The cathedra of the faculty and hospital surgery of the treatment faculty of the Tashkent medical academy Acute appendicitis

Acute appendicitis – not specific inflammation of the appendix

Projection of the appendix on the anterior abdominal wall

Localization of the appendix comparatively the caecum medial normal retrocaecal

Variants of the localization of the appendix in the abdominal cavity Subhepatical localization In the pelvis

Blood circulation of the appendix Arterial circulation Aorta – а.mesenterica superior – a.ileocolica – a.appendicularis Venous system v.appendicularis – v.ileocolica – v. mesenterica superior – v.portae

Spreading of the acute appendicitis among the acute surgical diseases Acute cholecystitis Ulcer disease of the duodenum

Frequency of the complications Factors of the frequency of the postoperative complications and death at the acute appendicitis № Authors Year Frequency of the complications Factor of death 1. Savchuk B.D. 1998 9,8% 0,31% 2. Savelev V.S. 1999 8,7% 0,24% 3. Gostishev V.К. 2001 7,6% 0,21% 4. Dronov А.F. 2002 7,9% 0,26% 5. Shurkalin B.К. 2003 8,6% 0,28% 6. Kriger А.G. 2005 0,22% 7. Goodwin C.S 2004 7,3% 0,19% 8. Bohnen J.M. 8,2% 0,23%

Frequency of the acute appendicitis depend on the age Acute appendicitis is the most spreaded surgical disease. Frequency - to 200-300 people one with the acute appendicitis Frequency of the acute appendicitis depend on the age Frequency of the acute appendicitis depend on the gender mal fem Postoperative death – 0,2-0,3%

Etiology and pathogenesis of the acute appendicitis Direct irritation of nerves (alien object in the appendix, excrement stone, bends) Sensibilisation of the organism (allergy, hookworms invasion) Reflector way (diseases of the stomach, liver, intestine) Breach of the nervous regulation of the appendix Spasm of the muscles and vessels of the appendix Breach of the blood circulation of the appendix Hypostasis of the wall of the appendix Closing of the mouth of the appendix ACUTE APPENDICITIS

Classification of the acute appendicitis Simple appendicitis Destructive appendicitis: flegmonous, gangrenous, perforative Complicated appendicitis: appendicular infiltrate, appendicular abscess, peritonitis, pilephlebitis and other.

Normal appendix

Acute simple appendicitis

Acute destructive appendicitis Empiema of the appendix Gangrenous perforative appendicitis

Complaints the most frequent 1 – pain in the right iliac area 1. Beginning of the pain in the epygastria with the transition to the right iliac area (Cocher-Volkovich symptome) 2. Constant (seldom fight), 3. Low intensivity (blunt, nagging) 4. Without the irradiation 2 – sickness, retching (once or twice) 3 – weakness, loss of appetite

Compllaints depending on the localization of the appendix and stage of the process Constipation – at the peritonitis Tenesms – at the pelvic localization Diarrhea – at the medial localization Disuria – at the retrocaecal localization Dryness in the mouth, ballooned abdomen – at the peritonitis

Local symptoms of the acute appendicitis Cocher-Volkovich – transition of the pain from the epigastria to the right iliac area Rovsing – increasing of pain in the right iliac area at pushing to the left Voscresenskiy («shirt») – identification of the most painful zones at the sliding of the hand above the shirt Razdolskiy– pain at the percussion in the right iliac area Sitkovskiy – tumbling from the back to the left side inducts pain in the right iliac area Bartom’e-Mikhelson– palpation of the right iliac area at the state of the patient on the left side inducts pain

General symptoms of the acute appendicitis Dryness and coverness of the tongue Tachycardia Subfebril temperature Rising of the SES Leucocytosis with the movement of the formula to the left

Particularities of the clinic currency of the acute appendicitis At children. Fast development of the destructive changes (perforation), short omentum – spreading of the infection, prevalence of the general symptoms over the local: enxiety, breach of sleeping, rising temperature to 38,5-39С, increasing pain in the abdomen without defined localization, frequent sickness, retching, diarrhea At elders. Low significance of the main symptoms: pain, pain at the palpation, effort of the muscles, the temperature is normal or increased a little, the leucocytes of blood are without changes, aptitude to the development of thrombs, early development of the destructive changes, more frequent development of the complications At pregnants. Denominated pain appears later, in not typical place, but above and to the right from the uterus, seldom in the lumbar area, effort is less denominated Indicate the symptoms of the appendicitis is complicative or impossible frequently under the mask of pyelonephritis of pregnants.

Differential diagnostic of the acute appendicitis Diseases of the organs of the abdominal cavity Diseases of the organs of the chest Diseases of the organs of the extraperitoneal space Infectional diseases Diseases of the vessels Gynecological diseases Diseases of skin Neurological diseases

Ultrasound research Presence of the free liquid

Special methods of diagnostic Laparoscopy Special methods of diagnostic

Diagnostic laparoscopy More reliable method, that allows directly find out the source of the peritonitis, presence and character of the excaudate.

Laparoscopic signs of the inflammated appendix (by Criger А.G., 2000) Not changed appendix free droops on the instrument At the inflammation the appendix doesn’t droop because of the hypostasis, periodically slides

Incision of Dyakonov-Volkovich

Stages of the access Section of the aponeurosis Separation of the muscles Opening of the peritoneum

Stages of the operation Bandaging of the mesentery of the appendix Removing of the appendix Removing of the dome of the caecum

Stages of the operation Submersion of the cult of the appendix Putting of the pouch stitch Appendectomy

Stages of the retrograd appendectomy

Stages of the retrograd appendectomy

Character and frquency of the postoperative complications Wound complications– 80% Intraperitoneal – 6% Bronchopulmonar – 4% Cardio-vessel – 3% Others – 7%

The reasons of the not satisfactory results of the traditional appendectomy Defeat of the different cutaneus and muscle’s nerves Defeat of the vessels, inducting the development of the haemotomas, and wound complications Defeat of the muscular-aponeurotic tissues promotes the development of the postoperative hernias Manipulations, performing in the abdominal cavity indicate the soldering process in the abdominal cavity High per cent of the diagnostic mistakes, that confirmed by the high weight of the “cataral” appendicitis

History of the endoscopic surgery of the acute appendicitis The first appendectomy under the control of the laparoscopy was performed by De Kok in 1977 year with the minilaparotomy to delete the appendix At first the LAE was performed by K. Semm in 1982 year at the patient with the pathology of the apurtenances, moreover the changes of the appendix weren’t acute In 1987 year Schrieber J.H. has carried out the laparoscopic appendectomy because of acute appendicitis

Morphologic characteristic of the acute appendicitis in different groups Cataral Flegmonous Gangrenous Control group Main group

Variants of the performing of the laparoscopic appendectomy With using of the endostapler Endo-Gia-30 With using of the endoloop of Roeder With using of clipses

Laparoscopic appendectomy with the help of endoligature

Laparoscopic appendectomy with the help of clipping

Laparoscopic appendectomy with the help of endoscopic suturing instruments

Comparative estimation of the clinic picture in different groups Dynamic of changing of the painful syndrome Dynamic of changing of the moving activity

Comparative estimation of the postoperative complications in different groups Early complications (to 15 days) Lately complications (more than 3 months) Wound complications Abscess of the Douglas’s space Breach of the sensitivity Acute intestinal obstruction Breach of the sensitivity Traditional appendectomy Laparoscopic appendectomy

Analysis of the reasons of the conversions at performing of the laparoscopic appendectomy 1. retrocaecal, retroperitoneal localization of the appendix; 2. duration of the disease to the moment of the admition more than 48 hours; 3. technic impossibility of deleting of the appendix by the laparoscopic access during 1 hour from the moment of the beginning of the operation.

Group of the patients, at which it is better to perform the laparoscopic appendectomy 1. the patients, at which it is impossible to exclude acute appendicitis during the dynamic observation. Performing of the diagnostic laparoscopy allows to confirm the diagnosis, at the case of finding out the acute appendicitis - LAE. 2. the women of the reproductive age. Performing of the endoscopic research allows to carry out the differential diagnostic between the acute appendicitis and acute gynecological pathology. Besides, the reduction of the weight of the ungrounded appendectomies warns the development of soldering process and as a result – secondary sterility. 3. patients with the acompanying diabetes, obesity and other predisposing factors of the development of the wound complications. Using of the LAE at these patients reduces the risk of development of the wound complications.

Contraindications to the laparoscopic appendectomy 1. duration of the disease more than 48 hours. 2. diffuse peritonitis. At this case it is impossible ti carry out the sanation of the abdominal cavity. 3. general contraindications to the laparoscopy – pulmonary-cardiac insufficiency, big term of the pregnancy, acute infarct of myocardium, additional diseases, not allows to increase the intraabdominal pressure, presence of the significant soldering process in the abdominal cavity