Applied Anatomy of Lower GIT and

Abdominal Wall

Asisten Anatomi 2015

AB – DR – GR - LO – MI - ND – NS - RO - PA – SM – TO – YS
Case 1
JEJUNUM DAN ILEUM
• Bagian kedua dari intestinum tenue adalah
jejunum, berawal dari flexura duodenojejunalis
dan berlanjut menjadi ileum yang berakhir
hingga junction ileocecal.
• Intraperitoneal
• Memiliki penggantung: mesenterium
• Radix mesenterii: Berawal dari junction
duodenojejunalis pada sisi kiri setinggi VL2
hingga junction ileocolica dan articulasio
sacroiliaca dextra
• panjang 6-7 meter (jejunum 2/5, ileum 3/5)
• Sebagian besar jejunum berada pada kuadran
superior sinistra (LUQ) pada kompartemen
infracolica sedangkan sebagian besar ileum
berada pada kuadran inferior dextra (RLQ).
Jejunum vs Ileum
Jejunum vs Ileum
CAECUM DAN APPENDIX
Cecum  intraperitoneal, tapi tidak memiliki
penggantung.
Karena cecum relatif mobile, maka posisinya
dapat berubah namun biasanya terikat ke
dinding lateral abdomen oleh plica cecalis.
Appendix merupakan saluran buntu
(diverticulum intestinum), berisi jaringan
limfoid.
Appendix memiliki mesenterium kecil
berbentuk segitiga yang disebut mesoappendix
Proyeksi pangkal appendix disebut titik
McBurney: sepertiga lateral garis Monroe,
yaitu garis yang menghubungkan antara SIAS
dextra dan umbilicus.
Terminal Ileum, Caecum, dan Appendix
Vermiformis
COLON
• Empat bagian:
• colon ascending (retroperitoneal),
• transversal (intraperitoneal),
• descending (retroperitoneal)
• sigmoid (intraperitoneal)
• Alur vertical yang disebut paracolic gutter
terletak antara sisi lateral colon ascending &
descending dan dinding abdomen
disampingnya.
• Fleksura coli dextra
• Fleksura coli sinistra  menempel pada
diafragma melalui ligament phrenicocolica
Vascularization of Colon
Case I
Clinical Correlation
DIVERTICULUM ILEI /
DIVERTICULUM MECKEL
Diverticulum ilei: remnant of the proximal part of
the omphaloenteric duct (yolk stalk).

It appears as a fingerlike pouch (± 3 to 6 cm long)

that arises from the antimesenteric border (border
opposite the mesenteric attachment) of the ileum,
40 to 50 cm from the ileocecal junction
It is one of the most common anomalies of the
digestive tract.

An ileal diverticulum is of clinical significance

because it may become inflamed and cause
symptoms that mimic appendicitis.
The wall of the diverticulum contains all layers of
the ileum ( true diverticulum) and may contain
small patches of gastric and pancreatic tissues. This
ectopic gastric mucosa often secretes acid,
producing ulceration and bleeding.
Ileostomy
Surgical opening constructed by bringing the end
or loop of small intestine (ileum) out onto the
surface of the skin, or the surgical procedure
which creates this opening.
Intestinal waste passes out of the ileostomy and is
collected in an artificial external pouching system
which is adhered to the skin.
Ileostomies are usually sited above the groin on
the right hand side of the abdomen.
Ileostomies are necessary where injury or a
surgical response to disease has rendered the large
intestine incapable of safely processing intestinal
waste. Diseases like : IBD, Colorectal cancer,
Hirschprung’s disease.
 Ileostomy
Temporary/loop ileostomy
End ileostomy (permanent)
IBD (INFLAMMATORY
BOWEL DISEASE)
• Disease of small and large bowel, with a
constellation of symptoms associated with
inflammatory bowel processes, autoimmune
reactions, extraintestinal manifestations, and
multiple complications
• Types: Crohn’s disease, ulcerative colitis
• (About 10-15% cannot be distinguished, called
indeterminate colitis)
• Risk factors:
o Ashkenazi Jews
o whites > blacks
o presents in teens or early 20s
• Therapy
o Diet and lifestyle changes
o Medical (Symptomatic care & mucosal healing)
o Surgical  : bowel resection (ileocecectomy,
colectomy, dkk tergantung lokasi) dgn
rekonstruksi (ileostomy, colostomy, dkk yg
sesuai)
 CROHN’S DISEASE
VS
ULCERATIVE COLITIS
 DIVERTICULOSIS
• Terminologi penting
• Diverticulum: Kantong abnormal yang
merupakan protusi dari dinding organ
berongga.
• Diverticula: Divertikulum yang muncul
lebih dari satu.
• Diverticulosis: Divertikula pada kolon.
Paling sering ditemukan di sigmoid.
• Acquired diverticula  false diverticula,
krn bagian yg protrude hanyalah stratum
mukosa
• Pathogenesis: Kurang serat  isi lumen
colon sedikit  perlu peningkatan tekanan
kolon untuk mendorong feses  herniasi
mukosa melalui titik lemah pada dinding
colon
• Karakteristik : asimptomatis, kecuali tjd
komplikasi (bleeding & inflammation)
• Dx : Barium Enema atau Colonoscopy
 DIVERTICULITIS
Merupakan divertikulum yang mengalami
inflamasi.
Sign and symptoms: LLQ pain, Fever, Anorexia,
Leukositosis
Dx :
Acute diverticulitis:
Hindari Barium Enema & Colonoscopy
Gunakan CT-scan or USG
Tx :
• Non surgery (IV antibiotik  mayoritas
membaik)
• Surgery (Indikasi: tdk membaik dgn
antibiotik, peritonitis & close-loop
obstruction)
 Colectomy, tergantung letak lesi (plg
sering sigmoidectomy)
 Rekonstruksi (contoh: Hartmann
procedure  Kombinasi
sigmoidectomy dgn colostomy dan
penutupan rectal stump. 8 – 12 week
kemudian disambung,
coloproctostomy)
 KOMPLIKASI
DIVERTICULITIS

Striktura

Perforation

Fistula enterocutaneus

Hemorrhage
 INTUSSUSEPSI
• Intussusception is the most common cause of bowel obstruction
in the first 2 years of life.
• Definition: Telescoping of bowel into adjacent segment of
bowel, leading to obstruction; most frequently proximal to
ileocecal valve. The
part that prolapses into the
other is called the intussusceptum, and the part
that receives it is called the intussuscepiens.
• Types:
o Ileocaecal / ileocolic (most common type)
o Jejunojejunal
o Colocolic (< 5% of all cases)
• H/P:
o sudden abdominal pain that lasts <1 min and is episodic
o pallor, sweating, vomiting, bloody mucus in stool (i.e., currant jelly
stool)
o palpable, sausage-like abdominal mass
• Radiology:
o barium enema will show obstruction
o USG : Doughnut/Target Sign
• Treatment:
o barium enema may reduce defect
o surgery required for refractory cases
 VOLVULUS
• Definition: rotation of segment of bowel about its
mesenteric axis
• Berpotensi mjd volvulus : intraperitoneal organ (karena
mobile).
• Case: sigmoid (65%), cecum (30%), transverse colon (3%),
splenic flexure (2%)
• H/P:

• distention, abdominal pain, vomiting, obstipation

• possible palpable abdominal mass
• Investigations

• AXR (classic findings): “omega”, “bent inner-tube”,

“coffee-bean” signs
• Barium enema: “ace of spades” (or “bird’s beak”)
appearance due to funnel-like luminal tapering of lower
segment towards volvulus
• sigmoidoscopy or colonoscopy as appropriate
• CT
• Treatment: possibly self-limited; colonoscopic
decompression of sigmoid volvulus; surgical repair or
resection may be required in cecal volvulus or failed
colonoscopic detorsion
 Cecal Volvulus

• Dx :
o AXR: Central cleft of “coffee bean” sign
points to RLQ
o Barium enema (dpt jg meringankan pain
& distensi pd volvulus, jika blm tjd
iskemia)
• Tx : Surgery
• Cecopexy  viable cecum
o tacking of the cecum to the right paracolic
gutter with suture
• Cecectomy  non-viable cecum
o diikuti rekonstruksi (ileostomy sementara,
atau langsung ileocolostomy)

Barium enema AXR

Sigmoid Volvulus
• Karakteristik pasien : elderly, debilitated/lemah &
pny kondisi patologis lain
• Dx :
o AXR: Central cleft of “coffee bean” sign points
to LLQ
o Barium enema: “ace of spades” or “bird's beak”
sign
o CT-scan
• mirip dgn cecal volvulus, namun bbrp hal berikut
membedakan manajemen kedua kasus di atas (faktor
pasien elderly) :
o Initial condition pasien sigmoid volvulus srg
lebih buruk
o Morbiditas & mortalitas lbh tinggi pd sigmoid
volvulus
• Tx : Surgery
o Sigmoidectomy, diikuti rekonstruksi
(Colostomy sementara, atau langsung dibuat
coloproctostomy)

“ace-of-spades” sign “coffee bean” sign

ILEUS
Yaitu gangguan passage pada traktus
digestivus. Secara umum dibagi menjadi
ileus paralitik dan ileus obstruktif.

Ileus paralitik diakibatkan hilangnya

kemampuan kontraksi-relaksasi muskuler
(peristaltik) akibat adanya aganglionic
bowel. Contoh: hirschprung disease,
postoperative intestinal paralysis.

Ileus obstruktif diakibatkan karena

obstruksi, bisa ekstrinsik (hernia, volvulus,
adhesi, dll), intrinsik (inflamasi, neoplasma,
intususepsi, hematoma, dll), maupun
intraluminal (fecalith, gallstone, CorpAl, dll)
Case II
Lower GIT
INTESTINUM CRASSUM

Intestinum crassum terdiri dari caecum;

appendix; colon ascenden, transversal,
descenden, dan sigmoid; rectum; dan
canalis analis
Dapat dibedakan dengan intestinum tenue dari
beberapa karakteristik berikut yang ada pada
intestinum crassum, yaitu:
• Appendices omentalis.
• Taenia coli  merupakan penebalan
stratum muskularis longitudinal, dari
pangkal appendix hingga berakhir dan
menyatu pada junction rectosigmoidea.
• Haustra coli
• Diameter yang lebih besar.
Case II
Clinical Correlation
COLITIS
Colitis refers to inflammation of
the inner lining of the colon.
There are numerous causes of
colitis including infection,
inflammatory bowel disease
(Crohn's disease, ulcerative
colitis), ischemic colitis, allergic
reactions, and microscopic
colitis. Symptoms of colitis
depend upon the cause and may
include.
 F
E

COLECTOMY D
G
A-B : ileocecectomy
B : cecectomy
A-E : hemicolectomy dextra
A-F : extended hemicolectomy
dextra
D-G : transverse colectomy C A
F-H : hemicolectomy sinistra
B H
E-H : extended hemicolectomy
sinistra
I
H-I : sigmoidectomy
I-J : proctectomy
H-J : proctosigmoidectomy J
(Hartmann procedure)
A-I : subtotal colectomy
A-J : total proctocolectomy
HEMORRHOID
Klasifikasi (berdasar linea dentata):
Hemorrhoid interna (lapisan luar: mukosa)
Hemorrhoid externa (lapisan luar: kutis)
Faktor risiko :
Tekanan intraabomen yg tinggi (obese, pregnancy,
konstipasi kronis, batuk kronis, dll)
Change in bowel habit
Diet rendah fiber
Sedentary life (duduk terlalu lama, exercise -)
Kebiasaan BAB dgn jamban duduk (terutama yg
durasinya lama)
Sign & symptom :
Kebanyakan asimptomatis
Hemorrhoid interna: hematochezia, itchy, painless
(kecuali tjd thrombosis / nekrosis)
Hemorrhoid externa: painful
Dx :
Rectal Exam /
Endoscopy (Anoscopy & Proctoscopy)
HEMORRHOID INTERNA
Hemorrhoid Interna : Prolapsus dari
mucosa rectum yang mengandung plexus
venosus rectalis interna yang terdilatasi.
Hemorrhoid ini disebabkan karena
breakdown dari lapisan muscularis
mucosa.

Degree of Hemorrhoid interna :

Grade I : bleeding but no prolapse
Grade II : prolapse, spontaneus
reduction
Grade III : prolapse, manual reduction
Grade IV : prolapse, can’t be
manually reduced (risiko strangulasi)

*prolapse hemorrhoid = hemorrhoid interna

yg meluas dan terdorong keluar dr anus
HEMORRHOID EXTERNA
Hemorrhoid Externa :
keadaan dimana terjadi
thrombosis pada plexus
venosus rectalis externa
dan ditutupi oleh cutis.

Faktor Predisposisi :
Kehamilan
Konstipasi kronik
Duduk terlalu lama
Mengejan
Penyakit yang menyebabkan
gangguan aliran darah balik
vena
 Tx:
◦ Non Farmakologis
 Changing lifestyle (menghindari risk
factor)
 Diet tinggi serat
 Endoskopi (Rubber band & Sclerotherapy)
◦ Farmakologis
 Fecal softener
 Fiber supplement
 NSAID
◦ Surgery
 Electrocautery & Cryosurgery
 Hemorrhoidectomy (excision or stapled)
Atresia Anii
Penyebab: Gangguan
Pertumbuhan , fusi dan
pembentukan anus dari
tonjolan embriogenik

Gejala Klinis:
- Bayi tidak BAB
sampai 24 jam
Setelah lahir
- Bayi muntah
proyektil
TX:
COLOSTOMY

Dibikin Saluran 
Colorectal cancer
Carcinoma colorectal merupakan keganasan organ spesifik
dengan mortalitas tertinggi kedua setelah kanker paru.

Sign and symptoms: impede the passage of stool, abdominal

cramping, occasional obstruction, iron-deficiency anemia, etc

Dx: barium enema, colonoscopy

Tx: colon resection, radiotherapy, chemotherapy

RECTAL TOUCHER/DIGITAL
RECTAL EXAMINATION

Done to check for problems with organs or

other structures in the pelvis and lower belly.

A digital rectal exam is done for men as part

of a complete physical examination to check
the prostate gland. It is done for women as
part of a gynecological examination to check
the uterus and ovaries. Other organs, such as
the bladder, can sometimes also be felt
during a digital rectal exam.
PROLAPSUS
RECTI
Prolapsus recti dapat disebabkan oleh :
• Hilangnya lemak pada fossa ischioanal ini akan menghilangkan
supporting system pada rectum
• Supporting system pada rectum (m.levator ani) melemah, terutama
pada wanita tua prolaps recti sering terjadi puncaknya diusia tujuh
dekade
Symptoms include tenesmus, a sensation of tissue protruding from the
anus that may or may not spontaneously reduce, and a sensation of
incomplete evacuation. Mucus discharge and leakage may accompany
the protrusion. Patients also present with a myriad of functional
complaints, from incontinence and diarrhea to constipation and
outlet obstruction.
 Tx Surgery for Rectal Prolapse

Abdominal approach : Perineal approach :

1.Moschowitz repair reduksi hernia perineal dan penutupan cul 1. <gambar atas>Delorme procedure reefing rectal
de sac mucosa (memperpendek mucosa rectum)
2.Transabdominal Protopexy dilakukan penjahitan untuk 2. (atau) perineal rectosigmoidectomy (Altemeier
memfiksasi rektum ke fascia presacralis procedure) reseksi colon yang prolaps dari perineum
3. Sigmoid colectomy untuk mengurangi kelebihan panjang
colon
 Incontinentia Alvi

Etiology and pathogenesis:

◦ Underdevelopment sphincter
ani karena atresia
◦ Kerusakan sphincter dan atau
pelvic floor karena injury atau
prosedur operasi
◦ Prolaps rectum
◦ Kelemahan sphincter karena
kerusakan saraf (n. Pudendus)
Case III
1. Endoderm
2. Mesoderm
3. Ectoderm
Saluran GIT terbentuk
akibat terjadinya Cranial
and Caudal Folding
Caudal Folding Cranial Folding
 Embriologi GIT
The primordial gut forms during the fourth
week
The primordial gut is initially closed at its
cranial end by the oropharyngeal
membrane and at its caudal end by the
cloacal membrane
The epithelium at the cranial and caudal ends
of the alimentary tract is derived from
ectoderm of the stomodeum and anal pit
(proctodeum), respectively
The endoderm of the primordial gut gives
rise to most of the gut (except tunica serosa),
epithelium, and glands
 Foregut
The derivatives of the foregut are:
◦ The primordial pharynx and its derivatives
◦ The lower respiratory system
◦ The esophagus and stomach
◦ The duodenum, distal to the opening of the
bile duct
◦ The liver, biliary apparatus (hepatic ducts,
gallbladder, and bile duct), and pancreas
All but the respiratory system and most of the
esophagus is supplied by celiac trunk and its
branches.
 Midgut
The derivatives of the midgut are:
◦ The small intestine, including the
duodenum distal to the opening of
the bile duct
◦ The cecum, appendix, ascending
colon, and the right one half to two
thirds of the transverse colon
These midgut derivatives are
supplied by the superior
mesenteric artery
 As the midgut elongates, it forms a ventral, U-shaped
loop of intestine—the midgut loop—that projects
into the remains of the extraembryonic coelom in the
proximal part of the umbilical cord.
 The midgut loop of the intestine is a physiologic
umbilical herniation, which occurs at the beginning
of the sixth week because there is not enough room
in the abdominal cavity for the rapidly growing
midgut, mainly because of liver and kidney.
 The loop communicates with the umbilical vesicle
through the narrow omphaloenteric duct (yolk stalk)
 This herniation will last until the 10th week
The midgut loop has a cranial (proximal) limb
and a caudal (distal) limb and is suspended
from the dorsal abdominal wall by an elongated
mesentery—the dorsal mesogastrium
The cranial limb grows rapidly and forms small
intestinal loops, but the caudal limb undergoes
very little change except for development of the
cecal swelling (diverticulum), the primordium
of the cecum, and appendix.

Cranial Limb  jejunum distal, jejunum, ileum

proksimal
Caudal Limb  ileum distal, caecum, dst
 [A to B] Stage I: While it is in the umbilical cord,
the midgut loop rotates 90 degrees
counterclockwise around the axis of the superior
mesenteric artery (cranial = right; caudal = left)
 [C and D] Stage II: The midgut will enter the body
cavity during the 10th week. Small intestines
enter first, followed by large intestines (so the A B
small intestine is posterior to SMA). As the large
intestine returns, it undergoes a further 180-
degree counterclockwise rotation (descending +
sigmoid = left; caecum in upper right quadrant)
 [E] Stage III: The posterior abdomen will
elongates  ascending colon and caecum in adult
C
position + fixation of intestine

D E
 Hindgut
The derivatives of the hindgut
are:
◦ The left one third to one half of the
transverse colon and the descending
colon, sigmoid colon, rectum, and
superior part of the anal canal
◦ The epithelium of the urinary
bladder and most of the urethra
All hindgut derivatives are supplied
by the inferior mesenteric artery.
The expanded terminal part of the
hindgut is the cloaca, closed by the
cloacal membrane (composed of
endoderm of the cloaca and ectoderm of
the anal pit)
The cloaca is divided into dorsal (rectum
+ anal canal) and ventral parts (urogenital
sinus) by the urorectal septum that
develops in the angle between the
allantois and hindgut  also divide the
cloacal membrane to urogenital
membrane and anal membrane
Congenital Megacolon/
Hirschprung Disease
An absence of ganglion cells (aganglionosis)
in a variable length of distal bowel due to
failure of neural crest cell migration
Clinical features: failure to pass of
meconium, abdominal distention, feeding
intolerance, and billous emesis in first 48
hours of live
Dx: explosive bowel movement after digital
rectal examination (not spesific), barium
enema (may has bird’s beak appearance),
biopsy, anorectal manometry
Surgery treatment: Swenson Procedure,
Duhamel-Martin Procedure, Soave-Boley
Procedure
 Malrotation of Gut
 [A] Nonrotation  failure of stage I thus
failure in all subsequent stage. Caudal limb
enter first resulting in left-sided colon.
Inversion of SMA/SMV anatomical
relationship (SMA = dex; SMV = sin). Small
intestine is anterior to SMA
 [B] Incomplete / Mixed rotation failure of
stage II completion (only 90 degree). The
caecum is posteroinferior pylorus, suspended
to posterolateral abd wall by Ladd’s band 
compresing duodenum. May cause volvulus
[C] Reversed rotation  reversed stage II
normal stage I. Caudal limb enter first
thus posterior to SMA and duodenum
[D] Subhepatic caecum and appendix 
failure of stage III
Isolated rotation  either caudal/cranial
limb fail to rotates but the other succeed.
May cause paraduodenal hernia. Some
included this in mixed rotation.
[E] Hyperrotation  may cause the
caecum lie next to the splenic flexure or
intrapelvic caecum.
 Anorectal Congenital Anomalies
• Anus imperforata/ atresia ani (C)-> blind end anal
canal atau bahkan sampai bisa ectopic anus atau fistula
anoperinealis (D dan E). Canalis analis bisa juga
bermuara ke vagina (F) atau uretra (G)
• Anal stenosis (B), yaitu penyempitan canalis analis
yang disebabkan pertumbuhan septum urorectalis yang
terlalu deviasi ke dorsal
• Membranous atresia (C) posisi anus normal namun
ada membran tipis yang memisahkan anal canal
dengan bagian exterior yang gagal perforasi pada akhir
minggu ke 8 , remnan sumbatan epitel (epithelial plug)
terebut dapat membentuk bulging dan nampak biru bila
ada isi meconiumnya.
• Anorectal agenesis with fistula terjadi akibat separasi
inkomplit kloaka dan sinus urogenital oleh septum
urorectalis
• Rectal atresia (H dan I) terjadi akibat recanalisasi
tidak sempurna dari colon akibat defek suplai darah.
Canalis analis dan rectum ada, tapi keduanya tidak
saling berhubungan
Case IV
 Efek simpatis: Efek parasimpatis:
INERVASI GIT
Inervasi GIT dibagi berdasarkan asal Penghambatan sekresi Sekresi kelenjar
embryologi organ GIT. Setiap bagian
menerima inervasi autonom baik
kelenjar
simpatis maupun parasimpatis.

Klasifikasi organ berdasarkan Vasokonstriksi pembuluh Vasodilatasi pembuluh

embryology: darah darah
Organ (I) : Foregut  esophagus hingga
duodenum (proximal papilla duodeni
major) + hepar, billiary apparatus, Relaksasi otot-otot Kontraksi otot-otot
pancreas dinding vesica fellea, dinding vesica fellea,
Organ (II): Midgut  duodenum (distal
gaster, dan usus. gaster, dan usus.
papilla duodeni major) hingga 2/3
proximal colon transversum
Organ (III): Hindgut  1/3 distal colon Kontraksi Sfingter Relaksasi Sfingter
transversum hingga anus (proximal linea
dentata)
Sympathetic Parasympathetic
Abdominal Wall Dermatome
T7-9: superior dari umbilicus
T10: sekitar umbilicus
T11, T12, L1: inferior dari
umbilicus (termasuk regio
pubis)

N. Ilioinguinalis (L1):

inervasi skrotum/labium +
small cutaneus branch to
anterior thigh.
Defecation Reflex
Lower GIT Viewing Modalities
 Acute Appendicitis
Etiologi : unclear, most common: hiperplasia folikel limfoid (akibat viral infection,
parasit cacing & tumor) & fecalith
Patogenesis : Mucous
secretion
hiperplasi folikel obstruksi lumen INFLAMMATI
menumpuk
limfoid, fecalith, other appendix ON
factors Bacterial
overgrowth
Patofisiologi & komplikasi :
Lymphatic & venous
Distension of the obstruction Nekrosis, Perforated
lumen & (mulanya) – diikuti diikuti (konten PERITONITI
inflamasi intraluminal arterial translokasi intraluminal S
pressure (++) compromise / bakterial terburai)
iskemia

Stage :
Simple – suppurativa – gangrenous – rupture / perforated – abscess appendicitis
Temuan Klinis & Lab :
◦ Migrating pain : visceral colic pain (T10 /
periumbilical) > severe constant pain (RLQ / Mc
Burney point – akibat peradangan peritoneum
lokal)
◦ Anorexia (hampir pd semua pasien), nausea &
vomitus (50-60% kasus)
◦ Temperatur normal / mildly elevated 37,2-380C
◦ Leukositosis (10.000-18.000 cells/uL)

Tanda peritonitis (perforated

appendicitis) :
◦ Muscle guarding
◦ Rebound tenderness
◦ Fever (> 38,30C)
◦ Leukositosis (> 20.000 cells/uL)
Px patognomonis :
◦ Nyeri tekan/tenderness RLQ (Mc Burney)
◦ Rebound Tenderness
◦ Migrating Pain to RLQ

Rovsing Sign Psoas Sign Obturator Sign

(Posisi Retrocecal) (Posisi Intrapelvica)

Px penunjang :
◦ Blood tests (AL, differential WBC)
◦ Radiologis
 Ct-scan (melihat enlarged & thicked wall of appendix)
 USG (exclude others disease: ovarian cyst, ectopic pregnancy, etc)
 Appendicogram (foto dengan kontras)
 Alvarado Score for Acute Appendicitis
SIGNS POINTS
RLQ tenderness 2
Rebound tenderness 1
Elevated temperature (> 37,30C) 1
SYMPTOMS
Migrating pain to RLQ 1
Anorexia 1
Nausea or vomitus 1
LABORATORY VALUES
Leukocytosis (> 10.000 cells/uL) 2
Leukocyte left shift (> 75% neutrofil) 1

Intervention based on score (Mc Kay, 2007) :

I. >= 7 : surgery consultation
II. 4-6 : CT scan recommendation
III. <= 3 : unlikely appendicitis, observasi, rescoring
Appendectomy
Pengambilan Appendix melalui incisi transversal atau gridiron
pada titik McBurney di RLQ.

Incisi Gridiron  incisi tegak lurus terhadap linea

spinoumbilicalis.

Laparoscopic Appendectomy menjadi prosedur standard

pengambilan appendix. Cavun peritoneum diinjeksi CO2
sehingga terjadi inflasi  mendistensi dinding abdomen dan
memberi lapang pandang yang kuat. Kemudian diinsersikan
Laparoscope melalui suatu lubang di dinding anterolateral
Reffered Pain of Appendicitis
Case V
Abdominal Regions
 Dermatome Abdominal Wall

Dermatome is an area of skin that is mainly

supplied by a single spinal nerve.
T7 – T11 : n. Thoracoabdominal
T12 : n. Subcostal
L1 – L2 : n. Illiohypogastric & n.
Illioinguinal
n. Subcostal, n. Illiohypogastric, & n.
Illioinguinal berjalan di antara m. OIA dan m. TA
n. Illioinguinal masuk ke dalam canalis
inguinalis
Visceral Referred Pain
Layers of Abdominal Wall
Inguinal Region
Peritoneum
Peritoneal Cavity
Abdominal Incision
A. Midline incision
B. Paramedian incision
C. Right subcostal incision and “saber slash” extension
to costal margin (dashed line)
D. bilateral subcostal (also buckethandle, chevron,
gable) incision and “Mercedes Benz” extension (dashed
line)
E. Rocky-Davis incision and Weir extension (dashed
line)
F. McBurney incision
G. transverse incision and extension across midline
(dashed line)
H. Pfannenstiel incision.
Locus minoris resistance
 Abdominal Hernia

Hernias of the anterior abdominal wall, or ventral hernias, represent defects in the
parietal abdominal wall fascia and muscle through which intra-abdominal or
preperitoneal contents can protrude.

Hernia

Reducible Irreducible Strangulated Incarcerated

may reduce If the blood supply Irreducible;

spontaneously, with to the incarcerated requires surgical
recumbency, or with bowel is correction.
manual pressure.
compromised
Abdominal Hernia
1. Hernia of Linea Alba (Epigastric) are located
in the midline between the xiphoid process and the
umbilicus. These may be congenital and due to
defective midline fusion of developing lateral
abdominal
wall elements.
2. Umbilical hernias occur at the umbilical ring
and may be present at birth or develop later in life.
3. Spigelian hernias can occur anywhere along
the length of the Spigelian line or zone—an
aponeurotic band of variable width at the lateral
border of the rectus abdominis.
4. Incisional hernias may eventually develop
hernias at incision sites following open abdominal
surgery.
 Inguinal Hernia

1. Indirect inguinal hernia arises through

the deep inguinal ring lateral to the
inferior epigastric vessels.
2. Direct inguinal hernia arises medial to
the inferior epigastric vessels.
3. Femoral hernia protrudes through the
femoral ring, which is normally closed
by a femoral septum of extraperitoneal
tissue, and is therefore a site of potential
weakness.
Inguinal Hernia
 Inguinal Hernia
Pantaloon Hernia Femoral Hernia
• Ipsilateral, concurrent • Protrudes through the femoral ring
direct and indirect
inguinal hernia
Hernia Repair
Herniotomy (removal of the hernial sac only)
Herniorrhaphy (herniotomy plus repair of the posterior
wall of the inguinal canal)
Hernioplasty (herniotomy plus reinforcement of the
posterior wall of the inguinal canal with a synthetic
mesh)
Hernia Repair
Hernioplasty
Peritonitis and Peritoneal Adhesion
 Peritonitis
Inflammation of the visceral and parietal peritoneum, is most often but not
always infectious in origin, resulting from perforation of a hollow viscus.

 Peritoneal adhesions
Fibrous bands of tissues formed between organs that are normally separated
and/or between organs and the internal body wall. Most intraabdominal
adhesions are a result of peritoneal injury, either by a prior surgical
procedure or due to intra-abdominal infection.
 Treatment: Adhesiotomy (refers to the surgical separation of adhesions.)
 Ascites
 Ascites describes the condition of pathologic fluid collection within the abdominal cavity.
 Treatment: Abdominal Paracentesis (is a minimally invasive procedure using a needle to remove
fluid from the abdomen.)

Needle entry site

Laparotomy

Laparotomy is a large
incision made into the
abdomen. Exploratory
laparotomy is used to
visualize and examine
the structures inside of
the abdominal cavity.
 Intraperitoneal Injection and Peritoneal Dialysis

Intraperitoneal (I.P.) Injection

  is the injection of a substance into the
peritoneum (body cavity)
Peritoneal dialysis
 may be performed in which soluble
substances and excess water are removed
from the system by transfer across the
peritoneum, using a dilute sterile solution
that is introduced into the peritoneal
cavity on one side and then drained from
the other side.
Abdominal Paracentesis
Paracentesis is a procedure in
which a needle or catheter is
inserted into the peritoneal
cavity to obtain ascitic fluid
for diagnostic or therapeutic
purposes.  Ascitic fluid may
be used to help determine the
etiology of ascites, as well as
to evaluate for infection or
presence of cancer.
Thank YOU 