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بسم الله الرحمن الرحيم
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Difficult Appendesectomy In Surgical Practice
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Introduction 1889 Mac Burney described location, the clinical features of appendicitis and the importance of operative intervention and muscle-splitting incision.
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Surgical Anatomy Surface anatomy
Development: diverticulum of ceacum appearing in the 8th week of life Positions: constant base, tip varies (retroceacal, pelvic, subcaecal, preileal, pericolic)
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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 Yr
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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
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Fecalith
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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.
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Histology Histological terms used: Catarrhal appendicitis Inflamed
Suppurative Necrotic Gangrenous Perforated Appendicular mass
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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.
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Treatment Adequate hydration, correct electrolyte imbalance
Manage other medical problems Pre-operative antibiotics: Simple AP - hrs antibiotic Ruptured AP - antibiotic until fever Peritonitis days antibiotics
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Surgery: Open appendectomy Laparoscopy NOTES
McBurney (oblique); Rocky Davis (transverse); right paramedian; midline incision Laparoscopy NOTES
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Open appendectomy
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Open Appendectomy:
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Laparoscopy
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Laparoscopy:
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Difficult Appendesectomy
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Difficult Appendesectomy
Difficult Appendesectomy reasons : Surgeon and assistant . patient. Appendix. Operation field.
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Surgeon and assistant Qualified Surgeon with good assistant play important roles to get a simple appendectomy.
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patient. General condition Obesity The Very Young The Very Old
In AIDS Patients The Pregnant woman
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Obesity with acute appendicitis
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The Very Young Diagnosis may be more difficult to establish
Children are more likely to progress to perforated appendix (? Under-developed Greater Omentum).
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Children with acute appendicitis
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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
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old with acute appendicitis
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In AIDS Patients Be aware of CMV or Kaposi sarcoma as the underlying cause General condition Risk of infection
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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%
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Pregnant woman with acute appendicitis
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Position of Appendix
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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
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Pregnant woman with acute appendicitis
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Laparoscopic Appendectomy
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Appendix Site : Retroperitonum Subhepatic Pelvic Gross Pathology
The presence of parasites in the appendix Fixed cecum
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Appendix. Gross Pathology Perforated Very long Short Appendicular Mass
Chronic Appendicitis Appendicular abscess Tumors of The Appendix
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Perforated appendicitis
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Very long appendicitis
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Appendicular abscess
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Appendicular abscess
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Tumors of The Appendix Carcinoid Adenocarcinoma Lymphoma. Mucocele
Pseudomyxoma Peritonei
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Carcinoid
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Operation field Incision site size Exploration Homeostasis light
Instrument
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Operation field
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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
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الحمد لله
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