Surgery: The Appendix
antimesenteric border
References: Baby and Mommy Schwartz, 10th Edition
Anatomy and Function
 Base is attached to the cecum
 Tip may be retrocecal (most common), pelvic, subcecal,
preileal, or right pericolic in postion
 3 taenia coli converge at the junction of cecum and
appendix
 Length may be <1 cm to >30 cm (6-9 cm most common)
 Lymphoid tissue, secretes IgA (an integral component of
gut-associated lymphoid tissue [GALT])
o Function is “not essential” –no immune
compromise upon resection
Acute Appendicitis
Historical Background
 Charles McBurney – greatest contributor to treatment
(1889)
o Described McBurney’s point (point of maximum
tenderness)
o One-half to two inches inside the right anterior
spinous process of the ilium on a line drawn to
the umbilicus
 Semm – widely credited to 1st perform a successful
laparoscopic appendectomy (1982)
Incidence
 Lifetime rate: 12%m:25%f – 7% undergoes appendectomy
for acute appendicitis
 Seen more frequently in 2nd to 4th decades of life (20-40);
mean age of 31.3; median age of 22
 Male over female predominance – 1.2-1.3m:1f
 Rate of misdiagnosis: 15.3% (equivalent to appendiceal
rupture)
o Higher in women – 22.2%:9.3%
 Negative appendectomy rate for women of reproductive
age: 23.2% highest in 40-49 years old
o Highest negative appendectomy rate – women
>80 years old
 Etiology and pathogenesis (interpret as 1 will cause 2, 2
will cause 3…)
1. Proximal obstruction
2. Closed loop obstruction (Continuous luminal
secretion)
3. Distention
4. Stimulates visceral afferent stretch fibers
5. Pain (vague, dull, and diffuse) in mid/lower
epigastrium
6. Cramps (distention aggravates peristaltic waves)
7. Continued distention + multiplication of resident
bacteria (may cause nausea and vomiting)
8. Pressure exceeds venous pressure
9. Capillary and venous occlusion, arteriolar inflow
continues
10. Engorgement + vascular congestion
11. Arteriolar inflow occlusion
12. Involvement of serosa and parietal peritoneum
13. Pain shifts to RLQ
 Ultimately, distention + bacterial invasion + vascular
compromise + infarction = PERFORATION
o Usually in one of the infarcted areas of the
o Just beyond the obstruction and not at the
tip
 Sequence is NOT inevitable –some episodes
spontaneously resolves
 Causes of obstruction
o Fecalith or appendicolith (most common)
o Foreign bodies
o Intestinal worms
o Trauma
o Bezoars
Bacteriology
 Principal organisms involved are Escherichia coli (G-,
facultative, bacilli) and Bacteroides fragilis (G+, anaerobic,
bacilli)
o Both are normal flora of appendix
o Seen in both acute and perforated appendicitis
 Up to 14 different organisms were identified
 Culture – questionable (normal flora predominance)
o Peritoneal culture reserved for patients who are
immunosuppressed and PX who develop
abscess after treatment
 Broad-spectrum antibiotics indicated
o Non perforated → 24-48 hour-antibiotics
o Perforated → 7-10 days recommended
o IV antibiotics given when WBC count is normal
and patient afebrile for 24 hours
Clinical Manifestations
 Symptoms
o Abdominal pain – prime symptom in acute onset
 Classic presentation: diffusely centered
in lower epigastrium/umbilical area
 Moderately severe, steady, may have
superimposed intermittent cramping
 After varying period of 1-12 hours –
localizes to RLQ
 (there are cases where pain starts in
RLQ and stays there)
 Location of appendix account for
variation of pain locus (in the somatic
phase)
o Anorexia is almost always present
 Diagnosis is questionable if Px is not
anorectic
o Vomiting is present in 75% of cases
o Obstipation prior to onset of pain
o Diarrhea may occur (particularly in children)
o In 95% of cases: Anorexia → abdominal pain →
vomiting
 If vomiting comes before pain, think
otherwise
 Signs
o Determined principally by anatomic position of
appendicitis
o Vital signs
 Temperature elevation rarely exceeds
1C
 Pulse rate – N to sl↑
 Greater changes in VS indicate
complication
o General Survey and PE findings
  Prefers to lie supine with thighs drawn Alvarado Scale for Diagnosing Appendicitis
up (motion causes pain) Category Manifestation Value
 Classic RLQ pain if appendix is anterior Symptoms Migration of pain 1
of cecum Anorexia 1
 Tenderness maximal at or near Nausea/Vomiting 1
McBurney’s point Signs RLQ tenderness 2
 Direct rebound tenderness Rebound 1
 Referred/indirect rebound tenderness Elevated temp 1
may also be present (maximal at RLQ) Lab values Leukocytosis 2
 Indicates peritoneal irritation Left shift 1
 Rovsing’s sign (+) Total points 10
 Palpatory pressure in LLQ
produces pain in RLQ Appendiceal Rupture
 Cutaneous hyperesthesia at T10-T12
 Immediate appendectomy – standard treatment of acute
 Abdominal guarding
appendicitis due to risk of rupture
 Psoas sign (+)
 25.8% - overall rate of perforated appendicitis
 Obturator sign (+)
o Most prevalent in children <5 years old, and
 Laboratory Findings
older patients >65 years old
o Mild leukocytosis (10,000-18,000/mm3)
 Nonoperative treatment increases morbidiy and mortality
 Usually present in acute onset,
risk associated with ruptured appendicitis
uncomplicated cases
 Rupture should be suspected in the following
 With PMN predominance
o Fever >39C
 If WBC > than specified, suspect
o WBC >18,000/mm3
perforation
o Localized rebound/referred tenderness
o Urinalysis useful to rule-out UT as infection
o Ill-defined mass on PE
source
 Phlegmon
 Bacteriuria not found in catheterized
 Periappendiceal abscess
urine specimen in acute cases
 Px with mass – longer duration of
symptoms (5-7 days)
Imaging Studies
 Of note
 Plain radiographic films are rarely helpful
o Phlegmons and small abscesses may be treated
o Useful only to rule-out other pathologies
conservatively with antibiotics
o Acute – abnormal bowel gas pattern –
o Well-localized abscesses – percutaneous
nonspecific finding
drainage
o Fecalith is rarely noted – if present, highly
o Complex abscesses – surgical drainage
suggestive of diagnosis
o Interval appendectomy recommended after 6
 Graded compression sonography
weeks following acute event treated
o With maximal compression, appendiceal
nonoperatively or with simple drainage of
diameter is measured in the anteroposterior
abscess
dimension
o Positive – if appendix is noncompressible 6 mm
Differential Diagnosis
or more in anteroposterior direction
 Essentially the diagnosis of “acute abdomen”
o Presence of appendicolith establishes diagnosis
o Clinical manifestations are mostly not specific
o Other highly suggestive findings
and therefore may have identical clinical picture
 Thickening of appendiceal wall
with a wide variety of acute processes in the
 Periappendiceal fluid or mass
abdomen
o When acute appendicitis is excluded, perform
 Preoperative diagnosis accuracy of 85% is acceptable
brief survey of the abdominal cavity
o Less than this may result to unnecessary
 On CT scan
operations
o Inflamed appendix is dilated
o If consistently greater than 90% - would mean
o Wall thickened
you’re “observing” instead of operating
o Evidence of inflammation with “dirty fat”
 Diseases/conditions commonly misdiagnosed as acute
o Thickened mesoappendix
o Obvious phlegmon appendicitis and found to be naught ntraoperatively
(descending order of frequency):
o Fecalith (easily visualized)
o Arrowhead sign (thickening of the cecum, o Acute mesenteric lymphadenitis
o No organic pathologic condition
funnels contrast to the inflamed appendix)
o Acute pelvic inflammatory disease
 Laparoscopy
o Twisted ovarian cyst or ruptured graafian follicle
o Both diagnostic and therapeutic approach
o Acute gastroenteritis
o Most useful for females
 Differentials depend on four major factors:
 Used to differentiate acute
o Anatomic location
appendicitis from acute gynecologic
o Stage of process
pathology
o Px age
o Px sex
 Acute Appendicitis in the Young o TB
 Diagnosis is more difficult o Lymphoma
 Higher morbidity rate due to o Other causes of infectious colitis
o ↑ propensity for rupture  Immediate appendectomy is indicated
 Underdeveloped tissues and rapid  In patients with diarrhea as primary symptom,
progression colonoscopy may be warranted
o Underdeveloped greater omentum  Negative appendectomy rate – 5-10%
 Lesser ability to contain a rupture o Up to 25% will have AIDS-related entities in
 <5 vs. 5-12 years of age respectively operative specimen
o Negative appendectomy rate: 25% vs. <10%  CMV
o Appendiceal perforation rate: 45% vs. 20%  Kaposi
 Treatment regimen includes  M. aviumintracellulare
o Perforated – immediate appendectomy and  Postoperative morbidity rate higher in Px with perforation
irrigation of peritoneal cavity  Hospital stay rate is longer
o Antibiotics
 Nonperforated – 24-48 hrs Treatment
 Perforated – 7-10 days  Preoperative preparations
 IV preparations given when Px is o Adequate hydration
afebrile for at least 24 hrs o Electrolyte abnormalities corrected
o Laparoscopic appendectomy – safe and effective o Preexisting conditions should be addressed
 Cardiac
Acute Appendicitis in Older Adults  Pulmonary
 Incidence is lower than young  Renal
 Morbidity and mortality is higher o Preoperative antibiotics may be considered
 High index of suspicion should be observed (lowered infectious complications in trials)
 >80 years of age  Cefoxitin
o Perforation rate – 49%  Cefotetan
o Mortality – 21%  Ticarcillin-clavulanic acid
 More severe infections
Acute Appendicitis in Pregnancy  Carbapenems
 Most frequently encountered extrauterine disease  Combination therapy with
requiring surgical treatment in pregnancy o 3rd gen
 Most frequent during 1st and 2nd trimesters cephalosporin
 Diagnosis is inversely related to gestational age o Monobactam
o Due to displacement of appendix latero-  Aminoglycoside plus
superiorly o Clindamycin
 Nausea and vomiting (or new-onset) after 1st trimester o Metronidazole
may be of consideration for diagnosis  Open Appendectomy
 Abdominal pain and tenderness may be present but less o Incision is either McBurney (oblique) or Rocky-
guarding (due to abdominal laxity) Davis (transverse) at the point of maximal
tenderness or palpable mass
 WBC >15.000-20,000 /uL – PMN predominance
 (according to doc Cabredo, Rocky-
 Abdominal ultrasound is beneficial
Davis is more common now-a-days)
 Laparoscopy may be indicated especially in early
o Abscess suspected → lateral incision for
pregnancy
retroperitoneal drainage
 Premature labor risk of 10-15% in appendectomy during
o Diagnosis in doubt → midline incision for better
pregnancy
examination of cavity
 Appendiceal perforation – significant factor in fetal and
 Relevant in older Px where
maternal death
malignancy/diverticulitis is possible
o Fetal mortality – 3-5% in early appendicitis to
o Localization techniques
20% if with perforation
 Follow convergence point of taenia coli
 Sweeping lateral to medial motion
Appendicitis in Patients with AIDS or HIV Infection
 Limited mobilization of cecum
 Presentation of acute appendicitis same as noninfected o Once appendix is identified
persons except for  Divide mesoappendix
o Nonmanifestation of absolute leukocytosis (only  Ligate appendiceal artery
relative leukocytosis) o Appendiceal stump clearly viable with base of
 Increased risk for appendiceal rupture associated to cecum uninvolved in inflammatory process -
o Delay in manifestation managed by:
o Low CD4 count  Simple ligation
 Differential diagnosis should always include opportunistic  Ligation and inversion
infection such as but not limited to
 Purse-string stitch
o CMV
 Z-string stitch
o Kaposi sarcoma
o Mucosa obliterated to avoid mucocele formation
 o Peritoneal cavity irrigated
o Wound closed in layers
o If perforation or gangrene is found in adults
Skin and subcutaneous tissue left open to
heal by secondary intent (may be closed
after 4-5 days [delayed primary closure])
o In children primary wound closure is always
indicated
 Laparoscopy
o Performed under general anesthesia
o Requires 3 ports (or sometimes 4)
o Steps
 Surgeon in Px’s left
 Assitant 1 operates camera
 One trocar in the umbilicus
 Another trocar suprapubic
 3rd trocar variable (usually in LLQ,
epigastrium, or RUQ)
 Abdomen is first thoroughly explored
(rule-out other pathology)
 Identify appendix
 Dissection at the base
 Division of mesentery from
appendiceal base
 If mesoappendix involved,
divide appendix by stapler;
then divide mesoappendix
from appendix
 Base of appendix is not inverted
 Appendix removed via trocar site or
within retrieval bag
 Evaluate site for hemostasis
 RLQ irrigated
 Trocars removed
o Should be considered only as an option in thin
males aged 15-45
o May be beneficial to obese males
o Pregnant women withpresumed appendicitis
may benefit from diagnostic laparoscopy
Laparoscopy vs. Open Appendectomy
Category Laparoscopy Open
Duration and cost ↑ ↓
Wound infection ↓ ↑
Intraabdominal
↑ ↓
abscess
Pain of 1st
↓ ↑
postoperative day
Hospital length of
↓ ↑
stay
Benefit to thin
↓ ↑
males (15-45 yo)
Benefit to obese
↑ ↓
males
 Interval Appendectomy
o Performed on Px with palpable or
radiographically documented mass (abscess or
phlegmon)
 Initial conservative therapy with
interval appendectomy after 6-10
weeks later
o Provides lower morbidity and mortality rates
than immediate appendectomy
o Associated to added expense and longer
hospitalization
o Initial treatment include
 IV antibiotics
 Bowel rest
o Percutaneous or operative drainage of abscess is
not considered failure of conservative therapy
Prognosis
 Mortality is steadily decreasing
o Principal factors of mortality include rupture
before surgical treatment and age of Px
 Complications occur in 3% of Px with nonperforated vs.
47% in Px with perforations
 Serious early complication is usually septic (abscess and/or
wound infection)
 Complete wound dehiscence rarely occurs in McBurney
type of incision
 Predilection sites of abscesses
o Appendiceal fossa
o Pouch of Douglas
o Subhepatic space
o Between intestinal loops
o Rectally bulging abscess (transrectal drainage)
 Fecal fistula may occur as a complication of appendectomy
o May be due to sloughing of cecal portion inside a
constricting purse-string suture
o Ligature’s slipping off an appendiceal stump
o Necrosis from abscess encroaching on cecum
Chronic Appendicitis
 An uncommon disease
 Pain lasts longer but less intense in the same location
 Characteristic symptoms
o Vomiting (lower incidence)
o Anorexia
o Nausea (occasionally)
o Pain with motion
o Malaise
 Leukocyte counts are normal
 CT scans are non-diagnostic
 Laparoscopy is effective
 Appendectomy is curative
 Px whose symptoms are not cured or recur usually have
Crohn disease as an underlying diagnosis
Appendiceal Parasites
 Live parasites cause obstruction
 Ascaris lumbricoides – most common
 Others
o E. vermicularis
o S. stercoralis
o E. granulosis
 Presence of parasites make appendectomy difficult
 Px treated with helminthicide post-operation
 Amebiasis can also cause appendicitis
o Invasion by trophozoites
o Component of more generalized intestinal
amebiasis
o Appendectomy followed by antibiotic therapy
(metronidazole)
Incidental Appendectomy
 Both appendicitis and appendicitis with perforation are
more common in men than women
 NNT = 36 (36 incidental appendectomies performed to
prevent the occurrence of 1 appendicitis)
 Indications for incidental appendectomy
o Children about to undergo chemotherapy
o Disabled who cannot respond normally to
abdominal pain
o Crohn disease Px in whom cecum is free of
macroscopic disease
o Individuals about to travel to remote areas
without access to medical/surgical care
Tumors
 Extremely rare
 Incidence of primary appendiceal malignancy is 0.9-1.4%
found on appendectomy specimens
 <50% of cases diagnosed perioperatively
 Epidemiology
o Carcinoid (most common in most series studies)
– greater than 50% of cases
o NCI – SEER reports histologic update
 Mucinous adenocarcinoma as most
common (37%)
 Carcinoid as second most common
(33%)
 Carcinoid
o Appendix most common site of GI carcinoid
 Small bowel then rectum
(respectively)
o Carcinoid syndrome rarely associated with
appendiceal carcinoid unless metastases are
present
o The tumor may/may not obstruct the lumen
(most common site is apex/tip)
o Malignant potential directly proportional to size
of tumor
o <1 cm – 78%
o 1-2 cm – 17%
o >2 cm – 5%
o Treatment
 Simple appendectomy most common
 <1 cm with mesoappendiceal
extension and >1.5 cm – right
hemicolectomy
 Adenocarcinoma
o Rare neoplasm of appendix
o Has three subtypes
 Mucinous adenocarcinoma
 Colonic adenocarcinoma
 Adenocarcinoid
o Most commonly presents like an acute
appendicitis
 May have additional signs like ascites
and/or palpable mass
 Neoplasm may incidentally be
discovered perioperatively for an
unrelated cause
 Recommended treatment for all types
– formal right hemicolectomy
o Have propensity for early perforation
o Px are at risk for both synchronous or
metachronous neoplasms
 Mucocele
o Leads to progressive enlargement due to
intraluminal accumulation of mucoid substance
o Histologic type dictates course and prognosis of
disease
 Retention cysts
 Mucosal hyperplasia
 Cystadenomas
 Cystadenocarcinomas
o If benign – simple appendectomy
o Pseudomyxoma peritonei
 Rare condition where diffuse
collections of gelatinous fluid are
associated with mucinous implants on
peritoneal surfaces and omentum
 2-3x more common in females than
males
 Usually present with
 Abdominal pain
 Distention
 Mass
 Ureteral obstruction and/or venous
obstruction may occur
 CT scanning is preferred
 Perioperative location of mucinous
ascites and tumor deposits in women
 Right hemidiaphragm
 Right retrohepatic space
 Left paracolic gutter
 Ligament of Treitz
 Ovaries
 Surgical debulking is mainstay of
treatment (all gross disease removed)
 Appendectomy routinely performed
 Hysterectomy with bilateral salphingo-
oophorectomy is performed in women
 Not of benefit
 Ultra-radical surgery
 Adjuvant chemo
 Systemic post-op chemo
 Lumph node and distant mets are
uncommon
 Recurrences treated by additional
surgery – although associated with
 Enterotomies, anastomotic
leaks, fistulas
 Lymphoma
o Uncommon
o GIT most frequently involved extranodal site for
non-Hodgkin lymphoma
 Burkitt and leukemia also been
reported
o Primary lymphoma frequency of 1-3%
o Presents as acute appendicitis
o CT scan finding ≥ 2.5 cm or surrounding soft
tissue thickening prompts suspicion
o If confined to appendix – appendectomy (w/o
adjuvant therapy
o Extension of tumor onto cecum or mesentery -
right hemicolectomy
 With postoperative staging workup
before adjuvant therapy