4. Anatomic Aspects
Blind pouch off of cecum
Contains lymphoid tissue which peaks in
adolescence, atrophies with age
Function still unclear
Appendix can be anywhere within
peritoneal cavity
One study showed 65 % retrocecal, 31 %
pelvic
Review of 70,000 cases showed 4 % in
RUQ, 0.06 % LUQ, 0.04 % LLQ
5.
6. Pathophysiology of Appendicitis
Lymphoid hyperplasia leads to luminal obstruction
Often follows viral illness
Epithelial cells secrete mucus
Appendix distends, bacteria multiply
Visceral pain begins an average of 17 hours after
obstruction
Increased pressure compromises blood supply
Somatic pain develops
Average time to perforation = 34 hrs.
7. Classic Presentation
Seen in 60 %
Anorexia
Periumbilical pain, nausea, vomiting
RLQ pain developing over 24 hrs.
Anorexia and pain are most frequent
Usually nausea, sometimes vomiting
Diarrhea, esp. with pelvic location
Usually tender to palpation
Rebound is a later finding
8.
9. Physical Exam
Tenderness at McBurney's point
Cutaneous hyperesthesia in T 10 to 12
dermatomes
Rovsing's sign
Psoas sign
Obturator sign
10. High Risk Patients.
Pregnancy
Most common surgical emergency in
pregnancy
Mortality rate if missed = 2 % for mother,
up to 35 % for fetus
WBC elevated in pregnancy
Appendix changes location
11. High Risk Patients, cont'd.
Pediatrics
Most common surgical disorder in kids
Accounts for 5 % of abd. pain visits
Up to 50 % initially misdiagnosed
ƒ < 2 yrs. : perforation rate approaches 100 %
ƒ 3 to 5 yrs. = 71 %
ƒ 6 to 10 yrs. = 40 %
Most common misdiagnosis is AGE
Sequence of pain and vomiting may be helpful
Localized tenderness not a feature of AGE
12. High Risk Patients, cont'd.
Elderly
Vital signs and exam may not reflect
severity
> age 60 : only 5 to 10 % diagnosed
without delay
Perforation rate = 46 to 83 %
RLQ tenderness absent in 23 %
N/V, anorexia less common
Leukocytosis less pronounced
Only 20 % classic presentation
13. High Risk Patients, cont'd.
Immunocompromised
HIV, chronic steroids, sickle cell,
chemotherapy, DM, dialysis
Increased risk of complications and
misdiagnosis
Inflammatory response decreased
16. Laboratory Studies
CBC
75 to 85 % have elevated WBC, but it is
nonspecific
WBC normal in 80 % in the first 24 hrs.
Can see elevated ANC in up to 89 %
WBC usually 12 to 18,000 in appendicitis
Chemistry panel
May help with diagnosis of dehydration
17. Laboratory Studies, cont'd.
Urinalysis
Specific gravity, ketones
Can see WBC’s, RBC’s, bacteria if inflamed
appendix close to ureter
> 30 WBC’s = probable UTI
HCG
Essential in women of child-bearing age
CRP
Acute phase reactant
18. Imaging Studies
Plain films
Low sensitivity and specificity
Appendicolith specific, but seen in only 2 %
May see local air-fluid levels, psoas
obliteration, soft tissue mass, gas in
appendix : all nonspecific
19. Imaging Studies, cont'd.
Ultrasound
75 to 90 % sensitive, 86 to 100 % specific
Noninvasive, low cost, but operator-
dependent
Good for diagnosing GYN disorders
3 criteria for diagnosis
ƒ Tender, noncompressible appendix
ƒ No peristalsis of appendix
ƒ Overall diameter > 6 mm
20. Imaging Studies, cont'd.
CT
Early studies showed low yield, but helical
CT much more accurate
Sensitivity 97 to 100 %, specificity 95 %
(similar no matter what type or whether
contrast is used)
Often shows alternative diagnosis
More expensive, radiation exposure
21. Imaging Studies, cont'd.
CT
Criteria for appendicitis :
ƒ Diameter > 6 mm
ƒ Failure to completely fill with contrast or
air
ƒ Appendicolith
ƒ Wall thickening or enhancement
Other contributory signs include fat
stranding, fluid, inflammatory mass,
adenopathy
22. Imaging Studies, cont'd.
CT
One study showed negative laparotomy
rates of 4 % in men, 8 % in ovulating
women with CT (typical is 20 % and 45 %
respectively), but no change in perforation
rate
Another study showed increase in CT use
led to earlier diagnosis, less severe
pathologic findings, and decreased length
of stay
23. Do We Need Imaging Studies?
Literature conflicting
Pediatric Imaging -Evidence-Based
Guidelines
Imaging most useful in clinically equivocal
cases
Costs of imaging minor compared to cost
of unnecessary surgery or delayed
diagnosis
US and CT both specific enough to rule in
appendicitis, but only CT sensitive enough
to rule it out
24. Risk Management
Misdiagnosis of appendicitis = 5th
leading cause of successful litigation
against EPs
7 features of misdiagnosed cases :
No nausea / vomiting
Lack of distress
No rebound
No guarding
No rectal exam (controversial)
Narcotic pain meds given
Diagnosis of acute gastroenteritis
25. Risk Management, cont'd.
When discharging, stress unclear
diagnosis, what to watch for
Follow up in 12 hours (PMD or E.D.)
Can always observe if unsure
"When in doubt, don't send them out."
26. TREATMENT
1. OPEN APPENDECTOMY
2. Standard LAP APPENDECTOMY
3. SILS APPENDECTOMY
27.
28.
29.
30.
31.
32.
33. Patient is supine,
laying flat
Surgeon and
assistant
positioned on
patient’s left
Monitors on
patient’s right,
facing surgeons
Anesthesiologist
conventionally
stationed at
patient’s head
(not shown)
34. 10-mm trocar
placed through
umbilicus (this
port holds camera)
5-mm trocar
placed at
suprapubic region
5-mm trocar
placed at LLQ
*A fourth port containing
extraction tube may be
placed closer to McBurney’s
point later in procedure.
35. Step 1: Port placement A 10-mm trocar is placed
at the umbilicus, and the abdominal cavity is
insufflated to a pressure of 15 mmHg. The
camera is also inserted through this larger trocar.
A 5-mm trocar is placed at the suprapubis, and a
second 5-mm trocar is placed at the LLQ.
(Placement of the third port may vary by surgeon
preference or as case dictates but LLQ is standard
placement)
Step 2: Inspect abdominal cavity The area is
inspected to orient the surgeon to the position of
the appendix. Inspection will also alert surgeon to
any anatomic variation or pathological conditions
that may be relevant (e.g. peritonitis).
36. Step 3: Expose appendix The bowel is
gently retracted rostrally using
atraumatic graspers to allow access to
appendix.
Step 4: Locate and separate appendicular
artery The mesoappendix is separated
from the body of the appendix, and the
mesenteric fat is separated to reveal the
appendicular artery. This is best done
using the “spreader” action of a
dissector.
37. Step 5: Divide appendix from cecum
Using an endoloop, two loops are placed
proximal to the cecum, and a third loop is
placed 1-2 cm distally to these. The
appendix is then divided between the
two proximal and 3rd distal loops using
scissors or cautery. Staples may be
substituted for loops.
UK surgeons tend to use the Endo GIA
tool, which simultaneously seals and
cuts, eliminating the need for loops or
staples.
Step 6: Divide appendicular artery The
artery is divided using the Endo GIA or
the endoloop method described above
(two ligatures proximally, one distally).
38. Step 7: Extract appendix A fourth
port (10 mm) may be placed
containing the extraction tube.
Alternately, the camera may be
withdrawn and the existing 10 mm
port used for extraction (a 5 mm
camera is inserted into one of the
smaller ports in these cases).
In either case, an extraction tube is
placed through the appropriate 10
mm port, and the extraction
bag tool is placed through the extraction tube. The appendix is placed in the
capture bag, and removed from the abdomen through the extraction tube.
*(It should be noted that in the accompanying video, a non-conventional extraction technique is used,
probably because the appendix had already ruptured and the extraction bag was deemed unnecessary. The
image above comes from a different case.)
39. Step 8: Irrigate The abdominal
cavity should be irrigated
thoroughly with sterile saline and
suctioned clean several times. In the
event of a rupture, great care should
be taken to ensure all pus or other
infectious fluids have been
removed.
Step 9: Final inspection The
abdominal and pelvic cavities are
inspected one final time for any signs
of infection, errors, or other potential
complications of which the surgeon
might need to be aware. This can
often be done simultaneously with
irrigation.