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بسم الله الرحمن الرحيم.

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Presentation on theme: "بسم الله الرحمن الرحيم."— Presentation transcript:

1 بسم الله الرحمن الرحيم

2 Difficult Appendesectomy In Surgical Practice

3 Introduction 1889 Mac Burney described location, the clinical features of appendicitis and the importance of operative intervention and muscle-splitting incision.

4 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)

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6

7 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 Yr

8 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

9 Fecalith

10 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.

11 Histology Histological terms used: Catarrhal appendicitis Inflamed
Suppurative Necrotic Gangrenous Perforated Appendicular mass

12 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.

13 Treatment Adequate hydration, correct electrolyte imbalance
Manage other medical problems Pre-operative antibiotics: Simple AP - hrs antibiotic Ruptured AP - antibiotic until fever Peritonitis days antibiotics

14 Surgery: Open appendectomy Laparoscopy NOTES
McBurney (oblique); Rocky Davis (transverse); right paramedian; midline incision Laparoscopy NOTES

15 Open appendectomy

16 Open Appendectomy:

17 Laparoscopy

18 Laparoscopy:

19 Difficult Appendesectomy

20 Difficult Appendesectomy
Difficult Appendesectomy reasons : Surgeon and assistant . patient. Appendix. Operation field.

21 Surgeon and assistant Qualified Surgeon with good assistant play important roles to get a simple appendectomy.

22 patient. General condition Obesity The Very Young The Very Old
In AIDS Patients The Pregnant woman

23 Obesity with acute appendicitis

24 The Very Young Diagnosis may be more difficult to establish
Children are more likely to progress to perforated appendix (? Under-developed Greater Omentum).

25 Children with acute appendicitis

26 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

27 old with acute appendicitis

28 In AIDS Patients Be aware of CMV or Kaposi sarcoma as the underlying cause General condition Risk of infection

29 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%

30 Pregnant woman with acute appendicitis

31 Position of Appendix

32 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

33 Pregnant woman with acute appendicitis

34 Laparoscopic Appendectomy

35 Appendix Site : Retroperitonum Subhepatic Pelvic Gross Pathology
The presence of parasites in the appendix Fixed cecum

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38 Appendix. Gross Pathology Perforated Very long Short Appendicular Mass
Chronic Appendicitis Appendicular abscess Tumors of The Appendix

39 Perforated appendicitis

40 Very long appendicitis

41 Appendicular abscess

42 Appendicular abscess

43 Tumors of The Appendix Carcinoid Adenocarcinoma Lymphoma. Mucocele
Pseudomyxoma Peritonei

44 Carcinoid

45 Operation field Incision site size Exploration Homeostasis light
Instrument

46 Operation field

47 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

48 الحمد لله


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