prof. dr. faheem aly elbassiony prof. dr. mostafa abd ... · mostafa abd elhamid soliman ,...
TRANSCRIPT
Laparoscopic versus open appendectomy in females in childbearing period
Thesis Submitted for Partial Fulfillment of Master Degree
In General Surgery
By
Mohammed Abd Allah Fath Allah Salman
M.B.B.Ch
Supervised by
Prof. Dr. Faheem Aly Elbassiony
Professor of general surgery
Faculty of medicine
Cairo University
Prof. Dr. Mostafa Abd Elhamid Soliman
Professor of general surgery
Faculty of medicine
Cairo University
Dr. Tarek Osama Hegazy
Lecturer of General Surgery
Faculty of Medicine
Cairo Univesity
2012
Abstract
Laparoscopic appendectomy is safe and feasible. Despite that the
operating time for laparoscopic appendectomy is still higher than that for
open procedure, laparoscopic approach had several advantages over open
appendectomy in that, it has less incidence of wound infection, shorter
hospital stay, less need for post operative analgesia and faster return of
patients to normal activities. Moreover, it is very useful in reaching an
exact diagnosis in equivocal cases in females during their childbearing
period. We must convert laparoscopic procedure to open surgery when
indicated for the safety of the patient. A larger further study to evaluate
the cost, benefit of laparoscopic appendectomy is recommended.
Key words:
Laparoscopic appendectomy - open appendectomy - childbearing
period - wound infection - hospital stay - post operative analgesia- return
to normal activities
1
ACKNOWLEDGMENT
First and foremost, I feel always indebted to God, the kind and
merciful.
I’m very grateful and truly indebted for Prof. Dr .Faheem Aly
Elbassiony, Professor of General Surgery, Cairo University for his kind
support and generous co-operation to accomplish this work.
.
Words are not enough to express my great thanks and deep
appreciation to Prof. Dr . Mostafa Abd Elhamid Soliman, Professor of
General Surgery, Cairo University for his effort, comments, ideas,
constructive criticism and support throughout this thesis.
Many thanks to Dr. Tarek Osama Hegazy, Lecturer of General Surgery, Faculty of Medicine, Cairo University for his support , precious criticism and valuable advices throughout this work.
A very special thank to all my family for their support and
encouragement throughout this work.
2
Contents Introduction ......................................................................................................................... 6
Review of literature ............................................................................................................. 9
Patients and methods ....................................................................................................... 106
Results ............................................................................................................................. 112
Discussion ....................................................................................................................... 126
Summary ......................................................................................................................... 137
References ....................................................................................................................... 140
3
List of tables
Table 1: Bacteria commonly isolated in perforated appendicitis. ................ 28
Table 2: : Common Symptoms of Appendicitis. .......................................... 42
Table 3: The modified Alvarado score ......................................................... 58
Table 4: Differential diagnosis for acute abdominal pain ............................ 71
Table 5: Age distribution in the 2 groups ................................................... 113
Table 6: Intraoperative findings .................................................................. 115
Table 7: Methods to deal with the mesoappendix ...................................... 115
Table 8: Methods to deal with the appendiceal base. ................................. 115
Table 9: Operative time in the 2 groups ..................................................... 117
Table 10: Overall postoperative complicationsError! Bookmark not defined. 119
Table 11: Individual postoperative complications ...................................... 120
Table 12: Wound infection in both groups ................................................. 120
Table 13: Hospital stay, and time needed to return to work ....................... 122
Table 14:Time interval for analgesia needed and Fluid tolerance ............ 123
4
List of figures
Figure 1: Development of the appendix ............................................................................ 13 Figure 2: The interior of the cecum .................................................................................. 15
Figure 3: Endoscopic appearance of the appendix orifice ................................................ 16
Figure 4: Graphic illustration of appendiceal position ..................................................... 17 Figure 5: The attachment of the appendix to the cecum and terminal ileum .................... 19
Figure 6: Blood supply of the appendix ........................................................................... 20 Figure 7: Variations in the origin of the accessory appendicular arteries ......................... 20
Figure 8: Rate of appendiceal rupture by age group ......................................................... 26 Figure 9: Incidence of negative appendectomies by age group ........................................ 26
Figure 10: The psoas sign ................................................................................................. 47 Figure 11: Anatomic basis for the psoas sign ................................................................... 47 Figure 12: The obturator sign ............................................ Error! Bookmark not defined.
Figure 13: Anatomic basis for the obturator sign .............. Error! Bookmark not defined.
Figure 14: Normal appendix; barium enema radiographic examination .......................... 52
Figure 15: Perforated appendicitis with abscess; computed tomography scan ................. 54
Figure 16: Computed tomography scan reveals an inflammed appendix ......................... 55
Figure 17: Acute suppurative appendicitis; contrast-enhanced, fat-suppressed MRI ....... 56
Figure 18: Algorithm for the evaluation and management of patients with appendicitis . 61
Figure 19: Optional incisions for appendectomy .............................................................. 77 Figure 20: Muscle-splitting incision ................................................................................ 78 Figure 21: The appendix and the cecum are rolled out of the incision ............................. 78
Figure 22: The appendiceal vascular arcade is taken between clamps and ligated ........ 79
Figure 23: A purse sting suture is placed around the stump ............................................. 79
Figure 24: Position of the patient in laparoscopic appendectomy ................................... 89
Figure 25: Trocar placement ............................................................................................ 90 Figure 26: Trocar positioning ........................................................................................... 91 Figure 27: Camera in the left iliac fossa ........................................................................... 91 Figure 28: Laparoscopic appendectomy: Trocar placement ............................................. 92
Figure 29: Stapler technique: the transection of the mesoappendix ................................. 94
Figure 30: Stapler technique: the transection of the appendix. ......................................... 94
Figure 31: Exposure of the appendix and creation of a window in the mesoappendix .... 96
Figure 32: Mobilization of the cecum for retrocecal location of the appendix. ............... 96
Figure 33: Laparoscopic appendicectomy ........................................................................ 97 Figure 34: graphic illustration for age distribution ......................................................... 114 Figure 35: Intraoperative findings of laparoscopic cases ............................................... 116 Figure 36: Intraoperative findings of open cases ............................................................ 116 Figure 37: Comparison between time in both groups. ................................................... 117
Figure 38: Comparison between wound infection in both groups. ................................. 121
Figure 39: Comparison between hospital stay in both groups ........................................ 122
Figure 40: Comparison between time to return to work in both groups ......................... 123
Figure 41: Laparoscopic exploration of peritoneal cavity .............................................. 124
Figure 42: Laparoscopic appendiceal dissection t ......................................................... 124 Figure 43: Laparoscopic division of mesoappendix between clips ............................... 125 Figure 44 : Right ovarian cyst detected by laparoscope………………………..125
Introduction Introduction Introduction Introduction
6
Introduction
Appendectomy is the most common surgical procedure performed
in general surgery with a life-time risk about 6%, (Guller et al.,2004).
For almost a century, open appendectomy (OA), first described by
Charles McBurney in 1889, has remained the gold standard treatment for
acute appendicitis. The overall mortality rate for open appendectomy is
around 0.3% and morbidity about 11%, (Guller et al., 2004).
The introduction of laparoscopic surgery has dramatically changed
the field of surgery and now it is possible to perform almost any kind of
procedure under laparoscopic visualization. Laparoscopic
appendectomy(LA) was first described by Kurt Semm in 1983and the
application of the laparoscopic approach for acute appendicitis was first
reported by Schreiber in 1987. With advances in technology and surgical
technique, laparoscopic appendectomy has become the novel alternative
in the treatment of appendicitis in the last 2 decades, (Kehgias et al.,
2008).
The idea of minimal surgical trauma found in laparoscopic
approach which results in significantly shorter hospital stay, less
postoperative pain, faster return to daily activities and better cosmetic
outcome has made laparoscopic surgery for acute appendicitis very
attractive, (Kurtz and Heimann ., 2001).
The reported rate of negative appendectomy for young women
remains high despite of improvement in the diagnostic methods.
Although a "negative" appendectomy carries very little mortality risk to
the patient its morbidity is not uncommon as there is a measurable
incidence of wound infections and other complications of laparotomy.
Introduction Introduction Introduction Introduction
7
At minimum, several days with high cost in the hospital are required. The
rate of negative appendectomy in females is more than in males.
Consensus European Association of Endoscopic Surgeons (EAES)
guidelines have emphasized the value of routine laparoscopy as a
diagnostic tool in young women, (Garbarino and Shimi.,2009).
In premenopausal women the diagnosis of appendicitis is
suspicious because the differential diagnosis includes symptoms of
ovulation and menstruation. A management strategy involving early
laparoscopy could potentially provide a more accurate diagnosis, earlier
treatment and reduced risk of complications. In these patients laparoscopy
provides us both diagnostic and therapeutic values and even to deal with
other causes of acute abdomen. This advantage permits us to manage
even gynecological causes without extending or changing incisions, also
to decrease incidence of infertility after open technique, (Gaitán et al.,
2011).
Also when the origin of abdominal pain is unknown, removal of
appendix is indicated as a part of diagnostic laparoscopy to eliminate
appendicitis in differential diagnosis, (Popović et al., 2004).
This work aims to:
-Compare laparoscopic appendectomy versus open appendectomy as regards operative time, findings , postoperative complications, pain and postoperative hospital stay, and to
- Clarify the advantages of laparoscopic appendectomy over open technique as a diagnostic and therapeutic method in females in childbearing period with suspected appendicitis.
Review of Literature Review of Literature Review of Literature Review of Literature
Review of literature
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9
Anatomy
1. Historical Background
The appendix was probably first noted as early as the Egyptian
civilization (3000 BC). During the mummification process, abdominal
parts were removed and placed in Coptic jars with inscriptions describing
the contents. When these jars were uncovered, inscriptions referring to
the "worm of the intestine" were discovered, (Herrinton.,1991).
Aristotle and Galen did not identify the appendix because they both
dissected lower animals, which do not have appendices,
(Herrinton.,1991).
Leonardo da Vinci first depicted the appendix in anatomic drawings
in 1492, (Ho HS.,1999).
In 1521, Jacopo Beregari da Capri, a professor of anatomy in
Bologna, identified the appendix as an anatomic structure. In the 1500s,
Vesalius (1543) and Pare (1582) referred to the appendix as the caecum.
Laurentine compared the appendix to a twisted worm in 1600, and
Phillipe Verheyen coined the term appendix vermiformis in 1710,
(Herrinton.,1991).
In 1886, Reginald Fitz of Boston correctly identified the appendix as
the primary cause of right lower quadrant inflammation. He coined the
term appendicitis and recommended early surgical treatment of the
disease, (Ellis et al.,1997).
Credit for performance of the first appendectomy goes to Claudius
Amyand, a surgeon at St. George's Hospital in London in 1736.The first
published account of appendectomy for appendicitis was by Krönlein in
1886. However, this patient died 2 days postoperatively.
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10
Fergus, in Canada, performed the first elective appendectomy in 1883,
(Ellis et al.,1997).
The greatest contributor to the advancement in the treatment of
appendicitis is Charles McBurney. In 1889, he published his landmark
paper in the New York Medical Journal describing the indications for
early laparotomy for the treatment of appendicitis. It is in this paper that
he described McBurney's point as the point of "maximum tenderness”,
when one examines a case with appendicitis, (John et al.,2007).
2. Embryology and development of appendix
The appendix and the cecum develop as outpouchings of the caudal
limb of the midgut loop in the sixth week of human development. The
appendix becomes distinguishable by its failure to enlarge as fast as the
proximal cecum. This difference in growth rate continues into postnatal
life. By the fifth month, the appendix elongates into its vermiform shape,
(Williams et al.,1994).
At birth, the appendix is located at the tip of the cecum, but due to
unequal elongation of the lateral wall of the cecum, the adult appendix
typically originates from the posteromedial wall of the cecum, caudal to
the ileocecal valve, (Soybel et al.,2000).
Congenital Anomalies:
Appendiceal variations are few, and are all rare.
• Absence of the Appendix: Congenital absence of the appendix is
extremely rare, (Hei.,2003).
• Ectopic Appendix:
In cases of malrotation of the bowel, where the caecum fails to
descend to its normal position, the appendix may be found in the
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11
epigastrium, abutting against the stomach or beneath the right lobe
of the liver .In this situation, the symptoms and signs of acute
appendicitis may mimic acute cholecystitis, (Ellis et al.,1997).
• Left-Sided Appendix:
1. Situs inversus viscerum.
2. Nonrotation of the intestine.
3. Wandering cecum with a long mesentery.
4. Excessively long appendix crossing the midline, (Yang et
al.,2011).
• Duplication of the Appendix: A transient, appendix like structure,
appearing during week 5, has been described. It has been suggested
that persistence of this structure my explain certain forms of
duplication, (Williams et al.,1994).
Types of duplication: Duplication of the appendix is an anomaly
of extreme rarity and fewer than 100 cases have been reported.
Khanna 1983 and Wallbridge 1962, classified duplication of the
appendix into three types:
Type A: Partial duplication on single cecum.
Type B : Two completely separated appendices on single cecum.
Type C: Double cecum each bears appendix, (Edward et al.,2001).
• Congenital Appendiceal Diverticula, (Skandalakis et al.,2004).
• Heterotopic Mucosa in the Appendix , (Haque et al.,1996).
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3. Anatomical description
In humans, The vermiform appendix is a small, finger sized
structure, arising from the
and behind the iliocecal valve
The appendix communicates with the caecum with an orifice which
is guarded by a crescent
absence or incompetence of which may account for the presence of fecal
material within the process. It is considered as a continuation of the
caecum arising from its inferior tip. During infancy, more rapid growth of
the right and anterior portions of the caecum causes rot
appendix posterior and medially to its adult
Telford.,1991).
Figure (1): A: Development of the appendix.
stage showing the future appendix below. T
pushed medially by the outgrowth of the right wall of the Caecum. B.
(Decker and Plessis.,1986).
The lumen may be widely patent in early childhood and is often
partially or wholly obliterated in the size from early adulthood later
decades of life. The appendix usually contains numerous patches of
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12
Anatomical description
In humans, The vermiform appendix is a small, finger sized
structure, arising from the posteromedial caecal wall 1.7- 2.5 cm below
and behind the iliocecal valve, (Blakemore et al.,2001).
The appendix communicates with the caecum with an orifice which
guarded by a crescentic mucosal fold "Valvula processus vermiformis",
etence of which may account for the presence of fecal
material within the process. It is considered as a continuation of the
caecum arising from its inferior tip. During infancy, more rapid growth of
the right and anterior portions of the caecum causes rot
appendix posterior and medially to its adult position, (Condon and
Development of the appendix. A. Caecum at an early development
ing the future appendix below. The dotted line shows how the
pushed medially by the outgrowth of the right wall of the Caecum. B.
(Decker and Plessis.,1986).
The lumen may be widely patent in early childhood and is often
partially or wholly obliterated in the size from early adulthood later
cades of life. The appendix usually contains numerous patches of
AnatomyAnatomyAnatomyAnatomy
In humans, The vermiform appendix is a small, finger sized
2.5 cm below
The appendix communicates with the caecum with an orifice which
ic mucosal fold "Valvula processus vermiformis",
etence of which may account for the presence of fecal
material within the process. It is considered as a continuation of the
caecum arising from its inferior tip. During infancy, more rapid growth of
the right and anterior portions of the caecum causes rotation of the
Condon and
Caecum at an early development
he dotted line shows how the appendix is
pushed medially by the outgrowth of the right wall of the Caecum. B. the adult,
The lumen may be widely patent in early childhood and is often
partially or wholly obliterated in the size from early adulthood later
cades of life. The appendix usually contains numerous patches of
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13
lymphoid tissue although these tend to decrease in old age,
(Borley.,2008).
The adjective "vermiform" literally means "wormlike" and reflects
the narrow, elongated shape of the intestinal appendage. The appendix is
typically between two and eight inches long. It is longer in children and
may get atrophy or diminish after midadult life, (Borley.,2008).
The word "caecum" actually means "blind" in Latin, reflecting the
fact that the bottom of the caecum is blind pouch. The anatomical
definition of a vermiform appendix is a narrowed, thickened, lymphoid
rich caecal apex, (Blakemore et al.,2001).
Relations of the Caecum & the appendix:
The location of the appendix is dependent on the positions of the
caecum which usually lies in the right iliac fossa. Relations of the caecum
and appendix are as follows:
• Infront : If the caecum becomes distended, it may come in contact
with the anterior abdominal wall, but as a rule some coils of small
intestine and part of the greater omentum lie between it and the
anterior abdominal wall.
• Behind: it rests on the iliacus & psoas major muscles with femoral
nerve between the two muscles. It may lie also on the external iliac
artery.
• Medially : Coils of small intestine, (Skandalakis et al.,2004).
The relation of the base of the appendix to the caecum is constant
and it is the site of convergence of the three taeniae coli on the ascending
colon and caecum. The anterior caecal taenia is usually distinct and
traceable to the appendix, affording guide to it. The surface marking for
the appendicular base which is the point of on the posteromedial wall of
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the caecum, is at the junction of the lateral and middle thirds of line
joining the right anterior superior iliac spine to t
surface of the abdomen this is called "McBurney's point
(Chummy.,2011).
Figure (2):
The appendix may occupy one of several positions:
− Behind the caecum and the lower part of
(retrocaecal and retrocolic), which is the most common position,
(65.28%).
− Dependent over the pelvic brim (pelvic or descending), in females
in close relation to the right uterine tube and ovary,
− Laying below the caecum,
− In front of the terminal part of the ileum,
it may be in contact with the anterior abdominal wall.
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14
the caecum, is at the junction of the lateral and middle thirds of line
joining the right anterior superior iliac spine to the umbilicus. On the
surface of the abdomen this is called "McBurney's point
The interior of the cecum, (Agur et al.,2009).
The appendix may occupy one of several positions:
Behind the caecum and the lower part of the ascending colon
(retrocaecal and retrocolic), which is the most common position,
Dependent over the pelvic brim (pelvic or descending), in females
in close relation to the right uterine tube and ovary, (31.01%).
Laying below the caecum, (subcaecal), (2.26%).
In front of the terminal part of the ileum, (pre-ileal),
it may be in contact with the anterior abdominal wall.
AnatomyAnatomyAnatomyAnatomy
the caecum, is at the junction of the lateral and middle thirds of line
he umbilicus. On the
surface of the abdomen this is called "McBurney's point” ,
(Agur et al.,2009).
the ascending colon
(retrocaecal and retrocolic), which is the most common position,
Dependent over the pelvic brim (pelvic or descending), in females
(31.01%).
(1%), where
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− Behind the terminal ileum,(post
− -Paracolic, (0.4%).
The appendices specially the retrocaecal
retroperitoneally as far as the kidney
Laparoscopic positions of the appendix:
In one study, a total of 303 patients
appendectomy was performed in 67 patients, 49 had a diagnostic
laparoscopy, 179 underwent a laparoscopic cholecystectomy and eight
had other procedures. The appendix was pelvic in
ileal in (22.1%), retrocaecal in (20.1%)
ileal in (3.0%) patients
Contrary to the common belief the appendix is more often found in
the pelvic rather than the retrocaecal position. There is also considerable
variation in the position of the caecum
Figure (3): Endoscopic appearance of the appendix orifice.
small depression to an obvious lumenal structure
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15
Behind the terminal ileum,(post-ileal), ( 0.5%); or
(0.4%).
The appendices specially the retrocaecal ones may extend
retroperitoneally as far as the kidney, (Guidry and Poole.,1994).
Laparoscopic positions of the appendix:
study, a total of 303 patients were studied. An emergency
ectomy was performed in 67 patients, 49 had a diagnostic
laparoscopy, 179 underwent a laparoscopic cholecystectomy and eight
res. The appendix was pelvic in (51.2%) patients,
retrocaecal in (20.1%) , para-caecal in (3.6%)
patients.
common belief the appendix is more often found in
the pelvic rather than the retrocaecal position. There is also considerable
variation in the position of the caecum, (Irfan et al.,2007).
Endoscopic appearance of the appendix orifice. The orifice varies from a
small depression to an obvious lumenal structure, (Borley.,2008).
AnatomyAnatomyAnatomyAnatomy
ones may extend
.,1994).
e studied. An emergency
ectomy was performed in 67 patients, 49 had a diagnostic
laparoscopy, 179 underwent a laparoscopic cholecystectomy and eight
(51.2%) patients, post-
caecal in (3.6%) and pre-
common belief the appendix is more often found in
the pelvic rather than the retrocaecal position. There is also considerable
The orifice varies from a
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The position of the tip of the appendix
The position of the tip of t
variable and has been linked to the hands of a clock.
1- 11 and 12 O'clock Positions
The appendix passes upwards, and may be to the outer side
[paracolic (11) ] or directly behind the caecum [ retrocolic (12) ].
2- 2 O'clock Positions:
The organ is entirely intraperitoneal and lies behind or infront of the
terminal ileum. If inflamed it may affect this part of the ileum and causes
incomplete obstruction of the small gut
3- 4 O'clock or Pelvic Position:
The appendix hangs over the pelvic brim into the pelvis,
inflamed , it may cause irritation of the r
4- 6 O'clock Position:
The appendix passes down towards the middle of the inguinal
ligament, (Decker and Plessis.,1986).
Figure (4): Graphic illustration of appendiceal
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16
The position of the tip of the appendix:
The position of the tip of the appendix in relation to the
variable and has been linked to the hands of a clock.
11 and 12 O'clock Positions
The appendix passes upwards, and may be to the outer side
[paracolic (11) ] or directly behind the caecum [ retrocolic (12) ].
2 O'clock Positions:
The organ is entirely intraperitoneal and lies behind or infront of the
terminal ileum. If inflamed it may affect this part of the ileum and causes
incomplete obstruction of the small gut.
4 O'clock or Pelvic Position:
The appendix hangs over the pelvic brim into the pelvis,
inflamed , it may cause irritation of the rectum and urinary bladder
6 O'clock Position:
The appendix passes down towards the middle of the inguinal
(Decker and Plessis.,1986).
: Graphic illustration of appendiceal position, (Skandalakis et al.,2004).
AnatomyAnatomyAnatomyAnatomy
he appendix in relation to the caecum is
The appendix passes upwards, and may be to the outer side
[paracolic (11) ] or directly behind the caecum [ retrocolic (12) ].
The organ is entirely intraperitoneal and lies behind or infront of the
terminal ileum. If inflamed it may affect this part of the ileum and causes
The appendix hangs over the pelvic brim into the pelvis, if
ectum and urinary bladder.
The appendix passes down towards the middle of the inguinal
(Skandalakis et al.,2004).
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The appendix is usually connected by a short mesoappendix which is
a prolongation of the left (inferior) layer of ileal mesentery. This fold is
usually triangular, extending almost to the appendicular tip along the
whole tube, enclosing the appendicular artery. If the mesoappendix is too
short, it may be attached to the posterior abdominal wall near the pelvic
brim. The appendix is usually free within its own mesentery, but
sometimes it may lie extra-peritoneally behind the caecum or the
ascending colon or may adhere to the posterior wall of these two
structures, (Anson and MacVay.,2000).
The appendix is involved in the formation of several recesses in
association with the cecum. The superior ileocecal recess (fossa of
Luschka) lies anterior to the terminal ileum. It is formed by a peritoneal
fold, the superior ileocecal or vascular fold which extends from the
mesentery of the terminal ileum, and after crossing the ileum, it attaches
to the lowest part of the colon and cecum. This fold contains the anterior
cecal artery. Similarly, the inferior ileocecal recess lies between the
mesoappendix and a fold of peritoneum referred to as the inferior
ileocecal fold or the bloodless fold of Treves. This fold extends from the
antimesenteric border of the terminal ileum to the base of the appendix or
the anterior surface of the mesoappendix, or to both areas. The fold
contains no sizable blood vessels, (Drake.,2007).
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Figure (5): The attachment of the appendix to the cecum and terminal ileum,
which shows the superior and inferior ileocecal folds and the mesoappendix,
(Drake.,2007).
Blood supply of the appendix
Arterial supply:
The main appendicular artery originates posterior to the terminal
ileum as a branch of the lower division of the iliocolic artery, runs behind
the terminal part of the ileum to enter the mesoappendix a short distance
from the appendicular base. Here it gives off a recurrent branch which
anastomoses at the base of the appendix with a branch of the posterior
caecal artery, (Chumpelick.,2000).
The main appendicular artery approaches the tip of the organ, lying
at first near to and afterwards in the free border of the mesoappendix
however the terminal part of the artery, lies on the wall of the appendix
and may become thrombosed in appendicitis, resulting in distal gangrene
or necrosis, (Condon and Telford.,1991).
In addition to blood from the main appendicular artery, supply
from one or more accessory appendicular arteries may be present with
high frequency of arterial anastomoses, which could serve as alternate