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Questions 1–20
Published in Anna Kowalewski, SBAs and EMQs in Surgery for Medical Students, 2021
This patient is suffering from appendicitis. An inflammation of the vermiform appendix leads to changes such as oedema through to ischaemia and perforation. There is a maximal incidence in childhood because of the narrow neck of the appendix. The majority of cases are due to obstruction with a faecolith. The classic history (which occurs in 50% of cases) is as follows: there is a gradual onset of central, colicky abdominal pain and this pain then shifts to the right iliac fossa; the visceral pain now has become somatic, and this pain is worse on movement; there is nausea with or with vomiting, and there is a low-grade fever and anorexia. It is prudent to exclude ectopic pregnancy. There is guarding and rebound tenderness, usually over McBurney’s point, and pain can be felt on per rectum examination, which can mean a retrocaecal appendix.
SBA Answers and Explanations
Published in Vivian A. Elwell, Jonathan M. Fishman, Rajat Chowdhury, SBAs for the MRCS Part A, 2018
Vivian A. Elwell, Jonathan M. Fishman, Rajat Chowdhury
Afferent nerve fibres concerned with the conduction of visceral pain from the appendix accompany the sympathetic nerves and enter the spinal cord at the level of T10. Consequently, the appendix refers visceral pain to the T10 dermatome which lies at the level of the umbilicus. Only later, when the parietal peritoneum overlying the appendix becomes inflamed, does the pain become more intense and localize to the right iliac fossa in the region of McBurney’s point.
Clinical examination
Published in Nicholas Summerton, Primary Care Diagnostics, 2018
It is important to appreciate that some of these signs (i.e. rigidity, guarding, rebound tenderness and cough tenderness) are also general signs for peritonitis/ peritoneal irritation. However, finding a patient with pain and tenderness in the right iliac fossa, especially if they have McBurney’s point tenderness, a positive cough test and a positive Rovsing’s sign argues strongly in favour of appendicitis. One caveat is that some of the signs listed above that appear to have reasonable likelihood ratios exhibit poor inter-observer reliability. The kappa value for guarding is 0.36 (slight agreement), for rebound tenderness 0.25 (slight agreement) and for rigidity is only 0.14 (poor agreement).
Appendiceal sarcoidosis presenting as acute appendicitis
Published in Baylor University Medical Center Proceedings, 2020
Venkata Satish Pendela, Anisleidys Munoz, Mamta Chhabria, Pujitha Kudaravalli, Megan Soliman, Youssef Soliman
The patient was hemodynamically stable on arrival with a blood pressure of 120/70 mm Hg and a heart rate of 103 beats/minute. Palpation of the right iliac fossa disclosed tenderness. One hour after admission, the patient had an episode of nonbilious vomiting containing food particles. Her hemoglobin level was 11.2 g/dL; sedimentation rate, 9 mm/h; and white blood cell count, 4.2 × 103/µL. An ultrasound of the abdomen was suggestive of acute appendicitis with McBurney’s point tenderness. A computed tomography (CT) scan of the abdomen showed an appendicular mass. Magnetic resonance imaging (MRI) of the spine done just prior to this admission (for back pain) showed hypoechoic lesions concerning for vertebral metastases. A fluorodeoxyglucose–positron emission tomography scan done at the same time revealed extensive metastatic lesions with nodular uptake in the right upper lobe of the lung, numerous mediastinal lymph nodes, hypermetabolic foci in the axial skeleton, and focal hypermetabolism in the mid to distal appendix (standardized uptake value 3.8), concerning for an appendiceal neoplasm (Figure 1).
Trocar assisted distal shunt tube insertion with intra-operative X-Ray confirmation
Published in British Journal of Neurosurgery, 2019
Mostafa Osman, Ahmed Diraz, Andrew Wild
Surgical procedure The distal peritoneal entry point was in the left lower abdominal quadrant (inverse McBurney point) at which the abdominal wall is thin,2roughly, two finger breadth cephalad and medial to anterior superior iliac spine. Right side entry is usually avoided due to frequency of gaseous distention of the cecum and the increased prevalence of appendectomy scars at this site. Evacuation of the bladder, palpation of organomegally and avoidance of old scar decrease the incidence of visceral injury. The disposable split trocar (Codman©) was designed to be used for placement of both ventricular and peritoneal shunt ends.3 A small skin incision is done in all patients, with sometimes blunt muscle dissection in obese patients to decrease muscle layer resistance. The trocar (Figure 1) is inserted and directed in an angle of approximately 45°, away from retro-peritoneal vascular structures (Figures 2 and 3). We did not use plastic peel away catheters because of reported risks of kinking and breakage into the peritoneal cavity,4 requiring laparoscopy or laparotomy. The patient is brought to a light level of anesthesia prior to perforating the peritoneal cavity to minimize the possibility of damaging the intra-abdominal viscera and vessels. When anesthesia is light, the abdominal wall will tighten when the trocar is pressed firmly against it, allowing the surgeon to perforate the peritoneum without a large amount of displacement.3 A sustained Valsalva maneuver can be used to help trocar insertion; until a sudden release sensation and a noticeable “pop” sound when peritoneum pierced.
The application of improved abdominal wall punctures technique in ventriculoperitoneal shunt for hydrocephalus: a retrospective analysis versus open mini-laparotomy
Published in British Journal of Neurosurgery, 2018
Meiqing Lou, Guanghua Zhou, Yaodong Zhao
Recently, we treated hydrocephalus patients with VPS by placing the distal end of the shunt by blindly passing a trocar into the abdomibal cavity at the inverse McBurney point. Advantages of the inverse McBurney point puncture are: ease of future differential diagnose of suspected appendicitis; simple anatomic structures beneath with only small intestine or descending colon but without major vessels or nerve. The inverse McBurney point is a routine diagnostic abdominal paracentesis point with a good safety record. In comparison with traditional open mini-laparotomy, we found that the abdominal wall puncture technique had some advantages, and here we report it.