it is an inflammation of the vermiform appendix

Acute Appendicitis – Overview
Definition:
Acute appendicitis is an inflammation of the vermiform appendix, usually caused by obstruction of the lumen, leading to infection and potential perforation. It is the most common surgical emergency worldwide.

Etiology & Pathophysiology:
Obstruction: Due to fecaliths, lymphoid hyperplasia, tumors, or parasites.
Increased intraluminal pressure: Leads to ischemia, bacterial overgrowth, and inflammation.
Progression: If untreated, can lead to gangrene, perforation, peritonitis, or abscess formation.
Clinical Features:
Pain: Initially periumbilical (visceral pain), localizing to the right lower quadrant (McBurney’s point).
Nausea & vomiting: Usually follows pain onset.
Fever & tachycardia: Mild fever common; high fever suggests complications.
Rebound tenderness & guarding: Indicative of peritoneal irritation.
Positive signs:
Rovsing’s sign: RLQ pain with LLQ palpation.
Psoas sign: Pain on hip extension (retrocecal appendix).
Obturator sign: Pain on internal hip rotation (pelvic appendix).
Diagnosis:
Clinical assessment: Most important in early diagnosis.
Laboratory tests:
Elevated WBCs (leukocytosis with neutrophilia).
Elevated C-reactive protein (CRP).
Imaging:
Ultrasound: First-line in children and pregnant women.
CT scan: Gold standard for diagnosis.
MRI: Alternative in pregnancy.
Treatment:
Surgical: Appendectomy (gold standard), either open or laparoscopic.
Antibiotics: Given preoperatively and postoperatively in complicated cases.
Non-surgical management: Considered in select cases (e.g., early uncomplicated appendicitis with antibiotics).
Complications:
Perforation → Peritonitis, sepsis.
Appendiceal abscess → Requires drainage & antibiotics.
Postoperative infections (wound infection, intra-abdominal abscess).

1. Acute appendicitis
The department of the surgical diseases and transplantology of the
Urganch branch
of the Tashkent medical academy

2. Acute appendicitis – not specific
inflammation of the appendix

3. Projection of the appendix on the anterior
abdominal wall

4. normal
medial
retrocaecal
Localization of the appendix comparatively the
caecum

5. In the pelvis
Subhepatical
localization
Variants of the localization of the appendix in the
abdominal cavity

6. Blood circulation of the appendix
Arterial circulation
Aorta – а.mesenterica superior – a.ileocolica –
a.appendicularis
Venous system
v.appendicularis – v.ileocolica – v. mesenterica
superior – v.portae

7. Spreading of the acute appendicitis among the
acute surgical diseases
29,2%
18,7%
14,8%
0%
20%
40%
Acute
appendicitis
Acute
cholecystitis
Ulcer disease of
the duodenum

8. Factors of the frequency of the postoperative
complications and death at the acute appendicitis
№ Authors Year Frequency of the
complications
Factor of death
1.Savchuk B.D. 1998 9,8% 0,31%
2.Savelev V.S. 1999 8,7% 0,24%
3.Gostishev V.К. 2001 7,6% 0,21%
4.Dronov А.F. 2002 7,9% 0,26%
5.Shurkalin B.К. 2003 8,6% 0,28%
6.Kriger А.G. 2005 7,6% 0,22%
7.Goodwin C.S 2004 7,3% 0,19%
8.Bohnen J.M. 2005 8,2% 0,23%

9. Frequency of the acute
appendicitis depend on the age
до 2
лет
2-10
лет
15-25
лет
40 лет60 лет70 лет80 лет
Acute appendicitis is the most spreaded surgical disease.
Frequency - to 200-300 people one with the acute appendicitis
fem
mal
Frequency of the acute
appendicitis depend on the gender
Postoperative death – 0,2-0,3%

10. Etiology and pathogenesis of the acute
appendicitis
Breach of the nervous regulation of the appendix
Breach of the blood circulation of the appendix
ACUTE APPENDICITIS
Sensibilisation of the organism
(allergy, hookworms invasion)
Reflector way
(diseases of the stomach, liver, intestine)
Direct irritation of nerves
(alien object in the appendix, excrement stone, bends)
Spasm of the muscles and vessels of the appendix
Hypostasis of the wall of the appendix
Closing of the mouth of the appendix

11. Classification of the acute appendicitis
•Simple appendicitis
•Destructive appendicitis: flegmonous,
gangrenous, perforative
•Complicated appendicitis: appendicular
infiltrate, appendicular abscess, peritonitis,
pilephlebitis and other.

12. Normal appendix

13. Acute simple appendicitis

14. Acute destructive appendicitis
Empiema of the appendix Gangrenous perforative appendicitis

15. Complaints
the most frequent
1 – pain in the right iliac area
1. Beginning of the pain in the epygastria with the transition to
the right iliac area (Cocher-Volkovich symptome)
2. Constant (seldom fight),
3. Low intensivity (blunt, nagging)
4. Without the irradiation
2 – sickness, retching (once or twice)
3 – weakness, loss of appetite

16. •Constipation – at the peritonitis
•Tenesms – at the pelvic localization
•Diarrhea – at the medial localization
•Disuria – at the retrocaecal localization
•Dryness in the mouth, ballooned abdomen
– at the peritonitis
Compllaints
depending on the localization of the appendix and stage of
the process

17. Local symptoms of the acute appendicitis
Voscresenskiy («shirt») – identification of the most painful zones at the sliding of
the hand above the shirt
Rovsing – increasing of pain in the right iliac area at pushing to the left
Razdolskiy– pain at the percussion in the right iliac area
Sitkovskiy – tumbling from the back to the left side inducts pain in the right iliac
area
Bartom’e-Mikhelson– palpation of the right iliac area at the state of the patient on
the left side inducts pain
Cocher-Volkovich – transition of the pain from the epigastria to the right iliac area

18. General symptoms of the acute
appendicitis
•Dryness and coverness of the tongue
•Tachycardia
•Subfebril temperature
•Rising of the SES
•Leucocytosis with the movement of the
formula to the left

19. Particularities of the clinic currency of the
acute appendicitis
At children. Fast development of the destructive changes (perforation), short omentum –
spreading of the infection, prevalence of the general symptoms over the local: enxiety, breach of
sleeping, rising temperature to 38,5-39С, increasing pain in the abdomen without defined
localization, frequent sickness, retching, diarrhea
At elders. Low significance of the main symptoms: pain, pain at the palpation, effort of the
muscles, the temperature is normal or increased a little, the leucocytes of blood are without
changes, aptitude to the development of thrombs, early development of the destructive changes,
more frequent development of the complications
At pregnants. Denominated pain appears later, in not typical place, but above and to the right
from the uterus, seldom in the lumbar area, effort is less denominated
Indicate the symptoms of the appendicitis is complicative or impossible frequently under the
mask of pyelonephritis of pregnants.

20. Differential diagnostic of the acute
appendicitis
Diseases of the organs of the abdominal cavity
Diseases of the organs of the chest
Diseases of the organs of the extraperitoneal space
Infectional diseases
Diseases of the vessels
Gynecological diseases
Diseases of skin
Neurological diseases

21. Ultrasound research
Presence of the free liquid

22. Laparoscopy
Special methods of
diagnostic

23. Diagnostic laparoscopy
More reliable method,
that allows directly find
out the source of the
peritonitis, presence and
character of the
excaudate.

24. Laparoscopic signs of the inflammated appendix
(by Criger А.G., 2000)
Not changed appendix free
droops on the instrument
At the inflammation the appendix
doesn’t droop because of the
hypostasis, periodically slides

25. Incision of Dyakonov-Volkovich

26. Stages of the access
Section of the aponeurosis Separation of the muscles Opening of the peritoneum

27. Stages of the operation
Removing of the dome
of the caecum
Removing of the
appendix
Bandaging of the
mesentery of the
appendix

28. Stages of the operation
Putting of the pouch stitch
Appendectomy
Submersion of the cult
of the appendix

29. Stages of the retrograd appendectomy

30. Stages of the retrograd appendectomy

31. Character and frquency of the postoperative
complications
Wound complications– 80%
Intraperitoneal – 6% Bronchopulmonar – 4%
Cardio-vessel – 3%
Others – 7%

32. The reasons of the not satisfactory results of
the traditional appendectomy
•Defeat of the different cutaneus and muscle’s nerves
•Defeat of the vessels, inducting the development of the
haemotomas, and wound complications
•Defeat of the muscular-aponeurotic tissues promotes the
development of the postoperative hernias
•Manipulations, performing in the abdominal cavity
indicate the soldering process in the abdominal cavity
•High per cent of the diagnostic mistakes, that confirmed by
the high weight of the “cataral” appendicitis

33. History of the endoscopic surgery of
the acute appendicitis
The first
appendectomy
under the
control of the
laparoscopy
was
performed by
De Kok in
1977 year with
the
minilaparoto
my to delete
the appendix
At first the
LAE was
performed by
K. Semm in
1982 year at
the patient
with the
pathology of
the
apurtenances,
moreover the
changes of the
appendix
weren’t acute
In 1987 year Schrieber J.H. has carried out the laparoscopic appendectomy
because of acute appendicitis

34. Morphologic characteristic of the acute
appendicitis in different groups
13,2%
1,4%
64,2%
83,6%
22,6%
15,1%
0%
50%
100%
Cataral Flegmonous Gangrenous
Control group Main group

35. Variants of the performing of the
laparoscopic appendectomy
With using of the
endostapler Endo-
Gia-30
With using of the
endoloop of Roeder
With using of clipses

36. Laparoscopic appendectomy with the help of
endoligature

37. Laparoscopic appendectomy with the help of
clipping

38. Laparoscopic appendectomy with the help of
endoscopic suturing instruments

39. Comparative estimation of the clinic picture in
different groups
0%
20%
40%
60%
80%
100%
612182430364248546072
0%
20%
40%
60%
80%
100%
6 12 18 24 30 36 42
Dynamic of changing of the
painful syndrome
Dynamic of changing of the
moving activity

40. Comparative estimation of the postoperative
complications in different groups
10,7%
0,6%
15,7%
2,7%
0%
10%
20%
Early complications
(to 15 days)
Lately complications
(more than 3 months)
0,6%
13,2%
0%
10%
20%
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Laparoscopic appendectomyTraditional appendectomy

41. Analysis of the reasons of the conversions at
performing of the laparoscopic appendectomy
1. retrocaecal, retroperitoneal localization of
the appendix;
2. duration of the disease to the moment of the
admition more than 48 hours;
3. technic impossibility of deleting of the
appendix by the laparoscopic access during 1
hour from the moment of the beginning of the
operation.

42. Group of the patients, at which it is better to
perform the laparoscopic appendectomy
1. the patients, at which it is impossible to exclude acute appendicitis
during the dynamic observation. Performing of the diagnostic
laparoscopy allows to confirm the diagnosis, at the case of finding out the
acute appendicitis - LAE.
2. the women of the reproductive age. Performing of the endoscopic
research allows to carry out the differential diagnostic between the acute
appendicitis and acute gynecological pathology. Besides, the reduction of
the weight of the ungrounded appendectomies warns the development of
soldering process and as a result – secondary sterility.
3. patients with the acompanying diabetes, obesity and other
predisposing factors of the development of the wound complications.
Using of the LAE at these patients reduces the risk of development of the
wound complications.

43. Contraindications to the laparoscopic
appendectomy
1. duration of the disease more than 48 hours.
2. diffuse peritonitis. At this case it is impossible ti carry
out the sanation of the abdominal cavity.
3. general contraindications to the laparoscopy –
pulmonary-cardiac insufficiency, big term of the
pregnancy, acute infarct of myocardium, additional
diseases, not allows to increase the intraabdominal
pressure, presence of the significant soldering process in the
abdominal cavity