3. وإن تعدوا نعمة الله لا تحصوها And if you would count the favours of Allah, never could you be able to count them صدق الله العظيم بسم الله الرحمن الرحيم

7. By Prof. Waleed Wahdan Senior Consultant Surgeon 2015 Difficult Appendectomy In Surgical Practice

8. Introduction 1889 Mac Burney described location, the clinical features of appendicitis and the importance of operative intervention and muscle-splitting incision.

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

12. 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

13. 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

14. 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.

15. Histology Histological terms used: Catarrhal appendicitis Inflamed Suppurative Necrotic Gangrenous Perforated Appendicular mass

16. 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.

17. Diagnosis Ultrasonography and Spiral CT may lower the false-negative appendectomy diagnosis and reduce the rate of perforation by shortening in-hospital delay in treatment. Ultrasonography and Spiral CT may lower the false-negative appendectomy diagnosis and reduce the rate of perforation by shortening in-hospital delay in treatment.

18. 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

19. Surgery: Open appendectomy McBurney (oblique); Rocky Davis (transverse); right paramedian; midline incision Laparoscopy NOTES

20. Open Appendectomy:

21. 2.Laparoscopy:

22. Difficult Appendesectomy Difficult Appendesectomy

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

24. Surgeon and assistant Qualified Surgeon with good assistant play important roles to get a simple appendectomy.

25. patient. General condition Obesity The Very Young The Very Old In AIDS Patients The Pregnant woman

26. Obesity with acute appendicitis

27. The Very Young Diagnosis may be more difficult to establish Children are more likely to progress to perforated appendix (? Under-developed Greater Omentum).

28. Children with acute appendicitis

29. 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

30. old with acute appendicitis old with acute appendicitis

31. In AIDS Patients Be aware of CMV or Kaposi sarcoma as the underlying cause General condition Risk of infection

32. 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%

33. Pregnant woman with acute appendicitis

34. Position of Appendix

35. 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

36. Appendix Site : Retroperitonum Subhepatic Pelvic Gross Pathology The presence of parasites in the appendix Fixed cecum

39. Appendix. Gross Pathology Perforated Very long Short Appendicular Mass Chronic Appendicitis Appendicular abscess Tumors of The Appendix

40. Appendicular abscess

41. Tumors of The Appendix Carcinoid Adenocarcinoma Lymphoma. Mucocele Pseudomyxoma Peritonei

42. Carcinoid

43. Operation field Incision site size Exploration Homeostasis light Instrument

44. Operation field

45. Fecalith

50. Perforated appendicitis

51. Very long appendicitis

52. Appendicular abscess

53. 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

54. الحمد لله

55. Thank you!