RIGHT IL IAC FOSSAMASS

By,Prof R.A.Pandyaraj, MS, FICS,FAIS,FMAS(Laproscopy).Head of surgery department,Govt. Royapettah Hospital.

BOUNDARIES; TRANS TUBERCULAR LINE MIDCLAVICULAR LINE ILIAC CREST

CONTENTS;•Appendix•Caecum•Mesoappendix•Terminal ileum• Retro peritoneal tissue • iliac nodes•iliac arteries

APPROACH

•INSPECT•PALPATE•PERCUSS•AUSCULTATE•PV / PR•OTHER MASS

PAIN

•Dullaching•Colicky•Continuous / intermittent

CLASSIFICATION

RIF MASS

ANATOMICAL

PARIETALINTRA

ABDOMINAL

CLINICAL

SOLID CYSTIC

ANATOMICAL

PARIETALINTRA

ABDOMINAL

1. LIPOMA

2. DESMOID TUMOR

3. PYOGENIC ABSCESS

4. INTRA ABDOMINAL ABSCESS

BURROWING THROUGH

1. ILIAC ABSCESS

2. APPENDICULAR ABSCESS

ANATOMICAL

PARIETALINTRA

ABDOMINAL

INTRA PERITONEAL

1. APPENDICULAR MASS2. APPENDICULAR ABSCESS3. ILEOCAECAL TB4. CARCINOMA CAECUM5. MESENTRIC NODES6. ILIAC NODES7. TYPHILITIS8. CROHN’S DISEASE9. ACTINOMYCOSIS10. HUGE GALL BLADDER c LIVER11. INTUSSUSCEPTION12. AMOEBOMA

FEMALES1. OVARIAN CYST2. TUBO OVARIAN MASS3. FIBROID

ANATOMICAL

PARIETALINTRA

ABDOMINAL

INTRA PERITONEAL RETRO PERITONEAL

NORMAL1. SARCOMA2. ANEURYSM3. PSOAS ABSCESS4. TUMOR FROM BONE/

CARTILAGE

ABNORMAL5. UNDESCENDED TESTIS6. UNASCENDED KIDNEY

CLINICAL

SOLID CYSTIC•APPENDICULAR MASS•CARCINOMA CAECUM•ILEO-CAECAL TUBERCULOSIS•EXTERNAL ILLAC LYMPHADENITS•RETRO PERITONEAL SARCOMA•CROHN’S•UNASCENDED KIDNEY•ACTINOMYCOSIS

•APPENDICULAR ABSCESS

•PSOAS ABSCESS

•RT.OVARIAN CYST

•ILIAC ARTERY ANEURSYM

APPENDICULAR MASS

ILEO CAECAL TB CA.CAECUM

AGE ANY AGE,COMMON IN YOUNGER AGE

YOUNG& MIDDLE AGE

MIDDLE & OLDER AGE

PAIN SHORT DURATION, >3 DAYS,MIGRATING

INITIALLY

Colicky NO PAIN, MAY BE IN LATE

STAGEFEVER HIGH GRADE LOW GRADE

RECURRENTAbsent

VOMITING ++ +++,IF OBSTRUCTED

++ IF

OBSTRUCTEDALTERED BOWEL

HABITUS- DIARRHOEA ALTERED

WITH CONSTIPATION+

MASS CHARACTERISTICS

APPENDICULARMASS

ILEO-CAECAL TB CA.CAECUM

TENDER SOFT TO FIRM ILL DEFINED BORDERS IRREGULAR & FIXED TYMPANIC NOTE

NON-TENDERFIRM TO HARDHIGHLY PLACEDDOUGHY ABDOMEN

NON-TENDERHARDFIXEDASCITESHEPATOMEGALY

INVESTIGATIONS• Blood HB , TC,DC,ESR • RFT • X-Ray – Chest,Abdomen Erect• Barium Enema • USG Abdomen • CT Scan Abdomen

APPENDICULAR MASS

ILEO-CAECAL TB CA.CAECUM

PLAIN XRAY LOCALISED ILEUS MULTIPLEAIR-FLUID LEVELS CALCIFIEDTBNODES

_

BARIUM STUDY

NOT INDICATED PULLED UPCAECUM,NARROWED TERMINAL ILEUMWIDENING OF ILEO-CAECAL ANGLE

IRREGULAR FILLING DEFECT,APPLE CORE SIGN

USG MIXED ECHOGENIC LESION

DILATED ILEUMTHICKENED CAECUM

SOLID CAECAL MASS HEPATOMEGALY,ASCITIS

APPENDICULAR MASS

This is caused by inflammation and swelling of the appendix, caecum, omentum and distal part of the terminal ileum

•Treat conservatively with bowel rest, antibiotics, analgesics and fluids•Consider interval appendicectomy if symptoms recur

APPENDICULAR MASS

Approach A OSCHNER REGIMENInitial conservative treatment followed by interval appendicectomy six to eight weeks later

Approach BImmediate appendicectomy following inflammatory mass resolution

Approach CAn entirely conservative approach without interval appendicectomy in patients with appendiceal mass

APPENDICULAR MUCOCELE

•Appendicular mucocele is a rare lesion (0.2 0.3% of ‐surgical appendicectomy specimens)

•It is a descriptive term denoting an obstructive dilatation of the appendicular lumen by mucinous secretions

MUCINOUS CYSTADENOMA AND CYSTADENOCARCINOMA

MUCINOUS CYSTADENOMA AND CYSTADENOCARCINOMA ACCOUNT FOR 60 70% OF ALL MUCOCELES ‐

LESS COMMON CAUSES: RETENTION CYST MUCOSAL HYPERPLASIA CARCINOID APPENDICOLITH ENDOMETRIOSIS ADHESIONS VOLVULUS

‐ High Correlation Of Synchronous Or Metachronous Colorectal

Adenomas And Carcinomas (Up To 20%)

‐ Association With Mucin secreting Tumors Of The Ovary‐ ‐ Pseudomyxoma Peritonei (Avoid Iatrogenic Rupture Of The

Mucocele)

TREATMENT•Appendicectomy Is Used For Simple Mucocele Or For cystadenoma

•Right Hemi colectomy ‐ Is Recommended For Cystadenocarcinoma

MUCINOUS CYSTADENOMA AND CYSTADENOCARCINOMA

TREATMENT

ILEO-PSOAS ABSCESS

• Cough with expectorant,evening raise of temperature,haemoptysis,

• Attitude of flexion,spine tenderness,gibbus

• Cross fluctuation• No line of separation/space

between mass&iliac spine

CROHN’S DISEASE

• INFLAMMATORY DISEASE INVOLVING ILEUM , CAECUM , COLON

• PTS.PRESENT WITH DIARRHOEA , FEVER , MULTIPLE FISTULA (PERIANAL) , WITH SIGNS OF INTESTINAL OBSTRUCTION

• COBBLESTONE APPEARANCE , PSEUDOPOLYPS, SKIP LESIONS

• STRING SIGN OF KANTOR ( NARROWING OF TERMINAL ILEUM )

COBBLESTONE APPEARANCE

ILEO-CACEAL TB

ABDOMINAL TUBERCULOSIS

INTESTINAL

ULCERATIVE HYPERPLASTIC STRICTOROUS MIXED

EXTRA INTESTINAL

PERITONEUM

ACUTE CHRONIC

MESENTRY SOLID ORGANS

GENITO-URINARY SYSTEM

ABDOMINAL TUBERCULOSIS

ABDOMINAL TUBERCULOSIS

ILEO-CAECAL TB

ILEO CAECAL REGION IS MORE COMMONLY INVOLVED ???????

RICH LYMPHATICS IN PEYER’S PATCHES

ALKALINE MEDIUM

ILEOCECAL VALVE PRECIPITATES STASIS

TERMINAL ILEUM IS MAXIMUM AREA OF

RESORPTION

TREATMENT

• CATEGORY I – ATT• IN CASE OF COMPLICATIONS

–LIMITED RESSECTION–RIGHT HEMICHOLECTOMY

• CALCIFIED TB MESENTRIC NODES

MESENTERIC-CYST

CARCINOMA CAECUM

• APPLE CORE APPEARANCE IN CA.CAECUM

INTUSSUSCEPTION

INTUSSUSCEPTION

COMPLICATIONS

RT.TUBO-OVARIAN MASS

• Menstrual h/o; menorrhagia,polymenorrhagia,dysmenorrhea

• Leucorrhea,dyspareunia,• Lower border not felt,• Per vaginal; rt.fornix tenderness,

THANK YOU