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

2. Acute appendicitis – not specific inflammation of the appendix

3. Projection of the appendix on the anterior abdominal wall

4. Localization of the appendix comparatively the caecum
medial
normal
retrocaecal

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

6. 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

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

8. 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%

9. Frequency of the acute appendicitis depend on the age
Acute appendicitis is the most spreaded surgical disease.
Frequency - to 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%

10. 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

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

12. Normal appendix

13. Acute simple appendicitis

14. Acute destructive appendicitis
Empiema of the appendix
Gangrenous perforative appendicitis

15. 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

16. 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

17. 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

18. 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

19. 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.

20. 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

21. Ultrasound research
Presence of the free liquid

22. Special methods of diagnostic
Laparoscopy
Special methods of diagnostic

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

24. 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

25. Incision of Dyakonov-Volkovich

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

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

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

29. Stages of the retrograd appendectomy

30. Stages of the retrograd appendectomy

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

32. 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

33. 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

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

35. 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

36. Laparoscopic appendectomy with the help of endoligature

37. Laparoscopic appendectomy with the help of clipping

38. Laparoscopic appendectomy with the help of endoscopic suturing instruments

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

40. 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

41. 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.

42. 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.

43. 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