2. Historical Background
• Appendiceal disease is a frequent reason for emergency hospital
admission, and appendectomy is one of the most common emergency
procedures performed in contemporary medicine.
• the human appendix was not noted until 1492. Leonardo da Vinci
depicted the appendix in his anatomic drawings, but these were not
published until the eighteenth century.
3. Historical Background
• In 1886, Reginald H. Fitz presented his findings regarding appendicitis
and recommended consideration for operative treatment.
• In 1889, Charles McBurney published his landmark paper in the New
York State Medical Journal describing the indications for early
laparotomy for the treatment of appendicitis.
4. Epidemilogy
• incidence rate of about 100 per 100,000 inhabitants. Lifetime risk for
appendicitis is 8.6% for males and 6.7% for females, with the highest
incidence in the second decade of life.
7. Differential Diagnosis
• Pediatric Patient. Acute mesenteric adenitis is the disease most often
confused with acute appendicitis in children. Almost invariably, an
upper respiratory tract infection is present or has recently subsided.
The pain usually is diffuse, and tenderness is not as sharply localized
as in appendicitis.
• Elderly Patient. Diverticulitis or perforating carcinoma of the cecum or
of a portion of the sigmoid that overlies the right lower abdomen may
be impossible to distinguish from appendicitis
8. • Female Patient. Diseases of the female internal reproductive organs
that may erroneously be diagnosed as appendicitis are, in
approximate descending order of frequency, pelvic inflammatory
disease, ruptured graafian follicle, twisted ovarian cyst or tumor,
endometriosis, and ruptured ectopic pregnancy
9. • Computed tomography scan has improved diagnostic accuracy in
individual studies. However, in population-wide studies, the rate of
misdiagnosis of appendicitis remains constant. Rates of misdiagnosis
are highest in female patients of child-bearing age and patients on the
extremes of age (i.e., very young and very old)
10.
11.
12.
13. • Perforated or complicated appendicitis is more common in the very
young (age 65 years)
• Single-incision appendectomy provides no obvious advantage over
standard laparoscopic appendectomy. Natural orifice transluminal
endoscopic surgery remains an investigational procedure
• The incidence of fetal loss following normal appendectomy in
pregnant patients is 4%, and the risk of premature delivery is 10%
• Antibiotic prophylaxis is effective in the prevention of postoperative
surgical site infection. Postoperative antibiotics are unnecessary
following uncomplicated appendicitis. For complicated appendicitis, a
treatment duration of 4 to 7 days is recommended
14.
15.
16.
17. Special Circumstances
Acute Appendicitis In The Young
• diagnostic delays by both parents and physicians, and the frequency
of gastrointestinal distress.
• In children, the physical examination findings of maximal tenderness
in the right lower quadrant, the inability to walk or walking with a limp,
and pain with percussion, coughing, and hopping were found to have
the highest sensitivity for appendicitis.
18. • The treatment regimen for perforated appendicitis generally includes
immediate appendectomy. Antibiotic coverage is limited to 24 to 48
hours in cases of nonperforated appendicitis.
• Laparoscopic appendectomy has been shown to be safe and effective
for the treatment of appendicitis in children.
19. ACUTE APPENDICITIS IN THE ELDERLY
• Compared with younger adults, elderly patients with
appendi_x0002_citis often pose a more difficult diagnostic problem
because of the atypical presentation, expanded differential diagnosis,
and communication difficulty
the perforation rate appears to increase with age greater than 80
years
As a result of increased comorbidities and an increased rate of
perforation, postoperative morbidity, mortality, and hoSpital length of
stay are increased in the elderly compared with younger populations
with appendicitis.
20. ACUTE APPENDICITIS DURING
PREGNANCY
• Acute appendicitis can occur at any time during pregnancy but is rare in the
third trimester.110 The overall negative appendectomy rate during
pregnancy is approximately 25% and appears to be higher than the rate
seen in nonpregnant
women
• Recent data suggest that the incidence of perforated or complex
appendicitis is not increased in pregnant patients.
• Another option is magnetic resonance imaging, which has no known
deleterious effects on the fetus. The American College of Radiology
recommends the use of nonionizing radiation techniques for front-line
21. POSTOPERATIVE CARE AND
COMPLICATIONS
• Following uncomplicated appendectomy, complication rates are low,114
and most patients can quickly be started on a diet and discharged home
the same day or the following day.
• Patients should be continued on broad-spectrum antibiotics for 4 to 7 days.
22. SURGICAL SITE INFECTION
• Following laparoscopic appendectomy, the extraction port site is the most
common site of surgical site infection. Patients with cellulitis can be started on
antibiotics. The cultured organisms are typically bowel flora, as opposed to
skin flora.
• Small abscesses can be simply treated with antibiotics; however, larger
abscesses require drainage. Most commonly, percutaneous drainage with CT
or ultrasound guid_x0002_ance is effective. For abscesses not amenable to
percutaneous drainage, laparoscopic abscess drainage is a viable option.
23. STUMP APPENDICITIS
• A review of literature has revealed only 60 reports of this phenomenon.
Likely, incom_x0002_plete appendectomy is underreported, and the true
prevalence is much higher. Reported as “stump appendicitis,” patients
typically present with recurrent symptoms of appendicitis
approxi_x0002_mately 9 years after their initial surgery.
• There was no difference in initial surgery between laparoscopic and open
procedures
• The key to avoiding stump appendicitis is prevention. Use of the
“appendiceal critical view” (appendix placed at 10 o’clock, taenia
coli/libera at 3 o’clock, and terminal ileum at 6 o’clock) and identification
of where the taeniae coli merge and disappear is paramount to identifying
and ligating the base of the appendix during the initial operation
24. INCIDENTAL APPENDECTOMY
• During this period, an average of 250,000 cases of appendicitis and
310,000 incidental appendectomies occurred annually in the United
States. It was esti_x0002_mated that 36 incidental appendectomies
had to be performed to prevent one patient from developing
appendicitis.
• In view of the added costs and risk of morbidity for each extension of
a surgical intervention, this does not seem to justify incidental
appendectomy.
25. PREVALENCE OF NEOPLASMS
• The prevalence of identifying a mass within the appendix is less than
1%. Appendiceal carcinoid and appendiceal adenomas are the most
common lesions identi
• In older patients, the prevalence of identifying colon can_x0002_cer
appearing as appendicitis has been reported in a single study with a
prevalence of less than 1%. The mean age in this case series was 69
years (range, 42 to 89 years).
26. CARCINOID
• Carcinoid syndrome is rarely associated with appendiceal carcinoid
unless widespread metastases are present, which occur in 2.9% of
cases Symptoms attributable directly to the carcinoid are rare,
although the tumor can occasionally obstruct the appendiceal lumen
much like a fecalith and result in acute appendiciti
• The mean tumor size for carcinoids is 2.5 cm
• epidemiology, and end results data indicate that proper surgery for
carcinoids is not performed at least 28% of the time.
27. ADENOCARCINOMA
• Primary adenocarcinoma of the appendix is a rare neoplasm with
three major histologic subtypes: mucinous adenocarcinoma, colonic
adenocarcinoma, and adenocarcinoid.
• appendiceal adenocarcinoma are at significant risk for both
synchronous and metachronous neoplasms, approximately half of
which will originate from the gastrointestinal tract.
28. MUCOCELE
• A mucocele of the appendix is an obstructive dilatation by intraluminal
accumulation of mucoid material. Mucoceles may be caused by one of
four processes: retention cysts, mucosal hyperplasia, cystadenomas,
and cystadenocarcinomas
• a more aggressive approach to ruptured appendiceal neoplasms has
been advocated. This approach includes a thorough but
mini_x0002_mally aggressive approach at initial laparotomy, as
described earlier, with subsequent referral to a specialized center for
con_x0002_sideration of reexploration and hyperthermic
intraperitoneal chemotherapy
29. LYMPHOMA
• The gas_x0002_trointestinal tract is the most frequently involved
extranodal
• site for non-Hodgkin’s lymphoma.Other types of appendiceal
lymphoma, such as Burkitt’s lymphoma, as well as leukemia, have
also been reporte.
