dr. Mochamad Aleq Sander, M.Kes., Sp.B.

, FINACS
Sertifikasi dosen: 12107102411578
Bagian SMF Ilmu Bedah – RS UMM
Fakultas Kedokteran – Universitas Muhammadiyah Malang
 APPENDICITIS AKUT

 Definisi  Inflamasi akut apendiks vermiformis

 Di negara Barat  7% populasi

 Insidens tertinggi  dekade II - III

 Patologi:

- Obstruksi o/ fekolit, parasit, benda asing, tumor

- Hiperplasia limfoid

 Klinis  nyeri RLQ, distensi abd, nausea-vomiting,

febris, peritonitis
Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B
 ANATOMI
 Berpangkal dari sekum
 Organ berbentuk tabung
 Panjang  2,5 - 25 cm ; rata2  6-9 cm
 Posisi ante/retrocecal, retroileal,
pelvic, ileocecal
Lokasi  pertemuan 3 tinea coli

Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B

ALIRAN DARAH
APENDIKS

PERSYARAFAN APENDIKS

Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B

 FISIOLOGI

 Organ Imunologi  IgA  GALT

 Arah & posisi  sgt bervariasi 
keluhan pasien
 Lapisan  = usus lain

Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B

PATOFISIOLOG
I

Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B

 Initiation of inflammation
possibly by faecolith, or enlarged lymphnodes, or
adhesion obstruction
Poorly localised colicky
central abdominal pain
(visceral pain)
Acute inflammation of mucosa

Continuous central abdominal pain

Extension of inflammation across often associated with nausea &
appendiceal wall
vomiting (due to autonomic
stimulation)

Involvement of serosa by
inflammation
 Localization of symptoms & signs as
Spread of peritonitis to adjacent
parietal peritoneum becomes involved
structures (depends on the (somatic innervation): tenderness,
position of appendix) → local rebound tenderness, muscle rigidity, in
peritonitis the right iliac fossa.
 Moderate fever, facial flush & tachycardia
 Leucocytosis, mainly neutrophils
Gangrene of the appendix wall

PERFORATION
Tenderness extends to whole
abdomen with increasing
Attempts at walling off perforation by rigidity and more pronounced
omentum & adjacent bowel systemic features of sepsis:
fever, dehydration, organ
dysfunctions
Inadequate containment leading to spreading
peritonitis

Peri-appendicular Formation of appendicular mass

Intense & extensive walling off with gradual recovery
reaction phlegmone

Peri-appendicular abscess Fluctuant appendicular mass, &

intermittent fever

Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B

GEJALA KLINIS

 Mula  nyeri ulu hati, anoreksia, nausea, vomiting

 Nyeri kemudian berpindah ke abdomen kanan bawah
(RLQ)  Ligart’s sign
 Makin lama nyeri makin ↑ (terlokalisir)  bertambah
nyeri pada pergerakan, berjalan, atau batuk

Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B

 PEMERIKSAAN FISIK

 Suhu tubuh sedikit ↑ /subfebris (bila tanpa perforasi)

 Peristalsis normal / sedikit ↓

 RLQ  nyeri tekan (+), nyeri lepas (+)

 Peritonitis:

1. Lokal  NT (+) RLQ, defans muscular (+) RLQ

2. Difus  NT (+) seluruh abd, DM (+)

 DRE/RT  nyeri tekan jam 10-11

bila nyeri seluruh lingkaran  peritonitis

Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B
 Nyeri rangsangan peritoneum tidak langsung

1. Rovsing Sign (nyeri RLQ saat abdomen kontra mcburney ditekan)

2. Blumberg Sign (Rebound Fenomena) (nyeri saat tekanan pada kontra mcburney dilepaskan)
3. Psoas Sign (nyeri saat otot psoas mayor ditegangkan dgn cara:
a. Aktif (ekstremitas inferior Dx posisi ekstensi/lurus  Px diminta u/ memfleksikan
ekstremitas tsb mll hip joint)
b. Pasif (Px posisi LLD & ekstremitas inferior
Dx posisi lurus  pemeriksa mengekstensikan ekstremitas
tsb mll hip joint ke arah belakang)
4. Obturator Sign (nyeri saat otot obturator ditegangkan dgn cara memfleksikan femur Dx mll
hip joint & di endorotasikan)
5. Tenhorn Sign (testis Dx ditarik --- Px merasa nyeri di RLQ)
6. Ligart Sign (nyeri berpindah dari epigastrium ke RLQ)
7. Mc Burney Pain Sign (nyeri tekan daerah Mc Burney)
8. Dunphy Sign (nyeri RLQ saat batuk)

Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B

 PEMERIKSAAN FISIK

McBurney Sign

 Nyeri tekan = tenderness

 Nyeri lepas = rebound tenderness
 Defans muskuler = muscular guarding
Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B
PEMERIKSAAN FISIK

 Rovsing’s sign

 Obturator sign

 Psoas sign

Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B

PEMERIKSAAN FISIK

 Colok dubur  jangan terlewatkan!!!

Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B

 LABORATORIUM

 Leukosit  10.000 -18.000/mm3, tetapi bisa normal

 75% pasien  Diff count dominan neutrofil

 Urine normal  kecuali letak apendiks retrosekal /

pelvik: eritrosit/leukosit urine (+)

Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B

 PEMERIKSAAN PENUNJANG
 X-ray abd.  tidak khas, jarang membantu Dx
 tampak apendicolith
 Air-fluid level  ileus lokal
 Udara bebas (free air)  perforasi

 Barium enema  = appendicogram

 appendiks tidak terisi kontras (hanya u/ kasus Foto Polos Abdomen
appendicitis kronis)
 USG Appendiks

PEMERIKSAAN
PENUNJANG
 USG  dilatasi lumen &
dinding tebal
 u/ ♀ membantu mencari
kelainan ginekologi

CT Scan abdomen/pelvik
 CT-Scan  Gold Standar

Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B

Alvarado score
Bila:
Skor 1-4  Tidak dipertimbangkan mengalami apendisitis akut
Skor 5-6  Dipertimbangkan kemungkinan Dx apendisitis akut tetapi tidak perlu
tindakan operasi segera /dinilai ulang  Dx: Observasi nyeri RLQ
Skor 7-8  Dipertimbangkan kemungkinan (suspect) apendisitis akut
Skor 9-10  Hampir definitif apendisitis akut & dibutuhkan tindakan bedah

Yang Dinilai Skor

Gejala Nyeri beralih (Ligart’s sign) 1
Anoreksia 1
Nausea/Vomiting 1
Tanda Nyeri tekan fossa iliaka Dx 2
Nyeri lepas 1
Kenaikkan temperature 1
Laboratorium Leukositosis 2
Neutrofil bergeser kekiri 1

Skor Total 10

Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B

 DIAGNOSIS BANDING
1. Acute Mesenteric Adenitis
 Anak-anak
 Nyeri diffuse
 Observasi  self limited disease

2. Acute Gastroenteritis
 Diare, mual, muntah
 Nyeri tidak terlokalisir

3. Meckel's Diverticulitis
4. Intussusception
 Umur <2 th
 Kolik, BAB bercampur darah
 Massa seperti sosis di RLQ

5. Perforated Peptic Ulcer

Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B

6. Crohn's Enteritis
 Demam
 Nyeri perut kanan bawah
 Leukositosis
 Diare
 Anoreksia
 Mual, muntah

7. Urinary Tract Infection

 Nyeri CVA
 Pyuria
 Bakteriuria

8.Ureteral Stone
 Nyeri
 Hematuria
 Demam
 Leukositosis

9.Gynecologic Disorders
 Pelvic Inflammatory Disease
 Ruptured Graafian Follicle
 Ruptured Ectopic Pregnancy
 Twisted Ovarian Cyst
Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B
 PENATALAKSANAAN

 Terapi pilihan satu-satunya  apendektomi

 Pre-op: - Puasa
- AB profilaksis
- H2 blocker
- Rehidrasi
- Analgetika
 Jenis operasi tgt derajat komplikasi:

 Apendisitis akut  appendektomi simpel / Laparoskopik

 Apendisitis kronis  appendektomi simpel / Laparoskopik
 Apendisitis abses  laparotomi
 Apendisitis perforata  laparotomi
 Periappendikular infiltrat  laparotomi

Jenis insisi appendektomi simpel:

 Mc Burney insision = Gridiron’s incision (oblique)
 Rocky-Davis insision = Lantz’s incision (transverse) Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B
Old J.L., et al American Family Physician, Jan 1 2005 ;75, 1
Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B
 KOMPLIKA
SI
 Bakteria mencapai peritoneum dan
pembuluh darah  gangren, perforasi,
abses, peritonitis (mortalitas 5%)

 < 12 jam  94 % simpel

 < 36 jam  2 % ruptur
 Meningkat 5%/12 jam

Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B

APPENDEKTOMI SIMPLE

Lantz’s incision

Mc Burney’s incision
(Gridiron’s incision)

Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B

APPENDEKTOMI
LAPAROTOMY

Midline,s incision

Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B

APPENDEKTOMI

LAPAROSKOPIK

Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B

PERALATAN LAPAROSKOPIK

Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B

 Insisi ke-1 (1 cm)  smile incision infraumbilikal
 Tujuan: a. Insersi veres needle  u/ mengisi CO2 intra abdomen (pneumoperitoneum)
b. Insersi laparoscope  u/ melihat organ intra abdomen

Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B

 Insersi Trocar 10mm dgn teknik “blind”
 Tujuan: u/ memasukkan laparoscope (video camera)

Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B

 Insisi ke-2 (0,5 cm)  suprapubic

Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B

 Insisi ke-3 (0,5 cm)  RLQ sejajar umbilicus

Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B

 PROGNOSI
 S akut, 3% bila ruptur,
Mortalitas  0,1% pada apendisitis
15% bila ruptur pada geriatri

 Etiologi   sepsis tak terkontrol, emboli paru, aspirasi

 Komplikasi yang mungkin terjadi:

 Akut  infeksi luka operasi
 Kronis perlengketan, ileus obstruksi, hernia

Appendicitis - dr. Mochamad Aleq Sander, M.Kes., Sp.B