Appendicitis

Ahmad Akbar Nasution

Anatomy
Apendiks merupakan organ berbentuk tabung,
panjangnya kira-kira 10 cm (kisaran 3- 15cm), dan
• berpangkal di caecum. Lumennya sempit di bagian
proksimal dan melebar di bagian distal
Namun pada bayi, apendiks berbentuk kerucut, lebar
pada bagian pangkal dan mengecil pada arah
• ujungnya.
Apendiks terletak di regio iliaka dekstra dan
diproyeksikan ke dinding anterior abdomen pada titik
• sepertiga bawah garis yang menghubungkan spina
iliaca anterior superior kanan dan umbilicus
Apendiks ditutupi seluruhnya oleh peritoneum, yang
melekat pada lapisan bawah mesenterium
intestinum tenue melalui mesenteriumnya sendiri
yang pendek yang dinamakan mesoapendiks.
Mesoapendiks berisi arteri, vena dan saraf-saraf
(Snell, 2006).
Innervasi dan Vaskularisasi
• Persarafan apendiks berasal dari cabang-cabang saraf
simpatis dan parasimpatis. Persarafan parasimpatis
berasal dari cabang nervus vagus yang mengikuti arteri
mesenterika superior dan arteri apendikularis, sedangkan
persarafan simpatis berasal dari nervus thorakalis X.

• Aliran darah apendiks terutama dari arteri apendicular

yang merupakan cabang arteri ileokolika. Arteri ini
berjalan dari mesoapendiks posterior menuju ileum
terminal. Arteri apendiks aksesori dapat muncul dari
percabangan arteri cecal posterior. Kerusakan pada arteri
ini dapat menyebabkan perdarahan hebat intra-operatif
maupun pos-operatif.
Various positions of the appendix

Letak bagian distal/ ujung apendiks

bervariasi, 65 % terletak di retrocecal,
30 % terletak di pelvis, dan 5 % terletak
di ekstraperitoneal (di belakang sekum,
kolon asenden, atau ileum distal).
Definition:
• Apendisitis adalah peradangan dari apendiks vermiformis
dan merupakan penyebab nyeri akut abdomen yang paling
sering (Wibisono dan Jeo, 2013).

Etiology:
• Apendisitis diawali obstruksi lumen apendiks diikuti oleh
infeksi (Lee, 2013, DynaMed, 2013). Obstruksi dapat
disebabkan oleh hiperplasia limfoid (60 %), fekalit (35 %),
benda asing (4 %), tumor (1 %).
• Obstruksi juga dapat disebabkan oleh parasit Enterobius
vermicularis dengan proporsi 0,2 – 41,8 % di seluruh dunia
(Maki, 2012 dan Minkes, 2013).
PATHOPHYSIOLOGY
Risk Factors for Perforation of The
Appendix

Source: Bailey & Loves Short Practice of Surgery 25th

Clinical Manifestations

Source: Bailey & Loves Short Practice of Surgery 25th

Differential Diagnosis

Source: Bailey & Loves Short Practice of Surgery 25th

Investigation

Source: Bailey & Loves Short Practice of Surgery 25th

 The Alvarado (MANTRELS)
Score
Symptoms
Score

•Migratory RIF pain 1

•Anorexia 1
•Nausea and vomiting 1
Signs
•Tenderness (RIF) 2
•Rebound tenderness 1
•Elevated temperature 1
Laboratory
•Leucocytosis 2
•Shift to the left (segmented neutrophils) 1
TOTAL 10

• < 5 is strongly against a diagnosis of appendicitis

• 7 or more is strongly predictive of acute appendicitis
• In patients with an equivocal score of 5 or 6, abdominal USG or
contrast-enhanced CT scan is used to further reduce the rate of
negative appendicectomy
Source: Bailey & Loves Short Practice of Surgery 25th
 Treatment

• Appropriate antibiotics
Reduces the incidence of postoperative wound infection
When peritonitis is suspected, therapeutic intravenous antibiotics to cover Gram-
negative bacilli as well as anaerobic cocci should be given

• Appendicectomy

Source: Bailey & Loves Short Practice of Surgery 25th

Appendicectomy

• Conventional Appendicectomy
• Laparoscopic
• Appendicectomy
Postoperative Complications

Source: Bailey & Loves Short Practice of Surgery 25th

 Conventional
Appendicectomy
• Caecum is identified
• Base of mesoappendix is clamped in artery forceps, divided, and ligated
• The freed appendix is crushed near its junction with the caecum in artery forceps,
which is removed and reapplied just distal to the crushed portion
• An absorbable ligature is tied around the crushed portion close to the caecum
• The appendix is amputated between the artery forceps and the ligature
• An absorbable purse-string or ‘Z’ suture may then be inserted into the caecum
about 1.25 cm from the base
• The stump of the appendix is invaginated while the purse-string or ‘Z’ suture is tied,
thus burying the appendix stump

Source: Bailey & Loves Short Practice of Surgery 25th

 Problems Encountered During
Appendicectomy
Problems Management
A normal appendix is found Demands careful exclusion of other possible
diagnosis
Remove the appendix to avoid future diagnostic
difficulties

The appendix cannot be found Caecum should be mobilised, and the taeniae
coli should be traced to their confluence on the
caecum before the diagnosis of ‘absent
appendix’ is made

An appendicular tumour is found Small tumours (< 2.0 cm in diameter) can be

removed by appendicectomy
Larger tumours should be treated by a right
hemicolectomy

An appendix abscess is found and Should be treated by local peritoneal toilet,

the appendix cannot be removed drainage of an abscess and intravenous
easily antibiotics

Source: Bailey & Loves Short Practice of Surgery 25th

 Postoperative Complications
• Wound infection
• Intra-abdominal abscess
• Adhesive intestinal obstruction
• Rare
• Ileus
• Respiratory – pneumonitis or collapse
• Venous thrombosis and embolism
• Portal pyaemia (pylephlebitis)
• Faecal fistula

Source: Bailey & Loves Short Practice of Surgery 25th

THANK YOU