Appendicectomy is one of the most common surgeries performed worldwide. The incidence of acute appendicitis is higher among adolescents and young adults. Though various positions of the appendix, such as retrocecal, pelvic, subcecal, pre-or post-ileal, and their clinical implications have been well established, appendiceal anomalies like duplication or triplication of the appendix are yet to receive attention due to their very low incidence. We report an incidental finding of a duplicated appendix in a 19-year-old girl who presented with features of acute appendicitis. What makes this case report an interesting learning point for young surgeons is the identification of a perforated appendix with gangrene at the tip, along with an inflamed duplicated appendix. This report alerts us to the need for a thorough intraoperative inspection, to look for possible anatomical abnormalities, and to take the right management decisions to avoid unnecessary re-explorations. While operating a patient with features of acute appendicitis, a failure to identify a duplicated appendix is comparable to abandoning an inflamed appendix in-situ. Such instances not only increase the morbidity due to complications like the formation of pelvic abscesses, wound dehiscence, and surgical site infection, but also cause mortality.

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Introduction: Upper limb vascular trauma although less common than in the lower limbs, is steadily increasing in numbers due to increase in road traffic accidents and work place injuries. It poses as a significant cause of morbidity and has an impact on quality of life compared to lower limb injuries. A prospective study was done to see the factors affecting the type of management and limb salvage in our institute. Methods: Study was done from Dec 2017 till Jan 2019. Total of 52 patients presenting with upper limb vascular injuries were included. Patients were evaluated on the demographics, mode of injury, duration, type of injury, management and surgical procedures. Limb ischemia at the time of presentation was classified according to Rutherford acute limb ischemia classification. Based on the clinical and radiological findings patients were managed surgically or conservatively. Results: Mean age of presentation was 27.3AE16.5 years (Range: 2-65) and children < 15years comprised 23% (12). Males outnumbered females with a ratio of 3.7:1. Median time to presentation was 12hours. Blunt injury was the most common type (69%) followed by penetrating (25%) and crush injury (6%). Most common mode of injuries were due to road side accident (RSA) in 53% followed by fall from height (13.5%). Most patients had to Grade-2B ischemia (65%). Two patients presented with Grade-3 ischemia and underwent primary amputation. Right side was more common (52%). There were no bilateral injuries or associated lower limb injuries. Brachial artery injury was the most common artery involved (69%), axillary artery in (13%). Multilevel injury of both brachial and forearm arteries was present in (5.7%). Types of arterial injury included transection (32%), contusion (19%), thrombosis (17%). 67% patients had associated fractures, most common-shaft humerus (48%) and 21% had nerve injuries. 25% patients were managed conservatively with antiplatelets and anticoagulation. Among the patients undergoing surgery, reverse saphenous vein grafting (RSVG) was the most commonly performed procedure (38.5%), followed by thrombectomy (16.5%) and end to end anastomosis (13.5%). One patient underwent secondary amputation. One-month limb salvage rate was 94.2%. There was no significant correlation between time of injury, artery involved and associated bone or nerve injury to the type of management and outcomes. Patients aged < 15 underwent lesser number of fasciotomies and more likely to be managed conservatively (p< 0.001). Conclusion: Upper limb vascular injuries can be dealt with surgery or by conservative management in select group of patients, especially in children < 15years with good limb salvage rates.