Jadwal jaga Agustus 2012

Poster TERAPI BEDAH OBSTRUKSI USUS: STOMA ATAU RESEKSI ANASTOMOSIS

TERAPI BEDAH OBSTRUKSI USUS: 

STOMA ATAU RESEKSI ANASTOMOSIS

oleh Kshetra Rinaldhy, Benny Philippi, Taslim Poniman, Rofi Y. Saunar

Divisi Bedah Digestif, Departemen Bedah, FKUI-RSCM, 'SMF Bedah RSUP Fatmawati, Jakarta

Poster PSEUDOANEURISMA IATROGENIK PADA ARTERI FEMORALIS

PSEUDOANEURISMA IATROGENIK PADA ARTERI FEMORALIS

oleh Rahadianto R, Suhartono R

Divisi Vaskuler dan Endovaskuler Departemen Ilmu Bedah

Fakultas Kedokteran Universitas Indonesia

RSUPN Cipto Mangunkusumo

Poster PENERAPAN "MANNHEIM PERITONITIS INDEX" (MPI) PADA PASIEN PERITONITIS DI INSTALASI GAWAT DARURAT RUMAH SAKIT UMUM PUSAT CIPTO MANGUNKUSUMO

PENERAPAN "MANNHEIM PERITONITIS INDEX" (MPI) PADA PASIEN PERITONITIS 

DI INSTALASI GAWAT DARURAT RUMAH SAKIT UMUM PUSAT CIPTO MANGUNKUSUMO

oleh Syarif Mustika, Yarman Mazni

Departemen Ilmu Bedah Fakultas Kedokteran Universitas Indonesia

Rumah Sakit Umum Pusat Cipto Mangunkusumo

Poster MANAGEMENT OF SPIGELIAN HERNIA: LAPARASCOPIC APPROACH

MANAGEMENT OF SPIGELIAN HERNIA: LAPARASCOPIC APPROACH

by Ridho Ardhi Syaiful, Ibrahim Basir

Department of Surgery, RSCM

Faculty of Medicine, University of Indonesia

Poster ATRESIA JEJENUM DENGAN VOLVULUS MIDGUT

ATRESIA JEJENUM DENGAN VOLVULUS MIDGUT

oleh Rico D. Simorangkir, Sastiono

Divisi Bedah Anak, Departemen Ilmu Bedah

Fakultas Kedokteran Universitas Indonesia, RSUPN Cipto Mangunkusumo

Poster DIAGNOSIS DAN TATALAKSANA RUPTUR DIAFRAGMA PADA FASE AKUT DAN FASE LATEN

DIAGNOSIS DAN TATALAKSANA 

RUPTUR DIAFRAGMA PADA FASE AKUT DAN FASE LATEN

oleh Rizky Amaliah, Wuryantoro

Divisi Bedah Toraks Kardiovaskular FKUI-RSCM

Poster PERFORASI GASTER SPONTAN PADA NEONATUS PREMATUR

PERFORASI GASTER SPONTAN PADA NEONATUS PREMATUR

oleh John Karlie, Iskandar Rahardjo Budianto

Departemen Ilmu Bedah, Divisi Bedah Anak

RSUPN Cipto Mangunkusumo

Poster WOUND - TRACHEAL - TUBE PADA TRAUMA OROFARING TERBUKA

WOUND - TRACHEAL - TUBE PADA TRAUMA OROFARING TERBUKA

oleh Jamtani I, Wuryantoro

Divisi Bedah Toraks Kardiovaskular

Departemen Ilmu Bedah Fakultas Kedokteran Universitas Indonesia

Rumah Sakit Umum Pusat Nasional Cipto Mangunkusumo

Poster PROFILE OF PATIENTS ATTENDING ERECTILE DYSFUNCTION CLINIC: MULTIVARIATE ANALYSIS OF ITS ASSOCIATED FACTORS

PROFILE OF PATIENTS ATTENDING ERECTILE DYSFUNCTION CLINIC: 

MULTIVARIATE ANALYSIS OF ITS ASSOCIATED FACTORS

by Firtantyo Adi Syahputra, Ponco Birowo

Department of Urology Cipto Mangunkusumo Hospital

Division of Urology, Department of Surgery, Faculty of Medicine University of Indonesia

Poster PROFIL PASIEN BUERGER DISEASE DI DIVISI BEDAH VASKULER DAN ENDOVASKULER RSCM

PROFIL PASIEN BUERGER DISEASE 

DI DIVISI BEDAH VASKULER DAN ENDOVASKULER RSCM

oleh Simanjuntak B, Pratama D

Divisi Vaskular dan Endovaskular

Departemen Ilmu Bedah FKUI-RSCM

Poster PROFIL TUMOR PAROTIS DI RSCM

PROFIL TUMOR PAROTIS DI RSCM

oleh Valery Ivanov Arwadi, Bob Andinata, Muchlis Ramli

Subdivisi Bedah Onkologi, Departemen Bedah, RSUPNCM

Fakultas Kedokteran Universitas Indonesia, Jakarta 2012

Poster PULMONARY SEQUESTRATION

PULMONARY SEQUESTRATION

by Eliza Nindita, Wuryantoro S

Thoracic Cardiovascular Surgery Division, Department of Surgery

University of Indonesia, Cipto Mangunkusumo Hospital 

Prof. Dr.dr.H.Med Rasjid Soeparwata SpB,SpB(K)V,SpBTKV (K) Antara Bedah Vaskuler dan Pengalaman

Prof. DR. Dr.Med H. Rasjid Soeparwata SpB, SpB(K)V, SpBTKV(K)
Antara Bedah Vaskuler dan Pengalaman

Ali Reza, Indah Jamtani, Purnama Satria Bakti, Ruly Rahadianto, Bob Andinata

Tim wawancara blog General Surgery FK UI

April 2012

Jakarta, Indonesia

Prof. DR.Dr.Med. H. Rasjid Soeparwata SpB, SpB(K)V, SpBTKV(K) atau lebih dikenal dengan Prof Soeparwata merupakan staff medis di divisi Bedah Vaskuler FKUI/RSCM. Beliau yang dikenal santun, ramah dan bersahaja, lahir di Yogyakarta, dan merupakan anak pertama dari delapan bersaudara. Menghabiskan masa kecil hingga sekolah menengah di Yogyakarta, lalu sempat mengawali pendidikan kedokteran di FK UII. Dengan rekomendasi dari Rektor UII, pada waktu itu dan besarnya keinginan menjadi dokter akhirnya  beliau melanjutkan pendidikan ke Jerman untuk mewujudkan cita-cita, dengan diikuti beberapa orang saudaranya.

Berikut petikan wawancara tim blog General Surgery FK UI dengan beliau.

           

Prof, bisa diceritakan bagaimana pengalaman pendidikan di jerman?

Dijerman, saya diterima pertama kali di Guthenberg University dikota Mainz am Rhein , setahun kemudian pindah ke Justus Liebig Universitet Giessen, tiga tahun kemudian menyelesaikan pendidikan dokter. Satu tahun setelah menyelesaikan Medical Asisstenze, saya mendapatkan kesempatan pendidikan spesialis bedah umum di J.W.Goethe University selama enam tahun, sebelum akhirnya kembali Justus Liebig Universitaet untuk mendapatkan pendidikan bedah vaskular selama empat tahun dan menjalani program Doktors der Medizin dengan tema Auswirkungen unterschiedlicher Aminosauren in der parenteralen Ernahrung auf Proteinstoffwechsel and Katabolie nach herzchirurgischen Eingriffen . Setelah mendapatkan brevet ahli bedah vascular, lalu saya mendapatkan kesempatan memperdalam ilmu bedah jantung dan toraks di Universitet Giessen dan Wuerzburg di Bavaria selama empat tahun, kesemuanya itu ditempuh dalam waktu kurang lebih 18 tahun. Kemudian tahun 1989 saya mendapatkan posisi dalam rangka mengembangkan poliklinik toraks kardiovaskular di Westfaelischen Wilhelm Universitaet dan diberi kesempatan untuk melakukan penelitian Einfluss der Extrakorporalen Zirkulation auf das Mediatorensystem dan mendapatkan biaya riset sebesar 500.000 DM pada waktu itu. Dan menggapai Venia Legendi pada tahun 1996 sebagai penghargaan tertinggi akademik dibidang toraks kardiovaskular. Setelah menjadi ahli bedah jantung dan pembuluh darah, saya kemudian menjadi staff medis di sebuah rumah sakit di Muenster. Selama menjadi profesor, saya mempromotori 12 orang calon profesor, dan kebanyakan diantaranya orang jerman.

*Wawancara tim blog bedah FK UI dengan Prof Soeparwata di RSCM Kencana lantai 2 Cluster Cardiovascular, April 2012

Prof, pengalaman apa yang paling berkesan selama Prof menjalani profesi sebagai dokter?

Operasi tranplantasi jantung adalah operasi yang didambakan setiap ahli bedah jantung. Di jerman, operasi tranplantsi jantung sudah menjadi prosedur yang rutin pada kasus jantung dengan indikasi  End Stage Heart Failure. Bukan sulit untuk menemukan calon pasien transplantasi jantung. Namun mendapatkan orang pendonor jantung merupakan kendala untuk melakasanakan operasi transplantasi jantung. Saya pernah mengalami pengalaman yang sangat luar biasa.  Pengalaman yang juga sangat langka ditemukan di jerman pada waktu itu. Ini terjadi sewaktu saya sedang jaga on call dan mewakili direktur di Rumah sakit kota Muenster. Pada minggu itu, ada tiga orang yang mengalami kecelakaan sepeda motor. Ketiganya meninggal. Karena kebijakan di negara jerman yang menyediakan kartu bagi orang-orang yang bersedia mendonorkan organnya apabila meninggal, akhirnya saya mendapatkan kesempatan untuk mengerjakan tiga operasi transplantasi sekaligus dalam satu minggu. Hal ini saya anggap sesuatu hal yang luar biasa. Saya sangat bersyukur dan yakin bahwa Allah mendengar doa saya. Hingga saat ini, saya telah melakukan 14 kali operasi transplantasi jantung.

Lantas, bagaimana Prof bisa bergabung dengan FKUI?

Dari tahun 2000, saya telah diangkat sebagai Dosen Luar Biasa oleh Dekan FK UI. Pada waktu itu Prof. Dr. H. Ali Sulaiman, SpPD, KGEH menjabat sebagai dekan FK UI. Sewaktu saya diangkat menjadi dosen luar biasa, Dr. Dedy Pratama Sp.B yang merupakan kepala divisi bedah vaskuler saat ini, sedang mengambil fellowship dibidang bedah vaskuler di Jerman. Saya juga diangkat sebagai “ Visiting Profesor”  dibeberapa universitas di Indonesia, antara lain UGM dengan dekannya pada waktu itu, Prof. DR. Dr. Hardyanto Soebono, SpKK, dan juga di UMY dengan dekannya pada waktu itu Dr. Erwin Santosa, SpA, M.Kes. Pada akhir tahun 2008, Dekan FKUI DR. Dr. Ratna Sitompul, SpM(K), berkunjung langsung ke Muenster untuk bersilaturahim dengan Dekan Westfaelischen Wilhelm Universitaet  Prof DR Wilhelm Schmitz , sekaligus untuk menjalin kerjasama antara kedua pihak yaitu UI dan Universitas tempat saya bekerja. Gayung pun bersambut, saya yang memang sudah lama ingin kembali mengabdi di tanah air, segera menerima tawaran  tersebut dan akhirnya kembali ke tanah air dan ditempatkan di Bedah Vaskuler FKUI/RSCM mulai dari tahun 2009 sebagai Profesor akademik.

*Prof dengan antusias membagikan pengalaman menarik serta luar biasa yang ia miliki kepada tim blog bedah FK UI

           

Prof, mengenai prinsip hidup Prof?

Menjadi orang yang bermanfaat bagi yang lain. Saya  selalu ingin menolong orang yang kurang beruntung. Ilmu adalah alat yang digunakan untuk membantu orang lain, semaksimal mungkin.  Menguasai ilmu juga berarti mengoptimalkan akal. Kita tidak boleh berhenti apabila sudah mencapai sesuatu, tetapi kita harus mulai lagi dengan konsep yang baru. Kita juga tidak tahu kapan kita akan dipanggil oleh Yang Maha Kuasa. Maka sudah semestinya kita berbuat yang terbaik dalam hidup kita untuk diri kita, dan untuk sesama.

Terakhir, Apa pesan Prof untuk residen bedah FK UI?

Saya berpesan agar selalunya kita menanamkan 4C kepada para residen bedah khususnya dan pada seluruh dokter umumnya. Bahwa kita harus memiliki “Concept” tentang siapa kita, apa makna profesi kita, kemana tujuan hidup kita. Setelah itu kita pun memiliki “ Commitment” atas konsep yang telah ada dalam diri kita. “ Collaboration” adalah langkah kongkrit komitmen kita untuk saling bantu membantu dengan orang lain. Dan pada akhirnya kita akan “ Competent” pada suatu bidang ilmu tertentu. Kita mesti menjadi ahli dibidang ilmu tersebut, sehingga mengharuskan mengetahui hingga akar-akar dari ilmu tersebut. Tidak lupa saya berpesan agar  para dokter selalu mengutamakan perihal keselamatan pasien sebagai prinsip kita yang nomor satu dalam menjalani profesi dokter.

Terima kasih banyak atas pengalaman Prof yang telah dibagi kepada tim blog bedah FK UI. Kami juga mendoakan kesehatan, keberkahan dan kebajikan senantiasa mengiringi Prof. Bagi pembaca yang ingin langsung berkonsultasi dengan Prof Soeparwata, beliau dapat ditemui di RSCM Kencana, Rumah Sakit Pondok Indah Jakarta Selatan, dan Rumah Sakit Harapan Kita Grogol. ( AR,IJ,PSB,RR)

Dari kiri ke kanan : dr. Indah Jamtani, dr. Ali Reza, Prof Soeparwata, dr. Ruly R, dr.P.Satria.B

Jadwal jaga bulan Juli 2012

Jadwal Jaga Juni

Acara Pergantian COC & Pemilihan Wakil COC

Pada hari jumat, 4 mei 2012 telah diadakan acara pergantian Chief of the Chief(COC) dan pemilihan wakil COC selanjutnya. Dr. Syarif Mustika yang sebelumnya menjabat sebagai wakil COC naik menjadi COC menggantikan dr. Rino Meredian yang telah habis masa jabatannya. Acara ini dihadiri oleh residen-residen bedah mulai dari yang paling junior sampai yang paling senior. Setelah itu acara dilanjutkan dengan pemilihan wakil COC dan setelah melalui proses voting, maka terpilihlah dr. Danny Pratama sebagai wakil COC berikutnya. Kami mengucapkan selamat menunaikan tugas sebagai COC dan wakil COC ppds bedah selanjutnya.

Ujian Lokal Calon Spesialis Bedah FKUI

Pada tanggal 2-3 mei 2012 dilaksanakan ujian lokal calon spesialis bedah yang bertempat di ruang rapat bagian bedah lantai 3 gedung A RSCM. Ujian diikuti oleh dr.Rino Meridian,dr.Whisnu Pramudito DP, dan dr.Rachmawati..

Kita doakan semoga ujian abang dan mbak kita lancar. 

Sukses selalu untuk para calon Spesialis Bedah yang baru...

jadwal jaga mei

Management of Appendicitis

 John Karlie, Adra Firmansyah, Glenda Angeline, Bariah Agil

Budhi Arifin Noor, Dion Ade Putra, Oktaviati, Ridho Ardhi Syaiful, Rizky Amaliah, Rachmawati

General Surgery, Department of Surgery, FKUI/RSCM, Jakarta, Indonesia,

April 2012

CASE ILLUSTRATION

A  26 year old male came into the hospital with lower right abdominal pain and worsen 1 day before admission. Three days before, the patient complaint of epigastric pain which spreads into middle and lower right abdomen. The patient also had a fever and nausea.  There were no complaint about urinating and defecation. The Patient had a history of lower right abdominal pain two years ago.  On the physical examination there were not unusual finding except muscular defense on lower right region of the abdomen. Digital rectal examination shows no abnormalities, except for the tenderness between 10 – 11 clock direction.

The laboratory result shows that the leukocyte increased to15.700 whereas others were normal. The patient was diagnosed as chronic appendicitis and undergone an appendectomy surgery by administering antibiotics and analgesic. The Patient was treated for two days post-surgery and were treated as out patient.

Operative

A Gridiron incision through McBurney’s were undergone on a patient with spinal anesthesia.  The Omentum was attached on the lower right section. The Cecal wall was identified as being thickened and hyperemic. The appendix was located at Retrocecal, Retroperitoneal, gangrenous with fibrins surrounding as well as the appendix were visibly attached to its surrounding colon. The appendix were detached, then undergone an appendectomy procedure and a double ligation sutured. The bleeding was being treated and the abdominal cavity was being cleansed using a sterilized warm saline. The surgical wound were sutured layer by layer.

Literature Review

Acute appendicitis is an inflammation of the vermiform appendix and this case is the most common intraabdominal surgery that requires surgery.¹

The exact cause of appendicitis is not known for sure. Some studies pointed out that there are hereditary tendencies. The others revealed that due to eating habits, genetic resistance of bacterial flora. Eating habits of low-fiber, high sugar and fat also predispose disturbance of bowel movements that are not much food in the intestinal transit time is much longer, and increase pressure within the lumen of the intestine. ^2.3

Figure 4. Pathophisiology of Apendicitis

Diagnosis

Clinical character of appendicitis can be vary, but generally is shown with a history of vague abdominal pain, which is first felt in the gut. Possibly followed by nausea, vomiting, and mild fever. The pain usually moves from right iliac fossa after several hours, up to 24 hours. The point of maximum pain is a third from umbilicus to right iliac fossa, it's called Mc Burney point. Pain is usually sharp and aggravated by movement (such as cough and running). Pain at Mc Burney point is also felt when pressure applied in the left iliac, commonly called Rovsing’s sign. Patient’s position is affected by the position of the appendix. If the appendix is found at retrocecal side (exposed between the cecum and the psoas muscle), the patient does not feel pain at Mc Burney point, but found over the lateral hip. If the appendix is located at retrocecal , the patient doesn’t feel pain when pressure applied at left iliac. When the appendix is close to the psoas muscle, patient come with flexed hip and if we try to straighten out, there will be pain in the location of the appendix (psoas sign). When the appendix is located retrocecal it can cause irritation of the ureter so that the blood and protein may be found in urinalysis. If the appendix is located in the pelvis, the clinical signs are too less, so it must be done rectal examination, found pain and swelling on the right of inspection. If the appendix is located near the obturator internus muscle, the rotation of the waist increases the patient's pain (obturator sign). Cutaneous Hiperestesia in the area supplied by the right spinal nerves T10, T11 and T12 are usually also follow the events of acute appendicitis. If the appendix is located in front of the terminal ileum close to the abdominal wall, the pain is very clear. If the appendix is located behind the terminal ileum is very difficult diagnosis, the signs are vague and the pain is located at upper abdomen.^5-6

Rovsing’s sign	Positive if done palpation with pressure on the lower left quadrant and there is pain on the right side.
Psoas sign atau Obraztsova’s sign	The patient was placed on the left side, then do the extension of the right hip. Positive if there is pain on the bottom right.
Obturator sign	The patient was placed on the left side, then do the extension of the right hip. Positive if there is pain on the bottom right.
Dunphy’s sign	Accretion of pain in the lower right testis with cough
Ten Horn sign	Pain arising from the time when do soft traction at right spermatic cord
Kocher (Kosher)’s sign	Pain in the epigastric region beginning on the center, then move to the right lower quadrant.
Sitkovskiy (Rosenstein)’s sign	Increasing pain in the right lower quadrant abdomen while the patient is lie down on the left side
Bartomier-Michelson’s sign	Increasing pain in the lower right quadrant when patient is lie down on the left side compared with the supine position
Aure-Rozanova’s sign	Increased pain with petit finger on the right triangle (to be positive-Shchetkin Bloomberg's sign)
Blumberg sign	Also called “off pain”. Palpation in the right lower quadrant  then released suddenly

Table 1. Sign of Appendicitis^6-7

The possibility of appendicitis can be assured by using the Alvarado score. Scoring system is designed to improve the diagnose of apendicitis.⁶

The Modified Alvarado Score		Score
Symptoms	Migratory right iliac fossa pain	1
	Nausea/vomiting	1
	Anorexia	1
Signs	Tenderness in right iliac fossa	2
	Rebound tenderness in right iliac fossa	1
	Elevated temperature	1
Laboratory Findings	Leucocytosis	2
	Shift to the left of neutrophils	1
	Total	10
1-4     : Acute appendicitis is probably not 5-7     : Possible acute appendicitis 8-10   : Definite acute appendicitis

Table 2. The Modified Alvarado score⁶

On laboratory tests, we can find white blood cells raising. Pregnancy testing should be done on female patients to rule out cases of midwifery. Ultrasound examination is done if clinical signs are unclear, an ultrasound examination had 80% sensitivity and specificity of 100% .⁸

Table 3. Differential Diagnosis of Appendicitis

Management of appendicitis

Mostly the management of appendicitis is appendectomy. Delay in management, will increase the incidence of appendix perforation. Double ligation technique after open appendectomy will use absorbable suturing material. For most cases, surgeons will perform appendectomy with purse string (z-stich or tobacco sac) and double ligation technique. In normal condition, surgeons will use purse string. Double ligation technique is used when reversal of the stump cannot be safely done, so the surgeon will perform double ligation to the stump with two rows suturing. Nowadays, when laparoscopic technique has been well developed, this technique has been performed more frequent. This procedure has been claimed to reduce pain after the operation better than conventional procedure, it is also been claimed to get faster healing proccess and lesser wound infection, but it will increase the probability of intra abdomen abcess and prolonged operation time. Laparoscopic surgery is performed for diagnosis and therapy for patient with acute abdomen, especially for women. Few studies said that laparoscopic surgery will increase the surgeon’s skill to perform the operation.

Grid Iron Incision (McBurney Incision)11 Grid Iron incision is performed at McBurney area. Incision line is parallel with musculus obliqus externus, pass trough the McBurney area, which is located at 1/3 lateral of the line connecting right anterior superior spina illiaca and umbilicus
Lanz transverse incision Incision is performed 2 cm below umbilicus, incised transversal on midclavicula-midinguinal. It will give better cosmetic outcome than Grid Iron incision
Rutherford Morisson’s incision (Suprainguinal Incision) Is expansion from McBurney incision. It will be performed when appendix is located at paracecal or retrocecal and fixed
Low Midline Incision Will be performed for perforated appendix and there is peritonitis
Lower Right Paramedian Incision Vertical incision, parallel to the midline, 2.5 cm below umbilicus to above of the pubic

Table 4. Incisions for appendectomy

Discussion

Patient with complains of lower abdominal pain in men having differential diagnosis such as appendicitis, colic, urinary tract, digestive tract disorder (diverticulitis, ileocolitis, typhoid, and malignancies. Fever in these patients was precede by a  pain so that the possibility of typhoid can be removed. If urination symptoms and abnormalities of the urinary tract colic is not found, diseases like diverticulitis, ileocolitis and malignancy can be ruled out. If on physical examination at lower right abdomen is found muscular defans with a positive psoas and rovsing’s sign, then its likely that the location of the appendix at the retrocecal side. The value of Modified Alvarado system score is 9 out of 10. So that the patient must be diagnosed with appendicitis and perform appendectomy. The working diagnosis on the patient is chronic appendicitis acute exacerbation. If we find that the patient has a history of  right lower abdominal pain since 2 years ago the patient’s diagnosis was acute exacerbation of chronic appendicitis.

On operative report, we found an appendix is located at retrocecal retroperitoneal. It is according to sign that we got on physical examination. We can also found a gangrenous appendicitis, so that the post operative diagnosis is gangrenous appendicitis. Gangrenous appendicitis is the late stadium of appendicitis whereas we found blood flow disturbance at appendix, so that it will lead to perforation of appendix. Treatment using broad spectrum antibiotic on simple appendicitis and suppurative only can use for preoperative prophylactic.              

Glossary

Appendectomy(or appendicectomy)¹⁴ : Surgical removal of the appendix

Appendix¹⁵ : worm-shaped pouch attached to the cecum

Peritonitis¹⁶ : Inflamation of the peritoneum, the membrane lining the abdomen and pelvis.

Laparascopic surgery¹⁷ : a modern surgical technique in which operations in the abdomen are performed through small incisions (usually 0.5–1.5 cm) as opposed to the larger incisions needed in laparotomy

Retrocecal¹⁸ : pertaining to the region behind the cecum

BIBLIOGRAPHY

1.  Williams B A, Schizas A M P, Management of Complex Appendicitis. Elsevier. 2010. Surgery 28:11. p544048.

2.  Andersson N, Griffiths H, Murphy J, et al. Is appendicitis familial? Br Med J 1979 Sep 22; 2: 697e8.

3.  Heaton KW. In: Br Med J, Res Clin, eds. Aetiology of acute appendicitis 1987 Jun 27; 294:1632e3.

4.  Bewes P. Appendicitis. [Internet] April 2003. [cited April 2011] E-Talc Issue 3. Available from: http://web.squ.edu.om/med-Lib/MED_CD/E_CDs/health%2520development/html/clients/beweshtml/bewes_01.htm

5.  Soybel D. Appendix. In: Norton JA, Barie PS, Bollinger RR, et al. Surgery Basic Science and Clinical Evidence. 2^nd Ed. New York: Springer. 2008.

6.  Brunicardi FC, Andersen DK, Billiar TR, et al. Shwartz’s Principles of Surgery. 9^th Ed. USA: McGrawHill Companies. 2010.

7.  Appendicitis [Internet] [updated September 2010; cited April 2011]. Available from: http://en.wikipedia.org/wiki/Appendicitis

8.  Puylaert JB, Rutgers PH, Lalisang RI, et al. A prospective study ofultrasonography in the diagnosis of appendicitis. N Engl J Med 1987 Sep 10; 317: 666e9.

9.  Temple CL, Huchcroft SA, Temple WJ. The natural history of appendicitis in adults. A prospective study. Ann Surg 1995 Mar; 221: 278-81.

10. Birnbaum BA, Wilson SR. Appendicitis at the millennium. Radiology 2000 May; 215: 337e48.

11. Skandalakis JE, Colborn GL, Weidman TA, et al. Editors. Skandalakis’ Surgical Anatomy. USA: McGrawHill. 2004.

12. Russell RCG, Williams NS, Bulstrode CJK. Editors. Bailey and Love’s Short Practice of Surgery. 24^th Ed. London: Arnold. 2004.

13. Patnalk VG, Singla RK, Bansal VK. Surgical Incisions-Their Anatomical Basis. J Anat. Soc. India 50(2) 170-178 (2001)

14. Appendectomy. [Internet] [cited April 2011] Available from: http://en.wikipedia.org/wiki/Appendectomy

15. Vermiform Appendix. [Internet] [cited April 2011] Available from: http://en.wikipedia.org/wiki/vermiform_appendix

16. Peritonitis. [Internet] [cited April 2011] Available from: http://en.wikipedia.org/wiki/peritonitis

17. Laparascopic surgery. [Internet] [cited April 2012] Available from:

     http://en.wikipedia.org/wiki/Laparoscopic_surgery

18. Retrocecal. [Internet] [cited April 2011] Available from:

     http://medical-dictionary.thefreedictionary.com/retrocecal