3. SCHEME OF PRESENTATION
• Introduction : Dr.Subhashis Sharma
• Pathophysiology: Maj Nikhil Singh
• Acute uncomplicated/perforated appendix:Dr Anjali Goel
• Lap vs Open appendectomy: SLC Mehul Kohli
• Neoplasm/recent advances,SLC D J Choudhury
4. INTRODUCTION:
• Most Common urgent or emergent general surgical operation
performed.
• First “Major” case performed by the surgeon in training.
• Reminder of the art of surgical diagnosis.
• Propensity to the formation of tumors with dramatic clinical
consequences
Ref: Sabiston Textbook of Surgery
5. History:
• 1492: Leonardo da Vinci depicted the
appendix in his anatomic drawings.
• 1544 Jean Fernel described appendiceal
disease in a paper published
• 1735: First known appendicectomy
performed by Claudius Amyand.
Ref:A Brief History Of Appendicitis: Medical University of South Carolina
6. Cont.
• 1886:First formal description of the
disease process,clinical features by
Reginald Herber Fitz.
• 1894:McBurney’s description of technique
for removal of Appendix.
• 1982: Description of Laparoscopic appendectomy
by Kurt Semm.
7. APPENDIX
• A narrow, hollow, blind ended tube.
• Large aggregation of lymphoid tissues
• Point of attachment to the cecum is consistent.
• Suspended by mesoappendix
Ref: Gray’s Anatomy
8. Cont.
• Appendix length: Variable (5 to 15 cm)
• Luminal diameter: varies (Approx 5 mm)
• Blood Supply: Appendicular artery from
the ileocolic artery.
• Nerves :Superior mesenteric Plexus
• Surface projection of the base is at
McBurney's point.
• Most Common variety: Retrocecal (60%)
Ref: CUNNINGHAM’S MANUAL OF PRACTICAL ANATOMY
9. Histology:
• The lumen is irregular, being encroached on
by multiple longitudinal folds of mucous membrane.
• intestinal mucosa of colonic type
Ref: Netter’s surgical anatomy & approaches
19. Agenda
• Laparoscopic vs Open Appendectomy
• Non operative vs Operative treatment
• Management of Delayed presentation
• Normal Appearing Appendix
20.
21.
22. Patient Related
⚫Lesser wound
complications
⚫Reduced post op
pain
⚫Shorter recovery
time
Procedure Related
⚫Examination of
entire
peritoneal space
⚫Exclude other
intra abdominal
diseases
Advantages
Disadvantage ----------------------> Intra Abdominal Abscess
36. MUCINOUS APPENDICEAL TUMOUR AND
PSUEDOMYXOMA PERITONEI
• Peritoneal Surface Oncology Group
International (PSOGI) + AJCC 8 th classification
(2016)
• Low grade, High grade, High grade with signet
ring
• Consensus on pathologic classification
• Presentation: Incidental (2/3rd) / Appendicitis
(1/3rd)
• Surgical excision without capsular disruption
• Govaerts K, Lurvink RJ, De Hingh IHJT, Van der Speeten K,
Villeneuve L, Kusamura S, Kepenekian V, Deraco M, Glehen O,
Moran BJ; PSOGI. Appendiceal tumours and pseudomyxoma
peritonei: Literature review with PSOGI/EURACAN clinical
practice guidelines for diagnosis and treatment. Eur J Surg
Oncol. 2021 Jan;47(1):11-35. doi: 10.1016/j.ejso.2020.02.012.
Epub 2020 Feb 28. PMID: 32199769.
• PMP syndrome: peritoneal dissemination of mucinous neoplasm
• Appendiceal/ gastric/ ovarian/ pancreatic/ colorectal primary Tx
• Early detection of of limited peritoneal mets is favorable
• CRS + HIPEC
37. CRS & HIPEC IN APPENDICEAL TUMOURS
• Perforated epithelial appendiceal tumours are rare
• Present unexpectedly at elective or emergency abdominal surgery, often with PMP.
• CRS (Cytoreductive Surgery)and HIPEC (hyperthermic intra-peritoneal
chemotherapy) results in good long term outcomes in most patients.
• Parietal and visceral peritonectomies + intra-peritoneal heated (42℃) Mitomycin
• Safe at high volume centres
Ansari N, Chandrakumaran K, Dayal S, Mohamed F, Cecil TD, Moran BJ. Cytoreductive surgery and
hyperthermic intraperitoneal chemotherapy in 1000 patients with perforated appendiceal epithelial
tumours. Eur J Surg Oncol. 2016 Jul;42(7):1035-41. doi: 10.1016/j.ejso.2016.03.017. Epub 2016 Apr
9. PMID: 27132072.
38.
39. SPECIAL CONSIDERATIONS IN APPENDICITIS
PEDIATRIC POPULATION
• Perforation in 51-100% in
infants/ young children, lower in
school age groups
• PAS similar to Alvarado Score
• RLQ tenderness / pain with cough,
hopping: 2 points
• Exclusion of DDs
• Lap > Open > Conservative
(22% recurrence)
ELDERLY
• Reduced inflammation
• Perf/ Abscess ↑
• Complications due to co-morbs
• Diagnostic imaging important
• Lap > Open
40. APPENDICITIS IN PREGNANCY
• First/ Second trimester
• 1/800 to 1/1000 pregnancies (most
common surgical emergency in
pregnancy)
• C/F include heartburn/ bowel
irregularity change in bowel habits
• Point of max tenderness: usually
displaced
• USG (preferred)/ MRI
• Risk of fetal loss 36% in perf
• Low threshold for exploration
(negative exploration 30%)
• Lap safe (7% vs 3% fetal loss risk)
• Lower pressures (10-12mm Hg) to
prevent early labour
• Non-op Mx (failure rates ~ 25%)
Andersen B, Nielsen TF. Appendicitis in
pregnancy: diagnosis, management and
complications. Acta Obstet Gynecol Scand. 1999
Oct;78(9):758-62. PMID: 10535336.
41. A COMPLEX DISEASE ENTITY
Teng TZJ, Thong XR, Lau KY, Balasubramaniam S, Shelat VG. Acute appendicitis–advances and controversies. World J
Gastrointest Surg 2021; 13(11): 1293-1314 [PMID: 34950421 DOI: 10.4240/wjgs.v13.i11.1293]
Open appendectomy has been the gold standard for treating patients with acute appendicitis for more than a century, but the efficiency and superiority of laparoscopic approach compared to the open technique is the subject of much debate nowadays .
There is evidence that minimal surgical trauma through laparoscopic approach resulted in significant shorter hospital stay, less postoperative pain, faster return to daily activities related with gastrointestinal surgery.
However, several retrospective studies, several randomized trials and meta-analyses comparing laparoscopic with open appendectomy have provided conflicting results.
Some of these studies have demonstrated better clinical outcomes with the laparoscopic approach while other studies have shown marginal or no clinical benefits and higher surgical costs
Retrospectively collected data from 593 consecutive patients with acute appendicitis were studied. These comprised 310 patients who underwent conventional appendectomy and 283 patients treated laparoscopically. The two groups were compared for operative time, length of hospital stay, postoperative pain, complication rate, return to normal activity and cost.
Conclusion
The laparoscopic approach is a safe and efficient operative procedure in appendectomy and it provides clinically beneficial advantages over open method (including shorter hospital stay, decreased need for postoperative analgesia, early food tolerance, earlier return to work, lower rate of wound infection) against only marginally higher hospital costs.
This study compares laparoscopic appendectomy and open appendectomy in cases of a perforated appendix by assessing surgical site infection, mean operating time, and length of hospital stay.
Results:
Laparoscopic appendectomy is superior to open appendectomy in terms of wound site infections and operating time. The operating time depends on the surgical skills of the operating surgeon and the magnitude of the condition. With regards to the length of hospital stay, there is no difference between the two techniques
It is general opinion that the appendix has no significant function in humans. De Coppi et al. in 2006 showed that the vermiform appendix was capable of producing mesenchymal stem cells. They found that appendix-derived mesenchymal stem cells are present in the vermiform appendix. These cells can differentiate into osteoblasts, lipoblasts, and myoblasts, depending on the stimulation. They suggested the possibility that vermiform appendix acts like a reservoir for stem cells capable of bowel repair trough life.
Some authors moreover suggested the possibility that appendix serves as a reservoir for bacteria of the gut flora, and it is necessary to recolonize the bowel after bacterial infections. Appendectomy either open either laparoscopic is still associated with a significant morbidity and mort ality despite advances in surgery and care.
A 3.5-fold excess mortality after surgical intervention for non-perforated appendicitis and a 6.5-fold excess mortality in perforated ones. In patients with a discharge diagnosis of nonspecific abdominal pain the mortality rate after negative appendectomy was increased by 9.1-fold. This mortality rate may only partially be explained by an underlying condition that was concealed by the appendectomy.
Previous studies have identified the following factors as being associated with diagnostic errors of acute appendicitis in adults: age >60 years
appendicitis in the pelvic region
atypical symptoms or inadequate examination
poor clinical findings
the experience level of the emergency physician
female sex
the presence of coexisting conditions, constipation, and appendicitis without pain
In addition, other physician- and environmental-related factors, such as physician specialty, access to ultrasound, and hospital size, have been reported as factors associated with misdiagnosis in pediatric studies.
