Surgery: The Appendix
Chapter 30: The Appendix | Surgery
Embryology, Anatomy, Physiology
Embryology
▪ Sixth week appendix and cecum appear as outpouchings from the caudal limb of the midgut
▪ Appendiceal outpouching, initially noted in the eighth week, begins to elongate at about the 5th month
to achieve vermiform appearance
▪ Subsequent unequal growth of the lateral wall of the cecum cause the appendix to find its adult position
on the posterior medial wall, just below the ileocecal valve
▪ Situs inversus is a rare autosomal recessive congenital defect characterized by the transposition of
abdominal and or thoracic organs
o In this situation appendix is found in the lower left quadrant of the abdomen
Anatomy
▪ Average length is 6 to 9 cm
▪ Arterial supply from the appendicular branch of the ileocolic artery
o This artery originates posterior to the terminal ileum
▪ Lymphatic drainage nodes that lie along the ileocolic artery
▪ Innervation derived from sympathetic elements contributed by the superior mesenteric plexus and
afferents from the parasympathetic elements via vagus nerves
▪ Outer serosa is an extension of the peritoneum
▪ Crypts are irregularly sized and shaped, in contrast to more uniform appearance of the crypts in colon
Physiology
▪ Immunologic organ that actively participates in the secretion of immunoglobulin A
▪ An inverse association between appendectomy and the development of ulcerative colitis, suggesting a
protecting effect of the appendectomy
▪ May function to reservoir to recolonize the colony with healthy bacteria
Acute Appendicitis
Epidemiology
▪ Lifetime risk is 8.6% for males and 6.7% for females
▪ Highest incidence in the second and third decades
▪ Increased use of diagnostic imaging has led to a higher detection rate of mild appendicitis
Etiology and Pathogenesis
▪ Not completely understood
▪ Obstruction of the lumen due to fecaliths or hypertrophy of lymphoid tissue is proposed as main
etiologic factor
▪ Proximal obstruction of the appendiceal lumen produces a closed loop obstruction and continuing
normal secretion by the mucosa rapidly produces distention
o Distention stimulates nerve endings  producing vague, dull, diffuse pain in the mid-
abdomen or lower epigastrium
o Distention increases from continued mucosal secretion and from rapid multiplication of the
resident bacteria of the appendix
▪ This causes reflex nausea and vomiting, and the visceral pain increases
▪ Capillaries and venules are occluded but arterial inflow continues, resulting in engorgement and vascular
congestion
▪ Inflammatory process soon involves the serosa of the appendix and in turn the parietal peritoneum
o Produces characteristic shift in pain to the right lower quadrant
▪ Mucosa of appendix is susceptible to impairment of blood supply; its integrity is compromised early in
the process, which allows bacterial invasion
▪ Area with the poorest blood supply suffers the most: ellipsoidal infarcts develop in the antimesenteric
border
Microbiology
▪ Flora of the inflamed appendix differs from that of the normal appendix
▪ 60% of aspirates of inflamed appendices have anaerobes compared to 25% of aspirates from normal
appendices
▪ Fusobacterium nucleatum/necrophorum, which is not present in the normal cecal flora, has been
identified in 62% of inflamed appendices
▪ Patients with gangrene or perforated appendicitis appear to have more tissue invasion by Bacteroides.
Natural History
▪ Not all patients with appendicitis will progress to perforation and that resolution may be a common
event
Clinical Presentation
▪ Presents as pain, which initially is of a diffuse visceral type and later becomes more localized
Symptoms
▪ Starts with periumbilical and diffuse pain that eventually localizes to the right lower quadrant
o Pain in an atypical location or minimal pain will often be the initial presentation
▪ Variations in the anatomic location of the appendix may account for the differing presentations of the
somatic phase of pain
▪ Appendicitis is also associated with gastrointestinal symptoms like:
o Nausea
o Vomiting
o Anorexia
▪ GI symptoms that develop before the onset of pain suggest a different etiology such as gastroenteritis
Signs
▪ Body temperature and pulse rate may be normal or slightly elevated
o Changes of greater magnitude may indicate a complication has occurred or another
diagnosis should be considered
▪ Patients usually move slowly and prefer to lie supine due to the peritoneal irritation
▪ Tenderness with a maximum at or near McBurney’s point
▪ On deep palpation muscular resistance (guarding) in the right iliac fossa
▪ Rebound tenderness
▪ Indirect tenderness (Rovsing’s sign) and indirect rebound tenderness pain in the right lower quadrant
when the left lower quadrant is palpated are strong indicators of peritoneal irritation
▪ Pain with extension of the right leg (psoas sign) indicates a focus of irritation in the proximity of the
right psoas muscle.
▪ Stretching of the obturator internus through internal rotation of a flexed thigh (obturator sign) suggests
inflammation near the muscle
Laboratory Findings
▪ Mild leukocytosis is often present in patients with acute, uncomplicated appendicitis and is usually
accompanied by a polymorphonuclear prominence
▪ Counts above this level (>18,000 cells/mm3) raise the possibility of a perforated appendix with or
without an abscess
▪ C-reactive protein (CRP) concentration is a strong indicator of appendicitis, especially for complicated
appendicitis
▪ Urinalysis can be useful to rule out the urinary tract as the source of infection
Scoring systems
▪ The Alvarado score is the most widespread scoring system. It is especially useful for ruling out
appendicitis and selecting patients for further diagnostic workup
▪ The Appendicitis Inflammatory Response Score resembles the Alvarado score but uses more graded
variables and includes CRP
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Imaging Studies
▪ Plain films of the abdomen can show the presence of a fecalith and fecal loading in the cecum
associated with appendicitis
o Rarely helpful in diagnosing acute appendicitis however
o Of benefit in ruling out other pathology
▪ Chest radiograph is helpful to rule out referred pain from a right lower lobe pneumonic process.
▪ If the appendix fills on barium enema, appendicitis is unlikely
▪ Ultrasonography and computed tomography (CT) scan are the most commonly used imaging
tests in patients with abdominal pain
o CT is more sensitive and specific
Differential Diagnosis
Pediatric patient Acute mesenteric adenitis most commonly confused
Almost invariably, upper respiratory infection is present or has subsided
True rigidity is rare, generalized lymphadenopathy may be noted
Self-limited disease
Elderly patient Diverticulitis or perforating carcinoma of the cecum
CT scanning is often helpful
If managed successfully, internal surveillance of the colon may be warranted
Female patient In descending order of frequency, pelvic inflammatory disease, ruptured graafian
follicle, twisted ovarian cyst or tumor, endometriosis and ruptured ectopic
pregnancy
Immunocompromised Incidence of patients infected with HIV is reported to be 0.5%
patient Presentation is similar to noninfected patients
Majority have fever, periumbilical pain radiating to the right lower quadrant
Surgery: The Appendix
Initial Management
Uncomplicated Appendicitis
Operative versus Nonoperative Management of Uncomplicated Appendicitis
▪ Operative treatment of presumed uncomplicated appendicitis still remains the standard of care
▪ There is a reported 9% short-term (<30 days) failure rate with nonoperative management of
appendicitis
Urgent versus Emergent Appendectomy for Uncomplicated Appendicitis
▪ Emergent versus urgent operation for uncomplicated appendicitis is dependent on each institution and
surgeon.
▪ Institutions without readily available operating rooms and staff may consider performing appendectomy
in an urgent fashion as opposed to emergently
Complicated Appendicitis
▪ Refers to perforated appendicitis commonly associated with an abscess or phlegmon (localized area of
acute inflammation of the soft tissues)
▪ Children less than 5 years of age and patients more than 65 years of age have the highest rates of
perforation
▪ No association of in-hospital delay with perforation
o This suggests that most perforations occur early, before the patient arrives to hospital
▪ Rupture should be suspected in the presence of generalized peritonitis and a strong inflammatory
response
▪ CT scan may be beneficial in establishing a diagnosis and guiding therapy.
Operative versus Non-Operative Management of Complicated Appendicitis
▪ Patients who present with signs of sepsis and generalized peritonitis  operating room immediately
with concurrent resuscitation
▪ In patients with complicated appendicitis and a contained abscess or phlegmon but limited peritonitis
o Options include operative management versus conservative management (antibiotics, bowel
rest, fluids, and possible percutaneous drainage)
▪ Nonoperative management included intravenous fluids, minimizing gastrointestinal stimulation,
parenteral antibiotics, and percutaneous drainage where deemed appropriate
Interval Appendectomy Following Non-Operative Management of Complicated Appendicitis
▪ Defined as performing an appendectomy following initial successful non-operative management in
patients with no further symptoms
▪ Major argument for interval appendectomy is to prevent future attacks of appendicitis or to identify
other disease, such as appendiceal malignancy
Operative Interventions for the Appendix
(1) Open Appendectomy
▪ Typically performed with a patient under general anesthesia, the patient is placed in supine position.
▪ For early nonperforated appendicitis, a right lower quadrant incision at McBurney’s point (one-third of
the distance from the anterior superior iliac spine to the umbilicus) is commonly used.
▪ If perforated appendicitis is suspected or the diagnosis is in doubt, a lower midline laparotomy can be
considered.
▪ The patient should be placed in slight Trendelenburg position with rotation of the bed to the patient’s
left.
▪ If the appendix is not easily identified, the cecum should be located.
▪ Tracing the taenia libera (anterior taenia), the most visible of the three taeniae coli, distally, the base of
the appendix can be identified.
▪ Dividing the mesentery of the appendix first will often allow improved exposure of the base of the
appendix.
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 Surgery: The Appendix

▪ The appendiceal stump can be managed by simple ligation or by ligation and inversion. ▪ If the base of the appendix cannot be definitively identified or the appendiceal critical view cannot be
▪ As long as the stump is clearly visible and the base of the cecum is not involved with the inflammatory obtained, additional ports can be placed to perform a “plus one” or even standard laparoscopic
process, the stump can be safely ligated. appendectomy.
▪ Pus in the abdomen should be aspirated, but irrigation in complicated appendicitis is not recommended. ▪ The appendix may be placed in a retrieval bag or removed through the single incision.
▪ The skin can also be closed primarily in patients with perforated appendicitis. ▪ There have been multiple small trials evaluating the efficacy of laparoscopic single-incision
▪ If appendicitis is not found, a methodical search must be made for an alternative diagnosis. appendectomy compared to standard appendectomy
▪ The cecum and mesentery should be inspected. The small bowel should be evaluated in a retrograde ▪ Gill and colleagues, in 2012, reviewed nine studies for a total of 275 laparoscopic single-incision
fashion beginning at the ileocecal valve. appendectomies and 348 standard laparoscopic appendectomy procedures.
▪ Concerns for Crohn’s disease or Meckel’s diverticulum should be of priority. ▪ In this meta-analysis, there was no difference in operative time, complications, incisional surgical site
infections, intraabdominal abscesses,or length of stay.
▪ In female patients, the reproductive organs should be closely inspected.
▪ It appears that in laparoscopic appendectomy, laparoscopic single-incision appendectomy conveys no
▪ A medial extension of the incision (Fowler-Weir) or superior extension of the lateral incision is
discernible advantage or disadvantage with short-term outcomes.
appropriate if further evaluation of the lower abdomen or right colon is warranted.
▪ If upper abdominal pathology is encountered, a midline incision should be made.
(4) Natural Orifice Transluminal Endoscopic Surgery (Notes)
▪ Natural orifice transluminal endoscopic surgery (NOTES) is a new surgical procedure using flexible
(2) Laparoscopic Appendectomy
endoscopes in the abdominal cavity.
▪ The first reported laparoscopic appendectomy was performed in 1983 by Semm; however, the
▪ In this procedure, access is gained by way of organs that are reached through a natural, already-existing
laparoscopic approach did not come into widespread use until much later, following the success of
external orifice.
laparoscopic cholecystectomy.
▪ The hoped-for advantages associated with this method include the reduction of postoperative wound
▪ Standard laparoscopic appendectomy typically uses three ports.
pain, shorter convalescence, avoidance of wound infection and abdominal wall hernias, and the absence
▪ Typically, a 10- or 12-mm port is placed at the umbilicus, whereas two 5-mm ports are placed
of scars.
suprapubic and in the left lower quadrant.
▪ The main concern with NOTES has been complications with closure of the enterotomy. To date, there
▪ The patient should be placed in Trendelenburg and tilted to the left
is no reliable method of closure of the gastrotomy site, and there has been significant morbidity
▪ Through the suprapubic port, the appendix should be grasped securely and elevated to the 10 o’clock reported with this approach.
position. ▪ Much work remains to demonstrate whether NOTES is able to provide the theoretical benefits
▪ An appendiceal critical view should be obtained where the taenia libera is at the 3 o’ clock position, purported. Great care must be taken to prevent significant morbidity or mortality enroute to studying
the terminal ileum at the 6 o’ clock position, and the retracted appendix at the 10 o’ clock position to these procedures
allow proper identification of the base of the appendix
▪ Through the infraumbilical port, the mesentery should be gently dissected from the base of the appendix Special Considerations
and a window created.
Acute Appendicitis in the Young
▪ The stump should be carefully examined to ensure hemostasis, complete transection, and ensure that
▪ PE findings with highest sensitivity:
no stump is left behind.
o Maximal tenderness in the right lower quadrant
▪ The appendix is removed through the infraumbilical trocar in a retrieval bag.
o Inability to walk or walking with a limp
o Pain with percussion, coughing, and hopping
Laparoscopic versus Open Appendectomy
▪ Conditions that lead to higher mortality rates:
LAPAROSCOPIC OPEN
o More rapid progression to rupture
INFECTION Fewer More o Inability of the underdeveloped greater omentum to contain a rupture
ABSCESS Increased risk Decreased risk
HOSPITALIZATION Less pain, shorter length of stay Longer stay Negative Appendectomy Rate Perforated Appendix Rate
DIAGNOSIS May provide a benefit when the --- Children <5 years old 25% 45%
diagnosis is in question Children 5-12 years old <10% 20%
*Patients tend to have improved satisfaction scores with laparoscopic appendectomy. *Negative Appendectomy: occurs when a normal appendix is removed following a medical workup for acute abdominal
pain that indicates surgical intervention
(3) Laparoscopic Single Incision Appendectomy
▪ There has been growing interest in laparoscopic single-incision appendectomy.
Wound Infection Rate After Incidence of Intraabdominal
▪ Instead of two or three incisions, a single incision is made, typically periumbilical.
Treatment Abscess After Treatment
▪ The first published laparoscopic-assisted, single-incision appendectomy was reported by Inoue in 1994.
Nonperforated appendicitis 2.8% 3%
▪ The first reports of a pure laparoscopic single-incision appendectomy were described in 2009 by
Perforated appendicitis 11% 6%
multiple surgical groups.
▪ The patient is prepared similarly to laparoscopic appendectomy.
▪ Under general anesthesia, the patient is secured in a supine position with the left arm tucked. The Treatment for Perforated Appendicitis
surgeon and assistant stand on the left side facing the appendix and the screen. 1. Immediate appendectomy
▪ The surgeon’s right hand will grasp the appendix and retract it to the right lower quadrant at the 10 o’ 2. Antibiotic coverage
clock position. o Given until WBC count is normal and patient is afebrile for 24 hours
▪ The surgeon’s left hand will dissect the mesenteric window and, upon identifying the appendiceal critical o Limited to 24-48 hours for nonperforated appendicitis
view, staple across the base of the appendix and mesentery. 3. Laparoscopic appendectomy (safe and approved for children)

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 Surgery: The Appendix

Acute Appendicitis in the Elderly Surgical Site Infections (SSIs)

▪ Factors affecting appendicitis in the elderly, which contribute to a disproportionately high perforation ▪ Treatment for incisional SSIs
rate: o Opening on the incision
o Atypical presentation o Obtaining a culture – typically bowel flora
o Expanded differential diagnosis o Extraction port site – most common site of SSI after laparoscopic appendectomy
o Communication difficulty ▪ Treatment for intra-abdominal abscesses
▪ Perforation rates reach 50-70% in the elderly, and increases with age >80 o Small abscesses – antibiotics
▪ Clinical presentation: o Larger abscesses – antibiotics and drainage
o Lower abdominal pain ▪ Percutaneous drainage with CT or ultrasound guidance (preferred)
o Localized RLQ tenderness not as common ▪ Laparoscopic abscess drainage (alternative)
o May also report periumbilical pain radiating to the RLQ
o Priority given to patients with: Stump Appendicitis
▪ Temperature of >38°C (100.4°F) ▪ Incomplete appendectomy represents a failure of removing the entire appendix on the initial
▪ Shift to the left in WBC count of >76% procedure; also reported as “stump appendicitis”
▪ Male, anorexic, with pain of long duration o Clinical presentation:
▪ Laparoscopic appendectomy for the elderly ▪ Recurrent symptoms of appendicitis ~9 years after initial surgery
o Shortens length of hospital stay o More likely to have complicated appendicitis, have an open procedure, and undergo
o Reduces complications and mortality rates colectomy
o Greater chance of discharge to home ▪ The key to avoiding stump appendicitis is prevention
o Makes use of:
Acute Appendicitis During Pregnancy ▪ Appendiceal Critical View
▪ Appendectomy for presumed appendicitis is the most common surgical emergency during • Appendix – 10 o’clock
pregnancy (1 in 766 births) • Taenia coli/libera – 3 o’clock
▪ Occurs at any time during pregnancy but is rare in the 3rd trimester • Terminal ileum – 6 o’clock
o Highest rate in the 2nd trimester ▪ Identification of where the taenia coli merge and disappear
▪ Higher negative appendectomy rate (25%) than in nonpregnant women o Those mentioned above are paramount to identifying and ligating the base of the appendix
▪ Appendicitis in pregnancy should be suspected when: o Remaining stump should be no longer than 0.5 cm
o Complaint of abdominal pain of new onset
o Pain in the right side of the abdomen (most consistent sign, 74%)
o Diffuse periumbilical pain migrating to the RLQ (57%)
▪ Laboratory evaluation is not helpful
▪ Request for abdominal ultrasound or MRI for further investigation
▪ Laparoscopic appendectomy for pregnant women
o Advocated especially in early pregnancy
o May be associated with an increase in pregnancy complications

Risks after appendectomy Risks after negative appendectomy

Fetal loss 4% Fetal loss 5%
Early delivery 7% Early delivery 10%

Postoperative Care and Complications

Uncomplicated Appendectomy Complicated Appendectomy

▪ Low complication rates
▪ Most patient can be quickly started on a
diet
▪ Discharge home the same or following day
▪ Postoperative antibiotic therapy is
unnecessary
▪ Increased complication rates
▪ Continue broad-spectrum antibiotics for
4-7 days
▪ Post-operative ileus may occur (diet
should be started based on daily clinical
evaluation)
▪ Increased risk for SSIs
Incidental Appendectomy
▪ Removal of a clinically normal appendix during non-appendiceal surgery
▪ Generally, neither clinically not economically appropriate
▪ Indications:
o Children about to undergo chemotherapy
o Disabled who cannot describe symptoms or react normally to abdominal pain
o Patients with Crohn’s disease in whom the cecum is free of macroscopic disease
o Individuals who are about to travel to remote places where there is no access to medical
or surgical care
o Patients who will undergo Ladd’s procedure for malrotation

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 Surgery: The Appendix

Neoplasms of the Appendix Mucocoele

▪ A mucocoele of the appendix is an obstructive dilatation
▪ The prevalence of finding a mass within the appendix is <1%
▪ The most common lesions are appendiceal carcinoids and appendiceal adenomas by intraluminal accumulation of mucoid material
▪ No clear age relationship with the masses ▪ Caused by one of 4 processes:
o Retention cysts
▪ Includes:
o Carcinoids o Mucosal hyperplasia
o Adenocarcinoma o Cystadenomas
o Cystadenocarcinomas
o Mucocoele
▪ Clinical presentation:
o Pseudomyxoma peritonei
o Lymphoma o Nonspecific; often an incidental finding at
operation for acute appendicitis
▪ No future risk with an intact mucocoele (opposite for
Carcinoid
▪ Finding of a firm, yellow, bulbar mass in the appendix ruptured mucocoele)
raises the suspicion of an appendiceal carcinoid ▪ If a mucocoele is visualized during laparoscopy, convert to open laparotomy
o Ensures that a benign process will not be converted to a malignant one through rupture
▪ Appendix – most common site of gastrointestinal
carcinoids
▪ Symptoms are rare, but can obstruct the Pseudomyxoma Peritonei
▪ A rare, slowly progressive condition in which diffuse
appendiceal lumen and result to acute appendicitis
▪ Majority are located at the tip of the appendix collections of gelatinous fluid are associated with
▪ Malignant potential is related to size mucinous implants on peritoneal surfaces and omentum
▪ 2-3 times more common in females than in males
o Tumors <1 cm rarely extend outside the
appendix or adjacent to the mass ▪ Caused by neoplastic mucus-secreting cells within the
o Mean tumor size – 2.5 cm peritoneum
▪ Clinical presentation:
o Abdominal pain, distention, or a mass
Treatment
o Ureteral obstruction
Tumors ≤ 1 cm Appendectomy
o Obstruction of venous return
Tumors 1-2 Right hemicolectomy ▪ A CT scan (preferred imaging modality) before surgery
cm located at the base, involving the mesentery, or is done
with lymph node metastases ▪ Treatment:
o Surgical debulking
Adenocarcinoma
▪ Rare; consists of 3 major histologic subtypes: Lymphoma
o Mucinous adenocarcinoma ▪ Extremely uncommon
o Colonic adenocarcinoma ▪ Types of appendiceal lymphoma:
o Adenocarcinoid o Non-Hodgkin’s lymphoma (GI tract involvement)
▪ Clinical presentation o Burkitt’s lymphoma
o Appendicitis (most common for appendiceal carcinoma) o Leukemia
o Ascites ▪ Clinical presentation:
o Palpable mass o Acute appendicitis
o Discovered during an operative procedure for an unrelated cause ▪ Findings on the CT scan of an appendiceal diameter >2.5 cm or surrounding soft tissue thickening
▪ Treatment for all types: formal right hemicolectomy should prompt suspicion of an appendiceal lymphoma
▪ Management and treatment:
o Appendectomy
o Right hemicolectomy – for tumors that extend beyond the appendix onto the cecum or
mesentery
o Staging workup for adjuvant therapy (not indicated for lymphoma confined to the appendix)

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