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APPENDICITIS OR WHY I’M GRATEFUL
I’M NOT A KOALA BEAR SURGEON!
BY CONOR MAGEE MD FRCS, CONSULTANT SURGEON
If you ask the general public to name an operation, it’s highly
likely that they will come up with appendicectomy - literally
“the removal of the appendix”. An appendicectomy is one of the
commonest procedures surgeons perform but what exactly is the
appendix and why does it need to be removed?
The appendix is a blind ending tube about 7cm long that originates in
the caecum - the caecum is the first part of the large bowel/colon and
sits low down in the right hand side of the abdomen. For many years
anatomists believed the appendix was just a vestigial evolutionary
throwback to the days when our ancestors were mainly plant eaters.
Plants are not the easiest foodstuff to digest - requiring a long stay
in our bowels to allow the digestive enzymes time to work. The
plant eaters of today (herbivores) have hugely capacious colons and
appendixes to let this take place. In contrast over countless millennia
the omnivorous diet of humans has allowed the appendix to wither
into a short, narrow stump.
Unfortunately, the narrow stump of the appendix means it is
susceptible to becoming blocked - and blockages within internal
organs is never a good thing.
Once the appendix is blocked it starts to swell and become inflamed
- and inflamed tissues are much less resilient to bacteria and over 72
hours the appendix transforms from a healthy tube into a sodden,
inflamed mess of pus and bacteria - true appendicitis.
The clinical presentation of appendicitis is so classical that it is one of
the diseases medical students learn about. Initially, the patient has a
general feeling of malaise and a vague pain around the belly button.
The reason for this is that although the appendix is inflamed your
brain has a very poor idea of localising where the appendix (or any
other internal organ is). There are very few sensory nerve fibres that
travel from the organs to the brain. The brain has to make a best
guess of where the trouble is, and in the case of the appendix it feels
pain around the belly button.
62 wirrallife.com
As time progresses there is a definite shift in the location of the pain -
at around 72 hours the patient complains of severe pain low down on
the right hand side of the abdomen. The pain is made worse by moving
and at this point the patient is clearly unwell. This characteristic shift
in pain is because the appendix is so swollen and inflamed it starts to
affect the lining of the abdomen- the peritoneum. The peritoneum
has an incredibly rich nerve supply and the brain knows exactly
which part is affected - and as the appendix lives low down on the
right side of the abdomen that is where the patient feels exquisite
pain. The peritoneum will become infected and inflamed and cause
peritonitis. It is a sobering thought that even today appendicitis can
be fatal- especially if it is diagnosed or treated late. Appendicitis can
cause sepsis - and it is the sepsis that kills.
The best treatment for appendicitis is surgical removal - open
appendicectomy. Appendicectomy is the operation junior surgeons
cut their teeth on- most patients are young and healthy and in many
cases removal can be swift and stratightforward. For decades the
operation was done through a moderate sized incision centred
over where the surgeon believed the appendix to be (a anatomical
landmark known as McBurney’s point). Often surgeons would try
and make the cut as small as possible to impress their peers, leading
generations of scrub nurses to watch inexperienced surgeons
struggle to find the appendix through a too-small cut. It is always
a significant learning event for a junior surgeon when their senior
arrives after hours of unsuccessful toil to simply make the cut larger
and remove the appendix within minutes!
Today the drive for smaller incisions has resulted in the adoption
of laparoscopic (keyhole) appendicectomy. The cuts are very small
and this allows a faster recovery. Despite this I am still called in to
help my trainees- sometimes the good old-fashioned open operation
is needed- and I always tell them to be thankful they aren’t a koala
bear surgeon- the appendix of a koala bear is over two meters long!!
Mr Magee operates at Spire Murrayfield Hospital and can be contacted
there. He can be followed on Twitter @mageefrcs.