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Difficult Appendesectomy

In Surgical Practice

IntroductionIntroduction1889 Mac Burney described

location, the clinical features of appendicitis and the importance of operative intervention and muscle-splitting incision.

Surgical AnatomySurgical AnatomySurface anatomyDevelopment: diverticulum of

ceacum appearing in the 8th week of life

Positions: constant base, tip varies (retroceacal, pelvic, subcaecal, preileal, pericolic)

ACUTE APPENDICITISACUTE APPENDICITIS

Incidence 0.1-0.2%Appendectomy for appendicitis is

the most common performed emergency operation in the world.

Disease of young with 40 % of cases being between 10-24 Yr

EITIOLOGY AND PATHOGENESISEITIOLOGY AND PATHOGENESIS

Obstruction of the lumen is the dominant causal factor. The obstructing object can be:*fecalith ; the most common*lymphoid tissue hypertrophy*inspisated barium from previous study*tumors*seeds

Fecalith

BACTERIOLOGYBACTERIOLOGY

Bacteria cultured in cases of appendicitis are similar to those seen in other colonic infection.

The principal organisms seen are E. coli and Bacteroid fragilis.

HistologyHistologyHistological terms used:

Catarrhal appendicitis Inflamed Suppurative Necrotic Gangrenous Perforated Appendicular mass

ALVARADO SCALEALVARADO SCALE

9-10: almost certain appendicitis and should go to OR.7-8: high likelihood of appendicitis, imaging study.5-6: compatible but not diagnostic, CT scan is

appropriate.0-4: extremely unlikely.

TreatmentTreatment Adequate hydration, correct

electrolyte imbalance Manage other medical problems Pre-operative antibiotics:

◦ Simple AP - hrs antibiotic◦ Ruptured AP - antibiotic until

fever◦ Peritonitis - 10 days antibiotics

Surgery:Surgery:Open appendectomy

McBurney (oblique); Rocky Davis (transverse);right paramedian; midline incision

LaparoscopyNOTES

Open appendectomyOpen appendectomy

Open Appendectomy:

LaparoscopyLaparoscopy

2. Laparoscopy:

Difficult Difficult AppendesectomAppendesectomyy

Difficult AppendesectomyDifficult Appendesectomy

Difficult Appendesectomy reasons :

Surgeon and assistant . patient.Appendix.Operation field.

Surgeon and assistantSurgeon and assistantQualified Surgeon with good

assistant play important roles to get a simple appendectomy.

patient.patient.

General conditionObesityThe Very YoungThe Very OldIn AIDS PatientsThe Pregnant woman

Obesity with acute Obesity with acute appendicitis appendicitis

The Very YoungThe Very YoungDiagnosis may be more difficult

to establishChildren are more likely to

progress to perforated appendix (? Under-developed Greater

Omentum).

Children Children with acute with acute appendicitisappendicitis

The Very OldThe Very OldGreater morbidity and mortalityLess typical presentationCancer may be a possibility as an

underlying cause.Perforation of 50% and mortality

of 20% has been reported

old with acute old with acute appendicitisappendicitis

In AIDS PatientsIn AIDS PatientsBe aware of CMV or Kaposi

sarcoma as the underlying causeGeneral conditionRisk of infection

The PregnantThe PregnantMore common in the first two

trimestersThe appendix is pushed

superiorly and laterallyPremature Labor 10-15% with

surgeryPerforated appendix leads to

fetal death in 20%

Pregnant woman with acute Pregnant woman with acute appendicitisappendicitis

Position of Position of AppendixAppendix

Surgical ApproachSurgical ApproachIncision over point of maximal

tendernessMidline incision if diffuse peritonitis,

or doubt about diagnosisTilt table 30° to left Minimize uterine manipulation to

decrease risk of irritability and preterm labor

External fetal monitoring – especially if perforation

Pregnant woman with acute Pregnant woman with acute appendicitisappendicitis

Laparoscopic Laparoscopic AppendectomyAppendectomy

AppendixAppendixSite : Retroperitonum Subhepatic Pelvic

Gross PathologyThe presence of parasites in the

appendix Fixed cecum

Appendix.Appendix.

Gross PathologyPerforated Very longShortAppendicular MassChronic AppendicitisAppendicular abscessTumors of The Appendix

Perforated appendicitis Perforated appendicitis

Very long Very long appendicitis appendicitis

Appendicular abscessAppendicular abscess

Appendicular abscessAppendicular abscess

Tumors of The AppendixTumors of The Appendix

CarcinoidAdenocarcinoma Lymphoma.MucocelePseudomyxoma Peritonei

Carcinoid

Operation fieldOperation field

Incision site sizeExploration HomeostasislightInstrument

Operation fieldOperation field

summarysummaryAcute appendicitis is the common

cause of acute abdomen.Open, Laparoscopic or NOTES

Appendectomy.Difficult appendectomy is

multifactoreal.Qualified Surgeon with good

assistant , well prepared Pt. , early diagnosis , and good exploration…. Factors of simple appendectomy

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