APPENDIX

EMBRYOLOGY
• maintains position at tip of the cecum
caudal limb of the midgut
• subsequent unequal growth of the
6th week lateral wall of cecum → adult position
on posterior medial wall - just below
appendix & cecum - outpouchings ileocecal valve
8th week • tip - anywhere in RLQ
appendiceal outpouching • midgut malrotation - appendix
remains LUQ
5th month • situs inversus - appendix is in LLQ
vermiform appearance • Previously considered vestigial organ,
now linked to development and
preservation of GUT-associated
lymphoid tissue and to the
maintenance of intestinal flora
 ANATOMY

ANATOMY HISTOLOGY
• average length - 6-9 cm (can vary from <1 - • 3 layers:
>30cm); width: 3-5cm
• outer serosa: extension of
• blood supply: appendicular branch of peritoneum
ileocolic artery (originates posterior to • muscularis layer – not well defined
terminal ileum entering mesoappendix
close to appendix base) • submucosa and mucosa
• Lymphoid aggregates – prominent
• lymphatic drainage: LN that lie along lymphatic channels
ileocecal artery
• nerve supply:
• Neuroendocrine complexes
• sympathetic: superior mesenteric • Composed of ganglion cells, Schwann
plexus (T10-L1) cells, neural fibers and
neurosecretory cells positioned just
• parasympathetic: vagus nerves below crypts
 PHYSIOLOGY
• immunologic function that actively participate in secretion of Igs,
particularly immunoglobulin A
• reservoir to recolonize colon with healthy bacteria
 ACUTE
APPENDICITIS
EPIDEMIOLOGY
• lifetime risk: 8.6% for males and 6.7% for females
• highest incidence in 2nd and 3rd decades
• One of the most frequent emergent abdominal operations

ETIOLOGY: luminal obstruction

• main: obstruction of lumen due to fecaliths (adults) or hypertrophy of
lymphoid tissue/lymphoid hyperplasia (pedia)
• 40% - fecaliths and calculi in simple acute AP
• 65% - gangrenous w/o rupture
• 90% - gangrenous w/ rupture
 proximal obstruction of
• mucosa of appendix is susceptible to impairment of blood
appendiceal lumen supply - allows bacterial invasion
• poorest blood supply: ellipsoidal infarcts develop in the
closed - loop obstruction antimesenteric border

continued mucosal secretion and rapid

DISTENSION multiplication of resident bacteria

stimulates nerve endings of nausea, vomiting, visceral

visceral afferent stretch fibers pain increases

pain in mid-abdomen or capillaries and venules occluded but engorgement and vascular
lower epigastrium arterial inflow continues congestion

involves serosa of appendix

and parietal peritoneum

PATHOGENESIS RLQ pain

PATHOPHYSIOLOGY
• EARLY OBSTRUCTION
•  bacterial overgrowth of aerobic organisms  mixed flora
• increased intraluminal pressure and referred visceral pain to periumbilical
region  impaired venous drainage  mucosal ischemia  bacterial
translocation  gangrene and intraperitoneal infection
• Distension, bacterial invasion, compromise of vascular supply and
infarction progress, perforation occurs, usually on antimesenteric
border just beyond point of obstruction
• MICROBIOLOGY
• Tissue specimens from inflamed appendix wall – ALL grow E. coli and
Bacteroides fragilis (gangrene / perforated)
CLINICAL PRESENTATION
• CLASSIC PAIN: migratory pain – inflammation of visceral progresses to
parietal peritoneum
• PAIN - initially diffuse visceral type then later becomes more localized as
peritoneal lining gets irritated
• Symptoms
• periumbilical and diffuse pain → RLQ pain (one of most sensitive signs; pain in
atypical location / minimal pain; sensi 81%; speci 53%)
• Nausea (sensi 58%; speci 36%)
• Vomiting (sensi 51%; speci 45%)
• Anorexia (sensi 68%; speci 36%)
• diarrhea - may be associated with perforation (esp in children)
• GIT symptoms before pain suggest other etiology
• Regional inflammation: ileus, diarrhea, bowel obstruction, hematuria
 CLINICAL PRESENTATION - SIGNS
• body temperature and pulse rate may be slightly elevated
• move slowly and prefer to lie supine due to peritoneal irritation
• abd palpation: tenderness with maximum at or near McBurney's point (point
of maximal tenderness)
• deep palpation: muscular resistance (guarding) in R iliac fossa
• REBOUND TENDERNESS - when pressure of examining hand is quickly
relieved, patient feels sudden pain
 CLINICAL PRESENTATION - SIGNS
• ROVSING'S SIGN: indirect tenderness - pain in RLQ when LLQ palpated;
strong indicators of peritoneal irritation
• retrocecal appendix: abd findings and tenderness are most marked in FLANK
• PSOAS SIGN: pain with extension of right leg - focus of irritation in proximity
of right psoas muscle (retrocecal)
• OBTURATOR SIGN: stretching of obturator internus through internal rotation
of flexed thigh - inflammation near muscle (pelvic)
• DUNPHY’S SIGN – increased abdominal pain when coughing (retrocecal)

*appendix hangs into PELVIS – absent; diagnosis missed; right sided rectal
tenderness*
LABORATORY FINDINGS
• mild leukocytosis with polymorphonuclear prominence
• >18000 comp AP – perforated +/- abscess
• increased CRP - strong indicator of AP especially complicated AP
• WBC may be low due to septic reaction but neutrop usually high
• URINALYSIS to rule out urinary tract as source of infection
• CRP, Bilirubin, IL-6 and Procalcitonin – gangrenous and perforated
 APPENDICITIS INFLAMMATORY RESPONSE SCORE
FINDINGS PTS
CLINICAL SCORING Vomiting 1
Pain in the right iliac fossa 1
ALVARADO SCORE Rebound tenderness or muscular defense
Light 1
FINDINGS POINTS Medium 2
High 3
Migratory right iliac fossa pain 1
Body temperature ≥38.5 C 1
Anorexia 1
Polymorphonuclear leukocytes
Nausea or vomiting 1
70-84% 1
Tenderness: right iliac fossa 2 ≥85% 2
Rebound tenderness right iliac fossa 1 White blood cell count
Fever ≥36.3 C 1 10.0-14.9 x 109 cells/L 1
≥15.0 x 109 cells/L 2
Leukocytosis ≥10 x 109 cells/L 2
C-reactive protein concentration
Shift to the left of neutrophils 1 10-49 g/L 1
<3: low likelihood ≥50 g/L 2
4-6: consider imaging 0-4: Low - OPD
≥7: high likelihood 5-8: indeterminate - active observation
9-12: high - surgical exploration
IMAGING STUDIES
• Abdominal plain films - show presence of fecalith and fecal loading in
cecum
• Chest radiograph - rule out referred pain from right lower lobe
pneumonic process
• Barium enema - not indicated in acute setting, if appendix filled,
unlikely
• Technetium-99m-labeled leukocyte scan - helpful but not widely
available
• Ultrasonography < CT Scan - most commonly used imaging test
IMAGING STUDIES
ULTRASONOGRAPHY
SPECIFICITY: 90% | SENSITIVITY: 85%
• graded compression UTZ -
inexpensive, can be performed
rapidly, can be used in pregnant
patients
• Highly suggestive: thickening of
appendiceal wall and presence
of periappendiceal fluid
• Noncompressible RLQ tubular
structure
• Diameter >6mm
• Pain with compression
• Appendicolith
• Increased echogenicity of fat
• Periappendiceal fluid
IMAGING STUDIES
COMPUTED TOMOGRAPHY SCAN
SPECIFICITY: 96% | SENSITIVITY: 96%
• inflammed appendix appears
dilated >5mm and wall is
thickened
• evidence of inflammation:
• periappendiceal fat stranding
• thickened mesoappendix
• periappendiceal phlegmon
• free fluid
• excellent technique for
identifying other inflammatory
processes masquerading AP
• Enlarged lumen
• Double wall thickness >6mm
• Wall thickening >2mm
• Periappendiceal fat stranding
• Appendiceal wall thickening
• Appendicolith
 DIFFERENTIAL DIAGNOSIS
• depends on 4 major factors:
• anatomic location of the inflammed appendix
• stage of process
• patient's age
• patient's gender
• descending order of frequency:
• acute mesenteric adenitis
• no organic pathologic condition
• acute pelvic inflammatory disease
• twisted ovarian cyst
• ruptured graafian follicle
• acute gastroenteritis
 DIFFERENTIAL DIAGNOSIS
• Pediatric patients
• Acute mesenteric adenitis
• pain is diffuse and tenderness not as sharply localized as AP
• +/- URTI
• voluntary guarding
• Generalized lymphadenopathy may be noted
• OBSERVATION is appropriate as it is self-limiting disease
• Elderly patients
• Diverticulitis or perforating carcinoma of the cecum or portion of sigmoid
• CT scan helpful
• if successfully managed conservatively, internal surveillance of colon (colonoscopy or
barium enema)
 DIFFERENTIAL DIAGNOSIS
• Female patient
• pelvic inflammatory disease
• infection usually bilateral, BUT if confined
to right presents as ACUTE AP
• nausea and vomiting (50%)
• pain and tenderness usually lower, and
motion of cervix
• intracellular diplococci on smear
• High during LUTEAL PHASE
• ovulation
• results in spillage of sufficient amounts of
blood and follicular fluid to produce lower
abdominal pain
• pain & tenderness - diffuse
• mittelschmerz - pain at midpoint of
menstrual cycle
• ruptured graafian follicle
• twisted ovarian cyst / tumor / torsion
• requires emergent operative treatment
• primary intervention: simple detorsion,
fenerstration of cyst and fixation of ovary
• endometriosis
• ruptured ectopic pregnancy
• RLQ pain or pelvic pain 1st symptom
• presence of pelvic mass and elevated levels
HCG - characteristic
• leukocyte count rise, hematocrit falls 
intraabdominal hemorrhage
• vaginal exam: cervical motion and adnexal
tenderness
• culdocentesis: definitive diagnosis: (+) blood
and decidual tissue
• treatment: EMERGENT SURGERY
 DIFFERENTIAL DIAGNOSIS
EXTRAPERITONEAL
• Pneumonia – RLQ pain, fever • Gastroesophageal Reflux Disease
and crackles • Herpes Zoster
• Acute Gastroenteritis • Uremia
• Dengue • CKD
• DKA • Spinal Cord injuries
• HSP • Lumbar Radiculopathy
• Myocardial Infarction • Heat stroke
• Malingering
• Myocarditis
• Precordial Catch Syndrome
• Pulmonary Emboli
 DIFFERENTIAL DIAGNOSIS
INTRAPERITONEAL
• Appendicitis • `UTI
• Typhoid Ileitis • Ureteral Colic
• Diverticulitis • Mittelschmerz
• Malignancy • Pelvic Inflammatory Disease
• Peptic Ulcer Disease • Pancreatitis
• Gastroesophageal Reflux Disease • Ovarian torsion
• Acute Mesenteric Ischemia • Acute Mesenteric Adenitis
• Cholecystitis
 HOW TO PREPARE PATIENT
• Admit patient under GS-ATS • Position patient supine
service • Palpate and reassess RLQ
• Secure consent to care and • Induct by anesthesia *
procedure
• Apply cautery pad
• NPO status
• Focus light on abdomen
• IVF: PLR @ MR
• Cleanse with cleanser and
• Baseline labs betadine
• Prophylactic antibiotics • Scrub in
• Drape
 ANESTHESIA
• General anesthesia with endotracheal tube and muscle relaxation
• Local anesthesia for the very ill patient
INITIAL MANAGEMENT
• UNCOMPLICATED APPENDICITIS
• SURGICAL TREATMENT - standard of treatment
• nonoperative management - high failure rate
• Surgical treatment not available; spontaneously resolved
• SURGICAL EMERGENCY
INITIAL MANAGEMENT
• COMPLICATED APPENDICITIS
• perforated appendicitis commonly associated with abscess or phlegmon
• <5 y/o or >65 y/o - higher incidence of perforation
• may cause infertility to females - impaired tubal function
• rupture should be suspected in presence of generalized peritonitis and strong
inflammatory response
• 2/10000 = yearly incidence of perforated AP
• 2-6% palpable mass – phlegmon – matted loops of bowel adherent to adjacent
inflamed appendix or periappendiceal abscess
• (+) mass, symptoms >5-7 days
• Perforated appendicitis managed wither operatively or nonoperatively
• Immediate surgery necessary – septic, usually associated with higher complications –
abscesses and enterocutaneous fistula d/t dense adhesions & inflammation
INITIAL MANAGEMENT
• COMPLICATED APPENDICITIS
• patients with signs of sepsis and generalized peritonitis - OR immediately with
concurrent resuscitation
• OPEN APPENDECTOMY THROUGH MIDLINE INCISION
• nonoperative management
• intravenous fluids
• minimizing gastrointestinal stimulation
• parenteral antibiotics
• percutaneous drainage
• interval appendectomy - performing appendectomy following initial
successful nonoperative management
 APPENDECTOMY
• INDICATIONS
• Acute appendicitis
• Recurrent appendicitis
• Interval appendectomy post drainage of abscess or appendiceal mass
• Carcinoid tumor: at the tip <2cm
• Mucocele of the appendix
• Appendicular graft; ileal conduit
• On table colonic lavage
 INCISIONS
INCISIONS DESCRIPTION
• Increased hernia rate
• Wide access and exposure of abdominal cavity
• ADVANTAGES: bloodless; no muscle fibers are divided; no nerves injured; good
MEDIAN INCISION
access to upper abdominal viscera; quick to make and close; can be extended
full length of abdomen; best visualization and intraabdominal access
• DISADVANTAGES: possible bladder injury; midline scar
• Incision of choice of most Aps
McBURNEY (GRIDIRON)
• Made obliquely at McBurney’s point
• Modified McBurney’s
LANZ-INCISION
• Made at same point but in transverse plane
(ROCKEY-DAVIS)
• Cosmetically good scar
• Oblique muscle cutting incision
• Extension of McBurney incision by division of oblique fossa
RUTHERFORD-MORRISON
• Can be used for R and L sided colonic resection, excostomy or sigmoid
colostomy
 OPERATIVE INTERVENTIONS FOR APPENDIX

• OPEN APPENDECTOMY
• under general anesthesia; patient in supine position | entire abd prepped and draped
• non-perforated appendicitis: RLQ incision at McBurney's point (1/3 of the distance
from anterior superior iliac spine to umbilicus)
• McBurney (oblique) or Rocky-Davis (transverse) RLQ muscle splitting incision
• perforated: lower midline laparotomy | pregnancy: appendiceal bases w/in 2cm of
McBurney’s pt
• following entry to abdomen, patient is placed in slight Trendelenburg position with
rotation of bed to patient's left
• if appendix not easily identified: cecum should be located → tracing the taenia libera
(anterior taenia) most visible taeniae coli
 OPERATIVE INTERVENTIONS FOR APPENDIX
• OPEN APPENDECTOMY
• dividing mesentery of appendix first will often allow improved exposure of base of appendix
• appendiceal stump managed by simple ligation or ligation and inversion
• obliteration of mucosa with electrocautery with intention to obviate the development of
mucocele
• inversion of stump with plication of cecum
• pus in abdomen should be aspirated but irrigation in complicated AP not recommended – skin
closed primarily in patients w/ perfo
• Valentino's appendicitis: perforated duodenal ulcer presenting as appendicitis - medial
extension of the incision (Fowler-Weir) or superior extension of lateral incision is appropriate –
evaluation of lower abd or right colon warranted
• If AP not found – search ALTERNATIVE diagnosis; cecum and mesentery inspected; small bowel
evaluated in retrograde fashion from ICV; prio: CROHN’S / MECKEL’S DIVERTICULUM; female:
reproductive organs inspected
 SURGICAL TECHNIQUE
OPEN APPENDECTOMY
• Phlegmon  appendectomy
• Abscess  drain  appendectomy
• PREOP: restoration of fluid balance
• Well-hydrated – good urine output
• NGT – decompress stomach to
minimize vomiting
• Antipyretic and external cooling for
fever
• POSITION: supine
• OPERATIVE PREP: usual manner
INCISION & EXPOSURE
• Surgeon determines location of
appendix chiefly from point of
maximal tenderness by PE
• Incision: right lower muscle
splitting incision – satisfactory
• If woman: midline incision
preferred for pelvic exposure
• If (+) abscess: incision made over
abscess site
 SURGICAL TECHNIQUE
OPEN APPENDECTOMY
• Wherever incision is, aponeurosis of
external oblique is split from edge of
rectus sheath out into the flank parallel to
its fibers
• With EO held aside, internal oblique is
split parallel to its fibers up to the rectus
sheath and laterally toward the iliac crest
• Rectus sheath may be opened for 1-2 cm
for add’l exposure
• Peritoneum is picked up in between
forceps
• First surgeon then first assist, then surgeon
drops original bite, picks it up again close to
the forceps of first assist, compresses the
peritoneum to free underlying intestine
• As soon as the peritoneum is opened, abd
wall structures are protected with moist
OS to prevent contamination
• Edges are clamped to moist OS
DETAILS OF THE PROCEDURE
• Cecum almost immediately present, pull
it into the wound, hold it in piece of moist
OS and deliver appendix without feeling
blindly around the abdomen
• Peritoneal attachments of cecum require
division to facilitate removal of appendix
• Once appendix is delivered, mesentery
near the tip may be clamped and cecum
returned to abd cavity
 SURGICAL TECHNIQUE
OPEN APPENDECTOMY
• Peritoneal cavity must be walled off with moist OS
• Mesentery of the appendix is divided between
clamps and vessels are carefully ligated
• Transfixing suture is applied, so when structures are
under tension, vessels not infrequently retract from
the clamp and bleed later
• With vessels of mesentery tied off, stump of
appendix is clamped.
• Clamp is moved 1cm toward appendiceal tip.
• Just at proximal edge of crushed portion, appendix
is ligated and straight clamp is placed on the knot.
• Purse string suture is laid in wall of cecum at
appendix base
• Appendix is held upward, cecum
walled off with OS to prevent
contamination and appendix is
divided between the ligature and
clamp
• Suture on the base of appendix is cut
and pushed inward with straight
clamp to invaginate the stump into
the cecal wall
• obliteration of mucosa with
electrocautery with intention to
obviate the development of mucocele
• Clamp is removed, purse-string suture
tied
 SURGICAL TECHNIQUE
OPEN APPENDECTOMY
• If appendix is not obviously involved, EXTENSIVE
EXPLORATION is mandatory
• (+) peritonitis (-) appendix involvement  ruptured
PUD or sigmoid diverticulitis
CLOSURE
• Peritoneum is closed with running or interrupted
absorbable suture
• Transversalies fascia incorporated with the
peritoneum offers better foundation for the suture
• Interrupted sutures are placed in the IO muscle and
small opening at the outer border of the rectus
sheath
• External oblique aponeurosis is closed
• Subcutaneous tissue and skin closed in layers
• Skin left open for delayed secondary closure
ALTERNATIVE METHOD
• Safe to ligate and divide base of
appendix before attempting to deliver
appendix into wound
• When AP not readily found, search
should follow anterior taenia of
cecum  base of appendix
• If appendix is found in the retrocecal
position, becomes necessary to incise
the parietal peritoneum parallel to
lateral border of appendix  allows
appendix to be dissected free from
position behind the cecum and on
peritoneal covering of iliopsoas
muscle
 SURGICAL TECHNIQUE
OPEN APPENDECTOMY
POSTOPERATIVE CARE • Pelvic localization of pus is
• Fluid balance maintained by IV of enhanced by placing the patient in
Ringer’s lactate semisitting position
• Permitted to sit up for eating post • If general condition warrants,
op patient is allowed out of bed
• May get out of bed • Prophylaxis against DVT is
instituted
• Sips of water as soon as nausea • Wound infection and abscess
subsides should be considered if with
• (+) peritoneal sepsis  frequent persistent signs of sepsis
doses of antibiotics • Prolonged sepsis, serial CT scan
POD 7
 OPERATIVE INTERVENTIONS FOR APPENDIX
• LAPAROSCOPIC APPENDECTOMY
• performed under general anesthesia, patient in supine position | left arm tucker 
better access: both surgeon and assistant stand on left of patient, screen at right / foot
of bed
• OGT/NGT and urinary catheter placed
• Standard uses 3-ports:
• 10mm or 12mm port at umbilicus
• two 5mm ports placed in suprapubic and in LLQ
• patient should be placed in Trendelenburg and tilted to left – to sweep bowel away
• identify appendix by tracking taenia liberia/coli to appendiceal base
• through suprapubic port, appendix grasped securely and elevated to 10 o' clock
 OPERATIVE INTERVENTIONS FOR APPENDIX
• LAPAROSCOPIC APPENDECTOMY
• appendiceal critical view - obtained where the taenia libera is at 3 o' clock, terminal ileum at 6
o' clock position and retracted appendix at 10 o' clock to allow proper identification of base of
appendix
• Infraumbilical port – mesentery gently dissected from base of appendix & window created
• Base of appendix stapled followed by stapling of mesentery
• Alternatively, mesentery may be divided by energy device or clipped & base secured w/
Endoloop
• Stump – examined to ensure hemostasis, complete transection, ensure no stump left behind
• Appendix removed through infraumbilical trocar in retrieval bag
• Occasionally, essential to release mesenteric attachments of cecum to mobilize retrocecal /
pelvic AP
• MARYLAND GRASPER  window created, mesoappendix divided w/ cautery, clip or bipolar
energy source
 OPEN vs LAPAROSCOPIC APPENDECTOMY

OPEN APPENDECTOMY LAP APPENDECTOMY

• Shorter OR time
• Lower intraabdominal infection
• Shorter length of stay
• Faster return to work / normal
activity
• Lower SSI rates
• Less pain
• Benefit if diagnosis in question:
• Female – repro age
• elderly: - malignancy
• Morbidly obese – larger incisions if open
SPECIAL CIRCUMSTANCES
• ACUTE APPENDICITIS IN THE YOUNG
• highest sensitivity:
• maximal tenderness in the RLQ
• inability to walk or walking with a limp
• pain with percussion, coughing, hopping
• More rapid progression to rupture and inability of underdeveloped omentum
to contain a rupture  significant morbidity rates
• IMMEDIATE APPENDECTOMY – treatment regimen
• Antibiotic coverage is limited to 24-48 hours - nonperforated AP
• perforated AP - intravenous antibiotics given until WBC count is normal and
patient is afebrile for 24 hours
SPECIAL CIRCUMSTANCES
• ACUTE APPENDICITIS IN THE YOUNG
• Wound infection after treatment of nonperforated AP: 2.8%
• Wound infection after treatment of perforated AP: 11%
• LAP AP!
• Pedia AP score: 10 pts | >/= 7 pts: max weight 2 pts each: RLQ tenderness; dunphy’s sign;
percussion or hopping
• NONOP: safe w/ early presentation (<48 hrs), limited inflammation (WBC <18000),
appendicoliths, (-) rupture on imaging
• DDx:
• Intussusception – abd mass; currant jelly stools
• Gastroenteritis – no leukocytosis
• Malrotation – pain our of proportion
• Pregnancy (ectopic)
• Mesenteric adenitis
• Omentum torsion
• Ovarian / Testicular torsion
SPECIAL CIRCUMSTANCES
• ACUTE APPENDICITIS IN ELDERLY
• difficulty: atypical presentation, expanded differential diagnosis and
communication difficulty
• perforation rate increased - >80 y/o
• not usual: pain migrating to RLQ, not localized pain
• prioritization for risk of rupture: temperature >38 C and shift to the left in
leukocyte count of >76% esp if male, anorexic, pain of long duration before
admission
• Increased comorbidities and increased rate of perforation, postop morbidity,
mortality and hospital length of stay
SPECIAL CIRCUMSTANCES
• ACUTE APPENDICITIS IN PREGNANCY
• appendectomy for presumed appendicitis is most common surgical
emergency during pregnancy
• occur at any time during pregnancy but rare in 3rd trimester
• suspect if woman complains of abdominal pain of new onset
• most consistent sign: pain in the right side of the abdomen
• when in doubt, abdominal UTZ or MRI is helpful
• Physiologic leukocytosis >16000 cells/mm3
• Overall incidence of fetal loss S/P AP: 4%
• Overall incidence of early delivery S/P AP: 7%
POSTOPERATIVE CARE AND COMPLICATIONS
• SURGICAL SITE INFECTION
• UNCOMP: post op antibiotics unnecessary
• COMP: broad-spectrum antibiotics – 4-7 days
• treatment: opening of incision and obtaining culture
• following laparoscopic appendectomy, extraction port is the most common site of
surgical site infection
• cellulitis: start antibiotics
• postoperative intra-abdominal abscesses can present in diff ways: fever, leukocytosis
and abdominal pain are common, patients with ileus, bowel obstruction, diarrhea,
tenesmus - harbor intraabdominal abscess
• small abscesses - treated with antibiotics
• larger abscesses - drainage, most commonly, percutaneous drainage with CT or UTZ
guidance
POSTOPERATIVE CARE AND COMPLICATIONS
• STUMP APPENDICITIS
• incomplete appendectomy represents a failure of removing entire appendix
on the initial procedure
• typically present with recurrent symptoms of appendicitis approximately 9
years after their initial surgery
• KEY TO AVOID: PREVENTION
• remaining stump should be no longer than 0.5cm as stump AP has only been
noted in stumps ≥0.5cm in literature
• Optimal management: requires reexcision of appendiceal base
INCIDENTAL APPENDECTOMY
• Children about to undergo chemotherapy
• disabled who cannot describe symptoms or react normally to
abdominal pain
• patients with Crohn's disease in whom cecum is free of macroscopic
disease
• individuals who travel to remote palces where there is no access to
medical / surgical care
• routinely performed during Ladd's procedure for malrotation because
displacement of cecum into LUQ would complicate diagnosis
NEOPLASMS OF THE APPENDIX
• most common lesions identified:
• appendiceal carcinoid
• appendiceal adenomas
• CARCINOID | GASTROENTEROPANCREATIC NEUROENDOCRINE TUMORS
• firm, yellow, bulbar mass in appendix
• appendix is the most common site of gastrointestinal carcinoid – followed by small bowel and
rectum
• majority are located in TIP OF APPENDIX
• malignant potential is related to size: mean tumor size: 2.5cm
• treatment for tumors ≤1cm - APPENDECTOMY
• >1-2cm tumors located at base, involving mesentery or with LN mets: RIGHT
HEMICOLECTOMY
• Submucosal rubbery masses that are detected incidentally on AP
• RIGHT COLECTOMY: mesenteric invasion, enlarged nodes or positive; unclear margins
• Serum Chromogranin A measurement
NEOPLASMS OF THE APPENDIX

• ADENOCARCINOMA
• primary ADC of appendix is a rare neoplasm with 3 major histologic subtypes:
mucinous adenocarcinoma, colonic adenocarcinoma and adenocarcinoid
• mode common mode of presentation: same as AP
• may present with ascites or palpable mass or incidental discovery during operative
procedure
• recommended: FORMAL RIGHT HEMICOLECTOMY
• Overall 5-year survival: 55%
• GOBLET CELL CARCINOMAS
• Worse prognosis than carcinoids
• Systematic surveillance
• Peritoneal CA index score
• (-) mets disease  right hemicolectomy  right colectomy >/= 2cm tumors
NEOPLASMS OF THE APPENDIX
• MUCOCELE – mucus-filled appendix
• obstructive dilatation by intraluminal accumulation of mucoid material
• causes (1 of 4): retention cysts, mucosal hyperplasia, cystadenomas,
cystadenocarcinomas
• often incidental finding at operation for acute AP
• principle of surgery: resection of appendix, wide resection of mesoappendix
including all appendiceal lymph nodes, collection and cytologic exam of all
intraperitoneal mucus and careful inspection of appendiceal base
• RIGHT HEMICOLECTOMY or ILEOCECECTOMY - reserved for patients with
positive margin at base of the appendix or positive periappendiceal lymph
nodes
NEOPLASMS OF THE APPENDIX
• MUCOCELE – mucus-filled appendix
• ruptured appendiceal neoplasms: minimally aggressive approach at initial
laparotomy with subsequent referral to a specialized center for consideration
of reexploration and hyperthermic intraperitoneal chemotherapy
• If ruptured and epithelial cells escaped into peritoneal cavity – benign process
will not be converted to malignant one through mucocele rupture
• LAPAROTOMY – abdominal exploration to rule out
• CROSS-SECTIONAL IMAGING – low attenuation, round, well exncapsulated
cystic mass; wall irregularity and soft tissue thickening – neoplastic process
• Assess ascites, peritoneal disease, scalloping of liver surface
NEOPLASMS OF THE APPENDIX
• PSEUDOMYOMA PERITONEI
• diffuse collections of gelatinous fluid are associated with mucinous implants
on peritoneal surfaces and omentum
• females > males
• appendix is the site of origin for the overwhelming majority of cases
• invariably caused by neoplastic mucus-secreting cells within peritoneum
• present with abd pain, distension or mass
• CT scan - preferred imaging modality
• MAINSTAY TREATMENT: surgical debulking
• if not done, appendectomy is done; in women, hysterectomy with bilateral
salpingo-oophorectomy
NEOPLASMS OF THE APPENDIX
• PSEUDOMYOMA PERITONEI
• Surgery: variable volume of mucinous ascites found together with tumor
deposits involving right hemidiaphragm, right retrohepatic space, left
paracolic gutter, LOT and ovaries in women
• 5 yr survival: 30%
• Cytoreductive surgery and hyperthermic intraperitoneal chemo (HIPEC) –
standard of care
• Surgical technique: parietal and visceral PERITONECTOMIES and
intraperitoneal administration of heated chemo (mitomycin)
NEOPLASMS OF THE APPENDIX
• LYMPHOMA
• Uncommon
• GIT is most frequently involved extranodal site for non-Hodgkin's lymphoma
• other types: Burkitt's lymphoma, leukemia
• presents as acute appendicitis
• management of appendiceal lymphoma: APPENDECTOMY
• RIGHT HEMICOLECTOMY: indicated if tumor extends beyond the appendix
onto cecum or mesentery
• postoperative staging workup - indicated before initiating adjuvant therapy
• adjuvant therapy not indicated for lymphoma confined to appendix
 CPG
ACUTE APPENDICITIS
OPERATIONAL DEFINITIONS
• UNCOMPLICATED
 Acutely inflamed
Phlegmonous
Suppurative or mildly inflamed appendix w/ or w/o peritonitis
• COMPLICATED
Gangrenous, perforated, localized purulent collection at operation,
generalized peritonitis and periappendiceal abscess
• EQUIVOCAL
RLQ pain + atypical history and physical examination
1) When should one suspect appendicitis?
• RLQ pain
2) What clinical findings are most helpful in
diagnosing acute appendicitis?
• HIGH INTENSITY OF PERCEIVED ABD PAIN ~7-12 hours duration
• Migration to RLQ  vomiting
• PE: RLQ tenderness (over McBurney’s point), guarding, rebound
tenderness, signs of peritoneal irritation
a) CLINICAL FINDINGS: highest discriminating power in AP
b) INFLAMMATORY PARAMETERS
c) DISEASE HISTORY
• 3/6 independent predictors of AP
a) Patient’s gender – MALE
b) Rebound tenderness
c) Abdominal tenderness/rigidity
2) What clinical findings are most helpful in
diagnosing acute appendicitis?
• Adequate scoring system should fulfill the following:
a) Negative appendectomy rate ≤15%
b) Potential perforation rate ≤35%
c) Missed perforation rate ≤15%
d) Missed appendicitis rate ≤5%

* ALVARADO SCORING fulfilled ALL

* Lindberg, Fenyo, Christian – 2/4
3) What diagnostic tests are helpful in the
diagnosis of acute appendicitis?
A. ALL CASES – WBC with differential count, PMN cell count and rate
• WBC >15 x 109 cells/L
• PMNC >13 x 109 cells/L
• 3/6 independent predictors of AP
 WBC
 PMNC
 CRP – unnecessary because only high power in discriminating for complicated AP; late
marker of inflammation
• Increased WBC and increased neutrophil percentage  useful diagnostic aids
in acute AP (esp 15-65 y/o)
• WBC > CRP for uncomplicated AP; very early marker of inflammation
• CRP > WBC for appendiceal perforation or abscess formation
3) What diagnostic tests are helpful in the
diagnosis of acute appendicitis?
B. EQUIVOCAL AP IN ADULTS
• CT scan > UTZ  superior accuracy
• CT SCAN
Should only be used as adjunctive modality in clinically equivocal appendicitis
Highest accuracy and specificity
Sensitivity 97%; specificity 100%, accuracy 94% (noncontrast)
• UTZ
Sensitivity 76%; specificity 90%, accuracy 83%
3) What diagnostic tests are helpful in the
diagnosis of acute appendicitis?
• 5 appendiceal imaging techniques:
i. Graded compression sonography
ii. Unenhanced focused appendiceal CT
iii. Standard abdominopelvic CT using IV contrast material
iv. Focused appendiceal CT using colonic contrast material
v. Sonography using colonic contrast material
• Abdominopelvic CT – greatest confidence in cases with negative
findings; initial exam for AP
• Focused appendiceal CT with colonic contrast material – greatest
confidence if with positive findings; used as problem – solving
technique in difficult cases
3) What diagnostic tests are helpful in the
diagnosis of acute appendicitis?
• CT SIGNS AND SENSITIVITY AND • CT SIGNS AND SENSITIVITY AND
SPECIFICITY: SPECIFICITY:
a) Enlarged (>6mm) unopacified i) Ileal wall thickening (3%, 86%)
appendix (93%, 100%) j) Sigmoid wall thickening (3%,
b) Appendicolith (44%, 100%) 95%)
c) Fat stranding (100%, 80%) k) Diffuse cecal wall thickening
d) Adenopathy (62%, 66%) (0%, 91%)
e) Paracolic gutter fluid (18%, 86%) l) Focal cecal apical thickening
f) Abscess (11%, 100%) (69%, 100%)
g) Extraluminal air (8%, 97%) m) Arrowhead signs (23%, 100%)
h) Phlegmon (7%, 99%) n) Cecal bar (10%, 100%)
3) What diagnostic tests are helpful in the
diagnosis of acute appendicitis?
• Use of high-resolution CT imaging significantly improves diagnostic
accuracy particularly in patients presenting with equivocal clinical
findings and in women of menstruating age
• BEST RADIOLOGICAL INDICATORS FOR POSITIVE CT FOR AP
 Pericecal inflammation (88%)
 Appendicolith (57%)
 Enlarged appendix (47%)
3) What diagnostic tests are helpful in the
diagnosis of acute appendicitis?
C. EQUIVOCAL APPENDICITIS IN PEDIATRIC AGE GROUP
• UTZ > CT  lack of radiation, cost effectiveness and availability
• UTZ findings:
i. Identification of a non-compressible tubular structure in right lower
abdomen >6mm in diameter
ii. Appendicolith
iii. Fluid  appendiceal perforation and/or abscess formation
• Early and selective use of UTZ in equivocal cases could rapidly allow
accurate diagnosis
3) What diagnostic tests are helpful in the
diagnosis of acute appendicitis?
C. EQUIVOCAL APPENDICITIS IN PEDIATRIC AGE GROUP
• GCUS  suggestive of appendicitis
i. Tender, blind-ending, non-compressible, non-peristaltic tube in right iliac
fossa
ii. Target-like in cross section
iii. Diameter >6mm
iv. Increased mucosal wall thickness
• Focused helical CT  accurate in pediatric patients
• UTZ  useful primary diagnostic modality ~40%
• Helical CT with rectal contrast  superior to GCUS in patients >10y/o
3) What diagnostic tests are helpful in the
diagnosis of acute appendicitis?
D. SELECTED CASES
1. DIAGNOSTIC LAPAROSCOPY
• Invasive procedure requiring anesthesia
• Selectively utilized like in situations where patient with clinically equivocal AP is in
childbearing age group but in whom CT scan / UTZ is inconclusive
E. NON-HELPFUL TESTS
1. PLAIN ABDOMINAL XRAY – frequently misleading
2. BARIUM ENEMA – not generally recommended, cannot reliably R/O
3. SCINTIGRAPHY – unable to distinguish AP from other inflammatory
conditions in RLQ, exposes reticuloendothelial system to significant
doses of radiation
4) What is the appropriate treatment for
acute AP?
•APPENDECTOMY!!!
5) What is the recommended approach to the
surgical management of acute AP?
• OPEN AP  recommended primary approach
• THERAPEUTIC LAPAROSCOPIC AP  alternative in selected cases
• OUTCOME MEASURES
i. Length of procedure
ii. Postop pain
iii. Speed of recovery
iv. SSI
v. Length of hospitalization
vi. Development of intraabdominal abscess
• LAPAROSCOPIC APPENDECTOMY
Women of childbearing age
Obese individuals who would require larger skin incisions during open AP
Athletic individuals who desire an early return to sporting activities
6) What is the role of laparoscopic appendectomy
in management of acute AP in children?
• LAPAROSCOPIC APPENDECTOMY recommended as alternative for
pedia age group
7) What is the role of antibiotics in
management of acute AP?
A. Is antibiotic prophylaxis indicated for uncomplicated AP?
YES  antibiotic prophylaxis for prevention of SSI
B/C. ANTIBIOTIC REGIMEN IN AP (next slide)
• Most commonly isolated organisms in acute AP: Gram-negative
Enteric Bacteria (E. coli)
• Pure/mixed also common: Bacteroides fragilis
• Occasionally: Gram-positive organisms: Enterococcus sp
 ANTIBIOTIC REGIMEN
ADULT CHILDREN
UNCOMPLICATED CEFOXITIN 2G IV SINGLE DOSE CEFOXITIN 40mg/kg IV SINGLE DOSE
AMPICILLIN-SULBACTAM 75mg/kg IV SINGLE
AMPICILLIN-SULBACTAM 1.5-3G IV SINGLE DOSE
DOSE
ALTERNATIVE
AMOXICILLIN-CLAVUNATE 1.2-2.4G IV SINGLE AMOXICILLIN-CLAVUNATE 45mg/kg IV SINGLE
DOSE DOSE
ALLERGY TO B- GENTAMICIN 80-120MG IV SINGLE DOSE + GENTAMICIN 2.5mg/kg IV SINGLE DOSE +
LACTAM CLINDAMYCIN 600MG IV SINGLE DOSE CLINDAMYCIN 7.5-10mg/kg IV SINGLE DOSE
ERTAPENEM 1G IV EVERY 24 HOURS TICARCILLIN-CLAVULANIC ACID 75mg/kg IV
COMPLICATED PIPERACILLIN-TAZOBACTAM 3.375G IV q6H or 4.5G IV q6H
q8H IMIPENEM-CILASTATIN 15-25mg/kg q6H
ALLERGY TO B- CIPROFLOXACIN 400MG IV Q12h + GENTAMICIN 5mg/kg IV Q24h +
LACTAM METRONIDAZOLE 500MG IV Q6H CLINDAMYCIN 7.5-10mg/kg IV Q6h

• ANTIBIOTICS PREOP: administered ~30-60 mins prior to skin incision

• UNCOMP: postop antibiotics not necessary
7) What is the role of antibiotics in
management of acute AP?
• Use of Gentamicin + Clindamycin  recommended for patients with
allergy to β-lactams because they offer appropriate coverage against
aerobic gram-negative enteric pathogens and anaerobes
• GANGRENOUS AP  treat as uncomplicated AP
• THERAPY MAY BE MAINTAINED FOR 5-7 DAYS
• Useful parameters for discontinuation of antibiotic therapy:
Absence of fever for 24H
Ability to tolerate oral intake
Normal WBC ≤3% band forms
 ANTIMICROBIAL THERAPY
• Critical adjunctive treatment that:
Combats bacteremia during operation
Limits spread of peritonitis
Speeds resolution of intraabdominal infectious process
• Selection of efficacious therapy result in:
Reduced incisional and organ-space infection
Early recovery of intestinal function
Timely discharge from hospital
• Optimal empiric antibiotic therapy for complicated AP should include
an AGENT or agents against both gram-negative enteric bacilli [E.
coli] and anaerobic bacteria [B. fragilis]
 ANTIMICROBIAL THERAPY
• Secondary bacterial peritonitis  Cefoxitin / Ampillin – Sulbactam
• Coverage against ENTEROCOCCUS must only be initiated when
patient shows no clinical improvement or response despite having
been previously treated with antibiotics or in situations where
organism is persistently isolated in repeat cultures
• ENTEROCOCCI selected as pathogens in patients who are:
Elderly
Debilitated
Immunocompromised
Severely ill
Hospitalized for prolonged periods
Undergoing reoperation for surgical complications / intractable disease
 ANTIMICROBIAL THERAPY
• Intraabdominal infections: Clindamycin [added strep/staph] /
Metronidazole [anaerobic bacteria] + Aminoglycoside
• Successful treatment of intraabdominal sepsis:
Removal source of infection
Eradication of residual bacteria
Metabolic and hemodynamic support
• IV to oral antibiotics – perforated AP who need prolonged antibiotic
but who can tolerate oral intake
8) Should gram stain and culture with
sensitivity be routinely done in acute AP?
• NOT ROUTINE except in high-risk and immunocompromised patients
• Post op complications:
 incisional SSI
 intraabdominal sepsis
 small bowel obstruction
• Presence of colonic flora can be predicted in perforated AP so
antibiotic therapy should be given without any abdominal cavity
culture
9) How should localized peritonitis be
managed?
• No necrotic tissue or purulent material should be left behind
• General peritoneal lavage NOT RECOMMENDED for localized peritonitis
• Intraperitoneal drains, while most useful in patients w/ well-established
and localized abscess cavity, should be selectively utilized
• MAJOR GOALS OF OPERATIVE MANAGEMENT IN PERITONITIS:
 reduce bacterial inoculum
 prevent recurrent or persistent sepsis
• At operation:
 gross / purulent exudates should be aspirated
Loculations in pelvic and paracolic gutters should be gently opened and debrided
9) How should localized peritonitis be
managed?
• Attempt to remove particulate debris w/c act as nidus for
intraperitoneal infection
• FIBRIN  building blocks of adhesions  nidus for infection
• ANTISEPTIC ADDED  no benefit [povidone iodine, noxythiolin,
hydrogen peroxide, taurolin, chlorhexidine]
• CHILDREN WITH POSTOP ABSCESS >5 DAYS OF SYMPTOMS BEFORE
OPERATION – drain placement was associated with decreased postop
abscess formation and shorter duration of fever and length of
hospitalization
• Drain placement helpful in children with late diagnosis
9) How should localized peritonitis be
managed?
• DRAINS: INDICATIONS FOR DRAINAGE:
 abscess evacuation
 establishment of controlled fistula
 provide postop lavage
• DISADVANTAGE
 may erode into bowels / vessels
 provide external bacteria access into peritoneum
 provide site for bacterial adherence and fibrin formation
9) How should localized peritonitis be
managed?
• 1993 – Guidelines for usage of drains
1. No drain is better than any drain
2. Drain selection should consider anticipated risk of complication
3. Active closed-system suction drains better than simple passive
drains
4. Drain placement should be in dependent area and exit near
watertight anastomosis through separate stab wound
5. Drains require careful observation for malfunction, frequent
irrigation and early removal when no longer required
10) What is the appropriate method of wound
closure in patients with complicated AP?
• Incision may be closed primarily in patients with complicated AP
• Primary wound closure did not increase incidence of incisional SSI
compared with delayed closure
11) What is the optimal timing of surgery for
patients with periappendiceal abscess?
• Periappendiceal abscess  surgery AS SOON AS DIAGNOSIS IS MADE
• Band count >15%  interval appendectomy
• ≥15% band count  IMMEDIATE OPERATION
 REVIEW - APPENDICITIS
• What is it?
• inflammation of appendix caused by obstruction of appendiceal lumen, producing
closed loop with resultant inflammation that can lead to necrosis and perforation
• What are the causes?
• lymphoid hyperplasia , fecalith
• rare: parasite, foreign body, tumor (i.e. carcinoid)
• Classically present? CLASSIC CHRONOLOGICAL ORDER
• periumbilical pain (intermittent and crampy)
• nausea/vomiting
• anorexia
• pain migrates to RLQ (constant and intense pain) usually <24 hrs
• Why does periumbilical pain occur?
• referred pain
 REVIEW - APPENDICITIS
• Why does RLQ pain occur?
• peritoneal irritation
• What are the signs/symptoms?
• signs of peritoneal irritation: guarding, muscle spasm, rebound tenderness,
obturator and psoas signs, low-grade fever (high grade if perforated), RLQ
hyperesthesia
• TERMS:
• OBTURATOR SIGN - pain upon internal rotation of leg with hip and knee
flexed; seen in patients with pelvic appendicitis
• PSOAS SIGN pain elicited by extending the hip with knee in full extension or
by flexing the hip against resistance; RETROCECAL APPENDICITIS
• ROVSING'S SIGN - palpation or rebound pressure of the LLQ results in pain in
RLQ; seen in AP
 REVIEW - APPENDICITIS
• TERMS:
• VALENTINO'S SIGN - RLQ pain / peritonitis from succus draining down to the
RLQ from perforated gastric or duodenal ulcer
• McBURNEY'S POINT - point 1/3 from the anterior superior iliac spin to the
umbilicus (often point of maximal tenderness)
 REVIEW - APPENDICITIS
Differential diagnosis
EVERYONE FEMALES
• Meckel's diverticulum, Crohn's • ovarian cyst, ovarian torsion,
disease, perforated ulcer, tuboovarian abscess,
pancreatitis, mesenteric mittelschmerz, pelvic
lymphadenitis, constipation, inflammatory disease, ectopic
gastroenteritis, intussusception,
volvulus, tumors, UTI, pregnancy, ruptured pregnancy
pyelonephritis, torsed
epiploicae, cholecystitis, cecal
tumor, diverticulitis (floppy
sigmoid)
 REVIEW - APPENDICITIS
• Lab tests performed?
• CBC: increased WBC >10,000/mm3 in >90%; most often with LEFT SHIFT
• urinalysis: evaluate for pyelonephritis or renal calculus
• Can you have abnormal UA with AP?
• Yes, mild hematuria and pyuria are common in AP with pelvic inflammation,
resulting in inflammation of ureter
• Does a positive UA rule out AP?
• NO; ureteral inflammation resulting from periappendiceal inflammation can
cause abnormal urinalysis
• What additional tests can be performed if diagnosis is not clear?
• Spiral CT, U/S, AXR
• In acute appendicitis, what classically precedes vomiting?
• PAIN (in gastroenteritis, pain follows vomiting)
 REVIEW - APPENDICITIS
• What radiographic studies are often performed?
• CXR - to rule out RML or RLL pneumonia, free air
• AXR - calcified fecalith present in about 5% of cases
• What are the radiographic signs of appendicitis on AXR?
• Fecalith, sentinel loops, SCOLIOSIS away from right because of pain, mass
effect (abscess), loss of psoas shadow, loss of preperitoneal fat stripe, and
small amount of free air if perforated
• What are the CT findings with acute AP?
• periappendiceal fat stranding, appendiceal diameter >6mm, periappendiceal
fluid, fecalith
• What are the preop meds/prep?
• rehydration with IV fluids (LR)
• Preoperative antibiotics with anaerobic coverage
 REVIEW - APPENDICITIS
• What is a lap appy?
• LAPAROSCOPIC APPENDECTOMY
• used in women, patient who needs to return to physical activity, obese
• What is the treatment for nonperforated acute AP?
• NONPERFORATED - prompt appendectomy (prevents perforation), 24 hrs
antibiotics, discharge home usually on POD 1
• What is the treatment for perforated acute AP?
• PERFORATED - IV fluid resuscitation and prompt appendectomy, all pus is
drained with postoperative antibiotics continued for 3-7 days; wound left
open in most cases after closing fascia (heals by secondary intention or
delayed primary closure)
• How is appendiceal abscess that is diagnosed preoperatively treated?
• usually by percutaneous drainage of the abscess, antibiotic administration
and elective appendectomy ~6 weeks later
 REVIEW - APPENDICITIS
• If normal appendix is found upon exploration, should you take out
normal appendix? YES
• How long after removal of nonruptured appendix should antibiotics
continue postoperatively? 24 hours
• Which antibiotic is used for NONPERFORATED appendicitis?
• Anaerobic coverage: Cefoxitin, Cefotetan, Unasyn, Cipro, Flagyl
• What antibiotic is used for a PERFORATED appendix?
• BROAD-SPECTRUM ANTIBIOTICS (e.g. Amp/Cipro/Clinda or a penicillin)
• How long do you give antibiotics for perforated appendicitis?
• Until patient has normal WBC count and is afebrile, ambulating and eating a
regular diet (usually 3-7 days)
 REVIEW - APPENDICITIS
• What is the risk of perforation?
• ~25% by 24 hours from onset of symptoms, ~50% by 36 hours and ~75% by 48
hrs
• What is the most common general surgical abdominal emergency in
pregnancy?
• Appendicitis (about 1/1750); appendix may be in the RUQ because of the
enlarged uterus
• What are the possible complications of appendicitis?
• pelvic abscess, liver abscess, free perforation, portal pylethrombophlebitis
• What percentage of the population has a retrocecal, retroperitoneal
appendix? ~15%
• What percentage of negative appendectomies is acceptable?
• up to 20%; taking out some normal appendixes is better than missing a case
of acute appendicitis that eventually ruptures
 REVIEW - APPENDICITIS
• Who is at risk of dying from acute appendicitis?
• very old and very young
• What bacteria are associated with “mesenteric adenitis” that can
closely mimic acute appendicitis? YERSINIA ENTEROLYTICA
• What is an “incidental appendectomy”?
• Removal of normal appendix during abdominal operation for different
procedure
• What are complications of appendectomy?
• SBO, enterocutaneous fistula, wound infection, infertility with perforation in
women, increased incidence of right inguinal hernia, stump abscess
• What is the most common postoperative complication?
• wound infection
 CLASSIC INTRAOPERATIVE QUESTIONS
• What is the difference between a McBurney's incision and Rocky-
Davis incision?
• McBurney's is angled down (follows ext oblique fibers), and Rocky-Davis is
straight across (transverse)
• What are the layers of the abdominal wall during McBurney incision?
• Skin
• Subcutaneous fat
• Scarpa's fascia
• External oblique
• Internal oblique
• Transversus muscle
• Transversalis fascia
• Preperitoneal fat
• Peritoneum
 CLASSIC INTRAOPERATIVE QUESTIONS
• What are the steps in laparascopic appendectomy?
• Identify the appendix
• Staple the mesoappendix (or coagulate)
• Staple and transect the appendix at the base (or use Endoloop and cut between)
• Remove the appendix from abdomen
• Irrigate and aspirate until clear
• Do you routinely get peritoneal cultures for acute appendicitis
(nonperforated)? NO
• How can you find the appendix after identifying the cecum?
• Follow the taeniae down to where they converge on the appendix
• Which way should your finger sweep trying to find the appendix?
• Lateral to medial along the lateral peritoneum - this way you will not tear the
mesoappendix that lies medially!
 CLASSIC INTRAOPERATIVE QUESTIONS
• How do you get to retrocecal and retroperitoneal appendix?
• Divide the lateral peritoneal attachments of the cecum
• Why use electrocautery on the exposed mucosa on the appendiceal stump?
• To kill the mucosal cells so they do not form a mucocele
• If you find Crohn's disease in the terminal ileum, will you remove the
appendix?
• Yes, if the cecal / appendiceal base is not involved
• If the appendix is normal what do you inspect intraoperatively?
• Terminal ileum: Meckel's diverticulum, Crohn's disease, intussusception
• Gynecologic: cysts, torsion
• Groin: hernia, rectus sheath hematoma, adenopathy (adenitis)
 CLASSIC INTRAOPERATIVE QUESTIONS
• Who first described the classic history and treatment for acute
appendicitis?
• Reginal Fitz
• Who performed the first appendectomy?
• Harry Hancock in 1848 (McBurney popularized the procedure in 1880s)
• Who performed the first lap appy?
• Dr. Semm in 1983
 APPENDICEAL TUMORS
• What is the most common appendiceal tumor? CARCINOID TUMOR
• What is the treatment of appendiceal carcinoid less than 1.5 cm?
APPENDECTOMY
• What is the treatment of appendiceal carcinoid >1.5 cm? RIGHT
HEMICOLECTOMY
• What percentage of appendiceal carcinoids are malignant? <5%
• What is the differential diagnosis of appendiceal tumor?
• carcinoid
• adenocarcinoma
• malignant adenocarcinoma
 APPENDICEAL TUMORS
• What type of appendiceal tumor can cause the dreaded
pseudomyxoma peritonei if appendix ruptures?
• malignant mucoid adenocarcinoma
• What is “mittelschmerz”? pelvic pain caused by OVULATION
• Should one remove normal appendix with Crohn's disease found
intraoperatively?
• YES, unless base of appendix is involved with Crohn's disease, normal
appendix should be removed to avoid diagnostic confusion with appendicitis
in the future
REFERENCES
• Schwartz's Principle of Surgery 10th/11th edition - Chapter 30
• Clinical Practice Guidelines – Acute Appendicitis
• Surgical Recall - Chapter 45
• Zollinger – Atlas of Surgical Operations