McBurney Incision Research Articles

Open to laparoscopic conversion in hemoperitoneum of unknown origin.

Demonstrating the potential, in spite of the current trend, of closing an open emergency surgical procedure and to convert it to a minimally invasive approach. Case report of an open converted to a laparoscopic approach in an emergency setting for hemoperitoneum of unknown origin. A 28-year-old-female patient was transported to the operating room for suspected acute appendicitis. Through McBurney's incision, hemoperitoneum was found. She was hemodynamically stable. The open incision was closed and a laparoscopic approach established. The diagnosis was a ruptured right ectopic pregnancy with mild hemoperitoneum. After a laparoscopic salpingectomy, her recovery was uneventful. For selected cases, the conversion of an open procedure to a laparoscopic approach offers a real benefit for the patient, avoiding a large laparotomy and its associated morbidity.

Acute appendicectomy for appendicular mass: a study of 87 patients.

To study the feasibility of acute appendicectomy in patients with an appendicular mass. Department of Surgery, Bankura Sammalani Medical College (BSMCH), Bankura, West Bengal, India. From January 1998 to May 2001. 87 patients were diagnosed and operated for appendix mass within 24 h of admission. None of the patients had any associated complications. A McBurney's incision with Rutherford-Morrison extension was made in most patients. 48 patients presented with a classical appendix mass. 25 patients (28.7%) had classical features of appendix abscess, and in 14 (16.1%) a loculated collection of pus (10 to 50 ml) was found. Operative time ranged from 45 to 90 min (mean 65). Pathologic evidence of appendicitis was present in all patients. 71 patients were discharged on the seventh postoperative day. 15 patients developed minor wound infection. One patient developed band obstruction, which subsided spontaneously on conservative treatment. Rest of the patients are doing well. Low morbidity, reduced hospital stay, low cost and patient compliance favour operative management of appendicular mass by experienced surgeons thus obviating the old practice of conservative treatment followed by interval appendicectomy.

Scarless surgery: a warning for shortcut history-taking

The examination of the abdomen from the end of the bed provides vital information to the medical student and the clinician alike. It can give a picture of the problems inside from its size, shape and sometimes even its colour before palpation. Since the first successful laparotomy in the early 1800s by Ephraim McDowell,1 the midline scar seen from the end of the bed examination of the abdomen has been a good indicator to the clinician that the patient has had a previous surgical procedure. The tell-tale signs of exact surgical procedures were apparent from the location of a scar such as the Kocher's incision for an open cholecystectomy or McBurney's incision for an open appendicectomy. As surgical innovation and technology advance,the skills involved in deciphering a patient's previous operations are going back to first principles. The first laparoscopic cholecystectomy dates back to 1985 over 100 years after the first open procedure.2 As we have just begun to be familiar with the locations of laparoscopic scars for various procedures, single incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) for common procedures have now come into play. The first NOTES procedure demonstrated that abdominal surgical interventions can be carried without abdominal wall incisions.3 Shortly after that the first transvaginal cholecystectomy was reported in 2007 by Zorron et al.4 Hence, the common scars once seen are now disappearing. The goal, especially for medical students and junior surgical trainees, is to understand the presentation of surgical disease.5 Medical students easily get distracted with the primary skill they are required to master is the physical examination. Without effective history-taking it is not possible to elicit the necessary signs to make differential diagnoses. Learning about patients as clinicians still comes from the history that we take which captures not only the physical problems but also sometimes the underlying psychological concerns. We naturally learn through story-telling when we present our patients to others or as we live our own lives. The history-taking and presenting forms an integral part of medicine. Data processing to make a diagnosis comes from taking the story and the history of the story. Our observational skills go hand in hand with the stories that form part of our life cycle. Hence, clinical reasoning can be challenging without a proper history. The history-taking is not only about making a diagnosis but also being able to communicate and build rapport with your patient. The multidisciplinary approach to patient care relies heavily on the history elicited by different health professionals and the communication between them is all about ‘story-telling’. Invariably, listening to the patient's story usually reveals the answer. The examination and investigation part of our management is guided by the story. History teaches us many things, once bitten with brief history-taking when examining a patient that has undergone a SILS or NOTES procedure the individual will not shy away from taking a full history next time. A change to medical history-taking is yet to come, till a chip-and-pin approach to medical notes becomes commonplace, clinicians have to rely on the patient's memory to recall parts of their anatomy removed. The evolution of operative surgery means the telling tales of the long lines of surgical incisions will be no more. Hunting the facts of human activity can lead to profound understanding.6 The approach to patient management will continue for a while yet to be in the traditional three-step approach of history, examination and diagnostic tests.7 Despite the sophistication and innovation of technology as scarless surgery and robotic surgical procedures become the norm in the future, taking the patient's history has no short cuts. The emphasis from clinical teachers should continue to be history before examination.

Appendiceal Mucinous Cystadenocarcinoma with Implantation Metastasis to the Incision Scar and Cutaneous Fistula

Mucinous cystadenocarcinoma of the appendix with invasion of the anterior abdominal wall and cutaneous fistula development is a rare condition. To the best of the authors' knowledge, five such cases have been reported in the medical literature. The patient was a 68-year-old man who presented with a mass growing through the incisional scar and a skin fistula with mucinous discharge 1 year after appendectomy via McBurney's incision. Carcinoembroyonic antigen and carbohydrate antigen 19-9 concentration was elevated. Abdominal computed tomography scan revealed a mass in the cecum with involvement of the abdominal wall. Right hemicolectomy with en bloc abdominal wall implant and skin fistula resection with clear margins was performed. The patient received intraperitoneal intra- and postoperative chemotherapy. Gross examination of the specimen showed a mass emerging from the remnant stump of the appendix. The patient showed no relapse 1 year after surgery. Clinical, paraclinical features, and treatment options are discussed with review of the literature.

Isolated abdominal wound recurrence after lymph-node dissection for appendiceal adenocarcinoma

A 47-year-old man with acute abdominal pain in the right lower quadrant underwent an appendectomy via McBurney's incision. Postoperative histology revealed a moderately differentiated adenocarcinoma in the appendix that invaded the submucosa along with lymphatic involvement. Forty-three days later, an ileocecal resection with radical lymph node dissection was performed through a midline incision. Three of the 30 resected lymph nodes were found to have adenocarcinoma metastasis. Five years later, an isolated abdominal wall recurrence occurred within the wound scar of the midline incision. A complete excision of the tumor and the invaded portion of the ileum was performed. To date, the patient has been well, with no evidence of recurrence for 5 years since the resection. The mechanism of abdominal wound recurrence is considered the leakage of carcinoma cells from transected lymph vessels during lymph node dissection, followed by the implantation of these cells into the abdominal wound.

Bowel Obstruction Following Appendectomy

Appendicitis is a common problem that is typically treated with an appendectomy. Following abdominal surgery, adhesions may form and may cause a subsequent small bowel obstruction (SBO). The purpose of our study was to determine the rate of post-appendectomy SBO in an adult population, and to observe any difference in SBO rates between open versus laparoscopic appendectomies. All patients who underwent an appendectomy at an adult hospital in the Calgary Health Region between 1999 and 2002 were identified by using the administrative discharge database. Pathology and operative technique (laparoscopic, McBurney incision, midline laparotomy) were reviewed. Using those regional health numbers, any further admissions with a diagnostic code for bowel obstruction were identified. Medical charts (n = 1777) were reviewed to confirm the rate of post-appendectomy SBO. A logistic regression was performed to identify risk factors of post-appendectomy SBO and expressed as odds ratios (95% confidence interval). The overall SBO rate was 2.8% over an average 4.1-year follow-up period. The risk factors for developing SBO following appendectomy for appendicitis included, perforated appendicitis (odds ratio [OR] = 3.1, 95% confidence interval [CI]: 1.5-6.6), and midline incisions (OR = 5.4, 95% CI: 2.8-10.4). Those with pathology of cancer or chronic appendicitis conferred the greatest overall risk of SBO (OR = 7.4, 95% CI: 2.7-20.3). The rate of SBO following appendectomy in adults was 2.8%, or 0.0069 cases per person-year. The greatest risk factors for developing SBO were midline incision and nonappendicitis pathology. There is no statistically significant difference in SBO rates following laparoscopic appendectomy compared with open approaches.

Laparoskopische Appendektomie

Since the introduction of laparoscopic appendectomy by Semm in 1983, the role of this minimally invasive surgical technique has been the focus of controversial discussion. Meta-analyses have identified its advantages as having significantly lower wound infection rates, less postoperative pain and earlier resumption of normal everyday activities. The disadvantages are higher rates of intra-abdominal abscesses, longer operating times and higher inpatient treatment costs. However, some of the advantages identified by meta-analyses have been called into question by the results obtained from research into aspects of care. These discrepancies are attributable to the different surgeons involved in the various studies. The results are greatly influenced by the qualifications and experience of the surgeons. Therefore conventional appendectomy using a right lower lateral McBurney incision should continue to be the gold standard. Surgeons who have extensive experience in the field of laparoscopic surgery can achieve better results with minimally invasive appendectomy than with open surgery. This also holds true for specific situations such as complicated appendicitis and for morbidly obese patients. However, the operating costs incurred for laparoscopic appendectomy are higher because it has been shown that removal of the appendix with a linear stapler is the most reliable method.

Laparoscopic Restorative Proctocolectomy with Small McBurney Incision for Ileal Pouch Construction without Protective Ileostomy

Restorative proctocolectomy is a standard treatment for colorectal diseases over decades. At present, this technique is frequently performed via minimal invasive approach. Most reported techniques of laparoscopic restorative proctocolectomy involved a Pfannenstiel incision for the major part of the operation to be performed openly; a double-stapled pouch anal anastomosis technique and protective ileostomy. This study was designed to demonstrate the modification of this technique. This was a retrospective study of seven patients (4 had ulcerative colitis and 3 had familial adenomatous polyposis) who underwent laparoscopic restorative proctocolectomy at King Chulalongkorn Memorial Hospital between September 2004 and February 2007. The details of the procedure are shown in the video. The techniques involve the following: full mobilization of entire colon and rectum using medial to lateral approach, division of submesenteric arcades for ileal pouch elongation with preservation of three to four inner most arcades of distal ileum segment and preservation of both superior mesenteric and ileocolic trunk, ileal pouch construction via a small (3-4 cm) McBurney incision, transanal mucosectomy with removal of the entire rectum and colon transanally, and handsewn ileal pouch-anal anastomosis. None of the patients underwent protective ileostomy. Mean surgical time was 360 (270-510) minutes, and median blood loss was 230 (100-400) ml. There were neither conversions nor intraoperative surgical complications. However, one patient developed small-bowel obstruction, which was successfully treated by laparoscopic approach. Anastomotic leakage was not found in this series. All patients have good control of their bowel movement as well as a very good cosmetic result during the follow-up period. Laparoscopic restorative proctocolectomy with small McBurney incision for ileal pouch construction, without protective ileostomy, is technically feasible and safe.

Rectus Abdominis Muscle Resection for Abdominal Wall Recurrence of Mucinous Adenocarcinoma or Peritoneal Mesothelioma

Diagnostic technologies which penetrate the abdominal wall in an attempt to definitively diagnose an intraabdominal malignancy by biopsy can contaminate the abdominal wall by cancerous cells. With follow-up these entrapped cancer cells may progress as an abdominal wall recurrence of the disease process. Frequently, laparoscopy is the definitive diagnostic study which results in the abdominal wall cancer progression. We examined recurrences within the abdominal wall and attempted to establish a surgical approach to this problem which would maximize a functional result and minimize the incidence of disease persistence within the abdominal wall. Eighteen patients with abdominal wall recurrence were studied. Laparoscopy port sites resulted in the abdominal wall disease in eight patients, in four the recurrence was at a previous ostomy site, in three it was in a Pfannenstiel incision and in three it was in a McBurney incision site. All of these patients were treated by total resection of the rectus abdominis muscle. This resulted in a complete removal of visible disease that was dissecting along the fibers of the rectus abdominis muscle. No patients required reoperation for abdominal wall hernia and mesh repair was not used in any of these patients. Disease control within the abdominal wall has been excellent.

Laparoscopy-Assisted Ureter Interposition by Ileum

To report our experience with the laparoscopic approach to managing ileal ureter substitution for extensive ureteral stenosis. Two patients, one man and one woman, ages 38 and 51 years, respectively, underwent laparoscopic ileal substitution between March 2004 and December 2005 because of extensive ureteral stenosis after stone disease management. A three-port technique was used. The ileal segment was managed extracorporeally through a McBurney incision. Pyeloileal or ileoureteral anastomosis was performed intracorporeally. Follow-up included clinical evaluation, nuclear renography, intravenous urography. and serum chemistry analysis. There were no complications, and there was minimal blood loss. Mean operative time was 195 minutes (range 180-210 min). Both patients remain without any symptoms or complaints at a median of 18.5 months follow-up (range 8-29 months). Postoperative pyelography verified adequate excretion from the renal unit. Nuclear renography showed no evidence of loss of renal function. No evident variations of preoperative and postoperative serum chemistry values were noted. None of the patients had any complaint or symptoms of urinary-tract infection or urolithiasis. The laparoscopic approach appears to be a safe and effective alternative to open surgery for ileal ureter substitution. Extracorporeal management of the ileal segment would appear advantageous because it reduces operative time and morbidity.

Teníase: uma causa rara de apendicite aguda

Acute appendicitis is the most common surgical condition of acute abdomen. Approximately 7 percent of the population will have appendicitis during their lifetime, with the peak incidence occurring between 10 through 30 years-old. Obstruction of the appendix lumen with subsequent bacterial infection initiates the pathophysiological sequence of acute appendicitis. Obstruction may have multiple causes, including fecalith, lymphoid hyperplasia (related to viral illnesses, including upper respiratory infection, mononucleosis, and gastroenteritis), foreign bodies, carcinoid tumor, and parasites. In Asia, Africa and Latin America, Enterobius vermicularis has been reported as the main parasite that causes appendix obstruction. Rarely, Taenia sp., has been pointed as a cause of parasitic appendicitis. We reported a 30 years-old patient clinically diagnosed with acute appendicitis. The appendectomy was performed through a McBurney incision. The patient's convalescence was uneventful, and he was discharged from hospital 48 hours after operation. Histological examination of the appendix showed acute appendicitis, and it was found a parasite (Taenia sp.) lying inside of the appendix lumen at a transverse section. He has received 10 mg/Kg weight of praziquantel for taeniasis treatment.

Incisional Hernia after McBurney Incision: Retrospective Case‐control Study of Risk Factors and Surgical Treatment

Few reports have dealt with incisional hernias originating at a McBurney incision after appendectomy. The purpose of the present study was to identify risk factors for development of incisional hernia at a McBurney incision, and to describe our experience with the treatment of this kind of hernia. We reviewed 4,862 files of patients older than 15 years of age operated on for acute appendicitis. Some 4,523 (93%) of that group were operated on through a McBurney incision, and 34 (0.7%) of them developed incisional hernia. To identify risk factors for development of incisional hernia we used binary logistic regression analysis. The following risk factors were identified: female gender (p = 0.011), diabetes (p < 0.0001), peritonitis, abscess or phlegmon as the cause of the first operation (p = 0.009), wound infection (p = 0.034), seroma (p = 0.023), the use of catgut to suture the aponeurosis (p < 0.0001), and interrupted suture to the aponeurotic layer (p = 0.046). Twenty-two hernias were repaired with Mayo-herniorrhaphy and 12 with a subaponeurotic polypropylene prosthesis. Recurrences developed in 3 patients, none in hernias repaired with prosthesis. The risk of incisional hernia after a McBurney incision for acute appendicitis was very low; we recommend the repair of this uncommon incisional hernia with current standard tension-free prosthetic techniques.

Current clinical features of acute appendicitis in adult in Yaounde, Cameroon

Our study on acute appendicitis in adults aimed to report current data in Yaounde, Cameroon. This retrospective study included 323 patients, with 185 men against 138 women (sex ratio: 1.37). Mean age was 28.3 years old. Incidence was of 4.6%. Symptoms appeared within a delay of 3 to 4 days and consisted of the triad: abdominal pain (97.5%), vomiting (44%) and anorexia (39.9%). 99.7% of the patients presented with hyperthermia whereas defence on palpation in the right iliac fossa was noted in 307 patients. Rectal examination was evocative in 92.7% of the cases. Hypemeutrophilia was found in 84.9% of the patients. Plain abdominal radiography (PAR) orientated the diagnosis in 74.3% of cases; echography was very useful in abscesses (6,5%). 96.7% of the patients underwent surgery within an average time of 48 hours. McBurney incision was performed in 232 cases. Appendice in the inner latero caecal position was predominant in 243 cases. In seven cases (2.2%), appendice was normal; 2 Meckel's diverticula were discovered (0.6%). We carried out 309 anterograde appendectomies, 317 irvaginations of the appendicular root and 14 epiplooplasties. 302 histological exams were performed; catarrhal appendicitis were ranking first: 167 cases. Morbidity reached 14.2% dominated by sepsis (71.7%). The mortality rate was 0.6%. A better diagnostic approach together with a better sensitisation of the population may shorten surgical delays inducing a decrease of morbidity of acute appendicitis in Cameroon.

Incisional Hernia after McBurney Incision: Retrospective Case‐control Study of Risk Factors and Surgical Treatment

Incisional Hernia after McBurney Incision: Retrospective Case‐control Study of Risk Factors and Surgical Treatment

Comparison of postoperative effects of McBurney incision and cosmetological incision in appendectomy

目的 对阑尾切除术美容切口与麦氏切口的术后观察与护理进行比较分析.方法 将接受阑尾切除术的患者按手术切口的选择分成2组:对照组(MC组:86例)为进行传统的经麦氏口阑尾切除术的患者;实验组(MR组:76例)为进行经美容切口(改良腹直肌外缘切口)的阑尾切除术的患者.对2组患者术后切口愈合情况、使用止痛剂的次数、下床活动时间、肛门排气时间进行比较分析,并通过单盲法的问卷形式比较2组患者对其切口的满意程度.结果 2组患者的切口愈合情况差别无显著性意义(P＞0.05),MR组患者术后使用止痛剂的次数少于MC组、下床活动时间及肛门排气时间早于MC组,差别有非常显著性意义(P＜0.01),问卷结果差别有显著性意义(P＜0.01).结论 阑尾切除术采用美容的改良式腹直肌外缘切口具有美观、经济、术后恢复快、患者满意,并且为临床护理带来了诸多便利。

The analgesic efficacy of continuous elastomeric pump ropivacaine wound instillation after appendectomy

Study Objective To evaluate the analgesic efficacy and safety of ropivacaine 0.2% when administered continuously via elastomeric pump after appendectomy. Design Prospective, randomized, double-blinded study. Setting Surgical ward of a university hospital. Patients 96 ASA physical status I and II patients of at least 14 years of age, undergoing appendectomy through a McBurney incision. Interventions Patients were randomly assigned into two groups: 500 mg of ropivacaine in 48 hours (10 mL of 0.2% ropivacaine 20 mg, starter dose plus 5 mL/h continuous wound infusion via elastomeric pump device; n = 48) in the experimental group and 250 mL of normal saline, as placebo, in the control group. Measurements Postappendectomy pain, measured either with a simple verbal scale or with a visual analog scale, parenteral analgesic consumption, and global satisfaction were all measured. Main Results A reduction in postoperative pain was observed in the ropivacaine group. Degree of pain, with a simple verbal scale measurement of severe and unbearable, was significantly lower in the ropivacaine group than in the normal saline group from time 0 to 24 hours at rest and from time 0 to 36 hours on coughing. A significant lower pain intensity (visual analog scale) was found in the ropivacaine group both at rest and on coughing, beginning at three hours and continuing to 36 hours postoperatively. The mean number of rescue analgesic doses was significantly lower in the ropivacaine group. There were no statistically significant differences in the frequency of adverse events between the two groups. Conclusions Wound instillation with ropivacaine 0.2% is a useful, practical, and safe method for management of postoperative pain after appendectomy.

Laparoscopic versus Open Appendectomy in Children: A Retrospective Comparative Study of 2,332 Cases

The laparoscopic treatment of paediatric appendicitis remains controversial, especially in the presence of complications. This study evaluated the outcomes of open appendectomy (OA) and laparoscopic appendectomy (LA) by analysing the data from a multicentre study. The authors retrospectively reviewed a series of 2,332 appendectomies (1,506 LA and 826 OA) performed in children and adolescents (median age 8 years) in 9 different centres of paediatric surgery. For the patients operated using laparoscopy, an IN procedure was employed in 921 (61.2%), an OUT procedure in 571 (37.9%) and a MIXED procedure in 14 (0.9%). In the open surgery, a McBurney incision was adopted in 795 patients (96.4%). Median duration of surgery was 40 minutes for LA and 45 minutes for OA. Median hospital stay was 3 days (LA) and 4.3 days (OA) in case of simple appendicitis and 5.2 days (LA) and 8.3 days (OA) in case of peritonitis. Complications were recorded in 124 LA cases (8.2%) and 65 OA cases (7.9%). The conversion rate in laparoscopy was only 1.6% (25 cases). The statistical analysis was performed using the Mann-Whitney test, and the main significant difference that emerged was the length of hospital stay, which was in favour of laparoscopy compared with open surgery (P < 0.0001). We conclude that in clinical settings where laparoscopic surgical expertise and equipment are available and affordable, LA seems to be an effective and safe alternative to OA. Three out 9 centres participating in our survey perform LA in all patients with a suspicion of appendicitis. Our study shows that laparoscopy significantly reduces hospital stay in case of appendicitis and peritonitis and presents an extremely low conversion rate (1.6%) to open surgery. Laparoscopic transumbilical appendectomy (37.9%) in our series seems to be a simple option, even for less-skilled laparoscopic surgeons.

Omental infarction—an unrecognized cause of acute abdomen

A 6-year-old boy was admitted to hospital complaining of periumbilical pain of 2 days duration. Pain increased with breathing or coughing and was associated with low grade fever. There was no history of vomiting. The past medical history was unremarkable. The patient weighed 23 kilograms and his oral temperature was 37.2 0 C. The right side of abdomen was tender especially in right lumbar and right iliac region. Laboratory studies revealed leukocyte count of 11,000/cu.mm, predominantly polymorphs (78%). Other routine investigations were normal. The child was initially treated with intravenous fluids and parenteral antibiotics. Abdominal ultrasound showed little free fluid in the right iliac region, and distended bowel loops . The appendix was not visualized. With a presumptive diagnosis of appendicitis. the child underwent a diagnostic laparoscopy . The bowel loops were adhered to the anterior abdominal wall. On separation, omental infarct of size 3 x 4 x 6 cms was seen. There were no gangrenous changes seen. This was left alone and appendectomy was done. Post operative period was uneventful and the patient was discharged on D-3 of surgery. Histology of the appendix showed a normal vermiform appendix. Omental infarction is a rarely considered diagnosis for acute abdomen in children. Because of its low incidence and lack of awareness among clinicians, a pre-operative diagnosis of omental infarction is rarely made. The etiology and pathogenesis of this disorder is not known. However, abnormal coagulation profile, autoimmune disorder, trauma, obesity, congenital vascular anomalies with low perfusion and extension from another inflammatory focus have been suggested. 1 In such patients, a mass is usually located in the right upper quadrant of the abdomen. 2 Males are affected twice as often as females. Symptoms may consist of sudden onset of acute abdominal pain, low grade fever and occasional vomiting. Right side omentum is more often affected than the left side. 3 Surgical resection usually results in immediate resolution of symptoms with little or no morbidity. 4 The standard McBurney incision used for

Acute Appendicitis-like Symptoms as Initial Presentation of Ovarian Vein Thrombosis

Postpartum ovarian vein thrombosis is a rare condition, with an incidence rate being 1/600 deliveries. It most often arises in the right ovarian vein. A 33-year-old patient who had had normal vaginal delivery presented with fever, pain in the right iliac fossa, and leukocytosis on the sixth day after delivery. An antibiotic course was instituted but 3 days later symptoms reappeared. Diagnosis of acute appendicitis was made. At surgery through a McBurney incision, a woody tumoration consistent with ovarian vein thrombosis was found. Anticoagulation therapy with heparin and antibiotics were instituted. Phlebography and color Doppler sonography confirmed the presence of thrombosis of both the common femoral iliac and inferior vena cava. Fribrolysis with urokinase was performed. The patient has remained stable and symptom-free over a 4-year follow-up. Ovarian vein thrombosis typically presents with symptoms suggestive of acute appendicitis, as was the case in our patient. Color Doppler sonography is the favored diagnostic procedure, with CT being a supplementary tool. Surgery is not necessary and treatment consists of anticoagulants and antibiotics. Even though postpartum ovarian vein thrombosis is rare, early recognition of the condition is of paramount importance to institute the adequate treatment and avoid potential serious sequelae.

Les diverticulites du côlon droit

Diverticulitis involving the right colon is uncommon in the Occident ; only one case for every 300 cases of appendicitis occurs in Western countries compared to a ratio of 1/40-1/180 in Asia. The preferential localization of diverticula in the right colon among Asiatics is probably due to genetic factors. In Asia as in the West, a right colon diverticulum is more likely to cause hemorrhage than diverticulitis. The peak age of symptoms is 40-45 years and the sex ratio is 1:1. The patient most commonly presents with symptoms suggestive of acute appendicitis, acute localized peritonitis, or, more rarely, a psoas abscess. Clinical exam reveals an inflammatory mass in the right lower quadrant in 30 % of cases ; diffuse peritonitis, large abscesses, and fistulae are rare. Helical CT scan is the best tool for extablishing the diagnosis and also helps to rule out other possible etiologies in the differential diagnosis––particularly a perforated right colon cancer. In noncomplicated cases with convincing evidence for the diagnosis by CT scan, a conservative (non-surgical) treatment with antibiotics is possible ; a later stage colonoscopy will rule out other colonic lesions. More commonly, the correct diagnosis is only made after embarking on an appendectomy via a McBurney incision ; the surgical strategy thereafter depends on the level of suspicion regarding the diagnosis and the extent and complexity of the diverticulitis. Therapeutic options may be conservative (appendectomy), limited (diverticulectomy, or extensive (ileocecal resection or right hemicolectomy). For complicated disease (abscess, localized perforation), an aggressive surgical approach is warranted. Surgical strategies need to be validated, particularly in the light of the increasing use of the laparascopic approach for suspected appendicitis.