Acute appendicitis is one of the most common causes of acute abdomen. It may occur from the time of infancy to old age, but the peak age of incidence is in the second and third decades of life. The diagnosis is based on a careful history and physical examination. In patients who have atypical clinical and laboratory findings, US, CT, MRI, a scoring system and laparoscopy can be used. Laparoscopic appendectomy is a safe and effective method for the treatment of appendicitis. It has proven advantages in relation to the open method: less post-operative pain, and a short stay in hospital, quicker recovery and return to normal activities. The causes of unsuccessful procedures vary, and most of the reasons for conversion occur due to the operator's lack of experience. In general, laparoscopic appendectomy has advantages, but it must be borne in mind that surgical experience in laparoscopic techniques is a pre-condition for surgeons to expect clinical benefits from laparoscopic appendectomy. In clinical conditions, where surgical experience is present, and the necessary equipment, the use of laparoscopy and laparoscopic appendectomy may be recommended in all patients with suspected appendicitis, if laparoscopy itself is not contra-indicated or is not feasible.

Aims: To study the trends in admission for diseases of the appendix and to attempt to present a potential basis for the observed (complex) age -dependent trendsand etiologies. Study Design:Longitudinal study of admissions relating to the appendix with analysis by age and gender.

Copyright © 2014, Colorectal Research Center and Health Policy Research Center of Shiraz University of Medical Sciences; Published by Safnek. This is an openaccess article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/ by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited. Dear Editor

A milder postoperative inflammatory change was noted with polydioxanone Endoloop ligatures than with polyglactin ligatures.

Background: In laparoscopic appendectomy, various methods of securing the appendix base are used. However, the use of different materials may cause inflammation, foreign body reaction and infection in the surgical field. It would be ideal to use material which cause the minimum tissue response. Methods: One hundred twenty rats were divided randomly into three groups: the first group, in which the base of the appendix was secured using an endoloop, was divided into two sub-groups: subgroup a: consisted of 30 rats in which the appendix base was secured using a Vicryl ligature, subgroup b consisted of 30 rats in which the appendix base was secured using a PDS ligature. The second group, in which the appendix base was secured with a Hem-o-lok plastic clip, consisted of 30 rats. The third group, in which the resection of the appendix was performed with a 45 mm Stapler, consisted of 30 rats. Ten animals from each group of subjects were sacrificed on days 7, 28 and 60 post-surgery for histo-pathological testing, to establish the presence and scope of reaction of the tissue to the clip, where an inflammation was semi-quantified graded as mild, moderate and severe. After opening the abdomen, the formation of adhesion was assessed according to the Surgical Membrane Study Group on Days 7, 28, and 60. Results: On day 7 after surgery, a mild mucosa inflammation was present in the Hem-o-lok group (7/10) and the Stapler group (2/10). The exact Fisher Test established that the frequency of mild and moderate inflammation was statistically significantly greater in the PDS, Hem-o-lok and Stapler groups than in the Vycril group (p= 0.01, using the Bonferroni correction, p=0.04). However, there was no statistically significant difference in the frequency of mild and moderate inflammation between the PDS, Hem-o-lok and Stapler groups (p=1 in each comparison). On day 28 and 60 there is no significant difference between studied materials. The SMSG score was statistically significantly higher on Day 7 than on Day 28 (U=466.5, p=0.0005) and Day 60 (U=154.0, p<0.0001). The PDS group had a statistically significantly lower score than the Hem-o-lok group (U=15.5, p=0.003), but it was not statistically differ ent from the score of the Stapler group (U=44.5, p=0.343). The Stapler group had a statistically lower score than the Vycril group (U=10.00, p=0.0005) and the Hem-o-lok group (U=5.9, p<0.0001). Conclusions: Considering our results, it may be said with caution that titanium clips and

INTRODUCTION Laparoscopic appendectomy is one of the simplest laparoscopic procedures, which is gradually becoming the method of choice in treatment of acute appendicitis due to its advantages over open appendectomy. In South-Eastern Europe the use of laparoscopic appendectomy is still very limited although it is a very simple procedure, suitable for training laparoscopic techniques. Technique of Laparoscopic Appendectomy. This review article describes the position of the patient and surgical team during laparoscopic appendectomy, position of troacars and working instruments which result in expressive cosmetic effect, technique of laparoscopic appendectomy, different ways of securing the base of appendix. Complications of Laparoscopic Appendectomy. This review article describes management of complicated appendicitis, and intra- and post-operative complications. CONCLUSION Laparoscopic appendectomy has many advantages over open appendectomy. The risk of wound infection is lower, postoperative pain is weaker and the hospital stay is shorter.

BACKGROUND During laparoscopic appendectomy, the standard technique in securing the base of the appendix is by endoloop ligatures or a stapler. We earlier demonstrated the possibility of the application of a double Hem-o-lok(®) clip in securing of the base of the appendix. The application of only one plastic clip would, however, lower the cost of the laparoscopic procedure even further and shorten the surgery time. The objective of this prospective study was to evaluate the possible advantages of securing of the base of the appendix using only one Hem-o-lok clip. PATIENTS AND METHODS The 90 patients with acute appendicitis were randomly divided into three groups: In the first group, the base of the appendix was secured using one endoloop ligature, in the second group using a 45-mm stapler, and in the third group using only one nonabsorbable Hem-o-lok clip. The data collected included age, gender, surgery time, time of endoloop/stapler/clip application, hospital stay, costs associated with these, and intra- and postoperative complications. RESULTS There were no significant differences in hospital stay among the three groups of patients; but the average time of the operation was significantly longer in the endoloop group than in the stapler group (P=.002), whereas the endoloop and Hem-o-lok groups were not statistically different (P=.22). The time of application of the endoloop was significantly longer than for the stapler (P<.0001) and Hem-o-lok (P<.0001) groups. The time of application of the stapler was significantly shorter than that of the Hem-o-lok (P<.0001). However, the price of one endoloop is €28.85, for the stapler is €230.7, and for one Hem-o-lok clip is €2.35. CONCLUSION The use of one Hem-o-lok clip is as safe as an endoloop and/or stapler; however, the time of the laparoscopic procedure using the Hem-o-lok was shorter in comparison with the use of an endoloop, with the cost of the procedure being the lowest.

The mildest inflammatory changes postoperatively were found in the staple group followed by those in the Hem-O-Lok group.

Optimal approach to appendicitis in pregnancy remains controversial issue. There is also some concern that laparoscopy during pregnancy may cause fetal injury and alter fetal perfusion. Supporters of laparoscopy claim that minimally invasive approach even in pregnant state possesses several advantages, including fewer wound complications and less postoperative pain, producing faster return to normal activities and early hospital discharge, with no increased fetal risk. We present our series of pregnant patients who underwent laparoscopic appendectomy that shows that in the hands of an experienced surgeon, this method is a safe option in pregnant patients in the second trimester.

BACKGROUND There are several scoring systems used in the prediction of outcome in critically ill patients. This study was undertaken to evaluate APACHE II, SAPS I, Sepsis score, MOF, TISS-28 and MPI scoring systems in prediction of the outcome in patients with perforative peritonitis. PATIENTS AND METHODS The prospective study of 145 patients of both sexes with perforative peritonitis was performed. The main outcome of study was peritonitis-related death. Variables necessary for calculation of the scoring systems were recorded at the initial admission to the hospital and the third and seventh day of hospitalization, except Mannheim Peritonitis Index, which was calculated during the first 24 hours after hospitalization. Cut-off points were specified and all values greater than cut-off points were taken to predict death. Sensitivity and specificity are graphically shown for the different values of cut-off points and represented with the receiver-operating characteristic curve. The difference in the area below the curve between scoring systems was statistically compared. RESULTS The area under the curve for the first postoperative day was 0.87 for TISS-28 score, 0.86 for APACHE II score, 0.83 for MOF and SAPS I, 0.72 for MPI and 0.70 for Sepsis score. This demonstrated that TISS-28 and APACHE II are significantly better than other systems (p < 0.01). In addition, this discriminatory ability remained on the third and seventh postoperative day as well. The highest rate of correlation between the observed and the expected mortality rate for the first (Kendall's tau correlation 0.964) and the third day (Kendall's ścorrelation 0.810) was in APACHE II system. CONCLUSION APACHE II is superior in prediction of the outcome to other tested scoring systems.

Bezoars are accumulations of foreign material within the gastrointestinal tract. They most often occur in the stomach, but they may also be found in the small and large intestine. The commonest type of bezoar is the phytobezoar, which is composed of undigested food material. These usually develop in patients who have undergone gastrointestinal surgery or who have impaired gastric motility. There are several ways to remove a bezoar. Medical therapy, with or without endoscopy, surgical removal, and with the development of laparo-scopic surgery, new options for treatment are available. We report here the case of the laparoscopic treatment of gastric bezoar. A patient presented to the hospital with symptoms of gastric obstruction with nausea, vomiting and abdominal pain. Endoscopy revealed a large gastric bezoar, 11 centimeters in diametar localized in antrum with decubital ulceration of the mucosa, but endoscopic extraction was unsuceessful. Therefore the patient underwent a linear laparoscopic gastrotomy and the bezoar was removed with the use of an endobag. Gastrotomy was closed using intracorporeal suturing. There were no intra and postoperative complications. This case demonstrates that laparoscopic extraction of a phytobezoar as an alternative to laparotomy in patients whose disease is not amenable to endoscopic resolution.