You are on page 1of 10

Emergency Medicine: Open Access Delibegovic, Emerg Med (Los Angel) 2015, 5:3

http://dx.doi.org/10.4172/2165-7548.1000255

Review Article Open Access

Acute Appendicitis: Diagnosis and Treatment, with Special Attention to a
Laparoscopic Approach
Samir Delibegovic*
University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina
*Corresponding author: Samir Delibegovic, Chief of colorectal department, University Clinical Center Tuzla, Bosnia and Herzegovina, Tel: +38761149131; E-mail:
delibegovic.samir@gmail.com
Received date: March 10, 2015; Accepted date: April 24, 2015; Published date: May 01, 2015
Copyright: © 2015 Delibegovic S. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Acute appendicitis is one of the most common causes of acute abdomen. It may occur from the time of infancy to
old age, but the peak age of incidence is in the second and third decades of life. The diagnosis is based on a careful
history and physical examination. In patients who have atypical clinical and laboratory findings, US, CT, MRI, a
scoring system and laparoscopy can be used. Laparoscopic appendectomy is a safe and effective method for the
treatment of appendicitis. It has proven advantages in relation to the open method: less post-operative pain, and a
short stay in hospital, quicker recovery and return to normal activities. The causes of unsuccessful procedures vary,
and most of the reasons for conversion occur due to the operator's lack of experience.

In general, laparoscopic appendectomy has advantages, but it must be borne in mind that surgical experience in
laparoscopic techniques is a pre-condition for surgeons to expect clinical benefits from laparoscopic appendectomy.
In clinical conditions, where surgical experience is present, and the necessary equipment, the use of laparoscopy
and laparoscopic appendectomy may be recommended in all patients with suspected appendicitis, if laparoscopy
itself is not contra-indicated or is not feasible.

Keywords: Appendicitis; Appendectomy; Laparoscopic appendicitis in Western countries [7,8]. Genetic factors have been
appendectomy suggested as important. However, separating environmental, dietary,
and genetic influences is very difficult.
Introduction We may conclude that it is most likely that there are several
Acute appendicitis is one of the most common causes of acute aetiologies of appendicitis; each leads to the final common pathway of
abdomen. It may occur from the time of infancy to old age, but the invasion of the wall of the appendix by intraluminal bacteria.
peak age of incidence is in the second and third decades of life [1-3].
The lifetime risk of appendicitis is approximately 7-8% [2]. Today in Diagnosis
developed countries, about 8% of the population is treated for acute
appendicitis in the course of their lifetime [2]. Clinical examination
The diagnosis of acute appendicitis is based on a careful history and
Pathogenesis physical examination.
The exact mechanisms leading to appendicitis are not still clear. It is In patients with the typical picture, the diagnosis is easy. Symptoms
likely that luminal obstruction by external (lymphoid hyperplasia) or such as: localization of pain, nausea, vomiting, sensitivity and
internal (fecalith) compression, followed by secondary bacterial leukocytes, are clear criteria for diagnosis of acute appendicitis.
invasion of the wall, plays a key pathogenic role [4]. That is why it is However, 20-30% of patients have atypical clinical and laboratory
conceivable that early surgical intervention prevents the progression of findings [9,10], and in these patients we can use Ultrasound (US),
the disease. But cases of spontaneous recovery, treatment of this Computerized tomography (CT), Magnetic resonance imaging (MRI),
disease only with antibiotics, shed doubt in this hypothesis. a scoring system and laparoscopy.
There are other hypotheses which could explain other pathways. It
has suggested that viral infection (enteroviruses) may induce mucosal Laboratory tests
ulceration, which is then followed by secondary bacterial invasion [5].
The most commonly used laboratory tests in the diagnosis of acute
Ischemia is another possible cause. Cases have been observed in which
appendicitis are leukocyte count and C-reactive protein (CRP) [11].
obstruction of the blood supply to the appendix is associated with
They are used routinely, and their advantage is low cost, where CRP
morphological changes resembling ischemic colitis [6]. The hygiene
has the advantage in relation to leukocyte count, and may be a useful
hypothesis proposes that appendicitis is triggered by enteric infection
marker in evaluation of acute appendicitis. Also, as a predictor of
during childhood and early adulthood [7]. The diet hypothesis
perforated appendicitis, serum bilirubin may be used. Other
suggests that a diet relatively low in fibre and high in refined
inflammatory markers are also used, such as: D-dimer, Procalcitonin
carbohydrates, was in some way responsible for the low incidence of
(PCT) but their diagnostic value in acute appendicitis is low [11].

Emerg Med (Los Angel) Volume 5 • Issue 3 • 1000255
ISSN:2165-7548 EGM, an open access journal

It may ease differential their guidelines [45] (Table 1). Common to all Imaging techniques these scores is that they use symptoms. on the other hand. scores have been intro-duced. treatment of acute appendicitis [41]. or risk of allergic reaction [31]. In experienced hands. It may be performed safely in patients with outcome [33-35].45]. with Special Attention to a Laparoscopic Approach. patients have a moderately raised number of leukocytes pregnant women. The serum bilirubin is significantly raised in patients with a Scores for appendicitis perforated appendix. the Alvarado score goes 80% [21-25]. and elderly patients [4. and exclude acute appendicitis. but not to US is an accessible and cheaper method than CT and should be the "include" acute appendicitis. sensitivity is 76-90%. doi:10. Emerg Med (Los Angel) 5: 255. and feasible procedure [40-44]. It should be preferred in In general.7% sensitivity and 100% specificity [36]. Also. Laparoscopic appendectomy for a non-inflamed appendix was reported in 1983 by the gynae-cologist Semm [40] and then in 1987 Various combinations of oral. However. US is especially an adequate diagnostic tool in female patients when adnexal pathology can be ruled out as part of the For more than 100 years McBurney’s appendectomy was the gold differential diagnosis. with a positive predictive value of 71-95%. coverage from the diaphragmatic crus to the pubis. 91. various from 70 to 87% [20]. appendicitis. intravenous or rectal contrast are Schreiber reported a laparoscopic assisted appendectomy for the most often used. its accuracy depends on the diagnostic aid when it is suspected that there is some other cause of experience and skill of the operator. an open access journal . signs (sensitivity. such as fewer infections of wounds. in rare cases ileocolonopscopy may be necrosis and perforation of the appendix. A biopsy may be to about 38-87%. where the use of imaging techniques is not possible [39]. It shows interluminal bulging method is slightly higher in relation to the leukocite count. faster recovery and return to everyday activities. efficient procedure. shorter imaging method. It has all the corresponding values greater than 85%. perforated appendicitis. CT diagnosis of acute appendicitis may be uncertain or difficult in patients with scarce intraperitoneal fatty tissue. apart from a transversal CT scan. vomiting). appendectomy is a safe and effective method for treatment of MRI increases diagnostic precision and improves the clinical appendicitis [44]. is recommended in adults with suspected knowledge of laparoscopic surgery and more expensive equipment. It should certainly be pointed out that even with this Possible advantages. In such patients it is common laparoscopic procedure. which may have the same clinical picture of acute appendicitis. amounting and mucous erythema on the appendicular lumen. Teicher and Arnbjorson score. are most precision of the interpretation. with which it beyond these scores. CRP) [38]. in relation to a simple acute appendicitis without perforation. which can be performed by most surgeons. to use a coronal or appendectomy through McBurney’s incision is a simple. where the score is below 5 points (sensitivity 94-99%). However. and specificity In order to facilitate clinical diagnosis of acute appendicitis. US and CT are used in establishing the diagnosis of The Alvarado score has medium to high sensitivity (82-87%) and acute appendicitis. Since then many reports have since there is no need to wait for the transit of the oral contrast. especially in low-resource patients. However. CRP levels are related to the evolution of In unclear cases. The specificity of this indicated as an alternative method [37]. no risk been published indicating that laparoscopic appendectomy is a safe of contrast induced nephropathy. operative US and CT. fertile women.1000255 Page 2 of 10 A leukogram is a useful test in the diagnostics of acute appendicitis. Many greatly improves preoperative diagnosis. with Although laparoscopic appendectomy was performed several years suboptimal opacification of the terminal ileum. is possible to achieve diagnostic precision greater than using a purely clinical approach. This approach may be preferred method in It may effectively document the various phases of appendicitis. and a negative predictive value of Treatment 76-98% [26-28]. (1. The Van Way. the experience of the radiologist can affect the hospital stay. but no contrast protocols are being used more often. with persistent pain and normal levels of the infection of the appendix. and its sensitivity is up to 94% [17-19]. It may be said that only patients with often accompanied by a longer operative procedure (which is shorter unclear clinical signs and symptoms should be subjected to pre. but also for establishing alter-native diagnosis of 81% specificity. especially in cases when the international associations have included the results of this study in typical clinical manifestations are lacking.Citation: Delibegovic S (2015) Acute Appendicitis: Diagnosis and Treatment. migration of pain. in most studies.000/mm3) with a prevalence of neutrophils. it is sometime impossible to diagnose appendicitis using US. In obese and uncooperative acute abdomen imitating acute appendicitis. taken. without any risk of radiation or from contrast media. but that this should be a routine imaging The results of many randomized studies show that laparoscopic method for all patients who have appendicitis. which may ease diagnosis. (the duration of pain. One of the reasons is that classic recommended.4172/2165-7548. Systematic reviews support the use of the Alvarado illness. Eskelin and Fenyo. standard in the treatment of acute appendicitis. and right up until the recent development of laparoscopic surgery. nausea. fever) and The clinical accuracy of diagnosis of appendicitis is approximately findings (leukocytes. little in the diagnosis and CT significantly reduces the percentage of negative appendectomies treatment of appendicitis has changed since then. needs some level of focused on the pelvis alone. a major The endoscopy method problem is the low specificity of the leukocyte count of about 25% and sensitivity of about 85% [11]. diagnosis between simple appendicitis and appendiceal abscess. and values above 50 mg/dl indicate inflammatory markers. Leukocytes above 20. quick and curved scan. such as the Alvarado score. score as a triage tool. which may be used to exclude appendicitis.000/mm3 may indicate complications [12-16]. It obese patients. it has only recently become a an appendix located by the adnexa [32]. specificity 86-100%. However. and US and CT are valuable imaging tools. even without enteral or intravenal contrast [29-30]. retrocecal appendix or before laparoscopic chole-cystectomy. countries. It has Emerg Med (Los Angel) Volume 5 • Issue 3 • 1000255 ISSN:2165-7548 EGM. The Alvarado score may be a valuable first imaging method used. but not Laparoscopic appendectomy. as the number of appendectomies performed rises) and higher costs. Its sensitivity varies between 38 and 77%.

needle. 3. assistant on the patient's left. However. grade appendicitis A should be the preferred method of treatment. It can be seen (red arrows) that suprapubic position of trocars patients. bleeding from the ovaries) an unchanged appendix should not be removed. Technique Laparoscopic appendectomy may be performed safely in Level II. an open access journal . Laparoscopic appendectomy may be performed safely in Level II. pregnancy. in the Laparoscopic appendectomy traditionally requires three Trendelenburg position (with his head down) sloping at 10º to 15º.1000255 Page 3 of 10 Level of Evidence The indications for appendectomy are identical whether Level III. After making incision along the Toldt line and mobilize the cecum. on his back. quadrant (Technique 1) seems the best.4172/2165-7548. Grade OR time. which makes it easier to remove. grade treatment of uncomplicated appendicitis and may be used as A an alternative to standard open appendectomy. Laparoscopic appendectomy may be the preferred approach in Level III. a sub. which is removed immediately. Some Some authors place a 5 mm trocar in the upper right quadrant and a surgeons operate with the operator between the patient's legs. extra-uterine Figure 2: Dissection of the mesoappendix. obese patients. grade line. performed laparoscopically or open. with Special Attention to a Laparoscopic Approach. When the trocar is in this position. and no other cause is found of acute abdomen.Citation: Delibegovic S (2015) Acute Appendicitis: Diagnosis and Treatment.dotted Laparoscopic appendectomy is safe and effective in obese Level II. doi:10. Grade A Laparoscopic appendectomy is a safe and effective method for Level I. second one in in the lower left quadrant .a full line. and the monitor is on the right of the patient. equipment and the surgical team Technique of laparoscopic appendectomy The patient is on the operation table. approach Grade C Laparoscopic approach for fertile women with presumed Level I. The operation is performed under general anaesthetic.g. Indications for laparoscopic appendectomy are: 1. Emerg Med (Los Angel) Volume 5 • Issue 3 • 1000255 ISSN:2165-7548 EGM. If another cause of acute abdomen is found (e. Developing a consistent operative method decreases costs. of the patient. laparoscopic ports (Figure 1). B Table 1: SAGES guidelines. In all approaches. level II. one trocar is placed in the right pregnant patients with suspicion of appendicitis B upper quadrant. Clinical signs of acute appendicitis. The operator and the assistant stand to the left umbilical port is used. 2. equipment and the surgical team. and complications. B (Technique 1). a 10 or 12 mm towards the operator. and the 12 mm trocar in the lower left quadrant (Figure 2). where a 5 mm trocar is placed in the lower right patient. The bladder and especially easier manipulation of the retrocecal positioned is emptied using a Foley catheter. or appendix. whilst the positions of the other ports vary. B Laparoscopic appendectomy is possibly the preferred Level III. with the best cosmetic effect. Technique 1: The suprapubic position . grade treatment in B elderly patients. it is easy to make an the patient urinates immediately prior to the procedure. Emerg Med (Los Angel) 5: 255. The position of the patient. Figure 1: The position of the patient. grade patients with perforated appendicitis. this is very difficult (Technique 2). The monitor is set up to the right of the pubic trocar position. appendix Grade A should be considered but based on the individual clinical scenario. the decision to remove the Level III. Laparoscopic approach may be the preferred method of Level II. grade 2: Another position of trocars. in a retrocecal position of appendix. Laparoscopic removal of a normal appendix is indicated if the indication for laparoscopic procedure was pain in the right lower quadrant. a pneumoperitoneum is created with a Veress trocar is in different position. Grade C If no other pathology is identified. enables the cecum to be pushed upwards. or a 10 mm trocar is introduced by open technique and then the camera. whilst when the the umbilical incision.

and after taking care of Figure 5: Securing the base of the appendix with a Hem-o-lok XL the base of the appendix. an open access journal . although rarely. and may have an advantage in relation to other methods (Figure 7). Figure 4: Securing the base of the appendix using a stapler. are much cheaper than endoscopic staplers. with Special Attention to a Laparoscopic Approach. (if a linear stapler is being introduced. The differences between the level of inflammation and foreign body reaction to different materials used in laparoscopic appendectomy favour the use of a stapler and plastic clips [47]. The end of the appendix is seized by the grasper for the mesoappendix placed through the right lower abdominal 5 mm port. DS titanium clips (Braun. Germany) retain the advantages of the Figure 6: Securing the base of apendix with DS titanium clip. clips. the mesoappendix is dealt with gradually. Emerg Med (Los Angel) Volume 5 • Issue 3 • 1000255 ISSN:2165-7548 EGM. produced in a single size. Also. and sometimes. Emerg Med (Los Angel) 5: 255. an endoloop is introduced through the same trocar.4172/2165-7548.Citation: Delibegovic S (2015) Acute Appendicitis: Diagnosis and Treatment. use of titanium [49]. After that. The appendix may also be resected using a linear stapler. the creation of adhesion in the area of the base of the appendix is lowest when a stapler is used [48]. taking care of the appendix. Figure 3: Securing the base of the appendix with an endoloop. In complicated forms of appendicitis. The mesoappendix is skeletized from the top to the base using a harmonic scalpel (Figure 3) an electrocauter. loop ligature or linear intestinal stapler. Non-resorptive polymer plastic clips are an alternative technique by which the base of the appendix may be secure with more quickly and cheaply than using standard techniques [46] (Figure 6). and the mucous is cauterized. three endoloops are passed over the tip of the appendix whereby the base is secured. Then the "base first” technique is the only solution. epigastric blood vessels. above the symphisa. if the base of the appendix is healthy (Figure 4). clip. very often the dissection of the mesoappendix is very difficult and may cause complications. doi:10. It may be said that these characteristics of the stapler may be an advantage in taking care of the base of the appendix during laparoscopic appendectomy. introduced through the supra-pubic trocar. leaving two ligatures on the base. in order to obtain triangulation. and it is necessary to apply an additional clip. The appendix is resected. The usual technique of securing the base of the appendix is a single endoloop ligature.1000255 Page 4 of 10 Under direct control. a plastic non-resorptive clip or a titanium clip. another 12 mm trocar is placed along the But the problem of clips is that both plastic and titanium clips are medial line. they are not or a 10 mm or 5 mm trocar if clips or ultrasound stapler are being able to encompass the entire circumference of the base of the used) and a 5 mm one in the lower right quadrant. The appendix is removed by introducing an endobag through a 12 mm supra-pubic trocar. A stapler provides reliable closure of all forms of acute appendix (Figure 5) and clinical evidence favors the routine use of endoscopic staplers.

uncomplicated appendicitis [6. it is very difficult to analyse these studies. There is no difference in the degree of wound infection. whose aim is to increase the benefit of the classical technique. there is a higher degree of re-interventions in cases of complicated appendicitis treated by SALA [56].4172/2165-7548.59]. and the existence location or an undocumented location of the abscess [84]. due to the small number of patients included and the lack of the characteristics of the Appendectomy with a single. Single Access Laparoscopic Appendectomy (SALA) SALA further minimizes surgical trauma. and triangulation is lacking. infection and antimicrobial therapy of should be limited to 4–7 days.63. However. conducting such studies with high quality methodology remains very difficult [62]. But there is longer operation time. that SALA does not have any advantages over conventional laparoscopic appendectomy. after laparoscopic opportunity to establish a histological diagnosis of the removed dissection. externally. is exteriorized and the appendectomy is performed appendix. Conservative antibiotic treatment of acute appendicitis Despite the fact that appendectomy is the standard treatment of Two-port laparoscopic appendectomy acute appendicitis. with Special Attention to a Laparoscopic Approach. several authors have studied conservative antibiotic This technique includes a 12 mm infra-umbilical port and one 5 treatment of acute appendicitis [62]. It may be said that this technique be used as primary treatment for selected patients with suspected is a transition to single port laparoscopic appendectomy [52]. transumbilical trocar patients. The advantage of surgical treatment in comparison to antibiotic treatment is the This is the method where the appendix. especially in severe forms of appendicitis. Needlescopic instruments are defined as those of 3 mm or less in diameter. com-pared with appendectomy. The most common bacteria which cause acute Alongside the classical laparoscopic appendectomy described above appendicitis are intestinal bacteria. However.64]. They suggest that antibiotics may mm port in the lower left quadrant. an open access journal . including peritonitis or abscess formation. reduce post-operative pain and have an even better cosmetic result. However. with accompanying severe inflammation. a larger dose of narcotics and hospital costs with SALA are higher. Adjuvant antibiotic therapy Alternative techniques Antibiotic prophylaxis is considered routine in emergency appendectomies. which create an even smaller trocar wound and thereby less Complicated appendicitis includes perforated or gangrenous tissue trauma [50]. It is less invasive and cosmetically superior to classical appendectomy [51]. the length of hospitalization and the time of return to work between laparoscopic appendectomy and SALA [55]. very often this procedure cannot be completed using only one trocar. of adhesion. However. especially young girls. since the cosmetic effect is minimal. an increasing number of reports are appearing on transgastric appendectomy [57]. It may be said therefore. It is said that this method gives better cosmetic results than laparoscopic appendectomy. this Figure 7: Locations of intraabdominal abscesses. and is increasingly considered as an alternative technique to the classical laparoscopic technique.1000255 Page 5 of 10 time of regulated diet. Alongside the reduced field of vision and compromised motor function. ‘‘Other’’ indicates method of appendectomy is extremely difficult in cases of generalized multiple fluid collections without specific designation of abscess peritonitis. The longer duration of the surgery and the larger appendicitis. Emerg Med (Los Angel) 5: 255. It may be said that this is a feasible procedure but only in experienced unless it is difficult to achieve adequate source control [61].54]. doi:10. as in open appendectomy [53. including Escherichia coli and using three trocars. the Emerg Med (Los Angel) Volume 5 • Issue 3 • 1000255 ISSN:2165-7548 EGM.Citation: Delibegovic S (2015) Acute Appendicitis: Diagnosis and Treatment. but following the learning curve these parameters improve. this makes extraction of severe forms of appendicitis impossible. However. which is key. hands and in selected patients. This method in Better quality randomized studies are needed on the effectiveness of fact represents a transition to single access laparoscopic antibiotic therapy. Because conversion rate to open appendectomy should be emphasized at the complicated appendicitis is treated as a complicated intraabdominal beginning. appendectomy. Transgastric appendectomy With the development of the concept of natural orifice transluminal endoscopic surgery (NOTES) surgery. the recommended regimen is a single dose of a cephalosporin with anaerobic activity (cefoxitin or Needlescopic laparoscopic appendectomy cefotetan) or a single dose of a first-generation cephalosporin (cefazolin) plus metronidazole [60]. various alternative techniques have been described bacteria belong to the Bacteroides fragilis group [58. For uncomplicated appendicitis.

only few acute appendicitis [79]. and the entire abdomen may be explored and lavaged. laparoscopic approach results in inflamed. or by an endoloop. securing with endoloop. However. In cases of retrocecal appendix. During dissection position is avoided to prevent contamination of the upper abdomen of a distended. When the appendix is gangrenous. Periappendicular abscess Fecalith If a periappendicular abscess is suspected. in this location. it is need to know this possible clinical entity. and removed in the usual manner. but frustrating complication [78]. which is a laparoscopic assisted procedure. Therefore fecaliths need to be dealt with carefully and the appendectomy is performed as described above. adhesions and uncontrolled bleeding.1000255 Page 6 of 10 Complications of Appendicitis Conversion to open procedure The only absolute contraindication for laparoscopic appendectomy Retrocecal appendix is the inability to safely obtain a pneumoperitoneum under general If the appendix is in the retrocecal position. the anatomy is often obscure. Although. retrograde dissection should be performed. Haemostasis Sometimes. retrocecal appendix. localizing the appendix. The laparoscopic appendectomy into an open procedure for various trocar placement is the same as for the usual antegrade resection. However. with increased experience. the injury. postoperatively. Retained fecaliths may cause an intrabdominal loops away. In very rare closure the base of appendix. fear of intestinal the cecum and the base of the appendix have been identified. a fecalith may drop into the [65]. especially treated. gangrenous appendix and the use of an endobag prevent this complication. compared to open approach [67].reflecting the cecal pole up and to the left will expose the [65]. the Trendelenburg This is a rare. but most conversions the area of the cecum or in the pelvis an exudate is found. The view is better. extensive appendix can be resected between the ligatures or by stapler. of mobilization is indicated extremely rarely. the can be managed laparoscopically. may be covered by adhesions. the tip. In because of the magnification of the camera [65]. the appendix. This condition is associated with a significant risk of and it can be from the retroperitoneum. with Special Attention to a Laparoscopic Approach. Gentle treatment of an inflamed. The abscess is identified by bluntly dissecting the adherent bowel peritoneal cavity.69]. Atraumatic bowel graspers are used for retraction of the managed through the laparoscope than through a McBurney incision cecum . dried and irrigated. The cecum should be mobilized adequately and the bleeding with an instrument or gauze and an additional trocar appendix removed by applying the stapler across the base appendix. The abscess cavity is aspirated. The major source of bleeding is placement of trocars through the central rectus muscle and laceration of inferior epigastric artery. pressure of the site of be impossible. Thoracic empyema This complication will be found more often as laparoscopic appendectomy becomes a more common method in the treatment of It is very rare complication of perforated appendicitis. after Most reports of laparoscopic appendectomy indicate a low which laparoscopic appendectomy is performed.4172/2165-7548. and the pelvis. clips. appendicitis [22]. In that case. Then abscess. or stapling of the stump may Bleeding is not difficult to recognize. doi:10. Once reasons that include the inability to gain exposure. where Complications of laparoscopic appendectomy mobilization of the appendix is performed with a finger [64-66]. Bleeding Gangrenous appendix Bleeding is usually overestimated during laparoscopic procedures. Insufficient experience with laparoscopic of appendicitis may be atypical and imitate other ailments. during dissection of an postoperative complications. If the perforation is close to the base of the appendix. US is often appendectomy or advanced and complicated appendicitis may be insufficient for diagnosis. however. Surgeons should be aware of this complication cases have been previously reported [68. most appendicular conditions If the appendix is not identified during the initial exploration. A drain should be cautiously to avoid them being lost between the loops of the intestine placed in the abscess cavity. The inferior epigastric artery can be avoided by placing trocars either Perforated appendix medially or laterally through rectus muscle. the suturing of the base of appendix is only way for the may be achieved by coagulation. in literature “fingeroscopy” is described. facilitate identification and control of the site of bleeding. quite rare. but CT is a quick and effective way of indications for conversion to an open procedure.Citation: Delibegovic S (2015) Acute Appendicitis: Diagnosis and Treatment. situations conversion to open procedure is needed. Empyema could be in order to treat fecalith adequately when recognized intra or explained by bacterial translocation of bacteria from peritoneal cavity. Emerg Med (Los Angel) 5: 255. inability to recognize the base of the appendix. Moreover. appendix is identified with careful blunt dissection. most skilled laparoscopic cecum is mobilized by electrocautery or a harmonic scalpel along the surgeons find that complicated appendicitis can often be better Told line. Careful dissection with control of the significantly fewer incisional SS and similar organ/space infection rates mesoappendix can prevent this complication. a prudent surgeon will occasionally have to convert a [63]. Suction. But. Since in all described cases of Emerg Med (Los Angel) Volume 5 • Issue 3 • 1000255 ISSN:2165-7548 EGM. the signs and symptoms anesthesia [65]. Fecatliths should be thrown into an endobag and careful lavage performed. gangrenous appendix. The to open procedure occur for this complication [42]. making the operation difficult Nevertheless. Perforated appendicitis occurs in 20-30% of patients with acute Aggressive dissection of the mesoappendix may lead to bleeding. this form incidence of intraoperative and postoperative complications [70-77]. an open access journal . abscesses are more easily identified and appendix. However.

in that in children is longer than 5 mm. in patients who have atypical clinical and the port or in a plastic bag (endobag). and in children. with or without cause this complication [83]. an open access journal . With improve-ment of camera quality. Other benefits (the improvement of the quality of life. this complication is rarely the lower right quadrant. and better visualization of Accepted treatment of acute appendicitis is appendectomy. A menopausal women [87. Laparoscopic appendectomy is a safe and effective Emerg Med (Los Angel) Volume 5 • Issue 3 • 1000255 ISSN:2165-7548 EGM. US. possibly due to the spread of infected fluid into standard three-port laparoscopic appendectomy. However. related to postponing diagnosis [89]. and the abdomen is more flexible [105]. an abscess develops. incomeplete appendectomy may lead to recurrent appendicitis. it can be sometimes laparoscopic appendectomy which has all the benefits it has in adults. laboratory findings. It has the advantage over the open approach due to the excessive coagulation of the stump and the consequent necrosis [65]. Pre-operative. Stump appendicitis is delayed obstruction and inflammation of residual tissue left after an incomplete appendectomy [80].86]. it may easily be transformed and subphrenic abscesses. it may serve as a reservoir for the fecalith and hybrid and single-port techniques are popular. and the base is dealt with extra-corporeally.4172/2165-7548. during the peritoneal space [100]. Postoperative abscesses Transumbilical laparoscopic assisted appendectomy (TULAA) is Postoperative abscesses are uncommon with laparoscopic often used [106]. dissection and ligation of recurrent branches of the Laparoscopic appendectomy in children appendicular artery help to mark the base of the appendix [81]. shorter hospitalization. where the appendix is pulled through a 5 mm cannula in lavage and cleaning of the operative field. Abscesses are treated by ultrasound guided punction distance of the base of the appendix from the umbilicus. Therefore early laparoscopy potentially retained fecalith which is manifested as an intra-abdominal abscess is leads to more accurate diagnosis and reduces the risk of complications treated like any other abscess [79]. and the particular cosmetic effect) are present as in Stump appendicitis other patients after laparoscopic appendectomy.88]. Poor identification of the join between the appendix and the concentrations and arterial blood gases must be monitored in order to cecum appears to play an important role. Some reports Pregnancy is not an absolute contra-indication [90]. doi:10. Laparoscopic appendectomy in obese persons Stump dehiscence Laparoscopic appendectomy is also a safe and effective method in Stump dehiscence is a very rare complication. the signs of acute appendicitis. the reduced complications relating to the an inadequately placed endoloop. Laparoscopic appendectomy usually this procedure the stump must be left shorter than 5 mm. while the patient is in the Trendelenburg position. with Special Attention to a Laparoscopic Approach. distance between the cecum and the umbilicus is shorter.1000255 Page 7 of 10 a dropped fecalith after open appendectomy. Post-operative wound infection Infection of a surgical wound is rarer than in open appendectomy. lower levels of wound infection. It is necessary to take this rare complication into account. its removal by relaparoscopy is possible [78]. but older children and adolescents are suitable candidates for dimensional perspective and tactile feedback. The reduction in the level of Acute appendicitis is one of the most common causes of acute wound infection has probably been achieved due to the extraction of abdomen. seen. but this is an This technique is impossible in older children due to the greater unproven theory. but it should be pointed out that longer trocars and instruments are needed [107].Citation: Delibegovic S (2015) Acute Appendicitis: Diagnosis and Treatment. but appendicitis occurs more frequently in the second This complication arises when the appendix is cut a long way from trimester [95-99]. better techniques. quicker return to normal activities. It may be related to obese persons. improved visualization. Following the taenia coli control maternal hyper-ventilation and prevent fetal acidosis [90]. and drainage. CT. If the presence of a fecalith is confirmed The incidence of misdiagnosis is between 26% and 45% in pre- postoperatively. appendectomy in pregnancy may be performed in any trimester [91-94]. Emerg Med (Los Angel) 5: 255. with antibiotic therapy. if a The umbilical region is less innervated than other areas of the patient who has undergone appendectomy again has symptoms and abdomen [104] so there is less post-operative pain. Conclusion even in cases of gangrenous appendicitis. but the suggest an increased incidence of incomplete appendectomy with increased size of the uterus reduces the working space and makes laparoscopy. Laparoscopic appendectomy. MRI. through physical examination. It is therefore necessary to treat the join of the base of the appendix with The range of acute illnesses in children is completely different than the cecum carefully. This is a Laparoscopic appendectomy in pregnant women serious but very rare complication. but most published cases appear after open laparoscopic appendectomy more difficult. better cosmetic effect. pain reduction. Alternatively. Although the diagnosis is based on a careful history and the appendix without direct contact with the wound [85. As laparoscopic surgery does not have the three in adults. a scoring system and laparoscopy can be used. possible cause of longer stump left [82]. If the stump involves the 3 trocar technique described above. exteriorrization of the appendix through the umbilical port [100-103]. wound. maternal end-tidal CO2 the base. It is manifested by a stercoral fistula. from the cecum to the appendix helps to identify the base. and recent reports have noted a significant decrease in abscesses The technique is cost-effective and gives excellent cosmetic results. which is a combination of open and laparoscopic appendectomy [71]. reduction in the length of hospitalization. it is Laparoscopic appendectomy in women of childbearing age recommended to remove the fecalith when it is established that one has dropped intraoperatively. after laparoscopic appendectomy [84]. There are reports of subhepatic and if there are any technical problems.

Int J Med tomography versus magnetic resonance imaging-based contouring in Sci 9: 909-915. Ann R Coll Surg Engl 91: 113-115. operator. Fowler BS. (2005) Role of leukocyte count. Chung PK. Bat O. especially acute appendicitis. Ahlvin RC. Radiology 167: 327-329. Most of these 16. Bulas DI. CMAJ 152: 1617-1626. who are going back to work. Johnstone JM (1998) Is the incidence of acute appendicitis really falling? Ann R Coll Surg Engl 80: 27. Ann Surg 225: 252-261. Paterson-Brown S (2009) White cell count and C- reasons lead to conversion due to the lack of experience of the reactive protein measurement in patients with possible appendicitis. Molloy M. There is less post- operative pain and a shorter hospital stay. AJR Am J Roentgenol 158: 773-778. UnalmiÅŸer S (1995) Accuracy of serum C- In cases of generalized peritonitis. if laparoscopy itself is not contra-indicated or is not Appendectomy: a contemporary appraisal. doi:10. Jeffrey RB Jr (1998) CT and sonographic evaluation of References acute right lower quadrant abdominal pain. Pearl RH. Liu DM. Suspected procedures vary . to expect clinical benefit from laparoscopic appendectomy. 8. adhesion. et al. Watters JM1 (2008) The appendicitis inflammatory response score: a tool 10. Williams NM. Lane MJ. Coll Abbottabad 20: 70-71. Naylor CD (1995) Diagnostic accuracy and short-term surgical for the diagnosis of appendicitis that outperforms the Alvarado score. Hale DA. 1. procalcitonin and CRP in acute appendicitis. Radiology 213: 341-346. Segal I (1990) What causes appendicitis? J Clin Gastroenterol 32. Harris JP. Wang YC. A prospective study. Andersson RE. Hlibczuk V. systematic review. location of the incision [109]. sonographic criteria based on 250 cases. Simpson J (2006) Acute appendicitis. Ann Emerg Med 55: 51-59. neutrophil percentage. All in all. outcomes in cases of suspected acute appendicitis. 7. Xi S. in published studies are experts in laparoscopy. Ditillo MF. Chen WK. Newman KD. Pommergaard HC. Addiss DG. Int J Radiat Oncol Biol 13. J Ayub Med superfast MRI sequence in the diagnosis of suspected acute appendicitis. Br J Surg 91: 28-37. et al. Tauxe RV (1990) The epidemiology of 28. et al. Nazir A. Ann Surg 221: 278-281. 25. author reply 963-964. Molloy M. Naveed D. Burkitt DP (1971) The aetiology of appendicitis. 31. Kamran H. Sivit CJ. Jeffrey RB Jr. Pearl RH. 21. Jaques DP (1997) appendicitis. Thulin AJ (1992) Diagnostic accuracy and perforation rate in appendicitis: association with age and sex of the experience in laparoscopic techniques is a precondition for surgeons patient and with appendicectomy rate. Emerg Med (Los Angel) 5: 255. J R Coll Surg Edinb 37: these cases. Wen SW. Ungar WJ. Akman H. Jaffe TA. Pappas TN (2003) Clinical practice. Ann Surg 200: but it must be borne in mind that the laparoscopy surgeons included 567-575. surgical 22. et appendicitis in young children: cost-effectiveness of US versus CT in al. 14. with Special Attention to a Laparoscopic Approach. 132: 910-925. the use of laparoscopy and laparoscopic specific and sex-specific analysis. Rosenberg J. appendicitis: added diagnostic value of coronal reformations from isotropic voxels at multi-detector row CT. Jackson D. Andersson RE (2004) Meta-analysis of the clinical and laboratory preliminary guidelines for standardized contours” by Viswanathan et al. Yildiz F. Hameed M. Phys 69: 963. (2012) An evaluation of a of total leukocyte count in diagnosis of acute appendicitis. Ahmed M. with less compared with surgeon's clinical impression. Zhu B. the laparoscopic method makes reactive protein measurements in diagnosis of acute appendicitis the complete cleansing of the abdominal space possible. 29. Temple CL. Nysted A. Dziura JD. Söndenaa K. feasible. 34. Carr NJ1 (2000) The pathology of acute appendicitis. Nelson RC (2005) Acute 12: 127-129. The causes of unsuccessful 15. Therefore. (1999) 3. Quant Imaging Med Surg 2: 280-287. 4. (2012) The diagnostic 35. Yang HR. Br J Surg 58: 695-699. 11. N Engl J Med 348: 236-242. Two situations make laparoscopic appendectomy especially difficult: the retrocecal position and the presence of an abscess. (2007) (Int j radiat oncol biol phys 68: 491-498). BMJ 333: 530-534. Am J Surg 122: 378-380. Li M. Am Surg 71: 344-347. Laing FC. Rabinovici R (2006) Is it safe to delay 30. Townsend RR (1988) Acute appendicitis: 122-124. et al. cervical cancer brachytherapy: results of a prospective trial and 12.Citation: Delibegovic S (2015) Acute Appendicitis: Diagnosis and Treatment. Kalady MF. Eur J Surg 158: 37-41. Walker AR. Sung L. Ann Surg 225: 252-261. diagnosis of appendicitis. Harlow MC (1971) Superficial mucosal ulceration and the pathogenesis of acute appendicitis. Bax G.most often the position of the appendix. Gurleyik G. Temple WJ (1995) The natural history of appendicitis in adults. and the Incidence of acute nonperforated and perforated appendicitis: age- necessary equipment. Hugander A. Zhang B. Gögenur I (2013) implications which favor this approach should also not be overlooked Hyperbilirubinemia as a predictor for appendiceal perforation: a [110]. Jeffrey RB Jr. Eris C. Paulson EK. Nussbaum-Blask AR. 33. AJR Am J Roentgenol 170: 361-371. an open access journal . Sisson RG. Everson NW. Jeng LB. 18. Söreide JA. Falzon L. Kaya B. Kuzucu K (2002) Diagnostic value appendectomy in adults with acute appendicitis? Ann Surg 244: 656-660. Ozyigit G (2007) Comment on “computed value of D-dimer. bleeding and abscess are mentioned [108]. Humes DJ. Karabulut K. Jaques DP (1997) Suspected acute appendicitis: nonenhanced helical CT in 300 consecutive Appendectomy: a contemporary appraisal. (2009) Acute 9. Sana B. 5. et al. 26. Ann Diagn Pathol 4: 46-58. appendicitis.4172/2165-7548. Berry J Jr. al-Saigh AH (1992) C-reactive protein in the differential diagnosis of the acute abdomen. Scand J Surg 102: 55-60. Schutt DC. Br J Radiol 75: 721-725. traumatized tissue and less irritation of the bowels. adults: a systematic review. and C-reactive protein in the return to normal activities. et al. (2008) Role 36. World J Surg 32: 1850. Radiology 185: 549-552. Mindelzun RE. Caku E. appendectomy may be recommended in all patients with suspected 24. Dis Colon Rectum 38: 1270-1274. patients. laparoscopy facilitates open access. which is especially important in patients diagnosis of acute appendicitis in the elderly. Andersen E. indicating the exact 238-240. 23. Boenning DA. Gurleyik E. et al. Selek U. Radiology 235: 879-885. Krahn M. Burcharth J. population. Haugan PA. Radiology 250: 378-386. Yu D. World J Surg 21: 313-317. Even in 17.1000255 Page 8 of 10 method for the treatment of appendicitis. Malt RA (1984) Appendicitis near its centenary. Huynh MD. Sahin A. the effects of laparoscopic appendectomy are astounding. and quicker recovery and 19. Bugra D. (1997) In clinical conditions. Körner H. Rioux M1 (1992) Sonographic detection of the normal and abnormal appendicitis and appendectomy in the United States. Paulson EK. Brown MD (2010) Diagnostic accuracy of noncontrast computed tomography for appendicitis in 6. Schutt DC. Dattaro JA. Shaffer N. where surgical experience is present. (1992) Appendicitis: usefulness of US in diagnosis in a pediatric diagnosis--a Markov decision analytic model. Sengupta A. 2. Ege G. adiposity. Birnbaum BA. Am J Epidemiol appendix. Hale DA. of unenhanced helical CT in adult patients with suspected acute appendicitis. Emerg Med (Los Angel) Volume 5 • Issue 3 • 1000255 ISSN:2165-7548 EGM. Jin Z. The economic importance and 20. Huchcroft SA. Wan MJ. Cengiz M.

Tech surgery. Soffer D. 42. Radcliffe Medical Press. 53. Galli R. 56. Br J Surg 84: 1045-1050. Minimal access 43. Banz V. Gagner M. Hederman WP. Philadelphia. Armellino MF. 44. Eur J Surg 82. Appendectomy versus antibiotic treatment for acute appendicitis. its complications. 59. 78. (1999) Laparoscopic finger-assisted technique (fingeroscopy) for treatment of open surgery for suspected appendicitis (review). Tanaka Y. Ortega AE. Cattey RP. Goh PM. Surg Endosc 1: 211-216. Dellinger EP. Goldstein EJC. Tursi A (2013) Endoscopic diagnosis of appendicitis. Gorey TF. Nikku R. O'Connell PR. et al. Br J 49. 39. Peters JH. Surgical Laparoscopy. Murr P. Delibegovic S. randomized comparison of laparoscopic appendectomy with 50. Ngoi SS. Baca B. et al. Schein M (2012) Antibiotics as first-line therapy for acute in women. Tade AO (2007) Evaluation of Alvarado score as an admission criterion Cochrane Database Syst Rev : CD008359. Lo HG. Laparosc Endosc 8: 171-179. 45. Am J Health-Syst Pharm 70: 195-283. 55. Sackier JM. Janzing HM (2011) BMC Med 9: 139. Dis Colon Rectum 36: 463-467. Roberts KE (2009) Two-port laparoscopic appendectomy: minimizing the minimally invasive approach. doi:10. Smithers BM. Burton EM.4172/2165-7548. In: Arregui ME. Ludwig KA. Humes DJ. 72. Bailey WC (1978) Empyema. Siitonen A. Br J Surg 100: 911-915. et al. Götz F. Reed W (2010) SAGES guideline for 67. versus appendectomy for acute appendicitis: a meta-analysis. Liang MK. JSLS 15: 70-76. port laparoscopic appendectomy. Garcia-Ruiz A (1998) Technical aspects of minimally invasive open appendectomy. 83. Kawashima H. Hunter JG. Single-incision laparoscopic-assisted appendectomy in children: exteriorization of the appendix is a key component of a simple and cost. de Hoog DE. Ersoy Y. Surg Endosc 27: 2928-2933. collaboration. Smith AG. Rivera RT. et al. Schirmer B (1995) A prospective. A rare presentation of perforated appendicitis. Endosc 23: 2851-2854. (2011) A case. Jaschinski T. Deie K. (2011) Single 77. 46. Klausner J. 61. Iljazovi E. Br J Surg 79: 818-820. Saxén H.1000255 Page 9 of 10 37. Ann Surg 254: 586-590. Ed. Appendix stump closure with titanium clips in laparoscopic appendectomy. Garey CL. an open access journal . Stahlfeld KR (2002) Case report. (2013) Biocompatibility and adhesion formation of different endoloop ligatures in securing the base of the appendix. Walsh DC. Intern Med 52: Infection in Adults and Children: Guidelines by the Surgical Infection 1141. Pediatr Surg Int 29: 1187-1191. Rickert A. effective surgical technique. J Int Coll Surg 29: 141-146. Korndorffer JR Jr. Lobo DN (2010) Antibiotic therapy Med 26: 210-212. Metzger J (2013) Laparoscopic approach in perforated appendicitis: increased incidence of surgical site infection? laparoscopic appendectomy. et al. Panait L. Dimitrov BD (2011) The Intra-abdominal Infection Guidelines CID 50: 133-164. Marks JL (2006) Stump appendicitis: a comprehensive review of literature. Kapan M (2003) Stump appendicitis and (2013) Clinical practice guidelines for antimicrobial prophylaxis in generalized peritonitis due to incomplete appendectomy. evaluation. 52. Kum CK. 81. O'Reilly F. Wong TC. J Am Coll Surg 189: 131-133. Law DK. Bacher C (1991) Laparoscopic appendectomy in 625 cases: from innovation to routine. Uchida H. Endoscopy 15: 59-64. Matović E (2009) Hem-o-lok plastic clips in securing of the base of the appendix during laparoscopic appendectomy. Transgastric appendicectomy. Retained fecalith. Fallahzadeh H1 (1998) Should a laparoscopic appendectomy be done? Am Surg 64: 231-233. Surg 54. Bönninghoff R. Olsen KM. et al. Auwaerter PG. Katica M. 47. 57. Hansen JB. Chiu PW. 62. 65. Rautio M. In: Ponsky JL. Neal KR. Langenbecks Arch Surg 397: 327-331. JSLS 17: 543-548. Masuko T. Miller BJ. Austin O. Post S. 51. Rodvold KA . Durgun AV. Lai PB. Schreiber JH1 (1987) Early experience with laparoscopic appendectomy 64. John Willey & Sons 10: 1-139. Hunter JG (1997) Complications in appendectomy. absorbable endoloop. Oxford and New York 103-121. Rispoli G. Surg Surg 169: 208-212. Wilms IM. (1996) Laparoscopic versus open appendectomy: prospective randomized trial. incision versus standard 3-port laparoscopic appendectomy: a Prevention and management. Pediatr Surg Int 14: 142-143. Montgomery A (1997) Appendicitis: laparoscopic versus conventional operation: a study and review of the literature. et al. Peckler D. Kluger Y (2001) Peritoneal cultures and antibiotic treatment in patients with perforated appendicitis. Mason RJ. Hunter JG (1995) Laparoscopic approach to suspected appendicitis. et al. after laparoscopic appendicectomy. et al. Walz M. Eds. Pediatr Infect Dis J 19: 1078-1083. Richardson WS. Schache D. 41. Mavor E. Koluh A (2011) Tissue reaction to 69. Oddsdottir M. Koluh A. Am J abdominal surgery performed with needlescopic instruments. Sharp SW. Surg 34: 199-209. Society and the Infectious Diseases Society of America. (2012) Surg 80: 1599-1600. 58. 75. Schoenberg MB. Endoscopy and controlled comparison of single-site access versus conventional three- percutaneous techniques 12: 441-442. Isaac JR (1993) Randomized controlled trial comparing laparoscopic and open appendicectomy. Sauerland S. Katkhouda N. Laparoscopic Appendectomy Study Group. 70. Hatley R (1994) Thoracic empyema in a patient with acute appendicitis: a rare association. Neugebauer EAm (2010) Laparoscopic versus 66. Katica M. Henry LG (1993) Initial experience with coloproctology. Fellinger E. laparoscopic appendectomy. Surg Endosc 16: 833-835. 60. J Pediatr Surg 29: 1623-1625. Schumer W. Herline A. Am Surg 72: 162-166. and polymer Hem-o-lok clip after laparoscopic appendectomy. Delibegovic S. nonabsorbable titanium staples. Greene JM. Surg Endosc 24: 757-761. Campos GM. with Special Attention to a Laparoscopic Approach. 76. Bacteriology of histopathologically defined appendicitis in children. Ripepi A. Surg Laparosc Endosc 1: 8-13. Delibegovic S. appendicitis: evidence for a change in clinical practice. Jousimies-Somer H (2000) 80. Wong SK. Pier A. Bratzler DW. Kienle P. Strathern DW. Surg 68. West Afr J 63. Teoh AY. Fahey T. Magdeburg R (2013) 79. Bradley JS. World J Surg 36: 2037-2038. Post S. Tekant Y. Perl TM. Kaehler G. World J Surg 20: 17-20. Laparoscopic removal. Surg Laparosc Endosc 7: 357-358. Lippincot-Raven 171-176. JAMA 240: 2566-2567. et al. (2010) Diagnosis and Management of Complicated Intra-abdominal Emerg Med (Los Angel) Volume 5 • Issue 3 • 1000255 ISSN:2165-7548 EGM. Esposito C (2002) One-trocar appendectomy. prospective randomized trial. Sharples K. (1992) Laparoscopic versus open appendicectomy: a prospective 48. appendicectomy. Solomkin JS. Surg Endosc 13: 287-289. Surg Endosc 25: 1415-1419. Varadhan KK. Jakić-Razumović J. Jadallah F (1997) Systematic review of randomized controlled trials comparing laparoscopic with open 153: 167-171. O'Brien KK. in patients with suspected diagnosis of acute appendicitis. Swanstrom LL. Ohle R. The Cochrane complicated appendicitis. 71.Citation: Delibegovic S (2015) Acute Appendicitis: Diagnosis and Treatment. Bell RL. Schier F (1998) Laparoscopic appendectomy with 1. Moberg AC.7-mm instruments. (2013) Laparosc Endosc 7: 459-463. Coloproctol 7: 102-104. Wall DR. Latić F. Duffy AJ. Zait S. 73. J Surg Res 74. World J 40. Emerg Med (Los Angel) 5: 255. Semm K (1983) Endoscopic appendectomy. Jones BT (1999) Retained fecalith after laparoscopic appendectomy. St Peter SD. Greene EI (1958) Incomplete surgical removal of the appendix. Adibe OO. Runkel N. Andersson RE. Juang D. de Visser DC. Roediger WE (1997) Stump appendicitis--a potential problem 167: 214-216. Mazuski JE. McAnena OJ. Alvarado score for predicting acute appendicitis: a systematic review. Complications of endoscopic and laparoscopic surgery. Complicated 38. Fenner H. McCall JL.

Emerg Med (Los Angel) 5: 255. et al. Surg and extra-corporeal laparoscopic appendectomy techniques. Neudecker J. Egan JC. Asarias JR. Sauerland S. Cafasso DE. Dehni N. Schlussel AT. Eds. Tzovaras G. Landy HJ (2009) Appendicitis and cholecystitis in (2001) A prospective randomized comparison of laparoscopic pregnancy. (2001) Laparoscopic vs open appendectomy in overweight patients. 107. Bac B. Akgun Y. 98. et al. Fenyo G. Lee SY. Mahomed AA (2004) Outcome after intra. Bannon MP. Eijsbouts QA.320 patients. Tate JJ (1996) Laparoscopic appendicectomy. Hellberg A.4172/2165-7548. Surgery 129: 390-400. Br J Surg 83: 1169-1170. Laparoscopic procedure for suspected appendicitis. Springer 39-85. Bouillot JL. Suarez C. J Laparoendosc Adv Surg female patients with suspected acute appendicitis. Achanta KK. a guessing game in young women. Am J Surg 180: 456-459. 96. Gordijn RV. Morimura T. Salah S. Buess G. Ashton MW. Alicchio F. et al. al-Hajj G. Esposito C1 (1998) One-trocar appendectomy in pediatric surgery. Surg Endosc 25: 1115-1120. 100. Visnjic S1 (2008) Transumbilical laparoscopically assisted appendectomy A prospective study on the role of laparoscopy. Grant SW. 89. appendicitis--a clear-cut case in men. 106. Helgeson ER. et al. Surg Endosc 26: 523-527. Egger MJ. Ordorica-Flores RM. Zietlow SP. Hayashi S (2012) Transumbilical laparoscopically 91. Castagnetti M. Seth S. Ivanusic JJ. 102. Price RR (1999) The laparoscopic assisted appendectomy in children: the results of a single-port. Cuesta MA (1997) Acute Endosc 12: 177-178. Steyaert H. Gastinger I (2004) Ninety- (2000) Intraabdominal abscess rate after laparoscopic appendectomy. Amini D. 86. Valla J. Goldman RD. Baloyiannis I. et al. Surg Endosc 18: versus laparoscopic appendectomies. Ueberrueck T. World J Surg 31: Tech A 22: 834-839. Price RR (2004) Laparoscopy for appendicitis and (2011) Incidence of postoperative intraabdominal abscesses in open cholelithiasis during pregnancy: a new standard of care. (2006) The EAES clincial practice guidelines on the (2008) Refining the course of the thoracolumbar nerves: a new pneumoperitoenum for laparoscopic surgery (2002). et al. Driver CP. Millat B. Chuang JH (2011) Transumbilical the management of acute abdominal pain: a review of . (1995) 809-812. World J Surg 28: 508-511. pregnancy. Lee HM. A report on 388 operations. Essani R. Merrot T. Spyridakis M. early pregnancy: what is the preferred surgical approach? Am Surg 71: 109. Suttie SA. Bacher C (1990) Modified laparoscopic appendectomy in 94. Surg 178: 523-529. In: EAES guidelines understanding of the innervation of the anterior abdominal wall. Rozen WM. Bernard AC. Koren G (2004) Appendicitis during in 283 consecutive patients. Barrington MJ. (1999) 92. single- management of appendicitis and cholelithiasis during pregnancy. Fernandez F. an open access journal . Surg Endosc 11: 923-927. Calvo AI. Mantzos F. Liakou P. doi:10. Surg laparoscopic appendectomy for acute appendicitis: a reliable one-port Endosc 19: 882-885. Hsieh CS. Gudbjartson T. in children: high-tech low-budget surgery. Surg Endosc 4: 6-9. Chan KJ. 85. Surg 88. Schoemann MB. Bergamaschi R. et al. Harmsen WS. 108. Surg Endosc 25: 2678-2683. Brown CV (2005) Appendectomy during surgery. Yilmaz HG. with Special Attention to a Laparoscopic Approach. 99. Boulanger BR Umbilical one-puncture laparoscopic-assisted appendectomy in children. 104. Surg Endosc Endosc 15: 387-392. Handrahan DL. Am Surg 70: 733-736. Neugebauer EAM. A. Borgstein PJ. Emerg Med (Los Angel) Volume 5 • Issue 3 • 1000255 ISSN:2165-7548 EGM. Willson PD (2005) Early laparoscopy as a routine procedure in 103.1000255 Page 10 of 10 84. 18: 1123-1125. Katkhouda N. Esposito C. 90. pregnancy--risk factors associated with principal outcomes: a case control study. Fingerhut Anat 21: 325-333. (2012) 87. 110. Rollins MD. 93. Open versus laparoscopic appendectomy in the pediatric population: a (2007) Laparoscopic appendectomy: differences between male and literature review and analysis of complications. four appendectomies for suspected acute appendicitis during pregnancy. Tran TM. 105. Shane MD. procedure. Neugebauer EAM. Barnes SL. Enochsson L. et al. et al. two cases and description of technique. Guttman R. Surg Endosc 22: 1667-1671. Pier A. 101. Bonjer HJ. 409-413. Long KH. Celik Y (2007) Acute appendicitis in analyses. Clin Obstet Gynecol 52: 586-596. 237-241. Surg Endosc 9: 957-960. Koch A. Friedlander MH.Citation: Delibegovic S (2015) Acute Appendicitis: Diagnosis and Treatment. et al. Carlson TL. Bartels A. Clin for endoscopic surgery. Affleck DG. Hinkel M. Antevil J. Meyer L. Int J Surg 5: 192-197. Sauerland S. Ohno Y. Kasprenski MC. A prospective study 95. Rudberg C. Golash V. appendectomy with open appendectomy: Clinical and economic 97. Carver TW. Am J channel procedure. Götz F. Gilo NB. (2004) Laparoscopic appendectomy after 30 weeks pregnancy: report of Surg Endosc 13: 83-85. Can Fam Physician 50: 355-357.