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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.


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.


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.


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.



All the methods dealing with appendiceal stump has advantages' and disadvantages. It has been proved pragmatically that the invagination of the ligated stump and only ligation of the stump has no difference in post operative complications (8, 13). The invagination of stump may compromise blood supply of the caecum and can cause inflammation and may promote the adhesions. The interupted sutures creat,e no problem about vascularity of Lhe caecum and it is also guarded by second sero muscular layer. Persistence of small appendieeal stump may be nesponsible for post appendicectomy pain and perforation of the long stump has been reported by Francis 1979 (17). The complete removal of the appendiceal tissue is only possible along vlith core of the caecal wall. In general the understanding about poor healing of the caecal wounds due to less vascularity is changed and confirmed by caecoplasties. Only 1\o/o cases had wound infection (Table 4) similar incidence holds good for the routine appendicectomies with or without invagination of the stump (8,9,12). The modif ied procedure has no added complications like increase in the incidences of wound infection, faecal fistula or intraperitoneal abscess. All the way it has proved complete removal of the appendiceal tissue, doubly secured haemorrhage from the caecal wall, absolute reduction in raw surf ace, no compromisation of theblood supply of the caecal wall and no deformity of caecum The average operation time required is 46 minutes is also same as routine procedures require (12). Though it is small series of 150 cases in this .n"tyrir, it is encouraging to advocate a better appendicectomy truly needed for the disease appendicitis.


1. Berry J. Malt R.A. Appendicitis near its centenary Ann. Surgery 1984 Z0O 569 _ 5J5.

2' Edwards F.H. Davies R.s. use of a bayesian algorithm in the computer assisted diagnosis of appendicitis. 4

3' Gottrup F' Prophylactic metronidazole in prevention of infection  after the appendicectomy. Repor[ of a double blind trial, Acta chir scand. 146_133.1980.

4' Loffal Ld, cooperman A. Etal, Appendicitis : A continuing surgical challenge An. J. Surg. 11j-654_1961.

5' Oschner A. Lilly G.; The technique of appenflicectomy - Surgery 19Jl l;5)2-53.

6' Bradley EL III and ,lsaac J' Appendiceal abscess revisited Arch surg.113-1tA-82 1g78.

7. Sinha Ap. : Appendieectomy an assessmdnt of the advisibility of stump, invagination, Br. J. Surg. G4 z 449-?00- 1977.

B' Thomas M. P, Burst stump abscess f ollowing appendieectomy. A report of our cases N,Z" Surg. 441 4l-49 z 1974.

9' Lassalle AJ, Andrassy RJ : Page Cp, etal. Intussusception of appendiceal stump, elin. pediatri , 19 : 4jz_4j5_1980.

10' Sandmark M. Serious delayed rectal haemorrohage following haeomplinatecl appendieectomy. Report of a case, Acta. Chir Scand 143 : l,l5-18(t ^,gll.

11' 'Kronlen RU. Ueber die operalive Behandlund der aeulen difusen Jauchigeiteri-gen peritcultis. Arehis Klin chir. lBBg z 33 z 507 - ?4,

12. L. Engstron, G. Fenyo, Appendicectomy assessment of stumP invagination '-versus simPle ligation. Br. J. Surg. 1985 z 7?. 971-97''

13. 1t. Kingsley DEP, some observation on appendicectomy with particular reference to technique' Br' J' Surg' 1969 z 491-496'

14. A. Murray and MR. Madigan' The leukocyte count and histological appearance in acute appendicitis - Br' J' Surg' Vol 171-119-'20 - 1984'

15. BatesT;DownRHLetal,Topicalampicitlinsinthepreventionsofwound infection after appendicectomy Br' J' Surg' 61 z 489' 1974'

16. Tanphiphatic; Sangsuubhanc; vanqvarvipartv etal a lvound infection in emergency appendieectomy a prospective trial with topical ampicillin and antiseptic solution irrigation' Br'J'surg' 1978 t 65'

17. Fransis D. The grumbling appendix Br' Med' J' 21 936-1979'



Incidence of acute appendicitis, in relation to age and sex.

AGE                Male            Females

1- 10              84                     4

10-2o              06                    2

20-30              33                   23

10-40              29                   07

40-50              06                   10

50-60               02                  02

Total                84                   66




I    Plain in Right Iliae Fossa                                    140 Cases ( 97.2 %)

around Mc Burney's point

II Onset of Pain                               24hr              48 hours             72 hours                    More than 72 hour

72   ( 48%)       45 ( 30 % )         21 ( 14% )                   14 ( 9.2% )


III Fever     36 Cases (24 %)


IV  Nausea  - Vomitting    52 cases (34%)


V Change in bowel movement           24 cases ( 16%)

VI  Pulse              > 100/min.           100-120/ min.    < 120/min.

78 ( 52% )             24 ( 16% )            48 ( 32%)


VII  Tenderness In                 RIF                     150 (100%)

Right Flank         25 ( 16.6%)

Right abdomen   17(11.2%)

Generalized         24 ( 16%)

VIII Gaurding                         in RIF                   76 (50.6 %).

Rt.  Quadrant     25 (16%)

Rt Abdomen       22(14.6%)

IX  Rebound Tenderness                                   27 (16%)


Table No 3

Laborotary & Radiology

W.B.C.                                  >  10000                   <10000

66 (44%)                     84 (56% )

Poly. Morph.                        60% or more              60 % or less

78 ( 52 % )                 72 ( 48 % )

Radiology        Plain X-ray Abdomen

Paralytic Illus        15 ( 10 %)

Gas Under diaphragm   3 Cases ( 2 % )


Table No 4

Post operative complication

Wound infection.                                 27 ( 18%)

Wound dehiscence                              03 ( 2%)

Post appendicectomy Abscess         Nil.

Feacal fistula                                        Nil.

Paralytic ilus                                        24 ( 16 %)

Bleeding PR.                                           Nil.

Respiratory problems                           09 (6% )


Table No 5

Histology study

Normal Appendix                                         03 ( 2 %)

Acute appendicitis                                       51 (34%)

Catarrhal Appendicitis                                   54 (36 %)

Plegmon                                                    14 ( 16 % )

Perforation                                                 18 ( 12%)

Gangrene                                                   10 ( 6.6% )