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DISEASES OF THE APPENDIX

ALFONSO C. DANAC, MD, FPCS, FPSGS, FPALES


Associate Professor, Department of Surgery
Angeles University Foundation
School of Medicine
dix

ology: becomes visible as a protuberance of the terminal portio


cecum at 8 wks AOG

h rate is exceeded by the cecum during antenatal and postnatal


resulting to medial displacement of the appendix medially towa
the ileocecal valve
Appendix

- narrow muscular tube containing large amounts of


lymphoid tissue
in its wall

- attached to the posteromedial surface of the cecum


about 2.5 cm below
the ileocecal junction

- has a complete peritoneal covering, which is


attached to the mesentery
of the small intestine by a short mesentery of
its own,
the mesoappendix

- mesoappendix contains the appendicular vessels


and nerves
Appendix

- base of the appendix can be located inside the


abdomen by tracing
the taenia coli of the cecum and following them
to the appendix,
where they converge to form a continuous
muscle coat

- can vary in length from less than 1 cm to greater


than 30 cm; most appendices are 6 to 9 cm in length

- appendiceal absence, duplication, and diverticula


have all been reported
Appendix

Arterial Supply: Appendicular Artery, branch of


posterior cecal artery

Venous Drainage: appendicular vein, drains into the


posterior cecal vein

Lymphatic Drainage: one or two nodes in the


mesoappendix and
then to the superior mesenteric
nodes

Nerve Supply: sympathetic and vagus nerves from the


superior mesenteric plexus
- relationship of the base of
the appendix to the
cecum remains constant

- tip can be found in a


retrocecal, pelvic, subcecal,
preileal, or right pericolic
position

- these anatomic
considerations have
significant clinical importance
in the context of acute
appendicitis

- the three taenia coli


converge at the junction of
the cecum with the
appendix and can be a useful
Appendix

- erroneously viewed, in the past, as a vestigial organ


with no known function

- now well recognized as an immunologic organ that


actively participates in the secretion of
immunoglobulins, particularly immunoglobulin A (IgA)

- an integral component of the gut-associated lymphoid


tissue (GALT) system

- function is regarded as not essential and


appendectomy is not associated with any
predisposition to sepsis or any other manifestation of
immune compromise
Appendix

- Lymphoid tissue first appears in the appendix


approximately 2 weeks after birth

- amount of lymphoid tissue increases throughout


puberty, remains steady for the next decade, and then
begins a steady decrease with age

- after the age of 60 years, virtually no lymphoid tissue


remains within the appendix, and complete
obliteration of the appendiceal lumen is common
Historical Background

-first appendectomy by Claudius Amyand, a


surgeon at St. George's Hospital in London and
Sergeant Surgeon to Queen Ann, King George I,
and King George II.

-In 1736, he operated on an 11-year-old boy


with a scrotal hernia and a fecal fistula. Within
the hernia sac, Amyand found the appendix
perforated by a pin. He successfully removed
the appendix and repaired the hernia.

The appendix was not identified as an organ


capable of causing disease until the nineteenth
century.

In 1824, Louyer-Villermay presented a paper


before the Royal Academy of Medicine in Paris.
He reported on two autopsy cases of
appendicitis and emphasized the importance of
Historical Background

In 1827, François Melier, a French physician,


expounded on Louyer-Villermay's work.

He reported six autopsy cases and was the first


to suggest the antemortem recognition of
appendicitis.

This work was discounted by many physicians


of the era, including Baron Guillaume
Dupuytren.
Dupuytren believed that inflammation of the
cecum was the main cause of pathology of the
right lower quadrant.

The term "typhlitis" or "perityphlitis" was used


to describe right lower quadrant inflammation.
Historical Background

In 1839, a textbook authored by Bright and


Addison titled Elements of Practical Medicine
described the symptoms of appendicitis and
identified the primary cause of inflammatory
processes of the right lower quadrant.

Reginald Fitz, a professor of pathologic


anatomy at Harvard, is credited for coining the
term "appendicitis." His landmark paper
definitively identified the appendix as the
primary cause of right lower quadrant
inflammation.
Incidence

lifetime rate of appendectomy is 12% for men and 25% for


women, with approximately 7% of all people undergoing
appendectomy for acute appendicitis.

rate of appendectomy for appendicitis has remained constant at


10 per 10,000 patients per year.

Appendicitis is most frequently seen in patients in their second


through fourth decades of life, with a mean age of 31.3 years and
a median age of 22 years. There is a slight male to female
predominance (M:F 1.2 to 1.3:1)
Incidence

Despite an increased use of ultrasonography, computed


tomography (CT) scanning, and laparoscopy between 1987 and
1997, the rate of misdiagnosis of appendicitis has remained
constant (15.3%), as has the rate of appendiceal rupture.

The percentage of misdiagnosis of appendicitis is significantly


higher among women than men (22.2 vs. 9.3%).

The negative appendectomy rate for women of reproductive age


is 23.2%, with the highest rates identified in women age 40 to 49
years.

The highest negative appendectomy rate is reported for women


older than 80 years of age (
Etiology and Pathogenesis

Obstruction of the lumen is the dominant causal factor


Fecaliths are the usual cause of appendiceal obstruction.
Less-common causes are hypertrophy of lymphoid tissue,
inspissated barium from previous x-ray studies,
tumors, vegetable and fruit seeds, and intestinal
parasites.

The frequency of obstruction rises with the severity of the


inflammatory process.

Fecaliths are found in 40% of cases of simple acute appendicitis,


65% of cases of gangrenous appendicitis without rupture, and
nearly 90% of cases of gangrenous appendicitis with rupture.
Etiology and Pathogenesis

There is a predictable sequence of events leading to eventual


appendiceal rupture.

Obstruction of lumen - increased intraluminal pressure

-- distention of appendix (vague, dull, diffuse mid abdomen or


lower epigastric or periumbilical pain)

Congestion  suppuration  gangrene  perforation


Table 29-1 Common Organisms Seen in Patients with
Acute Appendicitis

Aerobic and Facultative Anaerobic

Gram-negative bacilli Gram-negative bacilli

E. Coli Bacteroides
fragilis Pseudomonas aeruginosa
Bacteroides species Klebsiella species
Fusobacterium species

Gram-positive cocci Gram-positive cocci

Streptococcus anginosus
Peptostreptococcus species Streptococcus species
Gram-positive bacilli Enterococcus
species Clostridium species
Peritoneal culture should be reserved for patients who are
immunosuppressed, as a result of either illness or medication,
and for patients who develop an abscess after the treatment
of appendicitis.

Antibiotic coverage is limited to 24 to 48 hours in cases of


nonperforated appendicitis.

For perforated appendicitis, 7 to 10 days is recommended.

Intravenous antibiotics are usually given until the white blood


cell count is normal and the patient is afebrile for 24
hours.

The use of antibiotic irrigation of the peritoneal cavity and


transperitoneal drainage through the wound are
controversial.
Clinical Manifestations
Symptoms

Abdominal pain is the prime symptom of acute appendicitis.

Anorexia nearly always accompanies appendicitis.

vomiting occurs in nearly 75% of patients

obstipation

Diarrhea

Fever
Signs

Vital signs are minimally changed by uncomplicated appendicitis.


Temperature elevation
pulse rate is normal or slightly elevated

usually prefer to lie supine, with the thighs, particularly the right
thigh, drawn up, because any motion increases pain. If asked
to move, they do so slowly and with caution.

Tenderness is often maximal at or near McBurney's point.

Direct rebound tenderness is usually present

referred or indirect rebound tenderness is present

Rovsing's sign—pain in the right lower quadrant when palpatory


pressure is exerted in the left lower quadrant
Signs

Cutaneous hyperesthesia in the area supplied by the spinal nerves


on the right at T10, T11, and T12

Muscular resistance to palpation of the abdominal


voluntary guarding becoming involuntary

psoas sign indicates an irritative focus in proximity to that muscle.


The test is performed by having patients lay on their left side
as the examiner slowly extends the right thigh, thus stretching the
iliopsoas muscle. The test is positive if extension produces
pain.

positive obturator sign of hypogastric pain on stretching the


obturator internus indicates irritation in the pelvis. The test is
performed by passive internal rotation of the flexed right thigh
with the patient supine.

Pararectal tenderness
Laboratory Findings

CBC – leukocytosis with neutrophilic predominance

Urinalysis – normal in most cases


presence of pus cells may indicate
bladder or ureteral irritation
Imaging Studies

Plain film of the abdomen

Barium enema

Radionuclide tagged WBC Scan

Graded compression sonography

Abdominal CT scan – gold standard


Table 29-2 Alvarado Scale for the Diagnosis of
Appendicitis

Manifestations Value
Symptoms Migration of pain 1

Anorexia 1

Nausea/vomiting 1

Signs RLQ tenderness 2

Rebound 1
Elevated temperature 1

Laboratory values Leukocytosis 2


Left shift 1
The likelihood of appendicitis can be ascertained
using the Alvarado scale This scoring system was
designed to improve the diagnosis of appendicitis and
was devised by giving relative weight to specific
clinical manifestation.

Patients with scores of 9 to 10 are almost certain to


have appendicitis; there is little advantage in further
workup, and they should go to the operating room.

Patients with scores of 7 to 8 have a high likelihood


of appendicitis, while scores of 5 to 6 are
compatible with, but not diagnostic of
appendicitis.

CT scanning is certainly appropriate for patients with


Alvarado scores of 5 and 6, and a case can be
built for imaging those with scores of 7 and 8.

On the other hand, it is difficult to justify the expense,


radiation exposure time, and possible
Appendiceal Rupture
Appendiceal rupture
- occurs most frequently distal to the point of luminal obstruction
along the antimesenteric border of the appendix

- suspected in the presence of fever greater than 39°C (102°F) and a


white blood cell count greater than 18,000/mm3.

-In the majority of cases, rupture is contained and patients display


localized rebound tenderness.

- Generalized peritonitis will be present if the walling-off process is


ineffective in containing the rupture.

-In 2 to 6% of cases, an ill-defined mass will be detected on physical


examination.
- maybe a phlegmon, which consists of matted loops of
bowel adherent to the adjacent inflamed appendix, or
a periappendiceal abscess.
Appendiceal rupture

-Patients who present with a mass have a longer duration of


symptoms, usually at least 5 to 7 days

- Phlegmons and small abscesses can be treated conservatively with


intravenous antibiotics; well-localized abscesses can be
managed with percutaneous drainage; complex abscesses should
be considered for surgical drainage.

- If operative drainage is required, it should be performed by using


an extraperitoneal approach, with appendectomy reserved for
cases in which the appendix is easily accessible.

-Interval appendectomy performed at least 6 weeks following the


acute event has classically been recommended for all patients
treated either nonoperatively or with simple drainage of an
abscess.
Differential Diagnosis

- essentially the diagnosis of the "acute abdomen"


- most common erroneous preoperative diagnoses
-accounting for more than 75%—in descending
order of frequency acute mesenteric
lymphadenitis,
no organic pathologic conditions,
acute pelvic inflammatory disease,
twisted ovarian cyst or ruptured graafian
follicle,
and acute gastroenteritis.

differential diagnosis of acute appendicitis depends


upon four major factors:
the anatomic location of the inflamed
appendix;
the stage of the process (i.e., simple or
ruptured);
the patient's age;
and the patient's sex.
Differential Diagnosis

Acute Mesenteric Adenitis

Acute Gastroenteritis
Salmonella gastroenteritis (typhoid fever)

Diseases of the Male Urogenital System


Torsion of the testis
Acute epididymitis,
Seminal vesiculitis

Meckel's Diverticulitis

Intussusception

Crohn's Enteritis
Differential Diagnosis

Perforated Peptic Ulcer

Colonic Lesions
Diverticulitis
perforating carcinoma of the cecum, or
sigmoid clinical presentations.

Epiploic Appendagitis

Urinary Tract Infection


Acute pyelonephritis

Ureteral Stone

Primary Peritonitis
Differential Diagnosis

Henoch-Schönlein Purpura

Yersiniosis (Yersinia enterocolitica or Y.


pseudotuberculosis)

Campylobacter jejuni

Salmonella typhimurium

Gynecologic Disorders
pelvic inflammatory disease
ruptured graafian follicle
twisted ovarian cyst or tumor
endometriosis
ruptured ectopic pregnancy
Differential Diagnosis

Other Diseases

foreign-body perforations of the bowel


closed-loop intestinal obstruction
mesenteric vascular occlusion
pleuritis of the right lower chest
acute cholecystitis
acute pancreatitis
hematoma of the abdominal wall
Acute Appendicitis in the Young

-Establishing diagnosis is more difficult than in the


adult
due to inability of young children to give an
accurate history, diagnostic delays by both
parents and physicians, and the frequency of
gastrointestinal upset in children are all
contributing factors.

-more rapid progression to rupture and the inability


of the underdeveloped greater omentum to
contain a rupture lead to significant morbidity
rates in children

- Children younger than 5 years of age have a


negative appendectomy rate of 25% and an
appendiceal perforation rate of 45%.

- negative appendectomy rate of less than 10% and


a perforated appendix rate of 20% for children
5 to 12 years of age.
-appendix rate of 20% for children 5 to 12 years of
age.

-incidence of major complications after


appendectomy in children is correlated with
appendiceal rupture

-wound infection rate after the treatment of


nonperforated appendicitis in children is 2.8%
as compared to a rate of 11% after the
treatment of perforated appendicitis.

-The incidence of intra-abdominal abscess is also


higher after the treatment of perforated
appendicitis as compared to nonperforated
cases (6% vs. 3%).

- treatment regimen for perforated appendicitis


generally includes immediate appendectomy and
irrigation of the peritoneal cavity.
Acute Appendicitis in the Young

- Antibiotic coverage is limited to 24 to 48 hours in


cases of nonperforated appendicitis.

-For perforated appendicitis, 7 to 10 days of


antibiotics is recommended.
-
-Intravenous antibiotics are usually given until the
white blood cell count is normal and the patient is
afebrile for 24 hours.

- The use of antibiotic irrigation of the peritoneal


cavity and transperitoneal drainage through the
wound are controversial.

-Laparoscopic appendectomy has been shown to be


safe and effective for the treatment of appendicitis
in children. 62
Acute Appendicitis in the Elderly

incidence of appendicitis in the elderly is lower than


in younger patients,

the morbidity and mortality are significantly


increased in this patient population

Delays in diagnosis, a more rapid progression to


perforation, and comorbid disease are all
contributing factors

diagnosis of appendicitis may be subtler and less


typical than in younger individuals, and a high
index of suspicion should be maintained.

In patients older than age 80 years, perforation


rates of 49% and mortality rates of 21% have been
reported
Acute Appendicitis During Pregnancy

-most frequently encountered extrauterine disease


requiring surgical treatment during pregnancy.

-incidence is approximately 1 in 2000 pregnancies.

-can occur at any time during pregnancy, but is


more frequent during the first two trimesters.

- As fetal gestation progresses, the diagnosis of


appendicitis becomes more difficult as the
appendix is displaced laterally and superiorly

-nausea and vomiting after the first trimester or


new-onset nausea and vomiting should raise the
consideration of appendicitis.
Acute Appendicitis During Pregnancy

Abdominal pain and tenderness will be present,


although rebound and guarding are less frequent
because of laxity of the abdominal wall.

Elevation of the white blood cell count above the


normal pregnancy levels of 15,000 to 20,000/L, with
a predominance of polymorphonuclear cells, is
usually present.

When the diagnosis is in doubt, abdominal


ultrasound may be beneficial.

Laparoscopy may be indicated in equivocal cases,


especially early in pregnancy.
Acute Appendicitis During Pregnancy

The performance of any operation during


pregnancy carries a risk of premature labor of
10 to 15%, and the risk is similar for both
negative laparotomy and appendectomy for simple
appendicitis.

The most significant factor associated with both


fetal and maternal death is appendiceal
perforation.

Fetal mortality increases from 3 to 5% in early


appendicitis to 20% with perforation.

The suspicion of appendicitis during pregnancy


should prompt rapid diagnosis and surgical
intervention
Appendicitis in Patients with AIDS or HIV Infection

-incidence of acute appendicitis in HIV-infected patients is


reported to be 0.5%.
>higher than the 0.1 to 0.2% incidence reported for the
general population.

-presentation of acute appendicitis in HIV-infected patients is


similar to that of noninfected patients

- majority of HIV-infected patients with appendicitis will have fever,


periumbilical pain radiating to the right lower quadrant
(91%), right lower quadrant tenderness (91%), and rebound
tenderness (74%)

- HIV-infected patients will not manifest an absolute leukocytosis;


however, if a baseline leukocyte count is available, nearly
all will demonstrate a relative leukocytosis.
Appendicitis in Patients with AIDS or HIV Infection

- increased risk of appendiceal rupture in HIV-infected patients.


>43% of patients were found to have perforated
appendicitis at laparotomy.
>increased risk of appendiceal rupture may be related to
the delay in presentation seen in this patient
population. 68

- mean duration of symptoms prior to arrival in the emergency


room has been reported to be increased in HIV-infected
patients, with more than 60% of patients reporting the
duration of symptoms to be longer than 24 hours

- significant hospital delay also may have contributed to high rates


of rupture.
Appendicitis in Patients with AIDS or HIV Infection

- low CD4 count is also associated with an increase in


appendiceal rupture
>In one large series, patients with nonruptured appendices
had CD4 counts of 158.75 ± 47 cells/mL 3 compared
with 94.5 ± 32 cells/mL 3 in patients with
appendiceal rupture

-differential diagnosis of right lower quadrant pain is expanded in


HIV-infected patients when compared to the general
population
>opportunistic infections should be considered as a
possible cause of right lower quadrant pain
>cytomegalovirus (CMV), Kaposi's sarcoma,
tuberculosis, lymphoma, and other causes
of infectious colitis
Appendicitis in Patients with AIDS or HIV Infection

-CMV infection may be seen anywhere in the gastrointestinal


tract.
*CMV causes a vasculitis of blood vessels in the
submucosa of the gut, leading to thrombosis.
Mucosal ischemia develops, leading to ulceration,
gangrene of the bowel wall, and perforation.

-Spontaneous peritonitis may be caused by opportunistic


pathogens including CMV, Mycobacterium avian- intracellulare,
M. tuberculosis, Cryptococcus neoformans, and strongyloides.

- Kaposi's sarcoma and non-Hodgkin's lymphoma may present


with pain and a right lower quadrant mass. Viral and
bacterial colitis occur with a higher frequency in HIV-
infected patients than in the general population
Appendicitis in Patients with AIDS or HIV Infection

- Colitis should always be considered in HIV-infected patients


presenting with right lower quadrant pain

- Neutropenic enterocolitis (typhlitis) should also be considered in


the differential diagnosis of right lower quadrant pain

-obtain a thorough history and physical when evaluating any


patient with right lower quadrant pain.

-In the HIV-infected patient with classic signs and symptoms of


appendicitis, immediate appendectomy is indicated.

- In those patients with diarrhea as a prominent symptom,


colonoscopy may be warranted.

-In patients with equivocal findings, CT scan is usually helpful


Appendicitis in Patients with AIDS or HIV Infection

-majority of pathologic findings identified in HIV-infected patients


who undergo appendectomy for presumed appendicitis are
typical

- negative appendectomy rate is 5 to 10%

- up to 25% of patients will have AIDS-related entities in the


operative specimens, including CMV, Kaposi's sarcoma, and M.
aviumintracellulare

- 30-day mortality rate for patients undergoing appendectomy was


reported to be 9.1%.
*More recent series report 0% mortality
Appendicitis in Patients with AIDS or HIV Infection

- Morbidity rates for HIV-infected patients with nonperforated


appendicitis are similar to those seen in the general
population

- Postoperative morbidity rates appear to be higher in HIV-infected


patients with perforated appendicitis

- length of hospital stay for HIV-infected patients undergoing


appendectomy is twice that of the general population

- no series has been reported to date that addresses the role of


laparoscopic appendectomy in the HIV-infected population.
Treatment

-importance of early operative intervention should not be


minimized

- adequate hydration should be ensured; electrolyte abnormalities


corrected; and pre-existing cardiac, pulmonary, and renal
conditions should be addressed

- efficacy of preoperative antibiotics in lowering the infectious


complications in appendicitis

- most surgeons routinely administer antibiotics to all patients with


suspected appendicitis
Treatment

- If simple acute appendicitis is encountered, there is no benefit in


extending antibiotic coverage beyond 24 hours

- If perforated or gangrenous appendicitis is found, antibiotics are


continued until the patient is afebrile and has a normal
white blood cell count

- for intra-abdominal infections of gastrointestinal tract origin of


mild to moderate severity, the Surgical Infection Society
has recommended single-agent therapy with cefoxitin,
cefotetan, or ticarcillin-clavulanic acid

- for more severe infections, single-agent therapy with


carbapenems or combination therapy with a third- generation
cephalosporin, monobactam, or aminoglycoside plus
anaerobic coverage with clindamycin or metronidazole is
indicated.
Open Appendectomy

- McBurney (oblique) or Rocky-Davis (transverse) right lower


quadrant muscle-splitting incision in patients with
suspected appendicitis
*centered over either the point of maximal tenderness or a
palpable mass. If an abscess is suspected, a
laterally placed incision is imperative to allow
retroperitoneal drainage and to avoid generalized
contamination of the peritoneal cavity

-If the diagnosis is in doubt, a lower midline incision is


recommended to allow a more extensive examination of the
peritoneal cavity
*especially relevant in older patients with possible
malignancy or diverticulitis
Open Appendectomy

-several techniques can be used to locate the appendix


*because the cecum is usually visible within the incision,
the convergence of the taeniae can be followed to the base
of the appendix. A sweeping lateral to medial motion can
aid in delivering the appendiceal tip into the operative field.

- occasionally, limited mobilization of the cecum is needed to aid in


adequate visualization. Once identified, the appendix is
mobilized by dividing the mesoappendix, taking care to
ligate the appendiceal artery securely.
Open Appendectomy

- appendiceal stump can be managed by simple ligation or by


ligation and inversion with either a purse-string or Z stitch.
* the stump can be safely ligated with a nonabsorbable
suture
*mucosa is frequently obliterated to avoid the development
of mucocele

-peritoneal cavity is irrigated and the wound closed in layers

-if perforation or gangrene is found in adults, the skin and


subcutaneous tissue should be left open and allowed to heal
by secondary intent or closed in 4 to 5 days as a delayed
primary closure
Open Appendectomy

- In children, who generally have little subcutaneous fat, primary


wound closure has not led to an increased incidence of
wound infection.

-If appendicitis is not found, a methodical search for an alternative


diagnosis must be performed
* inspect cecum and mesentery then the small bowel is
examined in a retrograde fashion beginning at the
ileocecal valve and extending at least 2 feet

- in females, special attention should be paid to the pelvic organs.

- An attempt is also made to examine the upper abdominal


contents
Open Appendectomy

- peritoneal fluid should be sent for Gram's stain and culture. If


purulent fluid is encountered, it is imperative that the
source be identified

- medial extension of the incision (Fowler-Weir), with division of


the anterior and posterior rectus sheath, is acceptable if
further evaluation of the lower abdomen is indicated

if upper abdominal pathology is encountered, the right lower


quadrant incision is closed and an appropriate upper
midline incision performed
Laparoscopy

-Semm first reported successful laparoscopic appendectomy in


1983, several years before the first laparoscopic
cholecystectomy

- However, the widespread use of the laparoscopic approach to


appendectomy did not occur until after the success of
laparoscopic cholecystectomy
*appendectomy, by virtue of its small incision, is already a
form of minimal-access surgery

-Laparoscopic appendectomy is performed under general


anesthesia.
*usually requires the use of three ports
*four ports may occasionally be necessary to mobilize a
retrocecal appendix
Laparosocopy

-utility of laparoscopic appendectomy in the management of


acute appendicitis remains controversial
*hesitant to implement a new technique because the
conventional open approach has already proved
to be simple and effective

-duration of surgery and operation costs were higher for


laparoscopic appendectomy than for open appendectomy
- Wound infections were approximately half as likely after
laparoscopic appendectomy than after open appendectomy

-intra-abdominal abscess was three times greater after


laparoscopic appendectomy than after open appendectomy
Laparosocopy

- principal proposed benefit of laparoscopic appendectomy has


been decreased postoperative pain

- hospital length of stay also is statistically significantly less


after laparoscopic appendectomy
*more important determinant of length of stay after
appendectomy is the pathology at operation,
specifically whether a patient has perforated or
nonperforated appendicitis

- shorter period prior to return to normal activity, return to work,


and return to sports
Laparosocopy

-little benefit to laparoscopic appendectomy over open


appendectomy in thin males between the ages of 15 and 45
years
*Laparoscopic appendectomy should be considered an
option in these patients, based on surgeon and
patient preference

- Laparoscopic appendectomy may be beneficial in obese


patients in whom it may be difficult to gain adequate
access through a small right lower quadrant incision.
*decreased risk of postoperative wound infection
Laparosocopy

-Diagnostic laparoscopy has been advocated as a potential tool


to decrease the number of negative appendectomies
performed.
* However, the morbidity associated with laparoscopy
and general anesthesia is acceptable only if
pathology requiring surgical treatment is present
and is amenable to laparoscopic techniques

-question of leaving a normal appendix in situ is a controversial


*17 to 26% of normal-appearing appendices at
exploration have a pathologic histologic finding
*availability of diagnostic laparoscopy may actually lower
the threshold for exploration, thus impacting the
negative appendectomy rate adversely
Laparosocopy

- Fertile women with presumed appendicitis constitute the group


of patients most likely to benefit from diagnostic
laparoscopy
*1/3 will not have appendicitis at exploration
*most will have gynecologic pathology identified
*diagnostic laparoscopy reduced the number of
unnecessary appendectomies

-It has not been resolved whether laparoscopic appendectomy is


more effective at treating acute appendicitis than the
time-proven method of open appendectomy
Laparosocopy

- effective in the management of acute appendicitis.


*should be considered part of the surgical
armamentarium available to treat acute
appendicitis

- decision regarding how to treat any single patient with


appendicitis should be based on surgical skill, patient
characteristics, clinical scenario, and patient preference.
Interval Appendectomy

-accepted algorithm for the treatment of appendicitis associated


with a palpable or radiographically documented mass
(abscess or phlegmon) is conservative therapy with
interval appendectomy 6 to 10 weeks later

- provides much lower morbidity and mortality rates than


immediate appendectomy

- associated with added expense and longer hospitalization (8 to


13 vs. 3 to 5 days)

- initial treatment consists of intravenous antibiotics and bowel


rest.
*9 to 15% failure rate, with operative intervention required
at 3 to 5 days after presentation
*Percutaneous or operative drainage of abscesses is not
considered a failure of conservative therapy. 85
Interval Appendectomy

- major argument against interval appendectomy is that


approximately 50% of patients treated conservatively never
develop manifestations of appendicitis, and those who do, can
generally be treated nonoperatively. In addition, pathologic
examination of the resected appendix is normal in 20 to 50%
of cases.

- timing of interval appendectomy is somewhat controversial.


*Appendectomy may be required as early as 3 weeks
following conservative therapy
*2/3 of the cases of recurrent appendicitis occur within 2
years
- associated with a morbidity rate of 3% or less and a
hospitalization of 1 to 3 days in length.
Prognosis

- overall mortality rate for a general anesthetic is 0.06%


- overall mortality rate in ruptured acute appendicitis is about 3%
- mortality rate of ruptured appendicitis in the elderly is approximately
15%
- Death is usually attributable to uncontrolled sepsis—peritonitis,
intra-abdominal abscesses, or gram-negative septicemia.
- Pulmonary embolism continues to account for some deaths. –
- Aspiration is a significant cause of death in the older patient group.
Prognosis

-
Morbidity rates parallel mortality rates, being significantly increased
by rupture of the appendix and to a lesser extent by old age

abscess
wound infection
intra-abdominal abscesses
Fecal fistula
Intestinal obstruction
inguinal hernia
Incisional hernia
Chronic Appendicitis

-true clinical entity has been questioned for many years


- histologic criteria have been established
*pain lasts longer and is less intense than that of acute
appendicitis, but is in the same location
*lower incidence of vomiting, but anorexia and occasionally
nausea, pain with motion, and malaise are
characteristic
*Leukocyte counts are predictably normal and CT scans are
generally nondiagnostic.

- diagnosis established at operation


- Laparoscopy can be effectively used
- Appendectomy is curative.
- symptoms resolve postoperatively in 82 to 93% of patients
- Many of those whose symptoms are not cured or recur are
ultimately diagnosed with Crohn's disease.
Appendiceal Parasites

Ascaris lumbricoides - most common


Enterobius vermicularis
Strongyloides stercoralis
Echinococcus granulosis

- occlude the appendiceal lumen, causing obstruction


- makes ligation and stapling of the appendix technically difficult.
- therapy with helminthicide post op is necessary

Amebiasis
-can also cause appendicitis.
-Invasion of the mucosa by trophozoites of Entamoeba histolytica
incites a marked inflammatory process
-Appendiceal involvement is a component of more generalized
intestinal amebiasis
- Appendectomy must be followed by appropriate antibiotic therapy
(metronidazole).
Incidental Appendectomy

-neither clinically nor economically appropriate


- special circumstances during laparotomy or laparoscopy for other
indications in which it should be performed
children about to undergo chemotherapy
disabled who cannot describe symptoms or react normally
to abdominal pain
Crohn's disease patients in whom the cecum is free of
macroscopic disease
individuals who are about to travel to remote places where t
there is no access to medical/surgical care
Tumors

Carcinoid
-firm, yellow, bulbar mass in the appendix should raise the
suspicion of an appendiceal carcinoid.
- appendix is the most common site of gastrointestinal
carcinoid, followed by the small bowel and then rectum.

- Malignant potential is related to size, with tumors less than 1 cm


rarely resulting in extension outside of the appendix or
adjacent to the mass.

Treatment rarely requires more than simple appendectomy


For tumors smaller than 1 cm with extension into the
mesoappendix, and for all tumors larger than 1.5 cm, a right
hemicolectomy should be performed
Tumors

Adenocarcinoma
-rare neoplasm of three major histologic subtypes: mucinous
adenocarcinoma, colonic adenocarcinoma, and
adenocarcinoid
-most common mode of presentation for appendiceal carcinoma is
that of acute appendicitis
- Patients may also present with ascites or a palpable mass, or the
neoplasm may be discovered during an operative procedure
for an unrelated cause.
- The recommended treatment for all patients with adenocarcinoma
of the appendix is a formal right hemicolectomy.
-Appendiceal adenocarcinomas have a propensity for early
perforation, although they are not clearly associated with a
worsened prognosis.
- Overall 5-year survival is 55% and varies with stage and grade.
Tumors

Mucocele

An appendiceal mucocele leads to progressive enlargement of the


appendix from the intraluminal accumulation of a mucoid
substance. Mucoceles are of four histologic types, and the type
dictates the course of the disease and prognosis: retention cysts,
mucosal hyperplasia, cystadenomas, and cystadenocarcinomas. A
mucocele of benign etiology is adequately treated by a simple
appendectomy.
Tumors

Pseudomyxoma Peritonei

rare condition in which diffuse collections of gelatinous fluid are


associated with mucinous implants on peritoneal surfaces and
omentum
invariably caused by neoplastic mucous-secreting cells within the
peritoneum.

Appendectomy is routinely performed.


Hysterectomy with bilateral salpingo-oophorectomy is performed in
women.
Ultra-radical surgery has not been shown to be of significant
benefit.
adjuvant intraperitoneal chemotherapy (with or without
hyperthermia) or systemic postoperative chemotherapy have
not been shown to be of benefit.
Tumors

Lymphoma

extremely uncommon
frequently involved extranodal site for non-Hodgkin's lymphoma.
frequency of primary lymphoma of the appendix ranges from 1 to
3% of gastrointestinal lymphomas
management of appendiceal lymphoma confined to the appendix is
appendectomy
Right hemicolectomy is indicated if there is extension of tumor
beyond the appendix onto the cecum or mesentery
postoperative staging workup is indicated prior to initiating
adjuvant therapy.
Adjuvant therapy is not indicated for lymphoma confined to
the appendix.
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