Difficult

Appendesectomy
In Surgical Practice

Introduction
1889

Mac Burney described

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

Surgical Anatomy
Surface

anatomy
Development: diverticulum of
ceacum appearing in the 8th week
of life
Positions: constant base, tip
varies (retroceacal, pelvic,
subcaecal, preileal, pericolic)

ACUTE 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 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

BACTERIOLOGY
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.

Histology
Histological terms used:

Catarrhal appendicitis
Inflamed
Suppurative
Necrotic
Gangrenous
Perforated
Appendicular mass

ALVARADO 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.

Treatment
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:
Open

appendectomy

McBurney (oblique); Rocky Davis

(transverse);
right paramedian; midline incision

Laparoscopy
NOTES

Open appendectomy

Open Appendectomy:

Laparoscopy

2. Laparoscopy:

Difficult
Appendesectom
y

Difficult Appendesectomy
Difficult Appendesectomy reasons :
Surgeon and assistant .
patient.
Appendix.
Operation field.

Surgeon and assistant

Qualified

Surgeon with good

assistant play important roles to
get a simple appendectomy.

patient.
General

condition

Obesity
The

Very Young
The Very Old
In AIDS Patients
The Pregnant woman

Obesity with acute

appendicitis

The Very Young

Diagnosis

may be more difficult

to establish
Children are more likely to
progress to perforated appendix
(? Under-developed Greater
Omentum).

Children with acute

appendicitis

The Very Old

Greater

morbidity and mortality

Less typical presentation
Cancer may be a possibility as an
underlying cause.
Perforation of 50% and mortality
of 20% has been reported

old with acute

appendicitis

In AIDS Patients
Be

aware of CMV or Kaposi

sarcoma as the underlying cause
General condition
Risk of infection

The Pregnant
More

common in the first two

trimesters
The appendix is pushed
superiorly and laterally
Premature Labor 10-15% with
surgery
Perforated appendix leads to
fetal death in 20%

Pregnant woman with acute

appendicitis

Position of
Appendix

Surgical Approach
Incision

over point of maximal

tenderness
Midline incision if diffuse peritonitis,
or doubt about diagnosis
Tilt 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

appendicitis

Laparoscopic
Appendectomy

Appendix
Site

:
Retroperitonum
Subhepatic
Pelvic

Gross

Pathology
The presence of parasites in the
appendix
Fixed cecum

Appendix.
Gross Pathology
Perforated
Very

long
Short
Appendicular Mass
Chronic Appendicitis
Appendicular abscess
Tumors of The Appendix

Perforated appendicitis

Very long appendicitis

Appendicular abscess

Appendicular abscess

Tumors of The Appendix

Carcinoid
Adenocarcinoma
Lymphoma.
Mucocele
Pseudomyxoma

Peritonei

Carcinoid

Operation field
Incision

site size
Exploration
Homeostasis
light
Instrument

Operation field

summary
Acute

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