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MODIFIED APPENDICECTOMY

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The incidence of wound infection, hospital stay and operation time showed no significant difference. Modified appendicectomy has accomplished complete removal of the pathologi-cal appendiceal tissue along with doubly secured closure of the caecum and minimum raw surface. There no risk of compromisation of the blood supply to the caecum or no deformity of caecum would be there. It has reduced the incidences of the post appendieectomy pain. It is encouraging to advocatemodified appendicectomy a better procedure truly needed for the disease appendicitis.

INTRODTJCTION

Last one century there was less appreciable development in the management of the disease appendicitis, (1-2) Overall improvement in the result is due to introduction and free use of the antibiotics (3). It has continued to pose with diagnostic as well as therapeutic challenge to medical practitioners especially surgeons (4). Appendicectomy is being commonest surgical procedure performed in emergency laparotomies. Even minor improvement in the modality of the treatment will be beneficial to a large number of patients. The management of the appendiceal stump has been discussed and published on large scale (5) Pragmatically three main methods in dealing the appendiceal stump are evolved. The commonest method used all over the world is to crush and ligate base of the appendix. The appendicectomy is performed by leaving, small stump which requires imaginations into caecal wall by means of a purse string suture whenever possible. Theoretical, advantage of this method include good control of haemorrhage from the stump, minimum peritoneal contamination and doubly secured closure of the caecal wall. The serosa to serosa good approximation reduces raw surface to minimum and thought to be a factor for reducing risk in forming the adhesions. In fact purse string suture by which invagination of the appendiceal stump is achieved may compromise blood supply of the caecal wall, leading to inflammation, necrosis, abscess or resolving ultimately into adhesions (6). Perforation of the appendiceal stump, further complicating into abscess formation had been observed in about 0.5 % of the appendicectomies (7-B) Rarely disruption of the purse string suture on caeeal wall with intact ligature present on stump of the appendix has been reported (B) In 20 cases intussusceptions of invaginated stump of the appendix has been recorded (9).In 1937 Osehner & Lilly prefened only invagination of the appendiceal stump without ligating it. ( 5) It has significant incidences of bleeding into the caecum or into the peritoneal cavity. It was prevented by stump ligation Probably Kronlein inlroduced simple ligation of stump without any invagination in 1984 (11). It was theoretical consideration that, following simple ligation of the' appendiceal stump without burying may contaminate peritoneal cavity from the open end of the stump. Even sloughing of the religated stump or loosening of the ligature is possible, It is pragmatically observed whenever stump is only ligated usually it is longer than routine stump at least by 2-J m.m. in length in apprehension of sliping of the ligature. It may produce post appendicectomy pain due to remnant of the appendiceal lymphoid tissue. It has certainly few advantages like simplification of technique, shortening of the operation time and produces no deformity of the caecum (12), In review of over 1000 cases of the appendiceetomies Kingsley reported that there were less complication when invagination step was omitted (11). All above methods are in the practice implemented in treatment of appendicitis since last one century with their few advantages and with few potential dangerous complications. The new technique is in the form of modified appendicectomy which is devised to achieve, complete removal of the appendix along with the core of the caeeum, It gives doubly secured closure of the Caecum without, Compromising its blood supply and deformity. A review of experience of l50 Case is presented to consider small change in technique.

MATERIAL AND METHOD

150 cases of the acute appendicitis were treated by modified  appendicectomy from year 1983 to 1985, The disease noted in 2nd, third, 4th decades maximum in males predominantly than in females (Table 1). Table 2 reflects from the patients case history recorded at the time of admission. Classical pain over or around Mc Burney,s point was present in 97.2o/o cases. Patients reached to the hospital  within 24 hours, 30 within 48 hours, 14o within 72 hours after f first attack and 9.Zo/o after 72hours. Dyspepsia followed by nausea and/or vomiting was present in j;.Zo/o cases pyrexia was noted in ?4o/o eases. Bowel habits were chranged in 11o/o cases. Tachycardia was noted in 41o/o cases, where as normal pulse rate was in 52o/o cases. Temperature above 100oF.  was present in 14o/o cases. Tenderness in the right iliac fossa was the key point for the diagnosis present in all cases. 11.2o/o of the cases had tenderness over right flank and in 16vo eases all over the abdomen. Guarding was noted in 50.60/o of cases in right iliac fossa, over right flank in 16,60/o cases and all over abdomen in 14.60/ocases. The rebound tenderness in 1\o/o cases was indicating peritonitis. Total white cell count was raised in 55o/o cases above 10,000 where polymorphs were above 600/o in only 52o/o cases indicated a significant, aid but was not mandatory for diagnosis (14) (tabte j). plain X-ray abdomen in standing position had demonstrated paralytic ileus in 10o/o cases and free gas under diaphragm in 2%o cases.

Exploratory laparotomy was done through Mc Burney's or mid right paramedian incision depending on positivity of the clinical diagnosis for acute appendicitis. The base of the appendix as may. always be *", 'fornd by tracing the anterior tenia coli of the caecunr. onee the appendix had been mobilized the mesentry of the appendix was divided between clamps and ligated with 60 number linen near the appendix. Two Bab cocks were applied to caecum on either side of the appendix and lifted up, contentsof caecum milked down, and isolated by moist packs. Intestinal clamp was used to occlude lumen and to avoid bleeding wherever possible. A haemostat was applied at the base of the appendix on the caeeum and cut flushed under it. The opened caecum was closed with 2/0 chromic cat gut on eyeless needles including all layers. The sero muscular second layer enforced over it by 100 flo' barbour. In case of oedematous caecutn it was covered with mesoappendix as second layer. The drain was kept in those cases where free pus was noted with instillation of antibiotics into the peritoneal cavity. (15-15) Tne average operation time required was 45 minutes.

RESULTS

There Was no mortatity in 150 cases in the post operative period, wound problems were noted in the form of infection in 27 cases (18%) and wound dehiscence in t cases (2o%). Paralytic ileus was present, in 24 eases (16%) which was settled with electrolyte corrections and nasogastric aspiration. Respiratory problems like pneumonia and atelectesis noted in 6% cases were treated by steam inhalations and repeated endotrachial suctions. The expected complications like faecal leak or fistula was not detected (table No. 4).

Histoiogy study of the appendicectomy specimen indicated there was no typical clustered follicular lymphoid appendiceal tissue at cut edges in atl cases on longitudinal sections. Acute inflammation was noted in 51 cases and catarrhal inflammation in 54 cases which accounts for 105 cases(7OYo) (Table 5). Phlegmons and perforations were present in 14 and 18 cases respectively.