2. Ileocaecal junction
3. Female genital organs
Ectopic caecum location:
1. Right iliac fossa
3. Subhepatic position
4. Retroverted caecum
Unlike the rest of the colon, the appendix has a complete longitudinal muscle layer. The ostium of the appendix is situated on the medial part of the base of the caecum at the confluence of the free taenia.
2. Superior ileocaecal recess
3. Inferior ileocaecal recess
The ileocaecal fold delimiting the anterior or superior ileocaecal recess as well as the ileo-appendicular peritoneal fold delimiting the posterior or inferior ileocaecal recess with the meso-appendix are identified.
1. Ileocolic artery
2. Posterior caecal artery
3. Anterior caecal artery
4. Appendicular artery
The blood supply of the appendix is found in a separate mesentery, the meso-appendix, and consists of an appendicular branch of the ileocolic branch of the superior mesenteric artery (Sleisenger et al., 2006).
The appendix varies its anatomical position during pregnancy. It migrates from the right iliac fossa to the right hypochondrium, and it might be located under the right costal margin on the 8th month.
The diagnosis of acute appendicitis in the pregnant woman is a difficult task with several challenges. First, the ionizing radiation is a potential hazard for the developing foetus, the avoidance of unnecessary exposure should be a standard practice. Another challenge is the anatomical and physiological displacements of the appendix during the pregnancy or the physiologic leukocytosis.
If the US result is normal (negative) or inconclusive, a MRI or a CT-scan should be obtained (Chen et al., 2008; Wallace et al., 2008). The reason for not going directly to a CT-scan is to avoid the exposure of the patient and of the developing foetus to potentially unnecessary radiation. If the MRI is not available and a CT-scan is to be performed, a low dose protocol should be considered (McCollough et al., 2007; Lowe, 2004).
Appendectomy is the most frequent non-obstetric surgery performed during pregnancy (Ueberrueck et al., 2004; Tracey and Fletcher, 2000). It is usually associated with an increased risk for rupture and peritonitis due to: altered location of the appendix, overlap of signs and symptoms, limited sensitivity of laboratory studies (Melnick et al., 2004), and the reluctance to perform unnecessary surgery in a pregnant woman. Due to these disadvantages, some authors agree that a correct diagnosis of appendicitis is made more often during the first trimester of pregnancy than the later periods (Mazze and Kallen, 1991). The earlier the diagnosis is made, the fewer the rate of associated complications, the recommended interval between the onset of symptoms and the operation should not exceed 20-24 hours (Guidelines Committee of the Society of American Gastrointestinal and Endoscopic Surgeons, Yumi H, 2008; Yilmaz et al., 2007).
The laparoscopic approach has proven to be a safety procedure during any trimester of pregnancy (Park et al., 2010; Kirshtein et al., 2009), without any increased risk to the mother or foetus (Oelsner et al., 2003; Rollins et al., 2004). The decision to operate through a laparoscopic approach should be determined based on the surgeon’s experience and the availability of the competent equipment.
- technical difficulty due to the gravid uterus;
- possible injury to the pregnant uterus (mainly in the third trimester);
- decrease in the uteroplacental blood flows due to the increased intra-abdominal pressure.
The laparoscopic approach does not replace the preoperative examinations, which are conventionally performed when appendicitis is suspected (clinical examination, blood test, ultrasonography, CT-scan).
Despite advances in diagnosis, the clinical history and physical examination remain paramount to the diagnosis of appendicitis. Preoperative management includes:
- pain in the peri-umbilical or epigastric regions that subsequently localizes to the right lower quadrant over several hours (localization differs based on the position of the appendix). Nausea and anorexia are present nearly always and typically occur after the onset of pain. Vomiting may accompany the nausea, but rarely happens before the onset of pain if appendicitis is present. A subtle increase in rectal temperature (37.5-38.5°C) with a moderate pulse rate is classic, but this hyperthermia is only found in 50% of the cases.
Physical examination (Sauerland et al., 2006):
- tenderness in the right lower quadrant (RLQ), direct rebound tenderness; Rovsing’s sign, involuntary guarding, psoas sign and obturator sign.
- laboratory data: no single laboratory value is accurate by itself, but a combination of values may be promising. The combination of values based on WBC count, neutrophil differential and C-reactive also known as a “triple test”, when they are within normal reference ranges, have a negative predictive value of 100% (Dueholm et al., 1989).
Advances in the diagnostic accuracy of imaging have altered the approach to patients who have suspected appendicitis. Adjunctive diagnostic tests are useful to confirm the diagnosis and indication for surgery.
The differential diagnosis of appendicitis is broad, but the patient’s history and physical exam may clarify the diagnosis. Many gynaecologic conditions mimic appendicitis; therefore, a pelvic examination should be performed on all women with abdominal pain.
The pulmonary and genitourinary examinations are equally important.
The most common pathologies are: Meckel’s diverticulum, mesenteric lymphadenitis, cholecystitis, Crohn’s disease, diverticulitis, duodenal ulcer, pancreatitis, ectopic pregnancy, ovarian torsion, pelvic inflammatory disease, ruptured ovarian cyst, tubo-ovarian abscess, pleuritis, pneumonia, kidney stone, prostatitis, pyelonephritis, testicular torsion, urinary tract infection, omental appendix torsion.
- uncertain diagnosis in female patients of reproductive age;
- suspected ectopic appendix (retrocaecal, etc.);
- obese patient;
- suspected appendicular peritonitis: the laparoscopic approach enables the surgeon to better assess the extent of the peritoneal sepsis (subphrenic collection, generalized peritonitis).
The laparoscopic approach does not replace the preoperative examinations which are conventionally performed when appendicitis is suspected (clinical examination, blood test, ultrasonography, etc).
According to the EAES recommendations (Surg Endos 2006; Yilmaz et al., 2007): patients with symptoms and diagnostic findings suggestive of acute appendicitis should undergo diagnostic laparoscopy (Grade of Recommendation A) and if the diagnosis is confirmed laparoscopic appendectomy (Grade of Recommendation A).
The Société Nationale Française de Gastroentérologie (SNFGE) states that the diagnosis of severe appendicitis can be ruled out if none of these situations occur (http://www.snfge.asso.fr/02-Connaitre-maladie/0H-urgences/faq/urgences_appendicite.htm):
- peritoneal guarding at abdominal exploration;
- temperature > or = 38°C;
- leukocytosis > 10,000 WBC/mL.
Contraindications are the same for all laparoscopic procedures:
- hemodynamic unstable patient (absolute);
- multiple previous abdominal surgery (relative);
- extensive adhesions (relative);
- radiation or immunosuppressive therapy (relative);
- severe portal hypertension (relative);
- coagulopathies (relative).
- supine position;
- legs together and stretched out;
- right arm at an angle;
- left arm alongside the body.
The operating table is slightly tilted to the left in a Trendelenburg position.
An intra-abdominal pressure of less than 12mmHg is recommended due to the potential effects of CO2 insufflation on the pregnant patient and her foetus (Malangoni, 2003).
As in all laparoscopic procedure, the axis of vision, the surgery site and the monitor should follow the same line (Begin, 2006).
2. Anesthetic equipment
4. Operating table
1. 0° laparoscope
2. Fine dissection scissors
3. Peanut swab (iodine)
4. Fenestrated grasping forceps
5. Bipolar cauterizing grasper
6. Clip applicator
7. Electrocautery hook
8. Suction-irrigation device
9. 2 surgical loops
10. Extraction bag.
1. 30° laparoscope
2. Endoscopic linear stapler
3. Needle holder
All ports should be placed in such a manner that they have free movement and do not interfere with each other. A symmetric triangulation is recommended.
Special considerations that should be taken into account before inserting the ports include:
- anatomical landmarks;
- cosmetic expectations;
- presence of scars from previous abdominal operations.
Three trocars (for most procedures) are used in a triangular formation.
Optical: 10/11mm trocar (5mm for some authors, notably used in children), supra-umbilical position, but also sub-umbilical or latero-umbilical.
Operating: Two operating trocars at a minimum of 8 to 10cm from one another.
One operating trocar (5 or 10/11mm) is placed in median suprapubic position and another operating trocar (5 or 10/11mm) is placed in left iliac fossa position; for some authors, this trocar can also be placed in the right iliac fossa or the suprapubic position.
Another option is to use two 5mm operating ports placed similarly.
- is used specially in cases of difficult exposure (obese patients) and in peritonitis;
- the right subcostal position is the most common, but its position depends on each clinical case.
Occasionally, for purely cosmetic reasons; the left operating trocar can be placed in the left suprapubic region at the limit of the pubic hair. The second operating suprapubic trocar must be slightly pushed towards the right.
- one supraumbilical trocar,
- two suprapubic trocars (on the border of the pubic hair).
An open approach is recommended for the first trocar insertion (Friedman et al., 2002). The height of the fundus of the uterus should be determined prior to its insertion. The trocar can be placed in the supra-umbilical, subxiphoid midline or the left upper quadrant.
These trocars are also inserted higher than in non pregnant women. Their locations vary according to the uterus height. An open approach is also recommended.
- Previous abdominal surgery
Trocar 1: Aorta, inferior vena cava, iliac vessels, colon
Trocar 2: Epigastric arteries
Trocar 3: Bladder
It was demonstrated that there was no method superior to the others; in fact, they have to be selected based on the surgeon’s preferences, patient characteristics and experience.
A small incision is made on the superior border of the umbilicus. The subcutaneous tissue is dissected in order to reach the aponeurosis. The use of long retractors allows for adequate visualization (especially in obese patients), a 10mm incision is made on the aponeurosis and after confirming that there are no adhesions, an atraumatic trocar is introduced.
Needle aspiration should be performed to rule out blood or intestinal contents. An air test is also useful: 10cc of air are aspirated in a syringe and then introduced through a Veress needle. The impossibility to re-aspirate that air means that the needle is correctly positioned. Intra-abdominal pressure must be low when connected to the insufflator.
2. Terminal ileum
3. Female genital organs
Exploration of the abdominal cavity is the first step of the procedure that may need to change the table’s position.
In this way, the diagnosis is confirmed or another pathology is assessed (female organs, diverticulitis, inguinal hernias, liver disease, carcinomatosis).
When the diagnosis of appendicitis is established, further exploration of the abdominal cavity is completed to search for purulent collections (subphrenic, subhepatic, paracolic, pelvic, between the loops of the small bowel); if necessary, bacteriological sampling is performed.
The value of intraoperative abdominal cavity culture is controversial due to the fact that colonic flora is largely predictable and the fact that broad-spectrum antibiotic therapy is very effective (Gladman et al., 2004; Chen et al., 2008; Wallace et al., 2008). The clinical outcome seems not to be influenced by the results obtained and even the positive intraoperative cultures do not predict infective complications.
Some authors recommend microbiological sampling in high risk and in immuno-compromised patients in whom the mortality and morbidity may increase significantly if an inadequate empirical antibiotic coverage is started (Chen et al., 2008).
In female patients, an inspection of the gynaecologic sphere is routinely done.
Exposure of the appendix and of its mesentery is the first step of the procedure. This step must be performed carefully as the wall of the appendix must not be ruptured nor even weakened during its manipulation.
If the appendix is in its usual paracaecal position, the surgeon retracts the caecum and subsequently exposes the appendix.
Grasping and exposure of appendix:
The appendix is grasped with an atraumatic grasper.
If the appendix is significantly inflamed and friable, it is advisable not to grasp the appendix itself but rather to place a Babcock forceps around it. It is also preferable to grasp the meso-appendix with an atraumatic grasper.
3. Appendicular artery
The grasping and upward retraction of the distal part of the appendix with an atraumatic grasper exposes the meso-appendix. In some peri-appendicular inflammatory masses, the distal portions of the small bowel and the omentum form an adhesive phlegmon, which must be freed before exposing the appendix.
Inflammation-induced changes in the ileocaecal junction can make it difficult to identify the usual anatomical landmarks (free taenia, antimesenteric border of the terminal ileum, etc.).
The first option for the control of the meso-appendix is to electrocoagulate all dividing branches of the appendicular artery close to the appendicular wall from the apex towards the base. The meso-appendix is cauterized with the monopolar hook until the base of the appendix is identified and completely freed.
3. Appendicular artery
The second option for the control of the meso-appendix is to control the trunk of the appendicular artery at the base of the appendix using either a ligature or clips after creation of a window, followed by the distal division of the meso.
Control of meso-appendix bleeding is achieved using a bipolar electrocautery device.
When the tip of the appendix is not clearly visible or in cases of fixed ectopic appendix, a retrograde appendectomy can be performed.
- gangrenous appendicitis;
- severe inflammation of the caecum;
- abscess, perforation or peritonitis;
- questionable viability of the base of the appendix.
A window is created at the base of the meso-appendix. A 30mm Endostapler is used to divide the appendix.
This technique initially saves time, but it is more expensive and it will require a 12mm port.
When the base of the appendix on the caecum is highly inflamed with thick walls, a ligature may cut it, then it is better to use a mechanical stapler or to suture the caecal wall in 1 or 2 layers.
Care must be taken not to damage the ileocaecal valve.
Various technical tips can be used depending on the size of the appendix.
Conventionally, the specimen is extracted through the 10/11mm port site located suprapubically or in the left iliac fossa.
Rupture of the retrieval bag within the abdominal wall due to an inadequate fascial gap should be avoided under any circumstances. If delivery of the Endobag is difficult, it is recommended to widen the fascial incision.
- when the extraction is performed without wall protection;
- if the extraction bag tears.
The purpose is to remove all debris and purulent fluid collections and blood from the surgical area.
Lavage of the peritoneal cavity with a normal saline solution is meant to clear any pus or blood collections, which may lead to postoperative abscesses, but remains controversial.
The routine use of drains is no longer recommended in case of laparoscopic appendectomy, but in case of associated peritonitis, a drain may be left in place according to the surgeon’s preference.
The musculo-aponeurotic plane is closed only for 10/11mm openings. The skin is approximated in a conventional manner using clips or suture.
- visceral injury;
- vascular injury.
- parietal haematoma;
- intra-abdominal haematoma;
- scapular pain (diaphragmatic irritation);
- subcutaneous emphysema;
- abdominal wall abscess/intra-abdominal abscess;
- abdominal wall hernia;
- obstructive syndrome (Nottingham, 2002);
- persistent appendicitis due to a persistent appendicular stump.
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