T.Kravchenko

1. O.O.Bogomolets National Medical University
Department of Faculty Surgery #1
“Approved”
at the Methodist Faculty Surgery
Department # 1 Council
“__”_____2008, protocol #_____
Head of
Faculty Surgery Department # 1
Professor _______ M.P.Zakharash
Study Guide for Practical Work for Teachers and Students
Topic: “Complications of appendicitis”.
Course 4
Foreign Students’ Medical Faculty
Duration of the lesson – 45 min.
Worked out by
Assistant T.Kravchenko
Kyiv
2008

2. I. The theme actuality.
Despite diagnostic and therapeutic advancement in medicine, appendicitis remains a
clinical emergency. In fact, this illness is one of the more common causes of acute
abdominal pain. Left untreated, appendicitis has the potential for severe
complications, including perforation or sepsis, and may even cause death.
II. Startup aims of the study.
To teach students major methods of appendicitis complications diagnosis and
treatment.
Student should have knowledge:
1. Definition and prevalence of appendicitis complications.
2. Classification of appendicitis complications.
3. Clinical manifestations (features) of appendicitis complications.
4. Pathogenesis of appendicitis complications
5. Methods of diagnosis.
6. Treatment of appendicitis complications.
7. Prevention of appendicitis complications.
Student should be able to:
1. Correctly gather an anamnesis.
2. Compose adequate examination plan for patient with appendicitis
complications.
3. Interpret received results of examinations.
4. Interpret data of x-ray, ultrasound scan, CT, endoscopy.
5. Determine the type of complications basing on investigations’ data.
6. Determine the severity of appendicitis complications.
7. Compose plan for treatment of patient with appendicitis complications.
8. Treat patient with complication of appendicitis.

3. III. Educative aims of the study.
1. To acquire the skills of psychological contact establishment and creation of
trusting relations between the doctor and the patient.
2. The development of insight of ecological and socio-economic factors’
influence on health condition.
3. The formation of deontology concepts and practical skills related to patients
with complication of appendicitis.
4. The development of responsibility sense for timeliness and completeness of
patient’s investigation, as well as for patient awareness about possible
methods of treatment and adverse effects which are concerned with them.
5. To develop deontology presentations, be able to carry out deontology
approach to the patient
IV. The content of the theme.
Introduction
Severe and untreared cases of acute appendicitis may lead to a numbers of
complications.
Classification
1. Complication of appendicitis
– Perforation
– Peritonitis (local, spread, total)
– Appendix mass
– Appendix abscess
– Pylephlebitis
– Sepsis
2. Morbidity (complications after appendectomy)
 Early (up to 1week)

4. – Wound infection, hematoma, evisceration
– Intraabdominal bleeding
– Abdominal mass /abscess
– Intestinal obstruction
– peritonitis
 Late (after 2weeks)
– Wound fistula, mass
– p/o hernia
– Abdominal mass /abscess (right iliac fossa, pelvic, subphrenic)
– Fecal fistula
Perforated Appendicitis
Patients with perforation of the appendix may be very ill and require several hours of
fluid resuscitation before safe induction of general anesthesia. Broad-spectrum
antibiotics directed against gut aerobes and anaerobes are initiated early in the
evaluation and resuscitation phase. In children, a laparoscopic approach to the
perforated appendix appears to reduce the incidence of postoperative wound
infections and ileus and is associated with shorter hospital stays and lower costs.
Recent studies in adults suggest that patients successfully treated laparoscopically
realize similar benefits, albeit with a higher risk for conversion to an open procedure
than for patients with simple appendicitis. We usually begin with a diagnostic
laparoscopy and use a rolled gauze to gently sweep adherent loops of small bowel
away from the cecum, thereby exposing the appendix. Depending on the ease of
completing that task, a decision is made whether or not to convert to an open
appendectomy. Any pus encountered during the dissection is aspirated and sent for
Gram stain and culture. Oozing from the severely inflamed retroperitoneum is easily
controlled with argon beam coagulation, if available. The inflamed, indurated

5. mesoappendix is divided using the LigaSure or harmonic scalpel. The taeniae of the
cecum are followed onto the base of the appendix, and the stump is divided either
between Endoloops or with a stapler, depending on the integrity of the tissues. When
the mesoappendix is densely adherent to the cecum or retroperitoneum, it may be
helpful to divide the stump of the appendix with the stapler before dividing the
mesoappendix. The abdomen and pelvis are irrigated and the fluid aspirated. We
leave a closed-suction drain in place only if a well-defined residual abscess cavity
exists after reflection of the small bowel away from the appendiceal bed. Antibiotics
may be altered, if necessary, based on the culture results and are continued until the
patient is afebrile postoperatively.
Appendiceal Abscess
Patients who present late in the course of appendicitis with a mass and fever may
benefit from a period of nonoperative management, which reduces complications
and overall hospital stay. Imaging studies are useful both in confirming the diagnosis
and in evaluating the size of any abscess present. Patients with large abscesses,
greater than 4 to 6 cm in size, and especially those patients with abscess and high
fever, benefit from abscess drainage. This may be accomplished via the transrectal
or transvaginal route using ultrasound guidance if the abscess is suitably located, or
by a percutaneous image-guided approach. Those patients with smaller abscesses or
phlegmon and who are not sick may be successfully managed initially with
antibiotics alone. Patients who continue to have fever and leukocytosis after several
days of nonoperative treatment are likely to require appendectomy during the same
hospitalization, whereas those who improve promptly may be considered for interval
appendectomy.
After nonoperative treatment of suspected late appendicitis, adults undergo
colonoscopy or barium enema because colon cancer is detected in about 5% of

6. cases. The risk for recurrent appendicitis is about 15% to 25% after nonoperative
treatment and warrants consideration of interval appendectomy. We typically
perform this procedure laparoscopically about 6 weeks after the initial bout of
appendicitis. Interval appendectomy is associated with low morbidity and a short
hospital stay. The procedure is routinely performed in children. The decision about
whether to proceed with interval appendectomy for adult patients includes factors
such as patient age, comorbid conditions, and prior abdominal surgery.
Chronic or Recurrent Appendicitis
A small number of patients report episodic bouts of right lower abdominal pain in
the absence of an acute febrile illness. Some are found to have appendicoliths on CT
or sonographic evidence of an enlarged appendiceal diameter; most of these will
have both surgical and pathologic evidence of chronic inflammation of the appendix
and relief of symptoms after appendectomy. These findings support the notion that
appendicitis represents a spectrum of inflammatory changes that may, in rare cases,
wax and wane.
Normal-Appearing Appendix
If a normal-appearing appendix is identified at the time of surgery, should it be
removed? This question has been raised again after the introduction of the
laparoscopic approach; consensus is lacking on this point. Although it is difficult to
know how many patients benefit from this practice, removal of the appendix adds
little morbidity to the procedure. In some cases, pathologic abnormalities that were
not apparent on visual inspection are identified.[37–39] Our practice is to remove
the appendix and perform a thorough search for other causes of the patient's
symptoms. We specifically examine the small intestine for Meckel's diverticulum

7. and Crohn's disease, the mesentery for lymphadenopathy, and the pelvis for
abscesses, ovarian torsion, and hernias.
Treatment Algorithm
Patients are considered to have so-called simple appendicitis if the duration of
symptoms is less than 48 hours or imaging studies show the absence of a large
abscess or phlegmon. These patients typically undergo appendectomy. For patients
with an atypical or long history and those who present during the recovery phase,
imaging studies are obtained. CT is typically selected for nonpregnant adults and
ultrasound for pregnant women and children. Occasionally, these patients are found
to have radiographic features of simple appendicitis and undergo appendectomy.
More commonly, a phlegmon is found. An associated large abscess (>4-6 cm) is
drained either percutaneously, if it is located in the iliac fossa, or transrectally, if it is
in the lower pelvis. Patients who are systemically ill are treated with antibiotics and
bowel rest and re-evaluated. If they do not improve, we perform an open
appendectomy. Similarly, sick patients with a phlegmon or a small abscess are
treated with antibiotics and bowel rest and re-evaluated for signs of improvement as
described earlier. Some patients present during the recovery phase from the acute
illness and may be managed as outpatients. Adults who are managed nonoperatively
during their initial presentation undergo colonoscopy 2 to 4 weeks after their acute
illness to exclude colitis or neoplasms. We typically remove the appendix in these
patients 6 to 8 weeks after the initial presentation. The procedure is performed
laparoscopically as an outpatient.
Outcomes
The mortality rate after appendectomy is less than 1%. The morbidity of perforated
appendicitis is higher than that of nonperforated cases and is related to increased

8. rates of wound infection, intra-abdominal abscess formation, increased hospital stay,
and delayed return to full activity.
Surgical site infections are the most common complications seen after
appendectomy. About 5% of patients with uncomplicated appendicitis develop
wound infections after open appendectomy. Laparoscopic appendectomy is
associated with a lower incidence of wound infections; this difference is magnified
among groups of patients with perforated appendicitis (14% versus 26%). Patients
with a fever and leukocytosis and a normal-appearing wound after appendectomy
undergo CT or ultrasonography to exclude an intra-abdominal abscess. Similarly, if
pus emanates from a fascial opening during wound inspection, an imaging study is
obtained to identify any undrained intra-abdominal fluid collections. In this
situation, we place a percutaneous drain into the collection to divert the infected
material away from the fascia and facilitate wound healing. For pelvic abscesses that
are located in proximity to the rectum or vagina, we prefer ultrasound-guided
transrectal or transvaginal drainage, thereby avoiding the discomfort of a
percutaneous perineal drain.
Small bowel obstruction occurs in less than 1% of patients after appendectomy for
uncomplicated appendicitis and in 3% of patients with perforated appendicitis who
are followed for 30 years. About one half of these patients present with bowel
obstruction during the first year.
The risk for infertility following appendectomy in childhood appears to be small. A
history of either simple or perforated appendicitis was sought in a large cohort of
infertile patients and compared with the frequency of appendicitis in pregnant
women; no significant differences were found.

9. There are rare reports of appendicocutaneous or appendicovesical fistulas after
appendectomy, typically for perforated appendicitis. Fistulas to the skin generally
close after any local infection is treated. Fistulas to the bladder have been
successfully diagnosed and treated laparoscopically in recent years.
V. Lesson topic control questions.
Key points:
• Severe cases of acute appendicitis and delay of treatment may lead to a number of
complications
• Complications of acute appendicitis are numerous and correlate well with the
severity of the inflammatory process.
• Diagnosis is not easy and includes Contrast-enhanced CT, endoscopy, ultrasound,
plain abdominal films or CT, laboratory tests
Cases
A 65-year-old female comes to the ER with a complain of mild abdominal pain in
the right, lower abdomen. She describes the pain now as 7/10 in intensity, with no
exacerbating or alleviating factors. She admits to a 4-days history of constipation, as
well as nausea and vomiting. Lab reveals WBC 10,000; UA shows Escherichia coli
50,000. The patient had a Foley catheter placed, yielding dark concentrated urine. A
mass was palpated in the RLQ. CT of the abdomen and pelvis showed an enlarge
appendix. The patient was taken to the operation room where a Rocky-Davis
incision was used and the tip of appendix appeared to be neoplastic. Frozen section
comes back as adenocarcinoma. What operative procedure is warranted?
1. Appendectomy with culture and stain of peritoneal fluid
2. Appendectomy with frozen section

10. 3. Create a midline incision to check for intraabdominal metastasis and perform
appendectomy
4. Rerform a Fowler-Weir incision and perform right hemicolectomy and
ileocolic anastamosis
Answer is 4
Primary adenocarcinoma of the appendix is rare and encompasses three
types:mucinous adenocarcinoma, colonic adenocarcinoma, and adenocarcinoid.
Typical presentation is that of appendicitis which may also present with ascites or
palpable mass. Recommended treatment is right hemicolectomy, which can be
performed with medial extension of a Rocky-Davis incision throught the anterior
and posterior rectus sheaths. 5-year survival is 60% after a righy hemicolectomy and
20% for appendectomy alone.
VI. Supporting materials required for teaching
1. Participation in clinical duties on admission
2. Working in library
VII. Literature
1. Townsend CM, Harris JW. Sabiston’s Textbook of Surgery, 16th ed.
Philadelphia, PA: W.B. Saunders Co, 2001, vol.44
2. Schwartz SI, Schires GT, Spencer FC, Daly JM, Fischer JE, Galloway AC.
Principles of Surgery, 7th ed. New York: McGraw-Hill, 1999, vol.27
3. Bruce E. Jarrell, R.Antthony Carabasi. Surgery, 3rd ed. Williams & Wilkins,
1998