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Acute Appendicitis
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AndreaPakula andRubySkinner
1 Introduction
Appendectomy for acute appendicitis is one of the most commonly performed surgical procedures for acute care surgeons. The estimated lifetime risk for acute
appendicitis is 7–8%, and there are approximately 300,000 patients diagnosed with
acute appendicitis in the United States. Luminal obstruction of the appendix is commonly causative of appendicitis, and this obstruction can be related to a fecalith,
impacted stool, or lymphoid hyperplasia [1, 2].
Surgical approaches to appendectomy have evolved from open surgery to minimally invasive approaches. Kurt Semm performed the rst laparoscopic appendectomy in September 1980, and with the subsequent evolution of the minimally
invasive technology, an open appendectomy is not frequently done in the adult
populations [3].
In a 2010 meta-analysis of randomized controlled trials comparing minimally
invasive to open appendectomy, it was determined that laparoscopy offers signicant advantages over open appendectomy to include less pain, a lower incidence of
surgical site infection, a decreased length of hospital stay, an earlier return to work,
a lower overall cost, and better quality of life scores. This was an early study documenting the superiority of the minimally invasive approach based on high strength
studies that allowed for the strong recommendation of the laparoscopic approach
for both uncomplicated and complicated acute appendicitis [4].
Similarly, in a more recent 2017 meta-analysis comparing laparoscopic versus
open appendectomy in cases of complicated appendicitis, laparoscopy
A. Pakula (*)
Adventist Health Simi Valley Hospital, Simi Valley, CA, USA
e-mail: pakulaam@ah.org
R. Skinner
St. Bernadine’s Medical Center, San Bernadino, CA, USA
e-mail: ruby.skinner@commonspirit.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
F. Coccolini et al. (eds.), Mini-invasive Approach in Acute Care Surgery,
Hot Topics in Acute Care Surgery and Trauma,
https://doi.org/10.1007/978-3-031-39001-2_5
45
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demonstrated less surgical site infections, reduced time to oral intake, and length of
hospitalization. There was no signicant difference in intra-abdominal abscess
rates. Operative time was longer for laparoscopy but did not reach statistical signicance in the RCT subgroup analysis [5]. Overall, laparoscopy for appendectomy is
safe and can be applied in traditionally high-risk populations. Laparoscopy is safe
for patients with obesity, the elderly population with medical comorbid conditions,
and pregnant patients in all trimesters [6–9].
The adoption of robotic-assisted laparoscopic techniques has become more prevalent in general surgery, and approaches to acute care cases are evolving [10, 11].
The adoption of robotic-assisted laparoscopic appendectomy into the surgical armamentarium of the acute care surgeon is also feasible.
A. Pakula and R. Skinner
2 Preoperative Diagnosis andIndications forSurgery
Patient presentation can vary from minimal symptoms with vague lower abdominal
pain to more localized pain with or without peritoneal inammation. The classic
physical exam ndings and patient complaints are described as periumbilical pain
that radiates and ultimately localizes to the right lower quadrant. If the appendix is
more anterior and adjacent to the parietal peritoneum, patients will have focal tenderness on palpation. If the appendix is located in the retrocecal position, physical
exam ndings may not be as clear. Common laboratory ndings include leukocytosis and an elevated c-reactive protein. Though imaging is not always necessary,
ultrasound is recommended in pregnant or pediatric patients, and computed tomography (CT) of the abdomen and pelvis is the preferred diagnostic study in adults. In
the 2016 ACS NSQIP database, CT scan was shown to have higher positive predictive values compared to ultrasound (US) and MRI [12]. CT is specically useful in
identifying a periappendiceal phlegmon or abscess if the duration of symptoms is
questionable. The utilization of imaging or modality selected is based on physician
preference and condence in the diagnosis.
3 Operative Technique forLaparoscopic
andRobotic Appendectomy
Prior to making skin incisions, local anesthesia can be injected into the skin. The
rst step is to then gain access to the peritoneal cavity. This can be done using a
Veress needle, open/Hassan, or optical view entry technique. Port placement for
laparoscopic appendectomy relies on triangulation of instruments to the right lower
quadrant. Selection of port size is surgeon preference, but at least one 12mm port is
needed if an endoscopic stapler is to be used. For the robotic-assisted approach,
either three 8mm or two 8mm and a 12mm cannula are used. Again, the 12mm
port is necessary to accommodate the stapler if this is the chosen technique. There
are some variations to port placement utilizing the robotic approach which are
shown in (see Figs. 1 and 2) Fig. 2a, b. Once ports have been placed and
a
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Fig. 1 Laparoscopic port
placement
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b
Fig. 2 Robotic assisted port placement
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Fig. 3 Creation of
mesenteric window
A. Pakula and R. Skinner
pneumoperitoneum is achieved to 15mmHg, the patient is placed in Trendelenburg
position and rotated left side down. The operation begins with initial exploration to
identify any unexpected pathology. Atraumatic graspers are then inserted, and the
rst step is to identify the appendix. This can sometimes be difcult so identifying
the cecum can help to facilitate this step. The ligament of Treves located on the
distal ileum near the ileocecal valve can also be used to locate the appendix. During
acute appendicitis, it is often adherent to the mesoappendix or the appendix itself.
The omentum and small bowel are gently swept away from the right lower quadrant.
The appendix can be found lateral to the ileal cecal valve at the base of the taenia. If
the appendix is in the retrocecal position, the cecum will need to be mobilized medially by dividing the white line of Toldt in order to expose the appendix. The principles of mesenteric division as well as division of the appendix are similar regardless
of the minimally invasive approach. Once identied, the appendix can be gently
grasped taking care not to cause rupture. The mesoappendix should be identied,
and either a window can be created at the base of the appendix using a dissector or
the mesoappendix can be divided moving distally to proximally (Fig. 3). The window would allow for hemoclips, a suture, or an endoscopic stapler to be used to
control the mesoappendix vessels. Alternatively, an energy device such as the ultrasonic scalpel, advanced bipolar energy, simple bipolar, or monopolar energy can be
used to divide the mesoappendix which contains the appendiceal artery.
There are several different techniques for dividing the appendix itself, and this
depends on surgeon preference as well as the characteristics of the appendiceal tissue. These include stapled division, suture ligation, or placement of an Endoloop
with or without dunking of the appendiceal stump. The robotic technology facilitates suturing, though this can be done laparoscopically as well. If a stapler is used,
a short-height load (2.0–3.0mm) is typically chosen to seal the mesoappendix and
artery, and a medium height staple load (2.5–3.5mm) is often used to divide the
appendix itself (Fig. 4). Once divided, the staple lines are inspected to assure there
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Fig. 4 Division of base of
appendix with stapler
49
is no bleeding or leakage of stool. Next the appendix can be placed in a retrieval bag
and removed through the larger port. If there is evidence of contamination, this can
be judiciously irrigated and suctioned. Once the procedure is complete, the ports are
removed, and the fascial incision at any port site larger than 5mm is closed to prevent hernia formation. This is usually done with a 0-vicryl suture. Skin incisions are
then closed, and sterile dressing or skin glue is applied.
4 Complicated Appendicitis
In patients who present with signs and symptoms consistent with appendicitis and
demonstrate evidence of perforation with phlegmon or abscess on preoperative
imaging, immediate surgical intervention is not always recommended. If the patient
is not septic requiring immediate surgical exploration, they are admitted to the hospital, started on IV antibiotics, and treated nonoperatively, which may or may not
include radiology-guided drain placement to control the infection depending on the
location and size of the phlegmon or abscess. These patients can then go on to
undergo appendectomy in 6–8weeks after resolution of acute inammatory changes
and drainage of the abscess. 25% of appendectomies performed each year are due
to complicated appendicitis [13].
5 Conclusion
Appendectomy for acute appendicitis is one of the most common procedures performed by acute care surgeons, and minimally invasive approaches are standard.
Laparoscopy in general is associated with signicant clinical benets and overall
cost benets for patient care, and patients with acute appendicitis are afforded with
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A. Pakula and R. Skinner
those benets. High-risk populations including elderly patient, those with obesity,
and pregnant patients, all can safely be managed with laparoscopy for acute appendicitis. Finally, robotic-assisted appendectomies are being performed; although the
literature is sparse for this application, there are evolving benets reported of applying robotic surgery for common acute care surgical emergencies.
References
1. Stewart B, Khanduri P, McCord C, etal. Global disease burden of conditions requiring emergency surgery. Br J Surg. 2014;101:e9–e22.
2. Bhangu A, Soreide K, Di Saverio S, etal. Acute appendicitis: modern understanding of pathogenesis, diagnosis , and management. Lancet. 2015;383:1278–87.
3. Meljnikov I, Radojcic B, Grebeldinger S, Radojcic N.History of surgical treatment of appendicitis. Med Pregl. 2009;62(9–10):489–92.
4. Li X, Zhang J, Sang L, et al. Laparoscopic versus conventional appendectomy—a metaanalysis of randomized controlled trials. BMC Gastroenterol. 2010;10:129.
5. Athanasiou C, Lockwood S, Markides GA.Systematic review and meta-analysis of laparoscopic versus open appendicectomy in adults with complicated appendicitis: an update of the
literature. World J Surg. 2017;41(12):3083–99. https://doi.org/10.1007/s00268- 017- 4123- 3.
6. Werkgartner G, Cerwenka H, El Shabrawi A, etal. Laparoscopic versus open appendectomy
for complicated appendicitis in high risk patients. Int J Color Dis. 2015;30:397–401.
7. Wang D, Dong T, Shao Y, etal. Laparoscopy versus open appendectomy for elderly patients, a
meta-analysis and systematic review. BMC Surg. 2019;19:54.
8. Michailidou M, Sacco Casamassima MG, Goldstein SD, et al. The impact of obesity on
laparoscopic appendectomy: results from the ACS National Surgical Quality Improvement
Program pediatric database. J Pediatric Surg. 2015;50:1880–4.
9. Lee SH, Lee JY, Choi YY, etal. Laparoscopic appendectomy versus open appendectomy for
suspected appendicitis during pregnancy: a systematic review and updated meta-analysis.
BMC Surg. 2019;19:41.
10. Certulo LN, Harmon K, Ortiz J, etal. Case report of a robotic-assisted laparoscopic repair of
a giant incarcerated recurrent inguinal hernia containing bladder and ureters. Int J Med Robot.
2015;1:15–7.
11. Cengiz TB, Aghayeva A, Atasoy D, etal. Robotic TAPP repair of incarcerated femoral hernia
with utilization of indocyanine green dye—a video vignette. Color Dis. 2017;19(8):186.
12. Agathis AZ, Miller M, Divino CM.National trends in diagnostic imaging for appendicitis: a
cross-sectional analysis using NSQIP.Am Surg. 2019;85(6):625–30.
13. Perez KS, Allen SR.Complicated appendicitis and considerations for interval appendectomy.
JAAPA. 2018;31(9):35–41.
Acute Cholecystitis andEmergency
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Common Bile Duct Exploration
SimoneFrassini, PaolaFugazzola, MatteoTomasoni,
andLucaAnsaloni
1 Background
1.1 Anatomy andPhysiology
The gallbladder is a small hollow organ attached to the inferior surface of the liver,
and it is divided into four components: neck, infundibulum, body, and fundus [1]
(Fig.1).
The gallbladder function is to store and concentrate the bile synthesized by the
liver—from 30 to 60mL per day—as an extrahepatic reservoir. Vagal stimulation
and release of cholecystokinin from neuroendocrine cells in the duodenum, in
response to the presence of the fat in the diet, cause gallbladder contraction and the
transport of the bile down along the cystic duct [2].
The cystic duct drains into the common bile duct forming typically an acute
angle and can range from 1 to 5cm in length: there are several uncommon anatomic
variations in cystic duct anatomy, and knowledge of these variations is important to
avoid possible injury to the biliary tree during surgery.
Above the cystic duct lies the common hepatic duct, draining the left and the
right hepatic duct system: after the conjunction with the gallbladder, the common
bile duct descends behind the rst part of the duodenum and passes through the
S. Frassini (*) · L. Ansaloni
General Surgery I Unit, Fondazione IRCCS Policlinico San Matteo, University of Pavia,
Pavia, Italy
Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, Università degli Studi di
Pavia, Pavia, Italy
e-mail: simone.frassini01@universitadipavia.it; l.ansaloni@smatteo.pv.it
P. Fugazzola · M. Tomasoni
General Surgery I Unit, Fondazione IRCCS Policlinico San Matteo, University of Pavia,
Pavia, Italy
e-mail: p.fugazzola@smatteo.pv.it; m.tomasoni@smatteo.pv.it
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
F. Coccolini et al. (eds.), Mini-invasive Approach in Acute Care Surgery,
Hot Topics in Acute Care Surgery and Trauma,
https://doi.org/10.1007/978-3-031-39001-2_6
51
52
Spiral part of cystic duct
tmann’s pouch)
Descending (2nd) par
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Neck of gallbladder
Body (corpus) of gallbladder
S. Frassini et al.
Right hepatic duct
Left hepatic duct
Common hepatic duct
Infundibulum (Har
of gallbladder
Smooth part of cystic duct
Fundus of gallbladder
t of duodenum
Gland openings
Major duodenal papilla (of Vater)
Common bile duct
Pancreatic duct
Ampulla (of Vater)
Fig. 1 Anatomy of gallbladder and the biliary tract
pancreas head forming the intrapancreatic portion of the biliary tree. The pancreatic
duct also joins the common bile duct on its distal part, composing the ampulla of
Vater and nally going within the wall of the third part of the duodenum to release
its content. Rarely, the common bile duct and the pancreatic duct may have a separate course encompassed by the head of the pancreas with two separate orices in
the duodenum (Figs.2 and 3).
1.2 Pathogenesis
Acute cholecystitis is an acute inammatory process involving the gallbladder,
mainly attributable to the presence of gallstones but also due to other factors such as
ischemia, motility disorders, direct chemical injury, infections, collagen disorders,
and allergic reactions. In a recent survey in the United States, over 10% of patients
with gallstone-related complications have a rst clinical presentation with acute
calculous cholecystitis (ACC) [3, 4]. The pathological process of acute cholecystitis
is an obstruction of the neck or in the cystic duct by a gallstone with two factors
determining the progression and the severity of the disease: the degree of obstruction and the duration of obstruction. When the obstruction is of short duration and
partial, the patients can experience biliary colic; otherwise, when the obstruction is
complete and of long duration, the patients can develop acute cholecystitis, and
more serious septic complications can occur. Possible complications when gallstonerelated ACC is ignored or misdiagnosed are acute cholangitis, acute biliary
Joining
Joining
left side
n
left side
Acute Cholecystitis andEmergency Common Bile Duct Exploration
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53
Figs. 2 and 3 Possible
anatomic variations of
biliary tract tree
common
hepatic duct
Low union
with common
hepatic duct
Joining
gallbladder
Adherent to
common
hepatic duct
Joining cystic
duct
High union with
common
bile duct
Two accessory
hepatic ducts
common
hepatic duct
pancreatitis, gallstone ileus, Mirizzi syndrome, gallbladder carcinoma, and porcelain gallbladder [5]. According to the most recent evidence, the pathogenesis of
ACC goes through a four-step classication:
1. Edematous cholecystitis (0–4days): rst reactive pathological phase, with inter-
stitial uid and parietal edema but tissues are intact without deeper layer
involvement.
2. Necrotizing cholecystitis (3–5 days): gallbladder has edematous changes with
areas of necrosis and local hemorrhage. There are portions of scattered necrosis,
but they are supercial and do not involve the full thickness of the wall.
3. Suppurative cholecystitis (7–10days): the active repairing process of inamma-
tion is evident. The gallbladder wall is thickened by brous proliferation, and
pericholecystic abscesses are present.
Cystic duct
absent or
very short
Anterior spiral
joining common
hepatic duct on
Posterior spiral
joining commo
hepatic duct on
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4. Chronic cholecystitis: it occurs after repeated occurrence of mild cholecystitis
attacks and consequently brotic or atrophic process in the gallbladder wall.
With the obstruction of a tubular structure as the cystic duct, pain may come
from increased intraluminal pressure, and it precedes infectious complications due
to the biliary stasis.
S. Frassini et al.
1.3 General Consideration
1.3.1 Symptoms
The three most common symptoms associated with the biliary disease are resumed
by the “Charcot triad”: right upper quadrant pain, fever, and jaundice.
• PAIN: when the gallbladder lumen cannot fully empty due to obstruction by a
stone, pain bers are activated resulting in a typical abdominal pain in the epigas-
trium or the right upper quadrant. From a weak and occasional postprandial pain,
in case of severe ACC, the clinical condition can evolve to abdominal tenderness
and Murphy’s sign. A recent paper, including 17 studies about clinical assess-
ment of ACC, showed a positive likelihood ratio for right upper quadrant tender-
ness and Murphy’s sign in the diagnosis of acute cholecystitis [6].
• FEVER: this symptom is a common systemic manifestation of infection or
inammation of the biliary tract. In case of fever associated with common right
upper quadrant pain, ACC or even cholangitis must be immediately suspected.
• JAUNDICE: a serum bilirubin level of 2.5mg/dL or even more is necessary to
detect scleral icterus; levels above 5mg/dL will cause cutaneous jaundice. Fever,
right upper quadrant pain, and jaundice suggest generally a blockage of biliary
secretion due to gallstones but could be also secondarily to other less common
origins. Jaundice is typically related to surgical, from obstruction, or medical,
from hepatocellular disease, cause.
1.3.2 Laboratory Test
When a biliary alteration is suspected, the routine hepatic panel of blood test is
mandatory as a rst-level diagnostic tool. Determination of the conjugated or
unconjugated level of bilirubin, alkaline phosphatase, and serum transaminases is
useful to detect and discriminate a hepatic or cholestatic source of the pathological
process.
In addition, in the case of ACC, also phlogistic signals in the blood exams must
be checked out: white blood cells count (WBC), C-reactive protein (CRP), and procalcitonin (PCT) increase when infection or inammation are evolving, and they
represent also a key component of all the existing diagnostic score.
1.3.3 Imaging
• Ultrasound (US): Transabdominal ultrasound is an inexpensive, sensitive, accu-
rate, and reproducible test—when in expert hands—to evaluate the gallbladder
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