Appendectomy - An Osteopathic Approach

Principles of scar tissue:

Firstly I want to highlight a principle I think is the most important in my line of work. If you read ‘what is Osteopathy’ in the ‘Osteopathy’ tab on this blog you will see I have written about what I believe Osteopathy is.  There I remark on the principle of motion and that the body is constantly moving.  It is very important to have this in the back of your mind as I try to explain the consequences of an appendectomy or scar tissue in general.

When the appendix is removed an incision is made in the right lower quadrant of the abdomen.  This cut slices through a lot of different layers of tissue.  The appendix is then cut away and the large intestine is stitched up.  More recently they have started using a laparoscopic procedure to remove the appendix – link here. 

The point I want to highlight though, is when the various incisions are stitched up scar tissue will form.  Scar tissue is non flexible, it doesn’t stretch.  All the other layers and tissues that have been cut through can stretch; they expand and relax with the various motions of the body.  They adapt, they live and by this I mean there is cellular exchange and interaction. Scar tissue however cannot move or stretch, it is considered ‘dead tissue’.  I’ll explain more about scar tissue in a different blog.

When you have something that is not flexible blend into something that is flexible it will create tension throughout the tissue that is trying to expand, it will act like an anchor.  When this occurs constantly every minute of every day, stress will eventually build in the surrounding tissues in connection with the scar tissue.  A good picture to paint here is normal tissue acts like a healthy runner.  It can jog for hours not draining the system.  When you get scar tissue the healthy tissue continues to jog, but now it is dragging a car tire behind it.  Stress builds, compensation occurs, function is reduced and ultimately injury can occur. 

Another feature of scar tissue is the production of adhesions.  In very simple terms this basically means that different layers of healthy tissue can stick together and this stops the natural function and mobility of that tissue. 

On an interesting note, injuries can develop years later after surgery or any other kind of trauma.  Just because there are no symptoms now, it does not mean compensation and adaptation patterns are not already occurring due to the increased task load of that tissue.  It is also common to have an apparently non-symptomatic scar tissue trigger into a symptomatic problem when another injury/trauma in the body occurs later on.  This is why someone can often develop a shoulder problem years later after a pelvis or leg injury for example.  Years of compensation build over time and then a new trigger in the form of a new injury/trauma can occur.

Conversely, do not fear that all of a sudden you are going to get serious problems just because you may have had surgery in the past.  I am merely highlighting why sometimes things can suddenly become symptomatic years down the line, when apparently there has been no problem.

So what can happen after an appendectomy?

With an appendectomy, the cecum (beginning of the large intestine) can become fixed to the back wall of the abdomen and the back wall, in this case, would be the transverses abdominis or iliacus muscle.  The cecum is also the junction between the small and large intestine and in some woman it attaches to the right ovary via the ligament of Cleyet.  When I talk about attachments I'm referring to either ligament, fascial or membrane connects between various organs or bodily structures. 

Higher up as part of the ascending colon it attaches to the duodenum (the beginning of the small intestines), the right kidney, liver, gallbladder and finishing up fixing to the diaphragm.  I highlight all these attachments because these can become potential areas of compensation, irritation or sites of 'injury'/symptoms.  So when the inherent movement of the cecum has stopped due to fixation caused by the scar tissue it creates what I call drag.  This is another principle resulting from scar tissue.  This drag almost acts like a gravity field.  Not only is the inflexibility of the scar tissue causing tension to spread through the structure, it also causes other nearby structures associated with it to get pulled towards the scar tissue or fixation. 

[The picture above shows all the attachments of the large colon - indicated by arrows].

Knee and ankle problems can develop:

The cecum attaches to the iliacus muscle of the pelvis, which works to produce flexion and internal rotation of the hip.  If the cecum becomes stuck (it's lost its inherent movement) it can cause the iliacus muscle to pull towards the area of fixation.  It is almost like the two structures start to act as a single structure.  Ultimately this causes the muscle to become chronically contracted and the hip to become more and more internally rotated and flexed.  This will lead to internal rotation of the femur and then internal rotation of the knee joint.  The knee joint will also stay further in flexion.  Both these actions result in the tibia shifting further forward on the ankle joint and inwards towards the medial arch of the foot.  This can predispose to stress on the medial arch, which over time can lead to collapsing of that arch known as over pronation.  Conditions like plantar fascitis and heel spurs can develop.  So with just this simple chain we can see the potential of knee, ankle and foot problems occurring just from a fixation due to an appendectomy.  Remember these are all potentials and NOT definite compensations that will happen to everyone that has had an appendectomy.

Neck problems can develop:

So going back to the other structures that attach directly or indirectly to the cecum.  I'm going to leave out the duodenal and kidney attachments here otherwise I'll end up writing a book rather than a blog.  But let's focus on the liver and diaphragm attachments.  So through fixation of the cecum, the ascending colon is gradually being drawn down towards the cecum area via the drag and this directly pulls on the liver and diaphragm.  Remember the image of the car tire.  Suddenly the liver is having to move with an unnatural force pulling it constantly downwards towards the hip.  The liver has massive attachments to the diaphragm and then with the direct attachments of the ascending colon as well we suddenly find the diaphragm is struggling too.

[The picture directly above and left shows how high the ascending colon goes, sitting directly under the liver and diaphragm.  The picture to the right shows the pleura of the lungs, the grey membrane sitting on top of the red muscle (diaphragm)].

Now on the upper surface of the diaphragm you have the pleura of the lungs (the membrane that covers the lungs) which blends directly into the diaphragm.  On the upper surface of the lungs, the pleura attaches to the vertebral bones of the neck via a fascia called Sibson's fascia.  So with the pull of the diaphragm down, you also get a pull of the pleura, which pulls on the neck.  Neck pain, stiffness and tension can occur. 

I think it is important to clarify here that although I’m talking about one structure pulling on another structure and then that other structure pulling still further on another structure; it is slightly different within the body.  We have to remember the body is living and everything is connected, even if it is not physical, it is still connected by blood, nerves, emotions, hormones and gravity.  It is very difficult to highlight how this represents in the body via words.  It is something I have just learnt to feel – perhaps it is intuition.  In the medical world when we learn anatomy we cut everything down and separate everything to its basic level, so we can learn.  But to grasp how the body truly works we need to build up that anatomy again and see a whole living body once more.  It is very easy to think “how is it possible for the Cecum, which is all the way down near the hip to affect the neck – the two structures are so far away?”  In the body these structure are not far away.  In fact they are touching, but perhaps not in a direct way, but rather in an indirect way.

Low back pain is common:

Here I am going to talk about a structure called ‘toldt’s fascia’.  This structure is a membrane type structure or for understandings sake let’s just say it acts like a piece of ‘cling film’ or ‘shrink wrap’.  This membrane starts from the spine, spreads out and wraps around the ascending colon to then travel back to the spine again.  So when the colon becomes fixed, this can lead to stress and tightness spreading through the fascia, resulting in a pull on the spine.  Over a prolonged period of time it puts a greater demand on the spine and it gradually stiffens up.  This is what happened to the patient I had recently; refer to the ‘Bob the builder story’ on my blog.  The Cecum became fixated due to the scar tissue and adhesions.  This created tension to spread through toldt’s fascia and then lead to tightness and pain in the lower back.  This is why after 4 treatments of manipulation, stretching and pulling on the spine, no improvement was achieved; because all the while his colon was still fixed causing the tightness in the spine to remain.

Signs and symptoms of cecum fixation:

The large intestine works to absorb the remaining water (about 10%) and take in the remaining vitamins (mainly E, K & B12).  Interestingly the large colon has a very high percentage of bacteria which ferments the food (this is very healthy for the body).  This increases gases and therefore smell, but this is normal. 

Depending on whether the fixation of the cecum is in a state of irritation or a state of passivity will depend of the symptom.  An irritation is more an excitatory response and the speed of which peristalsis occurs increases.  Therefore diaherria and dehydration can occur, simply because the stools pass through too quickly for the water to be absorbed. 

If it is passive then think stagnicity.  Constipation, bloating and flatulence can occur because the stools are not passing through quick enough, all the water is absorbed leading to harder, firmer stools, which are difficult to pass.  Stagnicity leads to longer fermentation periods and this obviously produces more gas and bloating, also known as trapped wind, which actually is extremely painful.