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Sx: Hernia

Abdominal Wall Hernia.
Definition of hernia. The term hernia denotes abnormal protrusion of a part or whole of any viscus through an opening or weakness in the wall of the cavity in witch it is contained. Such protrusion may be present inside the body (called internal hernia), viz, within the abdomen or in the thorax and from the abdomen to outside the body presenting a swelling on the skin surface (known as external hernia).
Hernias of the abdominal wall are the most common condition requiring major surgery.
Despite the frequency of surgical repair, perfect results continue to elude surgeons and the rate of surgical failure is humbling. The outcome of hernia surgery is very surgeon –dependent.
“No disease of the human body, belonging to the province of surgeons requires in its treatment a greater combination of accurate anatomical knowledge with surgical skill that hernia in all its varieties.”(Astley P. Coopers, 1804)
A hernia is external, if the sac protrudes completely through the abdominal wall; interparietal if the sac is contained with the abdominal wall, and internal, if the sac is within the visceral cavity.
Congenital indirect inguinal hernia (a preformed peritoneal sac provided by the processus vaginalis) is which accompanies the testis into the scrotum and remains patent.
Prolapsus.
Eventratio.

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Sx: Pelvic Abscess

Pelvic Abscess.
A pelvic abscess may follow any general peritonitis, but it is particularly common after acute appendicitis (75%), or after gynecological infections.
In the male the abscess lies between the bladder and the rectum; while in the female it lies between the uterus and posterior fornix of vagina anteriorly, and the rectum posteriorly (Douglas pouch).
The most chracteristic symptoms of pelvic abscess are diarrhoea and the passage of mucus in the stools.
Rectal examenetion revils a bulging of anterior rectal wall which,when the abscess is ripe,becomes softly cystic.
An ultrasound examination.
An aspirating needle intoduced through the rectal wall will settle the queston..
The abscess should be drained deliberattely.
In women,vaginal drainage through the posterior fornix is often chosen.
In oher causes, where the abscess is definitely pointing into the rectum, rectal drainage is employed.

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Sx: Subphrenic Abscess

Subphrenic Abscess.
The subphrenic region lies between the diaphragm above and the transverse colon with mesocolon below and is divided further by the liver and its ligaments.
The right and left subphrenic spaces lie between the diaphragm and the liver and are separated from each other by the falciform ligament.
The right and left subhepatic spaces are below the liver, the right forming Morison’s pouch and the left being the lesser sac which communicates with the former through the foramen of Winslow.
The right extraperitoneal space lies between the bare area of the liver and the diaphragm.
About 2/3 of subphrenic abscesses occur on the right side; rarely they are bilateral.
Etiology: A localized collection of pus may occur in the subphrenic region following general peritonitis. Usually underlying cause is a peritonitis involving the upper abdomen - leakage following biliary or gastric surgery or a perforated peptic ulcer. Rarely, infection occurs from haematogenous spread or from direct spread from a primary chest lesion; ex. empyema.

Clinical Features.
Subphrenic infection usually follows general peritonitis after 10-21 days, although if antibiotics have been given and abscess may be disguised and may only become manifested weeks or even months after the original episide.
There may be no localizing symptoms, the patient presenting with malaise, nausea, loss of weight, anemia, and pyrexia; hence the aphorism “pus somewhere, pus nowhere else, pus under the diaphragm”.
At least half of the cases have fever which continues from the original peritonitis, although the standard description is of a swinging temperature which commences some 10 days after the initial illness.
Localizing features are: pain in the upper abdomen, lower chest or referred to the shoulder with localized upper abdominal or chest wall tenderness. There may be signs of fluid or collapse at the lung base. In late cases a swelling may be detected over the lower chestwall or upper abdomen.
Special investigations:
The WBC count is raised and is in the region of 15000-20000 with a polymorph leucocytosis. The important initial investigation is screening of the chest which reveals an abnormality in nearly all cases
The radiological signs are:
1- Elevation of the diaphragm. on the affected side.
2- Diminished or absent mobility of the diaphragm.
3- Pleural effusion and/or collapse of the lung base.
4- Gas and fluid level below the diaphragm.
Accurate localization may be achieved by ultrasound or CT scan.

Treatment.
In early cases where there is absence of gas and free fluid on X-ray, the patient is placed on broad spectrum antibiotic therapy. There is rapid response the diagnosis is one of spreading cellulitis of the subphrenic space. If there is clinical or radiological evidence of a localized abscecc, or if resolution fails to occur on chemotherapy, then drainage may be carried out under ultrasound control.
If this fails, or if the abscess is loculated, then surgical drainage is performed.
Depending on the localization of the abscess, this is carried out either by a posterior extraperitoneal approach through the bed of or below the 12th rib, or an anterior approach via a subcoastal incision.

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Sx: Appendix Abscess

Appendix Abscess.

During the 5th to 10th day the appendix mass either becomes larger and an appendix abscess results, or it becomes smaller and subsides slowly as inflammation resolves. The following signs are found: Pyrexia. The pulse is usually less than 100.
An increased leucocyte count with a relative increase of polymorphonuclear cells.

The Treatment of Appendix Abscess.
Failure of resolution of an appendix mass usually indicates that there is pus within the mass.
Indications for opening an appendix abscess:
1- When the swelling is not diminishing in size after the 5th day of treatment.
2- When the temperature is swinging above 37.8 on several successive days.
3- A pelvic abscess seldom resolves.
Ultrasonography will confirm the diagnosis.

Opening an appendix abscess.

The swelling is papable under anasthetic. A retrocaecal appendix abscess should be opened extraperitoneally.A subcaecal abscess can be opened in the same manner. The incision being placed nearer the anterior superior iliac spine.
A pre- or post-ileal abscess can be reached only through the peritoneal cavity.
A pelvic abscess is opened into the rectum.
No attempt should be made to perform appendicectomy, unless the appendix is lying free in the abscess cavity.
It is necessary to drain an appendix abscess.

Interval Appendicectomy.
It is highly important to explain to the patient that drainage of an appendix abscess is no safeguard against future attacks of appendicitis and the patient should return for appendicectomy 3 months after the wound has healed.

Localized Intraabdominal (intraperitoneal) collections of pus following peritonitis.
Pus may collect in the subphrenic spaces or in the pelvis.

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Sx: Differential Diagnosis for Mass

Differential Diagnosis of a Mass in the Right Iiac Fossa.

The causes of mass in the right iliac fossa are best thought of by considering the possible anatomical structures in this region:
1- Appendix abscess or appendix mass.
2- Carcinoma of caecum (differentiated from the above by a longer history, often presence of diarrhea, positive occult blood with anemia and finally the barium enema examination).
3- Crohn’s disease (always to be thought of when there is local mass in a young patient with diarrhea).
4- Ileo-caecal tuberculosis (rare in the UK, common in India).
5- Psoas abscess; but rare.
6- Pelvic kidney.
7- A distended gall bladder (which may quite often extend down as far as the right iliac fossa).
8- Ovarian carcinoma or tubal mass.
9- Aneurysm of the common or external iliac artery.
10- Retroperitoneal tumor arising in the soft tissues of lymph nodes of posterior abdominal wall or from the pelvis.

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Sx: Appendicular Mass

The Appendix Mass
Not uncommonly the patient will present with a history of 4 or 5 days of abdominal pain and with a localised mass in the right iliac fossa.
The mass is composed mainly of the greater omentum, oedomatus caecal wall, and oedomatous portion of the small intestine. In its midst is an inflamed vermiform appendix.
The rest of the abdomen is soft, bowel sounds are present and the patient obviously has no evidence of general peritonitis.
In these circumstances the inflamed appendix is walled off by adhesions to adjacent viscera, with or without the presence of a local abscess.

The Management of an Appendix Mass.

If an appendix mass is present and condition of the patient is satisfactory, the standard modern treatment is conservative.
Surgery at this time is difficult, bloody and dangerous. It may be impossible to find the appendix and occasionally, a faecal fistula may form. For these reasons it is wise to observe a rigid non-opperative program, but to be prepared to operate at any time should nature fail to control the infection.
The outlines of the mass are marked on the skin. A careful watch kept on patient’s general condition, temperature and pulse.
Charts: as a routine, temperature is recorded every 4 hours. Pulse is the indication of intoxication.
Diet: Water, 30ml/hour may be given by mouth. Mouth-washes are given frequently. Desire for food is an indication that satisfactory progress is being made and that oral feeding may be started. The first feeds should be fluids only and progression to solid food take place over the next few days.
Intravenous fluids with fluid balance chart and daily assay of electrolytes must be instituted.
Drugs: It should be particularly noted that no morphine or its derivatives are given in borderline cases.
Antibiotic therapy: parenteral ampicillin, gentamycin, and metronidazole are given.
If bowels are not opened naturally by the 4th or 5th day, a glycerine suppository will encourage normal evacuation. No purgatives of any kind are given.
Anti-thrombolytic therapy: It is given to patients confined to bed as prophylaxis against thrombosis of the pelvic veins; should be given with compression stockings.
The outcome of cases suitable for delayed treatment is that 90% resolve without incident. The appendix, however, must be removed later to avoid further attacks. This should be done after an interval of 3 months.
Present day practice, however, favours appendicectomy as soon as convenient after complete resolution of the mass.
Delayed appendicectomy should be carried out through a paramedian incision.
Unless interval appendicectomy is performed there is considerable risk of a further attack of acute appendicitis.
In the remaining cases the abscess obviously enlarges over the next day or two and the temperature fails to subside. In these circumstances drainage of the abscess is instituted. In neglected cases an appendix abscess may burst spontaneously into the general peritoneal cavity, into the rectum or through the abdominal wall.

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Sx: Acute Appendicitis 6 - Treatment 2

Drainage of Peritoneal cavity.
Adequate peritoneal toilet has been done. If there is considerable purulent fluid in retrocaecal space or the pelvic, or if there is persistent oozing, it is wise to bring out a penrose or silastic drain through a separate stab incision.

Drainage of the Parietes.
This is indicated if there is any soiling of the wound, especially in obese and in children.
The rule is: if in doubt drain, and especially the parietes.
Prognosis.
The mortality risk of an individual patient with avute but not gangrenous appendicitis is less than 0.1%.
In gangrenous appendicitis mortality rises to about 0.6%
The mortality of perforated appendicitis today is approximately 5%
Morbidity from appendicitis continues to be high. Overall, morbidity currently occurs in 10% of all patients morbidity.
An appendix may perforate in under 12 hours, or an inflamed but non-perforated appendix may be removed after 3 or 4 days.
It is now acknowledged that a general peritonitis complicating acute appendicitis is best treated surgically.
When at operation peritonitis is dicovered, antibiotic therapy is commenced. We give Metronidazole and Gentamycin deal with both the anaerobic and aerobic bowel organisms; but this may require to be supplemented or changed when the bacteriological sensitivities of cultured pus become available after 24-48 hours.
Very occasionally the inflamed and adherent appendix cannot be safely removed and in such circumstances the area of the appendix requires adequate drainage and subsequent interval appendic-ectomy” advised in about 3 months.
After appendicectomy, a drain is inserted when:
- Severe inflammation of the appendix bed.
- Local abscess is present.
- Closure of the appendix stump is not perfectly sound.

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Sx: Acute Appendicitis 5 - Treatment 1

Treatment.
If the diagnosis is made at anearly stage in the attack and particularly in the abscence of a localized mass, all agree that the appendix should be removed urgently.
The treatment of acute appendicitis is appendicectomy except under the following circumstances:
1- The patient is moribund with advanced peritonitis; here the only hope is to improve his condition by drip and suction, antibiotics and blood transfusion.
2- The attack has already resolved; in such a case, appendicectomy can be advised as a n elective procedure, but there is no immediate emergency.
3- An appendix mass has formed without evidence of general peritonitis (see below).
4- Where circumstances make operation difficult or impossible (ex: at sea).
Here reliance must be placed on conservative regime and the hope that resolution or local abscess will form .
One should avoid using such statements as ” conservative treatment is employed after 48 hours”. Nature does not on any time relationships.

Appendicectomy.
When the diagnosis is certain, the grid-iron incision is the best one to be employed.
When the diagnosis is in doubt the lower right paramedian incision is preferable because it gives good access to the pelvic organs in the female and if necessary it can be readily extended upwards to deal with a perforated duodenal ulcer or other unexpected intra-abdominal pathology.
I- The grid-iron incision:
- An adequate incision is made at the right iliac fossa at right angles to a line joining the anterior superior iliac spine to the umbilicus; its center being at Mc Burney’s point.
- The external oblique is incised in the length of incision.
- The fibers of the internal oblique and transversus abdominis are seperated, and after suitable retraction the peritoneum is opened.

II- The paramedian incision:
- Is a vertical incision lying parallel to and 1.25 to 2.5 cms to the right of the middle line. It commences 2.5cms below the level of the umbilicus and ends just above the pubis.
- The anterior rectus sheath is incised in the line of the incision and the rectus muscle us retracted laterally.
- Branches of the inferior epigastric vessels may require ligation.
- The transversalis fascia and the peritoneum are incised together.
Care must be taken not to injure the bladder inferiorly.
III- Rutherford Morison’s incision:
It is useful if the appendix is para- or retro-caecal and fixed. It is essentially an oblique muscle cutting incision with its lower end over Mc Burney’s point and extending obliquely upwards and laterally as necessary. All layers are divided in the line of incision.
The caecum is withdrawn; once the appendix has been delivered the caecum is grasped by an assistant. The base of the mesoappendix is clamped in a hemostat, tied, and severed.
The appendix now completely freed is crushed near its junction with the caecum in a hemostat, which is removed and reapplied just distal to the crushed portion.
A catgut ligature is tied around the crushed portion of the caecum.
An atroumatic catgut purse-string suture is inserted into the caecum about 1.25cms from the base. The stitch passes through the muscle coat, especially picking up taenia coli. It is left untied until the appendix has been amputated with a scalpel below the hemostat.
The stump is invaginated while the purse-srtring suture is tied, thus burying the appendix stump.
It is better not to attempt invagination. The stump of appendix should be ligated and the cut surface touched with the diathermy in attempt to reduce infection.
IV- Retrograde appendicectomy: When appendix is retrocaecal and adherent. We have to divide the base of the organ between hemostats. The organ is removed from base to tip.

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Sx: Acute Appendicitis 4 - Differential Diagnosis

Differential Diagnosis.
This should be considered systemically under the following headings:
1- Other intra-abdominal causes of acute pain.
2- The urinary tract.
3- The chest.
4- The CNS.
5- Acute pain of gynecological origin in case of females.

1- Intra-abdominal diseases: which commonly simulate appendicitis are:
- Perforated peptic ulcer.
- Acute cholecystitis.
- Acute intestinal obstruction.
- Gastroenteritis.
- Non-specific mesenteric lymphadenitis.
- Acute regional ileitis (Crohn’s disease).
- Meckel’s diverticulitis and acute diverticulitis.
- Acute pancreatitis.

2- The urinary tract:
- Renal colic.
- Acute pyelonephritis.
The urine must be tested for blood and pus cells in every case of acute abdominal pain. Remember however, that an inflamed appendix adherent to the ureter or bladder may produce dysuria and microscopic hematuria or pyuria. If reasonable doubt exists it is safer to remove the appendix.

3- The chest:
- Basal pneumia.
- Pleurisy.
These may give referred abdominal pain which may be surprisingly difficult to differentiate especially in children.

4- The CNS:
the lightning pain of tabes dorsalis, the pain which procedes the eruption of herpes zoster affecting the 11th and 12th dorsal segments and the irritation of these posterior nerve roots in spinal disease (tuberculosis or invasive tumor) all occasionally mimic appendicitis.
Spinal W-rays will often be a guide.

5- Gynecological causes:
- Acute salpingitis.
- Ruptured ectopic pregnancy.
- Ruptured cyst of the corpus luteum.
- Ruptured ovarian follicle.
- Twisted right ovarian cyst.
If examination of the pelvis under anasthesia is practiced preparatory to laparoscopy/laparatomy, a mistake will be seldom made.

6- Bleeding into appendicular and related structures can result from blood dyscriasis or the use of anticoagulants.
- Henoch-Shoenlien syndrome.
- “Diabetic abdomen”.

Nothing can be so easy, nor anything so difficult, as the diagnosis of acute appendicitis.
The tiro may smile indulgently at the long list of differential diagnosis given in the textbooks but, as year follows year, he will experience the chagrin of making most if not al of these errors.

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Sx: Acute Appendicitis 3 - Special features

Special Features According to Position.
1- Retrocaecal: Rigidity is often absent (silent appendix) and even on deep pressure tenderness may be lacking; gurgling may even be elicited. However, deep tenderness is often present in the loin, and rigidity of the quadratus lumborum may be in evidence. Psoas spasm may be sufficient to cause flexion of the hip joint; to extend the joint causes abdominal pain.

2- Pelvic: Occasionally early diarrhea results from an inflamed appendix being in contact with the rectum. Complete absence of abdominal rigidity and often tenderness over Mc Burney’s point is lacking as well. A rectal examination reveals tenderness in Douglas pouch especially in the right side. Psoas spasm may also be present. An inflamed appendix in contact with the bladder may cause frequency of micturition.

3- Post-ileal: Although this is rare, it accounts for some of the cases of “missed appendix”. Here the inflamed appendix lies behind the terminal ileum. It presents the greatest difficulty in diagnosis because the pain may not shift, diarrhea is a feature, marked nausea may occur and tenderness, if any, is ill defined, though it may be preset immediately to the right of umbilicus. As the appendix the lower ileum, the patient usually passes small loose stools soon after eating or drinking.

4- Maldescended (Subhepatic): The tenderness is in the subhepatic region. It is sometimes mistaken for acute cholecystitis.

Special Features According to Age.

1- Acute appendicitis in infants: In infants under 36 months of age the incidence of perforation is over 80%, and the mortality is considerablt higher the general mortality. One of the reasons of the rapid onset of diffuse peritonitis is that the greater omentum, being comparatively short and undeveloped, is unable to give much assistance in localizing the infection. Even more important is the difficulty in arriving at an early diagnosis.
2- Acute appendicitis in children:
- Increase temperature and pressure.
- Vomiting
- Complete aversion to food.
- Don’t sleep during the attack.
- Bowel sounds are completely abscent, very often in the early stages.

3- Acute appendicitis in the old age: Gangrene and perforation occurs much more frequently in elderly patients.
- Lax abdominal wall: muscle atrophy, soft, abscence f rigidity.
- Obesity.
- Self medication with laxatives.
- Peritonitis may be spread more widely if enmas are given.
- The immune system becomes weaker in old age.
For all these reasons, acute appendicitis in older age groups carries a high mortality.

Acute appendicitis in obese: Obesity can obscure and diminish all the local signs of acute appendicitis.

Acute appendicitis in pregnancy: Because the appendix is displaced by enlarging uterus, pain and tenderness are higher and more lateral than in the usual circumstances.
Appendicitis in pregnancy is not rarer or commoner than appendicitis in the general community, but it has a higher mortality and morbidity because it is cinfused with other complications of pregnancy. The nearr to term the greater danger. After 6 months there is a maternal mortality of 20%- ten times greater than in first 3 months.
Differentiation must be made from:
- Pyelitis: inflammation of the pelvis of the kidney.
- Vomiting of pregnancy.
- Torsion of an ovarian cyst.
Microscopical examination of specimens of urine will help to exclude pyelonephritis, but in doubtful cases it is best to perform early appendicectomy.
There is considerable danger of abortion, particularly in the first trimester. The pregnant patient with acute perforated appendicitis aborts or goes into premature labor in 50% of cases.

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