APPENDIX AND SMALL

BOWEL DIVERTICULA
Arin L. Madenci • William H. Peranteau • Douglas S. Smink

HISTORY
Although appendicitis is now well recognized as a leading cause of surgically
treated abdominal pain, Galen and other early anatomists overlooked the
vermiform appendix for centuries.1 The Renaissance artist, Leonardo da
Vinci, became the first to document the existence of the appendix in sketches
circa 1500. Subsequently, anatomists da Carpi2 and Vesalius3 formally
described the appendix in the mid-1500s. Soon thereafter, in 1554, Fernel
described the first recorded case of disease of this organ: a 7-year-old girl
with diarrhea was administered treatment with a large quince fruit, which
obstructed the appendiceal lumen after it was ingested.4 She developed
severe abdominal pain and died. Autopsy showed the quince fruit obstructing
the appendiceal lumen, with resultant appendiceal necrosis and perforation,
thereby resulting in the first description, postmortem, of what would later be
known as “appendicitis.”
It was not until several centuries later that appendicitis was first diagnosed
before autopsy and treated. Amyand is credited with performing the first

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appendectomy in 1736, when he operated on a child with an inguinal hernia
that had been complicated by the development of an enterocutaneous fistula.5
On exploration of the hernia sac, he discovered the appendix, which had been
perforated by a pin, resulting in an appendicocutaneous fistula. As a result of
his original description, an inguinal hernia sac containing the appendix
carries Amyand’s eponym.6 Nearly 150 years passed before Lawson Tait in
London performed the first successful transabdominal appendectomy for a
gangrenous appendix in 1880.7 Less than a decade later, in 1886, Reginald
Fitz of Harvard Medical School described the natural history of the inflamed
appendix and coined the term “appendicitis.”8 In 1889, Charles McBurney of
the Columbia College of Physicians and Surgeons in New York presented his
series of cases of surgically treated appendicitis and, in doing so, described
the anatomic landmark that now bears his name. McBurney’s point is the
location of maximal tenderness “very exactly between an inch and a half and
two inches from the anterior spinous process of the ilium on a straight line
drawn from that process to the umbilicus.”9 In the 1890s, Sir Frederick
Treves of London Hospital advocated conservative management of acute
appendicitis followed by appendectomy after the infection had subsided10;
unfortunately, his youngest daughter developed perforated appendicitis and
died from such treatment. The first laparoscopic appendectomy was
performed by Kurt Semm in 1980.11 Refinement of the minimally invasive
approach is the most recent of numerous advances in the diagnosis and
treatment of appendicitis. Nonetheless, acute appendicitis continues to
challenge surgeons to this day.

ANATOMY
Embryologically, the appendix and cecum develop as outpouchings of the
caudal limb of the midgut loop in the sixth week of human development. By
the fifth month, the appendix elongates into its vermiform shape. Containing
all layers of the colonic wall, the appendix is, by definition, a true
diverticulum. At birth, the appendix is located at the tip of the cecum.
Because of unequal elongation of the lateral wall of the cecum, the adult
appendix originates from the posteromedial wall of the cecum, caudal to the
ileocecal valve. The adult appendix averages 9 cm in length,1 with its outside
diameter ranging from 3 to 8 mm and its lumen ranging from 1 to 3 mm. The

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base of the appendix is consistently found by tracing the teniae coli of the
colon to their confluence at the base of the cecum. The appendiceal tip,
however, can vary significantly in location (Fig. 41-1). Although usually
located in the right lower quadrant (RLQ) or pelvis, the tip can occasionally
reside in the left lower quadrant or right upper quadrant (RUQ).

FIGURE 41-1 Anatomic variation in the position of the appendix. (1)

Preilieal; (2) postilieal; (3) promontoric; (4) pelvic; (5) subcecal; (6) paracolic
or prececal.

The arterial supply of the appendix comes from the appendicular branch of

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the ileocolic artery, which originates posterior to the terminal ileum, enters
the mesoappendix near the base of the appendix, and runs its course through
to the tip of the appendix (Fig. 41-2). Lymphatic drainage flows to lymph
nodes along the ileocolic artery.

FIGURE 41-2 The appendix and its arterial supply.

ACUTE APPENDICITIS

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Epidemiology
The incidence of acute appendicitis ranges from 8.6 to 11 cases per 10,000
person-years.12,13 The disease is slightly more common in males, although
perforated cases have no gender predilection. In a lifetime, 8.6% of males and
6.7% of females can be expected to develop acute appendicitis. Young age is
a risk factor; nearly 70% of patients are younger than 30 years of age when
diagnosed with acute appendicitis. The highest incidence of appendicitis in
males is in the 10- to 14-year-old age group (27.6 cases per 10,000 person-
years), while the highest female incidence is in the 15- to 19-year-old age
group (20.5 cases per 10,000 person-years). Overall, perforation occurs in
19% of cases of acute appendicitis. Perforated appendicitis has a bimodal
distribution, with a predilection for patients at extremes of age. The ratio of
perforated to nonperforated appendicitis is significantly higher among
patients younger than 5 and older than 65 years, compared to those between 5
and 65 years of age. Although acute appendicitis is relatively uncommon in
people older than 65 years, the elderly have perforated disease up to 50% of
the time.12

Etiology and Pathophysiology

The physiologic function of the appendix remains unknown, although some
postulate it to be a microbial reservoir.14 Equally, the pathophysiology of the
appendix in appendicitis is incompletely understood. Wangensteen and
Dennis15 extensively studied the role of obstruction in appendicitis in the
1930s. Based on anatomic studies, he postulated that mucosal folds and a
sphincter-like orientation of muscle fibers at the appendiceal orifice make the
appendix susceptible to obstruction. As such, the pathophysiology of
appendicitis is commonly believed to adhere to the following sequence of
events: (1) Closed-loop obstruction caused by a fecalith (or other nidus, such
as a calculus or neoplasm) leads to swelling of the mucosal and submucosal
lymphoid tissue at the base of the appendix; (2) intraluminal pressure
increases as the appendiceal mucosa secretes fluid against the fixed
obstruction; (3) appendiceal wall pressure exceeds capillary pressure and
causes mucosal ischemia; and (4) luminal bacterial overgrowth and
translocation of bacteria across the appendiceal wall further result in

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inflammation, edema, ischemia, and ultimately necrosis. If the appendix is
not removed, perforation may ensue.
Although appendiceal obstruction is widely accepted as the primary cause
of appendicitis, some evidence suggests that this may be only one of several
possible mechanisms. First, some patients with a fecalith have a
histologically normal appendix and, furthermore, the majority of patients
with appendicitis show no evidence for a fecalith.16 Arnbjörnsson and
Bengmark17 intraoperatively inspected the appendices of patients with
suspected appendicitis. The intraluminal pressure of each appendix was
measured prior to removal and found to be elevated in only 8 of 27 patients
with nonperforated appendicitis. The authors did not observe signs of
obstruction in the remaining patients with nonperforated appendicitis or those
with a normal appendix. Taken together, these studies imply that obstruction
is just one of the possible etiologies of acute appendicitis. Further
mechanisms have yet to be completely elaborated.
Regardless of the role of obstruction as the inciting factor for appendicitis,
it is a tenet of general surgery that, if left untreated, appendiceal inflammation
will progress to necrosis and, ultimately, to perforation. In one study of the
natural history of appendicitis, patients undergoing appendectomy for
suspected appendicitis were queried about their duration of symptoms.18
Patients found to have nonperforated appendicitis reported an average
duration of 22 hours of symptoms prior to presentation to the hospital, while
those with perforated appendicitis reported an average of 57 hours. Similarly,
in a study of over 1000 patients who underwent appendectomy for acute
appendicitis, Ditillo and colleagues19 assessed the relationship between
duration of symptoms and rate of perforation. Compared to the 6%
perforation rate among those with less than 12 hours of symptoms, patients
with 48 to 71 hours of symptoms had a 33% perforation rate and patients
with greater than 71 hours of symptoms had a 39% perforation rate.19
However, the time course of this progression varies between patients.
Among cases of perforated appendicitis, as many as 20% present within 24
hours of the onset of symptoms.19 Although concern for perforation should
be elevated when evaluating a patient with more than 24-hour duration of
symptoms, the clinician must remember that perforation can also develop
more rapidly. Importantly, this does not mean that surgeons are obliged to
hastily proceed to an operation when appendicitis is suspected in order to

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minimize the likelihood of perforation in exchange for a higher rate of
misdiagnosis. Rather, Temple and colleagues18 demonstrated that patients
with perforated appendicitis proceeded to surgery more rapidly than those
with nonperforated appendicitis (6.5 vs 9 hours), but perforated patients had
significantly longer prehospital symptoms (57 vs 22 hours). That is, longer
duration of prehospital delay is the major contributor to perforation rather
than delayed in-hospital diagnosis.20,21
Some epidemiologic work highlights unsolved aspects of the mechanism
of progression from nonperforated to perforated appendicitis. A study of US
discharges in the National Hospital Discharge Survey notes that, although the
incidence of nonperforated appendicitis has continued to decrease over time,
the incidence of perforated appendicitis has slowly increased, despite the
increasing and nearly pervasive availability of cross-sectional imaging and
minimally invasive surgery.22 The authors suggest that this divergence in
trends may indicate an underlying difference in pathophysiology between
perforated and nonperforated appendicitis, rather than simply a difference in
duration of disease.

Diagnosis
PRESENTATION
Although acute appendicitis is the most common surgically correctable cause
of abdominal pain, its diagnosis remains challenging in many instances.
Presenting signs and symptoms are variable and often initially subtle.
Arriving at the correct diagnosis is essential, however, as a delay in diagnosis
may allow progression to increasingly complex disease with concomitantly
elevated morbidity and mortality. Conversely, incorrectly diagnosing
appendicitis, although not catastrophic, subjects the patient to a potentially
unnecessary operation.
The classic presentation of acute appendicitis begins with cramping,
intermittent abdominal pain, thought to be due to obstruction of the
appendiceal lumen, as nociceptors supplying the visceral peritoneum are
stimulated by stretch. Classically, in 12 to 24 hours, the pain migrates to the
RLQ as transmural inflammation of the appendix leads to inflammation of
the peritoneal lining of the right lower abdomen. The character of the pain
also changes from dull and colicky to sharp and constant. Movement or

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Valsalva maneuver often worsens this pain, so that the patient typically
desires to lie still; some patients describe pain with every bump in the car or
ambulance ride to the hospital.
The prototypical patient with appendicitis initially endorses pain that is
periumbilical or diffuse and difficult to localize. The onset of pain is typically
followed shortly thereafter with nausea. Vomiting may or may not be present.
If nausea and vomiting precede the pain, the astute clinician should consider
another diagnosis, such as gastroenteritis. Upon detailed questioning, patients
who have appendicitis commonly report anorexia, and appendicitis is
unlikely in those with a normal appetite. Patients may report low-grade fever,
while higher temperatures and shaking chills might again alert the surgeon to
consider other diagnoses, including appendiceal perforation or
nonappendiceal sources of abdominal pain.

PHYSICAL EXAMINATION
On inspection, patients with acute appendicitis appear mildly ill, feel warm to
the touch, and have a slightly elevated pulse. They often lie still to avoid the
irritation to the parietal peritoneum caused by movement. The surgeon should
systematically examine the entire abdomen, starting in the left upper quadrant
away from the patient’s described pain. Maximal tenderness is typically in
the RLQ, at or near McBurney’s point, located one-third of the way from the
anterior superior iliac spine to the umbilicus. This tenderness is often
associated with localized muscle rigidity and signs of peritoneal
inflammation, including rebound, shake, or tap tenderness. RLQ tenderness is
one of the most specific of all signs of acute appendicitis.23 Its presence
should always prompt diagnostic consideration of appendicitis, even in the
absence of other signs and symptoms. Because of the various anatomic
locations of the appendix, however, it is possible for the tenderness to be in
the right flank, RUQ, suprapubic region, or left lower quadrant. Patients with
a retrocecal or pelvic appendix may lack abdominal tenderness to palpation.
In such cases, digital rectal examination can potentially be helpful to elicit
right-sided pelvic tenderness. However, in general, digital rectal exam is an
inaccurate assessment tool for diagnosing appendicitis.24
Multiple physical exam signs contribute uniquely to the diagnosis of acute
appendicitis. The Rovsing sign, or pain in the RLQ that occurs with release of
applied pressure to the left lower quadrant, results from focal peritoneal

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inflammation in the RLQ. Psoas sign, or pain with right hip flexion, can be
seen with a retrocecal appendix due to inflammation adjacent to the iliopsoas
muscle group. The obturator sign, or pain with internal rotation of the flexed
right thigh, indicates inflammation adjacent to the obturator internus muscle
in the pelvis.
However, many patients with acute appendicitis do not endorse the
aforementioned typical history and physical examination. In practice, the
surgeon is frequently reminded that the classic presentation of acute
appendicitis is not universally present. For instance, the initial vague colicky
pain may be overlooked or forgotten. When the pain becomes constant, it
may localize to quadrants of the abdomen other than the RLQ due to
alteration in appendiceal anatomy, as with late pregnancy or underlying
malrotation. Among patients with a retrocecal appendix, the pain may not
localize until generalized peritonitis from perforation occurs. Increased
urinary or bowel frequency may occur due to appendiceal inflammation
irritating the adjacent bladder or rectum. Because appendicitis is so common,
a high index of suspicion for appendicitis is warranted in nearly all patients
with abdominal pain. At the same time, because the differential diagnosis of
appendicitis is extensive, patients should be queried about certain symptoms
that may suggest an alternative diagnosis. Surgeons must also remember that
a previous appendectomy does not definitively exclude the diagnosis of
appendicitis, as “stump appendicitis” (appendicitis in the remaining
appendiceal stump after appendectomy), although rare, has been described.25

SYMPTOMS AND SIGNS OF PERFORATED

APPENDICITIS
When acute appendicitis has progressed to appendiceal perforation, other
symptoms may be present. Patients will often endorse 2 or more days of
abdominal pain. The pain usually localizes to the RLQ if the perforation has
been walled off by surrounding intra-abdominal structures including the
omentum, but it may be diffuse if generalized peritonitis ensues. The pain
may become so severe that patients do not remember the antecedent colicky
pain. A history of poor oral intake and dehydration may also be present.
In cases of perforated appendicitis, patients can look gravely ill. Patients
with perforation often have rigors and high fevers. On physical examination,
patients may appear flushed with dry mucous membranes. If a systemic

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inflammatory response ensues, tachycardia and blood pressure depression
will eventually occur in the absence of treatment. If the perforation has been
walled off by surrounding structures to create an abscess or phlegmon, a mass
may be palpable in the RLQ. Finally, if free intraperitoneal rupture has
occurred, the patient can demonstrate signs of generalized peritonitis with
diffuse rebound tenderness.
While most patients with perforated appendicitis present with symptoms
related to the inflamed appendix itself or to a localized intraperitoneal abscess
from perforation, other more rare presentations may occur. These are most
likely to occur in the very young and very old, who may be unable to
describe their symptoms and often present late in the course of their disease.
On occasion, patients will present with bilious vomiting and obstipation due
to a small bowel obstruction resulting from appendiceal perforation.
Infectious complications can occur as well. A retroperitoneal abscess can
form due to perforation of a retrocecal appendix. Alternatively, a hepatic
abscess can form due to hematogenous seeding through the portal venous
system. An intraperitoneal abscess may fistulize to the skin, resulting in an
colocutaneous fistula. Finally, pylephlebitis (septic portal vein thrombosis)
presents with high fevers and jaundice and can be confused with cholangitis;
it is a rare dreaded complication of acute appendicitis and carries a high
mortality.26

LABORATORY STUDIES
Laboratory studies contribute to the diagnosis of appendicitis, but no single
test is definitive. A white blood cell (WBC) count is perhaps the most useful
laboratory test. Typically, the WBC is slightly elevated in nonperforated
appendicitis but may be quite elevated in the presence of perforation. The
clinician must remember, however, that the WBC can be normal in patients
with acute appendicitis, particularly in early cases. Although a late diagnostic
sign, serial WBC measurements commonly demonstrate a rising value over
time among patients with appendicitis.27 Urinalysis is performed to evaluate
other potential causes for abdominal pain, specifically urinary tract infection
and ureterolithiasis. Significant hematuria with colicky abdominal pain and
the inability to find a comfortable resting position suggest the alternative
diagnosis of ureterolithiasis. A urinary tract infection, on the other hand, is
not uncommon in patients with appendicitis. It is not uncommon for the

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urinalysis in a patient with appendicitis to show some degree of pyuria or
hematuria due to inflammation of the ureter by the adjacent appendix. As
such, its presence does not exclude the diagnosis of acute appendicitis, but it
should be identified and treated.
In certain clinical situations, other laboratory tests are indicated.
Measurement of serum liver enzymes and amylase can be helpful in
diagnosing liver, gallbladder, or pancreatic disease for patients endorsing
midabdominal or RUQ pain. Among women of childbearing age, the urine β-
human chorionic gonadotropin should be checked to alert the clinician to the
possibility of ectopic or concurrent pregnancy. Ectopic pregnancy is another
cause of RLQ pain that demands emergent diagnosis and treatment.
Concurrent pregnancy should be identified before a patient with suspected
appendicitis is subjected to ionizing radiation from imaging studies or to
general anesthesia.

DIAGNOSTIC SCORES
Diagnostic scoring systems have been developed in attempts to improve the
diagnostic accuracy of acute appendicitis.28 The most prominent of those
scores, developed by Alvarado,28 was based on a retrospective analysis of
305 patients with abdominal pain suspicious for appendicitis (Table 41-1).
This scoring system assigns points for symptoms (migration of pain, anorexia
or urine acetone, and nausea/emesis), physical signs (RLQ tenderness to
palpation, rebound tenderness, and pyrexia), and laboratory values
(leukocytosis and a left shift). One prospective study reported that an
Alvarado score ≥7 in male patients or ≥9 in female patients was equivalent to
computed tomography (CT) imaging consistent with acute appendicitis.29
Although these scores can help guide clinical thinking, they do not markedly
improve diagnostic accuracy.30 With the recent improvement in imaging
studies, these scores have become increasingly marginalized.

TABLE 41-1: ALVARADO SCORING SYSTEM FOR ACUTE APPENDICITIS28

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IMAGING STUDIES
The potential imaging modalities currently used for the diagnosis of acute
appendicitis include ultrasound (US), CT, and magnetic resonance imaging
(MRI). Of historic note, prior to the widespread use of modern imaging
techniques, an RLQ fecalith (or appendicolith) on abdominal plain film was
considered pathognomonic for acute appendicitis. However, identification of
a fecalith on abdominal plain film is not a specific or sensitive sign for acute
appendicitis. Teicher and colleagues31 reviewed the abdominal radiographs of
100 patients who underwent negative appendectomy and 100 patients who
underwent appendectomy with pathologically proven appendicitis. Of those
with appendicitis, 11% had an appendicolith on x-ray, compared to 3% of
those without appendicitis. Similarly, an extensive review of appendectomy
specimens at the Mayo Clinic16 showed that fecaliths or appendiceal calculi
were present in 9% of patients with nonperforated appendicitis and 21% of
those with perforated appendicitis. Fecaliths were also present in 7% of
patients with suspected appendicitis who had a pathologically normal
appendix and in 2% of patients who had an appendectomy for other reasons.
These data suggest that plain abdominal radiographs are neither helpful nor
cost-effective and, as such, are not recommended for the diagnosis of acute
appendicitis. Plain radiographs may be indicated for evaluation of possible

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perforated viscus, especially in certain patient populations such elderly
patients with severe abdominal pain.
Abdominal ultrasonography is an important imaging modality for the
diagnosis of acute appendicitis. A recent meta-analysis of 14 prospective
studies showed US to have an overall sensitivity and specificity of 86% and
81%, respectively.32 Findings that suggest appendicitis include thickening of
the appendiceal wall, loss of wall compressibility, increased echogenicity of
the surrounding fat signifying inflammation, and loculated pericecal fluid
(Fig. 41-3). The advantages of US include its widespread availability and the
avoidance of ionizing radiation and the side effects of intravenous contrast,
such as renal toxicity and allergic reactions. In addition, US (both abdominal
and transvaginal) is particularly useful in assessing obstetric and gynecologic
causes of abdominal pain in women of childbearing age. US is highly
operator-dependent, however, and it is frequently unable to visualize the
normal appendix.33 In the current epidemic of overweight and obesity in the
United States, body habitus also limits the utility of US in the diagnosis of
appendicitis, especially among patients with increasing body mass index
(BMI).34

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FIGURE 41-3 Appendiceal ultrasound showing distended, noncompressible
appendix measuring 1.7 cm in transverse dimension (>0.6 cm is abnormal).
(Used with permission from M. Stephen Ledbetter, MD, MPH, Brigham and Women’s Hospital,
Boston, MA.)

CT is the most frequently used imaging modality for the evaluation of

acute appendicitis. CT benefits from a high diagnostic accuracy for
appendicitis32 as well as visualization and diagnosis of many of the other
causes of abdominal pain that can be confused with appendicitis. The
radiographic findings of appendicitis on CT include a dilated (>6 mm), thick-
walled appendix that does not fill with enteric contrast or air, as well as
surrounding fat stranding to suggest inflammation (Fig. 41-4).35 In a meta-
analysis of 12 prospective studies, CT demonstrated a sensitivity of 94% and
a specificity of 95%.32 Appendicitis is highly unlikely if enteric contrast fills

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the lumen of the appendix and no surrounding inflammation is present.
However, the clinician must remember that a CT performed early in the
course of appendicitis might not show the typical radiographic findings.

FIGURE 41-4 Computed tomography of acute appendicitis. The arrow

points to an enlarged, fluid-filled appendix with wall hyperemia that does not
fill with oral contrast. The paucity of intra-abdominal fat limits identification
of fat stranding. (Used with permission from M. Stephen Ledbetter, MD, MPH, Brigham and
Women’s Hospital, Boston, MA.)

While CT imaging may rule out alternative diagnoses or assist in operative

planning, it is important to note that CT imaging only reduces the rate of
negative appendectomy among certain patients. Wagner and colleagues36
conducted a review of over 1400 patients who underwent appendectomy for
suspected acute appendicitis. The authors discovered that preoperative CT
was associated with a lower rate of negative appendectomy only for adult
female patients, but not for adult male patients or children.36
A number of prospective studies have compared the accuracy of CT and
US in imaging the appendix (Table 41-2).33,37,38 Balthazar and colleagues37
performed CT and US on 100 consecutive patients with suspected
appendicitis. The sensitivity of CT was considerably higher (96% for CT vs
76% for US), whereas the specificity was comparable (89% for CT vs 91%
for US), yielding a higher accuracy for CT (94% for CT vs 83% for US). CT

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was also able to provide an alternative diagnosis in more patients and was
better able to visualize an abscess or phlegmon (Fig. 41-5). Horton and
colleagues38 randomized patients with suspected appendicitis to either CT or
US. Their findings echo those of Balthazar, with both CT and US having high
specificity (100% for CT vs 90% for US), but CT demonstrating significantly
higher sensitivity than US (97% for CT vs 76% for US). Yet another
prospective study showed similar results, with CT having higher sensitivity
(96% for CT vs 62% for US) and specificity (92% for CT vs 71% for US)
than US33 and better ability to visualize other intra-abdominal pathology in
the absence of appendicitis.

FIGURE 41-5 Computed tomography of perforated appendix. Note

retrocecal abscess (arrows) with enhancing wall and periappendiceal fat
stranding and adjacent cecal thickening (arrowhead). (Used with permission from M.
Stephen Ledbetter, MD, MPH, Brigham and Women’s Hospital, Boston, MA.)

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 TABLE 41-2: ACCURACY OF CT AND US FOR THE DIAGNOSIS OF ACUTE
APPENDICITIS

Taken together, these studies suggest an algorithm for evaluation of

patients with suspected acute appendicitis. Patients with a history, physical
examination, and laboratory studies consistent with appendicitis should
undergo appendectomy based on clinical judgment. In those with an
evaluation suggestive but not convincing for appendicitis, further imaging is
warranted. In women of childbearing age, this should begin with a pelvic US
to evaluate for ovarian pathology. For other patients, transabdominal US
should be considered initially with a subsequent abdominopelvic CT scan if
the diagnosis remains questionable or an intra-abdominal abscess/phlegmon
requires better evaluation. Rectal contrast CT is rarely needed but can be
employed to better visualize the appendix.33,35 Patients with a CT showing
nonperforated appendicitis should undergo appendectomy. In many instances,
patients with a normal CT do not require hospital admission. If symptoms
persist, admission to the hospital for observation is warranted. Imaging
modalities that avoid ionizing radiation may be preferentially used among
children and pregnant patients, as discussed below.

DIFFERENTIAL DIAGNOSIS
Because many of its signs and symptoms are nonspecific, the differential
diagnosis of acute appendicitis is extensive and includes both abdominal and
nonabdominal sources of pain (Table 41-3). However, some diagnoses are
more likely than others in certain settings. Meckel diverticulitis causes
similar symptoms with the possible addition of episodic painless
hematochezia but is relatively uncommon.39 Gastroenteritis is considerably

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more common and should be expected when nausea and vomiting precede the
abdominal pain or when diarrhea is a prominent symptom. Crohn’s disease
affecting the terminal ileum may resemble appendicitis in its initial
presentation, but on further questioning, the patient may describe a subacute
course, including fever, weight loss, and pain.

TABLE 41-3: DIFFERENTIAL DIAGNOSIS OF ACUTE APPENDICITIS

Gastrointestinal causes
Cecal diverticulitis
Sigmoid diverticulitis
Meckel diverticulitis
Epiploic appendicitis
Mesenteric adenitis
Omental torsion
Crohn’s disease
Cecal carcinoma
Appendiceal neoplasm
Lymphoma
Typhlitis
Small bowel obstruction
Perforated duodenal ulcer
Internal hernia
Intussusception
Acute cholecystitis
Hepatitis
Pancreatitis
Infectious causes
Infectious terminal ileitis (Yersinia, tuberculosis, or cytomegalovirus)
Gastroenteritis
Cytomegalovirus colitis
Genitourinary causes
Pyelonephritis or perinephric abscess

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Nephrolithiasis
Hydronephrosis
Urinary tract infection
Nonabdominal causes
Streptococcal pharyngitis
Lower lobe pneumonia
Rectus muscle hematoma
In women
Ovarian cyst (ruptured or not ruptured)
Corpus luteal cyst (ruptured or not ruptured)
Ovarian torsion
Endometriosis
Pelvic inflammatory disease
Tubo-ovarian abscess
In pregnancy
Ectopic pregnancy
Round ligament pain
Chorioamnionitis
Placental abruption
Preterm labor

In middle-aged and older adults, other inflammatory conditions should be

considered, including gastric or duodenal ulcer (with symptoms from fluid
tracking into the right paracolic gutter), cholecystitis, and pancreatitis. In
addition, the symptoms of cecal or sigmoid diverticulitis overlap with those
of acute appendicitis. Cecal diverticula, like the appendix, are true diverticula
containing all layers of the intestinal wall. Cecal diverticulitis, intuitively, is
similar in pathogenesis and presentation to appendicitis. Because a redundant,
floppy sigmoid colon can extend to the right side of the abdomen, patients
with sigmoid diverticulitis can sometimes present with RLQ pain. Those
patients typically describe a more rapid progression to localized tenderness,
as well as a prodrome of alteration in bowel habits. Malignancies can present
with acute RLQ pain due to perforation of a cecal carcinoma or appendicitis
caused by tumor obstructing the appendiceal orifice. Such patients will also

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often have guaiac-positive stools, anemia, and a history of weight loss.
In women of childbearing years, diagnosing the underlying cause of RLQ
pain can be even more difficult. In addition to the causes of RLQ pain
mentioned above, young women can also have pain from obstetric and
gynecologic etiologies such as ruptured ovarian cyst or follicle, ovarian
torsion, ectopic pregnancy, acute salpingitis, and tubo-ovarian abscess. A
complete history including recent menstrual history, as well as pelvic
examination, can be helpful in differentiating these causes of pain from acute
appendicitis. Nonetheless, appendicitis can be difficult to diagnose in this
patient population, and higher rates of misdiagnosis have been described in
women of childbearing age.40

SPECIAL CONSIDERATIONS

Children
In the pediatric population, appendicitis most commonly afflicts children age
10 to 19 years, with an overall incidence of approximately 20 cases per
10,000 person-years.12 By age 20, approximately 4% of children and
adolescents will have undergone an appendectomy.41 Among those younger
than 20, infants age 0 to 4 have the lowest incidence of appendicitis (2 cases
per 10,000 person-years), but up to two-thirds will present with perforation.42
Perforation is disproportionately common because infants often present later
in their disease course due to the difficulty inherent in obtaining an accurate
history. The diagnosis is further complicated by diseases of childhood that
can mimic appendicitis. For instance, mesenteric adenitis, or inflammation of
the mesenteric lymph nodes, can present with fever and RLQ pain.
Streptococcal pharyngitis and bacterial meningitis can also present with
fever, nausea, and abdominal pain. These diagnoses and others including
ovarian cysts, ovarian torsion, urinary tract infection, pelvic inflammatory
disease, and complications of a Meckel diverticulum should be considered
when evaluating children or adolescents for suspected appendicitis.
For the many children with an equivocal history, physical examination,
and laboratory data, imaging with US is the preferred initial study.43 US lacks
ionizing radiation, does not require contrast or sedation, and is relatively

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inexpensive. Unfortunately, however, ultrasonography is operator dependent.
A meta-analysis by Doria and colleagues44 of over 7000 patients documents a
pooled sensitivity and specificity of 88% (95% confidence interval [CI],
86%-90%) and 94% (95% CI, 92%-95%), respectively, for the sonographic
diagnosis of appendicitis. An important determinant in the diagnostic success
of US is BMI of the child. The sensitivity of US has been reported to be 76%
for children with a BMI below 25, but as low as 37% for children with a BMI
of greater than 25. US had 82% sensitivity for appendicitis in one study in
which the patient population had a mean BMI of 17.45-47
When US results are indeterminate, cross-sectional imaging with MRI or
CT can help identify intra-abdominal pathology. MRI warrants consideration
as the preferred second-line imaging test among children with suspected
appendicitis, provided that the modality and its interpretation are
institutionally available, the child is clinically stable, and the child is of old
enough age to tolerate lying still for a relatively lengthy study. MRI lacks
ionizing radiation and has at least equivalent sensitivity and specificity to CT.
In a single-institution study of 510 MRIs, Kulaylat and colleagues48 reported
both a sensitivity and specificity of 97% for the diagnosis of acute
appendicitis. The median imaging duration was 11 minutes. In comparison,
CT has the benefits of nearly universal availability, ease of interpretation, and
rapid examination. ++However, ionizing radiation from CT in childhood
theoretically causes a small increase in the lifetime risk of certain cancers.49
Based on estimated radiation exposure from a CT scan, studies have
hypothesized that a 1-year-old and 15-year-old would theoretically develop a
0.18% and 0.11% lifetime risk, respectively, of fatal radiation-induced
malignancy following a CT scan.45 A recent study by Pearce and
colleagues50 studied the long-term outcomes of patients under age 22 who
underwent CT examination between 1985 and 2002. The authors reported
one excess occurrence of leukemia and one excess occurrence of a brain
tumor per 10,000 head CTs. Despite this association between ionizing
radiation and malignancy, the retrospective nature of the available research
and the small magnitude of the absolute risk of malignancy (given the low
overall rate) should be emphasized. Therefore, clinicians should consider the
risks and benefits of MRI and CT, and efforts should be directed toward
reducing radiation dose when imaging children.51
There is substantial variability in usage of imaging modalities. For

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example, in a study by Rice-Townsend and colleagues of data from the
Pediatric Health Information System database, hospital utilization of
preoperative imaging with CT or US ranged from 21% to 73%.52 In efforts to
systematically reduce such variation, Rangel and colleagues proposed an
algorithm to diminish the utilization of CT imaging for children with
suspected appendicitis. Incorporating laboratory tests and US findings, the
rate of CT utilization was substantially decreased, from 21% to 4%, with an
unchanged rate of negative appendectomy.53

Elderly
Although appendicitis is more common in younger age groups, it is an
important cause of abdominal pain in the elderly. Perhaps because of a
diminished inflammatory response, the elderly can present with less
impressive symptoms and physical signs, longer duration of symptoms, and
decreased leukocytosis compared to younger patients.54 Perforation is thus
more common, occurring in as many as 50% of patients older than 65.12
These patients may have cardiac, pulmonary, renal, and other comorbidities,
resulting in considerable potential morbidity and mortality from perforation.
In one series, the mortality from perforated appendicitis in patients older than
80 was 21%.55 These factors argue that RLQ pain in elderly patients must be
efficiently investigated. Because of the multiple other possible causes of
abdominal pain in this patient population (including malignancy,
diverticulitis, and perforated peptic ulcer disease), prompt CT scan should be
considered when the diagnosis is in question.

Pregnancy
The diagnosis of acute appendicitis in the pregnant patient can be particularly
challenging, as nausea, anorexia, and abdominal pain may be symptoms of
appendicitis, abnormal pregnancy, and normal pregnancy. The differential
diagnosis of appendicitis includes not only the conditions possible in
nonpregnant women but also certain conditions specific to pregnancy: ectopic
pregnancy, chorioamnionitis, preterm labor, placental abruption, and round
ligament pain. In addition, the gravid uterus can displace the abdominal
viscera, shifting the location of the appendix cephalad from the RLQ.

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Appendicitis affects 1 in every 1400 pregnant women.56 It can occur in any
trimester, with perhaps a slight increase in frequency during the second
trimester.57 Perforation is most common in the third trimester, potentially
resulting from a longer duration from the onset of symptoms to operation.57
In the first and early second trimesters, the presentation of appendicitis is
similar to that seen in nonpregnant women. In the third trimester, women
may not present with RLQ pain due to cephalad displacement of the appendix
by the gravid uterus. Baer and colleagues performed barium enemas on
normal pregnant women and found the appendix to migrate superiorly toward
the RUQ in later stages of pregnancy.58 Their findings suggest that
appendicitis may present with RUQ or flank pain in late pregnancy. Two
retrospective studies note that symptoms do not always reflect this cephalad
displacement, however. Even in the third trimester, pain and tenderness are
more common in the right lower quadrant than the RUQ.56
Several studies highlight the difficulty of clinically diagnosing a pregnant
patient with appendicitis. Brown and colleagues59 reviewed case-control
studies that defined the relationship between preoperative presentation and
the postoperative diagnosis of appendicitis in pregnant patients. Although
patients presented with RUQ pain, RLQ pain, and fevers, only nausea,
vomiting, and peritonitis were found to significantly correlate with the
diagnosis of appendicitis. Furthermore, laboratory values are altered in the
setting of pregnancy, and leukocytosis (including with a neutrophilic
predominance) can be a normal finding.60
Given the challenge of clinically diagnosing appendicitis in pregnancy,
imaging is critical. US is accurate in pregnancy61 and is a useful radiologic
study because it has no known adverse fetal effects.62 However,
nonvisualization of the appendix is a frequent problem, especially in
increasingly advanced gestations.63 In the setting of an US equivocal for
appendicitis, MRI is an excellent modality. Like US, to date, no adverse
effects of MRI on the developing fetus have been reported.64
In a retrospective, multicenter study of 709 pregnant women with
abdominal pain who underwent MRI for the evaluation of acute appendicitis,
66 (9%) had MRI findings consistent with appendicitis. The authors report
sensitivity and specificity rates of 97% and 99%, respectively.65 Gadolinium
should be avoided due to potential for teratogenicity. If MRI is unavailable or
will cause an extreme delay in management, CT imaging of pregnant patients

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with suspected appendicitis can and should be performed. The risk of
radiation should be weighed against the risk of spontaneous abortion from an
unnecessary laparotomy or from undiagnosed appendicitis progressing to
perforation. Although ionizing radiation has risks to the fetus, the radiation
from a typical abdominopelvic CT is below the threshold of 5 rad (50 mGy)
at which teratogenic effects are seen.66 Furthermore, CT imaging protocols
can be modified to reduce the amount of fetal radiation, without impacting
diagnostic value.67
The pregnant patient should proceed directly to appendectomy if
appendicitis is suspected. A normal appendix is not an uncommon finding, as
negative appendectomy has been reported in approximately one-third of cases
due to the difficulty of diagnosis in this population.56 Negative
appendectomy should not be considered an error in management, because the
risk to the fetus varies directly with the severity and progression of
appendicitis. In a large California inpatient database, the fetal loss rate after
negative appendectomy was 4%.56,68 However, fetal mortality was 2% to 5%
in cases of nonperforated appendicitis and 6% to 35% in cases of perforated
appendicitis.59 These data warrant an expedited approach to appendectomy
that favors operation.
As laparoscopic appendectomy has become increasingly popular, the
technique has been adapted to appendectomy in pregnancy.69 Pregnancy can
increase the complexity of the procedure, as the gravid uterus can make
laparoscopic visualization difficult, particularly if the appendix is located in
the pelvis. In addition, carbon dioxide insufflation of the abdomen results in
fetal hypercarbia and decreased placental blood flow, the effects of which
have not been completely studied.70 A meta-analysis including 11 studies
from 1990 to 2011 with 3415 patients estimated a 91% higher relative risk of
fetal loss in the laparoscopic group compared with the open appendectomy
group.71 However, a more recent retrospective review from 2009 directly
comparing laparoscopic to open appendectomy in 42 pregnant women found
no intra- or postoperative complications in either group and 1 fetal loss in
both groups.72 Given the large time frame and retrospective nature of
included studies in the aforementioned meta-analysis, the conclusions drawn
from this synthesis are limited. Caution should be exercised when selecting
surgical approach to appendectomy during pregnancy. Furthermore, certain
risk-minimizing measures should be taken, such as limiting the degree of

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pneumoperitoneum. After uncomplicated appendectomy, there do not appear
to be any lasting effects on child development. Choi and colleagues
prospectively studied pregnant women who underwent appendectomy.73 Of
29 patients who delivered without complication (1 fetal death occurred due to
extreme prematurity) and completed a detailed study survey of
developmental milestones, none indicated developmental delay for their
child, with a mean follow-up time of nearly 4 years.

Immunocompromise
The immunocompromised state alters the normal response to acute infection
and wound healing. Appendicitis must be considered among those with
abdominal pain who have undergone organ transplantation, are receiving
chemotherapy, have a hematologic malignancy, or have decreased CD4 cell
counts due to infection with the human immunodeficiency virus (HIV). The
differential diagnosis of abdominal pain in the immunosuppressed population
is broad and includes hepatitis, pancreatitis (from medications or
cytomegalovirus infection), acalculous cholecystitis, intra-abdominal
opportunistic infections (cytomegalovirus colitis or mycobacterial ileitis),
secondary malignancies (lymphoma or Kaposi sarcoma), graft-versus-host
disease, and typhlitis. This broad differential diagnosis often results in delay
in diagnosis and late presentation to surgical evaluation, at which time
perforation may be more likely.74
Appendicitis in patients with HIV and acquired immunodeficiency
syndrome (AIDS) presents unique challenges. Abdominal pain is not an
uncommon symptom in these patients, making differentiation between
surgical and nonsurgical causes difficult. Nonetheless, immunocompromised
patients with appendicitis present with symptoms similar to those of the
general population, including RLQ pain, nausea, and anorexia. Fever and
WBC may not be helpful in this population given the underlying poor
immune response. Therefore, imaging studies, particularly CT, have been
supported by some authors.74 There is no specific contraindication to
operation in immunocompromised patients. Once diagnosed with
appendicitis, appendectomy should be performed promptly.

TREATMENT

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Nonoperative Management
Appendectomy was one of the first intra-abdominal operations performed,
and appendicitis has since been a surgically treated disease. Historically,
Treves was an advocate of early nonoperative management of acute
appendicitis, even prior to the advent of antibiotics.10 In the postantibiotic
era, Coldrey75 presented his retrospective series of 471 patients with
appendicitis treated with antibiotics. This treatment failed in at least 57
patients, with 48 requiring appendectomy and 9 requiring drainage of an
appendiceal abscess. Decades after this 1959 study, interest in nonoperative
management (NOM) has reemerged, based on the results of several
randomized controlled trials. NOM is currently a topic of controversy in the
contemporary management of acute appendicitis.
Recent data suggest that NOM with intravenous antibiotics may present an
alternative to appendectomy. This management strategy parallels the
treatment of sigmoid diverticulitis and is based on work suggesting that
nonperforated and perforated appendicitis are distinct diseases.22 Potential
benefits of NOM derive from the upfront avoidance of an invasive procedure,
which must be weighed against the risk of immediate progression of disease
as well as the long-term risk of recurrent appendicitis. Given the association
between appendicolith and complicated appendicitis, patients with this
imaging finding should not undergo NOM.76,77 Similarly, these data on NOM
do not necessarily apply to other high-risk patients, such as pregnant patients,
the immunosuppressed, and the elderly. On the other hand, antibiotic
treatment is a useful temporizing measure in environments with no surgical
capabilities such as in space flight and submarine travel.78 Of note, early data
suggest feasibility of NOM among children with acute appendicitis. A recent
prospective, nonrandomized cohort study was conducted of 102 children 7 to
17 years of age with suspected uncomplicated acute appendicitis who were
offered the choice of NOM and appendectomy. Among children who
underwent NOM, the 1-year rate of appendectomy (ie, 1-year failure rate of
NOM) was 24%.79 Potential benefits of NOM in the pediatric population
were found to be fewer disability days and lower health care costs related to
treatment of appendicitis at 1 year after diagnosis, despite longer initial length
of hospital stay.79,80
There are several important issues to highlight when considering NOM.

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First, laparoscopic (or open) appendectomy for uncomplicated acute
appendicitis is a safe procedure, performed with very low levels of
complication. Second, recurrence rates after NOM can be as high as 35%.81
In the recent Appendicitis Acuta (APPAC) study (described below), the
recurrence rate of 27% exceeded the predefined threshold of an unacceptably
high rate of recurrent appendicitis.82 In addition, imaging alone has a
substantial false-negative rate for diagnosing perforated appendicitis.77 For
example, in a 2011 trial by Vons and colleagues,77 18% of patients who
underwent appendectomy were unexpectedly found to have perforated
appendicitis and peritonitis at the time of operation. Finally, NOM does not
assess the presence of appendiceal neoplasm, which is discovered in as many
as 1.5% of appendectomy specimens.82
An early randomized controlled trial, performed by Eriksson and
associates,81 first sought to evaluate the comparative effectiveness of NOM
and appendectomy in 1995. The authors randomized 40 adults with presumed
appendicitis to appendectomy or 10 days of intravenous and oral antibiotics.
The results included a high rate of recurrent appendicitis after NOM. Eight
(40%) of the 20 patients in the antibiotic group required appendectomy
within 1 year: 1 patient for perforation within 12 hours of randomization and
another 7 for recurrent appendicitis (1 of whom had perforation).
Since then, several other randomized controlled trials have addressed this
same question. Table 41-4 displays the characteristics of 6 important
randomized trials comparing the effectiveness of appendectomy and NOM.81-
86 These data generally suggest fewer workdays lost with NOM and

decreased duration and severity of abdominal pain. Initial cost may also be
decreased with NOM, although long-term cost in the setting of recurrence
and the need for close follow-up is challenging to define. In contradistinction,
length of hospital stay tended to be lower with appendectomy. Neoplasm was
detected after 0.5% to 1.5% of appendectomies. Recurrence rates after NOM
ranged from 8% to 32%. This is consistent with a recent meta-analysis, in
which the likelihood of failure was 23%.83

TABLE 41-4: STUDIES COMPARING NONOPERATIVE AND OPERATIVE

MANAGEMENT OF ACUTE APPENDICITIS

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 The most recent and largest to date randomized controlled trial was a
noninferiority study by Salminen and colleagues.82 The APPAC trial was
performed in 6 Finnish hospitals between 2009 and 2012. The researchers
evaluated the effectiveness of antibiotic therapy (intravenous ertapenem for 3
days followed by oral levofloxacin and metronidazole for 7 days) versus open
appendectomy (laparoscopic appendectomy was performed only 5% of the
time) as the primary treatment for uncomplicated acute appendicitis among
nonpregnant patients age 18 to 60 years. Patients with evidence of fecaliths,
perforation, abscess, or tumor on CT imaging were excluded. Among patients
randomized to NOM, the primary end point was need for appendectomy and
recurrent appendicitis during 1-year of follow-up. Based on existing
literature, the threshold for noninferiority was set at 24%. There were 273 and
257 patients randomized to appendectomy and NOM, respectively.82
Appendectomy was a successful management strategy 99.6% of the time. In
the NOM cohort, 27.3% of patients required an appendectomy within the first
year of follow-up, exceeding the a priori threshold for noninferiority. Those
with recurrent appendicitis underwent appendectomy at a median of 102 days
after initial treatment. The complication rate after appendectomy for recurrent
appendicitis in the NOM cohort was relatively low at 7%, compared to a
complication rate of 20% in the appendectomy cohort. While this difference
was statistically significant, many complications were minor, including
superficial surgical site infection and pain-related symptoms. Appendiceal
neoplasms were intraoperatively discovered in 1.5% of patients in the
appendectomy cohort.
In summary, currently available data show a moderately high rate of

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recurrence of appendicitis with NOM and a small but important risk of
malignancy. As such, for the majority of patients with uncomplicated acute
appendicitis, laparoscopic (or open) appendectomy should be considered the
gold standard treatment, while NOM may be offered on a case-by-case basis
in certain circumstances.

Preoperative Preparation
When the decision is made to perform an appendectomy for acute
appendicitis, the patient should proceed to the operating room with little
delay to minimize the chance of progression to perforation. While in-hospital
progression to perforation is rare and most cases of appendiceal perforation
occur prior to surgical evaluation, the operation should nevertheless be
expedited.20,21 Patients with appendicitis may be dehydrated from fever and
poor oral intake. Intravenous fluids should be infused, and vital signs
including urine output should be closely monitored. Markedly dehydrated
patients may require a Foley catheter to ensure accurate urine output
monitoring. Severe electrolyte abnormalities are uncommon with
nonperforated appendicitis, as vomiting and fever have typically been present
for 24 hours or less but may be significant in cases of perforation. Any
electrolyte derangements should be corrected prior to the induction of general
anesthesia.
Intravenous broad-spectrum antibiotics have been shown to significantly
reduce the incidence of postoperative wound infection and intra-abdominal
abscess, including after negative appendectomy.41 Antibiotics should be
administered at the time of diagnosis and re-dosed appropriately. The typical
flora of the appendix resembles that of the colon and includes gram-negative
aerobes (primarily Escherichia coli) and anaerobes (Bacteroides species). No
standardized antibiotic regimen exists. Acceptable options include a second-
generation cephalosporin or a combination of antibiotics directed at gram-
negative bacteria and anaerobes, tailored to institutional antibiogram. In
nonperforated appendicitis, a single preoperative dose of cefoxitin suffices.87
In cases of perforation, an antibiotic course of at least 4 days after source
control is obtained is advocated, in accordance with recent findings from the
randomized controlled Study to Optimize Peritoneal Infection Therapy
(STOP-IT).88

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Laparoscopic Versus Open Appendectomy
Open appendectomy (OA) has been the standard of care for the surgical
management of acute appendicitis since Amyand performed the first
appendectomy in 1736. Little changed in the surgical management of this
disease until Semm developed the laparoscopic appendectomy (LA) in 1980.
Over the ensuing decades, laparoscopy has increasingly taken hold as the
preferred approach to appendectomy. In an analysis of the Nationwide
Inpatient Sample, Masoomi and colleagues89 documented an increase in the
use of laparoscopy for appendectomy over the past decade, from 43% in 2004
to 75% in 2011.
Numerous randomized controlled trials have compared these 2 surgical
approaches, sometimes with conflicting results.90,91 Meta-analyses and
systematic reviews have combined these studies to address the controversy
(Table 41-5).92-94 These meta-analyses have similar findings, which can be
summarized as follows: (1) OA can be performed more quickly; (2) LA
patients have less postoperative pain and reduced narcotic requirements; (3)
there is a trend toward reduced length of stay with LA; (4) LA patients have
fewer wound infections; (5) OA patients develop fewer intra-abdominal
abscesses; (6) LA patients return to work more quickly; (7) operating room
and hospital costs are decreased with OA; and (8) societal costs may be
decreased with LA.92-94 Based on the available data, one cannot definitively
recommend either OA or LA over the other.

TABLE 41-5: LAPAROSCOPIC VERSUS OPEN APPENDECTOMY

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 Laparoscopic appendectomy may be especially advisable for certain
patient populations, including for women of childbearing age, obese patients,
and the elderly. Among women of childbearing age, obstetric and
gynecologic pathology may be clinically indistinguishable from appendicitis,
and a normal appendix is found in more than 40% of patients with suspected
appendicitis.95 However, when a normal appendix was discovered,
gynecologic pathology was found in 73% of women explored
laparoscopically but only 17% of women who had an OA.96 Among such
patients with uncertain diagnosis, laparoscopy can thus be both diagnostic
and therapeutic, avoiding a laparotomy if nonappendiceal pathology is found.
Additionally, laparoscopy warrants consideration among obese patients, for
whom open dissection is more technically challenging. In a National Surgical
Quality Improvement Program (NSQIP) study of obese patients undergoing
appendectomy, Mason and colleagues97 reported a 57% reduction in
morbidity with laparoscopy, compared to the open approach, after adjusting
for preoperative risk factors. For the elderly, LA was found to confer lower
mortality (0.4% vs 2.1%) for uncomplicated appendicitis and a less
complicated postoperative course (shorter length of hospital stay and higher
rate of discharge home) for perforated appendicitis.98 Finally, among
children, Esposito and colleagues99 conducted a literature review, which

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revealed a lower incidence of surgical site infection, lower analgesic use, and
more rapid recovery with laparoscopic, compared to open, appendectomy.
Operative time was longer with laparoscopy than laparotomy for complicated
appendicitis, but not for uncomplicated appendicitis. Ultimately, the decision
of surgical approach to appendectomy should depend on patient factors and
surgeon comfort with the technique.

Laparoscopic Appendectomy
Multiple port placements for LA exist. The authors use a three-port
technique, with an umbilical port, a suprapubic port, and a left lower quadrant
port (alternatively, an RLQ port could be used in the place of the latter).
Although the third port can be placed in either the left lower quadrant or
RLQ, we prefer the left lower quadrant. This follows the laparoscopic
principle of triangulation, such that the port locations direct the camera and
instruments toward the RLQ for optimal visualization of the appendix.
The patient is positioned supine on the operating room table with the left
arm tucked to allow room for both the surgeon and assistant (Fig. 41-6). The
video monitor is placed at the patient’s right side and, once
pneumoperitoneum is performed, the surgeon and assistant both stand on the
patient’s left. Prior to incision, a nasogastric tube and a Foley catheter can be
placed to decompress the stomach and urinary bladder. A Foley catheter can
be avoided if a reliable patient urinates immediately prior to entering the
operating room. A 1- to 2-cm vertical or transverse incision is made just
inferior to the umbilicus and carried down to the midline fascia. A 12-mm
trocar is placed using either Hasson or Veress technique, depending on
surgeon preference. After insufflation of the abdomen and inspection through
the umbilical port, a 5-mm suprapubic port is placed in the midline, taking
care to avoid injury to the bladder. Next, a 5-mm port is placed in the left
lower quadrant. These port sites typically provide excellent cosmesis
postoperatively due to their small size and peripheral location on the
abdomen.

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FIGURE 41-6 Laparoscopic appendectomy technique. A. Patient
positioning, B. Port placement, C. Creation of mesoappendix window, and D.
Transection of the appendix.

A 5-mm, 30-degree laparoscope is inserted through the left lower quadrant

trocar. Placing the laparoscope in the left lower quadrant allows triangulation
of the appendix in the RLQ by instruments placed through the 2 midline
trocars. The surgeon operates the 2 dissecting instruments and the assistant
operates the laparoscope. The appendix is identified at the base of the cecum
at the confluence of the teniae coli. Any adhesions to surrounding structures
can be lysed with a combination of blunt and sharp dissection supplemented
with electrosurgery. If a retrocecal appendix is encountered, division of the

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lateral peritoneal attachments of the cecum to the abdominal wall often
improves visualization. Care must be taken to avoid injury to underlying
retroperitoneal structures, specifically the right ureter and iliac vessels. The
appendix or mesoappendix can be gently grasped with a Babcock clamp
placed through the suprapubic port and retracted anteriorly. A dissecting
forceps placed through the umbilical port creates a window in the
mesoappendix at the appendiceal base. Caution should be taken not to injure
the appendiceal artery during this maneuver, the risk of which can be reduced
by dissecting close to the appendiceal base and out of the mesoappendix. The
base of the appendix should be adequately dissected so that it can be divided
without leaving a significant stump.25 The appendix should be divided at the
confluence of the appendix and cecum, or just onto the cecal wall, to avoid
the possibility of stump appendicitis or mucocele (see Fig. 41-6).
The appendix can be removed in a retrograde fashion, first dividing the
appendix, followed by division of the mesoappendix. A laparoscopic
gastrointestinal anastomosis stapler is placed through the umbilical port and
fired across the appendiceal base. After reloading, the stapler is again inserted
through the umbilical port and placed across the mesoappendix, which is also
divided with firing of the stapler. Alternatively, the appendix can be secured
using an Endoloop100 (Ethicon, Endo-Surgery, Cincinnati, OH) and the
mesoappendix secured with Endoloop, clips or an electrosurgery device. If
desired, the appendix can be removed antegrade by first dividing the
mesoappendix prior to directing attention to the base. The appendix should be
placed in a retrieval bag and removed through the umbilical port site to
minimize the risk of wound infection. The operative field is inspected for
hemostasis and can be irrigated with saline, although irrigation is typically
not necessary. Finally, the fascial defect at the umbilicus is closed with
absorbable 0 suture, and all skin incisions are closed with fine subcuticular
absorbable suture. For nonperforated appendicitis, no further antibiotics are
required.

Open Appendectomy
If OA is chosen, the surgeon must then decide on the location and type of
incision. The patient should be reexamined after the induction of general
anesthesia, which enables deep palpation of the abdomen. If a mass
representing the inflamed appendix can be palpated, the incision can be

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centered at that location. If no appendiceal mass is detected, the incision
should be centered over McBurney’s point, one-third of the distance from the
anterior superior iliac spine to the umbilicus. A curvilinear McBurney’s
incision is made in a natural skin fold to avoid tension on the closure. It is
important not to make the incision too medial or too lateral. An incision
placed too medial opens onto the anterior rectus sheath, rather than the
desired oblique muscles, while an incision placed too lateral may be lateral to
the peritoneal cavity.
The operation proceeds as McBurney first described it in 1894.101 The
incision extends through the subcutaneous tissue, exposing the aponeurosis of
the external oblique muscle, which is divided, either sharply or with
electrosurgery, in the direction of its fibers (Fig. 41-7). A muscle-splitting
technique is typically used, in which the external oblique, internal oblique,
and transversus abdominis muscles are separated along the orientation of
their muscle fibers. The peritoneum is thus exposed, grasped with forceps,
and opened sharply along the orientation of the incision, taking care not to
injure the underlying abdominal contents. Hemostat clamps can be placed on
the peritoneum to facilitate its identification at the time of wound closure.
Cloudy fluid may be encountered on entering the peritoneum. Although some
advocate bacterial culture of the peritoneal fluid, studies show that this
superfluous practice neither helps direct the antibiotic regimen102 nor reduces
infectious complications.103

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FIGURE 41-7 Open appendectomy technique.

With a correctly placed incision, the cecum will be visible at the base of
the wound. The incision should be explored with a finger in an attempt to
locate the appendix. If the appendix is palpable and free from surrounding
structures, it can be delivered through the incision. Frequently, the appendix
is palpable, but adherent to surrounding structures. Filmy adhesions can be
divided using blunt dissection, but thicker adhesions should be divided under
direct vision. The cecum can be partially delivered through the incision to
provide better exposure of the appendix. If necessary to further improve
exposure, the incision can be extended medially by partially dividing the
rectus muscle or laterally by further dividing the oblique and transversus

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abdominis muscles. If the nonpalpable appendix cannot be visualized, it can
be located by following the teniae coli of the cecum to the cecal base, from
which the appendix invariably originates. Once located, the appendix is
delivered through the incision. Grasping the mesoappendix with a Babcock
clamp can sometimes facilitate this maneuver.
The arterial supply to the appendix, which runs in the mesoappendix, is
now clamped, ligated with 3-0 silk suture, and divided. This is usually
performed in an antegrade fashion, from the appendiceal tip toward the base.
As in the laparoscopic approach, adequate dissection is necessary to ensure
that the entire appendix can be removed without leaving an excessively long
appendiceal stump, thereby allowing the potential for stump appendicitis.
In excising the appendix, the surgeon must decide whether or not to invert
the appendiceal stump. Traditionally, the appendix had been ligated and
divided and its stump inverted with a purse-string suture for the theoretical
purpose of avoiding bacterial contamination of the peritoneum and
subsequent adhesion formation.104 However, prospective studies show no
advantage to appendiceal stump inversion.105 In one such study, 735
appendectomy patients were randomly assigned to ligation plus inversion or
simple ligation of the appendiceal stump. There was no difference between
the 2 groups in the incidence of wound infection or adhesion formation, and
operating time was shorter in the simple ligation group. Inversion may also
have the deleterious effect of deforming the cecal wall, which could be
misinterpreted as a cecal mass on future contrast radiographs.105
Furthermore, the long-standing notion that stump inversion reduces
postoperative adhesions was discredited by Street and colleagues.106 In their
analysis, postoperative adhesions requiring operation were significantly
increased in the inversion group.
To divide the appendix, the surgeon can use either suture ligation or a
gastrointestinal stapler. For ligation, 2 hemostat clamps are placed at the base
of the appendix. The clamp closest to the cecum is removed, having crushed
the appendix at that site. Two heavy, absorbable sutures such as 0 chromic
gut are used to doubly ligate the appendix, and the appendix is subsequently
divided proximal to the second clamp. The exposed mucosa of the
appendiceal stump can be cauterized to minimize the theoretical risk of
postoperative mucocele, although no data exist to support this. If appendiceal
stump inversion is chosen, a seromuscular purse-string 3-0 silk suture is

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placed in the cecum around the appendiceal base after ligation but prior to
division of the appendix. The purse-string suture should be placed
approximately 1 cm from the base of the appendix, as placing it too close to
the appendix makes stump inversion difficult. After the appendix is divided,
the purse-string suture is tightened and tied while the assistant uses forceps to
invaginate the appendiceal stump. Alternatively, the appendix can be divided
at its base using a TA-30 stapler. Again, the stump need not be inverted, but
can be if desired, using interrupted Lembert sutures with 3-0 silk suture. No
matter how the appendix is divided, the residual appendiceal stump should be
no longer than 3 mm to minimize the possibility of stump appendicitis in the
future.25
Occasionally, inflammation at the tip of the appendix makes antegrade
removal of the appendix difficult. In such cases, the appendix can be
removed in a retrograde fashion. In so doing, the appendix is divided at its
base using one of the methods described previously. The mesoappendix is
then divided between clamps, starting at the appendiceal base and
progressing toward the tip (Fig. 41-8).

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FIGURE 41-8 Retrograde dissection of the appendix. The base of the
appendix is secured with a pursestring suture, transected, and dissected off
the cecum.

In certain cases, the appendiceal inflammation extends to the base of the

appendix or beyond to the cecum. Division of the appendix through inflamed,
infected tissue leaves the potential for leakage of cecal contents with a
resultant abscess or fistula. Ensuring that the resection margin is grossly free
of active inflammation minimizes this risk. If the base of the cecum is also
inflamed but there is sufficient noninflamed cecum between the appendix and

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the ileocecal valve, an appendectomy with partial cecectomy can be
performed using a stapling device.107 Care should be taken to avoid
narrowing the cecum at the ileocecal valve. If the inflammation extends to the
ileocecal junction, an ileocecectomy with primary anastomosis may be
necessary.
After the appendix is removed, hemostasis is achieved and the RLQ and
pelvis are irrigated with warm saline. The peritoneum is closed with a
continuous 0 absorbable suture. This layer provides no strength but helps to
contain the abdominal contents during abdominal wall closure. The internal
and external oblique muscles are then closed in succession using continuous
0 absorbable suture. To decrease postoperative narcotic requirements, the
external oblique fascia can be infused with local anesthetic. Interrupted
absorbable sutures are typically placed in Scarpa’s fascia, and the skin can be
closed with a subcuticular absorbable suture. With a preoperative dose of
intravenous antibiotics and primary closure of the skin, fewer than 5% of
patients with nonperforated appendicitis can be expected to develop a wound
infection.108

Postoperative Care
Postoperative care is similar after laparoscopic and open approaches. Patients
with nonperforated appendicitis typically require a 24- to 48-hour hospital
stay. Patients can be started on a clear liquid diet immediately, which can be
advanced to their preoperative baseline diet as tolerated. No postoperative
antibiotics are required for nonperforated appendicitis. Patients can be
discharged when they tolerate a regular diet and pain is controlled on oral
agents.

PERFORATED APPENDICITIS
When appendicitis progresses to perforation, management depends on the
nature of the perforation. If the perforation is contained, a solid or semisolid
periappendiceal mass of inflammatory tissue can form, referred to as a
phlegmon. In other cases, contained perforation may result in a pus-filled
abscess cavity. Finally, free perforation can occur, causing intraperitoneal
dissemination of purulent fluid and fecal material. In the case of free

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perforation, the patient is typically quite ill and perhaps septic. Urgent
laparotomy or laparoscopy, as described above, is necessary for
appendectomy and irrigation and drainage of the peritoneal cavity.
Sometimes patients with free perforation present with an acute abdomen and
generalized peritonitis, and the decision to operate is made without a
definitive diagnosis. Depending on the clinical stability of the patient, a
diagnostic laparoscopy or exploratory laparotomy through a midline incision
is performed. Once perforated appendicitis is confirmed, appendectomy again
proceeds as described previously. Peritoneal drains are not necessary, as they
do not reduce the incidence of wound infection or abscess after
appendectomy for perforated appendicitis.109,110 The final operative decision
is whether or not to close the surgical site. Because of wound infection rates
ranging from 30 to 50% with primary closure of grossly contaminated
wounds, many advocate delayed primary or secondary closure.111 However, a
cost-utility analysis of contaminated appendectomy wounds showed primary
closure to be the most cost-effective method of wound management.112 Our
technique of skin closure is interrupted permanent sutures or staples every 2
cm with loose wound packing in between. Removal of the packing in 48
hours often leaves an excellent cosmetic result with an acceptable incidence
of wound infection. Patients continue to receive treatment with broad-
spectrum antibiotics for at least 4 days after source control and should remain
in the hospital until afebrile and tolerating a regular diet.88
If the patient does not have signs of generalized peritonitis but an abscess
or phlegmon is suspected by history and physical exam, a CT scan can be
particularly helpful to confirm the diagnosis. A solid, inflammatory mass in
the RLQ without evidence of a fluid-filled abscess cavity suggests a
phlegmon. In such instances, appendectomy can be difficult due to dense
adhesions and inflammation. Ileocecectomy may be necessary if the
inflammation extends to the wall of the cecum. Complications such as
inadvertent enterotomy, postoperative abscess, or enterocutaneous fistula
may ensue. Because of these potential complications, many support an
initially nonoperative approach.113 Such an approach is only advisable if the
patient is not clinically ill. Nonoperative management includes intravenous
antibiotics and fluids as well as bowel rest. Patients should be closely
monitored in the hospital during this time. If fever, tenderness, and
leukocytosis improve, diet can be slowly advanced, usually within 3 to 5
days. Patients are discharged home when clinical parameters have

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normalized. Using this approach, many patients can be spared an
appendectomy at the time of initial presentation.
If imaging studies demonstrate an abscess cavity, CT- or US-guided
drainage can often be performed percutaneously or transrectally.113 Studies
suggest that this approach to appendiceal abscesses results in fewer
complications and shorter overall length of stay.113 Again, following
drainage, the patient is closely monitored in the hospital and is placed on
bowel rest with intravenous antibiotics and fluids. Advancement of diet and
hospital discharge progress as clinically indicated.

INTERVAL APPENDECTOMY
Treatment following initial nonoperative management of an appendiceal
phlegmon or abscess is controversial. Some recommend interval
appendectomy114 (appendectomy performed approximately 6 weeks after
inflammation has subsided), while others consider subsequent appendectomy
unnecessary.115 Factors to be considered when advising patients on interval
appendectomy include a relatively low incidence of future appendicitis
(8%-10% and often associated with an appendicolith) and a morbidity
associated with an interval appendectomy of approximately 11%.115
Importantly, malignancy was detected in 1.2% of cases, and colonoscopy is
recommended after resolution of acute disease.115 These factors must be
weighed against the higher morbidity associated with an immediate
appendectomy in the setting of acute recurrent appendicitis in the future (as
high as 36% when appendicitis is associated with a phlegmon or abscess)115
as well as the possibility of an ongoing appendiceal pathology, including
inflammatory bowel disease and cancer.115 Because it can now be performed
laparoscopically on an outpatient basis and with low morbidity,116 interval
appendectomy should be considered for patients who were initially treated
for perforated appendicitis with nonoperative management.

NORMAL APPENDIX
Because of the difficulty in diagnosing appendicitis, it is not uncommon for a
normal appendix to be found at appendectomy. Misdiagnosis can occur more

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than 15% of the time, with considerably higher percentages in infants, the
elderly, and young women.40 Negative appendectomy must be avoided when
possible, because of the risk of surgical complications and the cost associated
with unnecessary surgery.117 Nonetheless, in certain instances, a noninflamed
appendix is found at laparotomy or laparoscopy. The surgeon must then
decide whether or not to remove the appendix. For multiple reasons, it is
generally advisable to remove the grossly normal appendix. First, if the pain
recurs and the appendix has been removed, appendicitis will no longer be a
possibility and can be removed from the differential diagnosis. If the patient
suffers RLQ pain in the future and the appendix has not been removed, but
the patient has a classic RLQ scar, a surgeon evaluating the patient may
assume a history of appendectomy and erroneously disregard appendicitis as
a possible diagnosis. As LA becomes more popular, this may even become
true for patients with port site scars suggestive of appendectomy. Finally,
there is strong evidence that a surgeon’s gross assessment of the appendix
can be inaccurate. In one study, 11 (26%) of 43 appendectomy specimens
described as normal by the surgeon showed acute appendicitis on pathologic
examination.118 As a result, removal of a grossly normal appendix at the time
of the operation for suspected appendicitis is recommended.
When a normal appendix is discovered at appendectomy, it is important to
search for other possible causes of the patient’s symptoms. The terminal
ileum can be inspected for evidence of terminal ileitis, which could be from
infectious causes (Yersinia or tuberculosis) or Crohn’s disease. If Crohn’s
disease is discovered and the cecum is not inflamed, appendectomy should be
performed without an increase in complication rate. In the setting of cecal
inflammation, appendectomy should not be performed, and appropriate
medical therapy for the treatment of newly diagnosed Crohn’s disease should
be initiated postoperatively. The ileum should also be evaluated for an
inflamed or perforated Meckel diverticulum, which should be excised. In
females, the ovaries, fallopian tubes, and uterus should be examined for
pathology as well. Evaluation of the left adnexa can be difficult through an
RLQ incision, highlighting the utility of laparoscopy for female patients.

CHRONIC APPENDICITIS
Although rare, chronic appendicitis can explain persistent abdominal pain in

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some patients. Patients do not present with the typical symptoms of acute
appendicitis. Instead, they endorse weeks to years of RLQ pain and may have
had multiple medical evaluations in the past. When queried, they may
describe an initial episode with more classic symptoms of acute appendicitis,
for which no treatment was delivered.119 Diagnosis can be difficult, as
laboratory and radiologic studies are typically normal. Because the diagnosis
is often uncertain preoperatively, laparoscopy can be a useful tool to allow
minimally invasive exploration of the abdomen.120 Pathology evaluation
revealing chronic inflammation confirms the diagnosis.

ASYMPTOMATIC APPENDICOLITH
As CT imaging becomes more widely used, it is likely that an increasing
number of asymptomatic appendicoliths will be discovered. As discussed
previously, appendicoliths are not pathognomonic for appendicitis but should
be considered in conjunction with the clinical presentation and other
diagnostic studies. Lowe and colleagues121 compared CT imaging of children
with suspected appendicitis to children with abdominal trauma. Six (14%) of
44 patients with suspected appendicitis had an appendicolith but proved not
to have appendicitis. In addition, 2 (3%) of the 74 trauma patients had an
appendicolith on CT. These children were not followed to see if appendicitis
developed later in life, but the considerable number of asymptomatic
appendicoliths seen on adult abdominal radiographs suggests that many
patients with an appendicolith will never develop appendicitis.16,31 Based on
this, appendectomy for asymptomatic appendicolith cannot be recommended.

NEOPLASMS OF THE APPENDIX

Neoplasms of the appendix are rare, discovered in less than 1% of
appendectomies. Signs and symptoms of appendicitis prompt appendectomy
in up to 50% of patients with appendiceal neoplasms, and it is not uncommon
for such patients to develop acute appendicitis.122 Patients may also present
with a palpable mass, intussusception, urologic symptoms, or an incidentally
discovered mass on abdominal imaging or at laparotomy for another purpose.
Typically, the diagnosis is not known until the time of operation or
pathologic evaluation of the appendectomy specimen. However, preoperative

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