Surgery of Acute Appendicitis

What is the appendix?

The appendix is part of the large intestine and is considered a vestigial organ. That is, it has no function, and its possible removal has no impact on the patient’s further life. In childhood, it is largely occupied by lymphatic tissue, which slowly atrophies. The typical position of the appendix is to ‘hang’ from the cecum (which is the initial part of the large intestine) towards the pelvis. In smaller percentages it can be found either high and behind the large intestine (retrocecal), or low and deep in the pelvis.
Acute appendicitis
Acute appendicitis occurs from mechanical causes the lumen of the appendix is blocked by solid food residues or some coprolith, or by a viral or bacterial infection that creates inflammation.
The clinical picture of the patient with acute appendicitis varies greatly from case to case, which is why the disease has been described as a great imitator. The symptomatology also differs due to the location of the appendix, which has a large deviation from patient to patient


What are the symptoms of acute appendicitis?

The typical symptoms and characteristics of a patient with acute appendicitis are as follows:
• Acute abdominal pain, which is initially diffused around the navel and slowly over time is located more in the right lower abdomen.
• Depending on the location of the appendix, the pain may radiate back to the back (retrocecal) or very low in the abdomen if the appendix reaches low into the pelvis.
• Anorexia
• Nausea and vomiting
• Fever, which may be high in the case of a ruptured appendix.
• A general feeling of fatigue


How is acute appendicitis diagnosed?

Any patient with the above symptoms, raising suspicions of acute appendicitis, should be examined by a surgeon. Beyond the physical examination by the surgeon, the following tests may be necessary:

• general blood testing
• abdominal axial ultrasound
• CT scan

The patient with acute appendicitis will usually have elevated white blood cells and there will also be radiological findings on ultrasound or CT.
In typical cases, the diagnosis and decision for surgery can only be made after physical examination by an experienced surgeon.


What is the treatment for acute appendicitis?

The treatment of the appendicitis is to surgically remove the appendix (appendectomy) and wash the area with saline. If the appendix is ruptured with the presence of an abscess or inflammation, intravenous antibiotics are also necessary. Once the diagnosis is established, surgery must be performed as soon as possible. In the meantime, the patient is administered intravenous antibiotics and hydrated. Avoiding a ruptured appendix is especially important in young women. Any rupture and abscess formation can lead to the formation of adhesions in the pelvis affecting fertility.
There are cases when the clinical picture is not typical and the diagnosis cannot be made with certainty! Typically, these patients are admitted to the hospital with intravenous antibiotics and monitoring. The improvement that occurs with antibiotics in the patient’s clinical picture can be misleading since the acute appendicitis most probably recurs.


Surgery, Laparoscopic Treatment

Surgery is now performed laparoscopically. The operation is performed through three very small incisions. One of one centimeter in the umbilicus for the camera and two of half a centimeter for the laparoscopic tools. The operation is bloodless and very safe. The patient can usually go home the next day. The wounds are closed with intradermal plastic suture and after healing they are not visible at all.
The laparoscopic method allows an overview of the entire abdomen, and the surgeon can detect any other pathology that causes symptoms similar to appendicitis. The surgeon may check for Meckel diverticulum in the small intestine, or gynecological disorders such as ovarian cysts. Also, any atypical location of the appendix, either in the pelvis, or high retrocecally, can be treated without other incisions or extension of the incision.

Other advantages of laparoscopy compared to open surgery are:

• less postoperative pain
• shorter hospital stay
• much less chance of wound purulence especially in case of rupture
• the wound almost never needs to be left open for secondary healing
• much better cosmetic result
• Potential for better control of the abdomen