Incidental appendectomy

1. Incidental Appendectomy Mohamed El- Sayed Abosdira Resident Doctor at general surgery department Sohag university hospital

2. What is Incidental Appendectomy ??

3. Incidental appendectomy is the removal of the vermiform appendix accompanying another operation, without evidence of acute appendicitis .

4. Examples

5. Incidental appendectomy during the management of Malrotation Intestinal malrotation represents the classic clinical scenario when IA is performed. Ladd’s procedure , classically including laparotomy, lysis of Ladd’s bands, positioning of the large bowel on the left and small bowel on the right, and removal of the left-sided appendix to prevent future misdiagnosis.

6. Incidental appendectomy during Repair of congenital diaphragmatic hernia (CDH) As malrotation is the most common associated anomaly, Ladd’s procedure will done, including appendectomy.

7. Incidental appendectomy during Gynecologic surgery Appendectomy at the time of laparoscopic surgery for endometriosis does not increase operative morbidity , and has diagnostic and preventive value .

8. Incidental appendectomy during Intussusception

9. Incidental appendectomy during Amyand’s and De Garengeot hernia This is a rare form of inguinal hernia (less than 1 %,) that is defined by inclusion of the appendix within the hernia sac. De Garengeot hernia , describes the uncommon finding of the appendix positioned within a femoral.

10. Generally, IA is not recommended in cases where the appendix is contained with a hernia sac , unless the appearance of the appendix is abnormal ,as transection of the appendix converts the case from clean to clean-contaminated .

11. Incidental appendectomy during Exploratory laparotomy/trauma laparotomy IA prevents future diagnostic confusion, and preventing the need for an additional operation should acute appendicitis develop . However , addition of an appendectomy to a procedure increases operative time and provides a potential source of contamination to an otherwise clean field. Classic recommendations leave IA to the surgeon’s discretion, recognizing the conflict between the risks and benefits.

12. . A point of debate ?? why??

13. This depends on the use of the appendix as a tubular conduit for reconstruction

14. Utility of the appendix urological reconstruction , colonic irrigation, and biliary reconstruction .

15. Urologic indications for use of the appendix Reconstruction of the ureter when an interposed segment is required to bridge two segments of the ureter or bridge the ureter to the bladder

16. Urologic indications for use of the appendix The Mitrofanoff procedure Appendicovesicostomy mobilizes the appendix on its vascular pedicle to create a conduit from the anterior abdominal skin to the bladder. As the bladder fills, outward pressure is exerted on the tunneled appendix, compressing the lumen and maintaining continence. When a catheter is inserted, it drains readily.

17. neurogenic bladder or Bladder outlet obstruction Traumatic neurological injuries, posterior urethral valves, and congenital neurological deficits.

18. Advantages Less painful Avoid traumatic disruption of the urethra, urethral stricture, or development of a false passage. easy ,applicable “self-catheterization”

19. Utility of the appendix Fecal Stoma The introduction of the Malone antegrade continence enema (MACE) procedure in 1990 has improved the quality of life for patients suffering from conditions such as; Chronic constipation, imperforate anus , Hirschsprung’s disease , spinal disorders

20. MACE procedure The MACE procedure connects the cecum to the abdominal wall using the appendix as a continent stoma to allow antegrade flushing of the entire length of the colon to evacuate the stool.

21. Allow self-administration by the Pt. through anterior abdominal stoma . Advantages

22. Utility of the appendix Biliary reconstruction The appendix can also be useful in biliary reconstruction, after treatment for choledochal cysts. In 1971, Grosfeld et al. first tested the concept of relieving biliary obstruction by fashioning an appendiceal conduit between gall bladder and duodenum.

23. Advantages The appendix provides an anti-peristaltic, small-caliber , epithelialized, and vascularized conduit that greatly reduces the occurrence of cholangitis , compared to small bowel conduits .

24. Appendiceal conduits are usually reserved for patients who fail conventional hepaticojejunostomy , rather than routine biliary repair .

25. conclusion The decision to perform IA needs to be carefully weighed in regards to the procedure to be performed, the patients ’ medical history, and the likelihood of requiring the appendix for future use as a tubular conduit for reconstruction .

26. Referances Mitrofanoff P (1980) Trans-appendicular continent cystostomy in the management of the neurogenic bladder. Chir Pediatr 21(4 ):297–305 Leslie JA, Dussinger AM, Meldrum KK (2007) Creation of continence mechanisms ( Mitrofanoff ) without appendix: the Monti and spiral Monti procedures. Urol Oncol 25(2): 148–153 17 . Melnikoff AE (1912) Sur le replacement de l’ ureter pa anse isolee de l’intestine grele . Rev Clin Urol 1:601–610 . Stein R, Schro¨der A, Thu¨roff JW (2012) Bladder augmentation and urinary diversion in patients with neurogenic bladder: surgical considerations . J Pediatr Urol 8(2):153–161 Malone PS, Ransley PG, Kiely EM (1990) Preliminary report: the antegrade continence enema. Lancet 336(8725):1217–1218

27. Thank you