50

CHAPTER

The Appendix
Bryan Richmond
OUTLINE
Anatomy and Embryology
Appendicitis
Treatment of Appendicitis
Appendicitis in Special Populations
Neoplasms of the Appendix

Please access ExpertConsult.com to view the corresponding videos for this chapter.
Appendicitis remains one of the most common diseases faced by
the surgeon in practice. It is the most common urgent or emergent
general surgical operation performed in the United States and is
responsible for as many as 300,000 hospitalizations annually.1
Although appendectomy is often the first major case performed
by the young surgeon in training, few other operations will be
learned that will have such a dramatic impact on the patient being
treated.
It is estimated that as much as 6% to 7% of the general population will develop appendicitis during their lifetime, with the incidence peaking in the second decade of life.2 Despite its high
prevalence in Western countries, the diagnosis of acute appendicitis can be challenging and requires a high index of suspicion on
the part of the examining surgeon to facilitate prompt treatment
of this condition, thereby avoiding the substantial morbidity (and
even mortality) associated with perforation. Appendicitis is much
less common in underdeveloped countries, suggesting that elements of the Western diet, specifically a low-fiber, high-fat intake,
may play a role in the development of the disease process.3

ANATOMY AND EMBRYOLOGY

The appendix is a midgut organ and is first identified at 8 weeks
of gestation as a small outpouching of the cecum. As gestation
progresses, the appendix becomes more elongated and tubular as
the cecum rotates medially and becomes fixed in the right lower
quadrant of the abdomen. The appendiceal mucosa is of the
colonic type, with columnar epithelium, neuroendocrine cells,
and mucin-producing goblet cells lining its tubular structure.3
Lymphoid tissue is found in the submucosa of the appendix,
leading some to hypothesize that the appendix may play a role
in the immune system. In addition, evidence suggests that the
appendix may serve as a reservoir of good intestinal bacteria and
may aid in recolonization and maintenance of the normal colonic
flora.4 Consensus about this has not been achieved, however. Suc-

cessful removal of the appendix has not been definitively demonstrated to have any known adverse sequelae.
As a midgut organ, the blood supply of the appendix is derived
from the superior mesenteric artery. The ileocolic artery, one of
the major named branches of the superior mesenteric artery, gives
rise to the appendiceal artery, which courses through the mesoappendix. The mesoappendix also contains lymphatics of the appendix, which drain to the ileocecal nodes, along the blood supply
from the superior mesenteric artery.3,5
The appendix is of variable size (5 to 35cm in length) but
averages 9cm in length in adults. Its base can be reliably identified
by defining the area of convergence of the taeniae at the tip of the
cecum and then elevating the appendiceal base to define the
course and position of the tip of the appendix, which is variable
in location. The appendiceal tip may be found in a variety of
locations, with the most common being retrocecal (but intraperitoneal) in approximately 60% of individuals, pelvic in 30%, and
retroperitoneal in 7% to 10%. Agenesis of the appendix has been
reported, as has duplication and even triplication.3,5 Knowledge
of these anatomic variations is important to the surgeon because
the variable position of the appendiceal tip may account for differences in clinical presentation and in the location of the associated abdominal discomfort. For example, patients with a
retroperitoneal appendix may present with back or flank pain, just
as patients with the appendiceal tip in the midline pelvis may
present with suprapubic pain. Both of these presentations may
result in a delayed diagnosis as the symptoms are distinctly different from the classically described anterior right lower quadrant
abdominal pain associated with appendiceal disease.

APPENDICITIS
History
The first appendectomy was reported in 1735 by a French Surgeon,
Claudius Amyand, who identified and successfully removed the
appendix of an 11-year-old boy that was found within an inguinal
hernia sac and that had been perforated by a pin. Although
autopsy findings consistent with perforated appendicitis appeared
sporadically thereafter in the literature, the first formal description

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CHAPTER 50 The Appendix

VIDEOS
Video 50-1: Laparascopic Appendectomy
Video 50-2: Laparascopic Appendectomy in Pregnant Patient
Video 50-3: SILS Appendectomy Across a Spectrum of Disease
Severity

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1296.e1

CHAPTER 50 The Appendix

of the disease process, including the common clinical features and
a recommendation for prompt surgical removal, was in 1886 by
Reginald Heber Fitz of Harvard University.3
Notable advances in surgery for appendicitis include McBurneys description of his classic muscle-splitting incision and technique for removal of the appendix in 1894 and the description of
the first laparoscopic appendectomy by Kurt Semm in 1982.3
Laparoscopic appendectomy has become the preferred method for
management of acute appendicitis among surgeons in the United
States and may be accomplished using several (typically three)
trocar sites or through single-incision laparoscopic surgical techniques. Finally, but of no less significance, was the development
of broad-spectrum antibiotics, interventional radiologic techniques, and better surgical critical care strategies, all of which have
resulted in substantial improvements in the care of patients with
appendiceal perforation and its subsequent complications.

Pathophysiology and Bacteriology

Appendicitis is caused by luminal obstruction.3 The appendix is
vulnerable to this phenomenon because of its small luminal diameter in relation to its length. Obstruction of the proximal lumen of
the appendix leads to elevated pressure in the distal portion because
of ongoing mucus secretion and production of gas by bacteria
within the lumen. With progressive distention of the appendix, the
venous drainage becomes impaired, resulting in mucosal ischemia.
With continued obstruction, full-thickness ischemia ensues, which
ultimately leads to perforation. Bacterial overgrowth within the
appendix results from bacterial stasis distal to the obstruction.3 This
is significant because this overgrowth results in the release of a larger
bacterial inoculum in cases of perforated appendicitis (Table 50-1).
The time from onset of obstruction to perforation is variable and
may range anywhere from a few hours to a few days. The presentation after perforation is also variable. The most common sequela is
the formation of an abscess in the periappendiceal region or pelvis.
On occasion, however, free perforation occurs that results in diffuse
peritonitis.3
Because the appendix is an outpouching of the cecum, the flora
within the appendix is similar to that found within the colon.
Infections associated with appendicitis should be considered polymicrobial, and antibiotic coverage should include agents that
address the presence of both gram-negative bacteria and anaerobes. Common isolates include Escherichia coli, Bacteroides fragilis,
enterococci, Pseudomonas aeruginosa, and others.6 The choice and
TABLE 50-1 Bacteria Commonly Isolated

in Perforated Appendicitis
TYPE OF BACTERIA

PATIENTS (%)

Anaerobic
Bacteroides fragilis
Bacteroides thetaiotaomicron
Bilophila wadsworthia
Peptostreptococcus spp.

80
61
55
46

Aerobic
Escherichia coli
Viridans streptococcus
Group D streptococcus
Pseudomonas aeruginosa

77
43
27
18

Adapted from Bennion RS, Thompson JE: Appendicitis. In Fry DE,

editor: Surgical infections, Boston, 1995, Little, Brown, pp 241250.

1297

duration of antibiotic coverage and the controversies surrounding

the need for cultures are discussed later in the chapter.
The causes of the luminal obstruction are many and varied.
These most commonly include fecal stasis and fecaliths but may
also include lymphoid hyperplasia, neoplasms, fruit and vegetable
material, ingested barium, and parasites such as ascarids. Pain of
appendicitis has both visceral and somatic components. Distention
of the appendix is responsible for the initial vague abdominal pain
(visceral) often experienced by the affected patient. The pain typically does not localize to the right lower quadrant until the tip
becomes inflamed and irritates the adjacent parietal peritoneum
(somatic) or perforation occurs, resulting in localized peritonitis.3

Differential Diagnosis
Appendicitis must be considered in every patient (who has not
had an appendectomy) who presents with acute abdominal pain.7
Knowledge of disease processes that may have similar presenting
symptoms and signs is essential to avoid an unnecessary or incorrect operation. Consideration of the patients age and gender may
help narrow the list of possible diagnoses. In children, other considerations include but are not limited to mesenteric adenitis
(often seen after a recent viral illness), acute gastroenteritis, intussusception, Meckels diverticulitis, inflammatory bowel disease,
and (in males) testicular torsion. Nephrolithiasis and urinary tract
infection may be manifested with right lower quadrant pain in
either gender.3
In women of childbearing age, the differential diagnosis is
expanded even further. Gynecologic problems may be mistaken
for appendicitis and result in a higher negative appendectomy rate
than in male patients of comparable age. These include ruptured
ovarian cysts, mittelschmerz (midcycle pain occurring with ovulation), endometriosis, ovarian torsion, ectopic pregnancy, and
pelvic inflammatory disease.3,7
Two other patient populations deserve mention. In the elderly,
consideration must be given to acute diverticulitis and malignant
disease as possible causes of lower abdominal pain. In the neutropenic patient, typhlitis (also known as neutropenic enterocolitis)
should also be considered within the differential diagnosis. Appendicitis in these special populations is discussed later in the chapter.

Presentation

History
Patients presenting with acute appendicitis typically complain of
vague abdominal pain that is most commonly periumbilical in
origin and reflects the stimulation of visceral afferent pathways
through the progressive distention of the appendix. Anorexia is
often present, as is nausea with or without associated vomiting.
Either diarrhea or constipation may be present as well. As the condition progresses and the appendiceal tip becomes inflamed, resulting in peritoneal irritation, the pain localizes to its classic location
in the right lower quadrant. This phenomenon remains a reliable
symptom of appendicitis3,7 and should serve to further increase the
clinicians index of suspicion for appendicitis (Fig. 50-1).
Whereas these symptoms represent the classic presentation
of appendicitis, the clinician must be aware that the disease may
be manifested in an atypical fashion. For example, patients with
a retroperitoneal appendix may present in a more subacute
manner, with flank or back pain, whereas patients with an appendiceal tip in the pelvis may have suprapubic pain suggestive of
urinary tract infection.3,7 We have on occasion encountered
patients presenting with symptoms of small bowel obstruction
who were found to be obstructed by multiple interloop abscesses

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1298

SECTION X Abdomen

GENERAL APPROACH TO THE PATIENT WITH SUSPECTED APPENDICITIS

Appendicitis suspected clinically

Symptoms for 48 h

Symptoms for 48 h

Follow algorithm for delayed presentation

Male

Female

Pregnant
Classic presentation
Equivocal presentation
Localized peritonitis
No

Yes

Follow pregnancy algorithm

CT

Laparoscopic appendectomy

CT
() for appendicitis

() for appendicitis

Lap appendectomy

Brief observation

No improvement

Improving

Diagnostic laparoscopy

Discharge

Other diagnosis

Treat as indicated

() for appendicitis

() for appendicitis

Other diagnosis

Lap appendectomy

Brief observation

Treat as indicated

No improvement

Improving

Diagnostic laparoscopy

Discharge

FIGURE 50-1 Suggested algorithm for the approach to the patient with possible appendicitis.

as a consequence of unrecognized appendiceal perforation.

Although cases such as these are less common than the typical
presentation, knowledge of these variations is essential to maintain
the necessary index of suspicion to permit a prompt and accurate
diagnosis.

Physical Examination
Patients with appendicitis typically appear ill. They frequently lie
still because of the presence of localized peritonitis, which makes
any movement painful. Tachycardia and mild dehydration are
often present to varying degrees. Fever is frequently present,

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CHAPTER 50 The Appendix

ranging from low-grade temperature elevations (<38.5 C) to
more impressive elevations of body temperature, depending on
the status of the disease process and the severity of the patients
inflammatory response. Absence of fever does not exclude a diagnosis of appendicitis.1,3,7
Abdominal examination typically reveals a quiet abdomen with
tenderness and guarding on palpation of the right lower quadrant.
The location of the tenderness is classically over McBurney point,
which is located one-third the distance between the anterior superior iliac spine and the umbilicus. The pain and tenderness are
typically accompanied by localized peritonitis as evidenced by the
presence of rebound tenderness. Diffuse peritonitis or abdominal
wall rigidity due to involuntary spasm of the overlying abdominal
wall musculature is strongly suggestive of perforation.1,3
A number of signs have been described to aid in the diagnosis
of appendicitis. These include the Rovsing sign (the presence of
right lower quadrant pain on palpation of the left lower quadrant),
the obturator sign (right lower quadrant pain on internal rotation
of the hip), and the psoas sign (pain with extension of the ipsilateral hip), among others.1 Although these are of historical interest, it is important to realize that they are simply indicators of
localized peritonitis rather than a diagnostic of a specific disease
process. Still, they are useful maneuvers to perform in examining
a patient with suspected appendicitis and are supportive of the
diagnosis if it is suspected clinically.
Rectal examination findings are typically normal. However, a
palpable mass or tenderness may be present if the appendiceal tip
is located within the pelvis or if a pelvic abscess is present. In
female patients, pelvic examination is important to exclude pelvic
disease. However, cervical motion tenderness, a finding typically
associated with pelvic inflammatory disease, may be present in
appendicitis because of irritation of the pelvic organs from the
adjacent inflammatory process.3

Laboratory Studies
Laboratory studies should be interpreted with caution in cases of
suspected appendicitis and should be used to support the clinical
picture rather than definitively to prove or to exclude the diagnosis. A leukocytosis, often with a left shift (a predominance of
neutrophils and sometimes an increase in bands), is present in
90% of cases. A normal white blood cell count is found in 10%
of cases, however, and it should not be used as an isolated test to
exclude the presence of appendicitis.8 Urinalysis is typically
normal as well, although the finding of trace leukocyte esterase or
pyuria is not unusual and is presumably due to the proximity of
the inflamed appendix to the bladder or ureter. If the presentation
is strongly suggestive of appendicitis, a positive urinalysis should
not be used as an isolated test to refute the diagnosis. Pregnancy
testing is mandatory in women of childbearing age. C-reactive
protein has been demonstrated to be neither sensitive nor specific
in diagnosing (or excluding) appendicitis.1,8
No symptom or sign has been demonstrated to be discriminatory and predictive of appendicitis.1,8 The same may be said
of laboratory tests, which are also weakly predictive when considered in isolation. Rather, it is the assessment of the collective
body of information that allows more precise diagnosis.1,8

Imaging Studies
A variety of radiographic studies may be used to diagnose appendicitis. These consist of plain radiographs, computed tomography
(CT) scanning, ultrasound (US), and magnetic resonance imaging
(MRI).

1299

Plain radiographs are frequently obtained in the emergency

department setting for the evaluation of acute abdominal pain but
lack both sensitivity and specificity for the diagnosis of appendicitis and are rarely helpful. Findings that may support the diagnosis include the presence of a calcified fecalith in the right lower
quadrant, although this finding must be placed into the appropriate clinical context and is typically present in only 5% of cases.9
Pneumoperitoneum, if present, should alert the clinician to other
causes of a perforated viscus (such as a perforated ulcer or diverticulitis), as this is not typically observed in cases of appendicitis,
even with perforation.
CT scanning is the most common imaging study to diagnose
appendicitis and is highly effective and accurate.9 Modern helical
CT scans have the advantage of being operator independent and
easy to interpret. CT has been shown to have a sensitivity of 90%
to 100%, a specificity of 91% to 99%, a positive predictive value
of 92% to 98%, and a negative predictive value of 95% to
100%.9,10 The recommended imaging protocol from the Infectious Diseases Society of America (IDSA) and the Surgical Infection Society includes the intravenous administration of contrast
material only. Oral and rectal administration of contrast material
is not recommended.11
The diagnosis of appendicitis on CT is based on the appearance
of a thickened, inflamed appendix with surrounding stranding
indicative of inflammation. The appendix is typically more than
7mm in diameter with a thickened, inflamed wall and mural
enhancement or target sign (Fig. 50-2). Periappendiceal fluid or
air is also highly suggestive of appendicitis and suggests perforation. In cases in which the appendix is not visualized, the absence
of inflammatory findings on CT suggests that appendicitis is not
present.12 Although we do not recommend CT in cases in which
appendicitis is strongly suspected on clinical grounds based on
supportive history and physical and laboratory findings, published
data do suggest that use of CT in equivocal cases does indeed
reduce the negative appendectomy rate.13
US has been used for diagnosis of appendicitis since the 1980s.
As US technology has become more advanced, so has its ability
to visualize the appendix. The US probe is applied to the area of
pain in the right lower quadrant, and graded compression is used
to collapse normal surrounding bowel and to diminish the interference encountered with overlying bowel gas. The inflamed
appendix is typically enlarged, immobile, and noncompressible
(Fig. 50-3). If the appendix cannot be visualized, the study is
inconclusive and cannot be relied on to guide treatment. Although
US provides the advantage of avoiding ionizing radiation, the
technology is highly operator dependent. The sensitivity is
reported to range from 78% to 83%, whereas the specificity
ranges from 83% to 93%. Its greatest utility appears to be in the
evaluation of the pediatric or pregnant patient, in whom the
associated radiation exposure from CT is undesirable.9
MRI is typically reserved for use in the pregnant patient; the
study is performed without contrast agents. If it is obtained in a
pregnant woman, the study should be noncontrasted. MRI offers
excellent resolution and is accurate in diagnosing appendicitis.
Criteria for MRI diagnosis include appendiceal enlargement
(>7mm), thickening (>2mm), and the presence of inflammation.9 The sensitivity of MRI is reported to be 100%, the specificity 98%, the positive predictive value 98%, and the negative
predictive value 100%. MRI is also operator independent and
offers highly reproducible results. Drawbacks associated with the
use of MRI include its higher cost, motion artifact, greater difficulty in interpretation by nonradiologists who may have limited

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1300

SECTION X Abdomen

FIGURE 50-2 CT scan of the abdomen demonstrating classic findings of acute appendicitis. A, Sagittal view
with arrow demonstrating a thickened, inflamed, and fluid-filled appendix (target sign). B, Coronal view of
same patient. The arrow points to the thickened, elongated appendix with periappendiceal fat stranding and
fluid around the appendiceal tip.

Normal Appendix

Normal Appendix

Appendicitis

Appendicitis

FIGURE 50-3 Ultrasound image of a normal appendix (top) illustrating

the thin wall in coronal (left) and longitudinal (right) planes. In appendicitis, there is distention and wall thickening (bottom, right), and blood
flow is increased, leading to the so-called ring of fire appearance.
A, Appendix.

experience with the technology, and limited availability (especially

in the after-hours emergency setting).9

TREATMENT OF APPENDICITIS
Acute Uncomplicated Appendicitis
The appropriate treatment of acute uncomplicated appendicitis
is prompt appendectomy. The patient should undergo fluid resuscitation as indicated, and the intravenous administration of
broad-spectrum antibiotics directed against gram-negative and
anaerobic organisms should be initiated immediately.11 Operation
should proceed without undue delay.

For open appendectomy, the patient is placed in the supine

position. The choice of incision is a matter of the surgeons
preference, whether it is an oblique muscle-splitting incision
(McArthur-McBurney; Fig. 50-4), a transverse incision (RockeyDavis), or a conservative midline incision. The cecum is grasped
by the taeniae and delivered into the wound, allowing visualization of the base of the appendix and delivery of the appendiceal
tip. The mesoappendix is divided, and the appendix is crushed
just above the base, ligated with an absorbable ligature, and
divided. The stump is then either cauterized or inverted by a
purse-string or Z suture technique. Finally, the abdomen is thoroughly irrigated and the wound closed in layers.
For laparoscopic appendectomy, the patient is placed in the
supine position. The bladder is emptied by a straight catheter or
by having the patient void immediately before the procedure. The
abdomen is entered at the umbilicus, and the diagnosis is confirmed by inserting the laparoscope (Fig. 50-5). Two additional
working ports are then placed, typically in the left lower quadrant
and in either the suprapubic area or supraumbilical midline, based
on the surgeons preference. We have found it to be advantageous
for both the surgeon and assistant to stand to the left side of the
patient with the left arm tucked. This allows optimum triangulation of the camera and working instruments. Atraumatic graspers
are used to elevate the appendix, and the mesoappendix is carefully divided using the harmonic scalpel. The base is then secured
with endoloops and the appendix divided. Alternatively, the
appendix may be divided with an endoscopic stapler. We prefer
this technique in cases in which the entire appendix is friable
because it allows the staple line to be placed slightly more proximally, on the edge of the healthy cecum, thereby reducing the risk
of leakage from breakdown of a tenuous appendiceal stump.
Retrieval of the appendix is accomplished by the use of a plastic
retrieval bag. The pelvis is irrigated, the trocars are removed, and
the wounds are closed. Laparoscopic appendectomy may also be
performed with single-site laparoscopic surgical techniques as
well, although this technique remains less commonly performed
than the traditional multitrocar approach.
Antibiotic administration is not continued beyond a single
preoperative dose.11 Oral alimentation is begun immediately and

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CHAPTER 50 The Appendix

Superior ileocecal
recess

Ileum

Inferior
ileocecal
recess

Anterior cecal artery

Ileocecal fold

Cecum
Division of
appendiceal artery
in the mesoappendix

Appendix

D
FIGURE 50-4 A, Left, Location of possible incisions for an open appendectomy. Right, Division of the
mesoappendix. B, Ligation of the base and division of the appendix. C, Placement of purse-string suture
or Z stitch. D, Inversion of the appendiceal stump. (From Ortega JM, Ricardo AE: Surgery of the appendix
and colon. In Moody FG, editor: Atlas of ambulatory surgery, Philadelphia, 1999, WB Saunders.)

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1301

1302

SECTION X Abdomen

FIGURE 50-5 Laparoscopic appendectomy. A, Visualization and upward retraction of appendix. B, Division
of mesoappendix using harmonic scalpel. C, Application of endoloops to appendix. Two loops are used to
secure the base; a third loop is applied distally to avoid spillage of the luminal contents. The specimen is
then divided between the endoloops. D, View of completed appendectomy after removal of the specimen.
(Note: Depending on the surgeons preference, an endoscopic stapling device may be used to divide the
mesoappendix and appendix instead of the harmonic scalpel and endoloops.)

advanced as tolerated. Discharge is usually possible the day after

operation.

Perforated Appendicitis
The operative strategy for perforated appendicitis is similar to that
for uncomplicated appendicitis with a few notable exceptions.
First of all, the patient may require a more aggressive resuscitation
before proceeding to the operating theater. As with uncomplicated
appendicitis, antibiotic therapy should be initiated immediately
on diagnosis.11
Both the open and laparoscopic approaches are acceptable for
the treatment of perforated appendicitis. Although the technique
of appendectomy for perforation is the same as for simple appendicitis, the level of difficulty encountered in removing a friable,
gangrenous, perforated appendix can be a challenge to the most
experienced surgeon and requires gentle meticulous handling of
the friable appendix and inflamed periappendiceal tissues to avoid
tissue injury. Cultures are not mandatory unless the patient has
had exposure to a health care environment or has had recent
exposure to antibiotic therapy because these factors increase the
likelihood of encountering resistant bacteria. However, we routinely obtain them because they sometimes yield resistant bacteria
and are helpful in tailoring the switch to oral therapy on discharge.11 Once the appendix is successfully removed, careful attention should be given to the clearance of infectious material,
including spilled fecal material or fecaliths, from the abdomen.
This task may be accomplished by large-volume irrigation, with
special attention given to the right lower quadrant and pelvis.
Drains are not routinely placed unless a discrete abscess cavity is
present. If an abscess cavity is present, a single closed suction
Jackson-Pratt drain is placed within its base and left for several
days. If an open technique was used, the skin and subcutaneous
tissues are left open for 3 or 4 days to prevent development of
wound infection, at which time the wound may be closed at the

bedside with sutures, clips, or Steri-Strips, depending on the surgeons preference.

Postoperatively, broad-spectrum antibiotics are continued for
4 to 7 days in accordance with IDSA guidelines.11 If culture
specimens were obtained, antibiotic therapy should be modified
in accordance with the results. Nasogastric suction is not employed
routinely but may be necessary if postoperative ileus develops.
Oral alimentation is begun after return of bowel sounds and
passage of flatus and advanced as tolerated. Once the patient is
tolerating a diet, is afebrile, and has a normal white blood cell
count, the patient may be discharged home.
If the patient develops fever, leukocytosis, pain, and delayed
return of bowel function, the possibility of a postoperative abscess
must be entertained. Abscess complicates perforated appendicitis
in 10% to 20% of cases and represents the major source of
morbidity related to perforation.1,3 A CT scan with intravenous
administration of a contrast agent is diagnostic and also allows
simultaneous placement of a percutaneous drain within the
abscess cavity.9 If CT drainage is not technically possible because
of the location of the abscess, laparoscopic, transrectal, or transvaginal drainage is an alternative.

Laparoscopic versus Open Appendectomy

The debate about the choice of open versus laparoscopic appendectomy for the treatment of appendicitis remains a major point
of controversy among surgeons. Although no level I data exist to
support one approach over another, a study published in 2010
examined this issue in detail. Ingraham and colleagues14 analyzed
results from 222 hospitals comparing laparoscopic versus open
appendectomy using the American College of Surgeons National
Surgical Quality Improvement Program. In all, 24,969 laparoscopic and 7714 open procedures were included in the analysis.
Although the data were limited by the retrospective nature, the
investigators observed that laparoscopic appendectomy was

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CHAPTER 50 The Appendix

associated with lower risk of wound complications and deep surgical site infection in uncomplicated appendicitis. In complicated
appendicitis, laparoscopic appendectomy was associated with
fewer wound complications but a slightly higher incidence of
intra-abdominal abscess. The overall conclusion, however, was
that the laparoscopic approach was associated with an overall
lower incidence of complications than the open procedure. The
conclusions evident from a number of studies indicate that both
approaches are acceptable and that the advantages with laparoscopy, although small, were a lower overall morbidity, reduced
wound complications, reduced postoperative pain, and perhaps a
slightly shorter recovery time. The slightly higher risk of intraabdominal abscess formation after laparoscopic appendectomy in
cases of complicated appendicitis was a negative aspect of laparoscopic appendectomy, although the authors acknowledged that
this has not been observed in all studies.15
We prefer the laparoscopic approach for several reasons. Laparoscopy allows examination of the entire peritoneal space, making
it exceptionally useful to exclude other intra-abdominal disease
that may be manifested in a similar fashion, such as diverticulitis
or tubo-ovarian abscess, whereas visualization of these structures
would not be possible through a right lower quadrant incision.
We find it to be technically simpler in most patients, particularly
the obese, and have been impressed with our ability to discharge
patients within several hours of the operation.
The debate about the superiority of laparoscopic versus open
appendectomy will likely continue as a clearly superior choice has
not been conclusively demonstrated. What does appear clear,
however, is that regardless of the surgeons preferred approach, the
most important aspect of appendectomy is that it be done
promptly and safely.

Delayed Presentation of Appendicitis

Patients may occasionally present several days to even weeks after
the onset of appendicitis. In these cases, the treatment should be
individualized on the basis of the nature of the presentation (Fig.
50-6). Although rare, a patient may present with diffuse peritonitis. More commonly, however, patients present with localized
right lower quadrant pain and fever, with a history that is compatible with appendicitis. A mass may be palpable in children or thin
patients. Immediate exploration and attempted appendectomy in
these patients may result in substantial morbidity, including
failure to identify the appendix, postoperative abscess or fistula,
and unnecessary extension of the operation to include ileocecectomy, all due to the extreme induration and friability of the
involved tissues. For this reason, in general, treatment for these
patients is initially accomplished nonoperatively.16-20 Fluid resuscitation is initiated, and broad-spectrum antibiotic therapy is
initiated. A CT scan is obtained, and perforated appendicitis with
a localized abscess or phlegmon is confirmed (Fig. 50-7). If a
localized abscess is identified, CT-guided percutaneous drainage
is performed for source control. The drainage catheter is typically
left in place for 4 to 7 days, during which the patient is treated
with antibiotic therapy and after which time it is removed. If
CT-guided drainage is not technically feasible, operative drainage
may be accomplished through transrectal or transvaginal
approaches. Laparoscopic drainage is another option that we have
found to be exceptionally useful. This technique is performed by
visualizing the inflammatory mass with the laparoscope and then
entering the abscess with a laparoscopic suction tip, evacuating
the purulent material, and placing a drain within the residual
abscess cavity. Postoperative management is identical to that of

1303

patients who are successfully drained percutaneously. If a periappendiceal phlegmon is present or if the amount of fluid present
is not sufficient to drain, the patient may be treated with antibiotics alone, typically for 4 to 7 days also, as recommended by IDSA
guidelines for treatment of intra-abdominal infection.11
Traditionally, after successful nonoperative treatment of complicated appendicitis, patients were advised to undergo removal
of the appendix, a procedure known as interval appendectomy,
several weeks to months later. This practice has been reexamined.
The rationale for interval appendectomy is based on the potential
for development of recurrent appendicitis and the subsequent
risks associated with emergent removal or reperforation of the
appendix. However, the actual risk of recurrent appendicitis
appears to be small, 8% at 8 years in one study of 6400 pediatric
patients.21 The findings in this study as well as similar results
reported by others have led them to conclude that interval appendectomy should be reserved only for patients who present with
symptoms of recurrent appendicitis.21,22 In addition, the presence
of an appendicolith on CT has also been shown to be predictive
of a higher risk of recurrent appendicitis and has been used as a
justification to proceed with interval appendectomy in that subgroup of patients. This selective approach to interval appendectomy has also been demonstrated to be more cost-effective than
its routine performance in all affected patients.22
A systematic review published by Hall and colleagues23 examining the role of interval appendectomy found that the overall risk
of recurrent appendicitis was 20.5%. All recurrences were seen
within 3 years, and 80% of these occurred within 6 months. In
addition, the morbidity of interval appendectomy was significant,
with complications reported in 23 of the studies, for an overall
rate of 3.4%. Other authors have reported significant associated
morbidity with interval appendectomy as well, with rates as high
as 18%.24
One argument favoring interval appendectomy in adults has
been the observation by some investigators of a higher incidence
of appendiceal neoplasms found in interval appendectomy specimens.8,25-27 Also, perforated tumors of the cecum may be manifested in a similar fashion as perforated appendicitis.28 For this
reason, colonoscopy is recommended in all adult patients as
routine follow-up after nonoperative management of complicated
appendicitis.29 To date, no large-scale randomized controlled trials
examining the outcomes of patients who do or do not undergo
interval appendectomy after successful nonoperative treatment
have been conducted. For this reason, this issue is likely to remain
controversial for some time.

The Normal-Appearing Appendix at Operation

In cases of negative appendectomy, in which a normal appendix
is identified at operation, there is controversy as to whether the
appendix should be removed.30,31 Before that particular issue is
examined, it is important to emphasize the need to thoroughly
evaluate the abdomen for other causes of pain severe enough to
warrant an operation. The abdominal and pelvic organs should
be assessed for any abnormalities. In our experience, this is most
easily done through the laparoscopic approach, which we think is
a major advantage of laparoscopy over an open approach. Note
should be made of any free fluid as such a finding may suggest
perforation. The terminal 60cm of ileum should be examined for
a Meckels diverticulum and the serosa of the small bowel for any
stigmata of Crohns disease, such as inflammation, stricture formation, or the characteristic creeping fat appearance of the mesentery. Inspection of the ileal mesentery may reveal enlarged lymph

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1304

SECTION X Abdomen

APPROACH TO THE PATIENT WITH DELAYED

PRESENTATION OF SUSPECTED APPENDICITIS
Diffuse peritonitis present

Yes

No

Resuscitation, antibiotics, to OR for source control

CT

Other diagnosis

Appendicitis confirmed

Treat as indicated

Abscess

Phlegmon

CT drainage feasible

Antibiotics

Yes

CT drainage, antibiotics

Adult

Colonoscopy after discharge

Normal

Consider interval appendectomy

No

Laparoscopic drainage, antibiotics

Child

Consider interval appendectomy

Neoplasm

Follow algorithm for appendiceal neoplasm

FIGURE 50-6 Suggested algorithm for managing the patient with delayed presentation of appendicitis.

nodes suggestive of mesenteric adenitis. The uterine adnexa should

be examined for any evidence of tubo-ovarian or salpingeal
disease, such as ovarian torsion, tubo-ovarian abscess, endometriosis, or ruptured ovarian cysts. The sigmoid colon should be examined for evidence of acute diverticulitis, especially in cases in
which a redundant sigmoid colon is found in the right lower
quadrant. If these are all normal, attention should be turned to
the upper abdomen for examination of the gallbladder and duodenum. Inability to perform an adequate evaluation of the intraabdominal organs or demonstration of disease of other organs

requiring intervention may require conversion to a midline laparotomy if necessary.

We routinely remove the normal appendix for several reasons.
First, many causes of right lower quadrant pain discussed before
may be recurrent, such as pain from ruptured ovarian cysts or
mesenteric adenitis. Appendectomy is also advisable in cases of
Crohns disease when suggested by findings at operation, unless the
base of the appendix and cecum are involved. In this scenario,
appendectomy is deferred to avoid breakdown of the inflamed
stump and subsequent fistula formation. In these clinical

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CHAPTER 50 The Appendix

1305

FIGURE 50-7 Sagittal (A) and coronal (B) CT images demonstrate an appendiceal abscess in a patient who
presented with a 2-week history of abdominal pain and was found to have a palpable mass on examination.
The arrows point to a periappendiceal abscess cavity. She was successfully managed with percutaneous
drainage and antibiotic therapy.

circumstances, appendectomy is advisable because it removes

appendicitis from the differential diagnosis when the patient pre
sents with recurrent right lower quadrant pain. In addition, abnormalities of the appendix not apparent on gross inspection at the
time of operation are sometimes identified on pathologic
examination.30,31

Nonoperative Treatment of Uncomplicated Appendicitis

Although prompt appendectomy is the standard of care, a number
of studies have challenged this concept and have supported antibiotic therapy alone as a definitive treatment for acute uncomplicated appendicitis. Two meta-analyses analyzing the results of
randomized controlled trials examining this issue concluded that
nonoperative treatment was associated with a lower risk of complications (12% in the nonoperative group versus 18% in the
appendectomy group; P = .001).32,33 Appendectomy, however,
outperformed the nonoperative group in overall treatment failure
rate (40% nonoperative versus 9% in the appendectomy group;
P < .001). The authors concluded that antibiotic therapy was safe
as a treatment for uncomplicated appendicitis but was associated
with a significantly, perhaps prohibitively high failure rate compared with appendectomy.32,33 For this reason, our practice is to
reserve nonoperative therapy only for acute uncomplicated appendicitis for those patients in whom the operative risk is prohibitive.
Failures of nonoperative therapy in these high-risk patients
are then managed with adjunctive treatment measures, such as
CT-guided drainage of periappendiceal abscesses.

Chronic Appendicitis as a Cause of Abdominal Pain

On occasion, patients will present with a history of recurrent right
lower quadrant pain, and a surgical opinion will be sought as to
the benefit of elective appendectomy for treatment of this condition. Modest epidemiologic data exist to suggest that appendicitis
may spontaneously resolve, so it is conceivable that appendicitis
may wax and wane in some patients.1 In addition, some patients
with pain are found to have a thickened appendix or an appendicolith on CT but have no evidence of a systemic illness or acute
periappendiceal inflammation. In some cases, appendectomy will
produce relief of symptoms, and in these cases, examination of

the appendix will sometimes reveal findings consistent with

chronic inflammation.31,34 We will consider, on a case by case
basis, elective appendectomy in cases in which the history is consistent with appendiceal disease and there is radiographic (CT)
evidence of appendiceal disease.
More troubling, however, is the patient with pain in the
absence of radiographic evidence of appendiceal disease. We typically pursue a multidisciplinary workup in these patients involving input from specialists in gastroenterology and gynecology as
well as surgery. Appendectomy is typically not offered unless
disease is demonstrated radiographically; however, if diagnostic
laparoscopy is performed to investigate or to exclude other disease
(typically by a gynecologist), we will typically perform appendectomy, an approach advocated by others.35 We have found that as
with the management of any chronic pain syndrome, management of expectations is critical in caring for this very difficult
group of patients.

Incidental Appendectomy
Incidental appendectomy is the term applied when a grossly
normal appendix is removed at the time of an unrelated procedure, such as a hysterectomy, cholecystectomy, or sigmoid colectomy. Once commonly performed, incidental appendectomy has
become a controversial procedure. The theoretical benefit is that
of eliminating the patients risk for development of appendicitis
in the future, a concept that is thought to be most beneficial in
patients younger than 35 years because of their greater lifetime
risk for development of the disease compared with older patients.16
Data suggesting that incidental appendectomy may be performed
with no additional morbidity have been criticized for not having
been properly risk adjusted. When these data were scrutinized
further, Wen and coworkers actually demonstrated that incidental
appendectomy was associated with an increase in both morbidity
and mortality.36 Other investigators have demonstrated that incidental appendectomy does not appear to be cost-effective as a
preventive measure.37 Finally, the recent finding that the appendix
may actually have a role in the maintenance of healthy colonic
flora makes the practice of incidental appendectomy even more
controversial.4 For these reasons, we advocate careful inspection

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SECTION X Abdomen

of the appendix for abnormalities during abdominal operations

as part of a thorough exploration but do not advocate appendectomy unless an abnormality is detected.

APPENDICITIS IN SPECIAL POPULATIONS

Appendicitis in the Pregnant Patient
Appendicitis remains the most common nonobstetric emergency
in pregnancy and is consequently the most frequent reason for
general surgical intervention in this group of patients.38 The diagnosis of appendicitis in pregnancy presents a special challenge to
the surgeon. As with all conditions in pregnancy, the surgeon
must consider the welfare of two patients, the mother and fetus,
when considering possible diagnoses, workup, and treatment
(Fig. 50-8).
In pregnancy, appendicitis has a typical clinical presentation
in only 50% to 60% of cases.38 The common symptoms of early
appendicitis, such as nausea and vomiting, are nonspecific and
are also often associated with normal pregnancy. The normal
febrile response to illness may be blunted in pregnancy. Also, the
physical examination of the pregnant patient is difficult and is
altered because of the effect of the gravid uterus and its displacement of the appendix to a more cephalad location within the
abdomen. Lower quadrant pain in the second trimester produced

by traction on the suspensory ligaments of the uterus, a phenomenon known as round ligament pain, is a common occurrence
and further complicates the clinical picture further because 50%
of cases of appendicitis occur in the second trimester. Finally,
biochemical and laboratory indicators used to support the diagnosis of appendicitis in the nonpregnant patient are unreliable in
pregnancy. For example, a mild physiologic leukocytosis of pregnancy is a normal finding. C-reactive protein levels may also be
physiologically elevated in pregnancy. In addition, the surgeon
must be concerned about the possibility of obstetric emergencies
as a cause of abdominal pain, such as preterm labor, placental
abruption, or uterine rupture.38-40 All of these factors have contributed to the high rate of negative appendectomy in pregnant
patients, as high as 25% to 50%, when it is based on clinical
presentation alone.38
The impact of appendicitis on the pregnant patient is severe.
The risk of preterm labor has been shown to be 11% and fetal
loss 6% with complicated appendicitis.41 These data would appear
to favor an aggressive, early approach to appendicitis in the pregnant patient. Complicating this approach, however, was the
finding in the same series that negative appendectomy was also
associated with preterm labor and fetal loss (10% and 4%, respectively). The lowest rates of preterm labor and fetal loss (6%
and 2%, respectively) were seen in cases of uncomplicated

APPROACH TO THE PREGNANT PATIENT WITH SUSPECTED APPENDICITIS

Diffuse peritonitis present

Yes

No

Resuscitation, antibiotics, to OR for source control

US

Other diagnosis confirmed

Treat as indicated

Appendicitis confirmed

US ()

Appendectomy

MRI

MRI () for appendicitis

MRI () for appendicitis

Observe

Appendectomy

Pt improves

Pt worsens

Discharge

Diagnostic laparoscopy

FIGURE 50-8 Suggested algorithm for managing the pregnant patient with possible appendicitis.

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CHAPTER 50 The Appendix

appendicitis.41 For these reasons, preoperative accuracy of diagnosis is crucial in the pregnant patient with suspected appendicitis.
Routine imaging is recommended in pregnant patients. The
initial study of choice is US with graded compression.42 It has
the advantage of being safe, inexpensive, and readily available. In
addition, US may provide information as to fetal well-being and
obstetric causes of abdominal pain, such as placental abruption.
Scanning patients in a left posterior oblique or left lateral decubitus position rather than in the traditional supine position has
been advocated to increase the chances of visualizing the appendix. The criteria for US diagnosis are the same as in the nonpregnant patient and have been discussed previously. Unfortunately,
the sensitivity (78%) and specificity (83%) of US appear to be
reduced in pregnancy because of the presence of the gravid
uterus.42
If US examination findings are equivocal, MRI without gadolinium contrast, with its excellent soft tissue contrast resolution
and lack of ionizing radiation, remains a safe alternative for confirmation or exclusion of appendicitis in the pregnant patient. In
addition, the excellent sensitivity and specificity are preserved in
the pregnant patient (Fig. 50-9). A patient in whom MRI findings
are normal likely does not require appendectomy. Routine use of
MRI in pregnant patients has been demonstrated to reduce the
negative appendectomy rate by 47% without a significant increase
in the perforation rate, and it has been shown to be a cost-effective
study.42 For these reasons, we encourage liberal use of MRI in
pregnant patients suspected to have acute appendicitis without
frank peritonitis. However, MRI may not be available in some
institutions and may be available only on a limited basis or during
limited times in other institutions. The decision about any delay
in appendectomy to obtain an MRI study is a complex one and
should be made using all available clinical and imaging data available because there are potentially severe consequences associated
with both negative appendectomy and appendiceal perforation.
If US is inconclusive and MRI scanning is not immediately
available, CT scanning for diagnosis of appendicitis in pregnancy
has been reported. A study published in 2008 demonstrated that
the use of CT was associated with an 8% negative appendectomy
rate, compared with 54% by clinical assessment alone and 32%
by clinical assessment combined with US. The authors concluded
that CT should be used if US examination findings are equivocal

FIGURE 50-9 MRI scan with T1-weighted axial image of the abdomen
in a gravid woman. The arrow highlights the thickened appendix. (From
Parks NA, Schroeppel TJ: Update on imaging for acute appendicitis.
Surg Clin North Am 91:141154, 2011.)

1307

and argued that the amount of radiation delivered during a limited

CT examination is below the threshold required to induce fetal
malformations and that most cases of appendicitis in pregnancy
occur in the second or third trimester, when organogenesis in
already complete.42 Although protocols vary, if CT is used during
pregnancy for equivocal cases, care should be taken to perform as
limited a study as possible with avoidance of intravenous administration of contrast material. Further study is required before the
routine use of CT can be accepted in this clinical scenario.
The choice of laparoscopic versus open technique for appendectomy in pregnancy also merits discussion. Current Society of
American Gastrointestinal and Endoscopic Surgeons guidelines
state that laparoscopic appendectomy is safe in pregnancy and is
the standard of care in pregnant patients.43 Two studies, both
small and retrospective, have shown no increased fetal loss with
laparoscopic appendectomy compared with open appendectomy.
Another study reported higher preterm labor and overall complication rates in the open group compared with the laparoscopic
group.40 Others have reported higher fetal loss rates with laparoscopic appendectomy (5.6% versus 3.1%) compared with open
appendectomy.44 It is apparent that this debate would be best
resolved through randomized controlled trials, which to date have
not been performed.
Our institutional experience with laparoscopic appendectomy
in pregnancy has been positive, making it our preferred approach
to the pregnant patient. In our hands, we believe it allows an easier
identification of the highly variable location of the appendix, a
more expeditious removal, and an opportunity for more thorough
evaluation of the abdomen for any associated pathologic process.
We do routinely use an open access approach (Hasson technique)
for initial trocar placement to avoid any chance of injury to the
gravid uterus.

Appendicitis in the Elderly

Although it is not the peak age for its occurrence, appendicitis is
not infrequently seen in elderly patients and should remain in the
differential diagnoses of any elderly patient presenting with acute
abdominal pain who has not had an appendectomy. The most
important aspect is to realize the expanded differential diagnosis
that must be considered in the elderly. Other possible diagnoses
include but are not limited to acute diverticulitis (uncomplicated
or complicated), malignant disease, intestinal ischemia, ischemic
colitis, complicated urinary tract infection, and perforated ulcer.
Appendicitis may also be manifested in an atypical manner, so a
high index of suspicion must be maintained. A careful history and
physical examination may aid in diagnosis, but this may have little
value in certain circumstances, such as in patients with dementia
or an altered mental status. The higher perforation rate in the
elderly population, as high as 40% to 70%, combined with the
frequent coexistence of comorbidities resulting in higher morbidity makes the diagnosis and treatment of appendicitis in the
elderly a challenge, to say the least.3
When faced with an elderly patient with diffuse peritonitis,
immediate laparotomy should be performed without unnecessary
delay. When the pain is localized and peritonitis is absent, CT
scanning of the abdomen should be performed to confirm the
diagnosis and to evaluate for other pathologic changes. Laparoscopic appendectomy is safe in the elderly and is our procedure
of choice in this group of patients. Exceptions include patients
with severe cardiomyopathy, in whom we prefer the open
approach to avoid the deleterious effects of pneumoperitoneum
in patients with marginal cardiac function.45 We have

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1308

SECTION X Abdomen

also successfully performed open appendectomy under spinal

anesthesia in patients who are pulmonary cripples and in whom
the risk of general surgery is prohibitive and likely to result in
ventilator dependence.

Appendicitis in the Immunocompromised Patient

Appendicitis in the immunocompromised patient is managed in
the same manner as in the immunocompetent patient, with
prompt appendectomy. The key in the evaluation of this population lies in maintenance of a high index of suspicion because the
lack of the ability to mount an immune response may result in
absence of fever, leukocytosis, and peritonitis. For this reason,
early use of CT imaging is advisable. This allows confirmation of
the diagnosis of appendicitis as well as the exclusion of diagnoses,
such as neutropenic enterocolitis (typhlitis), that may be amenable
to nonoperative treatment.46

NEOPLASMS OF THE APPENDIX

Neoplasms of the appendix, although rare, require appropriate
treatment. An unanticipated appendiceal neoplasm may be
encountered at any elective or emergency operation. It is estimated
that 50% of appendiceal neoplasms present as appendicitis and
are diagnosed on pathologic examination of the surgical specimen,
but variable presentations have been reported. It is reported that
appendiceal neoplasms are identified in 0.7% to 1.7% of pathology
specimens. In addition, an appendiceal mass is sometimes noted
as an incidental finding on abdominal CT (Fig. 50-10). The
pathologic classification and biologic behavior of appendiceal neoplasms are diverse, which serves to make the classification, terminology, and treatment recommendations even more confusing.1
Overall, appendiceal neoplasms are thought to account for 0.4%
to 1% of all gastrointestinal malignant neoplasms.1
After appendectomy for presumed appendicitis, the incidence
of unexpected findings in the surgical specimen is low. Still, if
identified, appropriate counseling and treatment are essential.
Carcinoid tumors are the most common tumor primary identified
in the appendix.16 These neoplasms arise from neuroendocrine
cells from within the appendix and are detected in 0.3% to
0.9% of appendectomy specimens.1 These are typically small,

TI
R
1
9
0

L
2
0
8

well-circumscribed lesions that are located within the more distal

aspect of the appendix.
The biologic behavior of carcinoid tumors is highly variable.
Size appears to be the best predictor of malignant behavior and
metastatic potential, more so than histologic features, including
lymphovascular invasion. Carcinoids smaller than 1cm are typically thought to behave in a benign manner and are cured with
appendectomy. Carcinoids larger than 2cm are treated more
aggressively, however. Other considerations include whether the
carcinoid involves the base of the appendix or extends into the
mesoappendix. Patients with carcinoids larger than 2cm, with
involvement of the base, or with extension to the mesoappendix
should undergo right hemicolectomy with regional lymphadenectomy. For lesions between 1 and 2cm in size, recommendations
should be made after careful consideration of the individual
tumor characteristics as metastases have been reported.1,47
Adenocarcinoma of the appendix is rare and occurs at a frequency of 0.08% to 0.1% of all appendectomies.1 Treatment is
identical to that of cecal adenocarcinoma and consists of right
hemicolectomy with regional lymphadenectomy. Chemotherapy
is also identical to that of adenocarcinoma of the colon, with
adjuvant administration of 5-fluorouracil, leucovorin, and oxaliplatin (FOLFOX) to selected patients. FOLFOX has also been
used in the neoadjuvant setting in patients with mucinous adenocarcinoma before cytoreductive (debulking) surgery.48
Mucinous tumors of the appendix are appendiceal tumors that
are not frankly malignant but, if ruptured, can result in intraperitoneal spread and the development of pseudomyxoma peritonei
(PMP). Classification and nomenclature of these lesions are confusing and not universally agreed on.1 Because PMP results as a
consequence of perforation and direct peritoneal seeding from the
appendiceal contents, the surgeon should use great caution to
avoid rupturing an intact appendix if mucocele or mucinous
neoplasm is suspected on preoperative imaging or diagnosed
intraoperatively. If PMP occurs, treatment by extensive cytoreductive surgery involving removal of any involved organs combined
with heated intraperitoneal chemotherapy is typically employed49
and is associated with long-term survival.
Although many appendiceal neoplasms are diagnosed on final
pathologic examination, the mass will occasionally be visible at
the time of appendectomy. An excellent algorithm for the management of the incidentally identified appendiceal mass was proposed by Wray and colleagues, and a modified version is provided
for review (Fig. 50-11).1 This algorithm is useful both in cases of
appendicitis and in cases in which an appendiceal tumor is identified incidentally. The availability of frozen-section diagnosis may
provide additional help with intraoperative decision making.

SELECTED REFERENCES
Ingraham AM, Cohen ME, Bilimoria KY, etal: Comparison of
outcomes after laparoscopic versus open appendectomy for acute
appendicitis at 222 ACS NSQIP hospitals. Surgery 148:625635,
discussion 635637, 2010.
The authors provide one of the largest series to date, nearly
32,000 patients, comparing outcomes of laparoscopic versus
open appendectomy using the ACS NSQIP database.

FIGURE 50-10 CT scan of the abdomen in a patient with a benign

10-cm mucocele. The axial image shows a distended fluid-filled mass
medial to the appendix (arrow), without associated inflammation.
C, Cecum; TI, terminal ileum.

McGory ML, Zingmond DS, Tillou A, etal: Negative appendectomy in pregnant women is associated with a substantial risk of
fetal loss. J Am Coll Surg 205:534540, 2007.

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CHAPTER 50 The Appendix

APPROACH TO PATIENT WITH APPENDICEAL NEOPLASM

Tumor detected at operation

Yes

No

Tumor >2 cm

Tumor found after appendectomy

Yes

Adenocarcinoma

No

R hemicolectomy

Is base involved?

R hemicolectomy

No

Tumor <1 cm

Tumor >2 cm

Perforation?

Observation

R hemicolectomy

Yes

R hemicolectomy

Carcinoid

Tumor 1-2 cm

Lymphovascular invasion

Yes

No

Evidence of mucin spillage

or mucinous ascites

Yes

Yes

Appendectomy

R hemicolectomy

No

Observation

No

Appendectomy
Appendectomy
Peritoneal lavage
Consider referral for cytoreductive surgery/intraperitoneal chemotherapy
(CRC-HIPEC)
Note: All patients with appendiceal neoplasm should undergo routine colonoscopy

FIGURE 50-11 Suggested algorithm for managing the patient with an appendiceal neoplasm.

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1309

1310

SECTION X Abdomen

This article, which demonstrates that fetal loss is not only

highest with appendiceal rupture but also increased with
negative appendectomy, highlights the need for accurate
diagnosis in the pregnant patient.

Parks NA, Schroeppel TJ: Update on imaging for acute appendicitis. Surg Clin North Am 91:141154, 2011.
The authors present a thorough, evidence-based review of
the current available imaging studies used to diagnose
appendiceal disease along with the clinical circumstances in
which they are most useful.

Silen W: Copes early diagnosis of the acute abdomen, ed 22, New

York, 2010, Oxford University Press.
This classic text, now in its 22nd edition, provides a masterful overview of the differential diagnoses and subtle historical findings of appendicitis and related disease. It is a
timeless source of wisdom and is considered a must read
by many surgeons.

Solomkin JS, Mazuski JE, Bradley JS, etal: Diagnosis and management of complicated intra-abdominal infection in adults and
children: Guidelines by the Surgical Infection Society and the
Infectious Diseases Society of America. Clin Infect Dis 50:133
164, 2010.
This consensus statement from the IDSA and SIS provides
evidence-based guidelines for the treatment of complicated
intra-abdominal infections, including appendicitis.

Wray CJ, Kao LS, Millas SG, etal: Acute appendicitis: Controversies in diagnosis and management. Curr Probl Surg 50:5486,
2013.
This timely and well-written review article details some of
the controversial issues relating to surgery of the appendix
and includes an excellent overview of the treatment of
appendiceal neoplasms.

REFERENCES
1. Wray CJ, Kao LS, Millas SG, etal: Acute appendicitis: Controversies in diagnosis and management. Curr Probl Surg
50:5486, 2013.
2. Addiss DG, Shaffer N, Fowler BS, etal: The epidemiology
of appendicitis and appendectomy in the United States. Am
J Epidemiol 132:910925, 1990.
3. Prystowsky JB, Pugh CM, Nagle AP: Current problems
in surgery. Appendicitis. Curr Probl Surg 42:688742,
2005.
4. Randal Bollinger R, Barbas AS, Bush EL, etal: Biofilms in
the large bowel suggest an apparent function of the human
vermiform appendix. J Theor Biol 249:826831, 2007.
5. Deshmukh S, Verde F, Johnson PT, etal: Anatomical variants
and pathologies of the vermix. Emerg Radiol 21:543552,
2014.
6. Chen CY, Chen YC, Pu HN, etal: Bacteriology of acute
appendicitis and its implication for the use of prophylactic
antibiotics. Surg Infect (Larchmt) 13:383390, 2012.

7. Silen W: Copes early diagnosis of the acute abdomen, ed 22,

New York, 2010, Oxford University Press.
8. Andersson RE: Meta-analysis of the clinical and laboratory
diagnosis of appendicitis. Br J Surg 91:2837, 2004.
9. Parks NA, Schroeppel TJ: Update on imaging for acute
appendicitis. Surg Clin North Am 91:141154, 2011.
10. Birnbaum BA, Wilson SR: Appendicitis at the millennium.
Radiology 215:337348, 2000.
11. Solomkin JS, Mazuski JE, Bradley JS, etal: Diagnosis and
management of complicated intra-abdominal infection in
adults and children: Guidelines by the Surgical Infection
Society and the Infectious Diseases Society of America. Clin
Infect Dis 50:133164, 2010.
12. Brown MA: Imaging acute appendicitis. Semin Ultrasound
CT MR 29:293307, 2008.
13. Drake FT, Florence MG, Johnson MG, etal: Progress in the
diagnosis of appendicitis: A report from Washington States
Surgical Care and Outcomes Assessment Program. Ann Surg
256:586594, 2012.
14. Ingraham AM, Cohen ME, Bilimoria KY, etal: Comparison
of outcomes after laparoscopic versus open appendectomy for
acute appendicitis at 222 ACS NSQIP hospitals. Surgery
148:625635, discussion 635-637, 2010.
15. Fleming FJ, Kim MJ, Messing S, etal: Balancing the risk of
postoperative surgical infections: A multivariate analysis of
factors associated with laparoscopic appendectomy from the
NSQIP database. Ann Surg 252:895900, 2010.
16. Teixeira PG, Demetriades D: Appendicitis: Changing perspectives. Adv Surg 47:119140, 2013.
17. Deelder JD, Richir MC, Schoorl T, etal: How to treat an
appendiceal inflammatory mass: Operatively or nonoperatively? J Gastrointest Surg 18:641645, 2014.
18. Lugo JZ, Avgerinos DV, Lefkowitz AJ, etal: Can interval
appendectomy be justified following conservative treatment
of perforated acute appendicitis? J Surg Res 164:9194,
2010.
19. Fawley J, Gollin G: Expanded utilization of nonoperative
management for complicated appendicitis in children. Langenbecks Arch Surg 398:463466, 2013.
20. Zhang HL, Bai YZ, Zhou X, etal: Nonoperative management of appendiceal phlegmon or abscess with an appendicolith in children. J Gastrointest Surg 17:766770, 2013.
21. Puapong D, Lee SL, Haigh PI, etal: Routine interval appendectomy in children is not indicated. J Pediatr Surg 42:1500
1503, 2007.
22. Raval MV, Lautz T, Reynolds M, etal: Dollars and sense of
interval appendectomy in children: A cost analysis. J Pediatr
Surg 45:18171825, 2010.
23. Hall NJ, Jones CE, Eaton S, etal: Is interval appendicectomy
justified after successful nonoperative treatment of an appendix mass in children? A systematic review. J Pediatr Surg
46:767771, 2011.
24. Iqbal CW, Knott EM, Mortellaro VE, etal: Interval appendectomy after perforated appendicitis: What are the operative
risks and luminal patency rates? J Surg Res 177:127130,
2012.
25. Willemsen PJ, Hoorntje LE, Eddes EH, etal: The need for
interval appendectomy after resolution of an appendiceal
mass questioned. Dig Surg 19:216220, discussion 221,
2002.
26. Carpenter SG, Chapital AB, Merritt MV, etal: Increased
risk of neoplasm in appendicitis treated with interval

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For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.

CHAPTER 50 The Appendix

appendectomy: Single-institution experience and literature
review. Am Surg 78:339343, 2012.
27. Furman MJ, Cahan M, Cohen P, etal: Increased risk of
mucinous neoplasm of the appendix in adults undergoing
interval appendectomy. JAMA Surg 148:703706, 2013.
28. Gaetke-Udager K, Maturen KE, Hammer SG: Beyond acute
appendicitis: Imaging and pathologic spectrum of appendiceal pathology. Emerg Radiol 21:535542, 2014.
29. Lai HW, Loong CC, Chiu JH, etal: Interval appendectomy
after conservative treatment of an appendiceal mass. World J
Surg 30:352357, 2006.
30. Garlipp B, Arlt G: [Laparoscopy for suspected appendicitis.
Should an appendix that appears normal be removed?].
Chirurg 80:615621, 2009.
31. Chiarugi M, Buccianti P, Decanini L, etal: What you see is
not what you get. A plea to remove a normal appendix
during diagnostic laparoscopy. Acta Chir Belg 101:243245,
2001.
32. Varadhan KK, Neal KR, Lobo DN: Safety and efficacy of
antibiotics compared with appendicectomy for treatment of
uncomplicated acute appendicitis: Meta-analysis of randomised controlled trials. BMJ 344:e2156, 2012.
33. Mason RJ, Moazzez A, Sohn H, etal: Meta-analysis of randomized trials comparing antibiotic therapy with appendectomy for acute uncomplicated (no abscess or phlegmon)
appendicitis. Surg Infect (Larchmt) 13:7484, 2012.
34. Giuliano V, Giuliano C, Pinto F, etal: Chronic appendicitis
syndrome manifested by an appendicolith and thickened
appendix presenting as chronic right lower abdominal pain
in adults. Emerg Radiol 12:9698, 2006.
35. Teli B, Ravishankar N, Harish S, etal: Role of elective laparoscopic appendicectomy for chronic right lower quadrant
pain. Indian J Surg 75:352355, 2013.
36. Wen SW, Hernandez R, Naylor CD: Pitfalls in nonran
domized outcomes studies. The case of incidental appendectomy with open cholecystectomy. JAMA 274:16871691,
1995.
37. Wang HT, Sax HC: Incidental appendectomy in the era of
managed care and laparoscopy. J Am Coll Surg 192:182188,
2001.

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38. Brown JJ, Wilson C, Coleman S, etal: Appendicitis in

pregnancy: An ongoing diagnostic dilemma. Colorectal Dis
11:116122, 2009.
39. Flexer SM, Tabib N, Peter MB: Suspected appendicitis in
pregnancy. Surgeon 12:8286, 2014.
40. Peled Y, Hiersch L, Khalpari O, etal: Appendectomy during
pregnancyis pregnancy outcome depending by operation
technique? J Matern Fetal Neonatal Med 27:365367,
2014.
41. McGory ML, Zingmond DS, Tillou A, etal: Negative appendectomy in pregnant women is associated with a substantial
risk of fetal loss. J Am Coll Surg 205:534540, 2007.
42. Khandelwal A, Fasih N, Kielar A: Imaging of acute abdomen
in pregnancy. Radiol Clin North Am 51:10051022, 2013.
43. Korndorffer JR, Jr, Fellinger E, Reed W: SAGES guideline
for laparoscopic appendectomy. Surg Endosc 24:757761,
2010.
44. Walsh CA, Tang T, Walsh SR: Laparoscopic versus open
appendicectomy in pregnancy: A systematic review. Int J Surg
6:339344, 2008.
45. Richmond BK, Thalheimer L: Laparoscopy associated mesenteric vascular complications. Am Surg 76:11771184,
2010.
46. Hernandez-Ocasio F, Palermo-Garofalo CA, Colon M, etal:
Right lower quadrant abdominal pain in an immunocompromised patient: Importance for an urgent diagnosis and treatment. Bol Asoc Med P R 103:5153, 2011.
47. Boudreaux JP, Klimstra DS, Hassan MM, etal: The NANETS
consensus guideline for the diagnosis and management of
neuroendocrine tumors: Well-differentiated neuroendocrine
tumors of the jejunum, ileum, appendix, and cecum. Pancreas
39:753766, 2010.
48. Sugarbaker PH, Bijelic L, Chang D, etal: Neoadjuvant
FOLFOX chemotherapy in 34 consecutive patients with
mucinous peritoneal carcinomatosis of appendiceal origin.
J Surg Oncol 102:576581, 2010.
49. Wagner PL, Austin F, Maduekwe U, etal: Extensive cytoreductive surgery for appendiceal carcinomatosis: Morbidity,
mortality, and survival. Ann Surg Oncol 20:10561062,
2013.

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