Chapter 6. The appendix

Table of Contents
Appendicitis
Difficulties with appendicitis
Introduction
Biliary colic
Acute cholecystitis
Cholangitis
Cholangitis caused by [f10]Ascaris
Primary or recurrent pyogenic cholangitis
Cholecystectomy
Obstructive jaundice
Pancreatitis
Pancreatic pseudocyst
The surgery of the spleen

Appendicitis

Appendicitis is the commonest abdominal surgical emergency in the industrial world, and the one with the most variable symptoms. It is unusual in Indians or in African peoples living in their traditional way, but it has started to become more common as they discard their high-fibre diets. It can occur at any age, but is rare under five.

The disease starts as a localized infection of a patient's appendix, which either resolves, or proceeds further[md]perhaps to suppurate, or even to go gangrenous and perforate, or maybe only to quieten down and fibrose. If peritonitis does develop, it can either remain localized, or it can spread. If it remains localized, it does so by forming an ''appendix mass' of adherent coils of gut. This may then resolve, or pus may gather, so that an abscess forms. The distinction between: (1) a ''mass' which is not tender, or is only minimally tender, and over which there is no guarding or rigidity, and (2) an obviously tender ''abscess' is important, because an abscess may need draining, but a mass can be treated nonoperatively.

An abscess may resolve, or it may enlarge until it drains spontaneously to the surface, or into the patient's gut, or into his peritoneal cavity, where it causes generalized peritonitis.

The stages in the development of appendicitis merge into one another, they take time to develop, and a patient may present in any of them. So keep a picture of the evolution of the disease in your mind, and ask yourself ''What stage would his disease be in if he had appendicitis?''. If he has had time to develop a mass, an abscess, or peritonitis (several days), and he has not done so, he is unlikely to have appendicitis, or if he has it has resolved.

Peritoneal inflammation is responsible for the most important sign of appendicitis[md]tenderness in the right iliac fossa. Significant rigidity is a sign that peritonitis is spreading.

Central abdominal pain is usually his first symptom, and it may be severe enough to wake him from sleep. He feels it in the midline at or above his umbilicus, as a dull ache, or as central midline colic. Some hours later it moves to his right iliac fossa, and he may be able to point to it with one finger. Here it increases gradually, and is constant. It is now seldom severe or colicky, and is worse when he moves, as when he coughs, strains, or walks and so irritates his parietal peritoneum. He moves with caution, and may find it easier to stoop forwards. When he lies in bed, he is more comfortable with his right leg flexed.

He is almost always anorexic and nauseated. He usually vomits once or twice only, soon after pain starts; at this stage vomiting is never as severe as in cholecystitis, pancreatitis, or gut obstruction.

He may present at various stages:

(1) When the infection is localizing as an appendix mass. His history is likely to be that his symptoms began as above, then he began to feel better, his pain improved, and his appetite has begun to return. He now looks fairly well and he has only mild fever (37.5[de]C). The mass in his right iliac fossa is only mildly tender, with no guarding or rigidity.

(2) When infection has failed to localize, so that the mass has become an abscess. In this stage he is very unwell, anorexic and toxic; he has pain in his right iliac fossa, and his temperature has started to swing. The mass in his right iliac fossa has now become an abscess: (a) it may be only just palpable, (b) it may be bulging, tender, and fluctuant, (c) it may be in his pelvis, so that you cannot feel it abdominally, (d) it may bulge into the rectum, or (e) into the vagina (unusual), or (f) it may be palpable above the pubis. (g) It may even track along the right paracolic gutter to present in the right flank. (h) It may stretch and obstruct coils of gut.

(3) Just after perforation, when the colic and bursting pain of his distended appendix are suddenly relieved, so that he thinks he is much better, before peritonitis has had time to spread.

(4) When infection is spreading to cause local or generalized peritonitis. He now has generalized abdominal pain, tenderness, guarding, and rigidity. If he presents very late, he may be dehydrated, cachectic, oliguric, and hypotensive with a silent, distended abdomen. All you will know is that he has peritonitis[md]appendicitis is merely one of its possible causes. If he presents very late, he may be moribund.

Try to recognize appendicitis early, before it is allowed to reach the stage of peritonitis or an abscess. The delay of even a few hours can be critical. Experience will teach you when to operate. If you always wait until you are absolutely certain, an appendix may rupture while you wait. So be prepared to operate on the strong suspicion that a patient may have appendicitis. If you find a normal appendix on about 15% of occasions, your criteria for operating will be about right. Some of the alternative diagnoses require operation anyway, and some of those that might be harmed by operation, such as basal pneumonia, Ascaris infestation, or gastroenteritis, should be easy to exclude.

In spite of the long list of differential diagnoses that follows, the diagnosis is usually easy. But, remember that: (1) He may have no tenderness in his right iliac fossa if his appendix is deep in his pelvis. His pain may be central, but he may only be tender rectally[md]so always do a rectal examination. (2) He may have no central abdominal pain, so that pain first appears in his right iliac fossa. (3) The diagnosis is particularly difficult, but no less important, if he (or she) is very young, or very old, or pregnant.

Removing an appendix is sometimes easy, but is sometimes very difficult. Divide it between crushing clamps. Some surgeons invert the stump through a purse string suture. You may have difficulty: (1) His appendix may be difficult to find. (2) It may be difficult to deliver, if it is stuck deep in the wound and is obscured by bleeding. When this happens, you will find the procedure of retrograde removal described below very useful. (3) His caecum may be fragile[md]so take great care not to injure it. (4) If he has peritonitis, postoperative wound infection is common, so be prepared to leave his skin wound open.

Finally: Don't give him an antibiotic in the hope of ''cutting short early appendicitis'. It will only give you and him a false sense of security.

Fig. 12-1 REMOVING AN APPENDIX through McBurney's gridiron incision (if the diagnosis is in doubt a low midline or paramedian incision is easier). A, McBurney's point and the position of the incision. B, splitting the patient's external oblique aponeurosis. C, splitting his internal oblique and transversus muscles. D, opening his peritoneum between two haemostats. This drawing also shows how you can, if necessary, extend the incision medially by incising his anterior rectus sheath, and retracting his rectus muscle. E, passing a ligature through his mesoappendix. F, the purse string suture is in place, but is not pulled tight. His appendix has been tied, and is now being grasped between two haemostats and divided. G, the stump of his appendix is about to be pushed into his caecum, as the purse string is pulled tight. H, the stump of his appendix invaginated into his caecum by the purse string. I, the various positions in which you may find his appendix. About 3/4 of the time it is behind his caecum, and 1/4 of the time it is in his pelvis. It is seldom anywhere else. Partly after Maingot R, ''Abdominal Operations', (4th edn. 1961), p.811 Figs. 2 and 3. HK Lewis, with kind permission.

APPENDICITIS HISTORY EARLY HISTORY. Ask carefully how the symptoms began[md]''Where did the pain start?'' How do the other symptoms fit into the story? Most importantly, where in the natural history of the disease is the patient now? Remember that a retrocaecal or pelvic appendix may cause diarrhoea or frequency of micturition.

EXAMINATION PULSE AND TEMPERATURE. In the early stages his pulse is normal, and his temperature nearly so. If his pulse is raised, his appendix has possibly perforated. A steadily rising pulse is always serious. If he has a rigor or a high fever within 24 hours of the onset of symptoms, appendicitis is most unlikely.

INSPECTION. Typically, his lower abdomen moves little, but there is otherwise nothing else on inspection.

TENDERNESS on deep palpation in his right lower quadrant over McBurney's point is the single most useful sign, but: (1) You must examine his whole abdomen systematically with the flat of your hand. Examine his left hypochondrium first. Compare both sides, and his upper and lower quadrants on the right. Don't dig your fingers into his right lower quadrant. (2) If his appendix is behind his caecum, he may be tender in his flank. If it is in his pelvis, he may only be tender in his rectum, or above his pubis. (3) If he has spreading peritonitis, he may be tender well beyond McBurney's point, over much of his abdomen.

If you press gently but firmly in his right iliac fossa, and then quickly release your hand, he may feel a sudden pain. This is rebound tenderness, and is a sign of peritoneal irritation. A kinder way of eliciting this sign it to test for tenderness to light percussion. This is not so painful and is a better sign as to where the disease began.

Pain felt in the right iliac fossa when you press deeply in his left iliac fossa (Rovsing's sign) is another suggestive feature of appendicitis.

GUARDING is a sign of local peritonitis. Lay your hand flat on his abdomen, and gently flex your MP joints. If there is complete painless relaxation over his left inguinal fossa, and any tightening over his right fossa, the sign is positive. Gently compare both sides, testing the left one first and and distracting his attention while you do so.

RIGIDITY is a comparatively late sign, and shows that infection has reached his anterior abdominal wall. Generalized rigidity is a sign of generalized peritonitis. It is less marked if he is obese, emaciated, very old, or very young.

AN APPENDIX MASS may be palpable if his symptoms have lasted more than 2 or 3 days. If he is obese, or has a very low pain threshold, it will be difficult to feel. Distract his attention while you feel it. The mass is ill-defined and is probably an abscess if: (1) it is tender, (2) he has a high fever, or (3) there are features of intestinal obstruction.

RECTAL (or vaginal) EXAMINATION for a mass or tenderness must never be forgotten[md]the patient's inflamed appendix may be dangling into the pelvis. A rectal examination will often distinguish salpingitis, and a right-sided ectopic pregnancy. Slowly pass your half-flexed, well-lubricated index finger into his rectum (use your little finger in a child under 10). When it is completely inside, keep it still for a moment. Wait for him to relax, then gently press forwards, posteriorly, and on each side on his pelvic peritoneum with the tip of your finger.

CAUTION! Don't let him confuse the discomfort of you putting your finger into his anus, with the pain of you pressing on his pelvic appendix. Wait with your finger in his rectum until his initial discomfort has settled, then flex the tip of your finger and note the response.

SPECIAL TESTS. Do the psoas and iliacus tests (10.2).

THE DIFFERENTIAL DIAGNOSIS [s7]OF APPENDICITIS IN EITHER SEX. This is long list, but the most important possibilities are the first two.

Suggesting an UPPER RESPIRATORY INFECTION, a viral infection, or tonsillitis[md]upper respiratory symptoms, generalized muscle aches. All these can cause central abdominal pain in a child. Watch him, especially his pulse, and if this does not settle, and his abdomen remains painful and resistant to palpation, he probably has appendicitis.

Suggesting GASTROENTERITIS[md]diarrhoea, perhaps with vomiting. His pain will be colicky, his tenderness poorly localized, and there will be pus cells in his stool. Be sure to do a pelvic examination, if necessary several times, because he may be developing a pelvic appendix abscess.

Suggesting AMOEBIASIS[md]a history of diarrhoea with blood and especially mucus: look for amoebae in his stools (31.10).

Suggesting TYPHOID with involvement of his terminal ileum or a perforation[md]a history of fever, diarrhoea, and diffuse abdominal pain for about 3 weeks, suddenly becoming acute (31.8).

Suggesting ILEOCAECAL TUBERCULOSIS[md]chronic pain which is sometimes colicky, and general deterioration in his health (29.5).

Suggesting a PERFORATED PEPTIC ULCER[md]the pain, which he now has in his right iliac fossa, started suddenly in his upper abdomen, and he has a history of chronic dyspepsia. Enquire for shoulder tip pain (10.1).

Suggesting ILIAC ADENITIS[md]a tender fluctuant mass in his lower quadrant, and a marked flexion contracture of his hip (5-10). Look for the primary source of the infection in his legs or perineum (5.12).

Suggesting a URINARY INFECTION[md]frequency and dysuria. These symptoms can also be caused by appendicitis.

Suggesting HYDRONEPHROSIS[md]a nagging pain in his costovertebral angle.

Suggesting RENAL COLIC[md]severe intermittent pain radiating into his groin. No fever. Test his urine for red cells.

If he has adopted a western life style, carcinoma of his caecum and diverticulitis are other possibilities.

IN WOMEN there are several more possibilities.

Suggesting PID[md]pain on both sides of the patient's lower abdomen for 3 days or more (rather than 12 to 36 hours, as is usual with appendicitis), a history of infertility, and previous pelvic infection. A tender fixed, or occasionally fluctuant, adnexal mass on her right side. If she has advanced signs of pelvic peritonitis with a short history, the mass (a tubo-ovarian abscess) may have ruptured. Examine her cervix for a purulent discharge (6.6). PID may be impossible to distinguish from a pelvic appendix (12.1).

Suggesting TORSION OF AN OVARIAN CYST[md]a brief history of acute pain localized to her suprapubic area (20.7). A mass palpable vaginally or bimanually. Her temperature will not be high.

Suggesting a right-sided ECTOPIC PREGNANCY[md]signs of hypovolaemia, signs on pelvic examination (16.6), and the aspiration of blood on a 4 quadrant tap (66.1). If her ruptured ectopic pregnancy bleeds more slowly (16.7), diagnosis may be more difficult.

Suggesting OVULATORY BLEEDING[md]the pain started in the middle of a menstrual cycle; mild abdominal tenderess without fever. It will settle in a few hours.

MANAGEMENT [s7]OF APPENDICITIS Treatment is usually straightforward.

(1) If you see a patient early, with appendicitis or suspected appendicitis, remove his appendix.

(2) If you see him later, with a satisfactorily localizing condition (an appendix mass), and nothing suggesting peritonitis, an abscess or obstruction, treat him non- operatively, and delay the appendicectomy until 6 weeks later. Adhesions will not be much of a problem.

(3) If his history has lasted more than 3 days, and he has signs of an abscess which is enlarging, drain it through his abdominal wall, or else into the rectum or posterior fornix of the vagina. If, when you drain an abscess abdominally, you find an appendix which is not friable, remove it; otherwise leave this part of the treatment for 2 months, when the infection will have settled. See below.

(4) If he presents with local or general peritonitis, resuscitate him and treat him for peritonitis (6.2). If his appendix is friable, or requires much dissection from the neighbouring tissues, leave it, otherwise remove it.

(5) If he appears to be moribund with severe toxaemia, hypotension, oliguria, and a tense, tender, silent, abdomen, his outlook is poor. Resuscitate him as best you can, ''suck and drip him' (9.9), give him antibiotics (chloramphenicol and metronidazole, 2.9), and operate as soon as he is fit.

CAUTION ! (1) Infection is less likely to localize at the extremes of life, so don't be too non-operative if he is very young or very old, or in pregnancy. (2) Don't try to remove an appendix if infection is arrested or resolving. You can safely do an interval appendicectomy 6 weeks later. If you leave it, it will probably resolve.

NON-OPERATIVE TREATMENT [s7]FOR APPENDICITIS INDICATIONS. A patient who is satisfactorily localizing his infection[md]an appendix mass, with no signs of spread. It is seldom advisable in children under 10 or in the elderly.

METHOD. Monitor him with the greatest care. Give him no antibiotics. Rely on his own assessment of himself, especially on such questions as ''Is your pain still subsiding?'' ''Can you move about more freely?'' ''Has your appetite improved?''. Monitor his temperature, his pulse, and his white blood count. Palpate his mass gently, and mark its outline on his abdominal wall daily with a felt pen. Examine and manipulate it as little as possible. Give him fluids only by mouth at first, then after a day or two a light diet. If he continues to improve, and his mass continues to shrink[md]good. He can start to eat quite normally in 4 days and treatment can be relaxed. Ask him to return for an interval appendicectomy in 6[nd]12 weeks.

If any of the following occur, abandon non-operative treatment: (1) His pain gets worse, or he begins to feel generally worse. (2) His mass enlarges. (3) His abdominal tenderness increases or guarding develops (peritonitis). (4) He develops signs of intestinal obstruction (due to an abscess). (4) His pulse rate increases. This is a very important sign. A slightly raised temperature is of less importance in the early stages, provided that his pulse is steady or falling. A persistently high or swinging temperature shows an abscess that needs drainage. Any or all of these things show that infection is spreading, so operate for an enlarging abscess, peritonitis, or obstruction. Remember the danger signs as 4 ''Ps'[md]''pain, pulse, pyrexia, and palpable mass'.

If his general condition improves, but the mass shows little sign of shrinking, it may be a sterile abscess[md]wait until it is dull to percussion, showing that it is extraperitoneal, and then drain it extraperitoneally.

CAUTION ! (1) Non-operative treatment is only applicable in hospital. (2) Be particularly careful when you apply it to the very old or the very young. (3) Don't give him antibiotics (unless he has generalized peritonitis): they may mask the symptoms which show that non-operative treatment is failing.

Fig. 12-2 RETROGRADE APPENDICECTOMY. A, the proximal end of the patient's appendix has been freed from his caecum and tied. B, it has been divided proximally and is being released distally from his caecum. C, it is very nearly free. Partly after Maingot R, ''Abdominal Operations', (4th edn. 1961), p.816 Fig. 7. HK Lewis, with kind permission.

ACUTE APPENDICETOMY EQUIPMENT. A general set (4.12). Suction.

PREPARATION. Start nasogastric suction (4.9). If he is dehydrated, resuscitate him for an hour or two before you operate. Give him intravenous Ringer's lactate or saline. If an adult looks dehydrated, he may have a fluid deficit of up to 4 litres (A 15.3). If he has generalized peritonitis, insert an indwelling catheter, and monitor his urine output. He should pass 1 ml/kg/hour (A 15.5).

ANTIBIOTICS. If he has peritonitis, give him perioperative antibiotics (2.9). Some surgeons give rectal metronidazole routinely.

ANAESTHESIA. Aspirate his stomach and put 30 ml of magnesium trisilicate down the tube. (1) Thiopentone, suxamethonium, and intubation under cricoid pressure, followed by ether from a vapourizer. (2) Ketamine drip with relaxants. (3) Plain ether (A 11.1). (4) A general anaesthetic from a Boyle's machine. You will need good relaxation. In the early stages, anorexia and vomiting may have kept his stomach empty, but you cannot rely on this[md]if there is ileus it may be full.

WHICH INCISION? Prepare and drape his abdominal wall, so that you can see his anterior superior iliac spine and his umbilicus. As soon as it is relaxed under anaesthesia, palpate it carefully. You may be able to feel a mass whereas previously you could not. This may help you to site the incision.

If the diagnosis is not in doubt, and the symptoms have not lasted long, make a gridiron incision.

If he presented late, and you suspect that adhesions may make dissection difficult, make the same skin incision as for a gridiron, but cut through the muscles in the same line as the skin incision. This incision has the advantage of being easily extended in either direction. If you have just palpated a mass, centre your muscle-cutting incision on the mass.

If the diagnosis is in doubt, and a gynaecological condition or a perforated peptic ulcer is a possibility, or he has generalized peritonitis (especially if he is a child), make a median or right paramedian incision (9.2). You can explore more widely, and you will also be better able to wash out his peritoneal cavity afterwards if necessary.

TO MAKE A GRIDIRON INCISION draw a line from his umbilicus to his anterior superior iliac spine. McBurney's point lies at the junction of its outer and middle thirds. Centre a 7 to 10 cm skin incision on this point. Alternatively, site it over the mass or at the point of maximum tenderness and resistance.

Split his external oblique muscle aponeurosis in the line of its fibres, which is the same as that of the skin incision, over its whole length. Resist the temptation to extend the incision too far medially.

Hold the edges of his oblique aponeurosis aside with haemostats, and you will see the fleshy fibres of his internal oblique running transversely, and a little upwards. Insert a closed pair of blunt scissors between them and use the ''push and spread technique' (4-8) to separate them. Then extend the incision with your fingers. Replace these by retractors, to expose his transversalis fascia and peritoneum. Pick these up as a single layer and separate them in the same way. Open his peritoneum between haemostats by the method in Fig. 9-2.

EXPLORING THE ABDOMEN [s7]FOR ACUTE APPENDICITIS Raise the edges of his peritoneum with retractors and look inside. Some exudate may escape. It does not indicate peritonitis, unless it is obviously purulent and foul-smelling. Suck it away. If his caecum is covered by small gut, look for it by sliding a finger into his paracolic gutter. If there is much fluid, suck it away.

If you have difficulty finding his appendix: (1) Look for his pink to grey-blue caecum first. It is often higher than you expect, and it may lie under his liver (unusual). The three taenia coli of the caecum converge on the appendix, which lies on its posteromedial side. Follow the anterior taenia to its base. The tip of his appendix may lie under his caecum, or in his pelvis. With your index finger, feel for something tense and rigid. (2) Retract the wound edges a bit more. (3) Extend the incision as described below.

CAUTION ! (1) If he has localized peritonitis, take particular care not to spread the infection. (2) Don't mistake his caecum for his transverse colon[md]this has greater omentum attached along its anterior surface. (3) Try to break down as few fibrinous adhesions as you can.

Put your finger under the anterior taenia and test the mobility of his caecum. If the tip of his caecum is free, it and his appendix should come to the surface easily. Grasp his caecum with a moist pack, and gently drag its lower end into the wound. His appendix should follow it. Don't rupture it, and use the minimum of force. If omentum is folded round his appendix, try not to separate it. Instead, tie it, and remove the adherent part with his appendix.

If you need to extend a gridiron incision: (1) Extend the muscle splits. Or, (2) cut across his muscles superolaterally. Or, (3) cut into his rectus sheath medially (D, 12-1), taking great care not to cut his inferior epigastric artery, which runs vertically on the deep surface of his rectus muscle.

CAUTION ! (1) Don't try to work through too small a hole. (2) The only common differential diagnoses which you cannot treat through a gridiron incision are a perforated peptic ulcer and cholecystitis, in which case, close the gridiron incision and make a paramedian one.

If you have been able to deliver his caecum and appendix into the wound, the next step is to tie the vessels in his mesoappendix. Hold this up to the light, and look for a ''window' close to the base of his appendix, clear of blood vessels, in which to make a small incision. Pass an aneurysm needle through it, and tie the vessels with 2/0 chromic catgut. If they are friable, tie them several times.

Apply two clamps to the base of his appendix, and divide it between them. Tie its base with chromic catgut, as close to his caecum as you can.

Inversion of the stump (optional). Use an atraumatic suture of 2/0 or 3/0 chromic catgut to apply a purse string suture, about 1 cm away from his appendix, through the seromuscular layer only (F, 9-6). Leave this loose for the moment. Invert the stump with fine forceps, and then close the purse string snugly over it.

If his caecum is very oedematous, tie his appendix, but don't invaginate it[md]drain it instead.

If his appendix has stuck in his pelvis, or behind his ileum, and is surrounded by a small abscess, improve exposure by retraction, and by extending the wound downwards. Pack the area off with swabs, and cautiously free it by sharp or blunt dissection.

CAUTION ! (1) Don't apply artery forceps to his mesoappendix. If they fall off, there will be brisk bleeding. (2) Be patient and gentle when you try to remove a tense, unruptured, gangrenous appendix. (3) If it is on the point of bursting, try to deliver it intact. If it bursts, you will greatly increase the chances of peritonitis.

If his appendix is stuck down behind his caecum or colon, it will be held by fibrous tissue, so that you will not be able to free it with your finger. Extend the incision upwards and laterally by an oblique cut through all layers of the abdominal wall to get better access. Now expose the lateral side of his caecum where there is a gutter. Using MacIndoe scissors, carefully divide the peritoneal reflection on the lateral side of his caecum, using the ''push and spread' technique. Using a swab on a sponge-holding forceps, mobilize his caecum medially. Grasp it with a swab, and gently draw it up and out of the wound. If it will not come, work your finger in the plane between it and his posterior abdominal wall. If convenient, do a retrograde appendicectomy, by tying off the base of his appendix first, and then freeing it towards its tip.

If his appendix has perforated, there is a 90% chance that there is a faecolith somewhere, either in his abdomen or his appendix. Faecoliths are calcified, and may show on a plain X-ray.

CLOSING HIS ABDOMEN. If he had a ''cold' or early acute appendicitis, close his peritoneum with a running suture, and tie its ends together. Bring the edges of his transversus and internal oblique muscles together with a few stitches. If necessary, bring his peritoneum, transversus, and internal oblique together as a single layer, taking care not to strangulate them. If you have had to cut muscle, bring its edges together with one or two sutures. Close his external oblique with continuous catgut, and his skin with interrupted monofilament.

If you have removed a dirty contaminated appendix, leave his wound open. Close his peritoneum in the usual way, and close his muscles with interrupted monofilament, but don't put any sutures in his skin. Insert some gauze to keep the fascial layers a little open. If there is no significant discharge, suture his wound on the 5th day.

DRAINS are not usually indicated. They are much less important than sucking out and washing out the infected area at the time of surgery. Consider inserting an intraperitoneal drain if: (1) You have had to leave his appendix behind. (2) You are worried that there may be bleeding from any cause. (3) His caecum has been involved in the inflammatory process. (4) A gangrenous appendix has caused severe local contamination of his peritoneum.

If he does need a drain, insert a corrugated rubber one down to his appendix stump, or insert a 6 mm rubber tube. Remove one- third of its wall in the area which is to be drained, bring it out through a short incision in his flank, and suture it in place. Remove it as soon as it stops discharging.

Fig. 12-3 DRAINING AN APPENDIX ABSCESS. A, the anatomy of the appendix. If you cannot find a patient's appendix, follow the anterior taenia of his caecum down to it. Sometimes, a faecolith forms in his appendix. If this escapes into his peritoneal cavity, it may be the cause of a persistent abscess. B, approaching an abscess extraperitoneally. C, avoid the intraperitoneal approach, unless you happen to come across an appendix abscess unexpectedly during laparotomy.

DRAINING AN APPENDIX ABSCESS INDICATIONS. A tender mass which is increasing in size in a patient with a history of appendicitis, or more rarely following appendicectomy 3 or 4 days previously, especially if he has increasing pain, pyrexia, and toxaemia.

THE EXTRAPERITONEAL APPROACH is best. If his abscess is dull to percussion, there is no gut between it and his abdominal wall. It has probably stuck to his abdominal wall, so that you can easily drain it under local anaesthesia.

Try to enter the abscess, but not his peritoneal cavity. Mark the point of maximum tenderness and fluctuation with a felt pen. Anaesthetize and incise his skin and muscles at this point. Try to enter the abscess as far laterally as you can. His muscles will be soggy and oedematous, but you can split them in the usual way, by pushing in a haemostat and opening it. Push a finger in laterally and backwards to make sure that the drainage track is big enough. Suck out pus, break down any loculi, and feel for and remove any faecoliths. Then push a large corrugated rubber drain well in. Suture this to his skin and shorten it gradually after the 5th day. Remove it completely at the 8th or 9th day. He does not need an antibiotic unless there are signs of peritonitis. Ask him to return in 8 weeks to have his appendix removed.

CAUTION ! (1) Don't try to remove an appendix from the bottom of a large abscess cavity with much friable tissue that bleeds easily. Drain the abscess and leave his appendix in place. Do an interval appendicectomy later. (2) Avoid the intraperitoneal approach, unless it happens by accident, as when laparotomy unexpectedly reveals an appendix abscess.

INTERVAL APPENDICECTOMY If you have treated an appendix mass or abscess conservatively or by drainage, and left the appendix in, and he lives far from hospital, advise him to return for an interval appendicectomy at 8 weeks.

If he has any symptoms while he is waiting for it, ask him to report immediately. If you have allowed 6 to 12 weeks to elapse since his attack of appendicitis, you can usually remove his appendix quite easily. If you leave too long an interval (say three months), there is an increasing risk that he will get another attack of appendicitis meanwhile.