 So this episode of Let's Talk Surgery comes to you from a very sweaty me inside of a car So why inside of a car because the wind's blowing outside and it's very very noisy why sweaty and Inside the car first of all don't worry that I'm sweating inside the car. I'm a surgeon in academic practice So I'm poor and this is not a very good car And number two is there's a waterproof cover on the side So every time after I run, you know, I put it on so I don't damage the car Now I combine really my passions of making educational resources and jogging right here After work almost every day if at all possible I come to run my favorite places in Newlands Forest Which is if you don't know in Cape Town at the back of Table Mountain fantastic forest fantastic place to to run in if you ever Make make the effort come here or join me on your own So I always encourage people if you're in health care if you're a student Doesn't matter, you know your own fitness your own health is is very important so I always encourage that and I really take that to the extreme and I probably don't know but too much Anyway, so that's the context and you know, I try not to make these things inside of a lecture hall Maybe if you are like me, I hate you know listening to someone inside of a lecture hall And I hate being on the stage lecturing. I don't think really that's that that is how we learn stuff So here on let's talk so gee is very informal So as I said today, you're gonna come I come to you from inside my car after a very fantastic run that was five minutes of below my target time and Which my target time is one hour eight minutes, by the way, so this was one hour three minutes So actually quite a quite a quite a good run so in today's episode part one of acute appendicitis and I really want to bring in a bit of the anatomy and students ask me why the anatomy Why do we have to review the anatomy? Well, the anatomy has a lot to do obviously with the actual surgery if you don't know the anatomy you're gonna struggle a bit and many of us have had the experience of struggling to find the appendix at times even experienced people and Perhaps more importantly are the symptoms and signs of acute appendicitis So we know where the vermaforma appendix is If you if I can remind you remember it's at the base of the cecum about two centimeters below the iliocecal valve And that's where the three tiniac tiniac coli come together at the base here of Near the base of the cecum and that thing goes down into the appendix Appendix is anywhere from two centimeters to more than 20 centimeters long And you know that it can lie in a variety of of anatomical Places I'll put a link down below to a picture that shows you where this appendix can lie and The appendix of course is part of the mid gut So in the embryo it forms in the distal part of the mid gut doing rotation It goes posterior into the right-hand side and can sit in this retroperitoneal area Which if it goes into you know into the retro cecal space it can Really alter the symptoms so the anatomical position of it can really alter the system The symptoms and signs as part of remember it being as part of the mid gut Remember it gets a visceral nerve nerve supply That means when it becomes inflamed and then infected the pain is going to center on the mid abdomen because the visceral Neural sensation is not very specific as to where it is if that inflammation and infection spreads to the parietal Peritoneum you get somatic nervous system Involvement and that's where you get the pain spread to localize to the right-hand side Now we know that that doesn't always happen because of this variety of anatomical positions always remember always remember that if you have a Retrocecal appendix it might not touch the Interior lateral surface of the of the parietal peritoneum, and then you're not going to get this movement of pain towards the right-hand side Also because of this anatomical variation You know you might get either diarrhea or constipation if it really lies just behind or below the distal Ileum then you might have a bit of paralytic alias in that area and these patients might have a bit of constipation Of course if it goes down Towards the rectum it might irritate the rectum and these patients can have diarrhea Because this is gastrointestinal disease most of the people will have some gastrointestinal symptoms such as loss of appetite and And and nausea and even vomiting and we see that in the history of many of the patients So together with pain and this anatomia of the penis you're going to get a variety of symptoms and signs and In the right iliac fossa remember my Bernice point if you draw a line from the umbilicus down towards the anterior super iliac spine It's about two-thirds of the way down. That is where we find the base of the appendix. Remember in little children There's a relative if you just do The relation between the opening of the appendix and then the lumen of the appendix That that ratio is a bit more than an adults So it doesn't really obstruct and remember we think that obstruction is the cause of appendicitis in the majority of cases Remember the appendix lumen. That's a blindening lumen if there's any kind of obstruction You're going to get a proliferation of bacteria. We're going to get engorgement Of the lymphatic vessels of the blood vessels venous engorgement You're going to get inflammation. We're going to get neutrophils go into the area Breaking of the of the surface invasion of bacteria and this is better becomes a vicious a vicious cycle And that is the definition of appendicitis. Remember now we see it We are an adult unit So we would only see patients say from the age of about 14 that come to our ward if they get younger than that They do go to the pediatric surgical unit and we see them till the extremes of age You know at the end 80s and 90s we see them the vast majority of them an early adulthood there Perhaps we have them. That's when the lymphatic nodules At at the maximum and perhaps that is when we see most of the obstructions Although that's not the only cause fecaliths of course can obstruct and in many instances when we operate We find a fecalith fecalith very hard piece of stool, but that's not always unfortunately not always the case and People get appendicitis without us knowing so pay attention to this to the anatomy that will help really help you think about the symptoms and signs And then of course when it comes to this surgery, you know We make Bernice pointers if you are going to do open surgery Of course most of the most of the times these days we do laparoscopic surgery It helps us both with diagnosis and of course with the surgery So keep in mind this anatomy in the next video I want to talk to you about how we you know try and confirm the diagnosis We can't always do that. There's in this specific test, but we'll carry on this discussion of acute appendicitis See you next time