‫بسم هللا الرحمن الرحيم‬

Difficult Appendesectomy
In Surgical Practice
Introduction
 1889 Mac Burney described location, the
clinical features of appendicitis and the
importance of operative intervention and
muscle-splitting incision.
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)
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 10-24 Yr
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
Fecalith
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.
Histology
Histological terms used:

 Catarrhal appendicitis
 Inflamed
 Suppurative
 Necrotic
 Gangrenous
 Perforated
 Appendicular mass
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.
Treatment
 Adequate hydration, correct electrolyte
imbalance
 Manage other medical problems
 Pre-operative antibiotics:
◦ Simple AP - hrs antibiotic
◦ Ruptured AP - antibiotic until fever
◦ Peritonitis - 10 days antibiotics
Surgery:
 Open appendectomy
McBurney (oblique); Rocky Davis (transverse);
right paramedian; midline incision

 Laparoscopy
 NOTES
Open appendectomy
Open Appendectomy:
Laparoscopy
2. Laparoscopy:
 Difficult
Appendesectomy
Difficult Appendesectomy
Difficult Appendesectomy reasons :
 Surgeon and assistant .
 patient.
 Appendix.
 Operation field.
Surgeon and assistant
 Qualified Surgeon with good assistant play
important roles to get a simple
appendectomy.
patient.
 General condition
 Obesity
 The Very Young
 The Very Old
 In AIDS Patients
 The Pregnant woman
Obesity with acute appendicitis
The Very Young
 Diagnosis may be more difficult to
establish
 Children are more likely to progress to
perforated appendix
(? Under-developed Greater Omentum).
Children with acute appendicitis
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
old with acute appendicitis
In AIDS Patients
 Be aware of CMV or Kaposi sarcoma as
the underlying cause
 General condition
 Risk of infection
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%
Pregnant woman with acute
appendicitis
Position of
Appendix
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
Pregnant woman with acute
appendicitis
Laparoscopic Appendectomy
Appendix
 Site :
Retroperitonum
Subhepatic
Pelvic

 Gross Pathology
 The presence of parasites in the appendix
 Fixed cecum
Appendix.
Gross Pathology
 Perforated
 Very long
 Short
 Appendicular Mass
 Chronic Appendicitis
 Appendicular abscess
 Tumors of The Appendix
Perforated appendicitis
Very long appendicitis
Appendicular abscess
Appendicular abscess
Tumors of The Appendix
 Carcinoid
 Adenocarcinoma
 Lymphoma.
 Mucocele
 Pseudomyxoma Peritonei
Carcinoid
 Operation field
 Incision site size
 Exploration
 Homeostasis
 light
 Instrument
Operation field
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
‫الحمد هلل‬