The appendix and I

As an intern I had assisted, as a first assistant many appendectomies done either by MS (General Surgery) PGs or senior residents and possibly performed an appendectomy or two myself. It used to be a muscle cutting incision at times and muscle splitting one most of the times. I have seen surgeons struggle many a time to identify the inflamed appendix especially when it is retrocaecal and grossly inflamed. A struggle for more than an hour to identify an appendix was commonplace. A mildly inflamed anteriorly placed appendix is usually the easy one. Whenever locating an appendix becomes difficult, the skin incision is extended followed by cutting the muscles.

While doing my PG, Dr.S.Deivanayagam, my teacher used to remove an appendix through a 2cm incision ( just admitting the tip of the little finger) ?and I had tried doing the same. A simple appendix used to come off easily through that incision but a thickened and inflamed one needed a slightly bigger incision. The best way to do an appendectomy was to deliver the entire caecum through the wound. We all had learnt the art of taking the ‘Z’ stitch to bury the appendicular stump by the time we had finished MS. During my early days in surgery, I had seen very little wound infection or any morbidity from an appendectomy. But there were quite many occasions when we had opened up for an appendectomy to realize that the duodenum was perforated and the gastric juice had trickled down to the right iliac fossa and cause mild serosal inflammation of the appendix mimicking appendicitis. Sadly, these patients needed another upper midline incision for closure of duodenal perforation. Actually those were the days when a right lower para-median incision was made use of for an appendectomy by most of the senior surgeons. I have also had the good fortune of seeing a few patients who had undergone a ‘Nellore’ appendicectomy.

There was a senior surgeon in Ootacamund (Ooty) where I had worked for a while who used to perform 3-4 appendectomies every single day. I was told that he was a medal student in surgery during his training days and he had owned long stretches of tea plantation in Ooty. Most of the appendectomies used to be in young girls whose appendices used to be as white as their teeth. Still, it used to be mentioned as inflamed in the operation notes which used to be written even before shifting the patient into the operating room. I had confronted him once and was given a strong warning by the anesthetist there not to disrespect elders.

One of the first patients I was allotted to take care as soon as I joined AIIMS as a senior resident in the department of GI surgery was a young and educated Bangaldeshi girl called Ms.Hashmi, an 18 year old who had an open appendectomy elsewhere and came to AIIMS with a faecal fistula. Stoma bags did not come into existence at that point of time and I had to build a well all around the fistula with karaya gum and keep sucking the affluent 24/7. The patient’s mother used to relieve me once in a while and took pity on me. This patient had long painted nails and wore a ring on each finger and that put me off completely. Or else I would have made friends with her and possibly chit chatted with her while I sat on her bedside focusing my attention on her fistula. Funnily the liquid fistula output used to come in bouts and would have soiled the sheets if I was not attentive. That fistula eventually healed without surgery and the girl went home. Her father was working in the Bangladeshi high commission in Delhi then. Around that time there was another patient named Chun Chun Jha, under our care and he had developed a fistula within fistula (type IV fistula) after a laparotomy in Bihar. His fistula was very difficult to manage. His bowel biopsy was sent to Mass Gen hospital and was reported as Crohn’s. He succumbed later on.

While working in SVIMS, Tirupati, one of my registrars took a semi VIP patient for an open appendectomy. I could not supervise him as I was scrubbed in a major abdomen case. From his body language, I was not convinced of his capability of carrying on an appendectomy independently but I had no choice but to let him. The histopathology came as ‘fatty tissue’ a few days later and the patient’s pain abdomen persisted.

While I was working in Kochi, Kerala, I had ventured into laparoscopic appendectomy and soon developed reasonable expertise. Appendicitis used to be an Ultrasound diagnosis by our radiologist who usually ceased to be sober after the sunset. It looked as though his sensitivity and specificity for making a diagnosis of appendicitis with an ultrasound used to drastically improve with the increase in his blood levels of ethanol. On one occasion one of post lap appendectomy patients developed tachycardia and abdominal distension hours after a lap appendectomy. Our radiologist was called in and he somehow managed to walk into the hospital without support late that night He suspected intra-abdominal bleed and he was right. The appendicular artery was spurting creating havoc all around. Yet on another occasion in Kerala one another patient post appendectomy developed acute abdomen and a re-laparoscopy showed the endoloop slipping away from the appendicular stump. We used to have a strange gastroenterologist working alongside in that hospital. He was a fellow from Andhra Pradesh and used to admit all pain abdomens under him that included appendicular perforations, diverticular perforations etc and used to refer to me three days later and make my life miserable. He was shunted out by the management soon after.

Later on, we did not have much trouble with lap appendectomy excepting that an occasional retrocaecal appendix seen plastered to the caecal wall and was found hard to separate. There were few instances of landing up in limited resection of the ileo-caecal region because of inflammation extending on to the caecum and making it friable. There were also times when the Babcock forceps had avulsed a piece of caecum. We were taught as students to follow the taenia coli to reach the appendix in times of difficulty. I was using monopolar cautery in the beginning to buzz the appendicular artery but later on shifted to a bipolar forceps. And presently I do not do a lap appendectomy without a harmonic scalpel. I have never used a stapler on the appendicular stump. And I also abandoned using a 400 metal clip on the stump. Its an endoloop always. As a protocol I use an endobag as I have seen many a patient developing umbilical port sepsis and post-op fever when an inflamed appendix is removed from the umbilical port without a bag. A slipped faecolith or bits of faeces cause havoc later on.

Much water has flown under the bridge since I have started doing appendicectomy and I still enjoy doing a lap appendectomy given a chance since my associates do it most of the time. Even today I see a handful of patients every week with right iliac fossa pain advised appendicectomy with impunity by someone outside with a normal ?WBC count and a CT abdomen showing a non-inflamed appendix. I was also told that some ultrasonologists are hand in glove with some neophyte surgeons and give a report of appendicitis in all patients with right iliac fossa pain of non-appendicular origin. ??