Surgery: The Appendix o Usually in one of the infarcted areas of the

antimesenteric border
o Just beyond the obstruction and not at the
References: Baby and Mommy Schwartz, 10th Edition
tip
 Sequence is NOT inevitable –some episodes
Anatomy and Function spontaneously resolves
 Base is attached to the cecum  Causes of obstruction
 Tip may be retrocecal (most common), pelvic, subcecal, o Fecalith or appendicolith (most common)
preileal, or right pericolic in postion o Foreign bodies
 3 taenia coli converge at the junction of cecum and o Intestinal worms
appendix o Trauma
 Length may be <1 cm to >30 cm (6-9 cm most common) o Bezoars
 Lymphoid tissue, secretes IgA (an integral component of
gut-associated lymphoid tissue [GALT]) Bacteriology
o Function is “not essential” –no immune  Principal organisms involved are Escherichia coli (G-,
compromise upon resection facultative, bacilli) and Bacteroides fragilis (G+, anaerobic,
bacilli)
Acute Appendicitis o Both are normal flora of appendix
o Seen in both acute and perforated appendicitis
Historical Background  Up to 14 different organisms were identified
 Charles McBurney – greatest contributor to treatment  Culture – questionable (normal flora predominance)
(1889) o Peritoneal culture reserved for patients who are
o Described McBurney’s point (point of maximum immunosuppressed and PX who develop
tenderness) abscess after treatment
o One-half to two inches inside the right anterior  Broad-spectrum antibiotics indicated
spinous process of the ilium on a line drawn to o Non perforated → 24-48 hour-antibiotics
the umbilicus o Perforated → 7-10 days recommended
 Semm – widely credited to 1st perform a successful o IV antibiotics given when WBC count is normal
laparoscopic appendectomy (1982) and patient afebrile for 24 hours

Incidence Clinical Manifestations

 Lifetime rate: 12%m:25%f – 7% undergoes appendectomy  Symptoms
for acute appendicitis o Abdominal pain – prime symptom in acute onset
 Seen more frequently in 2nd to 4th decades of life (20-40);  Classic presentation: diffusely centered
mean age of 31.3; median age of 22 in lower epigastrium/umbilical area
 Male over female predominance – 1.2-1.3m:1f  Moderately severe, steady, may have
 Rate of misdiagnosis: 15.3% (equivalent to appendiceal superimposed intermittent cramping
rupture)  After varying period of 1-12 hours –
o Higher in women – 22.2%:9.3% localizes to RLQ
 Negative appendectomy rate for women of reproductive  (there are cases where pain starts in
age: 23.2% highest in 40-49 years old RLQ and stays there)
o Highest negative appendectomy rate – women  Location of appendix account for
>80 years old variation of pain locus (in the somatic
 Etiology and pathogenesis (interpret as 1 will cause 2, 2 phase)
will cause 3…) o Anorexia is almost always present
1. Proximal obstruction  Diagnosis is questionable if Px is not
2. Closed loop obstruction (Continuous luminal anorectic
secretion) o Vomiting is present in 75% of cases
3. Distention o Obstipation prior to onset of pain
4. Stimulates visceral afferent stretch fibers o Diarrhea may occur (particularly in children)
5. Pain (vague, dull, and diffuse) in mid/lower o In 95% of cases: Anorexia → abdominal pain →
epigastrium vomiting
6. Cramps (distention aggravates peristaltic waves)  If vomiting comes before pain, think
7. Continued distention + multiplication of resident otherwise
bacteria (may cause nausea and vomiting)  Signs
8. Pressure exceeds venous pressure o Determined principally by anatomic position of
9. Capillary and venous occlusion, arteriolar inflow appendicitis
continues o Vital signs
10. Engorgement + vascular congestion  Temperature elevation rarely exceeds
11. Arteriolar inflow occlusion 1C
12. Involvement of serosa and parietal peritoneum  Pulse rate – N to sl↑
13. Pain shifts to RLQ  Greater changes in VS indicate
 Ultimately, distention + bacterial invasion + vascular complication
compromise + infarction = PERFORATION o General Survey and PE findings
  Prefers to lie supine with thighs drawn Alvarado Scale for Diagnosing Appendicitis
up (motion causes pain) Category Manifestation Value
 Classic RLQ pain if appendix is anterior Symptoms Migration of pain 1
of cecum Anorexia 1
 Tenderness maximal at or near Nausea/Vomiting 1
McBurney’s point Signs RLQ tenderness 2
 Direct rebound tenderness Rebound 1
 Referred/indirect rebound tenderness Elevated temp 1
may also be present (maximal at RLQ) Lab values Leukocytosis 2
 Indicates peritoneal irritation Left shift 1
 Rovsing’s sign (+) Total points 10
 Palpatory pressure in LLQ
produces pain in RLQ Appendiceal Rupture
 Cutaneous hyperesthesia at T10-T12
 Immediate appendectomy – standard treatment of acute
 Abdominal guarding
appendicitis due to risk of rupture
 Psoas sign (+)
 25.8% - overall rate of perforated appendicitis
 Obturator sign (+)
o Most prevalent in children <5 years old, and
 Laboratory Findings
older patients >65 years old
o Mild leukocytosis (10,000-18,000/mm3)
 Nonoperative treatment increases morbidiy and mortality
 Usually present in acute onset,
risk associated with ruptured appendicitis
uncomplicated cases
 Rupture should be suspected in the following
 With PMN predominance
o Fever >39C
 If WBC > than specified, suspect
o WBC >18,000/mm3
perforation
o Localized rebound/referred tenderness
o Urinalysis useful to rule-out UT as infection
o Ill-defined mass on PE
source
 Phlegmon
 Bacteriuria not found in catheterized
 Periappendiceal abscess
urine specimen in acute cases
 Px with mass – longer duration of
symptoms (5-7 days)
Imaging Studies
 Of note
 Plain radiographic films are rarely helpful
o Phlegmons and small abscesses may be treated
o Useful only to rule-out other pathologies
conservatively with antibiotics
o Acute – abnormal bowel gas pattern –
o Well-localized abscesses – percutaneous
nonspecific finding
drainage
o Fecalith is rarely noted – if present, highly
o Complex abscesses – surgical drainage
suggestive of diagnosis
o Interval appendectomy recommended after 6
 Graded compression sonography
weeks following acute event treated
o With maximal compression, appendiceal
nonoperatively or with simple drainage of
diameter is measured in the anteroposterior
abscess
dimension
o Positive – if appendix is noncompressible 6 mm
Differential Diagnosis
or more in anteroposterior direction
 Essentially the diagnosis of “acute abdomen”
o Presence of appendicolith establishes diagnosis
o Clinical manifestations are mostly not specific
o Other highly suggestive findings
and therefore may have identical clinical picture
 Thickening of appendiceal wall
with a wide variety of acute processes in the
 Periappendiceal fluid or mass
abdomen
o When acute appendicitis is excluded, perform
 Preoperative diagnosis accuracy of 85% is acceptable
brief survey of the abdominal cavity
o Less than this may result to unnecessary
 On CT scan
operations
o Inflamed appendix is dilated
o If consistently greater than 90% - would mean
o Wall thickened
you’re “observing” instead of operating
o Evidence of inflammation with “dirty fat”
 Diseases/conditions commonly misdiagnosed as acute
o Thickened mesoappendix
o Obvious phlegmon appendicitis and found to be naught ntraoperatively
(descending order of frequency):
o Fecalith (easily visualized)
o Arrowhead sign (thickening of the cecum, o Acute mesenteric lymphadenitis
o No organic pathologic condition
funnels contrast to the inflamed appendix)
o Acute pelvic inflammatory disease
 Laparoscopy
o Twisted ovarian cyst or ruptured graafian follicle
o Both diagnostic and therapeutic approach
o Acute gastroenteritis
o Most useful for females
 Differentials depend on four major factors:
 Used to differentiate acute
o Anatomic location
appendicitis from acute gynecologic
o Stage of process
pathology
o Px age
o Px sex
 Acute Appendicitis in the Young o TB
 Diagnosis is more difficult o Lymphoma
 Higher morbidity rate due to o Other causes of infectious colitis
o ↑ propensity for rupture  Immediate appendectomy is indicated
 Underdeveloped tissues and rapid  In patients with diarrhea as primary symptom,
progression colonoscopy may be warranted
o Underdeveloped greater omentum  Negative appendectomy rate – 5-10%
 Lesser ability to contain a rupture o Up to 25% will have AIDS-related entities in
 <5 vs. 5-12 years of age respectively operative specimen
o Negative appendectomy rate: 25% vs. <10%  CMV
o Appendiceal perforation rate: 45% vs. 20%  Kaposi
 Treatment regimen includes  M. aviumintracellulare
o Perforated – immediate appendectomy and  Postoperative morbidity rate higher in Px with perforation
irrigation of peritoneal cavity  Hospital stay rate is longer
o Antibiotics
 Nonperforated – 24-48 hrs Treatment
 Perforated – 7-10 days  Preoperative preparations
 IV preparations given when Px is o Adequate hydration
afebrile for at least 24 hrs o Electrolyte abnormalities corrected
o Laparoscopic appendectomy – safe and effective o Preexisting conditions should be addressed
 Cardiac
Acute Appendicitis in Older Adults  Pulmonary
 Incidence is lower than young  Renal
 Morbidity and mortality is higher o Preoperative antibiotics may be considered
 High index of suspicion should be observed (lowered infectious complications in trials)
 >80 years of age  Cefoxitin
o Perforation rate – 49%  Cefotetan
o Mortality – 21%  Ticarcillin-clavulanic acid
 More severe infections
Acute Appendicitis in Pregnancy  Carbapenems
 Most frequently encountered extrauterine disease  Combination therapy with
requiring surgical treatment in pregnancy o 3rd gen
 Most frequent during 1st and 2nd trimesters cephalosporin
 Diagnosis is inversely related to gestational age o Monobactam
o Due to displacement of appendix latero-  Aminoglycoside plus
superiorly o Clindamycin
 Nausea and vomiting (or new-onset) after 1st trimester o Metronidazole
may be of consideration for diagnosis  Open Appendectomy
 Abdominal pain and tenderness may be present but less o Incision is either McBurney (oblique) or Rocky-
guarding (due to abdominal laxity) Davis (transverse) at the point of maximal
tenderness or palpable mass
 WBC >15.000-20,000 /uL – PMN predominance
 (according to doc Cabredo, Rocky-
 Abdominal ultrasound is beneficial
Davis is more common now-a-days)
 Laparoscopy may be indicated especially in early
o Abscess suspected → lateral incision for
pregnancy
retroperitoneal drainage
 Premature labor risk of 10-15% in appendectomy during
o Diagnosis in doubt → midline incision for better
pregnancy
examination of cavity
 Appendiceal perforation – significant factor in fetal and
 Relevant in older Px where
maternal death
malignancy/diverticulitis is possible
o Fetal mortality – 3-5% in early appendicitis to
o Localization techniques
20% if with perforation
 Follow convergence point of taenia coli
 Sweeping lateral to medial motion
Appendicitis in Patients with AIDS or HIV Infection
 Limited mobilization of cecum
 Presentation of acute appendicitis same as noninfected o Once appendix is identified
persons except for  Divide mesoappendix
o Nonmanifestation of absolute leukocytosis (only  Ligate appendiceal artery
relative leukocytosis) o Appendiceal stump clearly viable with base of
 Increased risk for appendiceal rupture associated to cecum uninvolved in inflammatory process -
o Delay in manifestation managed by:
o Low CD4 count  Simple ligation
 Differential diagnosis should always include opportunistic  Ligation and inversion
infection such as but not limited to
 Purse-string stitch
o CMV
 Z-string stitch
o Kaposi sarcoma
o Mucosa obliterated to avoid mucocele formation
 o Peritoneal cavity irrigated o Associated to added expense and longer
o Wound closed in layers hospitalization
o If perforation or gangrene is found in adults o Initial treatment include
Skin and subcutaneous tissue left open to  IV antibiotics
heal by secondary intent (may be closed  Bowel rest
after 4-5 days [delayed primary closure]) o Percutaneous or operative drainage of abscess is
o In children primary wound closure is always not considered failure of conservative therapy
indicated
 Laparoscopy Prognosis
o Performed under general anesthesia  Mortality is steadily decreasing
o Requires 3 ports (or sometimes 4) o Principal factors of mortality include rupture
o Steps before surgical treatment and age of Px
 Surgeon in Px’s left  Complications occur in 3% of Px with nonperforated vs.
 Assitant 1 operates camera 47% in Px with perforations
 One trocar in the umbilicus  Serious early complication is usually septic (abscess and/or
 Another trocar suprapubic wound infection)
 3rd trocar variable (usually in LLQ,  Complete wound dehiscence rarely occurs in McBurney
epigastrium, or RUQ) type of incision
 Abdomen is first thoroughly explored  Predilection sites of abscesses
(rule-out other pathology) o Appendiceal fossa
 Identify appendix o Pouch of Douglas
 Dissection at the base o Subhepatic space
 Division of mesentery from o Between intestinal loops
appendiceal base o Rectally bulging abscess (transrectal drainage)
 If mesoappendix involved,  Fecal fistula may occur as a complication of appendectomy
divide appendix by stapler; o May be due to sloughing of cecal portion inside a
then divide mesoappendix constricting purse-string suture
from appendix o Ligature’s slipping off an appendiceal stump
 Base of appendix is not inverted o Necrosis from abscess encroaching on cecum
 Appendix removed via trocar site or
within retrieval bag Chronic Appendicitis
 Evaluate site for hemostasis  An uncommon disease
 RLQ irrigated  Pain lasts longer but less intense in the same location
 Trocars removed  Characteristic symptoms
o Should be considered only as an option in thin o Vomiting (lower incidence)
males aged 15-45 o Anorexia
o May be beneficial to obese males o Nausea (occasionally)
o Pregnant women withpresumed appendicitis o Pain with motion
may benefit from diagnostic laparoscopy o Malaise
 Leukocyte counts are normal
Laparoscopy vs. Open Appendectomy  CT scans are non-diagnostic
Category Laparoscopy Open  Laparoscopy is effective
Duration and cost ↑ ↓  Appendectomy is curative
Wound infection ↓ ↑  Px whose symptoms are not cured or recur usually have
Intraabdominal Crohn disease as an underlying diagnosis
↑ ↓
abscess
Pain of 1st Appendiceal Parasites
↓ ↑
postoperative day
 Live parasites cause obstruction
Hospital length of
↓ ↑  Ascaris lumbricoides – most common
stay
 Others
Benefit to thin
↓ ↑ o E. vermicularis
males (15-45 yo)
o S. stercoralis
Benefit to obese
↑ ↓ o E. granulosis
males
 Presence of parasites make appendectomy difficult
 Px treated with helminthicide post-operation
 Interval Appendectomy
 Amebiasis can also cause appendicitis
o Performed on Px with palpable or
o Invasion by trophozoites
radiographically documented mass (abscess or
o Component of more generalized intestinal
phlegmon)
amebiasis
 Initial conservative therapy with
o Appendectomy followed by antibiotic therapy
interval appendectomy after 6-10
(metronidazole)
weeks later
o Provides lower morbidity and mortality rates Incidental Appendectomy
than immediate appendectomy
 Both appendicitis and appendicitis with perforation are  Mucocele
more common in men than women o Leads to progressive enlargement due to
 NNT = 36 (36 incidental appendectomies performed to intraluminal accumulation of mucoid substance
prevent the occurrence of 1 appendicitis) o Histologic type dictates course and prognosis of
 Indications for incidental appendectomy disease
o Children about to undergo chemotherapy  Retention cysts
o Disabled who cannot respond normally to  Mucosal hyperplasia
abdominal pain  Cystadenomas
o Crohn disease Px in whom cecum is free of  Cystadenocarcinomas
macroscopic disease o If benign – simple appendectomy
o Individuals about to travel to remote areas o Pseudomyxoma peritonei
without access to medical/surgical care  Rare condition where diffuse
collections of gelatinous fluid are
Tumors associated with mucinous implants on
 Extremely rare peritoneal surfaces and omentum
 2-3x more common in females than
 Incidence of primary appendiceal malignancy is 0.9-1.4%
males
found on appendectomy specimens
 Usually present with
 <50% of cases diagnosed perioperatively
 Abdominal pain
 Epidemiology
 Distention
o Carcinoid (most common in most series studies)
– greater than 50% of cases  Mass
o NCI – SEER reports histologic update  Ureteral obstruction and/or venous
 Mucinous adenocarcinoma as most obstruction may occur
common (37%)  CT scanning is preferred
 Carcinoid as second most common  Perioperative location of mucinous
(33%) ascites and tumor deposits in women
 Carcinoid  Right hemidiaphragm
o Appendix most common site of GI carcinoid  Right retrohepatic space
 Small bowel then rectum  Left paracolic gutter
(respectively)  Ligament of Treitz
o Carcinoid syndrome rarely associated with  Ovaries
appendiceal carcinoid unless metastases are  Surgical debulking is mainstay of
present treatment (all gross disease removed)
o The tumor may/may not obstruct the lumen  Appendectomy routinely performed
(most common site is apex/tip)  Hysterectomy with bilateral salphingo-
o Malignant potential directly proportional to size oophorectomy is performed in women
of tumor  Not of benefit
o <1 cm – 78%  Ultra-radical surgery
o 1-2 cm – 17%  Adjuvant chemo
o >2 cm – 5%  Systemic post-op chemo
o Treatment  Lumph node and distant mets are
 Simple appendectomy most common uncommon
 <1 cm with mesoappendiceal  Recurrences treated by additional
extension and >1.5 cm – right surgery – although associated with
hemicolectomy  Enterotomies, anastomotic
 Adenocarcinoma leaks, fistulas
o Rare neoplasm of appendix  Lymphoma
o Has three subtypes o Uncommon
 Mucinous adenocarcinoma o GIT most frequently involved extranodal site for
 Colonic adenocarcinoma non-Hodgkin lymphoma
 Adenocarcinoid  Burkitt and leukemia also been
o Most commonly presents like an acute reported
appendicitis o Primary lymphoma frequency of 1-3%
 May have additional signs like ascites o Presents as acute appendicitis
and/or palpable mass o CT scan finding ≥ 2.5 cm or surrounding soft
 Neoplasm may incidentally be tissue thickening prompts suspicion
discovered perioperatively for an o If confined to appendix – appendectomy (w/o
unrelated cause adjuvant therapy
 Recommended treatment for all types o Extension of tumor onto cecum or mesentery -
– formal right hemicolectomy right hemicolectomy
o Have propensity for early perforation  With postoperative staging workup
o Px are at risk for both synchronous or before adjuvant therapy
metachronous neoplasms