The Appendix

dr.Atler Khairul Muslim

General Surgery Resident Andalas University
2023
Historical Background

• Appendiceal disease is a frequent reason for emergency hospital admission,

and appendectomy is one of the most common emergency procedures
performed in contemporary medicine.
• the human appendix was not noted until 1492. Leonardo da Vinci depicted
the appendix in his anatomic drawings, but these were not published until the
eighteenth century.
Historical Background

• In 1886, Reginald H. Fitz presented his findings regarding appendicitis and

recommended consideration for operative treatment.
• In 1889, Charles McBurney published his landmark paper in the New York
State Medical Journal describing the indications for early laparotomy for the
treatment of appendicitis.
Epidemilogy

• incidence rate of about 100 per 100,000 inhabitants. Lifetime risk for
appendicitis is 8.6% for males and 6.7% for females, with the highest
incidence in the second decade of life.
Sign And Symptoms
Differential Diagnosis

• Pediatric Patient. Acute mesenteric adenitis is the disease most often

confused with acute appendicitis in children. Almost invariably, an upper
respiratory tract infection is present or has recently subsided. The pain
usually is diffuse, and tenderness is not as sharply localized as in
appendicitis.
• Elderly Patient. Diverticulitis or perforating carcinoma of the cecum or of a
portion of the sigmoid that overlies the right lower abdomen may be
impossible to distinguish from appendicitis
• Female Patient. Diseases of the female internal reproductive organs that may
erroneously be diagnosed as appendicitis are, in approximate descending
order of frequency, pelvic inflammatory disease, ruptured graafian follicle,
twisted ovarian cyst or tumor, endometriosis, and ruptured ectopic pregnancy
• Computed tomography scan has improved diagnostic accuracy in individual
studies. However, in population-wide studies, the rate of misdiagnosis of
appendicitis remains constant. Rates of misdiagnosis are highest in female
patients of child-bearing age and patients on the extremes of age (i.e., very
young and very old)
• Perforated or complicated appendicitis is more common in the very young
(age 65 years)
• Single-incision appendectomy provides no obvious advantage over standard
laparoscopic appendectomy. Natural orifice transluminal endoscopic surgery
remains an investigational procedure
• The incidence of fetal loss following normal appendectomy in pregnant
patients is 4%, and the risk of premature delivery is 10%
• Antibiotic prophylaxis is effective in the prevention of postoperative surgical
site infection. Postoperative antibiotics are unnecessary following
uncomplicated appendicitis. For complicated appendicitis, a treatment
duration of 4 to 7 days is recommended
Special Circumstances
Acute Appendicitis In The Young

• diagnostic delays by both parents and physicians, and the frequency of

gastrointestinal distress.
• In children, the physical examination findings of maximal tenderness in the
right lower quadrant, the inability to walk or walking with a limp, and pain
with percussion, coughing, and hopping were found to have the highest
sensitivity for appendicitis.
• The treatment regimen for perforated appendicitis generally includes
immediate appendectomy. Antibiotic coverage is limited to 24 to 48 hours in
cases of nonperforated appendicitis.
• Laparoscopic appendectomy has been shown to be safe and effective for the
treatment of appendicitis in children.
ACUTE APPENDICITIS IN THE ELDERLY
• Compared with younger adults, elderly patients with appendi_x0002_citis
often pose a more difficult diagnostic problem because of the atypical
presentation, expanded differential diagnosis, and communication difficulty
the perforation rate appears to increase with age greater than 80 years
As a result of increased comorbidities and an increased rate of perforation,
postoperative morbidity, mortality, and hoSpital length of stay are increased
in the elderly compared with younger populations with appendicitis.
 ACUTE APPENDICITIS DURING PREGNANCY
• Acute appendicitis can occur at any time during pregnancy but is rare in the third
trimester.110 The overall negative appendectomy rate during pregnancy is
approximately 25% and appears to be higher than the rate seen in nonpregnant
women
• Recent data suggest that the incidence of perforated or complex appendicitis is not
increased in pregnant patients.
• Another option is magnetic resonance imaging, which has no known deleterious
effects on the fetus. The American College of Radiology recommends the use of
nonionizing radiation techniques for front-line imaging in pregnant women.
POSTOPERATIVE CARE AND
COMPLICATIONS

• Following uncomplicated appendectomy, complication rates are low,114 and most

patients can quickly be started on a diet and discharged home the same day or the
following day.
• Patients should be continued on broad-spectrum antibiotics for 4 to 7 days.
 SURGICAL SITE INFECTION
• Following laparoscopic appendectomy, the extraction port site is the most common
site of surgical site infection. Patients with cellulitis can be started on antibiotics. The
cultured organisms are typically bowel flora, as opposed to
skin flora.
• Small abscesses can be simply treated with antibiotics; however, larger abscesses
require drainage. Most commonly, percutaneous drainage with CT or ultrasound
guid_x0002_ance is effective. For abscesses not amenable to percutaneous drainage,
laparoscopic abscess drainage is a viable option.
STUMP APPENDICITIS
• A review of literature has revealed only 60 reports of this phenomenon. Likely,
incom_x0002_plete appendectomy is underreported, and the true prevalence is
much higher. Reported as “stump appendicitis,” patients typically present with
recurrent symptoms of appendicitis approxi_x0002_mately 9 years after their
initial surgery.
• There was no difference in initial surgery between laparoscopic and open
procedures
• The key to avoiding stump appendicitis is prevention. Use of the “appendiceal
critical view” (appendix placed at 10 o’clock, taenia coli/libera at 3 o’clock, and
terminal ileum at 6 o’clock) and identification of where the taeniae coli merge
and disappear is paramount to identifying and ligating the base of the appendix
during the initial operation
INCIDENTAL APPENDECTOMY

• During this period, an average of 250,000 cases of appendicitis and 310,000

incidental appendectomies occurred annually in the United States. It was
esti_x0002_mated that 36 incidental appendectomies had to be performed to
prevent one patient from developing appendicitis.
• In view of the added costs and risk of morbidity for each extension of a
surgical intervention, this does not seem to justify incidental appendectomy.
PREVALENCE OF NEOPLASMS

• The prevalence of identifying a mass within the appendix is less than 1%.
Appendiceal carcinoid and appendiceal adenomas are the most common
lesions identi
• In older patients, the prevalence of identifying colon can_x0002_cer
appearing as appendicitis has been reported in a single study with a
prevalence of less than 1%. The mean age in this case series was 69 years
(range, 42 to 89 years).
CARCINOID
• Carcinoid syndrome is rarely associated with appendiceal carcinoid unless
widespread metastases are present, which occur in 2.9% of cases Symptoms
attributable directly to the carcinoid are rare, although the tumor can
occasionally obstruct the appendiceal lumen much like a fecalith and result in
acute appendiciti
• The mean tumor size for carcinoids is 2.5 cm
• epidemiology, and end results data indicate that proper surgery for carcinoids
is not performed at least 28% of the time.
ADENOCARCINOMA

• Primary adenocarcinoma of the appendix is a rare neoplasm with three major

histologic subtypes: mucinous adenocarcinoma, colonic adenocarcinoma,
and adenocarcinoid.
• appendiceal adenocarcinoma are at significant risk for both synchronous and
metachronous neoplasms, approximately half of which will originate from
the gastrointestinal tract.
MUCOCELE
• A mucocele of the appendix is an obstructive dilatation by intraluminal
accumulation of mucoid material. Mucoceles may be caused by one of four
processes: retention cysts, mucosal hyperplasia, cystadenomas, and
cystadenocarcinomas
• a more aggressive approach to ruptured appendiceal neoplasms has been
advocated. This approach includes a thorough but mini_x0002_mally
aggressive approach at initial laparotomy, as described earlier, with
subsequent referral to a specialized center for con_x0002_sideration of
reexploration and hyperthermic intraperitoneal chemotherapy
LYMPHOMA

• The gas_x0002_trointestinal tract is the most frequently involved extranodal

• site for non-Hodgkin’s lymphoma.Other types of appendiceal lymphoma,
such as Burkitt’s lymphoma, as well as leukemia, have also been reporte.
THANK YOU