Acute Appendicitis

The appendix is a tubular, blind-ended, vestigial structure which is attached to the caecum. Anatomically the location of the appendix corresponds to the right iliac fossa which is at the lower right quadrant of our abdomen. The human appendix is hypothesised to have lost its original function through evolution.

 Some of the functions of the appendix are:

-immunological functions - it contains lymphoid follicles which secrete immunoglobulins

-it contains serotonins which are neuroendocrine hormones

-it has a bacteriological function where it helps to control the normal gut bacterias

-Surgical functions - where the appendix is used as an 'urinary conduit' in bladder reconstruction in bladder surgery & it can also be used as an 'appendicostomy' which can be used for antegrade colonic enema (wash-out of faeces) in patients with constipation.

The appendix lies in close proximity to the caecum (the beginning of our large intestines). Approximately 75% of the appendix lies behind the caecum (retrocaecal), 20% in the pelvis and the remaining 5% either pre- or post-ileal (infront or behind the small bowel).

Appendix attached to the caecum

Acute appendicitis is the inflammation of the appendix. It is the commonest acute surgical condition in the abdomen. It typically presents with an initial pain around the umbilical region which later migrates and localises in the right iliac fossa. Usually the patient will have a low grade fever, loss of appetite and nausea. There will be tenderness of the abdomen localised at the right iliac fossa which is typically described as at McBurney's point (2/3 along the line drawn between the umbilicus and the anterior superior iliac spine).
Severe cases of appenditis can present with severe abdominal pain, high spiking temperature & dehydration. This usually happens when there is a delay in diagnosis and the appendix perforates leading to purulent or faeculent peritonitis (contamination of the abdominal cavity with pus or faeces).

Other causes of a right iliac fossa pain are:
-urinary tract infection
-kidney stones (renal colic)
-Meckel's diverticulitis
-mesenteric adenitis (usually associated with flu)
-colonis diverticulitis (usually in elderly people)
-torsion of ovary
-ectopic pregnancy
-pelvic inflammatory disease
-intestinal obstruction

The treatment for acute appendicitis is appendicectomy (surgical excision of the appendix). This procedure was traditionally done as an open surgery but most surgeons are doing laparoscopic (minimally invasive) appendicectomies now. The complications of appendicetomy includes:
-wound infection (<5% risk)
-intra-abdominal abscess
-faecal fistula (leakage of faeces from the resected appendix stump)

The sequelae of acute appendicitis includes:
- Perforated appendix: - as a result of inflammation and ischaemia (reduced blood supply) to the appendix, the wall weakens and perforates. This will lead to localised or generalised, purulent or feaculent peritonitis. The patient will be more ill.
- Appendicular mass: - a swelling noted at the right iliac fossa which is a mass of omentum covering the inflammed appendix. This typically happens a few days after the initial episode of right iliac fossa pain when our body tries to wall of the inflammed appendix.
- Chronic appendicitis: - this usually occurs in patients who were treated with antibiotics or anti-inflammatories for a bout of lower abdominal pain. They develop a chronic grumbling right iliac fossa pain which is very vague. It is usully a diagnosis of exclusion.

Abdominal Hernias

Hernias are abnormal protrusion of organs from the wall which contains it. Abdominal hernias are usually inguinal hernias, femoral hernias, paraumbilical hernias or incisional hernias.
Inguinal & femoral hernias occur in the inguinal (groin) region and may occur on one side (unilateral) or both sides (bilateral).

A huge Right sided indirect inguinal hernia which has entered the scrotum

Inguinal hernias are the commonest type of abdominal hernias. The main causes are: chronic cough, straining due to constipation or urine obstruction, weakness of the abdominal muscles or congenital defects (patent processus vaginalis). Inguinal hernias can be further divided into direct or indirect inguinal hernias but the management for both is the same. Direct inguinal hernia occurs thru the weakness in the transversalis muscle of the abdominal wall while indirect inguinal hernia occurs thru a defect in the deep inguinal ring. 
Both present with a swelling in the groin which expands on standing or upon straining. Most of the time the swelling is reducible. Sometimes the hernia may be stuck (incarcerated) or obstructed or strangulated (blood supply compromised). The swelling in an indirect inguinal hernia may enter into the scrotum in men. 
The management for inguinal hernia include treatment of the causes of the hernia and the mainstay of treatment is surgery.
Surgery can be either open surgery or laparoscopic surgery. Open surgery is a simple procedure which can be done under local anaesthesia as a day case in uncomplicated hernias. The hernia is reduced, the hernial sac excised and a polypropylene mesh inserted above the muscles to strenghten it. This is known as the Lichtenstein repair. Complicated cases (incarcerated or obstructed or strangulated) would need general anaesthesia and hospital stay. At the moment laparoscopic is indicated for recurrent hernias or bilateral inguinal hernias. The scars are smaller, it is less painful and patients are discharged earlier. 

Femoral hernias occur thru the femoral canal in the groin. The presentation is the same as inguinal hernias with a groin swelling. However, it has a much higher risk of strangulation due to the narrow opening of the femoral canal. Femoral hernias are more common in women. Treatment is with surgical repair which can be done under local anaesthesia for uncomplicated cases. Some surgeons approximate the femoral canal with sutures and reinforce with a pectineal fascia flap while some use a polypropylene mesh plug repair. Laparoscpoic repair can also be done. 

Paraumbilical hernias occur commonly is people with ascites (excess fluid collection in the abdominal cavity), those who are obese and those who have abdominal wall weakness. The swelling is usually noted just around the umbilicus. This should not be confused with umbilical hernias which occur in babies due to congenital defects. Paraumbilical hernias are repaired surgically. The surgery entails reduction of the hernial contents, excision of the hernia sac and application of a big piece of polypropylene mesh to cover the defect. 

Incisiona hernias occur as a late complication of abdominal surgery. A history of infection of the abdominal wound, malnutrition, complicated bowel surgery and obesity are predisposing causes. The swelling occur just under the incision scar of the abdominal wound. Surgery includes revision of the previous scar, reduction of the hernial contents and excision of the hernial sac. A big polypropylene mesh is used to cover the defect. Laparoscopic repair is also feasible for both paraumbilical and incisional hernias.

The complications of hernial repair are: bruising, bleeding, infection of the wound, infection of the mesh, seroma collection and recurrence. 
Complications specific to inguinal hernia repair include: ischeamic orchitis, testicular atrophy, scrotal oedema, hydrocoele, chronic pain due to neuroma or osteitis and numbness around the groin area.