1. ACUTE APPENDICITIS

2. ACUTE APPENDICITIS
Appendicitis is defined as an inflammation of the inner lining of the vermiform appendix that spreads to its other parts. This condition is a common and urgent surgical illness with protean manifestations, generous overlap with other clinical syndromes, and significant morbidity, which increases with diagnostic delay.

4. Anatomy
Normal appendix; barium enema radiographic examination. A complete contrast-filled appendix is observed (arrows), which effectively excludes the diagnosis of appendicitis

6. Variations in topographic position of the appendix
From its base at the cecum, the appendix may extend (A) upward, retrocecal and retrocolic; (B) downward, pelvic; (C) downward to the right, subcecal; or (D) upward to the left, ileocecal (may pass anterior or posterior to the ileum)

7. Surgical Anatomy - Position

8. Blood supply to the appendix.
A and B. Usual type with a single appendicular artery. C. Paired appendicular arteries.

9. Incidence
The lifetime rate of appendectomy is 12% for men and 25% for women, with approximately 7% of all people undergoing appendectomy for acute appendicitis during their lifetim
Despite the increased use of ultrasonography, computed tomography (CT), and laparoscopy, the rate of misdiagnosis of appendicitis has remained constant (15.3%), as has the rate of appendiceal rupture.
The percentage of misdiagnosed cases of appendicitis is significantly higher among women than among men

10. AGE

11. Etiology
Obstruction of the lumen is the dominant etiologic factor in acute appendicitis.
– Submucosal lymphoid hyperplasia
– Faecolith / faecal stasis
– Inspissated barium
– Vegetable/fruit seeds
– Worms (Entrobius vermicularis
– Tumours of caecum/appendix

13. Common organisms seen in patients with acute appendicitis
Bacteriology
Common organisms seen in patients with acute appendicitis

14. Classification (by V.I. Kolesnikov)
1. Appendiceal colic.
2. Simple superficial appendicitis.
3. Destructive appendicitis:
а) phlegmonous;
б) gangrenous;
в) perforated.
4. Complicated appendicitis:
а) appendicular infiltrate;
б) appendicular abscess;
в) diffuse purulent peritonitis.
5. Other complications of acute appendicitis (pylephlebitis, sepsis, retroperitoneal phlegmon, local abscesses of abdominal cavity).

15. Symptoms of simple appendicitis
1. Pain localized in a right iliac area.
In 70 % of patients the pain arises in a epigastric area – it is an epigastric phase of acute appendicitis. In 2-4 hours it migrates to the area of appendix (the Kocher’s sign).
2. Single nausea and vomiting.
3. Fever to C.
4. Retention of stool or single diarrhea.
5. Muscular tension in a right iliac area.
Rovsing's sign - pain in right lower quadrant during palpation of left lower quadrant
Sitkovsky’s sign - increase of pain in a right iliac area when the patient lies on the left side
Bartomier’s sign - the increase of pain intensity during the palpation of right iliac area when the patient lies on the left side.
Dunphy's sign-increased pain with coughing

16. Symptoms of phlegmonous appendicitis
1. Expressed pain in a right iliac area.
2. Fever to C.
3. Muscular rigidity in a right iliac area.
4. Peritoneal signs
Blumberg’s sign. After gradual pressing by fingers of anterior abdominal wall quick taking off the hand causes the sharp increase of pain.
Voskresenky’s sign. The increase of pain during quick sliding movements by the tips of fingers from epigastric to right iliac area.
Rozdolsky’s sign. Painfulness in a right iliac area during percussion.

17. Symptoms of gangrenous appendicitis
1. Pain in a right iliac area.
2. Grave condition of the patient.
3. Signs of local peritonitis.
4. Signs of intoxication

18. Symptoms of retrocaecal appendicitis
1. Non-expressive abdominal clinic.
2. Expressed pain in a right lumbar area.
3. Pain and muscular rigidity in a right iliac area during palpation.
Yaure-Rozanov sign - Painfullness during palpation of Petit triangle
Gabay’s sign - Blumberg’s sign in Petit triangle
Pasternatsky’s sign - tapping of lumbar region cause the pain
Psoas sign - pain on extension of right thigh

19. Symptoms of retrocaecal retroperitoneal appendicitis
1. Clinic of retroperitoneal phlegmon.
2. The signs of retrocaecal appendicitis.
3. Flank tenderness in right lower quadrant.

20. Symptoms of pelvic appendicitis
1. Clinic of irritation of pelvic organs (dysuria, pulling rectal pain, tenesmi).
2. Absence of muscular tenderness.
3. Painfullness of anterior rectal wall and posterior vaginal vault.

21. Complications 1. Appendicular infiltrate. 2. Appendicular abscess.
3. Diffuse peritonitis.
4. Pilephlebitis

22. Diagnostics 1. Anamnesis. 2. Objective examination.
3. General blood and urine analyses.
4. Vaginal examination for women.
5. Rectal examination for men.

23. Abdominal X-ray

24. Graded compression Ultrasound
Depends on the technique and experience
Normal appendix
– a blind-ended, tubular structure with a maximum wall thickness of 2 mm with an outer diameter of 6 mm,
– No peristalsis
– Originates from the base of the cecum

25. Graded compression Ultrasound

26. CT variable degree of distension (diameter 6–40 mm)
wall thickness of 1–3 mm.
Wall - asymmetrically thickened enhances with intravenous contrast medium.
periappendiceal inflammatory mass
Thickening and enhancement with intravenous contrast - adjacent wall of the cecum or ileum

27. CT

28. Differential diagnostics
Gastrointestinal
Cholecystitis
Crohn's disease
Duodenal ulcer
Gastroenteritis
Intestinal obstruction
Meckel's diverticulitis
Mesenteric lymphadenitis
Necrotizing enterocolitis
Neoplasm (carcinoid, carcinoma, lymphoma)
Gynecologic
Ectopic pregnancy
Endometriosis
Ovarian torsion
Pelvic inflammatory disease
Ruptured ovarian cyst
Tubo-ovarian abscess

29. Differential diagnostics
Systemic
Diabetic ketoacidosis
Henoch-Schonlein purpura
Pulmonary
Pleuritis
Pneumonia (basilar)
Pulmonary infarction
Genitourinary
Kidney stone
Pyelonephritis
Wilms' tumor
Other
Parasitic infection
Psoas abscess
Rectus sheath hematoma

30. Differential diagnostics of acute appendicitis with perforative peptic ulcer
Pain in the right iliac region
Muscular tenderness in the right iliac region
Single vomiting and diarrhea
Sharp acute diffuse pain
Ulcerative anamnesis
Absence of hepatic dullness
On X-ray of the abdomen air above the liver (air sickle)
Rigidity of anterior abdominal wall

31. Differential diagnostics of acute appendicitis with intestinal obstruction
Constant pain in the right iliac region
Muscular tenderness in the right iliac region
Single vomiting and diarrhea
Periodic acute diffuse pain
Constant vomiting and nausea without any relief
Retention of stool and gases
Abdominal distension
On X-ray of the abdomen Kloiber's cups (air-fluid levels)
Splashing sound, increased peristalsis

32. Management

33. Open Appendicectomy • Incission (transverse, Mc Burney’s point)
• Open in layers. (muscle split along its fibres)
• Check for fluid (+/-c&S)
• Identify caecum and exteriorized – follow taeniae to appendix
• Mesoappendix divided + ligated
• Clamp appendix 5mm above caecum and ligated
• Cauterise residual mucosa +/- purse string (not req)
• Return caecum, wash with warm saline
• Close in layers

34. Open Appendicectomy

35. Open Appendicectomy

36. Open Appendicectomy

37. Open Appendicectomy

38. Laparoscopic Appendicectomy

39. Laparoscopic Appendicectomy

40. Laparoscopic Appendicectomy

41. Laparoscopic Appendicectomy

42. Complications