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 correspond- cessful removal of the appendix has not been definitively demon-
ing videos for this chapter. strated to have any known adverse sequelae.
As a midgut organ, the blood supply of the appendix is derived
Appendicitis remains one of the most common diseases faced by from the superior mesenteric artery. The ileocolic artery, one of
the surgeon in practice. It is the most common urgent or emergent the major named branches of the superior mesenteric artery, gives
general surgical operation performed in the United States and is rise to the appendiceal artery, which courses through the mesoap-
responsible for as many as 300,000 hospitalizations annually.1 pendix. The mesoappendix also contains lymphatics of the appen-
Although appendectomy is often the first “major” case performed dix, which drain to the ileocecal nodes, along the blood supply
by the young surgeon in training, few other operations will be from the superior mesenteric artery.3,5
learned that will have such a dramatic impact on the patient being The appendix is of variable size (5 to 35 cm in length) but
treated. averages 9 cm in length in adults. Its base can be reliably identified
It is estimated that as much as 6% to 7% of the general popula- by defining the area of convergence of the taeniae at the tip of the
tion will develop appendicitis during their lifetime, with the inci- cecum and then elevating the appendiceal base to define the
dence peaking in the second decade of life.2 Despite its high course and position of the tip of the appendix, which is variable
prevalence in Western countries, the diagnosis of acute appendi- in location. The appendiceal tip may be found in a variety of
citis can be challenging and requires a high index of suspicion on locations, with the most common being retrocecal (but intraperi-
the part of the examining surgeon to facilitate prompt treatment toneal) in approximately 60% of individuals, pelvic in 30%, and
of this condition, thereby avoiding the substantial morbidity (and retroperitoneal in 7% to 10%. Agenesis of the appendix has been
even mortality) associated with perforation. Appendicitis is much reported, as has duplication and even triplication.3,5 Knowledge
less common in underdeveloped countries, suggesting that ele- of these anatomic variations is important to the surgeon because
ments of the Western diet, specifically a low-fiber, high-fat intake, the variable position of the appendiceal tip may account for dif-
may play a role in the development of the disease process.3 ferences in clinical presentation and in the location of the associ-
ated 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
ANATOMY AND EMBRYOLOGY present with suprapubic pain. Both of these presentations may
The appendix is a midgut organ and is first identified at 8 weeks result in a delayed diagnosis as the symptoms are distinctly differ-
of gestation as a small outpouching of the cecum. As gestation ent from the classically described anterior right lower quadrant
progresses, the appendix becomes more elongated and tubular as abdominal pain associated with appendiceal disease.
the cecum rotates medially and becomes fixed in the right lower
quadrant of the abdomen. The appendiceal mucosa is of the APPENDICITIS
colonic type, with columnar epithelium, neuroendocrine cells,
and mucin-producing goblet cells lining its tubular structure.3 History
Lymphoid tissue is found in the submucosa of the appendix, The first appendectomy was reported in 1735 by a French Surgeon,
leading some to hypothesize that the appendix may play a role Claudius Amyand, who identified and successfully removed the
in the immune system. In addition, evidence suggests that the appendix of an 11-year-old boy that was found within an inguinal
appendix may serve as a reservoir of “good” intestinal bacteria and hernia sac and that had been perforated by a pin. Although
may aid in recolonization and maintenance of the normal colonic autopsy findings consistent with perforated appendicitis appeared
flora.4 Consensus about this has not been achieved, however. Suc- sporadically thereafter in the literature, the first formal description

1296
 CHAPTER 50  The Appendix 1296.e1

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
 CHAPTER 50  The Appendix 1297

of the disease process, including the common clinical features and duration of antibiotic coverage and the controversies surrounding
a recommendation for prompt surgical removal, was in 1886 by the need for cultures are discussed later in the chapter.
Reginald Heber Fitz of Harvard University.3 The causes of the luminal obstruction are many and varied.
Notable advances in surgery for appendicitis include McBur- These most commonly include fecal stasis and fecaliths but may
ney’s description of his classic muscle-splitting incision and tech- also include lymphoid hyperplasia, neoplasms, fruit and vegetable
nique for removal of the appendix in 1894 and the description of material, ingested barium, and parasites such as ascarids. Pain of
the first laparoscopic appendectomy by Kurt Semm in 1982.3 appendicitis has both visceral and somatic components. Distention
Laparoscopic appendectomy has become the preferred method for of the appendix is responsible for the initial vague abdominal pain
management of acute appendicitis among surgeons in the United (visceral) often experienced by the affected patient. The pain typi-
States and may be accomplished using several (typically three) cally does not localize to the right lower quadrant until the tip
trocar sites or through single-incision laparoscopic surgical tech- becomes inflamed and irritates the adjacent parietal peritoneum
niques. Finally, but of no less significance, was the development (somatic) or perforation occurs, resulting in localized peritonitis.3
of broad-spectrum antibiotics, interventional radiologic tech-
niques, and better surgical critical care strategies, all of which have Differential Diagnosis
resulted in substantial improvements in the care of patients with Appendicitis must be considered in every patient (who has not
appendiceal perforation and its subsequent complications. had an appendectomy) who presents with acute abdominal pain.7
Knowledge of disease processes that may have similar presenting
Pathophysiology and Bacteriology symptoms and signs is essential to avoid an unnecessary or incor-
Appendicitis is caused by luminal obstruction.3 The appendix is rect operation. Consideration of the patient’s age and gender may
vulnerable to this phenomenon because of its small luminal diam- help narrow the list of possible diagnoses. In children, other con-
eter in relation to its length. Obstruction of the proximal lumen of siderations include but are not limited to mesenteric adenitis
the appendix leads to elevated pressure in the distal portion because (often seen after a recent viral illness), acute gastroenteritis, intus-
of ongoing mucus secretion and production of gas by bacteria susception, Meckel’s diverticulitis, inflammatory bowel disease,
within the lumen. With progressive distention of the appendix, the and (in males) testicular torsion. Nephrolithiasis and urinary tract
venous drainage becomes impaired, resulting in mucosal ischemia. infection may be manifested with right lower quadrant pain in
With continued obstruction, full-thickness ischemia ensues, which either gender.3
ultimately leads to perforation. Bacterial overgrowth within the In women of childbearing age, the differential diagnosis is
appendix results from bacterial stasis distal to the obstruction.3 This expanded even further. Gynecologic problems may be mistaken
is significant because this overgrowth results in the release of a larger for appendicitis and result in a higher negative appendectomy rate
bacterial inoculum in cases of perforated appendicitis (Table 50-1). than in male patients of comparable age. These include ruptured
The time from onset of obstruction to perforation is variable and ovarian cysts, mittelschmerz (midcycle pain occurring with ovula-
may range anywhere from a few hours to a few days. The presenta- tion), endometriosis, ovarian torsion, ectopic pregnancy, and
tion after perforation is also variable. The most common sequela is pelvic inflammatory disease.3,7
the formation of an abscess in the periappendiceal region or pelvis. Two other patient populations deserve mention. In the elderly,
On occasion, however, free perforation occurs that results in diffuse consideration must be given to acute diverticulitis and malignant
peritonitis.3 disease as possible causes of lower abdominal pain. In the neutro-
Because the appendix is an outpouching of the cecum, the flora penic patient, typhlitis (also known as neutropenic enterocolitis)
within the appendix is similar to that found within the colon. should also be considered within the differential diagnosis. Appen-
Infections associated with appendicitis should be considered poly- dicitis in these special populations is discussed later in the chapter.
microbial, and antibiotic coverage should include agents that
address the presence of both gram-negative bacteria and anaer- Presentation
obes. Common isolates include Escherichia coli, Bacteroides fragilis, History
enterococci, Pseudomonas aeruginosa, and others.6 The choice and 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
TABLE 50-1  Bacteria Commonly Isolated through the progressive distention of the appendix. Anorexia is
in Perforated Appendicitis often present, as is nausea with or without associated vomiting.
TYPE OF BACTERIA PATIENTS (%)
Either diarrhea or constipation may be present as well. As the con-
dition progresses and the appendiceal tip becomes inflamed, result-
Anaerobic ing in peritoneal irritation, the pain localizes to its classic location
Bacteroides fragilis 80 in the right lower quadrant. This phenomenon remains a reliable
Bacteroides thetaiotaomicron 61 symptom of appendicitis3,7 and should serve to further increase the
Bilophila wadsworthia 55 clinician’s index of suspicion for appendicitis (Fig. 50-1).
Peptostreptococcus spp. 46 Whereas these symptoms represent the “classic” presentation
of appendicitis, the clinician must be aware that the disease may
Aerobic
be manifested in an atypical fashion. For example, patients with
Escherichia coli 77
a retroperitoneal appendix may present in a more subacute
Viridans streptococcus 43
manner, with flank or back pain, whereas patients with an appen-
Group D streptococcus 27
diceal tip in the pelvis may have suprapubic pain suggestive of
Pseudomonas aeruginosa 18
urinary tract infection.3,7 We have on occasion encountered
Adapted from Bennion RS, Thompson JE: Appendicitis. In Fry DE, patients presenting with symptoms of small bowel obstruction
editor: Surgical infections, Boston, 1995, Little, Brown, pp 241–250. who were found to be obstructed by multiple interloop abscesses
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

Yes No

Follow pregnancy algorithm

Laparoscopic appendectomy CT

CT
() for appendicitis () for appendicitis Other diagnosis

Lap appendectomy Brief observation Treat as indicated

No improvement Improving

Diagnostic laparoscopy Discharge

() 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. Physical Examination

Although cases such as these are less common than the typical Patients with appendicitis typically appear ill. They frequently lie
presentation, knowledge of these variations is essential to maintain still because of the presence of localized peritonitis, which makes
the necessary index of suspicion to permit a prompt and accurate any movement painful. Tachycardia and mild dehydration are
diagnosis. often present to varying degrees. Fever is frequently present,
 CHAPTER 50  The Appendix 1299

ranging from low-grade temperature elevations (<38.5° C) to Plain radiographs are frequently obtained in the emergency
more impressive elevations of body temperature, depending on department setting for the evaluation of acute abdominal pain but
the status of the disease process and the severity of the patient’s lack both sensitivity and specificity for the diagnosis of appendi-
inflammatory response. Absence of fever does not exclude a diag- citis and are rarely helpful. Findings that may support the diag-
nosis of appendicitis.1,3,7 nosis include the presence of a calcified fecalith in the right lower
Abdominal examination typically reveals a quiet abdomen with quadrant, although this finding must be placed into the appropri-
tenderness and guarding on palpation of the right lower quadrant. ate clinical context and is typically present in only 5% of cases.9
The location of the tenderness is classically over McBurney point, Pneumoperitoneum, if present, should alert the clinician to other
which is located one-third the distance between the anterior supe- causes of a perforated viscus (such as a perforated ulcer or diver-
rior iliac spine and the umbilicus. The pain and tenderness are ticulitis), as this is not typically observed in cases of appendicitis,
typically accompanied by localized peritonitis as evidenced by the even with perforation.
presence of rebound tenderness. Diffuse peritonitis or abdominal CT scanning is the most common imaging study to diagnose
wall rigidity due to involuntary spasm of the overlying abdominal appendicitis and is highly effective and accurate.9 Modern helical
wall musculature is strongly suggestive of perforation.1,3 CT scans have the advantage of being operator independent and
A number of signs have been described to aid in the diagnosis easy to interpret. CT has been shown to have a sensitivity of 90%
of appendicitis. These include the Rovsing sign (the presence of to 100%, a specificity of 91% to 99%, a positive predictive value
right lower quadrant pain on palpation of the left lower quadrant), of 92% to 98%, and a negative predictive value of 95% to
the obturator sign (right lower quadrant pain on internal rotation 100%.9,10 The recommended imaging protocol from the Infec-
of the hip), and the psoas sign (pain with extension of the ipsi- tious Diseases Society of America (IDSA) and the Surgical Infec-
lateral hip), among others.1 Although these are of historical inter- tion Society includes the intravenous administration of contrast
est, it is important to realize that they are simply indicators of material only. Oral and rectal administration of contrast material
localized peritonitis rather than a diagnostic of a specific disease is not recommended.11
process. Still, they are useful maneuvers to perform in examining The diagnosis of appendicitis on CT is based on the appearance
a patient with suspected appendicitis and are supportive of the of a thickened, inflamed appendix with surrounding “stranding”
diagnosis if it is suspected clinically. indicative of inflammation. The appendix is typically more than
Rectal examination findings are typically normal. However, a 7 mm in diameter with a thickened, inflamed wall and mural
palpable mass or tenderness may be present if the appendiceal tip enhancement or “target sign” (Fig. 50-2). Periappendiceal fluid or
is located within the pelvis or if a pelvic abscess is present. In air is also highly suggestive of appendicitis and suggests perfora-
female patients, pelvic examination is important to exclude pelvic tion. In cases in which the appendix is not visualized, the absence
disease. However, cervical motion tenderness, a finding typically of inflammatory findings on CT suggests that appendicitis is not
associated with pelvic inflammatory disease, may be present in present.12 Although we do not recommend CT in cases in which
appendicitis because of irritation of the pelvic organs from the appendicitis is strongly suspected on clinical grounds based on
adjacent inflammatory process.3 supportive history and physical and laboratory findings, published
data do suggest that use of CT in equivocal cases does indeed
Laboratory Studies reduce the negative appendectomy rate.13
Laboratory studies should be interpreted with caution in cases of US has been used for diagnosis of appendicitis since the 1980s.
suspected appendicitis and should be used to support the clinical As US technology has become more advanced, so has its ability
picture rather than definitively to prove or to exclude the diagno- to visualize the appendix. The US probe is applied to the area of
sis. A leukocytosis, often with a “left shift” (a predominance of pain in the right lower quadrant, and graded compression is used
neutrophils and sometimes an increase in bands), is present in to collapse normal surrounding bowel and to diminish the inter-
90% of cases. A normal white blood cell count is found in 10% ference encountered with overlying bowel gas. The inflamed
of cases, however, and it should not be used as an isolated test to appendix is typically enlarged, immobile, and noncompressible
exclude the presence of appendicitis.8 Urinalysis is typically (Fig. 50-3). If the appendix cannot be visualized, the study is
normal as well, although the finding of trace leukocyte esterase or inconclusive and cannot be relied on to guide treatment. Although
pyuria is not unusual and is presumably due to the proximity of US provides the advantage of avoiding ionizing radiation, the
the inflamed appendix to the bladder or ureter. If the presentation technology is highly operator dependent. The sensitivity is
is strongly suggestive of appendicitis, a “positive” urinalysis should reported to range from 78% to 83%, whereas the specificity
not be used as an isolated test to refute the diagnosis. Pregnancy ranges from 83% to 93%. Its greatest utility appears to be in the
testing is mandatory in women of childbearing age. C-reactive evaluation of the pediatric or pregnant patient, in whom the
protein has been demonstrated to be neither sensitive nor specific associated radiation exposure from CT is undesirable.9
in diagnosing (or excluding) appendicitis.1,8 MRI is typically reserved for use in the pregnant patient; the
No symptom or sign has been demonstrated to be discrimi- study is performed without contrast agents. If it is obtained in a
natory and predictive of appendicitis.1,8 The same may be said pregnant woman, the study should be noncontrasted. MRI offers
of laboratory tests, which are also weakly predictive when con- excellent resolution and is accurate in diagnosing appendicitis.
sidered in isolation. Rather, it is the assessment of the collective Criteria for MRI diagnosis include appendiceal enlargement
body of information that allows more precise diagnosis.1,8 (>7 mm), thickening (>2 mm), and the presence of inflamma-
tion.9 The sensitivity of MRI is reported to be 100%, the specific-
Imaging Studies ity 98%, the positive predictive value 98%, and the negative
A variety of radiographic studies may be used to diagnose appen- predictive value 100%. MRI is also operator independent and
dicitis. These consist of plain radiographs, computed tomography offers highly reproducible results. Drawbacks associated with the
(CT) scanning, ultrasound (US), and magnetic resonance imaging use of MRI include its higher cost, motion artifact, greater diffi-
(MRI). culty in interpretation by nonradiologists who may have limited
1300 SECTION X  Abdomen

A B
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.

For open appendectomy, the patient is placed in the supine

position. The choice of incision is a matter of the surgeon’s
preference, whether it is an oblique muscle-splitting incision
A A (McArthur-McBurney; Fig. 50-4), a transverse incision (Rockey-
Davis), or a conservative midline incision. The cecum is grasped
by the taeniae and delivered into the wound, allowing visualiza-
Normal Appendix
Normal Appendix tion 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 thor-
oughly 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
A by having the patient void immediately before the procedure. The
abdomen is entered at the umbilicus, and the diagnosis is con-
firmed by inserting the laparoscope (Fig. 50-5). Two additional
Appendicitis working ports are then placed, typically in the left lower quadrant
Appendicitis
and in either the suprapubic area or supraumbilical midline, based
on the surgeon’s preference. We have found it to be advantageous
FIGURE 50-3  Ultrasound image of a normal appendix (top) illustrating for both the surgeon and assistant to stand to the left side of the
the thin wall in coronal (left) and longitudinal (right) planes. In appendi-
patient with the left arm tucked. This allows optimum triangula-
citis, there is distention and wall thickening (bottom, right), and blood
flow is increased, leading to the so-called ring of fire appearance.
tion of the camera and working instruments. Atraumatic graspers
A, Appendix. are used to elevate the appendix, and the mesoappendix is care-
fully 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
experience with the technology, and limited availability (especially this technique in cases in which the entire appendix is friable
in the after-hours emergency setting).9 because it allows the staple line to be placed slightly more proxi-
mally, on the edge of the healthy cecum, thereby reducing the risk
TREATMENT OF APPENDICITIS of leakage from breakdown of a tenuous appendiceal stump.
Retrieval of the appendix is accomplished by the use of a plastic
Acute Uncomplicated Appendicitis retrieval bag. The pelvis is irrigated, the trocars are removed, and
The appropriate treatment of acute uncomplicated appendicitis the wounds are closed. Laparoscopic appendectomy may also be
is prompt appendectomy. The patient should undergo fluid resus- performed with single-site laparoscopic surgical techniques as
citation as indicated, and the intravenous administration of well, although this technique remains less commonly performed
broad-spectrum antibiotics directed against gram-negative and than the traditional multitrocar approach.
anaerobic organisms should be initiated immediately.11 Operation Antibiotic administration is not continued beyond a single
should proceed without undue delay. preoperative dose.11 Oral alimentation is begun immediately and
 CHAPTER 50  The Appendix 1301

Superior ileocecal
recess

Ileum

Inferior
ileocecal
recess
Anterior cecal artery
Ileocecal fold

Cecum

Division of
appendiceal artery
in the mesoappendix

A 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.)
1302 SECTION X  Abdomen

A B

C D
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 surgeon’s 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 bedside with sutures, clips, or Steri-Strips, depending on the sur-
operation. geon’s preference.
Postoperatively, broad-spectrum antibiotics are continued for
Perforated Appendicitis 4 to 7 days in accordance with IDSA guidelines.11 If culture
The operative strategy for perforated appendicitis is similar to that specimens were obtained, antibiotic therapy should be modified
for uncomplicated appendicitis with a few notable exceptions. in accordance with the results. Nasogastric suction is not employed
First of all, the patient may require a more aggressive resuscitation routinely but may be necessary if postoperative ileus develops.
before proceeding to the operating theater. As with uncomplicated Oral alimentation is begun after return of bowel sounds and
appendicitis, antibiotic therapy should be initiated immediately passage of flatus and advanced as tolerated. Once the patient is
on diagnosis.11 tolerating a diet, is afebrile, and has a normal white blood cell
Both the open and laparoscopic approaches are acceptable for count, the patient may be discharged home.
the treatment of perforated appendicitis. Although the technique If the patient develops fever, leukocytosis, pain, and delayed
of appendectomy for perforation is the same as for simple appen- return of bowel function, the possibility of a postoperative abscess
dicitis, the level of difficulty encountered in removing a friable, must be entertained. Abscess complicates perforated appendicitis
gangrenous, perforated appendix can be a challenge to the most in 10% to 20% of cases and represents the major source of
experienced surgeon and requires gentle meticulous handling of morbidity related to perforation.1,3 A CT scan with intravenous
the friable appendix and inflamed periappendiceal tissues to avoid administration of a contrast agent is diagnostic and also allows
tissue injury. Cultures are not mandatory unless the patient has simultaneous placement of a percutaneous drain within the
had exposure to a health care environment or has had recent abscess cavity.9 If CT drainage is not technically possible because
exposure to antibiotic therapy because these factors increase the of the location of the abscess, laparoscopic, transrectal, or trans-
likelihood of encountering resistant bacteria. However, we rou- vaginal drainage is an alternative.
tinely obtain them because they sometimes yield resistant bacteria
and are helpful in tailoring the switch to oral therapy on dis- Laparoscopic versus Open Appendectomy
charge.11 Once the appendix is successfully removed, careful atten- The debate about the choice of open versus laparoscopic appen-
tion should be given to the clearance of infectious material, dectomy for the treatment of appendicitis remains a major point
including spilled fecal material or fecaliths, from the abdomen. of controversy among surgeons. Although no level I data exist to
This task may be accomplished by large-volume irrigation, with support one approach over another, a study published in 2010
special attention given to the right lower quadrant and pelvis. examined this issue in detail. Ingraham and colleagues14 analyzed
Drains are not routinely placed unless a discrete abscess cavity is results from 222 hospitals comparing laparoscopic versus open
present. If an abscess cavity is present, a single closed suction appendectomy using the American College of Surgeons National
Jackson-Pratt drain is placed within its base and left for several Surgical Quality Improvement Program. In all, 24,969 laparo-
days. If an open technique was used, the skin and subcutaneous scopic and 7714 open procedures were included in the analysis.
tissues are left open for 3 or 4 days to prevent development of Although the data were limited by the retrospective nature, the
wound infection, at which time the wound may be closed at the investigators observed that laparoscopic appendectomy was
 CHAPTER 50  The Appendix 1303

associated with lower risk of wound complications and deep surgi- patients who are successfully drained percutaneously. If a periap-
cal site infection in uncomplicated appendicitis. In complicated pendiceal phlegmon is present or if the amount of fluid present
appendicitis, laparoscopic appendectomy was associated with is not sufficient to drain, the patient may be treated with antibiot-
fewer wound complications but a slightly higher incidence of ics alone, typically for 4 to 7 days also, as recommended by IDSA
intra-abdominal abscess. The overall conclusion, however, was guidelines for treatment of intra-abdominal infection.11
that the laparoscopic approach was associated with an overall Traditionally, after successful nonoperative treatment of com-
lower incidence of complications than the open procedure. The plicated appendicitis, patients were advised to undergo removal
conclusions evident from a number of studies indicate that both of the appendix, a procedure known as interval appendectomy,
approaches are acceptable and that the advantages with laparos- several weeks to months later. This practice has been reexamined.
copy, although small, were a lower overall morbidity, reduced The rationale for interval appendectomy is based on the potential
wound complications, reduced postoperative pain, and perhaps a for development of recurrent appendicitis and the subsequent
slightly shorter recovery time. The slightly higher risk of intra- risks associated with emergent removal or reperforation of the
abdominal abscess formation after laparoscopic appendectomy in appendix. However, the actual risk of recurrent appendicitis
cases of complicated appendicitis was a negative aspect of laparo- appears to be small, 8% at 8 years in one study of 6400 pediatric
scopic appendectomy, although the authors acknowledged that patients.21 The findings in this study as well as similar results
this has not been observed in all studies.15 reported by others have led them to conclude that interval appen-
We prefer the laparoscopic approach for several reasons. Lapa- dectomy should be reserved only for patients who present with
roscopy allows examination of the entire peritoneal space, making symptoms of recurrent appendicitis.21,22 In addition, the presence
it exceptionally useful to exclude other intra-abdominal disease of an appendicolith on CT has also been shown to be predictive
that may be manifested in a similar fashion, such as diverticulitis of a higher risk of recurrent appendicitis and has been used as a
or tubo-ovarian abscess, whereas visualization of these structures justification to proceed with interval appendectomy in that sub-
would not be possible through a right lower quadrant incision. group of patients. This selective approach to interval appendec-
We find it to be technically simpler in most patients, particularly tomy has also been demonstrated to be more cost-effective than
the obese, and have been impressed with our ability to discharge its routine performance in all affected patients.22
patients within several hours of the operation. A systematic review published by Hall and colleagues23 exam-
The debate about the superiority of laparoscopic versus open ining the role of interval appendectomy found that the overall risk
appendectomy will likely continue as a clearly superior choice has of recurrent appendicitis was 20.5%. All recurrences were seen
not been conclusively demonstrated. What does appear clear, within 3 years, and 80% of these occurred within 6 months. In
however, is that regardless of the surgeon’s preferred approach, the addition, the morbidity of interval appendectomy was significant,
most important aspect of appendectomy is that it be done with complications reported in 23 of the studies, for an overall
promptly and safely. rate of 3.4%. Other authors have reported significant associated
morbidity with interval appendectomy as well, with rates as high
Delayed Presentation of Appendicitis as 18%.24
Patients may occasionally present several days to even weeks after One argument favoring interval appendectomy in adults has
the onset of appendicitis. In these cases, the treatment should be been the observation by some investigators of a higher incidence
individualized on the basis of the nature of the presentation (Fig. of appendiceal neoplasms found in interval appendectomy speci-
50-6). Although rare, a patient may present with diffuse perito- mens.8,25-27 Also, perforated tumors of the cecum may be mani-
nitis. More commonly, however, patients present with localized fested in a similar fashion as perforated appendicitis.28 For this
right lower quadrant pain and fever, with a history that is compat- reason, colonoscopy is recommended in all adult patients as
ible with appendicitis. A mass may be palpable in children or thin routine follow-up after nonoperative management of complicated
patients. Immediate exploration and attempted appendectomy in appendicitis.29 To date, no large-scale randomized controlled trials
these patients may result in substantial morbidity, including examining the outcomes of patients who do or do not undergo
failure to identify the appendix, postoperative abscess or fistula, interval appendectomy after successful nonoperative treatment
and unnecessary extension of the operation to include ileocecec- have been conducted. For this reason, this issue is likely to remain
tomy, all due to the extreme induration and friability of the controversial for some time.
involved tissues. For this reason, in general, treatment for these
patients is initially accomplished nonoperatively.16-20 Fluid resus- The Normal-Appearing Appendix at Operation
citation is initiated, and broad-spectrum antibiotic therapy is In cases of “negative appendectomy,” in which a normal appendix
initiated. A CT scan is obtained, and perforated appendicitis with is identified at operation, there is controversy as to whether the
a localized abscess or phlegmon is confirmed (Fig. 50-7). If a appendix should be removed.30,31 Before that particular issue is
localized abscess is identified, CT-guided percutaneous drainage examined, it is important to emphasize the need to thoroughly
is performed for source control. The drainage catheter is typically evaluate the abdomen for other causes of pain severe enough to
left in place for 4 to 7 days, during which the patient is treated warrant an operation. The abdominal and pelvic organs should
with antibiotic therapy and after which time it is removed. If be assessed for any abnormalities. In our experience, this is most
CT-guided drainage is not technically feasible, operative drainage easily done through the laparoscopic approach, which we think is
may be accomplished through transrectal or transvaginal a major advantage of laparoscopy over an open approach. Note
approaches. Laparoscopic drainage is another option that we have should be made of any free fluid as such a finding may suggest
found to be exceptionally useful. This technique is performed by perforation. The terminal 60 cm of ileum should be examined for
visualizing the inflammatory mass with the laparoscope and then a Meckel’s diverticulum and the serosa of the small bowel for any
entering the abscess with a laparoscopic suction tip, evacuating stigmata of Crohn’s disease, such as inflammation, stricture forma-
the purulent material, and placing a drain within the residual tion, or the characteristic “creeping fat” appearance of the mesen-
abscess cavity. Postoperative management is identical to that of tery. Inspection of the ileal mesentery may reveal enlarged lymph
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 No

CT drainage, antibiotics Laparoscopic drainage, antibiotics

Adult Child

Colonoscopy after discharge Consider interval appendectomy

Normal Neoplasm

Consider interval appendectomy 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 requiring intervention may require conversion to a midline lapa-
be examined for any evidence of tubo-ovarian or salpingeal rotomy if necessary.
disease, such as ovarian torsion, tubo-ovarian abscess, endometrio- We routinely remove the normal appendix for several reasons.
sis, or ruptured ovarian cysts. The sigmoid colon should be exam- First, many causes of right lower quadrant pain discussed before
ined for evidence of acute diverticulitis, especially in cases in may be recurrent, such as pain from ruptured ovarian cysts or
which a redundant sigmoid colon is found in the right lower mesenteric adenitis. Appendectomy is also advisable in cases of
quadrant. If these are all normal, attention should be turned to Crohn’s disease when suggested by findings at operation, unless the
the upper abdomen for examination of the gallbladder and duo- base of the appendix and cecum are involved. In this scenario,
denum. Inability to perform an adequate evaluation of the intra- appendectomy is deferred to avoid breakdown of the inflamed
abdominal organs or demonstration of disease of other organs stump and subsequent fistula formation. In these clinical
 CHAPTER 50  The Appendix 1305

A B
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 the appendix will sometimes reveal findings consistent with
appendicitis from the differential diagnosis when the patient pre­ chronic inflammation.31,34 We will consider, on a case by case
sents with recurrent right lower quadrant pain. In addition, abnor- basis, elective appendectomy in cases in which the history is con-
malities of the appendix not apparent on gross inspection at the sistent with appendiceal disease and there is radiographic (CT)
time of operation are sometimes identified on pathologic evidence of appendiceal disease.
examination.30,31 More troubling, however, is the patient with pain in the
absence of radiographic evidence of appendiceal disease. We typi-
Nonoperative Treatment of Uncomplicated Appendicitis cally pursue a multidisciplinary workup in these patients involv-
Although prompt appendectomy is the standard of care, a number ing input from specialists in gastroenterology and gynecology as
of studies have challenged this concept and have supported anti- well as surgery. Appendectomy is typically not offered unless
biotic therapy alone as a definitive treatment for acute uncompli- disease is demonstrated radiographically; however, if diagnostic
cated appendicitis. Two meta-analyses analyzing the results of laparoscopy is performed to investigate or to exclude other disease
randomized controlled trials examining this issue concluded that (typically by a gynecologist), we will typically perform appendec-
nonoperative treatment was associated with a lower risk of com- tomy, an approach advocated by others.35 We have found that as
plications (12% in the nonoperative group versus 18% in the with the management of any chronic pain syndrome, manage-
appendectomy group; P = .001).32,33 Appendectomy, however, ment of expectations is critical in caring for this very difficult
outperformed the nonoperative group in overall treatment failure group of patients.
rate (40% nonoperative versus 9% in the appendectomy group;
P < .001). The authors concluded that antibiotic therapy was safe Incidental Appendectomy
as a treatment for uncomplicated appendicitis but was associated Incidental appendectomy is the term applied when a grossly
with a significantly, perhaps prohibitively high failure rate com- normal appendix is removed at the time of an unrelated proce-
pared with appendectomy.32,33 For this reason, our practice is to dure, such as a hysterectomy, cholecystectomy, or sigmoid colec-
reserve nonoperative therapy only for acute uncomplicated appen- tomy. Once commonly performed, incidental appendectomy has
dicitis for those patients in whom the operative risk is prohibitive. become a controversial procedure. The theoretical benefit is that
Failures of nonoperative therapy in these high-risk patients of eliminating the patient’s risk for development of appendicitis
are then managed with adjunctive treatment measures, such as in the future, a concept that is thought to be most beneficial in
CT-guided drainage of periappendiceal abscesses. patients younger than 35 years because of their greater lifetime
risk for development of the disease compared with older patients.16
“Chronic” Appendicitis as a Cause of Abdominal Pain Data suggesting that incidental appendectomy may be performed
On occasion, patients will present with a history of recurrent right with no additional morbidity have been criticized for not having
lower quadrant pain, and a surgical opinion will be sought as to been properly risk adjusted. When these data were scrutinized
the benefit of elective appendectomy for treatment of this condi- further, Wen and coworkers actually demonstrated that incidental
tion. Modest epidemiologic data exist to suggest that appendicitis appendectomy was associated with an increase in both morbidity
may spontaneously resolve, so it is conceivable that appendicitis and mortality.36 Other investigators have demonstrated that inci-
may wax and wane in some patients.1 In addition, some patients dental appendectomy does not appear to be cost-effective as a
with pain are found to have a thickened appendix or an appen- preventive measure.37 Finally, the recent finding that the appendix
dicolith on CT but have no evidence of a systemic illness or acute may actually have a role in the maintenance of healthy colonic
periappendiceal inflammation. In some cases, appendectomy will flora makes the practice of incidental appendectomy even more
produce relief of symptoms, and in these cases, examination of controversial.4 For these reasons, we advocate careful inspection
1306 SECTION X  Abdomen

of the appendix for abnormalities during abdominal operations by traction on the suspensory ligaments of the uterus, a phenom-
as part of a thorough exploration but do not advocate appendec- enon known as round ligament pain, is a common occurrence
tomy unless an abnormality is detected. and further complicates the clinical picture further because 50%
of cases of appendicitis occur in the second trimester. Finally,
APPENDICITIS IN SPECIAL POPULATIONS biochemical and laboratory indicators used to support the diag-
nosis of appendicitis in the nonpregnant patient are unreliable in
Appendicitis in the Pregnant Patient pregnancy. For example, a mild physiologic leukocytosis of preg-
Appendicitis remains the most common nonobstetric emergency nancy is a normal finding. C-reactive protein levels may also be
in pregnancy and is consequently the most frequent reason for physiologically elevated in pregnancy. In addition, the surgeon
general surgical intervention in this group of patients.38 The diag- must be concerned about the possibility of obstetric emergencies
nosis of appendicitis in pregnancy presents a special challenge to as a cause of abdominal pain, such as preterm labor, placental
the surgeon. As with all conditions in pregnancy, the surgeon abruption, or uterine rupture.38-40 All of these factors have con-
must consider the welfare of two patients, the mother and fetus, tributed to the high rate of negative appendectomy in pregnant
when considering possible diagnoses, workup, and treatment patients, as high as 25% to 50%, when it is based on clinical
(Fig. 50-8). presentation alone.38
In pregnancy, appendicitis has a typical clinical presentation The impact of appendicitis on the pregnant patient is severe.
in only 50% to 60% of cases.38 The common symptoms of early The risk of preterm labor has been shown to be 11% and fetal
appendicitis, such as nausea and vomiting, are nonspecific and loss 6% with complicated appendicitis.41 These data would appear
are also often associated with normal pregnancy. The normal to favor an aggressive, early approach to appendicitis in the preg-
febrile response to illness may be blunted in pregnancy. Also, the nant patient. Complicating this approach, however, was the
physical examination of the pregnant patient is difficult and is finding in the same series that negative appendectomy was also
altered because of the effect of the gravid uterus and its displace- associated with preterm labor and fetal loss (10% and 4%, respec-
ment of the appendix to a more cephalad location within the tively). The lowest rates of preterm labor and fetal loss (6%
abdomen. Lower quadrant pain in the second trimester produced 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 Appendicitis confirmed US ()

Treat as indicated 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.
 CHAPTER 50  The Appendix 1307

appendicitis.41 For these reasons, preoperative accuracy of diagno- and argued that the amount of radiation delivered during a limited
sis is crucial in the pregnant patient with suspected appendicitis. CT examination is below the threshold required to induce fetal
Routine imaging is recommended in pregnant patients. The malformations and that most cases of appendicitis in pregnancy
initial study of choice is US with graded compression.42 It has occur in the second or third trimester, when organogenesis in
the advantage of being safe, inexpensive, and readily available. In already complete.42 Although protocols vary, if CT is used during
addition, US may provide information as to fetal well-being and pregnancy for equivocal cases, care should be taken to perform as
obstetric causes of abdominal pain, such as placental abruption. limited a study as possible with avoidance of intravenous admin-
Scanning patients in a left posterior oblique or left lateral decu- istration of contrast material. Further study is required before the
bitus position rather than in the traditional supine position has routine use of CT can be accepted in this clinical scenario.
been advocated to increase the chances of visualizing the appen- The choice of laparoscopic versus open technique for appen-
dix. The criteria for US diagnosis are the same as in the nonpreg- dectomy in pregnancy also merits discussion. Current Society of
nant patient and have been discussed previously. Unfortunately, American Gastrointestinal and Endoscopic Surgeons guidelines
the sensitivity (78%) and specificity (83%) of US appear to be state that laparoscopic appendectomy is safe in pregnancy and is
reduced in pregnancy because of the presence of the gravid the standard of care in pregnant patients.43 Two studies, both
uterus.42 small and retrospective, have shown no increased fetal loss with
If US examination findings are equivocal, MRI without gado- laparoscopic appendectomy compared with open appendectomy.
linium contrast, with its excellent soft tissue contrast resolution Another study reported higher preterm labor and overall compli-
and lack of ionizing radiation, remains a safe alternative for con- cation rates in the open group compared with the laparoscopic
firmation or exclusion of appendicitis in the pregnant patient. In group.40 Others have reported higher fetal loss rates with laparo-
addition, the excellent sensitivity and specificity are preserved in scopic appendectomy (5.6% versus 3.1%) compared with open
the pregnant patient (Fig. 50-9). A patient in whom MRI findings appendectomy.44 It is apparent that this debate would be best
are normal likely does not require appendectomy. Routine use of resolved through randomized controlled trials, which to date have
MRI in pregnant patients has been demonstrated to reduce the not been performed.
negative appendectomy rate by 47% without a significant increase Our institutional experience with laparoscopic appendectomy
in the perforation rate, and it has been shown to be a cost-effective in pregnancy has been positive, making it our preferred approach
study.42 For these reasons, we encourage liberal use of MRI in to the pregnant patient. In our hands, we believe it allows an easier
pregnant patients suspected to have acute appendicitis without identification of the highly variable location of the appendix, a
frank peritonitis. However, MRI may not be available in some more expeditious removal, and an opportunity for more thorough
institutions and may be available only on a limited basis or during evaluation of the abdomen for any associated pathologic process.
limited times in other institutions. The decision about any delay We do routinely use an open access approach (Hasson technique)
in appendectomy to obtain an MRI study is a complex one and for initial trocar placement to avoid any chance of injury to the
should be made using all available clinical and imaging data avail- gravid uterus.
able because there are potentially severe consequences associated
with both negative appendectomy and appendiceal perforation. Appendicitis in the Elderly
If US is inconclusive and MRI scanning is not immediately Although it is not the peak age for its occurrence, appendicitis is
available, CT scanning for diagnosis of appendicitis in pregnancy not infrequently seen in elderly patients and should remain in the
has been reported. A study published in 2008 demonstrated that differential diagnoses of any elderly patient presenting with acute
the use of CT was associated with an 8% negative appendectomy abdominal pain who has not had an appendectomy. The most
rate, compared with 54% by clinical assessment alone and 32% important aspect is to realize the expanded differential diagnosis
by clinical assessment combined with US. The authors concluded that must be considered in the elderly. Other possible diagnoses
that CT should be used if US examination findings are equivocal 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 morbid-
ity 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. Laparo-
scopic appendectomy is safe in the elderly and is our procedure
FIGURE 50-9  MRI scan with T1-weighted axial image of the abdomen of choice in this group of patients. Exceptions include patients
in a gravid woman. The arrow highlights the thickened appendix. (From with severe cardiomyopathy, in whom we prefer the open
Parks NA, Schroeppel TJ: Update on imaging for acute appendicitis. approach to avoid the deleterious effects of pneumoperitoneum
Surg Clin North Am 91:141–154, 2011.) in patients with marginal cardiac function.45 We have
1308 SECTION X  Abdomen

also successfully performed open appendectomy under spinal well-circumscribed lesions that are located within the more distal
anesthesia in patients who are “pulmonary cripples” and in whom aspect of the appendix.
the risk of general surgery is prohibitive and likely to result in The biologic behavior of carcinoid tumors is highly variable.
ventilator dependence. Size appears to be the best predictor of malignant behavior and
metastatic potential, more so than histologic features, including
Appendicitis in the Immunocompromised Patient lymphovascular invasion. Carcinoids smaller than 1 cm are typi-
Appendicitis in the immunocompromised patient is managed in cally thought to behave in a benign manner and are cured with
the same manner as in the immunocompetent patient, with appendectomy. Carcinoids larger than 2 cm are treated more
prompt appendectomy. The key in the evaluation of this popula- aggressively, however. Other considerations include whether the
tion lies in maintenance of a high index of suspicion because the carcinoid involves the base of the appendix or extends into the
lack of the ability to mount an immune response may result in mesoappendix. Patients with carcinoids larger than 2 cm, with
absence of fever, leukocytosis, and peritonitis. For this reason, involvement of the base, or with extension to the mesoappendix
early use of CT imaging is advisable. This allows confirmation of should undergo right hemicolectomy with regional lymphadenec-
the diagnosis of appendicitis as well as the exclusion of diagnoses, tomy. For lesions between 1 and 2 cm in size, recommendations
such as neutropenic enterocolitis (typhlitis), that may be amenable should be made after careful consideration of the individual
to nonoperative treatment.46 tumor characteristics as metastases have been reported.1,47
Adenocarcinoma of the appendix is rare and occurs at a fre-
quency of 0.08% to 0.1% of all appendectomies.1 Treatment is
NEOPLASMS OF THE APPENDIX identical to that of cecal adenocarcinoma and consists of right
Neoplasms of the appendix, although rare, require appropriate hemicolectomy with regional lymphadenectomy. Chemotherapy
treatment. An unanticipated appendiceal neoplasm may be is also identical to that of adenocarcinoma of the colon, with
encountered at any elective or emergency operation. It is estimated adjuvant administration of 5-fluorouracil, leucovorin, and oxali-
that 50% of appendiceal neoplasms present as appendicitis and platin (FOLFOX) to selected patients. FOLFOX has also been
are diagnosed on pathologic examination of the surgical specimen, used in the neoadjuvant setting in patients with mucinous adeno-
but variable presentations have been reported. It is reported that carcinoma before cytoreductive (debulking) surgery.48
appendiceal neoplasms are identified in 0.7% to 1.7% of pathology Mucinous tumors of the appendix are appendiceal tumors that
specimens. In addition, an appendiceal mass is sometimes noted are not frankly malignant but, if ruptured, can result in intraperi-
as an incidental finding on abdominal CT (Fig. 50-10). The toneal spread and the development of pseudomyxoma peritonei
pathologic classification and biologic behavior of appendiceal neo- (PMP). Classification and nomenclature of these lesions are con-
plasms are diverse, which serves to make the classification, termi- fusing and not universally agreed on.1 Because PMP results as a
nology, and treatment recommendations even more confusing.1 consequence of perforation and direct peritoneal seeding from the
Overall, appendiceal neoplasms are thought to account for 0.4% appendiceal contents, the surgeon should use great caution to
to 1% of all gastrointestinal malignant neoplasms.1 avoid rupturing an intact appendix if mucocele or mucinous
After appendectomy for presumed appendicitis, the incidence neoplasm is suspected on preoperative imaging or diagnosed
of unexpected findings in the surgical specimen is low. Still, if intraoperatively. If PMP occurs, treatment by extensive cytoreduc-
identified, appropriate counseling and treatment are essential. tive surgery involving removal of any involved organs combined
Carcinoid tumors are the most common tumor primary identified with heated intraperitoneal chemotherapy is typically employed49
in the appendix.16 These neoplasms arise from neuroendocrine and is associated with long-term survival.
cells from within the appendix and are detected in 0.3% to Although many appendiceal neoplasms are diagnosed on final
0.9% of appendectomy specimens.1 These are typically small, pathologic examination, the mass will occasionally be visible at
the time of appendectomy. An excellent algorithm for the man-
agement of the incidentally identified appendiceal mass was pro-
posed 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 identi-
fied incidentally. The availability of frozen-section diagnosis may
TI provide additional help with intraoperative decision making.
R C L
1 2 SELECTED REFERENCES
9 0
0 8 Ingraham AM, Cohen ME, Bilimoria KY, et al: Comparison of
outcomes after laparoscopic versus open appendectomy for acute
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discussion 635–637, 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 McGory ML, Zingmond DS, Tillou A, et al: Negative appendec-
medial to the appendix (arrow), without associated inflammation. tomy in pregnant women is associated with a substantial risk of
C, Cecum; TI, terminal ileum. fetal loss. J Am Coll Surg 205:534–540, 2007.
 CHAPTER 50  The Appendix 1309

APPROACH TO PATIENT WITH APPENDICEAL NEOPLASM

Tumor detected at operation

Yes No

Tumor >2 cm Tumor found after appendectomy

Yes No Adenocarcinoma Carcinoid

R hemicolectomy Is base involved? R hemicolectomy

Yes No Tumor <1 cm Tumor >2 cm Tumor 1-2 cm

R hemicolectomy Perforation? Observation R hemicolectomy

Lymphovascular invasion

Yes No Yes No

Evidence of mucin spillage Appendectomy R hemicolectomy Observation

or mucinous ascites

Yes 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.
1310 SECTION X  Abdomen

7. Silen W: Cope’s early diagnosis of the acute abdomen, ed 22,

This article, which demonstrates that fetal loss is not only
New York, 2010, Oxford University Press.
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Radiology 215:337–348, 2000.
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CT MR 29:293–307, 2008.
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This classic text, now in its 22nd edition, provides a master-
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256:586–594, 2012.
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14. Ingraham AM, Cohen ME, Bilimoria KY, et al: Comparison
timeless source of wisdom and is considered a “must read”
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by many surgeons.
acute appendicitis at 222 ACS NSQIP hospitals. Surgery
148:625–635, discussion 635-637, 2010.
Solomkin JS, Mazuski JE, Bradley JS, et al: Diagnosis and man-
15. Fleming FJ, Kim MJ, Messing S, et al: Balancing the risk of
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spectives. Adv Surg 47:119–140, 2013.
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18. Lugo JZ, Avgerinos DV, Lefkowitz AJ, et al: Can interval
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genbecks Arch Surg 398:463–466, 2013.
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appendiceal neoplasms.
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 CHAPTER 50  The Appendix 1311

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