Ministry of Health of the Repablic of Moldova [600105]

1
Ministry of Health of the Repablic of Moldova
State university of medicine and pharmacy
"Nicolae testemitanu"
Faculty of general medicine
Department of surgery
PHD Thesis

Walla Zubedat
Group: 1642

Acute appendicitis

Scientific coordinator: Dr. Z. Caragat

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I hereby declare that the license thesis titled "Acute appendicitis" is
written by me and has never been submitted to another university or
institution of higher education in the country or aboard. Also, that all
sources used, including those in the internet, are given in a paper with
the rules for avoid plagiarism:
– All the fragments of text reproduced exactly, even in his own
translation from another language are written be tween quotation
– Reformulation of the text in own words written by other authors
have detailed reference
– Summarizing the ideas of other authors have detailed references
of the original text

Walla Zubedat
___________

3
CONTENTS

Chapter 1 Introduction and definition 4
Etiology and causes 7
Epidemiology 8
Anatomy 9
Chapter 2 Pathophysiology and clinical 10
Diagnosis and work up 12
Differential diagnosis 1 7
Chapter 3 Treatment 18

Chapter 4
Conclusion 26
References 2 7

4
Introduction and definition:
Acute appendicitis is inflammation of the appendix, the narrow,
finger -shaped organ that branches off the first part of the large intestine
on the right side of the abdomen. Although the appendix is a vestigial
organ with no known function, it can become diseased. In fact, acu te
appendicitis is the most common reason for abdominal surgery in the
world. If it is not treated promptly, there is the chance that the inflamed
appendix will burst, spilling fecal material into the abdominal cavity. The
usual result is a potentially lif e-threatening infection (peritonitis), but the
infection may become sealed off and form an abscess. Appendicitis is
uncommon among older people, and symptoms are generally mild, so that
diagnosis of the acute episode is often not made. Members of this age
group are thus at greater risk for rupture with peritonitis or abscess
formation.

Objectives – the purpose of this thesis:
ž
ž To identify the most frequent symptoms of acute appendicitis. To
determine the findings.
ž To establish statistically the relationships between age, sex,
duration of abdominal pain and appendix position.

5
ž Classification of acute appendicitis:
ž
ž 1- catarrhal: (edematous, simple) when inflammation is located
withi n mucousal or submucosal layers, (macroscopically the
appendix and mesoappendix are slight edematous, enlarged with
hypervascularization on the serosa).
ž 2- Flegmonous appendicitis: inflammation in all appendiceal layers
(appendix is enlarged, edematous an d infiltrated and the serosa is
covered with fibrin ).
ž 3- gangrenous: may be resulted by anaerobe infection and
mesoappendix vessel thrombosis (appendix is very enlarged with
abcess and zones of wall necrosis).
ž 4- perforated: when fecal and suppurative cont ents of the
abdomen released into the abdominal cavity through perforation
orifice.

6
14 years old developed severe abdominal pain, with a high fever
(38.2 °C). He was admitted to the hospital because of his symptoms. A
physical examination revealed lowe r abdominal tenderness and a
positive McBurney's sign. A blood analysis revealed elevated levels of
white blood cells (18,000/μL; neutrophils, 87.5%), CRP (5.64 mg/dL), and
PCT (0.82 ng/mL). Furthermore, abdominal ultrasonography showed an
enlarged appendi x in the ileocecal region, different from the findings
during his previous admission. On the basis of the ultrasonographic
findings, an appendectomy was conducted. A pathological examination
of the resected appendix (diameter, 20 mm) confirmed a diagnosis of
acute phlegmonous appendicitis. The patient's SAA level, prior to his
appendectomy was elevated (493.1 μg/mL), but had decreased to
5.4 μg/mL within one month after discharge. During the six months since
his appendectomy, the patient has not shown signi ficant symptoms and
has not required any treatment. The patient's parents approved the
various diagnostic procedures and treatments described in this report.
To date, the patient's parents have not consented to a genetic analysis.

7
Causes

Based on experimental evidence, acute appendicitis seems to be the end
result of a primary obstruction of the appendiceal lumen . Once this
obstruction occurs, the appendi x becomes filled with mucus and swells.
This continued production of intra -lumenal mucus leads to increased
pressures within the lumen and the walls of the appendix. This increased
pressure resu lts in thrombosis and occlusion of the small vessels, and
stasis of lymphatic flow . At this point spontaneous recovery rarely
occurs. As the occlusion of blood vessels progresses, the appendix
becomes ischemic and then necrotic . As bacteria begin to leak out
through the dying walls, pus forms within and around the appendix
(suppuration). The end result of this cascade is appendiceal rupture (a
'burst appendix') causing peritonitis , which ma y lead to sepsis and
eventually death . This cascade of events is responsible for the slowly
evolving abdominal pain and other comm only associated symptoms.
The causative agents include bezoars , foreign bodies, trauma , intestinal
worms , lymphadenitis , and, most commonly, calcified fecal deposits that
are known as appendicoliths or fecaliths. The occurrence of obstructing
fecaliths has attracted attention since their presence in person s with
appendicitis is higher in developed than in developing countries. In
addition an appendiceal fecalith is commonly associated with
complicated appendicitis. Also, fecal stasis and arrest may play a role, as
demonstrated by persons with acute appendic itis having fewer bowel
movements per week compared with healthy controls. The occurrence of
a fecalith in the appendix was thought to be attributed to a right -sided
fecal retention reservoir in the colon and a prolonged transit time.
However a prolonged t ransit time was not observed in subsequent studies.
From epidemiological data, it has been stated that diverticular disease and
adenomatous polyps were unknown and colon cancer exceedingly rare in
communities exempt from appendicitis. Also, acute appendici tis has been
shown to occur antecedent to cancer in the colon and rectum. Several
studies offer evidence that a low fiber intake is involved in the
pathogenesis of appendicitis. This low intake of dietary fiber is in
accordance with the occurrence of a rig ht-sided fecal reservoir and the
fact that dietary fiber reduces transit time .

8
Epidemiology
In the Western world, the lifetime risk of acute appendicitis is 6.7 per
cent for females and 8. per cent for males 10. However, the chance of
undergoing appende ctomy during a lifetime is higher, 23.1 per cent in
females and 12 per cent in males 10. The discrepancy between frequency
of appendectomy and acute appendicitis reflects the number of incidental
and unnecessary appendectomies.
The overall incidence of acu te appendicitis has decreased by 40 per cent
in females and 34 per cent in males in the period from 1975 to 1994 in the
United Kingdom 11. This trend has also been noted in the United States
and other Western countries 10,12 -15. Appendicitis is rare in mos t of
Asia and Central Africa, but the incidences in developing countries are
increasing 16.
The causes of these changes are unclear, but could be attributed to dietary
changes 14,17. In the West, the perforation rate has remained the same,
about 20 per cen t from 1936 to 199318. Thus, despite progress in
medicine, the number of perforations has not changed in the past fifty
years. Improvements in health care are apparently not associated with
fewer perforations. This finding probably indicates that most perf orations
occur before patients are admitted to hospital with acute appendicitis.
This phenomenon is more apparent in the very young and old patients,
because in these groups the rates of perforation tend to be higher.

9
The appendix; Anatomy:

The appendix is a smal l tubular extension of the right side of the colon,
right near where the small intestine also inserts into the colon. Its length
is quite variable, from an inch or so to up to 8 or nine inches in length.
Most of the time is looks like a stubby #2 pencil.
The colon has three outer longitudinal muscle bands, called the tenia,
that run the lenvth of the colon as strips, equidistant around the
circumference of the colon. The appendix arises from the blind pouch of
the cecum where the three tenia merge. In fact, the easiest way of finding
the appendix in surgery is usually to pull up the colon, find a tenia, then
run it backwards until the appendix is found.
The appendix has its own blood supply in leaves of fat arising off the
mesentery of the cecum. There is a small appendiceal artery that runs as
an arcade along the lower edge of the organ.

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PATHOGENESIS AND CLINICAL PRESENTATION
The clinical presentation of appendicitis is notoriously inconsistent. The
classic history of anorexia and periumbilical pain followed by nausea,
right lower quadrant (RLQ) pain, and vomiting occurs in only 50% of
cases. Features include the following:
 Abdominal pain: Most common symptom
 Nausea: 61 -92% of patients
 Anorexia: 74 -78% of patients
 Vomiting: Nearly always follows the onset of pain; vomiting that
precedes pain suggests intestinal obstruction
 Diarrhea or constipation: As many as 18% of patients
Features of the abdominal pain are as follows:
 Typically begins as periumbilical or epigastric pain, then migrates
to the RL Q
 Patients usually lie down, flex their hips, and draw their knees up
to reduce movements and to avoid worsening their pain
 The duration of symptoms is less than 48 hours in approximately
80% of adults but tends to be longer in elderly persons and in those
with perforation

 Acute appendicitis is an inflammation of the entire wall of the
appendix, which is infiltrated with granulocytes. Bacteria in the infl
amed appendix are those of the normal colon flora, which suggests
secondary invasion of the appendix wall from the lumen of the
bowel. The pathogenesis of acute appendicitis is unclear. It has
often been postulated that obstruction of the lumen of the appendix,
either by swelling of the surrounding lymphoid tissue or a fecolith,
and subsequent retention o f mucus and swelling of the appendix,
results in disturbance of the capillary blood flow in the appendix,
followed by necrosis. Other foreign bodies, such as food debris,
gallstones or worms have been reported to obstruct the lumen of
the appendix.
 However , it has been shown that appendicitis can occur without
obstruction, possibly due to bacterial invasion of the lymphoid
tissue in the appendix wall, which may subsequently lead to
ulceration. The latter form should perforate less easily.
 The classical symp toms of acute appendicitis include the onset of
referred, central or upper abdominal pain, which is sometimes
colicky, followed by nausea and one or more episodes of vomiting.

11
The cause of this referred pain is stretching of the appendix. This
period of pa in and discomfort may be mild: pain is sometimes not
mentioned by the patient. After several hours the pain usually shifts
to the right lower abdominal quadrant and becomes continuous and
severe; movement becomes uncomfortable. This shifting of the
pain is due to the involvement of the parietal peritoneum. With
progression of the disease, the pain may spread diffusely over the
abdomen, as occurs in generalized peritonitis due to a perforation.
 If an abscess develops following a localized perforation of the
appendix, the pain remains in the right lower quadrant.
 Difficulties in making the diagnosis are common; not all cases
exhibit the clinical features just described. Particularly in young
children, the elderly, pregnant women, and obese patients the
diagnos is may be particularly challenging. The position of the
appendix as related to the cecum may also infl uence the clinical
presentation and the differential diagnosis.

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DIAGNOSTIC WORK -UP
Physical examination and medical history remain the cornerstones of
good clinical practice in patients presenting with acute abdominal pain
localized in the right lower abdominal quadrant. White blood cell (WBC)
count, erythrocyte sedimentation rate, and, sometimes serum C -reactive
protein (CRP) may be helpful. Urinary sed iment examination and a
pregnancy test should be undertaken to exclude urinary tract infection,
urolithiasis, and pregnancy when applicable. However, a recent report on
the diagnostic value of medical history, clinical presentation and indices
of inflammat ion.
Computer aided decision making and scoring systems Combining
clinical history, physical examination and laboratory studies has led to the
development of scoring systems and computer aided algorithms to help
clinicians in the decision making in appendi citis. In clinical studies
several of these computer aided algorithms can reduce the number of
unnecessary appendectomies. These modaliti es were shown to be cost
benefi cial but they require introduction of new and costly equipment and
expertise .
In contras t to this computer aided decision making, scoring systems can
be applied without special equipment and do not require new skills.
However, despite the reported excellent results, these systems are not
routinely used .
Diagnosis
The following laboratory test s do not have findings specific for
appendicitis, but they may be helpful to confirm diagnosis in patients
with an atypical presentation:
 CBC
 C-reactive protein (CRP)
 Liver and pancreatic function tests
 Urinalysis (for differentiating appendicitis from ur inary tract
conditions)
 Urinary beta -hCG (for differentiating appendicitis from early
ectopic pregnancy in women of childbearing age)
 Urinary 5 -hydroxyindoleacetic acid (5 -HIAA)

13
CBC
 WBC >10,500 cells/µL: 80 -85% of adults with appendicitis
 Neutrophilia > 75-78% of patients
 Less than 4% of patients with appendicitis have a WBC count less
than 10,500 cells/µL and neutrophilia less than 75%
In infants and elderly patients, a WBC count is especially unreliable
because these patients may not mount a normal resp onse to infection. In
pregnant women, the physiologic leukocytosis renders the CBC count
useless for the diagnosis of appendicitis.
C-reactive protein
 CRP levels >1 mg/dL are common in patients with appendicitis
 Very high levels of CRP in patients with ap pendicitis indicate
gangrenous evolution of the disease, especially if it is associated
with leukocytosis and neutrophilia
 In adults who have had symptoms for longer than 24 hours, a
normal CRP level has a negative predictive value of 97 -100% for
appendic itis.
Urinary 5 -HIAA
HIAA levels increase significantly in acute appendicitis and decrease
when the inflammation shifts to necrosis of the appendix.[8] Therefore,
such decrease could be an early warning sign of perforation of the
appendix.
CT scanning
 CT scanning with oral contrast medium or rectal Gastrografin
enema has become the most important imaging study in the
evaluation of patients with atypical presentations of appendicitis
 Low-dose abdominal CT may be preferable for diagnosing children
and young adults in whom exposure to CT radiation is of particular
concern .

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Ultrasonography
 Ultrasonography may offer a safer alternative as a primary
diagnostic tool for appendicitis, with CT sca nning used in those
cases in which ultrasonograms are negative or inconclusive
 In pediatric patients, American College of Emergency Physicians
(ACEP) clinical policy recommends ultrasonography for
confirmation, but not exclusion, of acute appendicitis; to
definitively exclude acute appendicitis, the ACEP recommends CT
 A healthy appendix usually cannot be viewed with
ultrasonography; when appendicitis occurs, the ultrasonogram
typically demonstra tes a non -compressible tubular structure of 7 -9
mm in diameter
 Vaginal ultrasonography alone or in combination with
transabdominal scan may be useful to determine the diagnosis in
women of childbearing age
Other imaging studies
 Kidneys -ureters -bladder radiographs: Insensitive, nonspecific, and
not cost -effective
 Barium enema study: Has essentially no role in the diagnosis of
acute appendicitis
 Radionuclide scanning: Localized uptake of tracer in the RLQ
suggests appendiceal inflammation
 MRI: Useful in pregnant patients if graded compression
ultrasonography is non -diagnostic

 Diagnostic laparoscopy Laparoscopic inspection of the abdominal
cavity enables the surgeon to diagnose acute appendicitis
accurately. Early laparoscopy in patients with acute non -specifi c
abdominal pain is associated with higher diagnostic accuracy and
better quality of life than occurs after close observation followed by
surgical interv ention, if signs of peritonism developed. It has been
shown that leaving an appendix that appears normal during
laparoscopic inspection is safe. Criteria for the diagnosis of
appendicitis during laparoscopic inspection are t he presence of
unequivocal infla mmatory changes, such as pus, fibrin, or vascular
injection of the serosa. Rigidity and lack of mobility at
manipulation are more uncertain signs of inflammation.

15
Scoring systems
Alvarado score
A number of clinical and laboratory -based scoring systems hav e been devised to assist
diagnosis. The most widely used is Alvarado score . A score below 5 is strongly
against a diagnosis of appendicitis, while a score of 7 or more is stron gly predictive of
acute appendicitis. In a person with an equivocal score of 5 or 6, a CT scan is used to
reduce the rate of negative appendicectomy.

Tzanakis scoring
Tzanakis scoring: Tzanakis and colleagues, in 2005 published a simplified system,
now c alled the Tzanakis scoring system for appendicitis, to aid the diagnosis of
appendicitis. It incorporates the presence of four variables made up of specific signs
and symptoms, laboratory findings, as well as ultrasound findings to compute a
scoring to pre dict the presence of appendicitis. The maximum score is a total score of
15. When a person with suspected appendicitis scores 8 or more points, there is
greater than 96% chance that appendicitis exists.

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Ultrasound image of acute appendicitis

A CT scan demonstrating acute appendicitis (note the appendix has a diameter of
17.1mm and there is surrounding fat stranding.)

17
Differential diagnosis
Children: Gastroenteritis , mesenteric adenitis , Meckel's diverticulitis ,
intussusception , Henoch -Schön lein purpura , lobar pneumonia , urinary
tract infection (abdominal pain in the absence of other symptoms can
occur in children with UTI), new -onset Crohn's disease or ulcera tive
colitis , pancreatitis , and abdominal trauma from child abuse ; distal
intestinal obstruction syndrome in children with cystic fibrosis; typhlitis
in children wi th leukemia.
Women: A pregnancy test is important in all women of child bearing age,
as ectopic pregnancies and appendicitis present similar symptoms. Other
causes pelvic inflammatory disease , ovarian torsion , menarche ,
dysmenorrhea, pelvic inflammatory disease , endometriosis ,
Mittelschmerz (the passing of an egg in the ovaries approximately two
weeks before an expected menstruation cycle).
Men: testicular torsion ;
Adults: new -onset Crohn's disease , ulcerative colitis , regional enteritis,
renal colic , perforated peptic ulcer , pancreatitis , rectus sheath hematoma ;
Elderly: diverticulitis , intestinal obstruction, colonic carcinoma ,
mesenteric ischemia , leaking aortic aneurysm .
The term "pseudoappendicitis" is used to describe a condition mimicking
appendicitis. I t can be associated with Yersinia enterocolitica .

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Treatment
Pre operation
The treatment begins by keeping the person who will be having surgery
from eating or drinking for a given period of time, usually overnight. An
intravenous drip is used to hydrate the person who will be having surgery.
Antibiotics given intravenously such as cefuroxime and metronidazole
may be administered early to help kill bacteria and thus reduce the spread
of infection in the abdomen and postoperative complications in the
abdomen or wound. Equivocal cases may become more difficult to assess
with antibiotic treatment and benefit from serial examinations. If the
stomach is empty (no food in the past six hours) general anaesthesia is
usually used. Otherwise, spinal anaesthesia may be used.
Once the decision to perform an appendectomy has been made, the
preparation procedure takes approximately one to two hours. Meanwhile,
the surgeon w ill explain the surgery procedure and will present the risks
that must be considered when performing an appendectomy. With all
surgeries there are certain risks that must be evaluated before performing
the procedures. However, the risks are different depen ding on the state of
the appendix. If the appendix has not ruptured, the complication rate is
only about 3% but if the appendix has ruptured, the complication rate
rises to almost 59%.[53] The most usual complications that can occur are
pneumonia, hernia of the incision, thrombophlebitis , bleeding or
adhesions . Recent evidence indicates that a delay in obtaining surgery
after admission results in no measurable difference in outcomes to the
person with appendicitis.[54]
The surgeon will also explain how long the recovery process should take.
Abdomen hair is usually removed in order to avoid complications that
may appear reg arding the incision. In most of the cases persons going in
for surgery experience nausea or vomiting which requires specific
medication before surgery. Antibiotics along with pain medication may
also be administrated prior to appendectomies.

19

Appendectomy
The surgical procedure for the removal of the appendix is called an
appendicectomy . Laparoscopic removal (via three small incisions with a
camera to visualize the area of interest in the abdomen) seem to have
some advantages over an open procedures especially in young females
and the obese patients.
Laparotomy – open surgery

Laparotomy is the tradit ional type of surgery used for treating
appendicitis. This procedure consists in the removal of the infected
appendix through a single larger incision in the lower right area of the
abdomen.[51] The incision in a laparotomy is usually 2 to 3 inches (51 to
76 mm) long. This type of surgery is used also for visualizing and
examining structures inside the abdominal cavity and it is called
exploratory laparotomy.
During a traditional appendectomy procedure, the person with suspected
appendicitis is placed under general anesthesia to keep the muscles
completely relaxed and to keep the person unconscious. The incision is
two to three inches (76 mm) long and it is made in the right lower
abdomen, several inches above the hip bone .[52] Once the incision opens
the abdomen cavity and the appendix is identified, the surgeon removes
the infected tissue and cuts the appendix from the surrounding tissue.
After careful and close inspection of the infected area, and ensuring there
are no signs that surrounding tissues are damaged or infected, the surgeon
will start closing the in cision. This means sewing the muscles and using
surgical staples or stitches to close the sk in up. In order to prevent
infections the incision is covered with a sterile bandage .
The entire procedure does not last longer than an hour if complications do
not occur.

20
ADDITIONAL TROCARS AND INSPECTION OF THE
ABDOMINAL CAVITY

The pressure of gas insuffl ations is determined per individual patient. The
key is to work at the lowest pressure possible to limit adverse
hemodynamic effects. After insuffl ating the peritoneal cavity, the patient
is placed in a Trendelenburg position to displace the small bowels
from the small pelvis. A zero degree 10 -mm laparoscope is introduced to
inspect the entire abdominal cavity. In most patients, placement of a
second trocar allowing for introduction of an atraumatic grasper is
required to retract small bowel loops and omentum. This second 5 –
mm trocar is placed just cranially to the pubic bone in the midline (Figure
2). The peritoneum tends to be very lax in the lower abdomen rendering
introduct ion of this distal trocar diffi cult.
Careful rotating this trocar during introduction and appropriate patience
will contribute to its safe introduction.
The fi rststep is the identifi catio n of the appendix. Laparoscopic
inspection of th e appendix involves assessment of color, c onsistency,
mobility, fi xation and possible perforation. Color assessment in
videoscopic surgery is dependent on many variables such as light
intensity, transparency of the laparoscope and quality of the camera and
screen. A defective imaging chain can obscure or exaggerate r edness of
the appendix. An infl amed appendix is rigid while an unaffected
appendix is fl oppy. Fixation of the appendix is indicative of appendicitis
when previous generalized peritonitis has not occurred. Perforation of the
appendix when present is obvious in most cases by the presence of pus or
faeces in the peritoneal cavity. When the appendix is located posteriorly
to the cecum, t he cecum should be mobilized fi rst by cutting
the peritoneum at Told’s line. This procedure will be facilitated by
placing a third trocar. This third trocar is placed just medially to the left
anterior superior iliac spine . Care should be taken not to damage the
epigastric vessels. Laparoscopic inspection can accuratel y
diagnose or rule out acute appendicitis. If the appendix appears normal,
inspection should continue and involve the gallbladder, stomach,
duodenum, sigmoid colon, distal 100 cm of ileum, ovaries, Fallopian
tubes and uterus if applicable. Inspection of th e pancreatic body and
tail requires opening of the lesser sac through the gastrocolic ligament
and is not routinely performed. A normal appendix should be left in situ,
even if no alternative diagnosis is confi rmed 4. Removing a normal
appendix is associat ed with considerable morbidity and costs 5. After
negative diagnostic laparoscopy, patients should be well informed about
the fact that the appendix was not removed. Murphy et al. 6 showed that
20 percent of patients

21
was unaware of the status of their appe ndix after a diagnostic laparoscopy
performed for right lower quadrant pain.

RESECTION OF THE APPENDIX

In the majority of patients a retrograde dissection of the appendix (from
base to tip) is preferred; only dense infi ltration of the base of the
appe ndix may require antegrade dissection.
Retrograde dissection requires skeletizing of the meso -appendix. To
allow dissection of the meso -appendix, the appendix has to be retracted.
The preferred method is retraction of the meso -appendix to avoid
perforation of the appendix due to grasping. When the mesoappendix
can not be grasped effectivily, a pre -tied loop at the tip of the appendix
can serve as retraction handle. The meso -appendix harbors the
appendicular artery that runs at the base of the meso -appendix.
Depending on the caliber of this artery, occlusion can be accomplished by
mono – or bipolar electrocautery, clips or an ultrasonic device. When
diathermy is used, care should be taken to avoid contact between the tip
of the dissection instrument and the te rminal ileum or cecum. This can
lead to unnoticed damage with late perforation of the ileum. Care should
be taken that the entire appendix is freed as multiple reports exist on
partial appendectomy during laparoscopic removal. The appendiceal
stump can be taken care of by pre -tied loops at the base of the appendix.
Application of diathermy during transsection of the appendix, which has
been advocated to cauterize bacteria in the appendiceal lumen, should be
avoided to prevent tearing the loop. The distal lo op should not
be cut since it can be used to remove the appendix from the abdomen. As
an alternative to pre-tied loops, the appendix can be occluded and
transected by a 30 -35 mm stapling device with a blue cartridge. When a
stapling device is used, care sh ould be taken not to include clips used on
the meso -appendix in the staple line because this will cause misfi ring. In
case of bleeding at the staple line, compression with a gauze usually suffi
ces. If bleeding persists, either a clip or a suture can be p laced. Diathermy
should be avoided to prevent necrosis at the staple line. Use of a stapling
device requires change of the suprapubic 5 mm trocar for a 12-mm trocar.
The use of a stapling device is mandatory when a perforation at the base
of the appendix i s present. In such cases, the stapler is placed over the
cecum to exclude the perforation.

22
REMOVAL OF THE APPENDIX
The appendix is removed from the abdominal cavity through the widest
trocar that has been used during the procedure. In case one 10 -mm tro car
and two 5 -mm trocars have been inserted, a 5 -mm laparoscope can be
inserted through one of the 5 -mm trocars to allow removal of the
appendix through the 10 -mm trocar. When easy passage of the appendix
through the trocar is unlikely, the appendix is pla ced in a plastic retrieval
bag prior to removal.
Drains are not left behind. Suction is performed routinely if blood or
purulent material is present after removal of the appendix. All trocars are
extracted under direct vision in order to identify possible bleeding at the
port site. If a port site bleeding is noticed, coagulation with a laparoscopic
instrument inserted throu gh another port is attempted fi rst to control
the bleeding. If this is unsuccessful, compression with a balloon catheter
or closure of t he port site with suture passers that are inserted under
laparoscopic monitoring is the next step.
Intracutanous closure of the trocar sites is routinely performed.

Laparoscopic

The newer method to treat appendicitis is the laparoscopic surgery . This
surgical procedure consists of making three to four incisions in the
abdomen, each 0.25 to 0.5 inches (6.4 to 12.7 mm) long. This type of
appendectomy is made by inserting a special surgical tool called
laparoscope into one of the incisions. The laparoscope is connected to a
monitor outside the person's body and it is designed to help the surgeon to
inspect the infected area in the abdomen. T he other two incisions are
made for the specific removal of the appendix by using surgical
instruments . Laparoscopic surgery also requires general anesthesia and it
can last up to two hours. The latest methods are NOTES appendectomy
pioneered in Coimbatore, India where there is no incision on the external
skin and SILS (single incision laparoscopic surgery) where a single
2.5 cm incision is made to perform the surgery.

23

Laparoscopic appen dectomy.

24
PRE -OPERATIVE WORK -UP

Hospital lengths of stay typically range from a few hours to a few days,
but can be a few weeks if complications occur. The recovery process may
vary depending on the severity of the condition, if the appendix had
ruptured or not before surgery. Appendix surgery recovery is generally a
lot faster if the appendix did not rupture.[55] It is important that persons
undergoing surgery respect their docto r's advice and limit their physical
activity so the tissues can heal faster. Recovery after an appendectomy
may not require diet changes or a lifestyle change.
After su rgery occurs, the patient will be transferred to a postanesthesia
care unit so his or her vital signs can be closely monitored to detect
anesthesia – and/or surgery -related complications. Pain medication may
also be administered if necessary. After patients are completely awake,
they are moved into a hospital room to recover. Most individuals will be
offered clear liquids the day after the surgery, then progre ss to a regular
diet when the intestines start to function properly. Patients are
recommended to sit up on the edge of the bed and walk short distances
for several times a day. Moving is mandatory and pain medication may
be given if necessary. Full recover y from appendectomies takes about
four to six weeks, but can be prolonged to up to eight weeks if the
appendix had ruptured.
Laparoscopic appendectomy requires a surgical team with proficient
training in basic laparoscopic procedures such as laparoscopic
appendectomy and high quality videoscopic imaging to allow proper
assessment of the appendix. If these criteria cannot be met, open
appendectomy is to be preferred. Both patient and family should be
informed pre -operatively that the incisions will be made i n the left lower
quadrant of the abdomen to remove the appendix laparoscopically, in
order to avoid confusion among those who expect an incision
in the right lower quadrant.
Prior to this laparoscopic procedure the intravenous line should be placed
in the right arm to allow for positioning of the left arm along the body of
the patient, since both the surgeon and camera driver stand on the left side
of the patient. Insertion of a urinary catheter is not mandatory if the
patient has voided prior to surgery. T he patient is placed in supine
position, optionally with the right side elevated to a tilt of 30 degrees in
order to facilitate mobilization of the cecum. Either a cushion or a
beanbag can be used to position the patient in right tilt.

25
Prognosis
Most persons with appendicitis recover easily after surgical treatment, but
complications can occur if treatment is delayed or if peritonitis occurs.
Recovery time depends on age, co ndition, complications, and other
circumstances, including the amount of alcohol consumption, but usually
is between 10 and 28 days. For young children (around 10 years old), the
recovery takes three weeks.
The real possibility of life -threatening peritoni tis is the reason why acute
appendicitis warrants speedy evaluation and treatment. Persons with
suspected appendicitis may have to undergo a medical evacuation .
Appende ctomies have occasionally been performed in emergency
conditions (i.e., not in a proper hospital), when a timely medical
evaluation was impossible.
Typical acute appendicitis responds quickly to appendectomy and
occasionally will resolve spontaneously. If appendicitis resolves
spontaneously, it remains controversial whether an elective interval
appendectomy should be performed to prevent a recurrent episode of
appendicitis. Atypical appendicitis (associated with suppurative
appendicitis) is more difficult t o diagnose and is more apt to be
complicated even when operated early. In either condition, prompt
diagnosis and appendectomy yield the best results with full recovery in
two to four weeks usually. Mortality and severe complications are
unusual but do occu r, especially if peritonitis persists and is untreated.
Another entity known as appendicular lump is talked about quite often. It
happens when the appendix is not removed early during infection and
omentum and intestine adhere to it, forming a palpable lum p. During this
period, surgery is risky unless there is pus formation evident by fever and
toxicity or by USG. Medical management treats the condition.
An unusual complication of an appendectomy is "stump appendicitis":
inflammation occurs in the remnant a ppendiceal stump left after a prior
incomplete appendectomy.

26
conclusion
Historically, the diagnosis of appendicitis has been made based on
clinical findings. Diagnostic imaging has been used primarily to
evaluate patients who have an atypical clinical presentation. Over the
past several years, improvements in imaging technology have
contributed to an increase in diagnostic accuracy in these patients.
Ultrasound has been suggested and used as the primary diagnostic
imaging modality to evaluate for appendicitis. However, sonography is
known to be highly operator dependent; large patient habitus and
atypical appendiceal location are additional factors that may reduce
the reliability of a negative sonographic examination for appendicitis.
CT is more ac curate than ultrasound in the diagnosis of acute
appendicitis. When dedicated CT examination of the appendix is
performed to evaluate all patients with clinically suspected
appendicitis, the diagnostic accuracy is 98%.
Early and accurate diagnosis of appe ndicitis can decrease patient
morbidity and hospital costs by reducing the delay in diagnosis of
appendicitis and its associated complications, as well as by avoiding
inpatient observation prior to surgery in patients who present with
atypical symptoms. Fu rthermore, both CT and ultrasound may rapidly
provide alternative diagnoses which can be treated on an outpatient
basis.

27
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