When it comes to appendicitis, many people may think it’s not worth mentioning. It’s something that county hospitals are doing, rural hospitals are doing, and it’s even a disease that can be treated in some private clinics. What else is there to say? In fact, people who do general surgery know that the simplest disease is appendicitis, and the most complicated disease is also appendicitis. The reason I say it is simple is that once the diagnosis is confirmed, the next step is surgery. This surgery, whether on the medical side or the affected side, is considered a minor surgery that can be completed in half an hour. It’s no big deal. It is complicated because of the diagnosis and the treatment. Clinical disputes caused by misdiagnosis and mistreatment, incision not healed for a long time, etc. often occur.
Complexities in the diagnosis of appendicitis.
Abnormal location. The appendix is usually located in the lower right abdomen, attached to the cecum with a free end. However, some people do not grow in these areas, and the appendix can grow in the hepatic flexure of the colon (upper right abdomen) or in the lower left abdomen, which are clinically known as “ectopic appendixes. When pregnancy is combined with appendicitis, the position of the appendix shifts as the uterus grows. One can imagine how difficult it would be to find the appendix and how long or twisted the incision would be if these people had an incision in the regular right lower abdominal appendix.
In other cases, the appendix does grow on the cecum, but the distal part of the appendix is folded back against the wall of the cecum or buried deep behind the peritoneum, and it can be difficult for an inexperienced person to find such an appendix because of the swelling of the local tissues during inflammation. Some people may have a long appendectomy and may be told afterwards, upon asking the doctor, that the appendix was “not found” during the operation.
Abnormal shape. In most cases, the appendix is about 5-8 cm long and 0.5-0.8 cm in diameter; some people are born with a very short appendix, perhaps a small, branching protrusion, and in acute inflammation, it may be difficult to determine whether it is the appendix or a prolapsed bowel. In some people, the appendix is still painful in the right lower abdomen after appendectomy, and when reoperation is performed, it is found that the appendix is still present, indicating that what the surgeon removed during the last operation may not have been the appendix.
Confusion with upper gastrointestinal perforation (gastric perforation or duodenal perforation). This is the most common misdiagnosis. Sometimes appendicitis is misdiagnosed as a GI perforation and sometimes a GI perforation is misdiagnosed as appendicitis. Upper GI perforation is in the upper right abdomen and appendicitis is in the lower right abdomen, so why is it easy to confuse them? The reason is that after the perforation of the upper gastrointestinal tract (in this case, a small perforation), digestive juices flow along the right paracolic groove (i.e., the lateral groove of the ascending colon) into the right lower abdomen, causing a limited peritonitis in the right lower abdomen, which can show clinical manifestations very similar to those of appendicitis. If one is not careful, it can be easily confused.
Confusion with diseases of the terminal small intestine (ileum). The terminal ileum is also a good site for disease, and diverticula, hemangiomas, or other lesions are likely to occur in this segment of the small intestine. I was once invited to perform an appendectomy on a patient. I viewed the patient prior to surgery and felt that the appendicitis presentation was not quite definitive and suggested a further examination. The inviter and the family told me that there was frequent right lower abdominal pain, many tests were done, no problem was detected, chronic appendicitis was highly suspected, and appendectomy was requested.
Even if it was not appendicitis, it was not a big problem, etc. During the operation, it was found that there was no major problem with the appendix, so the terminal ileum was examined and a hemangioma was found. Then, we asked if there was any history of black stool before, and the answer was that we had done gastroscopy, colonoscopy, CT, etc. for black stool, and no problem was found. The problem of black stool and “appendicitis” was solved at the same time.
Confusion with obstetrical and gynecological diseases. In some patients, the right-sided ovarian cyst is twisted, or the right-sided tubal pregnancy (ectopic pregnancy) is ruptured, or the right-sided corpus luteum is ruptured, all of which are located in the lower right abdomen and can be easily confused with appendicitis.
Confusion with right-sided urinary calculi. One patient was diagnosed with “acute appendicitis” and was told to undergo surgery. The family agreed to the surgery, but felt that the doctor was too young and worried whether the surgery would be done well. So, an older doctor was quietly called in, and after some consideration, he had the patient undergo an ultrasound and urinalysis, which confirmed the diagnosis of right ureteral calculus. The patient was saved from unnecessary surgery. Because the area against the lower right abdomen is also a stricture in the right ureter, the stone tends to get stuck here and cause pain.
Confusion with mesenteric lymphadenitis. This condition is most often seen in pediatric patients. In children, the lymphatic system is not fully developed, the tonsils are usually larger than in adults, and the mesenteric lymph nodes in the right lower abdomen (terminal ileum) are more developed than in adults. When an upper respiratory tract infection occurs, in addition to swollen tonsils, the mesenteric lymph nodes in the terminal ileum are also easily involved and inflamed. Of course, the appendix, which is rich in lymphatic tissue, is sometimes inflamed at the same time. In addition, children are often unable to express their condition well or are uncooperative, which makes diagnosis difficult.
Adding to the complexity of appendicitis treatment.
Appendicitis is usually told to require surgery. Families usually accept the doctor’s recommendation because they believe that appendectomy is a minor procedure and that without the appendix there is no appendicitis to worry about. Most appendectomies are quite simple, but sometimes they can be quite unexpected.
First, some appendectomies can take several hours. Because open appendectomies usually have a small incision, the surgeon may have difficulty finding the appendix, especially in obese patients, as mentioned earlier, where the appendix cannot be found. Sometimes difficulties in handling are encountered, as in some cases where the inflammation of the appendix is so severe that it can spread to the cecum, making the handling of the appendiceal root difficult, or even developing an intestinal (fecal) fistula after surgery.
Secondly, there is the problem of incision. The incision for an open appendectomy is usually a few cm. If it is found intraoperatively to be another problem, the incision may be extended, and this incision may be longer or more irregular. This is often scandalized by the patient or family as well. However, if the disease is properly treated and there are no other problems, the incision is ultimately acceptable. There is nothing more difficult for patients to accept than a long-term incision that does not heal. It is not uncommon for patients to have incisions that do not heal for two or three months, or even seven or eight months. Common explanations are fat liquefaction of the incision or draining reaction.
There is also the problem of intestinal obstruction after appendectomy. This is also a more frequent occurrence. It may be related to situations such as too much preoperative inflammation, a severe postoperative intra-abdominal inflammatory response, extensive adhesions, or excessive disturbance of the intestinal canal during the search for the appendix.
Then there is the problem of misdiagnosis of the diagnosis and treatment. For example, confusion with upper gastrointestinal perforation and ectopic pregnancy. In fact, misdiagnosis is not terrible, as long as the diagnosis is corrected intraoperatively and the correct treatment is made, the outcome is still good. For example, if the preoperative diagnosis is appendicitis but the intraoperative finding is upper gastrointestinal perforation, the surgery does not remove the appendix but repairs the perforation, and the outcome is still satisfactory. However, the problem is that the patient with upper gastrointestinal tract perforation only has his appendix removed, and the consequences are hard to imagine. Therefore, mistreatment is to be avoided at all costs.
Is it possible to avoid the above? The answer is yes, and that is laparoscopic appendectomy. Some doctors and patients may think that the incision for appendectomy is not big, and several holes have to be made in the abdomen during laparoscopy (usually three holes, one 5mm at the pubic hair margin in the pubic area, one 10mm at the navel, and another 10mm in the left lower abdomen), and connecting these holes is about the same length as open surgery, so they feel that laparoscopic appendectomy has no advantage. In fact, this is a misconception.
The advantages of laparoscopic appendectomy are not simply in the incision.
1. In laparoscopy, the whole abdominal cavity can be explored. Up to the liver and down to the pelvis, what a long incision would be required if it were replaced by open surgery! Therefore, no matter where the lesion is, laparoscopy can be seen clearly and can avoid misdiagnosis and mistreatment.
2, the pain after open appendectomy, a large part of it originates from the incision. Because the incision in appendicitis, the superficial part is cut with a scalpel, and the deep abdominal wall muscle tissue is bluntly pulled apart, which is required by the surgical specifications. The blunt trauma is much greater than the sharp, so the postoperative period is painful. Laparoscopic surgery is a perforated hole, and almost no one complains of incisional pain after surgery. Therefore, patients after laparoscopic appendectomy will have an easy time getting out of bed the next day; patients after open surgery must be gritting their teeth to get out of bed the next day.
3, open surgery due to incision restrictions, usually textbooks are clearly written, appendectomy end can not be abdominal flushing, because the saline used for flushing is likely to be unable to completely suck out, which will cause the spread of inflammation. Therefore, the inflammatory exudate caused by appendicitis after open surgery is bound to have more or less part of it remaining in the abdominal cavity, which is one of the reasons for the high incidence of intestinal adhesions, intestinal obstruction and abdominal abscesses after appendectomy. During laparoscopic surgery, sufficient flushing can be performed, and there is no need to worry about the residual flushing fluid caused by the visual field problem at all.
4. Incisional infection after open appendectomy is a common enough “complication”, especially in patients who are obese or have diabetes mellitus. Some people may not recover for a long time. The reason for this is that the appendectomy incision should not be too large, and it is not easy to explain to the patient if it is too large. As a result, contamination of the incision is inevitable as the surgeon’s hands or instruments go in and out of the abdominal cavity.
In laparoscopic surgery, the surgeon’s hand is outside the patient’s abdominal cavity, and only the instruments enter the abdominal cavity through the puncture sheath, so that the puncture hole is well protected. After laparoscopic appendectomy, there are few incisional infections. Even if there is infection, the degree of infection is much less than that of open surgery, and recovery is much easier.
5, after open appendectomy, the incision site usually has a hard knot, there is an obvious incision scar; laparoscopic surgery, the incision scar is much lighter, plus the site is hidden, even can not be seen. Therefore, it is popular among young women.
6, laparoscopic appendectomy patients are routinely discharged three days after surgery, while open appendectomy patients are rarely discharged three days after surgery.
7. Economically speaking, the total cost of laparoscopic appendectomy is not more than that of open surgery because of the short hospital stay, less postoperative medication and fewer postoperative complications.
Therefore, for appendicitis surgery, laparoscopic surgery must be chosen whenever possible.