CASE Report General Surgery Residency Presentation Appendicitis.pptx

Appendix

1. CASE Appendicitis By: Nuraga Wishnu Putra Consultant: dr. Dadik Agus S, SpBA (K) dr. Slamet Kuswantoro , SpBA dr. Santi Rini , SpBA (K)

2. Appendix embryology Appendix visible in 8 th week From inferior tip of caecum Appendix rotates on posteromedial aspect of caecum, 2 cm below ileocecal valve during late childhood. Variability of rotation: 95% case intraperitoneal 65% behind caecum 30% in pelvic 5% extraperitoneal ( retrocolic /retrocecal) 2

3. Anatomy Tuesday, February 2, 20XX Sample Footer Text 3 Averages 8 cm in length, varying around 0.3 – 33 cm Diameter ranges from 5 – to 10 mm. Blood supply: appendiceal branch of ileocolic artery, passes from terminal ileum Base appendix arises at the junction of 3 taeniae coli Colonic epithelium, circular and longitudinal muscle layers are contiguous with cecal layers A few submucosal lymph follicles are present at birth, increases to 200 at age 12, reduced after age 30, few trace after 60

4. Agenesis of appendix Tuesday, February 2, 20XX Sample Footer Text 4 Absence of appendix and cecum Rudimentary cecum and absence of appendix Normal cecum and absence of appendix Normal cecum and rudimentary appendix Normal cecum and normal appendix

5. Duplication of Appendix Tuesday, February 2, 20XX Sample Footer Text 5 Modified Cave-Wallbridge classification. Type A: Partial duplication Type B1: (bird type), two appendices are placed symmetrically on both sides of the ileocecal valve Type B2: (taenia coli type), one appendix is in the usual place and the other is far along taenia coli Type C: Duplication of cecum and appendix Type D: (horseshoe type), one appendix has two openings in the cecum Bulut et al. (2016)

6. The Disease 6 1 . Appendicitis is a very common pediatric disorder. 2. Most cases of appendicitis are secondary to appendix lumen obstruction. 3. Appendectomy, either open or laparoscopic is the treatment of choice for non-complicated (unruptured) appendicitis. 4. Complicated (perforated) appendicitis can be treated with immediate operation, or a delayed procedure if the infection is control led with antibiotics.

7. Incidence 7 Appendicitis is the most common abdominal condition requiring surgery in the pediatric age group. The mean age of presentation is 11 to 12 years. The lifetime risk of acquiring appendicitis is 1 in 14 (7%) . Appendicitis is unusual in patients less than 5 years of age and is exceptionally rare in the first year of life. In most series, males outnumber females, accounting for 55% to 65% of patients.

8. Perforated Incidence 8 The incidence of perforated appendicitis in the pediatric population ranges from 30% to 45%. Appendix will perforate between 24 and 48 hours after onset of inflammation. However, 13% may perforate in less than 24 hours. The perforation rate in preschoolers ranges from 60% to 65%. Children less than 2 years of age account for 2% of pediatric appendicitis and have a perforation rate of 95%. Neonatal appendicitis is exceedingly rare, and the surgeon must be wary of other underlying conditions, such as Hirschsprung disease and necrotizing enterocolitis.

9. Clinical manifestations 9

10. Pathogenesis Clinical findings Differential diagnosis 10

11. Imaging (USG) Tuesday, February 2, 20XX Sample Footer Text 11 Abdominal ultrasound ( U S) depicting acute appendicitis. The appendix is distended with increased wall thickness. Laboratory studies and imaging rarely add significant information especially in boys. Imaging studies should be reserved for equivocal cases when hospital observation versus discharge is anticipated, In preparation for management of complex cases, such as perforated appendicitis with phlegmon or abscess.

12. Imaging (CT Scan) 12 Classic pelvic computerized tomography (CT) scan depicting a distended appendix with enhanced wall thickness. More accurate, less safe.

13. Algorithm 13 Bhangu , Aneel ; Søreide , Kjetil ; Di Saverio , Salomone ; Assarsson , Jeanette Hansson; Drake, Frederick Thurston (2015). Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. The Lancet, 386(10000), 1278–1287. doi:10.1016/S0140-6736(15)00275-5

14. Pre-Operative Considerations 14 Primary Survey Thorough resuscitation prior GA In-House Observation Antibiotics Escherichia coli and Bacteroides fragilis are most common, aerob and anaerob AB Traditionally, perforated app treated with gram (+), gram (-), and anaerobic for 10-14 days Complete course with oral AB for 7 days

15. Operation 1 15 Simple ligation (Fig. 48-4) : The mesoappendix is divided and the cecum is clearly identified surrounding the base of the appendix, Appendiceal base is doubly ligated with 2-0 absorbable ties. The appendix is amputated and the exposed mucosa cauterized to prevent mucocele formation.

16. Operation 2 16 Purse string appendectomy (Fig. 48-5) : Once the appendix is accessible, the mesoappendix is taken down between damps and divided. Generally, 2-0, 3-0, or 4-0 absorbable suture ties are used. The mesoappendix is divided until the cecum surrounding the base of the appendix is completely exposed. The appendix is grasped with a sponge and a seromuscular purse string suture of 3-0 silk is placed in the cecal wall 1 to 2 mm away from the appendix. The base of the appendix is crushed with a clamp and ligated with a 2-0 or 3-0 absorbable suture. A clamp is placed just distal to the tie and the appendix is divided and passed off. The mucosa is electrocauterized. The stump is inverted as the purse string is tied. A Z-stitch may be placed to secure the purse string.

17. Operation 3 17 Inversion appendectomy : This technique was devised to eliminate intra-abdominal contamination encountered when cutting across an enteric structure. Its use should be confined to the incidental appendectomy

18. Laparoscopy Approach 18 Prior to laparoscopy, the stomach should be decompressed with an oro - or nasogastric tube and the bladder decompressed. A curvilinear infraumbilical or vertical trans umbilical incision is then made to place the first port. Two additional ports are then placed under direct vision, either in the left lower quadrant and suprapubic regions or in the left lower quadrant and right upper quadrant regions, depending upon surgeon preference.

19. Laparoscopy Approach 19 Stapled: Once there is an adequate window, an endovascular stapler is passed through the window, and the appendix is stapled and divided at the junction of the base of the appendix and the cecum. It is important to divide the appendix flush with the cecum to avoid the complication of stump appendicitis.

20. Laparoscopy Approach 20 Endoloop : Once the mesentery is divided, the appendix is grasped, and 3 2-0 PDS endoloops are placed at the base of the appendix-2 proximally at the base, as flush with the cecum as possible, and 1 more distally on the appendix. The appendix is then divided using endoscissors between the distal and proximal endoloops leaving 2 endoloops to secure the appendiceal stump. Alternative: doubly ligated with absorbable suture as in an open appendectomy using intra- or ex.tracorporeal knot-tying techniques.

21. Operation 21 If a normal-appearing appendix is encountered, the abdomen must be carefully inspected to exclude other causes for the abdominal pain and associated symptoms that prompted the operation. The small bowel is carefully inspected to exclude mesenteric adenopathy, terminal ileitis, Crohn disease, tumors, intussusception, and the Meckel diverticulum. The liver and gallbladder are inspected, as are the ovaries, uterus, and fallopian tubes in females. The internal rings are inspected for patency. In most cases, the appendix is still removed to avoid further diagnostic dilemma postoperatively.

22. Operation : Complication 22 Wound infection is the most common postoperative complication in either simple or complicated appendicitis. With proper selection and administration of preoperative antibiotics, and proper operative technique, the wound infection rate should be below 3%. Wound infection rates for complicated appendicitis should range from 6% to 8%.

23. Operation : Complication 23

24. Operation : Complication 24

25. Operation : Complication 25

26. Case Tuesday, February 2, 20XX Sample Footer Text 26

27. Identity Tuesday, February 2, 20XX Sample Footer Text 27 Name : Muthiah Fadhilah Gender : Female Age : 13 years old Body weight : 30kg Address : Jl. Gerilya , No 69 Rt 95 Samarinda Date of admission : 3 December 2022

28. Main complaint Tuesday, February 2, 20XX Sample Footer Text 28 Stomach pain

29. History taking 29 Patient was admitted to ER of AWS Hospital on 2 December 2022, 00.30 referred from an internist’s clinic, due to severe pain at the stomach which already lasted for 1 week. The pain originated from upper middle abdomen, but in the span of 12 hours migrated to right lower quadrant. In 4 days, the pain in the abdomen became generalized. Vomit (+) Fever (+) Diarrhea for 3 days. Unable to eat or move due to severe pain. Obstetric history Patient is the 1 st and only child, normal birth with normal labor, born with 3.200gr body weight. Antenatal care every month with a doctor. Born with assistance from a local hospital. Completed every vaccination except covid vaccine

30. Physical Examination Tuesday, February 2, 20XX Sample Footer Text 30 General status Overall condition : Weak Heart rate frequency : 112x/minutes Breathing : 28x/minutes Spo2 : 97% room air Body weight : 30kg

31. Physical Examination Tuesday, February 2, 20XX Sample Footer Text 31 Head : Normocephalic. Anemic -/-. Icteric -/-. Sunken eyes +/+. Isochoric pupil with 3mm/3mm diameters, light reflex +/+ Cor : S1S2 Regular, Murmur (-) Gallop (-) Pulmonary : Vesicular, symmetrical, rhonchi -/-, wheezing -/- Abdomen : Distended (+) Venectasis (+). Darm contour (-) Darm Steifung (-), Bowel Sound (minimal) Hyper tymphanic (+) Muscular defense (+) Genitalia : Normal status Extremity : Cold, CRT < 2 seconds, mobility normal.

32. Hematologi Kimia Klinik Hasil Nilai Rujukan Hasil Nilai Rujukan Leukosit 20.600 6.00-18.00 10^3/µL GDS 89 <200 mg/dL Eritrosit 4.25 3.10-4.30 10^6/µL Albumin 3.8 3.5-5.5 g/dl Hemoglobin 15.4 13.4-19.8 g/dl Ureum 35.6 19.3-49.2 mg/dl PLT 367.000 150-450 10^3/µL Creatinin 0.4 0.7-1.3mg/dl Hematokrit 43.1 28.0-42.0 % SGOT <40 u/L SGPT <41 u/L Bilirubin Total <1.0 mg/dl Bilirubin Direct 0.3-1.0 mg/dl BT 1-6 Menit Bilirubin Indirect 0.0-0.8 mg/dd CT 1-15 menit Alkali Phospatase 40-129 U/L Hemostasis Electrolyte APTT 26.7 24-36 detik Natrium 130 135-155 mmol/L PT 15.5 10.8-14.4 detik Kalium 2.6 3.6-5.5 mmol/L INR 1.10 Cloride 97 98-108 mmol/L Imuno-Serologi Imuno-Serologi Rapid Antigen SARS-CoV-2 Negatif Negatif Ab HIV Non Reaktif Non Reaktif Dengue Ig G Negatif HBs Ag Non Reaktif <0.09 COI Dengue Ig M Negatif ASTO <200 IU/ml Procalcitonin Elecsys <=0.020 ng/ml CRP Kuantitatif <=5 mg/L

33. Physical Examination (Alvarado) 33 Feature Score Migration of pain 1 Anorexia 1 Nausea 1 Tenderness in right lower quadrant 2 Rebound pain 1 Elevated temperature 1 Leucocytosis 2 Shift of white blood cell count to the left 1 Total 10

34. Working Diagnose Generalized peritonitis due to perforation of hollow organ, likely perforated appendix + hypokalemia + Tuesday, February 2, 20XX Sample Footer Text 34

35. X-Ray Name Title Name Title Sample Footer Text 35

36. USG Tuesday, February 2, 20XX Sample Footer Text 36

37. Intraoperative Tuesday, February 2, 20XX Sample Footer Text 37

38. Subtitle Subtitle Tuesday, February 2, 20XX Sample Footer Text 38

39. Diagnose Generalized peritonitis due to perforated appendix + adhesion grade 4 + hypokalemia Tuesday, February 2, 20XX Sample Footer Text 39

40. Follow up Day 1 Day 9 Day 12 40

41. Thank You Tuesday, February 2, 20XX Sample Footer Text 41