EMERGENCIESAPPENDICITIS

B.MONAMILesCliniquesStjoseph

Lige

BACKGROUND

Frequentcauseof acuteabdominalpainurgentintervention

Untreated,acuteappendicitiswillprogresstoperforationwithabscessformationand/ordiffuseperitonitis

Urgentoperativeintervention!

ACUTEABDOMENManagementOptions:

o Emergent( SurgeryNow )o Urgent( SurgeryToday )

o SemiUrgent( SurgeryTomorrow )

Elective

:: Localperitonitiswithformationofanappendicularmass

:: Abscessformation

:: Gangreneoftheappendix

:: Perforation

:: Generalperitonitis

EAESconsensusstatementLaparoscopyforabdominalemergencies

EvidencebasedguidelinesoftheEuropeanAssociationforEndoscopicSurgeryS.Sauerland,F.Agresta,R.Bergamaschi,G.Borzellino,A.Budzynski,G.Champault,A.Fingerhut,A.Isla,M.Johansson,P.Lundorff,

B.Navez,S.Saad,E.A.M.Neugebauer

SurgEndosc(2006)20:1429

Acuteappendicitis

Patientswithsymptomsanddiagnosticfindingssuggestiveofacuteappendicitis

shouldundergodiagnosticlaparoscopy(GoRA)and,ifthediagnosisisconfirmed,

laparoscopicappendectomy(GoRA).

Thisrecommendationalsopertainstoperforatedcases

RetrocaecalappendixOncethelastilealloopandthetaeniacolihavebeenidentified,searchforthe

insertionofthecaecalappendix

RetrocaecalappendixMobilizethecaecumbydividingits

retroperitonealattachment

Inflamedbasis

Insituationswherethebaseoftheappendixisinflamedornecrotic,itmaybenecessaryto

resectpartofthecaecumaswell.Inthiscase,itmaybeusefultousean

endoscopicstapler

Inflamedbasis

Endoscopicstaplerisusedtoensureclosureofthecaecum

APPENDICULARPERITONITIS

TheE.A.E.S.ClinicalPracticeGuidelineonthePneumoperitoneumforLaparoscopicSurgery

Therearenocontraindicationstocreateapneumoperitoneumwhenlaparoscopicsurgeryis

applicableincasesofperitonitis(gradeB)

Presupposing appropriateperioperativemeasures(e.g.adequatepreoperativevolumeloading)

haemodynamicstability

Laparoscopicmanagementofacuteperitonitis

CONTRA INDICATIONS

SEPTICSHOCK

ASAIV

SEVEREABDOMINALDISTENSION

Laparoscopicmanagementofacuteperitonitis

(Precautions)

IVAbbeforePNP

PNP:812mmHg

Firstlavage

Experiencedsurgicalandanesthesiologicalteams

APPENDICULARPERITONITISAdvantagesofLaparoscopic

approach

Highdiagnosticaccuracy(98%)Correctionofthepreopclinicalseverityperitonitis(26%)Avoidanceofaformallaparotomy(79%)Lowpostopintraabdominalabscessrate(2%)Lowpostopwoundsepsisrate(1%)McBurneyfirst>Laparoscopy(4%)

Navez,SurgLaparoscEndosc2001,313316

APPENDICULARPERITONITIS

Appendicular mass

Thisiscausedbyinflammationandswellingoftheappendix,caecum,omentumanddistalpartofthe

terminalileum

Appendicularmass

Treatconservativelywithbowelrest,antibiotics,analgesicsandfluids

Considerintervalappendectomyifsymptomsrecur

KEYPOINTS

Treatacute,gangrenousorperforatedappendixwithappendectomy

Treatappendicularmasswithmedicalmanagement

Appendicularabscess

QUIZ

1. Conservativetreatment(bowelrest,IVantibiotics,delayedcolonoscopy))

2. Percutaneousdrainage(IVantibiotics,delayedcolonoscopy)

3. Laparoscopicapproach4. Openapproach5. Askthesupervisor

AppendicularabscessPercutaneuousdrainage

AppendicularabscessTreattheabscesswithpercutaneousdrainage

Consider delayedcolonoscopy

intervalappendectomyifsymptomsrecur

Considersurgicaldrainageifpercutaneousdrainageisunsuccessfullorunavailable

Howtoperform? Noconsensus

Laparoscopy

Minilaparotomy

Laparotomywithresection

IVANTIBIOTICS

Amoxicillinclavulanate 12gevery6to8h

Ciprofloxacine 400mgevery12hMetronidazole 500mgevery

6to8h

SecondgenerationcephalosporinCefuroxime 12gevery8h

Metronidazole 500mgevery6to8h

Durationoftreatment

Acuteappendicitis:Singlepreoperativedose

ofbroadspectrumantibiotic

Gangrenousappendicitis:1to3daysaftersurgery

Perforatedappendicitis:3to7daysaftersurgery

AppendicularMucocele

QUIZ

1. Reassure,itsonlyacyst2. ControlCTscannerin6months3. Appendectomy

4. Colonoscopy&appendectomy5. Askthesupervisor

AppendicularMucoceleAppendicularmucoceleisararelesion

(0.2 0.3%ofsurgicalappendectomyspecimens)Itisadescriptivetermdenotinganobstructivedilatationofthe

appendicularlumenbymucinoussecretions

Mucinous cystadenoma and cystadenocarcinoma account for 60 70%

ofallmucoceles

Lesscommoncauses: retentioncystmucosalhyperplasiacarcinoidappendicolithendometriosisadhesionsvolvulus

Mucinouscystadenomaandcystadenocarcinoma

highcorrelationofsynchronousormetachronouscolorectal

adenomasandcarcinomas(upto20%)

associationwithmucinsecretingtumorsoftheovary

pseudomyxomaperitonei(avoidiatrogenicruptureofthemucocele)

Treatment

Appendectomyisusedforsimplemucoceleorforcystadenoma

Righthemicolectomyisrecommendedforcystadenocarcinoma