"Post-appendectomy"Acute Appendicitis in a rural area: A surgical dilemma.

.buka Ona Longombe AID, PhD. Professor of Surgery, University of Icisangani School of hledcine, Consultant Surgeon Evangelical Xledical Centre (ChlI<) N~nnkunde Democratic Republic of Congo. C/o P.O.13os 21283, Nairobi, Kenya.

Keywords: Post-appendectomy, appendicitis, surgical dilemma and rural area.

Acute appendicitis is the commonest leading to misunderstanding. Added to this is the abdominal surgical emergency worldwide. routine nature of the surgical treatment of Its diagnosis is a clinical one and its treatment appendicitis, which leads to esaggerations, to the is removal of the inflamed appendix. In this estent that me see in our daily practice patients paper, three cases of acute "post- niith a clinical picture of acute appendicitis after appendectomy" appendicitis are presented. appendectomy. The paper discusses the problems of communication between doctors and It was with such a background that the author patients in rural Africa. wanted to share his experience of three cases of acute appendicitis following "appendectomy" Introduction seen at the Evangelical Medical Centre (CME) of Acute appendicitis is the most common Nyanliunde in the Democratic Republic of Congo abdominal emergency \vordwidel. In Africa, the with a hope that other surgeons will not fall in condition has been recognized as a common similar traps. problem for many years2. Its diagnosis is basically a clinical one, requiring no sophisticated Case reports investigations. Its treatment is surgical, and in the Case 1. hands of a competent surgeon it is an easy S.U., a 22 year old student at a higher education procedure. Because it is easy to diagnose and to institution in the region, presented at CME with remove, many surgeons do incidental a two days hlstory of severe pain in the right iliac appendectomy during other procedures3~". fossa. He reported that he had had (< appendectomy" two years previously. On Unfortunately, because of the low education levels esamination, he alas found to have a typical in Africa, the majority of our people find it McBurney scar and there mas the classical difficult to understand the medical terminology. cutaneous hyperaesthesia in the RIF typical of For instance, it is a difficult undertaldng to make acute appendicitis. Considered in the differential an old grandmother appreciate the difference diagnosis were post appendectomy adhesions, t,etn,ecn an appcndectom\~ant1 h\.stercctom\.. t\.ph()id fc~.ci-associ2tccl \\.it11 mescntcric adenitis Thus we can see that a problem of communication or urinary tract infection with lithasis. The patient soon arises betsveen the patient and the doctor, was treated with anti-inflammatory drugs. On the 4th day of hospitalization, the patient developed on the right side. An initial diagnosis of right a fever with obvious signs of localized right iliac salpingo-oophritis \Tias made and the appropriate region peritonitis. Surgical exploration was done treatment started. through the old Mcburney's scar. On opening the abdomen, there was pus. An inflamed partially When the patient failed to improve and her amputated appendix was found. Appendectomy condition was getting worse, a lapasotomy was completed and a drain was left in the RIF. through a sub-umbilical incision was performed. sln inflamed oedematous appendix was found. Postoperatively, the patient did well on antibiotics A classical appendectomy with burial of the and had a generally uneventful recovery period. appen&x stump was done. The patient had a good He was &scharged on the 10th post-operative day. post-operative recovery period.

Case 2. On further enquiry into her past s~lrgicalhistor!; N.G., a 15 year old female student at a Girls' it was discovered that the so-called pre\~ious" Technical School, was admitted with a history of appendectomy" was only a scenario put on to pain in the right iliac fossa associated with avoid a family crisis after an unwanted pregnancy vomiting. Her parents reported that she had a The scar was of a small symbolical incision made similar episode of symptoms sis months in the FUF to justify the hospitalization and the previously for wl~icl~appendectomy was general anaesthetic given during the performance performed. On esamination, she was found to of a criminal abortion so as to put the family and have a temperature of 37.8 degrees centigrade. other doctors off track. She had a McBurney scar and all the classical signs of acute appendicitis. Laparotomjr was then done Discussion through a midline sub-umbilical incision. An It is not unusual to see a patient coming back inflamed retrocaecal appendis \vas found. A with symptoms of acute appendicitis after an retrograde appendectomy was done; the stump apparent appendectomy. We consider this to be a was then buried. deceptive trap which starts with the surgeon who gets convinced that an appendectomy had been When contacted later, the surgeon who performed firstly because of what the patient or performed the previous operation admitted that his family say and secondly because of the due to lack of esperience, he had failed to locate presence of a McBurney's surgical scar. Altemeier the appendix and therefore had concluded that and Culbertsonhoted that a diagnosis of "post- the patient must have been born without one. appendectomy" acute appendicitis is possible in However, he never communicated his findings situations such as after drainage of an to the parents who were sure that the appendix appendicular abscess without appendectomy, had been removed. when subtotal or partial amputation of the appendix is done when the organ is not totally Case 3. removed or when the surgeon is unable to bury B.V. was a 23 year old nurse who presented with the stump. a history of lower abdominal pain. She reported that she had had an appendectomy done when Several lessons are learnt from the second case. she nTasa student nurse. On esaniination, she had Congcnitnl nbscncc of an appentlis is such ;In a str:trige small scar in the right iliac region and estremelj. rare occurrence" that it sl~ouldonly be had signs of peritoneal irritation predominantly considered a possibility after a thorough inspection of all the recognized positions of the affects the quality of care. We must therefore appendix7and this demands of the surgeon to be realize that it is a thorny problem in countries meticulous and patient. The appendix in the where poverty and illiteracy dominate daily 'life. retrocaecal position can sometimes create serious In such situations, medical jargon belongs to a difficulties during its removal if the surgeon is handful of people. We must make an effort to inexperienced. In such situations it is not reduce the general impression that doctors have pejorative or demeaning to ask for the help of a their own private technical language. Terms such senior colleague. as peritonitis, appendicitis and others sound like a foreign language in the ears of the patients. It The third case clearly demonstrated the need to should not be surprising therefore if the term enforce the legislation against criminal abortion "drainage" is understood by the patient to mean and to try to discourage charlatans. We wanted to removal of the appendix. describe our experience because of the plethora of surgcal centres, which lack esperienced hands, In summary, "post-appendectomy" acute and the high frequency of provoked abortions appendicitis can be found in the following managed under all sorts of pretence. situations:

In the developing nations, it is important to 1. In cases of appendicular abscesses in mhicli consider the low educational status of our patients simple drainage is done without removing n7ho sometimes cannot remember what they were the appendis but leaving a McBurney or told about the indication for surgers the operative Jalaguier surgical incision scar. findings and the type of procedure performed. 2. \Yihen medical jargon was used for Moreover, record keeping in many of the hospitals communication with illiterate patients or is poor and the operating protocols difficult to families who by the time they report again find where they exist. In order to overcome all to hospital they can never remember the these obstacles in our hospital, a policy was put type of surgery done. in place that demands of the surgeon to show to 3. Lack of experience on the part of the first the patient and the family any organ or tissue surgeon, who when faced with certain removed at surgery \Ve believe that visual memory difficulties, fails to find the appendix and mould be more difficult to forget than the verbal comes to premature conclusion that the one. , appendix is congenitally absent or in cases of bad surgical technique. There is no For the appendicular abscess, our policy is not to indication for partial appendectomy. drain the abscess as is classically done, but to Appendectomy must al'ivays be total, at the perform appendectomy by taking the most direct base of the organ. route that is best indicated under the 4. Dishonesty of the patients and charlatans circumstances, carefully separating the adhesions who make people believe that they have had and then removing the appendix. or performed good surgery(Appendec- tomy) in order to hide their criminal act In addition to what has gone on before, me also (abortion). wish to raise the problems of communication befiveen the patients and the clinicians in our Therefore the presence of a McBurney or Jalaguier African environment. This factor has already been surgical incision scar for a wary surgeon can mean highlighted in the developed world as one that something else other than appendectomy. Doctors F in the rural hospitals should tlzerefore be more Compan!; New York; 1979:1257-67. prudent as they wait for arrival of sophisticated 2. Davey \Y' \Y! Large Intestine and Rectum. In: Adoloye I\, ed. Companion to Surgery in Africa. Livingstone L1-D, Edinburgh & diagnostic techniques such as ultrasound. London, 1968: 257-266. 3. Taniguchi T, IOlkenny G S. Prophylactic appendectomy in In conclusion, since appendectomy is a common gynaecological surger!: X rel-ieu-of 532 eases. Am J Obstet Gynxcol operation, we must reinforce extreme care of this 1950; 6@:1359-1362. 4. \\hters E G. Elective appendicectomy with abdominal and pelvic surgical procedure which because of its frequency surgery Obstet Gynaecol 1977; 50:jll-517. has probably become too much of a routine 5. Alterneiei-\\;. A, Culberston \\;' R. Complications of appenclicecto~ny operation. Sucl~an attitude will spare us from In: Artz C P,Harcl!. J D, Eds. Complications in Surgery and their \\;"I3 falling into traps, which in one way or another hlanagement 2nd edn. Saunders Cornpan!; Philadelphia and London, 1967; 564-576. may result in loss of life. 6. Robinson J 0.Confenital absence of vermiform appendix. Brit] Surg 1952; 39:344. References 7. \Y'akelcy C P. Thc position oi \-ermiforrn appenclix as ascertainetl I)!. 1. Storcr 1' 1-1. Appendix. 111: Sch\vartz S I, Shires G T, Spencer T: C, an anal!-sis of I0 000 cases. J Xnat 1933; Srorer l3 H, bids. Principals of Surgery 3rd edn. AIcsran-Hill Book