C H A P T E R 4 2 
Appendicitis
Veronica F. Sullins  •  Steven L. Lee
Appendicitis is one of the most common surgical emer-
gencies in children. Over 70,000 cases are seen in the
USA each year.1,2 The lifetime risk of appendicitis is 9%
in boys and 7% in girls. Unfortunately, there is a lack of
general consensus regarding its diagnosis and
management.3
PATHOPHYSIOLOGY
The spectrum of appendicitis ranges from simple inflam-
mation to gross perforation. This concept was initially
described by van Zwalenberg in 1905 and confirmed
in an experimental model by Wangensteen in 1939.4,5
Obstruction of the lumen can occur from multiple causes
including fecal material (fecalith), lymphoid hyperplasia,
foreign body, or parasites. Fecaliths are present in roughly
20% of children with acute appendicitis and 30–40% of
children with perforated appendicitis.6,7 Fecaliths and
appendicitis are more common in developed countries
with low-fiber diets compared to developing countries
with high-fiber diets.8 Hyperplasia of the lymphoid tissue
near the base of the appendix is also a common cause of
appendiceal obstruction in children. Interestingly, the
incidence of appendicitis closely resembles the amount of
appendiceal lymphoid follicles present.9 Organisms such
as Yersenia, Salmonella, and Shigella can cause a local or
generalized reaction of the lymphoid tissue leading to
obstruction. In similar fashion, parasitic infestations from
Entamoeba, Strongyloides, Enterobius, Schistosoma, or Ascaris
species and viral infections such as mumps virus, cox-
sackie virus B, cytomegalovirus, and adenovirus can
lead to luminal obstruction secondary to lymphoid
hyperplasia.10–18 In children with cystic fibrosis, obstruc-
tion may be due to abnormal production of mucus leading
to painful distention with or without inflammation.19
Appendicitis in neonates is rare and warrants evaluation
for cystic fibrosis and Hirschsprung disease.20 It is diffi-
cult to distinguish neonatal appendicitis from necrotizing
enterocolitis confined to the appendix.21
Following obstruction, the appendix becomes dis-
tended from the accumulation of mucus and proliferation
of bacteria. As intraluminal pressure increases, lymphatic
and venous drainage are impaired resulting in local
edema. A further increase in pressure will limit arterial
inflow, thus jeopardizing tissue integrity and ultimately
leading to tissue necrosis and perforation. Although the
natural history of untreated appendicitis is usually perfo-
ration and abscess, not all patients will progress in this
fashion. Resolution of untreated appendicitis has been
568
described and may be the mechanism behind the clinical
phenomenon of relapsing or chronic appendicitis.22,23
Historically, appendicitis has been considered a some-
what time-sensitive condition such that a significant delay
in treatment may lead to an increased risk of perforation.
It is for this reason that young children have a higher
appendiceal perforation rate compared to older chil-
dren.24 Younger children have less ability to understand
or articulate their developing symptoms. As a result, per-
foration rates have been reported to be as high as 82%
in children younger than 5 years and nearly 100% in
1-year olds.25
Age is not the only factor accounting for delays in
treatment and therefore higher perforation rates. One
of the biggest concerns contributing to this delay is the
lack of access to health care. It follows that patients with
poor access to health care will have higher perforation
rates. Indeed, children with no insurance or public
insurance have higher rates of appendiceal perforation
compared to children with private insurance.26–29 Minori-
ties also have higher perforation rates compared to
whites.26–29 Encouragingly, settings in which patients have
equal access to health care or a well-established primary
care network eliminate these racial, ethnic, and socioeco-
nomic differences.30,31
CLINICAL PRESENTATION
The clinical presentation of appendicitis closely corre-
lates with the pathophysiology of the disease process.
The most common initial symptom is vague abdominal
pain. This pain is due to activation of the visceral pain
fibers from distention of the appendix following obstruc-
tion. Pain is vague, nonspecific, and commonly located
in the periumbilical region as with distention of all midgut
derivatives. As the appendiceal distention progresses,
symptoms of nausea, vomiting, diarrhea, and anorexia
often follow. The appearance of these symptoms prior to
the onset of pain makes the diagnosis of appendicitis less
likely. Intermittent, crampy pain is also less commonly
associated with appendicitis.
Fever, tachycardia, and leukocytosis develop as a con-
sequence of systemic inflammatory mediators released by
ischemic tissues, white blood cells, and bacteria. The
inflamed appendix then irritates the overlying perito-
neum, typically by direct contact. This leads to focal
peritonitis and localized right lower quadrant pain. This
process explains the typical migrating pain from the
umbilicus to the right lower quadrant. Any movement of

the peritoneum will lead to an exacerbation of the
pain. Thus, children will often demonstrate voluntary
guarding of the right lower quadrant during the exam.
Furthermore, children will usually resist walking and
jumping due to the increased pain associated with such
movement.
The most common finding on physical examination is
focal tenderness in the right lower quadrant. Typically in
children, only gentle pressure is required to elicit wincing,
moving, or guarding. Applying pressure to a stethoscope
while listening to the abdomen is a subtle way to palpate
the abdomen in frightened children in whom it is difficult
to obtain an accurate exam. Narcotic analgesics improve
the comfort level of the patient, but do not alter the
inflammatory process. Thus, tenderness will persist in
patients receiving narcotics. Attempts to illicit rebound
tenderness in children are uncomfortable, inaccurate, and
should be avoided. An easier and more accurate method
for determining the degree of peritoneal irritation is to
ask the patient to walk or jump. Palpating a mass is dif-
ficult and often impossible due to the level of discomfort
and guarding. Masses are more easily detected after
induction of anesthesia. It is important to remember that
localized tenderness is dependent on peritoneal irritation.
Therefore, obesity, a retrocecal appendix, or an appendix
that is walled off by omentum, mesentery, or small bowel
may not be associated with localized tenderness, making
the diagnosis more challenging.
Laboratory studies often show a mild leukocytosis. A
markedly elevated leukocyte count suggests perforation
or another diagnosis. Patients with appendicitis will have
higher leukocyte counts compared to patients without
appendicitis.32 However a broad range of sensitivity (52–
96%) exists, which limits the usefulness of this laboratory
value alone. A left-shifted differential count may be a
better diagnostic indicator, but a wide range in sensitivity
(39–96%) also can lead to misinterpretation.33–35 Other
inflammatory markers including C-reactive protein
(CRP), procalcitonin, and d-lactate have also been inves-
tigated. Of these markers, only CRP has been shown to
be useful. A value greater than 3 mg/dL has been associ-
ated with the definitive diagnosis of appendicitis when
compared to children with abdominal pain from a differ-
ent etiology.32 The combination of elevated leukocyte
count and CRP level has the highest correlation of defini-
tively diagnosing appendicitis.32,36 Although normal
values of both leukocyte count and CRP make the diag-
nosis of appendicitis less likely, the clinical signs and
symptoms should be carefully considered as appendicitis
cannot be excluded based on normal laboratory values. A
urine analysis is typically obtained and is usually free of
bacteria, but a few or moderate number of red or white
blood cells may be found as the inflammatory process of
the appendix may locally affect the bladder or ureter.
The typical presentation of appendicitis as described
previously is found in roughly 50% of patients.37 Chil-
dren with appendicitis often present with wide deviations
from this classic picture making for a challenging
diagnosis. In patients with an atypical presentation of
appendicitis, clinical scoring systems have been used
to aid in making the diagnosis.38,39 Accuracy of these
scoring systems has been inconsistent which limits their
42  Appendicitis 569
usefulness over clinical judgment.40–42 They have, however
been shown to decrease the use of computed tomography
(CT) scans.43 Recent studies have stratified patients into
risk categories based on history, physical examination,
and laboratory studies to determine which patients should
have surgical consultation (high risk), additional imaging
studies (medium risk), or be discharged (low risk).38–42
This is the most applicable use of a scoring system or
clinical pathway at the present time.
IMAGING STUDIES
Misdiagnosing appendicitis can lead to significant delays
in treatment. Children are often diagnosed with gastro-
enteritis and parents are reassured that their child will
improve, which may delay them from seeking further
care. Epidemiologic data have shown the risk of a missed
diagnosis in children to be higher in hospitals with a
volume of less than one pediatric appendectomy per
week.44 Historically, negative appendectomy rates of 10%
to 20% were not only considered appropriate but advis-
able to minimize the number of patients with a missed
diagnosis and to decrease perforation rates. Some authors
have questioned this philosophy, citing the risk and
expense of an avoidable operation.45 Appropriate use of
diagnostic imaging can minimize both the negative
appendectomy and perforation rates. Currently, the neg-
ative appendectomy rate from high-volume children’s
hospitals is 3–4%.46–48 Despite the increased use of
imaging studies, correctly diagnosing children less than
5 years of age continues to be challenging with negative
appendectomy rates ranging from 13–17%.48
Plain radiography can show fecaliths in 10–20% of
patients and can contribute to the diagnosis if the history
and physical exam findings are consistent. Other helpful
findings on plain films include lumbar scoliosis and oblit-
eration of the psoas shadow. In general, plain films may
be more useful to evaluate for other disease processes
when the suspicion for appendicitis is low.
Ultrasonography (US) offers the advantages of being
an efficient bedside technique that is noninvasive, requires
no contrast, and emits no radiation. Thus, ultrasound
should be the first imaging study utilized in patients with
atypical presentations of appendicitis. Common ultra-
sound findings include a fluid-filled, noncompressible
appendix, a diameter greater than 6 mm (Fig. 42-1),
appendicolith, periappendiceal or pericecal fluid, and
increased periappendiceal echogenicity caused by inflam-
mation.49,50 Most studies demonstrate a sensitivity greater
than 85% and specificity greater than 90%.51,52 However,
ultrasound is operator dependent and results of published
studies may not be similar to results obtained in many
clinical settings. Patient factors such as bowel gas pattern,
obesity, and guarding or movement can affect the accu-
racy. False-positive results may be due to a large appendix
or another tubular structure being mistaken for the
appendix. When a normal appendix is identified, it is a
reliable study to rule out appendicitis. Unfortunately,
only 10–50% of children with normal appendices can be
identified.52–54 When a normal appendix is not seen, there
is still a risk of appendicitis despite an otherwise normal
570 SECTION IV  Abdomen

ultrasound study.55 Graded compression ultrasound
places pressure on the transducer to displace bowel loops
and identify the appendix. The pressure is felt adequate
if the psoas muscle and the iliac vessels are identified,
which assure the range of view is posterior to the appen-
dix. Furthermore, data from a large series employing
upward graded compression, posterior manual compres-
sion, left oblique lateral decubitus position, and a low
frequency convex transducer demonstrated that nearly all
appendices could be identified with over 98% accuracy
for correctly diagnosing appendicitis.56 Contrast-
enhanced power Doppler ultrasound imaging demon-
strated similar accuracy in a small study.57
When ultrasound is unable to exclude or confirm
appendicitis, additional imaging or observation with
serial examinations is warranted. In order to avoid hos-
pitalization for observation, many physicians obtain a CT
scan. The findings of an enlarged appendix (>6 mm),
appendiceal wall thickening (>1 mm), periappendiceal fat
stranding, and appendiceal wall enhancement are useful
diagnostic criteria (Fig. 42-2).58,59 For the most part, the
sensitivity and specificity of CT are around 95%.60–66
FIGURE 42-1  ■  This longitudinal view of an ultrasound in a
patient with acute appendicitis shows an enlarged appendix
measuring 11 mm. in diameter.
These values are significantly lower in diagnosing perfo-
rated appendicitis.67 The perceived improved diagnostic
accuracy of CT has led to a dramatic increase in the
number of CT scans performed in children even though
there is not good evidence that supports its routine use
for the diagnosis of appendicitis.68–71
There are, however, several concerns with CT. Some
protocols require a delay in the emergency department
for contrast administration, and younger children may
require sedation. Recently, the ease of rapid helical CT
has led to an estimated 200% increase in pediatric CT
scans, significantly increasing radiation exposure in young
patients.72 This has become a growing concern because
although no direct connection between CT scan and
malignancy has been made, lifetime radiation exposure
has been linked to an increased risk of malignancy.73 It
has been estimated that a complete abdominal CT scan
is equivalent to 25.7 months of natural background radia-
tion exposure.74 Developing tissues are more sensitive to
the effects of radiation as evidenced by an increased risk
of radiation-induced malignancy in patients exposed at
a younger age.73,75 The risk of a fatal radiation-induced
malignancy is estimated at 0.18% for a 1-year-old child.
In other words, one death due to malignancy would result
from an abdominal CT scan done on 555 1-year-old
patients, whereas about twice as many 15-year-olds would
need to be scanned to equal that risk. Although this esti-
mate seems significant, it represents only a 0.35% increase
in overall risk compared to the risk of cancer mortality
with natural background radiation.76 Use of a staged
imaging protocol, performing CT scan only if ultrasound
findings are equivocal, has shown a reduction in the
number of CT scans performed and therefore overall
radiation exposure without sacrificing diagnostic sensitiv-
ity and specificity.77 In addition, international guidelines
on radiation protection have implemented the ALARA
principle (as low as reasonably achievable), thus decreas-
ing radiation exposure in children by 30-50%.72,75,77
Although the overall increase in risk may be miniscule, it
is important to attempt to limit radiation exposure when
evaluating children with acute appendicitis.

A B C

FIGURE 42-2  ■  These three CT scans show differing presentations for appendicitis. (A) The appendix (arrow) is enlarged and has a
thickened wall. There are no inflammatory changes such as periappendiceal fat stranding seen on this study. (B) The appendix
(arrow) is enlarged and there is free fluid and inflammatory changes medially indicating likely perforation. (C) The patient presented
with a one week history of pain and the appendix has perforated with the development of two abscesses (asterisks). In addition, a
fecalith is seen medially (dotted arrow). This patient was initially managed nonoperatively with drainage of the abscesses and
intravenous antibiotics. She underwent laparoscopic interval appendectomy 10 weeks following the initial admission.

Magnetic resonance imaging (MRI) is an intriguing
nonradiation alternative to CT and is extremely accurate
in diagnosing appendicitis.78 The current version of this
technology makes it impractical for widespread applica-
tion, but future generations of scanners could allow it to
be the preferred diagnostic imaging modality.
DIFFERENTIAL DIAGNOSIS
Acute appendicitis can mimic virtually any intra-
abdominal process and should be high on the differential
diagnosis in children with abdominal pain.79 Causes of
acute right lower quadrant pain that are often indistin-
guishable from appendicitis include tubo-ovarian patho-
logic processes, Crohn disease, mesenteric adenitis, cecal
diverticulitis, Meckel diverticulitis, constipation, viral
gastroenteritis, and regional bacterial enteritis (Yersinia
and Campylobacter in particular). Lower abdominal pain or
vague nonfocal pain can result from a urinary tract infec-
tion, kidney stone, ureteropelvic junction obstruction,
uterine pathologic process, right lower lobe pneumonia,
sigmoid diverticulitis, cholecystitis, pancreatitis, gastro-
enteritis, vasculitis, bowel obstruction, and malignancy
(lymphoma). The most common diagnosis made in the
presence of missed appendicitis is reported to be gastro-
enteritis.80 Although many of these conditions may seem
easily distinguishable, they each possess a spectrum of
presentation that overlaps with appendicitis.
TREATMENT
The treatment of appendicitis begins with intravenous
fluids and broad-spectrum antibiotics to provide coverage
of enteric organisms. Management after initiating anti-
microbial therapy depends on the severity of inflamma-
tion and the discussion must therefore be separated into
uncomplicated (nonperforated) and complicated (perfo-
rated appendicitis). This distinction, however, is not
always clear. Diagnostic imaging may help but cannot
accurately diagnose perforation and many patients will
not undergo preoperative imaging.61 Even intraoperative
assessment showed high rates of discordance when com-
pared to histologic evaluation of gangrenous and/or rup-
tured appendicitis.81 Surgeons polled with photographs
showed extreme incongruence on which patients had
perforation,82 and a survey of American Pediatric Surgical
FIGURE 42-3  ■  These two images depict
the definition of perforation used in a pro-
spective randomized trial.103 This defini-
tion of either (A) a hole in the appendix
(arrow) or (B) stool in the abdomen was
subsequently validated.83 An objective
definition of perforation allows surgeons
to compare outcomes data more accu- A B
rately about perforated appendicitis.
42  Appendicitis 571
Association members revealed that most surgeons base
their practice patterns on individual preferences.3 For
this reason, the literature focusing on perforated appen-
dicitis must be viewed with caution.
In reality, appendicitis presents as a spectrum of disease
and it is important to distinguish which patients are at
higher risk of complications. The data comparing out-
comes of nonperforated versus perforated appendicitis is
extensive, but most studies fail to use a strict definition
of perforation. One prospective study showed that defin-
ing perforation as a visible hole in the appendix or a feca-
lith in the abdomen effectively identified those with
greater risk of developing intra-abdominal abscesses (Fig.
42-3).83 In addition, outcomes in gangrenous appendicitis
are similar to acute appendicitis and many patients may
actually be over-treated.84 Thus, in the following discus-
sion, the management of uncomplicated appendicitis will
include acute, suppurative, and gangrenous appendicitis
whereas complicated appendicitis will be synonymous
with perforated appendicitis.
Uncomplicated Appendicitis
After intravenous fluids and administration of broad-
spectrum antibiotics, the current standard of care for
uncomplicated appendicitis is appendectomy. Prophylac-
tic antimicrobial agents should be given for 24 hours or
less. In fact, a single preoperative dose of antibiotics has
shown to decrease the risk of wound infection and
abscess.85,86 Following appendectomy, patients are typi-
cally discharged within 24 hours. Additional postopera-
tive antibiotics for acute appendicitis are not necessary or
recommended.85,87 However, it may be reasonable to
administer additional antibiotics for patients with sup-
purative or gangrenous appendicitis during the first 24
hours after appendectomy or longer based on the patient’s
clinical status.
Recent data in adults suggests that administration of
antibiotics without appendectomy may be sufficient to
treat uncomplicated appendicitis. Multiple prospective
randomized trials in adults have demonstrated similar
outcomes from acute appendicitis treated with antibiotics
alone with success rates ranging from 44% to 85%.88–92
Adults managed nonoperatively demonstrated fewer
complications and less pain, although recurrence rates
were high, ranging from 14% to 37%.93 There have
been no prospective, randomized trials in children com-
paring antibiotics alone to appendectomy. Regardless of
572 SECTION IV  Abdomen
treatment modality, once antibiotics have been initiated,
appendectomy is no longer considered to be an emer-
gency and may even be considered somewhat elec-
tive.88,89,93–98 Until there is enough prospective randomized
data in pediatric patients proving the efficacy of primary
antibiotic treatment, appendectomy remains the standard
of care for uncomplicated appendicitis. However, the
need for operation may not be as urgent as previously
thought.
Complicated Appendicitis
Patients with perforated appendicitis should receive post-
operative antibiotics until clinical resolution has occurred.
The antibiotic regimen employed for perforated appen-
dicitis has traditionally been triple antibiotic therapy
(ampicillin, gentamicin, and clindamycin or metronida-
zole). However recently there has been a shift towards
more simple antibiotic regimens. Single agent therapy
with piperacillin/tazobactam or cefotaxime, or double
agent therapy with ceftriaxone and metronidazole, has
been shown to be as efficacious as triple antibiotic therapy
but is more cost effective.99–103 Several authors have high-
lighted a decrease in antibiotic expense with once daily
dosing of ceftriaxone compared with multi-dose mono-
therapeutic agents. In addition, a prospective randomized
study confirmed that single daily dosing of ceftriaxone
and metronidazole is equal to and more cost effective
than traditional triple antibiotic therapy in the treatment
of perforated appendicitis.103 Therefore, current best evi-
dence suggests once-a-day dosing with ceftriaxone at
50 mg/kg/day and metronidazole at 30 mg/kg/day pro-
vides the simplest and least expensive regimen.
Although the length of antibiotic course for perforated
appendicitis is not yet standardized, current findings
from multiple systematic reviews recommend continua-
tion of antibiotics until resolution of clinical symp-
toms.85,102 This includes normalization of leukocyte count
and differential, full return of gastrointestinal function,
resolution of fever, and normalization of physical exam.
In addition, if the duration of intravenous antibiotic
therapy is less than 5 days, patients can be discharged
safely on oral antibiotics to complete a 7-day course.104 A
patient who is clinically well by postoperative day three
is unlikely to develop an abscess.105 However, if a patient’s
clinical symptoms have not resolved, it should raise the
suspicion of an intra-abdominal abscess and intravenous
antibiotics should be continued.
After initial intravenous fluid administration and anti-
biotics, the management of complicated appendicitis can
be separated into nonoperative and operative treatment.
Choice of treatment depends on identification of patients
at high risk for treatment failure. It is also important to
consider that many patients will not be diagnosed with
perforated appendicitis preoperatively. Risk factors for
failure of nonoperative management include greater than
15% band forms on the white blood cell differential
count, disease that extends beyond the right lower quad-
rant, absence of a well-defined abscess, or presence of an
appendicolith on imaging.106–108 Conversely, a large meta-
analysis comparing appendectomy versus conservative
treatment for complicated appendicitis as defined by
abscess or phlegmon on presentation demonstrated
higher rates of overall complications, wound infections,
and intra-abdominal abscesses in those who had immedi-
ate appendectomy.109
The concept of managing complicated appendicitis
with antibiotics alone is to decrease the significant local
and regional inflammation that may make an immediate
operation very difficult and potentially more dangerous.
Once treated, most surgeons will perform interval appen-
dectomy after six to ten weeks. However, some advocate
that the interval appendectomy is not necessary as recur-
rence rates are low, ranging from 8–14%.110,111 One
problem with these studies is the relatively short length
of follow-up. A recent systematic review found a 20.5%
overall risk of recurrent appendicitis with a range of
0–42%. However, nearly all studies were retrospective
and thus only included patients specifically selected for
nonoperative management.112 Some studies showed high
rates of pathologic findings in interval appendectomy
specimens.113,114 Although there is a lack of long-term
data to accurately predict the rates of recurrence in both
adults and children, some studies suggest that most recur-
rences will occur within three years and the majority
within one to six months.110–112 For these reasons, most
pediatric surgeons perform interval appendectomy in
patients with complicated appendicitis who were initially
managed nonoperatively.3
The majority of patients who present with a well-
formed abscess on initial imaging are managed nonop-
eratively (see Fig. 42-2C). Historically, immediate
appendectomy in this patient population was difficult,
required a larger incision, and had a high morbidity.
Primary treatment of the abscess with antibiotics alone, or
antibiotics and percutaneous drainage with or without
drain placement for larger fluid collections, is a widely
accepted treatment strategy. Interval appendectomy is
then performed after the inflammation has subsided.3,115–119
Although treatment with percutaneous drainage and
interval appendectomy has inherent risk of complications,
success rates have been reported to be as high as 88%.107 A
recent pilot randomized trial comparing initial laparo-
scopic appendectomy versus antibiotics, percutaneous
drainage and subsequent interval laparoscopic appendec-
tomy in patients presenting with perforated appendicitis
and abscess demonstrated no difference in the rate of
recurrent abscess, length of hospital stay, or hospital
charges.120 Patients undergoing immediate appendectomy
had longer operations and a longer time to return of bowel
function. Alternately, patients who had interval appendec-
tomies had more CT scans. Quality of life surveys at pres-
entation, 2 weeks, and 12 weeks in both groups from this
study showed that families experience significant parent-
ing distress related to disruption in the child’s quality of
life until the appendectomy is performed.121
The majority of patients with complicated appendici-
tis can be safely managed with appendectomy. Specifi-
cally, patients with a phlegmonous mass, appendicolith,
or absence of a well-formed abscess on imaging have a
higher risk of failure of nonoperative management.107,122
These patients can safely and reliably undergo immediate
laparoscopic appendectomy.123,124 In patients with perfo-
rated appendicitis without abscess, a recent prospective

randomized trial demonstrated lower rates of adverse
events, shorter length of hospitalization, and earlier
return to normal activity with early appendectomy.122 In
addition, mean total hospital charges and resource use
were significantly higher in patients undergoing interval
appendectomy, likely due to the increased number of
adverse events.125
The choice of nonoperative versus operative treat-
ment depends on the preoperative diagnosis of perfora-
tion. As mentioned previously, it is difficult to interpret
data on perforated appendicitis because a strict definition
of perforation has not uniformly been used. Currently,
patients are initially managed operatively or nonopera-
tively based on disease severity and surgeon preference.
Although evidence suggests that the majority of patients
can safely undergo early appendectomy, the optimal man-
agement of complicated appendicitis still remains unclear.
Operative Technique
First described in 1893 by McBurney, the traditional
method of appendectomy was a muscle-splitting, right
lower quadrant incision.126 The cecum is delivered
through the incision, the mesoappendix is divided, and
the appendix is ligated at its base. In the laparoscopic
approach, both surgeon and first assistant stand on the
patient’s left facing a video monitor positioned on the
right (Fig. 42-4A).127 The patient is positioned supine on
the operating table, and the abdomen is prepped widely.
After insertion of a 10–12 mm umbilical cannula, pneu-
moperitoneum is established. Two 5 mm ports are then
placed, one in the left lower quadrant and one in the left
suprapubic area (Fig 42-4B). A 5 mm 30° or 45° telescope
is introduced through the left lower quadrant port, and
the other two ports are the working ports. This allows
effective triangulation of instruments to maximize utility
in a small space, a core principle of endoscopic surgery.
Diagnostic laparoscopy is initially performed. If present,
abscesses are opened and purulent fluid is aspirated from
the pelvis, perihepatic space and paracolic gutters. The
appendix is located by following the taenia of the cecum
inferiorly. After grasping the appendix and retracting it
inferiorly, a window is created in the mesoappendix close
to the cecum. The endoscopic stapler is inserted through
A B
FIGURE 42-4  ■  (A) Port positions for a laparoscopic appendectomy. Typically three cannulas are used, with the endoscopic stapler
introduced through the 12 mm umbilical port. The appendix is removed through this site as well. (B) Postoperative appearance.
42  Appendicitis 573
the 12 mm umbilical cannula and used to divide the
appendix and mesoappendix (Fig. 42-5). The appendix is
usually divided first, followed by division of the mesoap-
pendix. On occasion, however, it may be more expedient
to ligate the mesoappendix first. If the appendix can be
delivered through the cannula, an endoscopic bag is not
used. However, if the appendix is too large for the
cannula, an endoscopic bag is employed to avoid drag-
ging the appendix through the umbilical incision. Drains
are not routinely utilized for advanced disease.
Since the introduction of laparoscopic appendectomy
25 years ago, there has been an abundance of data com-
paring open and endoscopic techniques. Initial advan-
tages of the open approach seemed to be a shorter length
of operation and fewer postoperative intra-abdominal
abscesses.128–130 However, as expected, there were higher
rates of wound infections, presumably due to contamina-
tion of the incision when delivering an infected appendix
through the wound (Fig. 42-6). Advantages of the laparo-
scopic approach are multiple. It allows better visualiza-
tion of the entire abdomen, which is especially beneficial
in obese patients who would otherwise require a larger
incision, and fertile females who may have other intra-
abdominal pathology.131–133 Laparoscopy also allows lysis
of interloop abscesses and aspiration of purulent fluid,
and it facilitates dissection in obese patients in whom
open appendectomy would be challenging. Use of lapar-
oscopy has been associated with a higher negative appen-
dectomy rate.134 However, this discrepancy may be
explained by the increased use of diagnostic laparoscopy
in patients whose diagnosis is not clear, specifically
teenage females who may have gynecologic findings.
Open appendectomy may be easier in younger patients
due to lack of space in the peritoneal cavity relative to
the size of the laparoscopic instruments.
The use of laparoscopy has increased from about 20%
in 1998 to 70% in 2007.135–137 In the past decade, there
have been multiple prospective randomized trials, large
retrospective studies, and meta-analyses comparing out-
comes in open versus the laparoscopic approach. While
early studies found increased operating times for lapar-
oscopy, more recent studies have shown no difference in
length of operation.138–142 A few studies actually demon-
strated shorter operating times with laparoscopy.139–140
574 SECTION IV  Abdomen
A B
FIGURE 42-5  ■  (A) Initially, a window is made in the mesoappendix. (B) Usually, the appendix is ligated and divided with the stapler
first, followed by ligation/division of the mesoappendix.
FIGURE 42-6  ■  This child underwent open appendectomy through
a right lower abdominal incision and developed a wound infec-
tion which is being treated. The significant reduction in the
incidence of wound infections is one of the benefits of the
laparoscopic approach, especially for perforated appendicitis.
Laparoscopic appendectomy is also associated with
shorter hospitalization, fewer postoperative outpatient
visits, decreased time off work, and earlier return to
routine activity.134–136,138,142–144 One study suggested
increased inpatient costs but lower outpatient costs for
the laparoscopic approach, while a large national data-
base review found increased costs in uncomplicated
appendicitis but similar costs for complicated appendici-
tis.137,142 A prospective randomized double-blind study
demonstrated that patients who underwent laparoscopic
appendectomy had an improved quality of life at two
weeks.145
Overall complication rates are less than 3% for uncom-
plicated appendicitis and 16% to 18% for complicated
appendicitis with many studies showing the same if not
lower rates after laparoscopy.131,135,137,138,144 One of the
more common complications following appendectomy is
an intra-abdominal abscess. Rates of postoperative abscess
are estimated to be less than 1% in uncomplicated appen-
dicitis and 1–15% in complicated appendicitis. However,
in many of these studies, there is not uniform definition
of perforation. When a uniform definition is used, rates
as high as 20% have been reported.83,105,120,137 One group
found an increase in abscess rate from 19% to 46% when
comparing non-obese to obese patients.146 A decade
ago, a few groups reported a higher incidence of postop-
erative abscesses in patients who had a laparoscopic
appendectomy.128–130 However, there is now an abun-
dance of level 1, 2, and 3 evidence showing no difference
in rates of intra-abdominal abscesses.136–138,144,147–155 In
fact, the most recent national database review evaluated
212,958 pediatric patients and found a higher rate of
postoperative abscess in patients who underwent open
appendectomy for both uncomplicated and complicated
appendicitis.137 This discrepancy may be due to increas-
ing surgeon experience with laparoscopy, more advanced
endoscopic equipment, or possibly using an endobag for
removal of the perforated appendix.156
Regardless of whether laparoscopic or open appendec-
tomy is performed, culture of the fluid has not been
shown to be helpful at the time of the initial opera-
tion.157,158 One study demonstrated that children whose
antibiotic treatment was based on the cultures did some-
what worse than those whose fluid was not cultured.158
Peritoneal lavage with either saline or antibiotic solution
has also not been shown to decrease the incidence of
abdominal abscesses.159 Similarly, the use of drains has
not proved useful except in cases of walled-off abscess
cavities.160,161
With respect to wound infections, this complication
occurs in less than 1% of patients with uncomplicated
appendicitis. In contrast, patients with complicated
appendicitis may have up to 16% incidence of wound
infection.144 Most recent studies have found that laparos-
copy has a lower rate of surgical site infections.24,135–138,143,144
The use of laparoscopy has also demonstrated a nearly
fourfold decrease in postoperative bowel obstruc-
tions.162,163 Other less common postoperative complica-
tions include urinary tract infection and pneumonia.
The concept that higher complication rates accom-
pany the laparoscopic approach is outdated. It is now
widely accepted that laparoscopic appendectomy should
be the procedure of choice in both uncomplicated and
complicated appendicitis, except in centers without lapar-
oscopic experience.
Recently, the use of single-site laparoscopic surgical
techniques have been reported.164–171 In single-incision

A B
FIGURE 42-7  ■  This 10-year-old underwent a transumbilical laparoscopic-assisted appendectomy. (A) A 5 mm reusable cannula was
introduced in the cephalad aspect of the umbilical fascia followed by insertion of a 5 mm grasping forceps inferior to the cannula
for mobilization of the cecum and appendix..(B) Close-up view of the separate fascial incisions for introduction of the cannula and
instrument. Note the fascial bridge between the instrument and the cannula. This bridge prevents escape of CO2 around the instru-
ments. (C) Following mobilization of the cecum and appendix, an extracorporeal appendectomy was then performed.
laparoscopic appendectomy (SILA), a single transumbili-
cal incision is made and a 5 mm or 12 mm port is placed.
One or two additional ports are placed through the same
incision using multi-port devices or separate fascial inci-
sions. Subsequent dissection and appendectomy are iden-
tical to the traditional three-port procedure. Advantages
of this technique are thought to be shorter length of
hospitalization, better cosmesis, and lower hospital costs.
Technically the procedure can be more challenging as
close approximation of instruments limits range of motion
and narrows the visual field.172 Theoretically a larger
fascial incision may result in increased postoperative pain
and higher rates of incisional hernias although prelimi-
nary evidence is limited. Hybrid procedures such as
laparoscopic-assisted single-port appendectomy (SPA)
and transumbilical laparoscopic-assisted appendectomy
(TULAA) are other described techniques that combine a
laparoscopic single-incision approach for dissection fol-
lowed by extracorporeal removal of the appendix through
the umbilicus as in the traditional open procedure
(Fig. 42-7). Early retrospective reviews have shown no
difference in postoperative complication rates and similar
or even decreased hospital costs when compared to open
and other laparoscopic techniques.167,168,170 A recent
prospective randomized trial comparing single site to
traditional three-port appendectomy in patients with
nonperforated appendicitis demonstrated no difference
in postoperative wound infection or abscess rates, length
of hospital stay, or hospital charges.164 This particular
study found a longer operative time (in minutes) for the
single-incision approach, but this was not clinically
relevant.
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