when comes the way too, there are two ways, one is called complicated as in phlegm inflammatory mouse and second uncomplicated. And there is a contract to study going on for less than 15 years for conservative management of uncomplicated in other sense, cat, if you remember the previous slide right now, let's talk about open surgery. It is in surgery that yes, you can do surgery, but you need to know how to do open surgery, you can do laparoscopy. But what if laparoscopy as I was saying things so you need to know open surgery as well. Ok. So incidents as you can see on the screen. Mcburney's modified mcburney's mcburney is also called uh great iron incision because we do not cut muscles, we just plate them. Ok. So that is why it is called grade iron because chances of uh hernia becomes less when you just splitting the muscles. For example, you cut only oblique and then it oblique and uh transverse abdomen is you just split them in the line of fibers to reach the peritoneum and then you do appendicectomy. Ok. Lanzol lingo, which is like modification of my just because to avoid or rather making it more cosmetic, mainly used for females, transverse rocky Davis and Rupo MRI difference. Cutting be mus cells. Ok. And follow is medial extension of root. All other incisions except mcburney and possibly modified back, which is also called L Solans. They cut the muscles. Ok. Ruin. Um I would say they just rere the rectus muscle if they encounter because this picture is not 100%. But other than that, they avoid cutting as much as possible. Whereas all of those, they cut muscles laparoscopic. So these are the parts. Normally we put one part from the umbilicus. Depends on different techniques. It can be open incision, so called Hasan's technique. But sometimes they use we needle, OK? But at the end of the day, it should be safe, safe for patient. OK? I like open technique very much. And then one in left lower quadrant and one in suprapubic and two to be a little bit more uh specific. I use this technique. OK. So umbilical part, for example is here, I would do suprapubic here and uh left lower quadrant here. But it is different for different surgeons, other technique of co which is also used in some trusts which is umbilical um just uh later to suprapubic and right electrocyte cell. OK. But this one is more preferred. And if in case uh you end up doing right hemicolectomy, for example, then it would be easier to put on the part in this situation rather than this. Ok. Other methods of surgery, single incision, laparoscopic surgery. Yes, it is taking and being popular currently. And of course, the new well of robot robotic surgery for appendix, which is not done in UK. Of course, not usually ii mean very few centers are really unlikely but in us they do robotic appendicectomy as well. Ok. Let's go to conservative if you remember no Flegmon and conservative for others. So clinical spectrum wide ranging as we were talking about. OK. But the common belief is if you say conservative to for example, a parent, father or mother of kids who you think has got uh appendicitis. And if you are talking about conservative management, this is the normal belief. Why? Because like it can burst, it can give sepsis abscess and sometimes even it and it is reported and normally whoever comes to our doors, they usually google it and this is available there that yes, appendicitis means needs to be taken out. OK. But they don't see the down below one, which is several randomized controlled trials have shown antibiotic therapy can be successful in 70 to 75% a question but uncomplicated appendicitis. OK. However, they end up having another, I mean, episode means recurrence and end up having a surgery within a year about 25%. Ok. So yes, there is a, an option to treat appendicitis conservatively provided that it is uncomplicated. OK. Now let's talk about regime. I mean, I'm sorry, I cannot ask you questions. But anyway, let's go with the regime when to use when it is inflamed flag. That means appendicitis, which has created inflammation of surrounding structures. And now it is like a mass and operating on those in that situation wouldn't be advised as you might end up having a right hemicolectomy surgery. Ok. So this was basically, this is written in original, uh, Albert Wasner who is from Chicago. Uh, he thought the same thing, what we just thought that acute appendicitis needs surgery. Ok. Immediate operation. However, when he became a registrar to James seven, his views were changed and then he developed which was different than uh Mr Sein's regime itself. But what it says is treatment is not mainly a postponement of operation. It is to get a patient ready. That means just buying a time to control the inflammation and infection and then end up doing the surgery. How many hours or days you would wait with this regime. It is also called delayed treatment. However, that, uh, usually it is said 48 to 72 hours. If patient does not improve then or gets worse, then you end up doing a surgery because it is a complicated appendicitis. Ok. Whereas uncomplicated, which is also called simple cat, then I have a choice but discuss and ide where antibiotics as it per 70 to 75% good reasons. Ok. If we call it complicated, you don't have a choice but flag mom was not regime if not improved, then take it further. Ok. Now, very quickly, I think we are running out of the time. I'm sorry to take a lot of time. But uh let's see, variation very quickly appendicitis in pregnancy. So just to make it clear in fifth month, basically because uterus is enlarging, cecum and appendix are postop yeah, simple as that. And everyone should be knowing that I'm not saying anything more than that. But what happens is when it is inflamed and if it is touching or fixed with the uterus, it might be a trouble. Ok. So chances of uh say abortion with complicated appendicitis in pregnancy is about 50% but uncomplicated appendicitis, you can try antibiotics as we were talking and still there is a risk of Aulin 30%. Ok. And first trimester. Yeah, safe to operate provided it is confound appendicitis. Number one, confirm means with investigations because with general anesthesia, chances of abortions are about 40% and sometimes even more. Ok. So you should be clear with patient and clear with yourself as well. Trimester two risky to operate with the chances. So if complicated, you might not have a choice but uncomplicated. You should wait in trimester three, uh premature birth possibility again, more than 40% but with an anesthesia as well. But yes, safe to operate in a one and three. But you need to be clear in consent about other complications second Meckel's diverticulum, as I was saying, congenital abnormality, patent vitellointestinal duct, not patent part of anti meric border of ilium, same as appendix with separate blood vessels. This is what we were mentioning, but again, can contain aerobic tissue like stomach or pancreas. In fact, appendix can also have some kind of uh mucosal abnormalities uh which I'll quickly go through as we go along. But uh most of them are silent and rule of two of four me diverticulum, two person, two each and 2 ft. But other than that half, symptomatic second decade and half heterotropic mucosa. Yeah. So it is not just 32, there are a few more too. Why important can mimic as appendicitis. And in fact, in appendix surgery, usually if appendix is normal or in fact, in all appendix surgeries, we should be checking for Meckel, which is 2 ft after UC conjunction. Ok. So if me diverticulum hernia, what is it called? Little hernia? Just to know, isn't it? Ok. Then what is ambience hernia in honor of Claudia Ambien? Basically, it's uh appendix in a hernia, inguinal hernia or right inguinal hernia to be specific. Ok. And there is a classification for that as well. So if it is inflamed, it is normal. But yeah, at the end of the day, it might appear as a strangulated or inflamed hernia, but it might be appendicitis. Now, next mucocele of the appendix and cancers. Now, I don't want to go in detail. But mucocele means mucus collection in the appendix, usually obstructive at the end of the day, all these intestinal mucus are secret and absorbed. So if it is obstructive, same as gallbladder in say mucosal of the gallbladder, the same way it can be mucos of the appendix as well. However, there are some neoplasms which can arise as I was mentioning previously, which is mm low grade, high grade or even adenocarcinoma. OK. And it can spread to peritoneum, which is also called I it's like a jelly, literally jelly all. Uh it might be at the appendix, but it can spread to the peritoneal cavity, which is called pseudomyxoma peritonei. OK. And uh it is stage four in the sense, if it reaches the peritoneum, more common in women and surgery is the best option, clean whatever is needed. And chemo and radio has very low or limited rule, neuro endo occurring tumors. I can talk a lot about that. But yes, there is a possibility and it usually like it is usually incidental, there might be a small tumor and it comes in the histopathology of the specimens. So always check the histopathology once you do the surgery. And if it is, it usually says the location, if it is near to base, you end up doing another surgery of right hemicolectomy. But if you have enough margins, then appendicectomy itself is good enough intestinal malrotation. Uh just a quick one where to find appendix because when it rotates, I was saying outside of the tummy 90 degree inside of the tummy 180 degree, it ends up in right IOS. So in intestinal mild rotation usually appendix in left upper quadrant. So don't be fooled by seeing appendix in left upper quadrant because there is mild rotation of the intestine. OK. Very, very uncommon, less than one per 0.1%. But yes, you can end up seeing these kind of cases contract two trial. Uh In fact, I'm involved in it, but it is again, as I was mentioning, conservative management of kids uncomplicated appendicitis was this surgery. And the last but not the least went to discharge. And with what advice when to start, eat and drink as soon as he is awake, he's awake. But if you do dissection or if you are in doubt, you can advise accordingly. But otherwise once patient is awake, should start gradually eat and drink and mobilize as soon as possible as soon as he is able to pain control. Of course, because if patient is in pain, he is not going to mobilize. So remember, pain control is very important because we usually discharge patients in a day bracings. Common question, you see POSTOP patient, they want to know how the surgery was and whatever bracing or stitches. Usually we take subcuticular stitches and they do not need removal. But sometimes you end up doing skin stitches and then it has to be removed by I in in comin. Ok. But the important is is there any hematoma of the incision site might be open or laparoscopy doesn't matter. But yes, hematoma can help happen specifically check left lower quadrant colt. Ok. Because sometimes people can injure in gastric artery where they usually realize that and then, ok. And they document but then again, if it was missed or even if it was realized, you need to know is the hematoma expanding? Ok. Not improved. Any appendix, not improved. For example, having pain, having fever. Ok. And always check operative nodes if not improved in for that means there is something wrong going. There might be interruptive injury might be left or Colin was left inside. So do a CT or ultrasound check bloods take it out. Otherwise patients should go home within 48 hours if it went very well discharge. Otherwise of course, 6 to 8 weeks, no heavy lifting advise about dressing and stitches advise about antibiotics because if there is for example, any abscess, we advise so and so days of antibiotics. So please follow that up. And if any doubts raised by this operating surgeon, please arrange follow up accordingly. Otherwise we don't need to arrange follow up. Ok. These are the references and thank you very much. I'm happy to take any questions if there are any hi, if anyone has any questions, you can just put them in the chat box. Uh Yeah. Hi mister B can you see the question or should I uh just checking, sorry. Yeah, I had a question about surgical intervention with uh sorry. Uh coma is asking, I've seen in practice that surgeons usually wait until inflammation settle before surgical intervention. While this operation we can operate straight away rather than wait for. So, inflammation itself is an appendicitis, isn't it? So it depends on what inflammation you are talking comal because if it is complicated. Yeah, for example, if it is perforated, then we don't have a choice, we have to operate. But if, for example, and that's what I was mentioning. Flag M Yeah, Flegmon is an inflammatory mass which includes uh all surrounding structures. Yeah. So in that scenario, if you operate complication rate goes very, very high and that is the reason why we try to control the inflammation. OK. So that we can deliver a better surgery or services. But then, and then only it justifies otherwise, if you know this is appendicitis, yes, surgery is the best option. If uncomplicated, you can give a choice of, for example, conservative surgery. But then most of the patients do not like conservative surgery because they come with the impression. And that's what I was mentioning that any appendix, oh my uncle had uh appendicitis and then it bursted because doctors did not look at it and uh he ended up having the surgery. Yes, they are right. But in the sense, if it is uncomplicated, we can try conservative if it is complicated. But in the scenario where it is a flag month, it is better to wait because more chances of damaging something is high than helping patients. OK. Whereas perforated gangrenous, we don't have a choice. Yes, operation is the first choice anyway. OK. So these are the different scenario and it is just case to case based. So as you said, inflammation means what kind of inflammation that matters and situation of the patient also matters. Of course, hope I answered your question. But yes, you can be clear if I did not give a proper answer. Um OK, Gad uh stump appendicitis now, yes, it is very difficult when you know that appendix or appendicectomy was done. Yes, it is very, very difficult to diagnose. And uh usually then you need a proper scan to know that this is thrombi because clinically it is really, really impossible to diagnose thrombi. So yes, you are right. Very, very difficult to diagnose and you need proper scan to know if it is omits. OK? Asking a question. So thank you all and best of luck further. OK. See you next time. Thank you. So guys, if you could just take a moment to fill the feedback form and claim your certificates, that would be great. And we'll be conducting our next session in the coming days. So hope you all guys would join us for the next session and you hope you enjoyed today's session and thank you mister for the wonderful day. Thank you. Have a good evening, bye-bye and thank you for joining on a Sunday everyone. Thank you. Bye, good night. Bye.