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شمسشمسعینعینجامعةجامعةــالطبالطبكلیةكلیة

الطبالطبكلیةكلیةشمسشمسعینعینجامعةجامعة

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-I-

LIST OF CONTENTS

Subject Page

Introduction………………………………………………………. 1

Aim of the work………………………………………………….. 3

Chapter (I): Anatomy of the Vermiform Appendix ………….... 4

Chapter (II): Pathophysiology of Acute Appendicitis ………… 24

Chapter (III): Differential Diagnosis of Acute Lower Abdominal

Pain in Young Females…………………………

41

Chapter (IV):Investigations of Acute Appendicitis…………….. 79

Chapter (V): Technique of Laparoscopic Appendicectomy…….. 86

Chapter (VI): Advantages of Laparoscopic Appendicectomy….. 108

Chapter (VII): Complications of Laparoscopic Appendicectomy 135

Summary and Conclusion …………………………………….. 151

References ………………………………………………………. 155

Arabic Summary ………………………………………………..

-II-

LIST OF TABLES

Table Comment Page

Table (1) : The Alvarado (MANTRELS) score……………….. 80

Table (2) : Results of a randomized prospective study

comparing laparoscopic and open

appendicectomy……………………………………. 92

Table (3) : Terminology of single-incision laparoscopic

surgery……………………………………………… 115

Table (4) : Laparoscopic appendicectomy and surgical

experience………………………………………….. 134

-III-

LIST OF FIGURES

Figure Comment PageFig. (1) : Three types of caecum and appendix. A and B. Infantile

forms. When present in the adult, they represent milddevelopmental arrest. C. Mature and most common form 6

Fig. (2) : Duplication classification system of Cave and Wallbridge. 10

Fig. (3) : Diverticulosis of the appendix…………………………….. 11

Fig. (4) : Variations in topographic position of the appendix. Fromits base at the caecum, the appendix may extend……….. 14

Fig. (5) : Anterior and posterior positions of the appendiceal tip… 15

Fig. (6) : Blood supply to the appendix………………………………. 18

Fig. (7) : Variations in the origin of the accessory appendiculararteries………………………………………………………. 19

Fig. (8) : Anterior view of the external lymphatic drainage of theappendix with the position of the lower ileocolic lymphnodes indicated (L)………………………………………… 21

Fig. (9) : Posterior view of the external lymphatic drainage of theappendix and caecum with the position of the lowerileocolic lymph nodes indicated (L)……………………….. 21

Fig. (10) : Incision for appendectomy (blue line) in relation toMcBurney's point. Inset: Actual location of 30 appendicesin 30 patients…………………………………………………. 23

Fig. (11) : Changes in position and direction of appendix duringpregnancy……………………………………………………. 23

Fig. (12) : Frequent sites of referred pain and common causes…….. 44

Fig. (13) : Abdominal contrast-enhanced computerised tomographyscan showing a faecolith (open arrow) at the base of adistended (> 0.6 cm) appendix with intramural gas (whitearrows)……………………………………………………… 83

Fig. (14) : A. Patient positioning and trocar placement for alaparoscopic appendicectomy , showing the surgeon (S),assisting surgeon (AS), surgical nurse (SN), instrumenttable (IT), endoscopic instrument control console (EICC),anesthesia (AE), and video monitor (VM). B. Trocarpositioning: A is a 12-mm trocar and B and C are 5-mmtrocars……………………………………………………… 95

-IV-

Figure Comment PageFig. (15) : Trocar placement. A. Male patient. B. Female patient…… 97

Fig. (16) : Exposure of the appendix and creation of a window in themesoappendix……………………………………………….. 99

Fig. (17) : Mobilization of the cecum for retrocecal location of theappendix……………………………………………………. 100

Fig. (18) : Endoloop technique: the transection of the appendixbetween two loops…………………………………………… 101

Fig. (19) : Stapler technique: the transection of the mesoappendix. 101

Fig. (20) : Stapler technique: the transection of the appendix………. 102

Fig. (21) : Retrograde dissection with transection of the appendixbase, followed by its mobilization towards the tip…….. 105

Fig. (22) : If the appendiceal base is necrotic, a stapler should be usedto transect a portion of the cecum in order to achieveviable tissues………………………………………………. 106

Fig. (23) : McBurney incision, laparoscopic incision, SILS incisions 113

Fig. (24) : Types of Port in single port access in single-incision-laparoscopic sugary………………………………..……… 116

Fig. (25) : Given the risks of visceral and bowel injuries associatedwith prior abdominal and pelvic surgery, entry may beachieved safely in the upper left quadrant of the abdomen.Reproduced with permission from………………………… 138

-V-

LIST OF ABBREVIATIONS

Abbreviations MeaningAAA : Abdominal aortic aneurysm.APACHE : Acute physiology and chronic health evaluation.AV : Atrioventricular.BMI : Body mass index.CA125 : Cancer antigen 125.CBC : Complete blood count.CBD : Common bile duct.CDC : Centers for disease control and prevention.COPD : Chronic obstructive pulmonary disease.CT : Computed tomography.D & C : Dilatation and curettage.DVT : Deep venous thrombosis.ENOTS : Embryonic natural orifice transumbilical surgeryESR : Erythrocyte sedimentation rate.GI : Gastrointestinal.GIT : Gastrointestinal tract.hCG : Human chorionic gonadotrophin.Hct : Haematocrite.Hgb : Haemoglobin concentration.HIV : Human immunodeficiency virus.HNPCC : Hereditary non polyposis colon cancer.HPV : Human papilloma virus.IBD : Inflammatory bowel disease.IUD : Intra uterine device.LA : Laparoscopic appendicectomy.LESS : Laparo-endoscopic single-site surgery

LLQ : Left lower quadrant.

MRI : Magnetic resonance imaging.

NOTUS : Natural orifice tansumbilical surgery

NSAID : Non steroidal anti inflammatory drug.

OA : Open appendicectomy.

OCPs : Oral contraceptive pils.

OPUS : One port umbilical surgery

PEEP : Positive end expiratory pressure.

-VI-

Abbreviations MeaningPET : Position emission tomography.

PET CO2 : Pressure endtidal carbon dioxide concentration.

PID : Pelvic inflammatory disease.

RLQ : Right lower quadrant.

RUQ US : Right upper quadrant ultrasonography.

SA : SILS Appendicectomy.

SILS : Single incision laparoscopic surgery.

SPA : Single port access

TOAs : Tubo-ovarian abscess.

US : Ultrasonography.

UTI : Urinary tract infection.

VOC : Vaso- occlusive crises.

WBC : White blood cell.

- 1 -

Introduction

IntroductionThe introduction of laparoscopic surgery has dramatically changed

the field of surgery, with improvement in the equipment and increasing

clinical experience it is now possible to perform almost any kind of

procedure under laparoscopic visualization (Kehagias et al., 2008).

Although more than a century has elapsed since Mc Burney first

performed open appendectomy, this procedure remains the treatment of

choice for acute appendicitis for most surgeons (Kehagias et al., 2008).

Semm (1983) performed the first laparoscopic appendectomy,

ever since then, the efficiency and superiority of laparoscopic approach

compared to the open technique has been the subject of much debate

(Semm, 1983; Kurtz and Heimann, 2001).

The idea of minimal surgical trauma, resulting in significantly

shorter hospital stay, less postoperative pain, faster return to daily

activities and better cosmetic outcome has made laparoscopic surgery

for acute appendicitis very attractive (Kehagias et al., 2008)

However, several retrospective studies, several randomized trails

and meta analysis comparing laparoscopic with open appendectomy

have provided conflicting results (Ortega et al., 1995; Kurtz andHeimann, 2001; Guller et al., 2004).

Some of these studies have demonstrated better clinical outcomes

with laparoscopic approach (Ignacio et al., 2004).

The most valuable aspect of laparoscopy in management of

suspected appendicitis is as diagnostic tool, particularly in women of

child-bearing age, patients who undergo laparoscopic appendectomy are

likely to have less post operative pain and to be discharged from hospital

- 2 -

Introduction

and return to activities of daily living sooner than those who have

undergone open appendectomy, while the incidence of post operative

wound infection is lower after the laparoscopic technique, the incidence

of post operative intra abdominal sepsis may be higher in patients

operated on gangrenous or perforated appendicitis, there may be an

advantage for laparoscopic over open appendectomy in obese patients

(O’Connell, 2008).

Laparoscopic inspection of the abdominal cavity enables the

surgeon to diagnose acute appendicitis accurately. Moreover, it has been

showed that leaving an appendix that appears normal during

laparoscopic inspection is safe, criteria for the diagnosis of appendicitis

during laparoscopic inspection are the presence of unequivocal

inflammatory changes, such as pus, fibrin or vascular injection of the

serosa, rigidity and lack of mobility at manipulation are less certain signs

of inflammation (Cuesta et al., 2008).

Removing a normal appendix at open surgery is associated with a

7-13%risk of early complications and 4% of late complication such as

incisional hernia and chronic pain in the first year after operation. If a

normal appendix is left in situ during diagnostic laparoscopy, the number

of unnecessary appendicectomies will decrease, particularly in fertile

women (17-45%). The diagnostic yield of laparoscopy in patients with

suspected appendicitis is high, but laparoscopy may be considered too

invasive to justify its use only for diagnostic purposes. This reason

seems particularly true in the era of helical CT (Cuesta et al., 2008).

- 3 -

Aim of the Work

Aim of the Work

The aim of this work is to review the advantages and

disadvantages of laparoscopic surgery in the management of acute

appendicitis in young female patients compared to management by open

appendicectomy.

DDeeddiiccaattiioonn

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- 4 -

Chapter I Anatomy of the Vermiform

Appendix

The Caecum and VermiformAppendix

The caecum is a large blind pouch of large intestine lying in the

right iliac fossa below the ileocaecal valve and continuing distally as the

ascending colon. The blind-ending vermiform appendix usually arises on

its medial side at the level of the ileal opening. The average axial length

of the caecum is 6cm and its breadth 7.5cm. The caecum rests

posteriorly on the right iliacus and psoas major, with the lateral

cutaneous nerve of the thigh interposed. Posteriorly lies the retrocaecal

recess which frequently contains the vermiform appendix. The anterior

abdominal wall is immediately anterior to the caecum except when it is

empty, when the greater omentum and some loops of the small intestine

may be interposed (Borley, 2008).

Usually the caecum is entirely covered by peritoneum, but

occasionally this is incomplete posterosuperiorly where it lies attached to

the iliac fascia by loose connective tissue. In early fetal life the caecum

is usually short, conical and broad at the base, with an apex turned

superomedially towards the ileocaecal junction. As the fetus grows, the

caecum increases in length more than in breadth, to form a longer tube

with a narrower base but retaining the same inclination. Distal growth

later ceases, but the proximal part continues to grow in breadth, so that at

birth a narrow vermiform appendix extends from the apex of a conical

caecum. This infantile form persists throughout life in only a very small

percentage of individuals. Occasionally the conical caecum takes on a

quadrate shape as a result of the outgrowth of a saccule on each side of

- 5 -

Chapter IAnatomy of the Vermiform

Appendixthe anterior taenia: the saccules are of equal size and the appendix arises

from the depression between them instead of from the apex of a cone. In

the normal adult form, the right saccule grows more rapidly than the left,

forming a new 'apex'. The original apex, with the appendix attached, is

pushed towards the ileocaecal junction (Borley, 2008).

The caecum commences the process of fluid and electrolyte

reabsorption, which occurs to a large extent in the ascending and

transverse colon. The distensible nature and 'sac-like' morphology of the

caecum are adaptations for the storage of larger volumes of semi-liquid

chyme entering from the small bowel via the ileocaecal valve

(Borley, 2008).

Embryogenesis of the vermiform appendix

Normal Development

The appendix is the terminal portion of the embryonic caecum.

The appendix becomes distinguishable by its failure to enlarge as fast as

the proximal caecum. This difference in growth rate continues into

postnatal life. At birth, the diameter of the colon is 4.5 times that of the

appendix; at maturity, it is 8.5 times larger (Skandalakis et al., 2006).

The appendix is visible at about the eighth week of gestation.

At first, it projects from the apex of the caecum. As the caecum grows,

the origin of the appendix shifts medially toward the ileocaecal valve

(Fig.1C). The taeniae of the longitudinal muscle coat of the colon

originate from the base of the appendix, showing the same displacement.