SCHWARTZ’S

HOUR:
THE APPENDIX
Presenter: RIZA PAULA M. LABAGNOY, MD
Moderator: LYDANA C. CASUGA, MD, FPCS, FPSGS, FPCRS
Outline
■ Embryology, Histology, Anatomy
■ Acute appendicitis
– Diagnosis
– Management
– Operative intervention
– Special circumstances
■ Appendiceal neoplasms
 EMBRYOLOGY

■ Previously considered a vestigial

organ
■ Linked to development and
preservation of GALT and to the
maintenance of intestinal flora
■ Develops from the midgut along with
the ileum and colon
■ First appears at 8 weeks of gestation
■ Gut rotates medially  cecum
becomes fixed in the RLQ
HISTOLOGY

■ True diverticulum of
the cecum
■ Contains all the
histological layers
of the colon
ANATOMY

■ 6 to 9 cm on average
■ Blood supply: appendicular branch of the
ileocolic artery
■ Innervation: superior mesenteric plexus
(T10-L1) and vagus nerves
■ Location: intraperitoneal and retrocecal
– Pelvic (30%)
– Retroperitoneal (7%)
■ Appendiceal base can be identified by
tracing the convergence of the cecal taenia
ACUTE APPENDICITIS
EPIDEMIOLOGY

■ Significant public health problem

■ Lifetime incidence: 8.6% in men, 6.7% in women
■ Highest incidence: 2nd and 3rd decade of life
PATHOGENESIS
CLINICAL PRESENTATION

■ Classic sign: migratory pain

– Inflammation of the visceral peritoneum progresses to the parietal
peritoneum
■ Anorexia, nausea, vomiting, fever
■ Regional inflammation may present as ileus, diarrhea, small bowel
obstruction, hematuria
■ Important to elicit menstrual history and antecedent history of viral
infection
PHYSICAL EXAMINATION

■ Focal tenderness with guarding

– McBurney’s point
■ 1/3 of the distance between ASIS
and umbilicus
■ often the point of maximal
tenderness
■ Fever
■ Patient lay quite still
■ Rectal and cervical examinations
Physical signs
Rovsing’s sign Pain in the right lower quadrant after release of gentle
pressure on the left lower quadrant
Dunphy’s sign Pain with coughing (retrocecal appendix)
Obturator sign Pain with internal rotation of the hip (pelvic appendix)
Iliopsoas sign Pain with flexion of the hip (retrocecal appendix)
LABORATORY FINDINGS

■ WBC*
– Usually leukocytosis of 10, 000 cells/mm3
– Gangrenous and perforated – 17, 000 cells/mm3
■ C-reactive protein*
■ Bilirubin
■ IL-6
■ Procalcitonin
■ Pregnancy test
■ Urinalysis
ALVARADO SCORE
IMAGING

■ To confirm diagnosis of appendicitis

■ Reduces rate of negative laparotomies
– Males: <10%
– Females: <20%
■ Unclear diagnosis, high risk from operative intervention and general anesthesia
■ CT scan, ultrasound, MRI
CT Scan
■ Sn 96%, Sp 96%
■ Features:
– Enlarged lumen
– Double wall thickness (> 6mm)
– Wall thickening (> 2mm)
– Periappendiceal fat stranding
– Appendicolith
■ Low dose CT scans with low resolution
images do not affect clinical outcomes
■ IV contrast generally preferred
Ultrasound
■ Sn 85%, Sp 90%
■ Features:
– Diameter > 6mm
– Non-compressible, pain with
compression
– Appendicolith
– Increased echogenicity of fat
– Periappendiceal fluid
■ Pros:
– cheaper, readily available
– No ionizing radiation
■ Cons:
– User-dependent
– Limited utility in obese patients
MRI
■ Sn 95%, Sp 92%
■ Expensive test
■ Requires significant expertise
■ Patients for whom risk of ionizing radiation outweighs the relative ease of CT scan
– Pregnant
– Pediatric
MANAGEMENT: Uncomplicated

■ APPENDECTOMY is the preferred approach

■ Operative vs nonoperative
– 26.5% of nonoperative group required an appendectomy within 1
year
– Recurring appendicitis presented more frequently with complicated
appendicitis
MANAGEMENT: Uncomplicated

■ Emergent surgery is often performed

■ Urgent surgery after antibiotics  no significant difference in outcomes vs
emergent surgery
■ Delaying surgery less than 12 hours is acceptable
– Short duration of symptoms (< 48 hours)
– Nonperforated, nongangrenous appendicitis
MANAGEMENT: Uncomplicated

■ Relative equivalence of open and laparoscopic appendectomy

OPEN
- Shorter operative times
- Lower intra-abdominal infection rates
LAPAROSCOPIC
- Shorter length of stay
- Faster return to work
- Lower superficial wound infection
rates
MANAGEMENT: Complicated

■ Complicated appendicitis
– Perforated
– Gangrenous
– Appendicitis with abscess or phlegmon formation
■ Usually presents after 24 hours of onset
– 20% within 24 hours
■ Acutely ill, dehydrated, require resuscitation
MANAGEMENT: Complicated

■ Perforated appendicitis can be managed operatively or nonoperatively

■ Septic patients  immediate surgery
■ Long duration, complicated appendicitis  staged management
– Resuscitation
– IV antibiotics
– Percutaneous image-guided drainage
■ Operative intervention when conservative management fails and in
patients with free intraperitoneal perforation
Interval Appendectomy

■ 80% of patients with perforated appendicitis  resolution with drainage

and antibiotics
■ Debate whether to perform interval appendectomy 6 to 8 weeks after
– Incidence of recurrent appendicitis (7.4 – 8.8%)
– Presence of appendiceal neoplasms detected on the appendectomy
– High incidence of no future events after follow-up of 34 months in
91% of patients
Preoperative Preparation

■ Preoperative antibiotics 30 to 60 minutes prior to skin incision

– Uncomplicated
■ Cefoxitin, ampicillin-sulbactam, cefazolin plus metronidazole
■ (+) B-lactam allergies: Clindamycin plus fluoroquinolone, gentamicin or aztreonam
■ Postop antibiotics are usually not necessary
– Perforated
■ Piperacillin tazobactam or cephalosporin with metronidazole
– CPG: Piperacilin tazobactam or ertapenem; ciprofloxacin plus metronidazole if
with beta lactam allergy
■ Gram-negative and anaerobic coverage
■ Duration of postop antibiotics: 3-7 days (4 days from the STOP-IT trial)
OPEN APPENDECTOMY
■ General anesthesia or regional anesthesia
■ Incision  McBurney’s (oblique) or Rocky-Davis
(transverse)
■ Lower midline laparotomy for perforated
appendicitis with phlegmon
■ Identification of the appendix  tracing the
anterior taenia of the cecum distally
■ Viable base  ligation of the appendix
■ Imbricated with a Z-stitch or purse-string
configuration OR mucosa can be fulgurate
OPEN APPENDECTOMY
■ Skin closure usually performed in layered fashion
■ Significant abscess or contamination  secondary intention or delayed
primary closure
– No difference in surgical site infection rates between primary and
delated primary closure
■ Placement of surgical drains  no benefit
OPERATIVE TECHNIQUES
■ Laparoscopic appendectomy
■ Single incision laparoscopic appendectomy
■ Natural orifice transluminal endoscopic surgery (NOTES)
■ Robotic appendectomy
NEGATIVE EXPLORATION

■ If one finds no evidence of appendicitis upon operation, a thorough

exploration of the peritoneum must be performed to rule out contributing
pathology
■ Normal appendix is often removed to reduce future diagnostic dilemma
INCIDENTAL APPENDECTOMY

■ Routinely performed in the following:

– Children undergoing chemotherapy
– Compromised hosts with an unclear physical exam
– Patients with Crohn’s disease with a normal cecum
– Patients traveling to remote places with no urgent care
– Patients undergoing cytoreductive operations for ovarian malignancies
■ Risk of adhesions and future complications after appendectomy suggested to be
higher that the risk of future appendicitis
– Incidental appendectomy is currently not advocated
APPENDICITIS IN CHILDREN

■ 1 in 8 children undergo workup for appendicitis

■ Infants and young children are most likely to present with perforated disease (51-
100%
■ School-age children have lower rates if perforation
■ Presents similarly as adults
■ Neonates: may present with abdominal distention, lethargy, or irritability
■ Special considerations must be made to exclude relevant differential diagnosis
(e.g. intussusception, gastroenteritis, malrotation, pregnancy, mesenteric adenitis,
ovarian or testicular torsion)
Pediatric Appendicitis Score
Management

■ Laparoscopic appendectomy is preferrable both in early and complicated

appendicitis
■ Perforated  antibiotics are continued for 3-5 days
■ Nonoperative management
– Early presentation
– Limited inflammation (WBC < 18, 000)
– Appendicoliths
– No evidence of rupture on imaging
■ Recurrence rate of 22% at 1 year
APPENDICITIS IN OLDER ADULTS

■ Diminished inflammation  present with perforation or abscess more

frequently
■ Higher risk of complication due to premorbid conditions
■ Laparoscopic appendectomy
– Safe
– Reduced pain
– Shorter hospital stay
APPENDICITIS IN PREGNANCY

■ 1 in 800 to 1in 1000 pregnancies

■ 1st and 2nd trimesters
■ May also present with heartburn, bowel irregularity, flatulence, or a
change in bowel habits
■ Point of maximal tenderness is usually displaced
■ Ultrasonography is preferred imaging modality (Sn 67-100%, Sp 93-96%)
■ MRI as alternative (Sn 94%, Sp 97%)
APPENDICITIS IN PREGNANCY

■ 36% risk of fetal loss if perforation occurs  lower threshold to operate

■ Acceptable negative exploration rate: 30%
■ Laparoscopic appendectomy can be performed
– Studies suggest a higher rate of fetal loss vs open appendectomy
– Lower intra-abdominal pressures (10-12mmHg) may reduce early
labor
■ Nonoperative management  treatment failures as high as 25%
CHRONIC APPENDICITIS

■ Patients with recurrent RLQ pain not associated with a febrile illness with
imaging findings suggestive of an appendicolith or dilated appendix
■ Resolution of symptoms with appendectomy
■ No imaging abnormalities  prophylactic appendectomy is not
encouraged
STUMP APPENDICITIS

■ Development of appendicitis in an incompletely excised appendiceal

stump (greater than 0.5cm stum length)
■ Diagnosis can be difficult and requires careful assessment of the patient’s
history, PE, and imaging
■ Prior appendectomy should not be an absolute criterion in ruling put
acute appendicitis
■ Management : re-excision of appendiceal base
APPENDICEAL NEOPLASMS
Carcinoid Tumors
■ Gastroenteropancreatic neuroendocrine tumors
■ Submucosal rubbery masses
■ Relatively indolent but can develop nodal or hepatic metastases
■ Management:
– Evaluate nodal basin along the ileocolic pedicle
– Examine the liver for metastases

< 1 cm Negative margin appendectomy

2 cm or larger Right hemicolectomy
1-2 cm No consensus on completion colectomy
Mesenteric invasion, enlarged Right hemicolectomy
nodes, positive or unclear margins
Goblet Cell Carcinomas

■ With adenocarcinoma and neuroendocrine tumors

■ Worse prognosis than carcinoids, slightly better that adenocarcinomas
■ High risk of peritoneal recurrence
– Systemic surveillance of the peritoneum
– Peritoneal cancer index score
■ Right hemicolectomy in the absence of metastatic disease
– Some advocate it only for tumors 2 cm or larger
Lymphomas

■ Appendiceal lymphomas are rare (1-3% of lymphomas)

■ Difficult to diagnose preoperatively
■ Appendiceal diameter can 2.5 cm or larger
■ Management includes appendectomy
Adenocarcinoma

■ Primary adenocarcinoma of the appendix is rare

■ Three major histologic subtypes:
– Mucinous adenocarcinoma
– Colonic adenocarcinoma
– Adenocarcinoid
■ Most common presentation: acute appendicitis
■ Ascites, palpable mass, incidental finding during operation for unrelated cause
■ Propensity for early perforation
■ Significant risk for synchronous and metachronous neoplasms
■ Management: right hemicolectomy
 Mucoceles and Mucinous Neoplasms
■ Appendiceal mucocele: mucus-filled appendix
that can be secondary to neoplastic or
nonneoplastic pathologies
■ Commonly incidental, 1/3 presents as
appendicitis
■ On imaging: low attenuation, round, well-
encapsulated cystic mass
– Wall irregularity, soft tissue thickening 
suggestive of neoplasms
■ Diagnosis cannot be established with imaging
alone
■ Surgical excision WITHOUT capsular disruption
should be undertaken
– Rupture  intraperitoneal spread of
neoplastic cells  pseudomyxoma peritonei
Mucoceles and Mucinous Neoplasms

■ Examination of peritoneum and document peritoneal cancer index score

■ (-) mesenteric or peritoneal involvement  appendectomy with concurrent
appendiceal lymphadenectomy
■ (+) peritoneal spread
– Obtain biopsies
– Appendectomy if with acute appendicitis
– Suboptimal debulking is discouraged
– Examination of intra-abdominal structures
■ Colorectal, ovarian, and endometrial cancers can coexist
 Pseudomyxoma Peritonei Syndrome
■ Appendiceal mucinous neoplasms 
peritoneal dissemination 
pseudomyxoma peritonei
■ Can occur in gastric, ovarian, pancreatic,
and colorectal primary tumors
■ Cytoreductive surgery and hyperthermic
intraperitoneal chemotherapy (HIPEC)
as standard of care
– Parietal and visceral
peritonectomies
– Intraperitoneal administration of
heated chemotherapy (42C),
usually mitomycin
Thank you!