CHAPTER
Appendix
Geoffrey Fasen 
|   Bruce Schirmer 
|   Traci L. Hedrick
ACUTE APPENDICITIS
Acute appendicitis is one of the most common prob-
lems encountered by a general surgeon, accounting for
approximately 1% of all surgical operations.1 Historically
the appendix has been identified as a potential source
of right lower quadrant pain and disease for centuries,
with a scattering of case reports through the early 19th
century describing abscesses and evidence of inflammation
of the appendix in autopsies. The first description of an
appendectomy stems from 1735 when Dr. Claudius Amyand
removed one during treatment of a scrotal hernia, yielding
the description of the eponymous inguinal hernia contain-
ing the appendix. The first suggestion of appendectomy
to treat typhlitis stems from 1827. The coalescence of the
appendix as the source of disease, as well as appendectomy
as therapy for it, did not fully mature until 1886, when it was
presented in a paper from Reginald Fitz.2 The incidence
in the United States is estimated to be 9.38/10,000 per
year, a slight increase over the past 20 years. Approximately
300,000 appendectomies are performed annually. The
most common age group to be afflicted is 10 to 19 years,
with that age decile accounting for 23% of all diagnosed
cases; more than 50% of cases occur before the age of 30.3
Among teenagers and young adults the male-to-female
ratio is approximately 3 : 2. After age 25 years, the ratio
gradually declines until the sex ratio is equal by the mid-30s.
PATHOPHYSIOLOGY
The common end point for the different etiologies of
appendicitis is the translocation of bacteria across the
mucosa of the appendix, leading to suppurative appen-
dicitis. The classic teaching is that luminal obstruction,
secondary to fecalith, lymphoid hyperplasia, or malignancy
is the main initiator of this process. The proposed pathway
is that obstruction of the lumen leads to accumulation of
mucus in the appendix, creating increased intraluminal
pressure. The lack of luminal drainage leads to bacterial
overgrowth while the increased pressure leads to mucosal
ischemia with impaired venous and lymphatic drainage.
This combination of factors then leads to bacterial invasion
of the appendiceal wall and development of acute appen-
dicitis, which, left unchecked, can lead to gangrenous
and perforated appendicitis.
However, this teaching has been challenged by a number
of studies, demonstrating low frequency of obstructing
lesions, such as fecolith, tumor, or lymphoid hyperplasia
in pathologic specimens and their relative frequency in
normal appendices.4,5 In addition, normal intraluminal
pressures were found when measured in vivo on patients
undergoing appendectomy.6 The differing incidences of
appendicitis in developing and developed countries also
suggest that there may be environmental factors, including
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164 
diet, infection, and gut flora, that contribute to the
development of appendicitis.7 Genetic factors also appear
to play a role, with an increased risk of appendicitis in
families.8 This different understanding of the progression
of appendicitis has made itself relevant through new
methods of treating appendicitis, namely nonoperative
management.
CLINICAL PRESENTATION
SYMPTOMS
Irrespective of the etiology, the symptomatic progression
of appendicitis often follows a typical course. The initial
stages of appendiceal inflammation correspond with the
development of periumbilical, visceral type pain. This is
accompanied by anorexia (92%), nausea (78%), and
vomiting (67%).1 When vomiting does occur, it is rarely
persistent and most commonly occurs after the onset of
pain. As the appendiceal inflammation progresses, it leads
to irritation of the nearby parietal peritoneum, leading
to localized pain that manifests as migration of the visceral
pain from the periumbilical region to the right lower
quadrant somatic pain where the appendix typically lies.
This pattern of pain progression is found in approximately
75% of patients with acute appendicitis.1 Differences in
presentation of abdominal pain can be secondary to
abnormal appendiceal location, with retrocecal appendices
leading to diffuse right flank pain, or pelvic location of
the appendix causing poorly localized hypogastric dis-
comfort, or tenesmus. The presentation of atypical pain
is more common in the very young and older patients.
The early course of appendicitis is often not accompanied
by a fever because it remains a localized process. The
presence of constipation or diarrhea is generally not
helpful in the diagnosis of appendicitis.
SIGNS
Combined with the patient’s history, the physical examina-
tion can be sufficient to make a diagnosis of appendicitis,
especially in men where the differential diagnosis is not
as extensive as in women. The typical signs of acute
appendicitis include localized right lower quadrant tender-
ness, abdominal wall guarding, and rebound tenderness.
A flushed facial appearance can be present, with fever
more often than not being absent if the patient has an
acute uncomplicated appendicitis.
ABDOMINAL EXAM
Pain with pressure over McBurney point, or two-thirds
the distance between the umbilicus and anterior superior
iliac spine, is the physical exam finding in the vast majority
of patients (91%) and corresponds with an inflamed
appendix lying within the typical location in the right
1951
 Appendix  CHAPTER 164 1951.e1

ABSTRACT
Acute appendicitis is one of the most common problems
encountered by a general surgeon, accounting for approxi-
mately 1% of all surgical operations. The incidence in
the United States is estimated to be 9.38/10,000 per year,
a slight increase over the course of the past 20 years. The
most commonly accepted course of treatment is appen-
dectomy, with roughly 300,000 appendectomies performed
annually. However, there is increasing research about the
safety and efficacy of nonoperative management. This
chapter focuses on the pathophysiology, diagnostic implica-
tions, and treatment strategies for patients with appendicitis
and appendiceal neoplasm.

KEYWORDS
Appendix, appendicitis, appendiceal neoplasm,
appendectomy

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1952 SECTION IV  Colon, Rectum, and Anus
lower quadrant.1 For patients with an atypical position of
the appendix, such as retrocecal or deep pelvic, pressure
in this location may not elicit the typical exam findings.
In the case of a retrocecal appendix the pain may be
localized over the right flank, elicited by an extension of
the hip (psoas sign), or may not be well localized on physical
exam at all. An obturator sign may be present with appen-
dicitis located in the deep pelvis. A Rosving sign consists
of pain in the right lower quadrant with palpation in the
left lower quadrant. Jostling the bed or striking the heel
of the extended right leg can lead to right lower quadrant
pain. Similarly the patient may be asked to bounce or
attempt to jump, producing pain in the area. Although
these findings are typical for an uncomplicated appendi-
citis, perforation can lead to a more generalized peritonitis,
with involuntary diffuse guarding, high fever, and hemo-
dynamic changes.
An abdominal mass on physical exam is rarely present
and, when present, may be difficult to appreciate due to
discomfort with deep palpation and increased abdominal
wall thickness. The presence of a mass is suggestive of an
abscess or phlegmon, reflecting a rupture of the appendix
with adherence of omentum and surrounding bowel to
the inflamed appendix. After patients are adequately
treated with pain medication or when asleep after initiation
of anesthesia, a mass can sometimes be palpated in children
or thin patients.
DIAGNOSIS
PELVIC EXAMINATION
Pelvic examination is essential in all women of childbearing
age presenting with appendicitis. A speculum examination
of the cervix is undertaken to evaluate for purulent drain-
age caused by gynecologic infection. In addition, a
bimanual examination can be performed to palpate for
the adnexal structures.
LABORATORY EVALUATION
Blood tests are of limited use in the diagnosis of an
uncomplicated acute appendicitis because of their lack
of specificity but can help to confirm a suspicion based
on history and physical exam. As many as 50% of patients
with acute appendicitis can present with a normal leukocyte
count, with the variance attributable to both age and
ethnic factors.9–11 In uncomplicated appendicitis the
leukocytosis is typically mild, with an average value of
14.2 × 109/L.11 Attempts have been made to make a more
sensitive test for appendicitis by including the leukocyte
differential or C-reactive protein (CRP) values. A left shift
(increased percentage of neutrophils to greater than
74%) is present irrespective of the presence of leukocytosis
in up to 87% of patients. When all three variables are
used together, they are quite effective in ruling out
appendicitis. A physical exam suggestive of appendicitis
in the setting of normal white blood cell (WBC) count,
differential, and CRP is quite rare.
Urinalysis, pregnancy tests, and sexually transmitted
disease (STD) evaluation are all useful in identifying other
potential causes for lower abdominal pain but do not
contribute directly to a diagnosis of appendicitis.
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RADIOGRAPHIC EVALUATION
Plain abdominal radiograph is of little utility in the
diagnosis of appendicitis, except when it identifies another
source for abdominal pain or is able to identify a radi-
opaque fecolith, which is uncommon. Computed tomog-
raphy (CT) and ultrasound (US) imaging are the preferred
imaging modalities for diagnosis of abdominal pain and
appendicitis. Studies comparing the two modalities for
appendicitis reveal increased accuracy with CT over US,12
and in equivocal cases have demonstrated CT to be more
accurate.13 For most adult patients with abdominal pain
and suspected appendicitis, the abdominal CT has become
the main diagnostic imaging study with an accuracy of
greater than 94%.14,15 Typical findings of acute appendicitis
on CT imaging include the presence of a dilated appendix
greater than 6 mm, periappendiceal fat stranding, phleg-
mon, or abscess in the area (Fig. 164.1). Inflammatory
changes of the cecum or terminal ileum with a normal-
appearing appendix is insufficient for diagnosis and should
prompt evaluation for additional pathology, such as
inflammatory or infectious bowel disease.
US has a reported diagnostic accuracy of greater than
90%.16 The size criteria for diagnosing appendicitis with
US is a size cutoff of greater than or equal to 6 mm
appendiceal diameter; 7 mm is used in some centers to
increase specificity because 23% of normal appendices
can have a diameter of 6 mm or greater.17 A noncompress-
ible lumen, increased vascularity, and increased wall
thickness to greater than 2 mm are also used as diagnostic
criteria for appendicitis.16,18,19 Inability to visualize the
appendix has been noted to have as high as 90% negative
predictive value.20 US has found increased utility in the
pediatric population and in most children’s hospitals is
now the most commonly used imaging modality.21 Accuracy
is operator and patient-variability dependent.
R
P
FIGURE 164.1  Computed tomography demonstrating findings
consistent with acute appendicitis (white arrow), including fat
stranding of the appendiceal mesentery located between the
cecum and the appendix, as well as an enhancing appendiceal
wall consistent with hyperemia and enlarged appendiceal diameter
of 8 mm.

Magnetic resonance imaging (MRI) as a diagnostic
study is used primarily in pregnant women. The size
criteria remain the same as with CT and US, with appen-
diceal diameter usually greater than 6 mm. There is typi-
cally high signal intensity fluid in the appendiceal lumen
on T2-weighted imaging. Its accuracy is similar to that of
CT, with sensitivity reported in between 90% and 100%,
with specificity of 94% to 98%. Its ability to visualize a
normal appendix is markedly improved compared with
US at 87% versus 2%, which is useful in evaluating
abdominal pain in the pregnant patient.22
SPECIAL POPULATIONS
INFANTS AND TODDLERS
As noted previously, the clinical history and examination
can be the most important diagnostic tool for diagnosing
appendicitis. In pediatric patients, particularly those of a
preschool age range, the ability to provide an accurate
history may be impaired, leading to delayed or incorrect
diagnosis. Typical signs, such as anorexia, guarding, and
focal right lower quadrant pain, are more often absent
in this population than adults.23 The most common present-
ing symptoms are diffuse abdominal pain, nausea, and
vomiting, which are unfortunately quite nonspecific and
can indicate a host of abdominal pathologies. Most patients
will have had symptoms for 3 days by the time of evaluation,
with children less than 4 years of age averaging 4 days of
symptoms.24 As a result, an increased number of pediatric
patients present with perforated appendicitis, with 50%
of patients under the age of 5 presenting with a perforated
appendicitis. This rate goes up as patients become younger,
with 66% perforated below age 3, and almost 100% of
patients presenting with perforation in children younger
than 1 year of age.24,25
OLDER ADULTS
Approximately 5% of appendicitis cases occur in patients
age 70 and older.3 Morbidity and mortality are increased
in older patients with appendicitis compared with a
younger population. This has been attributed both to the
increased number of comorbidities in older patients, as
well as delay in diagnosis. The delay in diagnosis can be
due in part to milder signs at time of presentation but
also due to a delay in presentation.26 As a result, 25% to
44% of older patients will present with a perforated
appendicitis.27,28 Diagnostic delay has decreased with more
liberal use of CT imaging and operative morbidity has
decreased with wider use of laparoscopy.
PREGNANCY
The risk of appendicitis in pregnancy mirrors the risk
of developing appendicitis of the patient’s normal age
range. However, the consequences of a delay or missed
diagnosis are markedly higher due to the increased
mortality to the fetus. Rates of fetal loss are as high
as 8% in ruptured appendicitis, compared with 2% in
uncomplicated appendicitis.29 The risk of rupture is slightly
higher in the pregnant population, owing to atypical
presentation caused by displacement of the appendix by
the enlarging uterus. In addition, diagnosis is often delayed
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Appendix  CHAPTER 164  1953
when nonspecific symptoms, such as nausea, vomiting,
and abdominal discomfort, are mistakenly attributed to
the pregnancy. However, during the third trimester the
enlarging uterus tends to displace the appendix laterally
or cephalad, leading to atypical pain location and lack
of focal peritonitis in some cases. As noted, the typical
diagnostic imaging of CT is often avoided to reduce the
risk of ionizing radiation. MRI and US are the preferred
modalities for diagnosis; although, given the high rate of
prematurity or fetal loss, the use of CT when MRI is not
available may be justified, especially after the first trimester.
DIAGNOSTIC ALGORITHMS
In 1986 the first algorithm was developed as a scoring
system (Alvarado score), which used eight factors: focal
right lower quadrant (RLQ) tenderness, leukocytosis,
migratory pain, left shift, fever, anorexia, nausea/vomiting,
and rebound tenderness.30 More recently the appendicitis
inflammatory response (AIR) score incorporates more
factors, such as CRP and gradation of RLQ pain.31 When
compared head to head, the AIR score had a greater
specificity, as well as positive predictive value, than the
Alvarado score and performed better at discriminating
patients with both high- and low-risk of appendicitis.32,33
The utility of these scoring systems in reducing unnecessary
imaging studies has been suggested, with avoidance of up
to 33% of CT scans and 58% of USs.34
DIFFERENTIAL DIAGNOSIS
The diseases in children that are most frequently encoun-
tered on the differential for acute appendicitis include
Meckel diverticulum, mesenteric lymphadenitis, intus-
susception, and acute gastroenteritis. In the adolescent
age group, gynecologic issues begin to arise in young
women, including endometriosis, ectopic pregnancy, pelvic
inflammatory disease, mittelschmertz, and salpingitis.
For older patients the risk of malignancy, diverticulitis,
and inflammatory bowel disease can all masquerade as
appendicitis as well.
TREATMENT
After a diagnosis of acute appendicitis has been
made, the most commonly accepted course of treat-
ment is appendectomy, although there is increasing
research into nonoperative management. Preoperative
preparation typically consists of intravenous (IV) fluid
administration, pain medication, and antibiotic therapy
with a broad-spectrum antibiotic, such as cefoxitin,
ampicillin/sulbactam, or the combination of cefazolin
and metronidazole. A single prophylactic dose is all that
is necessary for uncomplicated appendicitis. In most
cases, surgery can be safely delayed for up to 12 hours
without any evidence of negative impact on patient
outcomes.35,36
Laparoscopic appendectomy—One of the earliest
general surgery operations to be undertaken laparoscopi-
cally, laparoscopic appendectomy is currently the most
common method for performing appendectomy in the
United States. It is associated with an overall decrease in
complications compared with an open approach, particu-
larly in obese patients.37,38
1954 SECTION IV  Colon, Rectum, and Anus
Our preferred technique begins with the placement
of the camera port in a supraumbilical location. Port
placement may be modified based on prior abdominal
surgery or other complicating factors, such as pregnancy.
A Hasson technique works well in thin patients, and a
Veress needle technique is beneficial in morbidly obese
patients. The suprapubic and left lower quadrant are
typical locations for working ports. A right upper quadrant
5-mm port is also helpful for retraction. Care must be
taken to avoid the bladder with placement of the supra-
pubic port. The patient is then placed in the Trendelenburg
position, with the table tilted to the left, to help to clear
omentum and small bowel from the right lower quadrant.
The patient must be adequately secured to the table with
a deflatable bean bag, a foam pad, or straps to prevent
shifting during the case. The typical finding is an inflamed,
engorged appendix. After being identified, the appendix
is traced back to its base at the cecum. If the appendix
is not acutely inflamed at this site, a window can be dis-
sected in the base of the mesoappendix. The mesoappendix
can then be divided using either a laparoscopic stapler,
harmonic scalpel or other sealing device, or clips. The
appendix is transected at its base with an Endo GIA stapler
and then placed into a retrievable bag and removed from
the abdominal cavity. We then inspect the staple lines for
hemostasis and aspirate any spilled blood or fluid free
from the pelvis and operative site. Thorough cleansing
of the pelvis and abdominal gutters of any fluid will
decrease the incidence of postoperative abscess. Irrigation
does not necessarily decrease the rate of postoperative
abscess.39–41 Laparoscopic appendectomy was associated
with a higher rate of postoperative intraabdominal abscess
compared with an open approach in the early randomized
controlled trials. The overall rate of surgical site infection
remained lower with the laparoscopic approach.42 This
may have resulted from inexperience and inadequate
cleansing of the pelvis and abdomen. More recent retro-
spective studies demonstrate equivalent rates of intra-
abdominal abscess formation after laparoscopic and open
appendectomies.43,44
Open appendectomy—There are several approaches
to incision orientation and location for an appendectomy.
The Rockey-Davis incision (transverse) and McBurney
incision (oblique following skin lines) are the two most
common incision types. The length of the incision is
dependent in part on the patient’s body habitus. In thin
patients and children a smaller incision is often sufficient,
whereas in obese patients the incision may have to be up
to 10 cm in length. The incision should typically be
centered over the location of the most intense pain identi-
fied during physical exam. When dividing the external
and internal oblique aponeuroses, it can be beneficial to
place clamps on the fascial edges to aid in identification
and closure of these layers at the end of the case (Fig.
164.2).
After the peritoneum is opened, the appendix can be
identified by first locating the ascending colon or cecum.
After the anterior taenia is located on these structures, it
can be followed to the base of the appendix. Loose adhe-
sions between the inflamed appendix and the surrounding
ileum or abdominal wall can be broken up with gentle
blunt dissection. In the case of a retrocecal appendix, the
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lateral peritoneal reflection may need to be incised to
mobilize the appendix sufficiently into the operative field.
When doing this, it is important to protect the right ureter
because it often runs in close proximity to the retrocecal
appendix.
After the appendix has been sufficiently mobilized into
the operative field, the next step is to divide the mesoap-
pendix and appendiceal artery. This can be accomplished
by dividing the mesoappendix immediately adjacent to
the appendiceal base between clamps or by sequentially
clamping, dividing, and ligating the mesoappendix in
parallel to the appendix until the base is reached. After
being free of its mesentery, a hemostat or Kocher clamp
is placed across the base of the appendix, crushing the
tissue and ensuring there is no fecalith at that location.
The clamp is then moved just distal, and an absorbable
suture is tied around the crushed base (2-0 Vicryl or 2-0
polydiaxanone suture). The appendix is transected just
proximal to the clamp. This is typically sufficient for
closure of the appendiceal base; however, some surgeons
continue to invert the base of the appendix using a Z-stitch
or purse-string suture.
Nonoperative management—There is a growing body
of evidence regarding the safety and efficacy of nonopera-
tive management, stemming from early reports of non-
operative management in patients aboard submarines.45,46
The first randomized studies were reported in the 1990s
and demonstrated successful early therapy but a high rate
of recurrence and need for surgery within the next year.47
Subsequent randomized studies confirmed the safety of
initial antibiotic therapy with successful nonoperative
management in 89% to 91% of patients within the first
30 days. However, in the following year, there was a rela-
tively high recurrence rate requiring appendectomy at 1
year, between 14% and 36%.48–52 Table 164.1 outlines the
specific details of the randomized trials. Currently, surgery
remains the gold standard for treating patients presenting
with appendicitis. Attempts at nonoperative management
should be undertaken only for patient contraindications
to surgery or as part of a clinical trial.
Gangrenous or perforated appendicitis—Cross-sectional
imaging will demonstrate evidence of an abscess, phleg-
mon, or free perforation in the setting of complicated
appendicitis. The presence of complicated appendicitis
is often suspected based on an evidence of sepsis at
presentation. Given the heterogeneity of presentation for
these patients, clear-cut recommendations cannot be made
regarding conservative versus operative management. In
general, patients presenting with diffuse peritonitis, overt
sepsis, or specific populations, such as pregnant patients
or immunosuppressed patients, should undergo urgent
operative exploration and appendectomy. Antibiotic
treatment should cover gram-negative rods and anaerobic
organisms. The Study To Optimize Peritoneal Infection
Therapy (STOP-IT) trial in patients with complicated
intraabdominal infection after adequate source control,
randomized patients to a fixed course of antibiotics (4
days) versus antibiotics until 2 days after resolution of
clinical signs of infection (up to a maximum of 10 days).53
There was no difference in the two groups in terms of
intraabdominal infection, indicating earlier stoppage of
antibiotics is appropriate.
 Appendix  CHAPTER 164  1955

Margin of
external oblique
muscle

A Margin of
rectus sheath
B
Internal
oblique muscle

Transversus
abdominis
muscle

Internal
oblique muscle
External
oblique muscle
C FIGURE 164.2  Steps in exposing the
appendix for an appendectomy through a
Cecum
transverse incision. (A) Placement of the
D skin incision. (B and C) External and
internal oblique and transversus
abdominis muscles are divided in the
direction of their fibers. (D) After incision
of the peritoneum, the cecum is exposed
and the appendix is located by following
Ileum the anterior cecal taenia inferiorly. (E) The
cecum is mobilized into the wound
through incision of its lateral peritoneal
Mesoappendix reflections. (From Moody FG, Carey L,
Jones RS, et al. Surgical Treatment of
E Digestive Diseases. Chicago: Year Book;
1986.)

Patients presenting with a phlegmon, well-contained
abscess, or localized peritonitis can safely undergo operative
intervention, although it should be cautioned that they
are at higher risk for complication or iatrogenic injury
to surrounding structures, such as bowel or ureter, and
are at higher risk for postoperative complications, such
as abscess or wound infection.54 These patients are also
more likely to require conversion to an open approach,
an ileocolic resection, and in the most extreme cases, a
stoma. Nonoperative management is generally most suc-
cessful in patients with a drainable fluid collection in the
absence of a fecalith. Nonoperative management in these
patients consists of IV antibiotics and percutaneous
drainage of any abscess present. The success rate of
nonoperative therapy in these patients approaches
75%.31,55,56 Such factors as smoking, generalized abdominal
tenderness, tachycardia, small undrainable (<5 cm) abscess
size, appendicolith, and small bowel obstruction have
been noted to be predictive of failure of nonoperative
management.55,57,58
Operative approach should be tailored to the patient’s
presentation and the surgeon’s preference. A lower midline
incision may be preferred in patients presenting with a
diffuse peritonitis to gain access to the rest of the abdomen
if necessary. Laparoscopy can also be used, and is our
method of choice, with conversion to an open operation

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1956 SECTION IV  Colon, Rectum, and Anus
TABLE 164.1  Randomized Controlled Trials Comparing Antibiotics to Appendectomy for the Management of Acute
Appendicitis
Study Inclusion Criteria
Eriksson et al. 47
• >18 y
(Sweden) • Clinical diagnosis
Styrud et al.52 • 18–50 y
(Sweden) • Clinical diagnosis and
CRP > 10 mg/L
• Women excluded
Hansson et al.49 • >18
(Sweden) • Clinical diagnosis
Vons et al.51 • >18 y
(France) • CT imaging
• Included pts with fecalith
Salminen et al.50 • 18–60 y
(Finland) • CT imaging uncomplicated
CRP, C-reactive protein; CT, computed tomography; IV, intravenous.
if needed. The surrounding inflammation will make the
dissection more difficult in the setting of perforated
appendicitis. Gentle blunt dissection is often effective at
releasing the appendix from the surrounding structures
and the retroperitoneum. If this is not easily accomplished,
it can be helpful to mobilize the right colon in an area,
where there may be less inflammation. Occasionally the
drainage of abscesses, irrigation, and placement of drains
is all that can be safely achieved.
INTERVAL APPENDECTOMY
Historically, interval appendectomy was recommended
after nonoperative management, due to concern for
recurrent appendicitis. More recent data demonstrate
that it is safe to defer appendectomy altogether. Only 5%
of patients with recurrence required surgical intervention
in a longitudinal population-based study.59 Children have
a low risk of recurrent appendicitis.60
The risk to foregoing appendectomy includes the
failure to identify an underlying neoplasm. Malignancy
has been reported in 4% to 29% of adult patients present-
ing with complicated appendicitis in which appendectomy
is delayed in the acute setting.61–63 Patients’ age 40 and
older managed nonoperatively with complicated appen-
dicitis should undergo colonoscopic evaluation, followed
by an interval appendectomy to evaluate for a possible
underlying malignancy.
Negative appendectomy rates of 20% were accepted
as necessary in the past to avoid perforated appendici-
tis.64 Cross-sectional imaging has reduced the negative
appendectomy rates to 1.7% to 7%. 65–68 If a normal
appendix is found during exploration, the abdomen
and pelvis should be carefully evaluated for the source
of pain, including ovarian cysts, colonic diverticulitis,
tuboovarian abscess, mesenteric adenitis, Meckel diver-
ticulum, and malignancy.68,69 It is reasonable to remove
a normal appendix in a patient with chronic abdomi-
nal pain to reduce the risk of diagnostic confusion in
the future.
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Failed Antibiotic Therapy
(%; Includes Immediate
No. of Patients Antibiotic Used Failures and Within 1 Yr)
Surgery: 20 IV: cefotaxime and tinidazole 8/20 (40)
Antibiotic: 20 Oral: ciproflaxacin plus metronidazole
Surgery: 124 IV: cefotaxime plus metronidazole 31/128 (24)
Antibiotic: 128 Oral: ciprofloxacin plus metronidazole
Surgery: 167 IV: cefotaxime plus metronidazole 111/202 (55)
Antibiotic: 202 Oral: ciprofloxacin plus metronidazole
Surgery: 119 IV: amoxicillin plus clavulanic acid 44/120 (37)
Antibiotic: 120 Oral: amoxicillin plus clavulanic acid
Surgery: 273 IV: ertapenem 70/257 (27)
Antibiotic: 257 Oral: levofloxacin
APPENDICEAL NEOPLASMS
The most common type of appendiceal neoplasm found
incidentally at the time of appendectomy for appendicitis
is a carcinoid or neuroendocrine tumor (NET) (0.3%).70
NETs account for 88% of all appendiceal tumors and
are the most frequent site of gastrointestinal (GI) tract
carcinoid tumors (38%), compared with small bowel
(29%) and colon (13%).71 Appendiceal carcinoid tumors
smaller than 2 cm, not involving the mesoappendix, and
remote from the base have been historically treated with
simple appendectomy alone.70 Reports of a higher rate
of lymph node metastasis in patients with tumors greater
than 1 cm in size has resulted in recommendation for a
right hemicolectomy in young patients with tumors greater
than 1 cm.72 However, these recommendations are soft
because even malignant appendiceal carcinoid tumors
have excellent long-term survival, with 10-year survival
approaching 90%.73
Other types of appendiceal malignancies include
mucinous cystadenoma, mucinous cystadenocarcinoma,
goblet cell carcinoid, and colonic-type adenocarcinoma.
Mucinous cystadenoma and cystadenocarcinoma are
typically indistinguishable prior to resection when confined
to the appendix and should be resected without rupturing
the appendix to reduce the risk of peritoneal seeding and
development of pseudomyxoma peritonei. When suspected
preoperatively or encountered intraoperatively, many
surgeons will convert from a laparoscopic to open approach
to avoid potential rupture; a right hemicolectomy is advised
if it is suspected preoperatively or identified intraoperatively.
Goblet cell carcinoid and colonic-type adenocarcinoma
are more aggressive tumor types and should be treated
in a similar fashion as a colon cancer, including the right
colon resection and adjuvant chemotherapy.74
ACKNOWLEDGMENTS
We thank Matthew I. Goldblatt, Gordon L. Telford, and James
R. Wallace for their previous work on this chapter.
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